 T A B L E O F C O N T E N T S INTRODUCTION OUR PHILOSOPHY 1DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .. . . . . . . . . 3
SECTION A - POLICIES POLICY ON COMPLIANCE WITH FEDERAL, STATE AND LOCAL LAWS. . . . . . . . . . . .A-1 STANDARDS FOR THE STRUCTURE & OPERATION OF A HOME HEALTH AGENCY. . .. . . . . . . .A4 POLICY ON ORGANIZATION, SERVICES, ADMINISTRATION CONTROL . .. . . . . .. . . . . . . . . . . A-8 POLICY ON COORDINATION OF PATIENT SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . A-10 SCOPE OF SERVICES AND SERVICES TO BE PROVIDED. . . . . . . . .. . .. . . . . . . . . . . . . . A-11 MISSION STATEMENT. . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-14 GOALS AND OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . A-15 POLICY ON PLAN OF CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . A-17 PHYSICIAN LETTER OF MEDICAL NECESSITY. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . A-18 INABILITY TO PROVIDE SERVICE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .A-19 OBJECTIVES AND SERVICES TO BE PROVIDED. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . A-21 POLICY ON GOVERNING BODY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A-22 BOARD OF DIRECTORS ORIENTATION. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . A-24 GOVERNING BODY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .. . . . . .. . A-25 MEDICAL DIRECTOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . A-26 PROFESSIONAL ADVISORY COMMITTEE A-27 ADVISORY COMMITTEE A-29 DELEGATION OF AUTHORITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-30 MANAGEMENT RESPONSIBILITIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . A-31 MANAGEMENT STAFF FUNCTIONS . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . .A-32 PLANNING PROCESS . . . . . . . . . . . . A-36 POLICY ON ADMINISTRATION A-38 BOARD OF DIRECTORS CONFLICT OF INTEREST A-39 SUPERVISORY PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-40 POLICY ON SUPERVISING PHYSICIAN OR REGISTERED NURSE . . . . . . . . . . . . . .. . . . . . . . . . .A-42 POLICY ON PATIENT VISITS A-43 POLICY ON RECORD KEEPING BY HOME HEALTH AIDES A-44 POLICY ON CLINICAL RECORD KEEPING A-45 HEPATITIS B VACCINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-46 HEPATITIS B DECLARATION FORM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-47 HIV AND HEPATITIS INFORMATION SHEET . . . . A-48 STANDARD PRECAUTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . A-50 UNIVERSAL PRECAUTIONS . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . A-51 TRANSPORTATION RESPONSIBILITY CONTRACT . . . . . . . . . . . . . . . . .. . . . . . . . .. . . . . . . . A-53 INFECTION CONTROL ACKNOWLEDGMENT . . . . . A-54 POLICY DURING THE ABSENCE OF THE ADMINISTRATOR . . . . . . . . . . . . . . . . . . . . . . . . . .A-55 POLICY DURING THE ABSENCE OF THE DIRECTOR OF NURSING . . . . . . . . . . . . . . . . . . . A-56 POLICY ON ADVANCE DIRECTIVES . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .A-57 ON CALL AND EMERGENCY SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-58 ON CALL DUTIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-59 EMERGENCY MANAGEMENT PLAN . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .A-60 DISASTER PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A-62 EMERGENCY MEASURES TO HANDLE BELLIGERENT CLIENT .. . . . . . . . . . . . . . . . . . . . . . . A-66 HANDLING BARRIERS TO COMMUNICATION POLICY AND PROCEDURES. . . . . . . . . . . . . .. A-67 AUXILIARY AIDS AND PERSONS WITH DISABILITIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-68 POLICY ON OASIS ENROLLED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-69 POLICY ON HIPAA ENROLLED . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A-71 CONFIDENTIALITY/PRIVACY OF PERSONAL HEALTH INFORMATION (PHI) POLICY. . . . . . . . . A-72 CONFIDENTIALITY STATEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-75 FAX PRIVACY POLICY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .A-76 PERSONAL HEALTH INFORMATION, PLEDGE OF CONFIDENTIALITY . . . . . . . . . . . . . . . . . . . A-78 PUBLIC DISCLOSURE A-79 STAFF CONFLICT OF INTEREST A-80 STATEMENT PRINCIPLE RELATING DISCLOSURE OF CONFLICTS OF INTEREST.. . . . . . . . . A-81 INDIVIDUAL STATEMENT REGARDING CONFLICT OF INTEREST A-82 STATE REGULATORY REQUIREMENTS A-83 INFORMATION MANAGEMENT SYSTEMS A-84 DATA COLLECTIONS AND REVIEWS . . . . . . . . . . . . . . . . . . . . . . . . A-86 LEGAL REQUIREMENTS A-88 ASSIGNMENTS AND STAFFING A-89 ADMINISTRATIVE RECORDS AND REPORTS A-90 RECORD POLICIES/CONFIDENTIALITY, RELEASE OF INFORMATION A-91 SENSITIVE PATIENT INFORMATION . . . . . . . . . . .. . . . A-97 PROTECTION OF DATA IN THE MANAGEMENT INFORMATION SYSTEM . . . . . . . . . . . . . . . A-98 PROTECTION AND RETENTION OF AGENCY DOCUMENTS . . A-99 VERIFICATION OF PHYSICIAN LICENSE A-101 CONSENT PRACTICES A-102 REFUSAL OF CARE A-103 COMPUTER FILES BACKUP A-104 CLIENT LIST A-105 CHANGE OF CONDITION ASSESSMENT A-106 RESTORATIVE NURSING A-107 CONTINGENCY PLAN A-108 COMPUTER USAGE POLICY A-109 MEDICARE’S ADVANCE BENEFICIARY NOTICE A-111 NOT TAKEN UNDER CARE A-113 ABN ADDITIONAL DIRECTIONS A-115 ILLEGAL REMUNERATION A-117 PATIENTS WITH ALZHEIMER'S DISEASE OR OTHER RELATED DISORDERS; STAFF TRAINING REQUIREMENTS A-118 DISCONTINUING OPERATIONS . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . A-119 EMPLOYEE’S RIGHTS AND RESPONSIBILITIES. . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .A-120 EMPLOYEE’S CODE OF CONDUCT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A-122COMPLIANCE PROGRAM A-123
