carepolicy Healthcare Agency Policies and Procedures Maryland State Licensure Owner’s Manual

carepolicy Healthcare Agency Policies and Procedures Maryland State Licensure

INDEX

10.07.03.08B(3)
ACTION / CONDITION| Reporting of an action or condition performed by a health care practitioner as required under Regulation .09C| COMAR 10.07.03.08B(4)
HEALTH STATUS| A health care practitioner referred by [AGENCY NAME] is of satisfactory health status and has received the necessary testing and immunization as required or requested by the client facility| COMAR 10.07.03.08B(5)(a)
DRUG SCREENING| Drug screening of a health care practitioner is performed before referral by [AGENCY NAME], if the client facility requires drug screening for facility employees| COMAR 10.07.03.08B(5)(b)
DRUG TESTING| Drug Testing of a health care practitioner referred by [AGENCY NAME] is performed, if there is probable cause to perform a drug test or if a client facility requests a drug test| COMAR 10.07.03.08B(5)(c)
CRIMINAL BACKGROUND CHECK| Criminal background checks of a health care practitioner are performed before the referral by [AGENCY NAME], if the client facility requires criminal background checks for facility employees| COMAR 10.07.03.08B(5)(d)
REFERENCES| The references of a health care practitioner referred by [AGENCY NAME]| COMAR 10.07.03.08B(5)(e)
I-9 STATUS (LEGAL TO WORK IN US)| A health care practitioner referred by [AGENCY NAME] has I-9 status that permits them to legally work in the United States| COMAR 10.07.03.08B(5)(f)
LICENSURE OR| A health care practitioner has active| COMAR 10.07.03.08B(5)(g)
CERTIFICATION| licensure or certification with the Board| **
JOB DESCRIPTIONS| Job Description for referred individuals| COMAR 10.07.03.09E(1)(a)
QUALIFICATIONS| A documented procedure for [AGENCY NAME] and client facility to determine that an individual’s qualifications are consistent with the assignment to which the individual is being referred| COMAR 10.07.03.09E(1)(b)
SCOPE OF PRACTICE| The facilities policies and procedures related to the individuals’ scope of practice and responsibilities in the referred assignment| COMAR 10.07.03. 09E(2)(a)
ABUSE & NEGLECT| The individual’s obligation under Maryland law to report abuse and neglect| COMAR 10.07.03.09E(2)(b)
INTERNAL COMPLAINTS| Description of how and to whom to file a complaint within [AGENCY NAME]| COMAR 10.07.03.08B(6)(a)
OHCQ COMPLAINTS| Description of how and to whom to file a complaint with the Office (of Health Care Quality)| COMAR 10.07.03.08B(6)(b)
INVESTIGATIONS| Commitment to conduct a thorough investigation into any allegations against individuals referred by [AGENCY NAME]| COMAR 10.07.03.08B(6)(c)
INSPECTIONS| Mechanism for making completed investigation reports available to the Department immediately upon request during inspections| COMAR 10.07.03.08B(5)(d)

INTRODUCTION

Welcome to the Policy and Procedure Manual of [AGENCY NAME]. This comprehensive manual serves as a guiding beacon for all aspects of healthcare service delivery within the state of Maryland. As a leading healthcare agency committed to excellence, we are dedicated to providing top-notch medical care, compassionate support, and innovative solutions to meet the diverse needs of our community.

Our commitment to delivering exceptional healthcare services aligns with the unique requirements and regulations set forth by the state of Maryland. This manual has been meticulously crafted to provide our staff, stakeholders, and partners with a clear and detailed framework for policies and procedures that govern our operations.

[AGENCY NAME], recognizes the vital role we play in enhancing the health and well-being of individuals across Maryland. Through this manual, we aim to establish consistent practices, maintain the highest standards of quality and safety, and promote a culture of continuous improvement.

Each section of this manual address specific aspects of our operations, ensuring that our personnel are equipped with the necessary knowledge and guidelines to uphold our commitment to excellence. By adhering to policies and procedures outlined herein, we ensure the delivery of patient-centered care, adherence to legal and ethical standards, and the efficient management of our resources.

We encourage all members of the [AGENCY NAME], family to familiarize themselves with the content of this manual and embrace its principles in their daily endeavors. Our shared dedication to these policies and procedures not only strengthens our organization but also nurtures the trust of our patients, their families, and the larger community we proudly serve.

