CarePolicy Home Health Care Agency Policies and Procedures User Guide

CarePolicy Home Health Care Agency Policies and Procedures User Guide

Version 1.0
[Month, Year]

Copyright [Year] © [Agency Name] Disclaimer: All rights reserved. No part of this publication may be utilized, reproduced, stored in a retrieval system, or transmitted in any form by any means, electronic, mechanical, recording or otherwise, without the prior written consent of the publisher.
[Agency Name] [Agency Address] [Contact Number] [Email Address] [Website]

INTRODUCTION

[Agency Name] primary focus is to provide superior home health care to members of our community. We strive to deliver the highest quality of care to the members.

At [Agency Name], we understand that making the best decisions for an aging or ill family member is priority. We assist member by creating a plan of care specific to them. While matching one of our compassionate caregivers to ensure satisfaction. Our services satisfy the following requirements of our members:

• Home Health Care: skilled and non-skilled nursing care, as well as other skilled care services, like physical and occupational therapy, speech- language therapy, and medical social services to clients in their own home.

OUR VALUES

• Service: providing a helping hand that allows our members to feel valued and cared for by upholding their sense of dignity.
• Trust: maintaining honest lines of communication with safe and competent care that protects privacy.
• Integrity: fostering an undivided attitude directed towards doing the right thing the first time around, every time.
• Respect: promoting esteem and acceptance for and towards everyone we come in contact with

MISSION

Our mission is to help our clients maintain their independence, dignity and quality of life with a kind, caring attitude. We strive always to deliver the most suitable trained personnel who can best meet each person’s needs while providing as much consistency in care as possible.

STATEMENT OF PURPOSE

The purpose of this policy is to define organization-wide processes and activities that maximize the coordination of quality home services to members at [Agency Name]. The goal of this plan is to coordinate member care in a manner that is seamless from the member’s perspective. This policy shall be made available for review, upon request, to members 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:

• Needs of our members and the community we serve;
• Policies and procedures;

We strongly adhere to compliance requirements stated by Massachusetts Law, Department of Health and follow the best practices implemented in terms of policies and procedures within [Agency Name].

DOCUMENT CONTROL & APPROVALS

Document Revisions shall be recorded in the table below;

Document review and approvals shall be recorded in the table below;

Note: All policies and procedures shall be reviewed at least annually, with recommended changes submitted to the governing body for approval, as necessary.

ORGANIZATIONAL CHART

ADMINISTRATIVE RECORDS
A medical record is considered a legal document used to protect the legal interest of a member as well as the [Agency Name]. Information maintained within the record serves as a basis for review, study and evaluation of the care rendered to the member. It is essential that medical records are neat, legible, accurate and readily accessible for purposes of service delivery, audit and possible litigation proceedings. The medical record shall be locked in a container and handled and transported in a manner that ensures the security and confidentiality of the record at all times.

Clinical record entries must be complete, legible and accurate. Inaccurate documentation can lead to errors in the treatment of the member, which could put the member at significant risk of harm. [Agency Name] shall strive for complete, legible and accurate documentation on all member records and will follow specific guidelines to ensure accurate documentation. All employees of [Agency Name] shall not disclose or knowingly permit the disclosure of any information in a member record except to appropriate provider staff, the member, responsible party (if applicable), or other health care providers, the department, other individual authorized by the member in writing.

All members are to be treated with consideration, respect, and dignity, including the provision of privacy during care. [Agency Name] will maintain confidentiality of clinical records in accordance with legal requirements and we will release information only with member authorization or as required by law.

To assure the maintenance and security of all member/member records, the following will take place:

• The Administrator will supervise the maintenance of all records
• Records will be maintained in a locked file cabinet located at the office of [Agency Name] to assure protection.
• The Administrator has total custody of all records.
• The records may be released to the member/responsible party by request (if applicable) and other members of the health care field authorized by the member or by subpoena.
• Confidentiality will be enforced during all staff meetings.
• Records will be retained with full protection for a minimum of 5 years after services are discontinued (the last date of service).

