Policy Manual sample

MDT Home Health Care Agency, Inc. 198 WAIVED TESTING POLICY: It is the policy of this organization to instruct and train appropriately licensed personnel to perform specified types of clinical laboratory specimen testing at the point of care rendered (or at the patient’s bedside). This type of testing will be referred to as waived testing and is understood to be performed by those individuals who have the clinical expertise and licensure to perform, interpret and take appropriate action on waived tests. REQUIREMENTS: • Any test requested for inclusion in the Waived Testing Index (list of those tests that may be performed at the point where care is rendered), must be approved by the medical staff and Clinical Laboratory and must meet FDA and CLIA requirements for waived testing. • Any individual performing approved tests listed on the Waived Testing Index must meet the following requirements: • Level of licensure required by the State Board of Nursing • Level of licensure required by the State Department of Health Services • Successful completion of instruction and training course on the specific test, for which the individual will perform waived testing on an annual basis • Successful completion of orientation specific to this organization and the unit upon which the waived test is performed • Successful completion of competency evaluation on specific test, for which the individual will perform waived testing  Competency evaluation will consist of: ♦ Written evaluation of theory ♦ Direct observation of test performance by a qualified proctor ♦ Direct observation of quality control methodology (QC = equipment calibration, outdating, troubleshooting, etc.) ♦ The frequency that the staff member performs the tests. For staff who perform tests infrequently, evaluation of competency must be conducted on a quarterly basis ♦ Technical backgrounds of the staff ♦ Complexity of the test methodology and the consequences of an inaccurate result  Competency evaluation, in addition to the above, may consist of: