CarePolicy Non Medical Home Health Agency Policy and Procedure User Guide
- May 15, 2024
- carepolicy
Table of Contents
CarePolicy Non Medical Home Health Agency Policy and Procedure User Guide
Introduction
[AGENCY NAME], an independently owned and operated Signal Health Group Business Franchise. The primary focus is to provide superior care to clients in our community.
Our personal care, Home health (Medicare certified), and hospice care services vows to contribute to our client’s quality of life. We strive to deliver the highest quality of care to the clients.
At [AGENCY NAME], we assist client by creating a plan of care specific to them. While matching one of our compassionate caregivers to ensure satisfaction.
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 clients at [AGENCY NAME]. The goal of
this plan is to coordinate
resident’s care in a manner that is seamless from the resident’s 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 Indiana
- Needs of our members and the community we serve;
- Our mission, goals and strategic objectives;
- Agency policies and procedures;
- Performance Improvement and member Safety Plan; and
- Organizational capability to provide the requisite staffing, facilities and services.
We strongly adhere to compliance requirements stated by Indiana Law,
Department of Health and follow
the best practices implemented in terms of policies and procedures within
[AGENCY NAME].
Document Control & Approvals
Ver. No| Rev. No.| Page No.| Description of Amendment|
Approved By| Date
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Note: All policies and procedures shall be reviewed at least annually, with recommended changes submitted to the governing body for approval, as necessary.
State Compliances
410 IAC 17-12-1 Home health agency administration and management
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Sec. 1. (a) Organization, services furnished, administrative control, and lines of authority for the delegation of responsibility down to the resident care level shall be:
- clearly set forth in writing; and
- readily identifiable.
Administrative and supervisory responsibilities shall not be delegated to another agency or organization, and all services not furnished directly, including services provided through a branch office, shall be monitored and controlled by the parent agency.
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(b) A governing body, or designated person or persons so functioning, shall assume full legal
authority and responsibility for the operation of the home health agency. The governing body
shall do the following- (1) Appoint a qualified administrator.
- (2) Adopt and periodically review written bylaws or an acceptable equivalent.
- (3) Oversee the management and fiscal affairs of the home health agency.
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(c) An individual need not be a home health agency employee or be present full time at the home
health agency in order to qualify as its administrator. The administrator, who may also be the
supervising physician or registered nurse required by subsection. -
(d), shall do the following:
Organize and direct the home health agency’s ongoing functions.
Maintain ongoing liaison among the governing body and the staff.
Employ qualified personnel and ensure adequate staff education and evaluations.
Ensure the accuracy of public information materials and activities.
Implement a budgeting and accounting system.
Ensure that the home health agency meets all rules and regulations for licensure.
Upon request, make available to the commissioner or his or her designated agent all:- (A) reports;
- (B) records;
- (C) minutes;
- (D) documentation;
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(E) information; and
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(F) files;
required to determine compliance within seventy-two (72) hours of the request or, in the event
the request is made in conjunction with a survey, by the time the surveyor exits the home health
agency, whichever is sooner.
Ensure that a qualified person is authorized in writing to act in the administrator’s absence.
A physician or a registered nurse who has two (2) years of nursing experience, with at least one
(1) year of supervisory or administrative experience, shall supervise and
direct nursing and other
therapeutic services. The person or similarly qualified alternate shall be on
the premises or capable of being reached immediately by phone, pager, or other
means. In addition, the person must be able to:
- respond to an emergency;
- provide guidance to staff;
- answer questions; and
- resolve issues; within a reasonable amount of time, given the emergency or issue that has been raised.
The administrator shall be responsible for an ongoing quality assurance program designed to do the following:
Objectively and systematically monitor and evaluate the quality and appropriateness of resident care.
Resolve identified problems.
Improve resident care.
Personnel practices for employees shall be supported by written policies. All employees caring for residents in Indiana shall be subject to Indiana licensure, certification, or registration required to perform the respective service. Personnel records of employees who deliver home health services shall be kept current and shall include documentation of orientation to the job, including the following:
Receipt of job description.
Qualifications.
A copy of an employee’s national criminal history background check or expanded criminal history check.
A copy of current license, certification, or registration.
Annual performance evaluations.
As follows, personnel records of the supervising nurse, appointed under subsection (d), shall:
- Be kept current.
- Include a copy of the following:
- (A) National criminal history background check or expanded criminal history check.
- (B) Nursing license.
- (C) Annual performance evaluations.
- (D) Documentation of orientation to the job.
Performance evaluations required by this subsection must be performed every nine (9) to fifteen (15) months of active employment.
Each employee who will have direct resident contact shall have a physical examination by a physician or nurse practitioner not more than one hundred eighty (180) days before the date that the employee has direct resident contact. The physical examination shall be of sufficient scope to ensure that the employee will not spread infectious or communicable diseases to residents.
- The home health agency shall ensure that all employees, staff members, persons providing care on behalf of the agency, and contractors having direct resident contact are evaluated for tuberculosis and documentation as follows:
Any person with a negative history of tuberculosis or a negative test result must have a baseline two-step tuberculin skin test using the Mantoux method or a quantiferon-TB assay unless the individual has documentation that a tuberculin skin test has been applied at any time during the previous twelve (12) months and the result was negative.
The second step of a two-step tuberculin skin test using the Mantoux method must be administered one (1) to three (3) weeks after the first tuberculin skin test was administered.
Any person with:
- (A) a documented:
- (i) history of tuberculosis;
- (ii) previously positive test result for tuberculosis; or
- (iii) completion of treatment for tuberculosis; or
- (B) newly positive results to the tuberculin skin test; must have one (1) chest radiograph to exclude a diagnosis of tuberculosis.
After baseline testing, tuberculosis screening must:
- (A) be completed annually; and
- (B) include, at a minimum, a tuberculin skin test using the Mantoux method or a quantiferon-TB assay unless the individual was subject to subdivision (3).
Any person having a positive finding on a tuberculosis evaluation may not:
- (A) work in the home health agency; or
- (B) provide direct resident contact; unless approved by a physician to work.
The home health agency must maintain documentation of tuberculosis evaluations
showing that
any person:
- (A) working for the home health agency; or
- (B) having direct resident contact; has had a negative finding on a tuberculosis examination within the previous twelve (12) months.
The information obtained from the:
physical examinations required by subsection (h); and tuberculosis evaluations and clinical follow-ups required by subsection (i); must be maintained in separate medical files and treated as confidential medical records, except as provided in subsection (k).
The following records shall be made available, on request, to the department for review:
Personnel records and policies that document the home health agency’s compliance with subsection (f).
Records of physical examinations that document the agency’s compliance with subsection (h).
Records of the following:
- (A) Tuberculosis evaluations.
- (B) Appropriate clinical follow-up for positive findings.
- (C) Any other records that document the home health agency’s compliance with subsection (i).
The department shall:
- treat the information described in subsection (k) as confidential medical records; and
- use it only for the purposes for which it was obtained.
Policies and procedures shall be written and implemented for the control of communicable disease in compliance with applicable federal and state laws.
410 IAC 17-12-2 Quality assessment and performance improvement
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(a) The home health agency must develop, implement, maintain, and evaluate a quality assessment and performance improvement program. The program must reflect the complexity of the home health organization and services (including those services provided directly or under arrangement). The home health agency must take actions that result in improvements in the home health agency’s performance across the spectrum of care.
The home health agency’s quality assessment and performance improvement program must use objective measures. -
(b) The home health agency shall provide at least one (1) of the following services:
- Nursing treatment and procedure.
- Home health aide services.
- Physical therapy.
- Speech-language pathology.
- Occupational therapy.
- Social services.
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(c) In all cases involving the provision of home health aide services, the home health agency shall
provide case management by a health care professional acting within the scope of his or her
practice. Such case management shall include an initial home visit for assessment of a resident’s
needs to determine the type, appropriateness, and adequacy of requested service, and the
development of the resident care plan. -
(d) If personnel under contracts are used by the home health agency, there shall be a written contract between those personnel and the home health agency that specifies the following:
That residents are accepted for care only by the primary home health agency.
The services to be furnished.
The necessity to conform to all applicable home health agency policies including personnel qualifications.
The responsibility for participating in developing plans of care.
The manner in which services will be controlled, coordinated, and evaluated by the primary home health agency.
The procedures for submitting clinical notes, scheduling of visits, and conducting periodic resident evaluation.
The procedures for payment for services furnished under the contract. -
(e) Services furnished under arrangements are subject to a written contract conforming with the requirements specified in subsection (d).
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(f) When contracting temporary services from another licensed home health agency, organization, or independent contractor, the personnel records shall be maintained at the office of the employer and shall be available to the home health agency upon two (2) hours’ notice.
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(g) All personnel providing services shall maintain effective communications to ensure that their efforts appropriately complement one another and support the objectives of the resident’s care.
The means of communication and the results shall be documented in the clinical record or minutes of case conferences. -
(h) The home health agency shall coordinate its services with other health or social service providers serving the resident.
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(i) A home health agency must develop and implement a policy requiring a notice of discharge of
service to the resident, the resident’s legal representative, or other individual responsible for the resident’s care at least fifteen (15) calendar days before the services are stopped. -
(j) The fifteen (15) calendar day period described in subsection (i) does not apply in any of the following circumstances:
The health, safety, or welfare of the home health agency’s employees would be at immediate and significant risk if the home health agency continued to provide services to the resident.
The resident refuses the home health agency’s services.
The resident’s services are no longer reimbursable based on applicable reimbursement requirements and the home health agency informs the resident of community resources to assist the resident following discharge.
The resident no longer meets applicable regulatory criteria, such as lack of physician’s order, and the home health agency informs the resident of community resources to assist the resident following discharge. -
(k) A home health agency must continue, in good faith, to attempt to provide services during the
fifteen (15) calendar day period described in subsection (i). If the home health agency cannot
provide such services during that period, its continuing attempts to provide the services must be
documented.- d medical condition of the individual;
- Updated progress on meeting the goals and objectives of the ISP.
(Please refer Annexure 18 for Transfer Form)
- This is only a preview of the Original Document
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retrieval system, or transmitted in any form by any means, electronic,
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otherwise, without the prior written consent of the publisher.
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