SECTION B - PERSONNEL/OPERATIONS POLICIES POLICY ON PERSONNEL POLICIES B-1 PERSONNEL POLICY STATEMENTS B-2 APPLICATION EMPLOYMENT PROCESS B-5 EMPLOYEE IDENTIFICATION. . . . . .. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .B-7 POLICY AND PROCEDURE DRESS CODE B-8 POLICY ON EMPLOYEE EVALUATION B-9 EMPLOYEE EVALUATION SHEET - ANNUAL B-11 PERFORMANCE EVALUATION B-12 PERSONNEL POLICIES SAFE AND ADEQUATE CARE OF THE PATIENT B-15 PATIENT SAFETY CHECKLIST B-16 HOME SAFETY PATIENT’S HOME ENVIRONMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-17 POLICY ON HIRING/REFERENCES B-19 REFERENCE FOR POTENTIAL EMPLOYEE B-21 POLICY ON MEDICAL EXAMINATION CERTIFICATE B-22 MEDICAL EXAMINATION CERTIFICATE B-23 POLICY AND PROCEDURE EMPLOYEE ORIENTATION B-24 POLICY AND PROCEDURE STATEMENT OF ORIENTATION COMPLETION B-25 POLICY ON ORIENTATION ADDITION - 8 HR ORIENTATION B-26 POLICY ON JOBS B-27 POLICY ON PERSONNEL UNDER HOURLY OR PER VISIT CONTRACT B-28 POLICY SICK LEAVE B-29 POLICY AND PROCEDURE EMPLOYEE HEALTH . . . . . . . . . . . B-30 SCREENING FOR GOOD MORAL CHARACTERS/SCREENING OF HOME HEALTH PERSONNEL . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-31 POLICY ON HIRING AND FIRING B-32 STAFF RECRUITMENT . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . .B-33 JOB POSTING . . . . . . . . . . B-34 NOTICE OF JOB OPENING. . . . . . . .. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . B-35 JOB INTERVIEWS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-36 HOME HEALTH CARE AGENCY INTERVIEW INFORMATION . . . . . . . . . . . . . . . . . . . . B-37 OUTCOME OF APPLICATION INTERVIEW FOR STAFF POSITION . . . . . . . . . . . . . . . . B-38 LICENSURE RENEWAL B-39 MEAL PERIOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-40 TERMINATION OF EMPLOYMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-41 INVOLUNTARY TERMINATION OF EMPLOYMENT . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-43 RESIGNATION OF EMPLOYMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-45 RESIGNATION NOTICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-46 TRANSFER REQUEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-47 TRANSFER REQUEST FORM . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-48 EXEMPT EMPLOYMENT STATUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-49 DISCIPLINE OF HOME HEALTH CARE STAFF MEMBER . . . . . . . . . . . . . . . . . . . . . . . B-50 EMPLOYEE WARNING/SUSPENSION/REINSTATEMENT/TERMINATION . . . . . . . . . B-52 HOME HEALTH CARE AGENCY STAFF CONCERN . . . . . . . . . . . . . . . . . . . . . . . . . . . B-53 HOME HEALTH CARE AGENCY INAPPROPRIATE BEHAVIOR DOCUMENTATION . . . . .B-55 EXIT INTERVIEW FOR HOME HEALTH CARE STAFF MEMBERS . . . . . . . . . . . . . . . . .B-56 ACCIDENT/INCIDENTS OF STAFF MEMBER . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . B-57 EMPLOYEE ACCIDENT/INCIDENT REPORT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-59 CONSENT FORM TO RELEASE PHYSICAL EXAMINATION/CRIMINAL BACKGROUND SCREENING DATA FORM . . . B-60 PAYROLL SYSTEM . . . . . . . . . . . . . . . . . . .. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . B-61 SALARY CHANGES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . .. . . . B-62 POLICY ON PATIENT VISITS AND CONSULTATION WITH A PHYSICIAN B-63 POLICY AND PROCEDURE CONTINUING EDUCATION B-64 PERSONNEL LICENSURE B-65 CRITERIA USED WHEN ASSIGNING NURSING PERSONNEL B-66 POLICY ON MONITORING OF CONTRACTED SERVICES B-67 POLICY ON "INSTITUTIONAL PLANNING" B-68 POLICY ON ANNUAL OPERATING BUDGET B-69 POLICY ON CAPITAL EXPENDITURES PLAN B-70 POLICY ON BOARD MEMBERSHIP B-71 ORGANIZATIONAL PHILOSOPHY . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . B-72 ORGANIZATIONAL CHART B-73 POLICY ON ANNUAL REVIEW OF PLAN AND BUDGET B-76 POLICY ON PROFESSIONAL PERSONNEL B-77 SELF-EVALUATION COMMITTEE MEETING B-78 POLICY ON ACCEPTANCE OF PATIENTS B-79 DISCHARGE OF PATIENTS B-80 POLICY ON PLAN OF CARE, MEDICAL SUPERVISION B-82 POLICY ON PERIODIC REVIEW OF PLAN OF TREATMENT B-84 RECERTIFICATION PROCESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-85 ANTI-HARASSMENT POLICY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B-86 POLICY ON PATIENT TRANSFER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B-88 BACK-UP STAFFING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B-90 CONTRACTOR BACK-UP SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-91 BACK-UP SERVICES POLICY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-92 BACK-UP SERVICE AGREEMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-93 CERTIFICATE OF WAIVER CLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-94 VOLUNTEERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-95 HEPATITIS C (HCV) EDUCATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-96 STAFF COMPETENCY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-97 MISSED VISIT POLICY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-98 EQUAL OPPORTUNITY EMPLOYMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . B-99 WORK RELATED INJURIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-100 WORKERS’ COMPENSATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B-102 RETENTION OF PERSONNEL RECORDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B-104STAFF SAFETY AT WORK . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-105 SITUATIONS WITH POTENTIAL FOR VIOLENCE . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .B-108 EQUIPMENT SAFETY . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-110 DRUG FREE WORKPLACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-111 EMPLOYEE DATABASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-113 EMPLOYMENT CATEGORIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-114 IMMIGRATION REFORM AND CONTROL ACTS (I-9) . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .B-116 INTRODUCTORY PERIOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-117 PRN STATUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .B-118 PRN QUESTIONNAIRE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-119 EXPENSE REPORTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-120 GARNISHMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-121 HOLIDAY PAY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-122 MEETING AND IN-SERVICE TIMES. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .B-123 MILEAGE REIMBURSEMENT/TRAVEL TIME . . . . . . . . . . . . . .. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .B-124 OVERTIME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-126 PAY PERIOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-127 TIMESHEETS/DVR’S . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-128 NOTICE OF RIGHT TO ELECT CONTINUATION COVERAGE . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .B-130 COBRA BENEFIT CONTINUATION. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-132 CONTINUING EDUCATION UNITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .B-133 DENTAL INSURANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-134 MEDICAL INSURANCE .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-135 PAID TIME OFF (PTO) . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-137 TIME OFF REQUEST FORM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .B-139 FAMILY/MEDICAL LEAVE OF ABSENCE . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .B-140 FAMILY/MEDICAL LEAVE OF ABSENCE REQUEST FORM .. . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .B-144 JURY DUTY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-145 MILITARY LEAVE OF ABSENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-146 PERSONAL LEAVE OF ABSENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .B-148 ABUSE INVESTIGATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .B-149 ATTENDANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-150 AUTOMOBILE USAGE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .B-151 EMPLOYEE COUNSELING AND GRIEVING. . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .B-154 PERFORMANCE NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . B-155 EMPLOYEE PERFORMANCE IMPROVEMENT PLAN . . . .. . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .B-156 PERSONAL CONDUCT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .B-157 SECURITY INSPECTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-159 SUBSTANCE ABUSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-160 WORKPLACE VIOLENCE PREVENTION . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .B-163 DRUG AND ALCOHOL TESTING . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-165 HEALTH REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .B-169
SECTION C - SKILLED NURSING SERVICE POLICY ON SKILLED NURSING SERVICE C-1 NURSING PHILOSOPHY AND OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-2 POLICY ON EMERGENCY PROCEDURES C-3 POLICY ON NURSES' NOTES C-4 POLICY ON THERAPY SERVICES C-5 POLICY ON MEDICAL SOCIAL SERVICES C-6 POLICY ON HOME HEALTH AIDE SERVICES C-7 POLICY ON SUPERVISING VISITS C-8 POLICY ON CLINICAL RECORDS C-9 POLICY ON RETENTION OF RECORDS C-11 POLICY ON PROTECTION OF RECORDS C-12 RELEASE OF INFORMATION FROM CLINICAL RECORDS . . . . . . . . . . . . . . . . . . . . C-13 AUTHORIZATION FOR RELEASE OF INFORMATION . . . . . . . . . . . . . . . . . . . . . . . . C-14 CLIENT’S SUMMARY REPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-15 CLINICAL RECORDS - SUMMARY REPORTS C-16 DISCHARGE PLANNING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . C-17 DISCHARGE PLANNING CONTROL LOG . . . . . . . . . . . . . . . .. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .C-19 SECURITY OF RECORDS/CONFIDENTIALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-20 FILE MOVEMENT REGISTER C-21 MEDICAL RECORD CORRECTION POLICY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-22 REPORTING MEDICAL DEVICE EVENTS . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . C-26 MEDICAL DEVICE INCIDENT REPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-28 ILLNESS AND INJURY PREVENTION . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .C SECTION D - EVALUATION OF AGENCY'S PROGRAM POLICY ON EVALUATION OF AGENCY'S PROGRAM D-1 PLAN FOR IMPROVE AGENCY PERFORMANCE . . . . . . . . . . . . . . . . . D-2 THE KEY TO "QUALITY ASSURANCE" D-8 POLICY AND PROCEDURES QUALITY ASSURANCE D-9 QUALITY ASSURANCE EVALUATION D-10 PATIENT SATISFACTION SURVEY. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . D-11 QUALITY ASSURANCE EVALUATION FORM PATIENT/FAMILY QUESTIONNAIRE . . . . . . . . . . . . D-12 FAMILY QUESTIONNAIRE (SPANISH VERSION) D-13 QA QUESTIONNAIRE SUMMARY TABLE D-14 QUALITY ASSURANCE FORM PHYSICIAN QUESTIONNAIRE D-15 POLICY AND PROCEDURE FOR CHART REVIEW D-16 CLIENT’S CLINICAL RECORD DISCHARGE ANALYSIS . . . . . . . . . . . . . . . . . . . . . .. .D-17 QUALITY ASSURANCE FORM FOR REVIEW OF CLINICAL RECORDS D-18 NOTIFICATION OF CLIENT’S CLINICAL RECORD DEFICIENCIES . . . . . . . . . . . . . . .D-20 PATIENT CARE PLAN D-21 HOME HEALTH CARE AGENCY ANNUAL REVIEW. . . . . . . . . . . . . . . . . . . . . . . . . . .D-22 ANNUAL EVALUATION FOR THE HOME HEALTH CARE AGENCY . . . . . . . . . . . . . . . D-24 POLICY AND PROCEDURE BOMB THREAT D-29 POLICY AND PROCEDURE HURRICANE/TORNADO WARNINGS D-30 POLICY ON DISPENSING FLUIDS TO CONFUSED PATIENTS D-32 URINARY CATHETER POLICY D-33 POLICY AND PROCEDURE FOR DENTURES D-34 FURTHER POLICIES & PRACTICES TO ENSURE PATIENT AND STAFF SAFETY D-35 POLICY ON HOME HEALTH AIDE IN-SERVICE TRAINING D-36 POLICY ON HOMEMAKER TRAINING D-37 POLICY ON EXPERIMENTAL DRUGS D-38 POLICY ON GOALS OF A PLAN OF TREATMENT D-39 BED SIDERAIL POLICY D-40 POLICY ON PATIENT'S PROGRESS NOTES D-41 PROGRESS NOTES QA CHECK LIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D-42 SIGN-UP PACKAGE CHECK LIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-43 POLICY ON WASTE DISPOSAL D-44 DISPOSING OF SYRINGES AND CONTAMINATED DRESSINGS. . . . . . . . . . . . . . . . . D-46 POLICY ON ACCOUNTING D-47 POLICY ON MISREPRESENTATION D-48 POLICY ON STERILE DRESSINGS D-49 POLICY ON SOILED DRESSINGS D-50 POLICY ON NON-DISCRIMINATION D-51 POLICY ON DRUG ORDERS AND CHANGES IN ORDERS D-52 POLICY ON MODIFY ORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . D-53 ORDER FOR DRUGS D-54 POLICY ON PLANNING D-55 POLICY ON HOME HEALTH AIDE SUPERVISION . . . . . . . . . . . . . . . . . . . . . . . . . . D-56 POLICY ON TYPE OF TRAINING REQUIRED OF HOME HEALTH AIDES D-57 POLICY ON COURTESY TITLE D-58 POLICY ON ADMISSION D-59 POLICY ON MEDICATION ERRORS AND DRUG REACTION POLICY . . . . . . . . . . . . . . . D-61 MEDICATION ASSESSMENT PROTOCOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-62NARCOTICS POLICY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-63 POLICY ON VERIFICATION OF SELF-ADMINISTERED MEDICATIONS . . . . . . . . . . . . . D-64 BIOMEDICAL WASTE PROTOCOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-65 POLICY AND PROCEDURE FOR BIOMEDICAL WASTE PICKUP . . . . . . . .. . . . . . . . . . .D-72 REORDERING SUPPLIES AND BIOHAZARDOUS WASTE CONTAINER . . . . . . . . . . . . D-73 ADMINISTRATION OF DRUGS AND BIOLOGICALS . . . . . . . . . . . . . . . . . . . . . . . . . . . D-74 UTILIZATION REVIEW. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . D-76 CLINICAL RECORD/UTILIZATION REVIEW . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . D-77 EMPLOYEE SATISFACTION SURVEY . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . D-78 QUALITY ASSESSMENT/PERFORMANCE IMPROVEMENT PLAN . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . D-80QUALITY IMPROVEMENT STAFF . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .D-81
SECTION E - TITLE VI OF CIVIL RIGHTS ACT OF 1964 POLICY ON COMPLIANCE WITH TITLE VI OF CIVIL RIGHTS ACT OF 1964 . . . . . . . E-1POLICY ON GRIEVANCE PROCEDURE (SECTION 504) . . . . . . . . . . . . . . . . . . . . . . E-2 CLIENT’S BILL OF RIGHTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-4 POLICY ON PERSONS WITH CONFIRMED OR SUSPECTED DISABLING OR INFECTIOUS DISEASES, INCLUDING AIDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-5 AFFIRMATIVE ACTION POLICY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-8 AMERICANS WITH DISABILITIES ACT (ADA) . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .E -9POLICY AND PROCEDURE FOR COMMUNICATING INFORMATION TO PERSONS WITH LIMITED ENGLISH PROFICIENCY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-10POLICY AND PROCEDURE FOR COMMUNICATING INFORMATION TO PERSONS WITH SENSORY IMPAIRMENTS . .E-11
SECTION F - OVERALL PLAN AND BUDGET POLICY ON BUDGET . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . F-1 FINANCIAL MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . F-2 FINANCIAL PLANNING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . F-3 FINANCIAL PLANNING LIST OF RESPONSIBILITIES . . . . . . . . . . . . . . . . . . . . . . . . . . . F-4 INCOME AND EXPENSE PROJECTION FOR THREE FISCAL YEARS. . . . . . . . . . . . . . . . F-6 POLICY ON WAGE SCALES AND CHARGES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .F-7 PATIENT CHARGES FOR OUR SERVICES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .F-8 CAPITALIZATION, DEPRECIATION AND AMORTIZATION F-9 CAPITALIZATION POLICY F-10 FINANCIAL ELIGIBILITY CRITERIA F-11 INSURANCE CASES AND PRIVATE PAY F-12 REDUCED AND NO-FEE SERVICES F-13 INVENTORY/FIXED ASSETS F-14 PROCEDURE TO ENSURE ACCURATE BILLING AND INSURANCE CLAIMS F-15 PAYMENT RECEIPT AND VERIFICATION F-16 BILLING, PAYROLL AND INVOICE INPUT F-18 REVIEW AND COLLECTION OF ACCOUNTS RECEIVABLE F-20 ACCOUNTS RECEIVABLE RECONCILIATION F-21 FEE SETTING AND COLLECTION POLICY F-22 REFUNDS F-23 INSURANCE AND BONDING F-24 UNCOMPENSATED CARE INDIGENT PATIENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . .F-25 BAD DEBT POLICY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .F-26 CHARGE VERIFICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .F-27 MEDICARE CREDIT BALANCE REPORT . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .F-28 MEDICARE DENIALS AND ADDITIONAL DOCUMENTATION (ADRs) .. . . . . . . . . . . . . . . . . . . . . . . . . .F-29 PURCHASING AND ACCOUNTS PAYABLE . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .F-30 MEDICAL SUPPLIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .F-31
SECTION G - CONTRACTS & AGREEMENTS CONTRACTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . G-1 POLICY ON SERVICES UNDER ARRANGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G-3 CONTRACT AGREEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . ..G-4 CONTRACT WITH A NON-LICENSED PROVIDER . . . . . . . . . . . . . . . . . . . . . . . . . G-6 SERVICES AGREEMENT WITH OTHER HEALTH CARE FACILITIES . . . . . . . . . .. . .G-8 CONTRACT (STAFF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G-9 INDEPENDENT CONTRACTOR AGREEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G-11 MEDICAL DIRECTOR AGREEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G-13 BUSINESS ASSOCIATE CONTRACT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G-15
SECTION H - BYLAWS BY-LAWS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . .H-1ADMINISTRATIVE POLICY . . . . . . . . . . . . . . .. . . . . . . . . . . . .. . . . . . . . . . . . . . . . H-2 HOME HEALTH SERVICES PROVIDED MEDICARE/MEDICAID/RECIPIENTS. . . . . . . . . . . . . . H-3 HOW TO ORDER HOME HEALTH SERVICES/REFERRAL PROCEDURES . . . . . . . . . . . . . . .. . . H-7 INFORMATION TO OUR PATIENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .H-8
SECTION I - JOB DESCRIPTIONS JOB DESCRIPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .I-1DIRECTOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-2 CHIEF OPERATING OFFICER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-5 ADMINISTRATOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-7 DIRECTOR OF NURSING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .I-9 FIELD REGISTERED NURSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .I-11 PSYCHIATRIC NURSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-13 HOME HEALTH AIDE / CNA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-14 POLICY ON SELECTION OF HOME HEALTH AIDE . . . . . . . . . . . . . . . . . . . . . . . . . .I-16 COMPANION OR SITTER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-17 HOMEMAKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-18 MEDICAL SOCIAL WORKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .I-19 PHYSICAL THERAPIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .I-20 PHYSICAL THERAPIST ASSISTANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-21 OCCUPATIONAL THERAPIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . I-23 OCCUPATIONAL THERAPIST ASSISTANT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-24 RESPIRATORY THERAPIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-26 LICENSED PRACTICAL NURSE . . . . . . .. . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . I-27 SPEECH THERAPIST . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . I-28 ALTERNATE DIRECTOR OF NURSING . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .I-29 ADMINISTRATOR ASSISTANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-31 NURSE FIELD SUPERVISOR . . . . . . . . . . . . . . . . . .. .. . . . . . . . . . . . . . . . . . . . .I-32 PATIENT/CLIENT REPRESENTATIVE . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . I-33 BILLING CLERK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .I-35 PATIENT CARE MANAGER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .I-37 OFFICE CLERK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-39 ALTERNATE ADMINISTRATOR . . . . . . . . . . . . . . . .. . . . . . . . . . . . .. . . . . . . . . . I-40 SUPERVISOR CLINICAL QUALITY IMPROVEMENT. .. . . . . . . . . . . . . . . . . . . . . . I-42 REGISTERED NURSE HIGH TECH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-45 DIETITIAN/NUTRITIONIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-48 OFFICE MANAGER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-49 SECRETARY/TYPIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-50 MEDICAL DIRECTOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-51 CODER/WORKFLOW COORDINATOR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-52 REFERRAL SERVICES ASSISTANT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-54 QUALITY ASSURANCE/PERFORMANCE IMPROVEMENT . . . . . . . . . . . . . . . . . . . . I-55 HUMAN RESOURCES SPECIALIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-57 CHIEF FINANCIAL OFFICER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-58 DIRECTOR OF HUMAN RESOURCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-59 GENERAL MANAGER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-61 COMMUNITY HEALTH PEDIATRIC REGISTERED NURSE . . . . . . . . . . . . . . . . . . . . I-63 MEDICAL SOCIAL WORK ASSISTANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-65 MEDICAL RECORD MANAGER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-67 MEDICAL RECORD ASSISTANT/CLERK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-69 COMMUNITY LIAISON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-71 REFERRAL HOSPITAL LIAISON. . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-73 COMMUNITY EDUCATION/LIAISON/OUTREACH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-75
SECTION L - INITIAL ASSESSMENT INITIAL NURSING ASSESSMENT/TEAM CONFERENCE . . . . . . . . . . . . . . . . . . . . . L-1 TEAM CASE CONFERENCE PROCEDURE . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . L-2 CLIENT’S CASE CONFERENCE . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . L-3 CLIENT’S CASE MANAGEMENT . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . L-5 CASE MANAGEMENT NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . L-8 CASE MANAGEMENT, CARE COORDINATION, COMMUNICATION NOTE . . . . . . . . L-9 CLIENT NUTRITIONAL STATUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .L-10 NUTRITION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-11 DO NOT RESUSCITATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .L-12 RESUSCITATION ORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-13 ASSESSMENT OF POSSIBLE ABUSE/NEGLECT. . . . . . . . . . . . . . . . . . . . . . . . . . . L-14 SAFETY IN THE HOME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .L-16 SAFETY CLIENT SETTING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .L-19 HOME SAFETY ASSESSMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-20 SAFETY GUIDELINES MEDICAL EQUIPMENT AND SUPPLIES. . . . . . . . . . . . . . . . . L-21 SAFETY PROGRAM, SAFE LIFTING. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . L-23 PREVENTION OF ACCIDENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-24 PATIENT INFORMED DECISION MAKING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . L-25 CONSENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-26 REINSTATEMENT / RESUMPTION OF CARE POLICY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-28SECTION M - MISCELLANEOUS POLICY ON EMPLOYEE TIME SLIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-1 CHANGES IN ASSIGNMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . M-2 POLICY SMOKE FREE ENVIRONMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-3 DURABLE POWER OF ATTORNEY FOR HEALTHCARE (WARNING) . . . . . . . . . . . . . . . . . . . . . . M-4 DURABLE POWER OF ATTORNEY FOR HEALTHCARE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-6 STATEMENT OF WITNESSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .. . . . M-8 DECLARATION TO WITHDRAW/WITHHOLD TREATMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-10 SECTION J - NURSING MANUAL OBJECTIVES OF NURSING CARE J-1 POLICY FOR NURSES NOTES, HINTS AND PATIENT’S TRAINING . . . . . . . . . . .. . . . . . . . . J-2 THE NURSING PROCESS J-3 ACCIDENTS J-4 COMPLAINTS J-5 PROCEDURE FOR THINNING CHARTS J-6 LEGAL ASPECTS OF CHARTING J-7 DESCRIPTIVE TERMS COMMONLY USED IN CHARTING . . . . . . . . . . . . . . . . . . . . .. . . . . . J-9 CLIENT’S CLINICAL RECORD FILING SYSTEM . . . .. . . . . . . . . . . . . . . . . . . .. . . . . . . J-26 CLIENT’S CLINICAL RECORD NUMBERING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .J-27 HOME CARE INFUSION THERAPY POLICY AND PROCEDURE . . . . . . . . . . . . . . . . . . . . . . . . .J-28 HOME IV THERAPY POLICY AND PROCEDURE . . . . . . . . . . . . . . . . . . . . . . . .J-29 HOME INFUSION NURSE RESPONSIBILITIES POLICY AND PROCEDURE. . . . . . . . . . J-33 INITIATION, MEDICATION, ADMINISTRATION, MONITORING & DISCONTINUATION OF IV THERAPY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . J-34 INFUSION THERAPY POLICY AND PROCEDURE . . . . . . . . . . . . .. . . . . . . . . . . . . . . . J-35 IV COMPETENCY SKILLS POLICY AND PROCEDURE . . . . . .. . . . . . . . . . . . . . . . J-36 IV COMPETENCY SKILLS . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . . . . . . . . . . J-37 ANAPHYLAXIS PROTOCOL POLICY AND PROCEDURE . . .. . . . . . . . . .. . . . . . . . . . . . . . . . . . . J-39 MEDICATION ADMINISTRATION . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . . . . . . . . . . J-40 MEDICATION PROFILE/MEDICATION MONITORING . . . . . . . . . . . .. . . . . . . . . . . . . . . J-41 POSSESSION OF STERILE WATER . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-42 MULTIDISCIPLINARY PATIENT EDUCATION . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . J-45 PATIENT EDUCATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-46 PATIENT INSTRUCTION SHEET OXYGEN CONCENTRATOR . . . . . . . . . . . . . . . . . . . . . . . . . . . J-50 MEDICATION TRANSFER COMMUNICATION . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . .J-53 SENTINEL EVENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-57
SECTION K - NURSING CARE & PROCEDURES TREATMENT FOR LICE K-3 OTHER INFECTION CONTROL MEASURES K-4 ORDERING OF SUPPLIES K-5 GUIDE FOR NURSING CARE PLAN K-6 DRUG DISTRIBUTION AND CONTROL K-7 STANDARD TIMES FOR MEDICATIONS K-8 PROCEDURE FOR DISPENSING FLUIDS TO CONFUSED PATIENTS K-9 OXYGEN PROCEDURES . . . . . . . . .. . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . K-10 TERMS USED IN NURSING K-11 HAND WASHING K-12 ISOLATION EQUIPMENT K-13 GOWN TECHNIQUE K-14 SPECIMEN COLLECTION K-15 CLEANSING ENEMA K-17 REMOVAL OF FECAL IMPACTION K-18 RETENTION ENEMA . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .K-19 EMERGENCY MEASURES FOR EPILEPTIC SEIZURES OR CONVULSIONS K-20 INTERMITTENT POSITIVE PRESSURE BREATHING K-21 PREVENTION & TREATMENT OF DECUBITUS K-22 PROCEDURE FOR DRESSING CHANGE K-23 FEEDING A PATIENT BY NASAL OR GASTROSTOMY TUBE K-24 INSERTION OF LEVINE TUBE K-25 LEVINE TUBE FEEDING K-26 TESTING DIABETIC URINE K-27 GENERAL GUIDELINES FOR GLUCOMETER QUALITY CONTROL TESTING . . . . . . . . . . . . . . . K-28 USE OF BLOOD GLUCOSE METERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . K-29 BLOOD GLUCOSE MONITORING . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . K-31 GENERAL GUIDELINES FOR DOCUMENTATION OF QUALITY CONTROL RESULTS . . . . . . . . K-32 URINARY CATHETERS K-33 APPLYING AN EXTERNAL CATHETER K-34 APPLICATION OF FOLEY DRAINAGE BAG K-35 APPLICATION OF LEG DRAINAGE BAG . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . K-36 FOLEY CATHETER IRRIGATION K-37 COLOSTOMY CARE K-38 CLEANSING ARTIFICIAL DENTURES K-39 SAFE WAYS OF TRANSFERRING YOUR PATIENTS K-40 BLIND PERSONS, AIDING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .K-41 GOING TO DOCTOR’S OFFICE FOR APPOINTMENT . . . . . . . . . . . . . . . . . . . . . . . . . . K-42 AMBULATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .K-43 TURNING A PATIENT K-45 POSITIONING K-46 MOVING PATIENT UP IN BED K-47 GETTING PATIENT IN/OUT OF BED K-48 ASSISTING PATIENT INTO AND OUT OF WHEELCHAIR K-49 ASSISTING PATIENTS ONTO AND OFF STRETCHER K-50 HOW TO UNDRESS A PATIENT K-51 HOW TO USE BED CRADLES K-52 HOW TO USE RUBBER RINGS, DOUGHNUTS, SANDBAGS K-53 APPLICATION OF COLD SPONGES K-54 APPLICATION OF ICE BAG K-55 COLD COMPRESSES/EYE K-56 APPLICATION OF HOT WATER BOTTLE K-57 HOW TO GIVE EARLY MORNING AND H.S. CARE K-58 PARTIAL BATH K-59 BED BATH K-60 HOW TO GIVE TUB BATH OR SHOWER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . K-62 SITZ BATH K-63 ORAL HYGIENE K-64 BACK RUB K-65 SHAVING THE FACE OF THE MALE PATIENT K-66 HOW TO CARE FOR THE HAIR K-67 MAKING AN UNOCCUPIED BED K-68 MAKING AN OPEN BED K-69 MAKING AN OCCUPIED BED K-70 NURSING PROCEDURES FOR THE DYING K-71 POST MORTEM CARE K-72 CARE OF THE DYING K-73 INFECTION CONTROL K-74 PERSONNEL INFECTION CONTROL K-75 POST EXPOSURE EVALUATION AND FOLLOW-UP PROCEDURES . . . . . . . . . . . . . . . . . . . . . . K-76 EXPOSURE CONTROL PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . K-78 HOME CARE ACQUIRED INFECTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .K-82 INFECTION CONTROL ORIENTATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . K-85 ANNUAL INSERVICE FOR INFECTION CONTROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .K-86 EMPLOYEE EXPOSURE INCIDENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . K-87 AIDS K-90 PROCEDURE ON ORDER LABS TEST . . . .. . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . K-93 PROCEDURE FOR 60 DAY SUMMARIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . K-94 PROCEDURE FOR WOUND/DECUBITUS SUMMARIES . . . . . . . . . . . . . . . . . . . . . . . . K-96 GUIDELINES FOR MAINTENANCE OF PERIPHERAL IV SITES & CENTRAL LINES .K-97 PROCEDURE HICKMAN CATHETER DRESSING CHANGE . . . . . . . . . . . . . . . . . . . .K-101 TRIPLE LUMEN CVP CATHETER PROCEDURE . . . . . . . . . . . . . . . . . . . . . . . . . . . .K-103 GROSHONG CATHETER PROCEDURE . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . .K-104 NEEDLE SAFETY AND PREVENTION OF INJURY . . . . . . . . . . . . . . .. . . . . . . . . . . . . .. . . . . K-105 USE OF THERMOMETER . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .K-108 FALLS POLICY . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . K-111 FALL RISK ASSESSMENT FORM . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . K-114 FALL RISK SCREENING TOOL . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .K-115 REQUEST FOR PHYSICIAN’S ORDERS TO DEAL WITH FALLS . . . . . . . . . . . . . . . . . . . . .. . . . .K-116 INCIDENT REPORT FALLS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . K-117 EMERGENT CARE FOR INJURY CAUSED BY FALL OR ACCIDENT AT HOME REVIEW TOOL . . . . . .. . . . . . . . . K-118 ABBREVIATIONS . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . K-120 DANGEROUS ABBREVIATIONS OR DOSE DESIGNATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . K-124
