SAMPLE - California Association for Health Services at...

HOSPICE I Organization’s Name Structure and Function

*Requires organization-specific information.

California CHAP Hospice Manual/Revised October 2015 © 2003 The Corridor Group

SECTION ONE

Structure and Function Policy No.

Philosophy, Mission, and Purpose ....................................................................................... H:1-001

Regulatory Compliance ....................................................................................................... H:1-002

Clinical Policies and Procedures .......................................................................................... H:1-003

Hospice Professional Advisory Committee ......................................................................... H:1-004

Addendum: Hospice Professional Advisory Committee Members* ............................ H:1-004.A

Hospice Administrator ......................................................................................................... H:1-005

Informed Consent for Patient and Family/Caregiver ........................................................... H:1-006

Medicare Hospice Benefit.................................................................................................... H:1-007

Medicaid Hospice Benefit.................................................................................................... H:1-008

Hospice Site Visitor Home Visit Consent ........................................................................... H:1-009

Financial Responsibility and Medicare Written Notices ..................................................... H:1-010

Addendum: Advance Beneficiary Notice (ABN) of Noncoverage .............................. H:1-010.A

Addendum: Notice of Medicare Provider Noncoverage .............................................. H:1-010.B

Addendum: FFS Expedited Review Detailed Notice ................................................... H:1-010.C

Addendum: Additional CMS Resources for ABN and Expedited Notices .................. H:1-010.D

Corporate Compliance Plan* ............................................................................................... H:1-011

Addendum: Sample Compliance Report ...................................................................... H:1-011.A

Corporate Compliance Officer ............................................................................................. H:1-012

Internal Control Systems/Accountabilities .......................................................................... H:1-013

Hospice Patient Bill of Rights.............................................................................................. H:1-014

Whistleblower Protection..................................................................................................... H:1-015

SAMPLE

HOSPICE II Organization’s Name Quality of Services and Products



SECTION TWO

Quality of Services and Products Hospice Services Policy No.

Scope of Services ................................................................................................................. H:2-001

Listing of Services Provided ................................................................................................ H:2-002

Interdisciplinary group Membership and Responsibilities .................................................. H:2-003

Hospice Nursing Care .......................................................................................................... H:2-004

Hospice Aide Services ......................................................................................................... H:2-005

Psychosocial Services .......................................................................................................... H:2-006

Spiritual Care Counseling Services ..................................................................................... H:2-007

Addendum: Hospice Spiritual Concerns ...................................................................... H:2-007.A

Bereavement Services .......................................................................................................... H:2-008

Volunteer Services ............................................................................................................... H:2-009

Rehabilitative Services......................................................................................................... H:2-010

Speech Therapy Services ..................................................................................................... H:2-011

Nutritional Services ............................................................................................................. H:2-012

Physician Services — Medical Director .............................................................................. H:2-013

Physician Services — Attending Physician’s Role ............................................................. H:2-014

Continuous Care Services .................................................................................................... H:2-015

Addendum: Responsibilities of Continuous Care Personnel ........................................ H:2-015.A

Addendum: Charting Guidelines For Continuous Care ................................................ H:2-015.B

Inpatient Services ................................................................................................................. H:2-016

Pharmacy Services ............................................................................................................... H:2-017

Access to Emergency Room, Pharmacy, Radiology, Laboratory ........................................ H:2-018

Durable Medical Equipment and Supplies .......................................................................... H:2-019

Safe, Operable Equipment ................................................................................................... H:2-020

Transportation Services ....................................................................................................... H:2-021

Hospice Community Education ........................................................................................... H:2-022

Admission to Hospice

Hospice Intake Process* ....................................................................................................... H:2-023

SAMPLE




SECTION TWO

Quality of Services and Products

Policy No.

Admission Criteria and Process ........................................................................................... H:2-024

Certification of Terminal Illness .......................................................................................... H:2-025

Addendum: Face-to-Face Policy* ................................................................................ H:2-025.A

Hospice Election Statement ................................................................................................. H:2-026

Admission for General Inpatient Services ........................................................................... H:2-027

Admission for Respite Care ................................................................................................. H:2-028

Care Planning

Unit of Care.......................................................................................................................... H:2-029

The Plan of Care .................................................................................................................. H:2-030

Interdisciplinary Group Plan of Care ................................................................................... H:2-031

Verification of Physician Orders ......................................................................................... H:2-032

Availability of Family/Caregiver ......................................................................................... H:2-033

Prioritizing Patient Problems/Needs .................................................................................... H:2-034

Coordination/Continuity of Care

Interdisciplinary Group Coordination of Care ..................................................................... H:2-035

Interdisciplinary Group Meeting .......................................................................................... H:2-036

Physician Responsibility in Managing Hospice Patients ..................................................... H:2-037

Monitoring Patient’s Response/Reporting to Physician ...................................................... H:2-038

Patient Notification of Changes in Care .............................................................................. H:2-039

On-Call/Weekend Services .................................................................................................. H:2-040

Coordination of Care With Contracts/Agreements .............................................................. H:2-041

Continuity of Care Between Inpatient Setting and Home ................................................... H:2-042

Provision of Care to Residents of SNF/NF or ICF/IID........................................................ H:2-043

Addendum: Compliance Tool for Hospices That Provide Care to

Residents of a SNF/NF, ICF/IID or Other Facility ................................. H:2-043.A

Internal Referral Process ...................................................................................................... H:2-044

SAMPLE




SECTION TWO

Quality of Services and Products Assessments Policy No.

Initial Assessment ................................................................................................................ H:2-045

Comprehensive Assessment ................................................................................................ H:2-046

Ongoing Assessments .......................................................................................................... H:2-047

Functional Assessment......................................................................................................... H:2-048

Nutritional Assessment ........................................................................................................ H:2-049

Pain Assessment .................................................................................................................. H:2-050

Psychosocial Assessment ..................................................................................................... H:2-051

Spiritual Assessment ............................................................................................................ H:2-052

Bereavement Assessment..................................................................................................... H:2-053

Assessment of Possible Abuse/Neglect ............................................................................... H:2-054

Addendum: “Organization List of Private and Public Community

Agencies That Provide or Arrange for Assessment of

Suspected or Alleged Abuse/Neglect Victims”* ..................................... H:2-054.A

Medication Administration

Medication Profile ............................................................................................................... H:2-055

Identification of Medication for Administration.................................................................. H:2-056

Administration and Documentation of Medications ............................................................ H:2-057

Addendum: Drug Classifications and Their Routes ..................................................... H:2-057.A

Addendum: Medications Not Approved For Safe Home Administration*................... H:2-057.B

Addendum: Drug Information for the Nurse* ............................................................... H:2-057.C

Addendum: Advice For the Patient—Drug Information in Lay Language* ................ H:2-057.D

Patient Self-Administration of Medication .......................................................................... H:2-058

Home Use and Disposal of Controlled Substances .............................................................. H:2-059

Addendum: List of Controlled Substances Available* ................................................. H:2-059.A

Addendum: Drug Disposal Instructions * .................................................................... H:2-059.B

Intravenous Administration of Medications/Solutions ........................................................ H:2-060

Addendum: Medications Approved/Not Approved For Intravenous Administration* H:2-060.A

SAMPLE




SECTION TWO

Quality of Services and Products

Medication Administration (continued) Policy No.

Intravenous Administration of Chemotherapy..................................................................... H:2-061

Addendum: Antineoplastic Medications Approved/Not Approved For Intravenous

Administration* ...................................................................... H:2-061.A

First Dose Policy .................................................................................................................. H:2-062

Crushing of Medications ...................................................................................................... H:2-063

Addendum: Oral Dosage Forms That Should Not Be Crushed* .................................. H:2-063.A

Pulse Rate Determination With Certain Drugs .................................................................... H:2-064

Storage of Medications and Nutritional Products ................................................................ H:2-065

Medication Labeling ............................................................................................................ H:2-066

Adverse Drug Reactions ...................................................................................................... H:2-067

Addendum: Advice About Voluntary Reporting .......................................................... H:2-067.A

Anaphylaxis Protocol ........................................................................................................... H:2-068

Medication Error .................................................................................................................. H:2-069

Medication Monitoring ........................................................................................................ H:2-070

Investigational Medications ................................................................................................. H:2-071

Clinical Care

Identification, Prevention, and Treatment of Secondary Symptoms ................................... H:2-072

Care of the Dying Patient ..................................................................................................... H:2-073

Death at Home ..................................................................................................................... H:2-074

Do Not Resuscitate/Do Not Intubate Orders ....................................................................... H:2-075

Cardiopulmonary Resuscitation ........................................................................................... H:2-076

Withdrawal of Life-Sustaining Care .................................................................................... H:2-077

Emergency Care ................................................................................................................... H:2-078

Suicide…………………….................................................................................................. H:2-079

Home Glucose Monitoring .................................................................................................. H:2-080

SAMPLE




SECTION TWO

Quality of Services and Products Clinical Care (continued) Policy No.

