Policy Manual sample

MDT Home Health Care Agency, Inc. SIGN UP PACKAGE CHECK LIST Patient’s Name: ______________________________________________ Med. Record: _________________ SOC: ____________ Period of evaluation: __________________ - _________________ ITEMS Completed N/A Advance Directives Info completed / Policy Bill of Rights/Responsibilities Care Plan all discipline as applicable (therapy) OASIS Assessment completed Agency Service Agreement fill out completed Disaster/Emergency Plan Aide Care Plan Hurricane Guide as applicable (during hurricane season) Grievance Procedure Medication Profile Client Information Handbook Abuse/Neglect assessment. State availability phones to report Abuse/Neglect/Complaints Nursing Note (initial, if applicable) Payment authorization/information completed in the agreement Frequency of visit completed in the Service Agreement Medicare Secondary Payer Questionnaire (if applicable) Accreditation, Medicare, Medicaid hotline information (if applicable) Appointment of Representative form (if applicable) Team Communication Patient informed of Agency’s ownership, administrator, DON, Clinical Manager names/phone Privacy Act Statement: OASIS/HIPAA Comments: ______________________________________________________________________________ ________________________________________________________________________________________ Staff’s Signature: ___________________________ Date: _______________________ Home Health Agency - - Skilled Professional Services D-35