Policy Manual sample

MDT Home Health Care Agency, Inc. keep documentation and maintain it in a secure place within the patient’s home where he/she can access, but is not easily accessed by other people coming in and out of the home. The patient can then determine whom, if anyone, he or she would like to share the documentation with. Documentation must reflect but is not limited to the following: * The patient’s name and date of service. * Arrival and departure times. * Tasks performed / not performed * Dated signature of staff * Dated signature of patient or other representative verifying service was completed. * Documentation must be completed by the staff and signed by the patient by the end of the visit in which services were rendered. Maintaining well organized documentation within the patient’s home gives the patient a sense that the staff is committed to professionalism and delivering quality care. Maintaining well organized documentation with in the staffs home enables the staff to review and compare past notes and 485’s / plans of care easily and comply with documentation requests made by representatives of the Agency Nursing department. Reporting Information: In the case of any significant finding, case conference or in-home incident, and in the event that the case manager can not be reached within 24 hours, the staff should then contact the case manager’s supervisor. If the event occurred after hours or on the weekend or holiday, the staff still needs to report the event to the Agency DON, Clinical Manager. There is a Agency’s supervisor available 24 hours per day, 7 days per week, every day of the year, including all holidays. It is the staff’s responsibility to ensure that events are reported within the above listed time frames. Once the initial report is given the staff must then fax, email, or mail written documentation of the event to the case manager within 5 days of the incident. This can be a written narrative and / or nurse’s note if the nurse’s note details the event. Depending on the event, further documentation may be requested. The following list includes but is not limited to events that must be reported to the Case Manager within the above timeframes. * Health and Safety Issues (Abuse, Neglect, Exploitation, Abandonment, Theft, Inappropriate Service Delivery, Medication Errors, Illegal Activity, Accidents /Injuries, staffs practicing beyond their scope of practice, death and/or any other issues that affect or have the potential to jeopardize the health and safety of the patient. * ER / Urgent Care visits. Hospital and/or Long Term Care Facility admissions (this includes scheduled and unscheduled), Surgical Procedures – inpatient and outpatient. * Any change in condition or care needs, This includes physical and/or emotional status such as a decline in the patient’s condition requiring a need for increased services and also an improvement in condition requiring a need for decreased or end in skilled service. * Any change in caregiver status. Decline in health, hospitalization or death of a caregiver or change in caregivers. * Any change in environmental conditions affecting the patient such as utility outages or disconnection, flooding, break-ins, people within the home participating in illegal activity, etc. * Any referrals made to protective agencies such as Adult or Child Protective Services, Law Enforcement, and AHCA. This should be reported whether the staff made the referral or someone else made the referral. The staff must also report any active / open cases with the Agency’s officials. * Patient consistently declining services. The patient has the right to decline services and may do so from time to time, however if this is occurring on a consistent basis, this must be reported. * Patient noncompliance with physicians orders, medication / treatment regime, diet, safety recommendations, All Services Plan (POC). * Patient behaving inappropriately toward the staff. This includes verbal and physical abuse, inappropriate and/or sexual conversation, comments, or actions. Home Health Agency. - - Personnel/Operations Policies B-164