Waived Testing .................................................................................................................... H:2-081

Addendum: Organization List and Criteria for Waived Tests Performed* .................. H:2-081.A

Transfer and Discharge

Change of Designated Hospice ............................................................................................ H:2-082

Transfer Information ............................................................................................................ H:2-083

Revocation of Hospice Benefit ............................................................................................ H:2-084

Discharge From Hospice Program ....................................................................................... H:2-085

Discharge Summary ............................................................................................................. H:2-086

Clinical Record, Documentation, and Data Collection

Contents of Clinical Record ................................................................................................. H:2-087

Assembly of Clinical Record ............................................................................................... H:2-088

Clinical Record Review ....................................................................................................... H:2-089

External Databases ............................................................................................................... H:2-090

Hospice Item Set .................................................................................................................. H:2-091

Family/Caregiver Experience of Care Survey ..................................................................... H:2-092

Addendum: Family/Caregiver Experience of Care Survey for Exempt or

Non-Participating Hospice ........................................................................................... H:2-092.A

Other

Missed Visits ........................................................................................................................ H:2-093SAMPLE

HOSPICE III Organization’s Name Human, Financial, and Physical Resources



SECTION THREE

Human, Financial, and Physical Resources Policy No.

Hospice Human Resources .................................................................................................. H:3-001

Hospice Staffing Guidelines ................................................................................................ H:3-002

Responsibilities/Supervision of Clinical Services ............................................................... H:3-003

Supervision .......................................................................................................................... H:3-004

Orientation of Hospice Personnel to Assigned Responsibilities.......................................... H:3-005

Access to Qualified Consultation......................................................................................... H:3-006

Communication With Office................................................................................................ H:3-007

Contracted Service Providers ............................................................................................... H:3-008

Hospice Aide Training ......................................................................................................... H:3-009

Hospice Homemaker Training ............................................................................................. H:3-010

Hospice Aide Supervisory Visits ......................................................................................... H:3-011

Volunteer Staff ..................................................................................................................... H:3-012

Hospice Volunteer Documentation ...................................................................................... H:3-013

Documentation of Volunteer Utilization ............................................................................. H:3-014

Training/Inservice Education ............................................................................................... H:3-015

Team Access to Emotional Support ..................................................................................... H:3-016

Physician Licensure Verification ......................................................................................... H:3-017

Donated Funds ..................................................................................................................... H:3-018

Hospice Contracted Services ............................................................................................... H:3-019

Addendum: Hospice Contracted Services Review* ..................................................... H:3-019.A

Note:

Job Descriptions can be found in Section 6 of this manual.

Clinical Competency Assessment Skills Checklists can be found as Appendices at the end of

Section 6 of this manual.

SAMPLE

HOSPICE IV Organization’s Name Long Term Viability



SECTION FOUR

Long Term Viability

Policy No.

Hospice Operational Planning ............................................................................................. H:4-001

Hospice Innovation .............................................................................................................. H:4-002

SAMPLE

HOSPICE V Organization’s Name Patient and Family/Caregiver Education



SECTION FIVE

Patient and Family/Caregiver Education

Policy No.

Patient Education Process .................................................................................................... H:5-001

Safe/Effective Use of Medications ...................................................................................... H:5-002

Pain Management Education ............................................................................................... H:5-003

Safe/Effective Use of Equipment and Supplies ................................................................... H:5-004

Basic Home Safety ............................................................................................................... H:5-005

Addendum: Fall Reduction Program* .......................................................................... H:5-005.A

Rehabilitation Techniques ................................................................................................... H:5-006

Storage, Handling, and Access to Supplies and Gases ........................................................ H:5-007

Identification, Handling, and Disposal of Hazardous Waste ............................................... H:5-008

Infection Control Precautions .............................................................................................. H:5-009

Natural Disasters/Emergencies ............................................................................................ H:5-010

Addendum: Guidelines for Emergency Management* ................................................ H:5-010.A

Appropriate Use of Restraints and Supplies ........................................................................ H:5-011

Signs and Symptoms of Approaching Death ....................................................................... H:5-012

Community Resources ......................................................................................................... H:5-013

Educational Resources ......................................................................................................... H:5-014

SAMPLE

HOSPICE VI Organization’s Name Job Descriptions



SECTION SIX

Job Descriptions Policy No.