AIMS AND OBJECTIVES

Mission Statement

Our mission at [AGENCY NAME], is to provide exceptional healthcare services that prioritize the physical, emotional, and mental well-being of our patients. Through a patient-centered approach, dedicated medical professionals, and cutting-edge practices, we strive to improve lives, promote health, and create an environment where every individual receives the care they deserve.

Vision Statement

At [AGENCY NAME], our vision is to be the foremost healthcare provider in the state of Maryland, setting a standard of excellence that transforms lives through compassionate care, innovative solutions, and a commitment to enhancing the well-being of our community.

CORE VALUES

1. Compassion: We approach every interaction with empathy, kindness, and understanding. We recognize the vulnerability of those under our care and are committed to providing not only medical treatment but also emotional support.
2. Excellence: We hold ourselves to the highest standards of quality and strive for continuous improvement in all aspects of our services. From medical treatments to administrative processes, excellence is our guiding principle.
3. Integrity: We conduct ourselves with honesty, transparency, and ethical behavior. Our patients and stakeholders trust us to make decisions that prioritize their well-being and safety.
4. Collaboration: We believe that the best outcomes are achieved through teamwork. We foster a collaborative environment that encourages open communication, information sharing, and a multidisciplinary approach to healthcare.
5. Innovation: We embrace innovation as a means to advance healthcare practices, improve patient experiences, and address evolving needs. We are open to new ideas and technologies that enhance our services.
6. Respect: We treat every individual with dignity, regardless of their background, beliefs, or circumstances. Respect is the foundation of our interactions, both within our organization and with the wider community.
7. Community Engagement: We actively engage with our community, seeking to understand its unique healthcare needs and contributing to its overall well-being through education, outreach, and partnerships.
8. Patient-Centeredness: Our patients are at the heart of everything we do. We tailor our services to meet their individual needs, preferences, and cultural sensitivities, fostering a sense of trust and partnership in their healthcare journeys.

Through these values, we embody the essence of [AGENCY NAME], and uphold our commitment to delivering exceptional healthcare services to the residents of Maryland. Our collective efforts are guided by these principles, and they underscore our dedication to making a positive impact on the lives we touch.

EQUAL EMPLOYMENT OPPORTUNITY POLICY

[AGENCY NAME] is an Equal Opportunity Employer. It is our policy to ensure equal employment opportunities in all personnel actions taken. The objective of the Company is to recruit, hire and train into all job levels the most qualified applicants without regard to race, religion, color, sex, sexual orientation, national origin, ancestry, citizenship status, uniform service member status, marital status, pregnancy, age, medical condition (cancer and genetic characteristics), handicap, disability (mental and physical) including HIV and AIDS or any other protected status in accordance with the requirements of all federal, state and local laws. Therefore, selection and other employment related decision will be made without regard to an individual’s race, religion, color, national origin, sex, age, disability or other legally protected status.

STATEMENT OF PURPOSE

The purpose of this policy is to define organization-wide processes and activities that maximize the coordination of quality and safe services to clients at [AGENCY NAME]. The goal of this plan is to coordinate client’s care in a manner that is seamless from their perspective. This policy shall be made available for review, upon request, to clients and their designated representatives and shall be readily available for staff use at all times within [AGENCY NAME].

STATEMENT OF POLICY

[AGENCY NAME] prohibits discrimination in all its activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, gender identity, genetic information, and any political beliefs.

[AGENCY NAME] is consistent with the:

• Federal and State Law of Maryland
• Needs of our staff and the community we serve;
• Agency policies and procedures;

We strongly adhere to compliance requirements stated by Maryland State Law, Department of Health and follow the guidelines as per the Maryland Health and Human Services implemented in terms of policies and procedures within [AGENCY NAME].

SELECTING & VERIFYING

POLICY

[AGENCY NAME] is dedicated to providing the Community with the highest level of Healthcare Professionals capable of performing in the most competent, professional, and reliable manner. We are an Equal Opportunity Employer. It is our policy to ensure equal employment opportunities in all personnel actions taken. Therefore, selection and other employment related decision will be made without regard to an individual’s race, religion, color, national origin, sex, age, disability or other legally protected status. Special Emphasis is however placed on the applicants work history, job experience and related Expertise. The following information is provided to assist in understanding Agency requirement and procedures.

PURPOSE

The purpose of the Policy and Procedure is to ensure [AGENCY NAME]:

• Demonstrates continued development and maintenance of high standards for screening and hiring of staffs.
• Has a process in place that validates/verifies the authenticity of the credentials and work experience of the field staff.
• Has a defined recruitment and selection process which ensures field staff meets the minimum requirements (Job Description Qualifications, Skill Competencies, and Testing). Staff will only be assigned to areas which they have qualifications.

