Policy Manual sample

MDT Home Health Care Agency, Inc. conflicts of interest; • Agency Mission Statement; • The Annual Report; • Proof of licensure; • A list of findings from the last annual licensure inspection and certification survey report (if applicable) and the list of deficiencies from any valid complaint investigation during the past 12 months; • Accreditation reports; • Policies and procedures regarding patient/client rights. Our Agency will disclose the following information to the state survey agency at the time of our initial request for certification, for each survey, at the time of any change in ownership or management, and during any other request: • The name and address of all persons with an ownership or control interest in the Agency • Disclosure of persons having controlling interest or ownership of greater than 5%. • Disclosure of persons with controlling interest, or managing employees convicted of criminal offenses against Medicare, Medicaid, or the title V (Maternal and Child Health Services) and title XX (Social Services) programs. • The name and address of each person who is an officer, a director, an agent or a managing employee of the Agency • The name and address of the corporation, association, or other company that is responsible for the management of our Agency, and the name and address of the chief executive officer and the chairman of the board of directors of our corporation, association, or other company responsible for the management of our Agency. • We will furnish updated information to CMS, state agencies and Accreditation body at intervals between re-certification, or re-enrollment, or contract renewals, within 30 days of a written request or change in authority, ownership or management. Home Health Agency Policies A-92