Record Procedures

• All entries will be dated and signed. Signatures/initials in the clinical records will be recorded in accordance with the agency’s legal signature list. No alterations will be permitted. If an Interpreter is used for member interaction the interpreter must sign the entry along with the provider of the service.
• Narrative notes are to be numbered with the most recent pages on the top progressing to earliest entry on the bottom.
• Each page in the chart is to include name (last, first, middle/maiden), date of birth and member number.
• All member/member encounters are documented in the medical record noting the type of contact.
• Entries are to be made within the margins and to the end of the line. If unable to fill the line, draw a line to the end. There is to be no crowding or writing in the margins, and no unfilled lines between entries. All unused lines will be crossed out between documentation.
• All telephone encounters (if any) will be documented in the member’s clinical record on the note sheet in chronological order.
• Each personal health program is responsible for providing program specific documentation guidelines and monitoring/reviewing those guidelines according to Quality Assurance.
• The employee who provided the service will document all member data collection and service provided. Provider must initial and date on the laboratory reports when reviewed.
• The Medical Records Policy adheres to guidelines regarding content, access, storage, removal and retention of medical records to ensure that the agency abides by statutes and regulations pertaining to legality, privacy and security.
• Late entries made out of chronological order must be recorded as soon as possible in the next available chart space, as a “note out of sequence”. The late entries should have time of entry and must have two dates, the date the entry was made and date of the encounter along with the reason for the late entry.
• Clinical records will be reviewed periodically by an audit review committee to determine compliance with policies and procedures.
• Records found to be incomplete or in need of clarification will be returned to the appropriate staff member.

Correction of documentation

• Documentation error will be corrected by drawing a single line through the incorrect documentation, initialing and dating the mistake and continuing with the note. The error will remain legible.
• The reader must be able to discern what the incorrect entry states.
• The person who documents the original information corrects the documentation. At no time should another discipline correct documentation or strike through documentation made by the original author.
• Correction fluid or erasers will not be used to correct documentation in the member’s record.

Records

All records, including but not limited to the following, must be accessible and made available on site for inspection by the MassHealth agency:
(a) payroll and staff records, including evidence of completed staff orientation and training;
(b) financial records;
(c) staffing levels;
(d) complaints and grievances;
(e) contracts for subcontracted services, including a description of how the home health agency will supervise the subcontracted services;
(f) contracts for independent contractor services, including a description of how the home health agency will supervise the independent contractors and their services; and
(g) job descriptions that include titles, reporting authority, qualifications, and responsibilities.

• Chart Maintenance – Central Filing: The central files must be kept up-to-date at all times in order to serve its purpose.
  o Ragged or damaged folders will be replaced with new ones.
  o Include these steps in preparing for filing:
  ▪ All charts are placed in alphabetical order.
  ▪ Remove all paper clips or notes (review and remove if not required).

• All charting to be completed on day of member visit and returned to central filing or pending file by 4:45 p.m.
• The staff is not allowed to keep charts in their own personal filing cabinets or offices.

Filing of Records
• Medical records are first filed alphabetically following a color-coded system based on the first two letters of the member’s last name. All active records will be maintained in the medical records area when not needed for delivery service. All in-active records are kept in locked files in the conference room; which is locked at closing. All records must be returned to medical records area after the delivery of service or by the end of the workday to ensure security of medical information. When a medical record is outside the medical records area it must be handled in a secure manner to protect the medical information from being disclosed to unauthorized persons.
• Notes, reports, medical forms, etc. will be secured inside each individual member’s folder according to the order specified by the agency. All note and problem pages in the medical record will be sequentially numbered and each page will have member identification information.