CLINICAL PROCEDURES Table of Contents
PROCEDURE PAGE
Ambulation 1 Allergic and Anaphylactic Reaction 3 Anaphylaxis Medication Recommendation 4 Anaphylaxis Treatment Guidelines 5 Arm Sling Application 8 Arteriovenous Fistula Assessment 9 Automatic Lancing Device 10 Backrub 11 Bed Bath 12 Bag Technique 14 Bedpan 15 Bladder Irrigation 17 Bladder Training 19 Blood Glucose Testing 20 Blood Pressure 21 Bowel Training Program 23 Calibrating & Cleaning Blood Glucose Meter 24 Catheter Care 25 Catheter Care-Suprapubic Catheter 27 Catheterization 28 Condom Catheter Application 31 Dangling Legs 33 Ear Irrigation 34 Elastic Stocking Application 36 Enema Administration 37 Enteral Tubes- Unclogging 38 Eye Drop Instillation 40 Eye Irrigation 42 Fecal Impaction-Removal 43 Feedings 45 Feeding-Enteric 46 First Dose Medication Administration 48 First Dose Registration Form 50 Foot Care 51 Gastric Residual Check 52 Gastric Tube Stabilization and Dressing 54 Gastrostomy Tube Care 55 Hair and Scalp Care 56 Handwashing 57 Heel Stick 58 Hot Water Bottle 59 Icebags 60 Infusion Therapy Administration 61 Intake and Output 65 Intramuscular Injections 66 Intravenous Access Device Maintenance 68 Jejunostomy Tube Stabilization & Dressing Change 71 Leg Bag Application 73 Manual Resuscitation Bag 74 Medication Administration (NG or GI) 75 Nail Care 77 Nasal Oral Pharangeal Suctioning 78 Nose Drop Instillation 80 Nasogastric Tube Placement 81 Nasogastric Tube Removal 83 Nasogastric Stabilization 84 Nostril Care 85 Oral Hygiene 86 Overbed Cradle 88 Ostomy Appliance Care 89 Ostomy-Colostomy Irrigation 90 Pericare 91 Peripheral Venipuncture Blood Draw 92 Positioning 94 Postural Drainage & Percussion 95 Pulse 96 Pulse Oximetry 98 Range of Motion 99 Rectal Suppository Administration 103 Respirations 104 Rectal Tube Insertion 105 Removal of PICC Line 106 Seizure Precautions 108 Shampoo Clients Confined to Bed 109 Shampoo Clients Not Confined to Bed 110 Shaving Male Patient 111 Sitz Bath 113 Skin Care 114 Sputum Collection 115 Sputum Collection-AFB 116 Storage of Solutions Left in Home 117 Subcutaneous Injections 118 Suture/Staple Removal 120 Temperature-Axillary 122 Temperature-Oral 123 Temperature-Rectal 124 Tracheostomy Care 125 Tracheostomy Tie Care 126 Tracheostomy Suctioning 128 Transfers 129 Tub Bath and Showers 132 Tuberculosis Testing 133 Unna Boot Application 135 Urinal 137 Urine Specimen Collection-Clean Catch Midstream 138 Urine Specimen Collection-Clean Catch Foley 139 Urine Specimen Collection-Urostomy 140 Use of Arm or Leg Splint 141 Vaginal Irrigation 142 Vaginal Pack Removal 143 Weight 144 Wound Care 145 Wound Culture 146 Wound Debridement 147 Wound Irrigation 149 Z Track Intramuscular Injection 150 First Dose Home IV Antimicrobial 151 Patient & Family Education Handout Hazardous Materials 156 Pain Management 157 Pain Management Education 160 Patient Assessment Functions & Qualifications 161 Patient Risk of Falls Assessment 165 Care Planning 167 Care Planning and Coordination 169 Care Plan Implementation 172 Interdisciplinary Care Planning 173 Verbal/Telephone Orders Read Back 175 Confirmation of Physician Telephone/Verbal Orders 176 Guidelines for Medical Management and Physicians Resp. 180 Coordination of services 181 Multidisciplinary Patient Education 184 Patient/Family Education Record 185 Patient & Family Education use of Restraint Devices 186 Patient Education Medical Equipment 187 Patient Instructions Sheet Cane & Quad Canes 189 Patient Instructions Sheet Walker 190 Patient Instructions Sheet Bedside Commode Procedure 191 Administration of Blood Component 192 Medication transfer Communication 195 Discontinuance of Service against Medical Advice 196 Waived Testing 197 Critical Test Result Reporting 199 Infusion Pump Safety 201 Medication Monitoring 202 Medication Safety 203 Emergency Medications 204 Adverse Drug Reaction Reporting 206 Adverse Drug Reaction Reporting Form 209 Medication Errors 210 Reducing Medication Errors 212 Use of Investigational Treatments/Trial 215 Medication Management Program 216 Controlled Drug Disposal 221 Medications – Patient Self Administration 222 Sharp Injury Protection Plan Addendum to Exposure Plan 224 Criteria to Select Safety Devices 225 Record Keeping 226 Sharp Injury Log 227 AIDS/HIV Positive Guidelines 228 Post Exposure Prophylaxis Hepatitis 229 Reporting Patient Infections 230 Antineoplastic Waste Management 232 Protective Clothing 234 Hazard Vulnerability Analysis 235
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