Policy Manual sample

MDT Home Health Care Agency, Inc. 167 • The patient’s/caregiver’s/significant other’s level of understanding and agreement to comply with the plan is documented in the medical record. • A copy of the identified risks and risk reduction plan is distributed to all healthcare team members providing care, treatment and/or services to the patient, including the physician. • The patient’s compliance with the initial risk reduction plan and potential for harm from falls, are to be assessed and documented in the record at the time of each visit and appropriate interventions implemented to decrease the potential for falls. • All patients at risk for falls and the number of reported falls are tracked and trended as part of the organization’s performance improvement program and the aggregated results are reported to the Board of Directors and Professional Advisory Committee on a quarterly basis. • Any falls that result in permanent harm or death to a patient are sentinel events and are reported to the accreditation company as per the organization’s Sentinel Event policy. • Root cause analysis is conducted on any identified variances and a plan of correction is developed, implemented and evaluated.