Security of Records
• As legal custodians of medical records generated in our agency, proper care will be exercised to assure that the records themselves and their contents are properly safeguarded and secure at all times. All of these individuals shall be made aware that access is allowed only to those records pertinent to official function or service delivery. Intrusion into a record for curiosity purposes at no time will be tolerated and appropriate disciplinary action will result or termination of access to records.
• All records must be properly signed out using out-guides with a label reflecting the member’s name, name of person or clinic needing records and date retrieved. Authorized personnel who signed out record(s) will be responsible for returning the record (s) when finished working with them or at the end of the workday. Records will not be left available for public viewing at any time and records must be secured to prevent accessibility to unauthorized persons.

• Ordinarily medical records will not be removed from the unless it is deemed necessary to provide member care. Records will not be removed from the building except by authorized personnel who can transport records according to agency transportation procedure for use at other sites, for court proceedings or for agency related activities.

SERVICE CRITERIA

Admission/Acceptance Criteria
[Agency Name] who admits a member into services must maintain written policies, procedures and criteria for accepting members for home health services.
• When the member has limitations, which make it difficult to perform normal daily living activities and live independently
• Have health needs that can be met in the community with services offered by the program

Admission/Acceptance can be granted as long as health and safety needs can be met by [Agency Name]. The criteria for members admitted to service may not discriminate or permit discrimination against any person or group of persons on the grounds of age, race, sex, color, religion, national origin, or handicap, in accordance with the Civil Rights Acts.

Termination Criteria
[Agency Name] may discharge a member if the care coordinator or utilization review analyst recommends a reduction or termination of service(s).
Except in an emergency, or when a member asks to terminate of his or her own accord or against program advice, no member shall be transferred or discharged unless a written plan has been developed by the staff in conjunction with the member and his or her primary counselor.

Termination occurs for the member when one of the following occurs:

• The care coordinator determines that the member is no longer appropriate or eligible for services.
• Utilization Review (UR) staff recommends in writing that a member be terminated from services.
• The enrolled member has not received services for 60 consecutive calendar days.
• A member fails to pay cost share in accordance with the agreement.
• Member/Member’s representative repeatedly refuses services.
• Member/representative or care coordinator requests immediate termination of services.
• Member expires
• Provider can no longer provide services ordered on the comprehensive care plan.

INFORMED CONSENT

• “Informed consent” means the knowing and voluntary agreement, without undue inducement or any element of force, fraud, deceit, duress, or other form of constraint or coercion, of a person who is capable of exercising free power of choice. For the purposes of human research, the basic elements of information necessary to determine the existence of such consent shall include the following:
  o A reasonable and comprehensible explanation to the person of the proposed procedures or protocols to be followed, their purposes, including descriptions of any attendant discomforts, and risks and benefits reasonably to be expected, how the results of the human research are disseminated, and how the identity of the person is protected;
  o A disclosure of any appropriate alternative procedures or therapies that might be advantageous for the person, together with their side effects, risks, and benefits;
  o A description of any adverse consequences and risks to be expected and an indication of whether there may be other significant risks not yet identified;
  o An instruction that the person may withdraw his consent and discontinue participation in the human research at any time without prejudice to him or fear of reprisal;
  o An explanation of any costs or compensation that may accrue to the person and, if applicable, the availability of third-party reimbursement for the proposed procedures or protocols or any medical care that may be available if an injury occurs; o An offer to answer any inquiries by the person or, if applicable, his legally authorized representative concerning the procedures and protocols and a description of the ways in which concerns may be raised or questions asked;
  o A statement that the study involves research, and an explanation that includes identification of any procedures that are experimental; the expected duration of the person’s participation; a statement describing the extent, if any, to which confidentiality of records identifying the participant will be maintained; and if any data from this study are published, the person will not be identified without his written permission;
  o A disclosure of any appropriate alternative procedures or therapies that might be advantageous for the person;
  o A statement that participation is voluntary, refusal to participate will involve no penalty or loss of benefits to which the person is otherwise entitled, and the person may discontinue participation at any time without penalty or loss of benefits to which he is otherwise entitled;
  o An explanation of whom to contact for answers to pertinent questions about the research and research participants’ rights, and whom to contact in the event of a research-related injury; and
  o For research involving more than minimal risk, an explanation as to whether any compensation or medical care is available if injury occurs and, if so, what is included or where further information may be obtained

• All information concerning an individual member is confidential.