PROCEDURE

[AGENCY NAME] Employment process is divided into 5 stages:

• Screening
• Interviewing
• Competency Testing
• Orientation
• Offer of Assignment

Screening

Prior to making an offer of employment, [AGENCY NAME]. requires all candidates to provide to the company the following current information (some of this information will be provided to MMHG, LLC after a conditional offer of employment has been made):

• Completed Application for Employment
• Completed Standards of Conduct Statement
• Completed Non-Compete Agreement
• Completed Conflict of Interest Statement
• W-4 forms
• I-9 form
• Completed reference requests
• Fingerprinting through Healthcare Worker Registry

Interviewing

1. The Agency Director or Supervisor will schedule interviews with qualified candidates. Candidates called in for interviews Will bring the documentation listed below with them. This documentation may not be reviewed during the actual interview but if the candidate proceeds beyond the interview stage, it will need to be verified at some point in the process.

   • Valid driver’s license

   • Proof of Car Insurance (not expired)

   • Social Security Card

   • Alien Registration Card where applicable

   • 2 Passport Size Photos For identification badges.

   • State Licensure/Certification Proof is necessary for each state in which a candidate may practice.

   • Three completed references, which are job related and, preferably, are from previous Supervisors. If Caregivers have recently attained accreditation but do not have three references, relative to the position they are applying for, they may submit three Supervisory references from previously held job positions.
     E verify confirmation

   • W-4 form for payroll as required by the Federal Government

   • Face-to-face interview document

   • Verification of previous employment

   • Verification of Education

   • Job description acknowledgement

   • MMHG, LLC Policies and Procedures Acknowledgement

   • Mandatory In-service acknowledgement

   • Orientation checklist

   • CPR/First Aid certification

   • Skill assessments and competency testing

   • Consent forms and results for:

   • Health Screen, Physical Examination and Annual physical exam is required including TB screen, Hepatitis B Screen or Declination, Immunization Record.

   • Drug Screening/Testing

   • Criminal Background Check

   • Continuing Education Credits Proof of CEUs or certificates of attendance for coursework as required by the state.

2. Candidates must have Basic verbal and written English communication skills

3. Demonstrate the ability to document in the client record according to professional standards and agency policies and procedures

4. Demonstrate Ability to identify and communicate significant findings to the supervisor

5. A complete understanding of company policies and procedures

6. Once all credentials and essential documents have been verified and validated, the Director reviews candidate’s profile and provides final approval for hire. Candidate is moved to Active status.

7. All PERSONNEL INFORMATION IS KEPT STRICTLY CONFIDENTIAL

Competency Testing/ Skills Assessment

• All Applicants are tested according to their area of Expertise. Applicants credentialed in highly specialized fields are required to provide updated resumes that explains and outlines their work history and experience.
• Each employee must complete a Comprehensive skills checklist inventory that is added to their individual file.
• Staff Members are required to renew and update their skills-checklist Annually.

Orientation

All new staffs participate in a general orientation program before assuming any job responsibilities or duties. Orientation of new staff members is the joint responsibility of the Registered Nurse and/or the Human Resource Manager with oversight by the Administrator. The Human Resources Manager is responsible for reviewing the policy and procedure handbook with each Staff at time of hire. New employees are invited to meet with each department head or designee to get overview of how each department interacts with each other. Department orientation and appropriate job training is provided to anyone new to a department and includes content not covered in general orientation. Development of the orientation programs takes into consideration the following: The design of the programs is based on sound adult educational principles.

Content is based on identified needs assessments, program evaluations and competency assessments, as well as applicable local, state and federal laws, regulations and standards.
Content of the general orientation program includes the following topics as Introduction to the Organization:

• Mission
• History
• Departments
• Organization’s Policies and Procedures:
• Job Description
• Communication Process
• HIPAA
• Health & Safety Procedures & Infection Control
• Ethics
• Responding to Medical & Non-Medical Emergencies
• OSHA
• Bloodborne Pathogens
• Disease Screening (form attached)
• Ergonomic

Offer of Assignment

Once all hiring conditions have been met, Qualified Applicants are offered assignments based specifically on their licensure, skill level, recent experience and the needs of our Clientele. Work assignments are scheduled by the care coordinator. A special emphasis is placed on continuity of service whenever possible. All Staffs members are required to adhere to the orientation expectations, policies and procedures of the Clients and Facilities we serve.

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