Policy Manual sample

MDT Home Health Care Agency, Inc. REINSTATEMENT / RESUMPTION OF CARE POLICY POLICY Home health care staff members provide coordination of client services to established effective interchange, reporting, and coordinate client’s continuing care. PURPOSE To provide safely procedures to reestablish the Patient Care after In-Patient facility stay. PROCEDURES 1. After Patient’s condition requires to transfer to any In-Patient facility, the nursing staff must: - Notify the transfer to the Patient’s Physician/Receiving Facility, document the communication following all Privacy/HIPAA guidelines within 24 hours of transfer - Complete the Communication Note stated the transfer, Patients Condition, In-Patient facility transferred within 24 hours of transfer, fax the summary to the Patient’s Physician and to the receiving facility. - Fill out the Hospital or In-patient facility LOG within 24 hours of transfer - Complete the OASIS “Transfer” if applicable within 24 hours of transfer - Put the Home Health services In-Hold (no time limit for hold period, if within current episode), pending Patient’s Hospital Discharge (Hospital discharge must be before the current episode ends, if not discharge the patient on the date of transfer, complete the Discharge in Office form) - Order the correction in our Home Care Software, stating the admission to In-Patient facility, and necessary correction in the Patient calendar/schedule of services. 2. After Patient’s Hospital or In-Patient Facility discharge: If the discharge is after the Home Care Certification episode: - Discharge the Patient from the date of the transfer, following all discharge procedures, to prevent conflict with the OASIS System, complete “In Office D/C form”). If the Discharge is within the Home Care Certification episode: Proceeds with all Reinstatement/Resumption of Care procedures - Complete the Nurse Reinstatement / Resumption of care Evaluation, including patient assessment, services, frequency/duration and discipline involve within 24 hours of the Agency’s is aware of patient’s hospital discharge - Complete the Resumption of Care order, and request Physician Signature and approval within 48 hours of the Agency’s is aware of patient’s hospital discharge - Complete the Resumption of Care OASIS assessment if applicable within 48 hours of discharge from Hospital or In-Patient facility - Resume the Home Care Services following Hospital orders and Patient’s physician approval and directions within 24 hours of hospital discharge - The Resumption of Care Medication Record must be reviewed, updated, reconciled as part of the reinstatement process. The use of “previous/continue with same medication order” is prohibited. 3. Document all procedures in the Patient’s Medical Record, following Agency’s guideline. L-37 Home Health Agency Client Assessments