• Home health care staff, and Ministry of Health staff in Massachusetts have access to confidential information for program purposes only (i.e. on a “need to know” basis).

• [Agency Name] must obtain and document informed verbal or informed written consent from the member as follows:
  o to assess the member;
  o to release the member’s personal health information to anyone other than internal staff and Massachusetts Ministry of Health personnel; and,
  o to provide service to the member.

• [Agency Name] must obtain and document informed verbal consent. To obtain informed verbal consent, the [Agency Name] must ensure that the member has full knowledge of the specific actions for which the consent has been requested.

• To obtain informed written consent, the [Agency Name] must ensure that the member has full knowledge of the specific actions for which the consent has been requested, and that those actions are specified in the consent document signed by the member. A witness must certify the member’s signature.

• When applicable, [Agency Name] shall discuss Health Care Directives and communicate this to appropriate team members.

• [Agency Name] must have a policy regarding disclosure of health information with consent or as otherwise specifically authorized in The Health Information Protection Act.

ADVANCE DIRECTIVES, INCLUDING DURABLE DO NOT RESUSCITATE ORDERS

• If a member is able to, and does, express to [Agency Name] the desire to be resuscitated in the event of cardiac or respiratory arrest, such expression shall revoke the provider’s or practitioner’s authority to follow a Durable Do Not Resuscitate Order. In no case shall any person other than the member have authority to revoke a Durable Do Not Resuscitate Order executed upon the request of and with the consent of the member himself.
• If the member is a minor or is otherwise incapable of making an informed decision and the Durable Do Not Resuscitate Order was issued upon the request of and with the consent of the person authorized to consent on the member’s behalf, then the expression by said authorized person to [Agency Name] of the desire that the member be resuscitated shall so revoke the provider’s or practitioner’s authority to follow a Durable Do Not Resuscitate Order.
• When a Durable Do Not Resuscitate Order has been revoked as provided in this section, a new Order may be issued upon consent of the member or the person authorized to consent on the member’s behalf.

MEMBER RIGHTS

• [Agency Name] must establish practices regarding the rights of members. This includes the promotion and protection of each member’s right to receive necessary information, to be given reasonable choices and to be treated with dignity.

• [Agency Name] will ensure that processes are in place to:
  a) ensure that members understand their rights;
  b) help members exercise their rights; and,
  c) investigate and resolve claims regarding a violation of member’s rights.

• Members have the right to refuse service.

• Members have the right to live at risk.

• Members have the right to fully participate in the assessment process.

• Members have the right to participate in the service delivery and make personal choices within the parameters of services available.

• Members have the right to appeal service plan decisions.

• Members have the right to receive safe, appropriate and timely service.

• Members have the right to be referred to other appropriate services.

• Members have the right to participate in team conferences. Members must be treated with consideration, respect and full recognition of their dignity and individuality.

• Members have the right to freedom from abuse, neglect or exploitation from home health staff.

• Members have the right to be assured of confidential treatment of their care records and personal information.

• Members, or the persons authorized to make health care decisions on behalf of the members, have the right to have their concerns heard, reviewed and where possible, resolved.

• [Agency Name]s 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 and any such discrimination shall be reported to the Care Manager or external regulator.

As a home health member, each member has the right to be informed of their rights and responsibilities before the initiation of care/service. If /when a member has been judged incompetent, the member’s responsible appointee or guardian may exercise rights.

The following procedures must be practiced:

• Every member will be provided with a copy of their rights and responsibilities.
• The Administrator will review the document with member/responsible party and be open for any questions or concerns.
• After member understands the rights and responsibilities, the administrator will ask them to sign a receipt of acceptance of the statement of member rights and responsibilities.
• In addition, every employee will be asked to review the Rights and Responsibilities Statement and sign a receipt of acceptance and understanding.

*This is only a preview of the Original Document

*For inquiries or assistance, please reach out to us at www.carepolicy.us

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