Policy Statement .................................................................................................................. H:6-001

Addendum: Job Description (Template) ...................................................................... H:6-001.A

Addendum: Physical Requirements .............................................................................. H:6-001.B

Professional Services Agreement For Medical Director ..................................................... H:6-002

Addendum: Professional Services Agreement for Medical Director (Sample)............ H:6-002.A

Addendum: Medical Director Job Description ............................................................H:6-002.B

Addendum: Sample Evaluation Criteria .......................................................................H:6-002.C

JOB TITLE/POSITION

Executive Director/Administrator

Finance Director

Controller

Human Resources Director

Information Systems Director

Marketing/Community Relations Director

Clinical Director/Director of Patient Care Services

Clinical Records Manager

Clinical Supervisor

Managed Care Coordinator

Referral/Intake Supervisor

Performance Improvement Coordinator

Hospice Nurse Practitioner

Registered Nurse

Addendum A: Performance Evaluation for the Registered Nurse (Template)

Licensed Practical/Vocational Nurse

SAMPLE




SECTION SIX


Addendum A: Performance Evaluation for the Licensed Practical/Voc. Nurse (Template)

Certified Hospice Aide

Addendum A: Performance Evaluation for the Certified Hospice Aide (Template)

Addendum B: Hospice Aide Training Agreement

Homemaker

Physical Therapist

Physical Therapy Assistant

Speech—Language Pathologist

Occupational Therapist

Certified Occupational Therapy Assistant

Social Services Supervisor

Social Worker

Registered Dietician

Volunteer Coordinator

Volunteer

Hospice Chaplain

Bereavement Coordinator

Secretary/Receptionist

Billing Manager

Accounting Clerk

Data Entry/Computer Operator

Billing/Collections Clerk

Filing/Data Processing Clerk

Office Manager

Payroll and Benefits Coordinator

SAMPLE




SECTION SIX


Scope of the Program/Process Methodology ....................................................................... H:6-003

Competency Based Orientation ........................................................................................... H:6-004

Addendum: Initial Competency Assessment Skills Checklist/RN ............................... H:6-004.A

Addendum: Initial Competency Assessment Skills Checklist/LPN ............................. H:6-004.B

Addendum: Initial Competency Assessment Skills Checklist/Inf Nurse ..................... H:6-004.C

Addendum: Initial Competency Assessment Skills Checklist/Hosp. Aide .................. H:6-004.D

Addendum: Initial Competency Assessment Skills Checklist/PT ............................... H:6-004.E

Addendum: Initial Competency Assessment Skills Checklist/PTA .............................. H:6-004.F

Addendum: Initial Competency Assessment Skills Checklist/Speech–Lan ................ H:6-004.G

Addendum: Initial Competency Assessment Skills Checklist/OT ............................... H:6-004.H

Addendum: Initial Competency Assessment Skills Checklist/OTA ............................. H:6-004.I

Addendum: Initial Competency Assessment Skills Checklist/MSW ............................ H:6-004.J

Addendum: Initial Competency Assessment Skills Checklist/Reg Dietician .............. H:6-004.K

Addendum: Volunteer Coordinator/Volunteer ............................................................. H:6-004.L

Addendum: Initial Competency Assessment Skills Checklist/Hos. Chaplain............. H:6-004.M

Addendum: Initial Competency Assessment Skills Checklist/Ber. Coord ................... H:6-004.N

Addendum: Initial Competency Assessment Skills Checklist/Hos. Physician ............ H:6-004.O

Core Competency Skills ...................................................................................................... H:6-005

Annual Core Competence .................................................................................................... H:6-006

Addendum: Performance Criteria (Template) .............................................................. H:6-006.A

Addendum: Performance Criteria (Sample) ................................................................. H:6-006.B

Addendum: Performance Criteria (Sample for the Infusion Nurse) ............................. H:6-006.C

Addendum: Performance Criteria (Sample for the Hospice Chaplain) ........................ H:6-006.D

Addendum: Performance Criteria (Sample for the Hospice Physician) ....................... H:6-006.E

Specialized Services............................................................................................................. H:6-007

Requirements for Supervisors/Preceptors ............................................................................ H:6-008

Addendum: Performance Observation Report (Sample) .............................................. H:6-008.A

SAMPLE




SECTION SIX


Report to the Governing Body ............................................................................................. H:6-009

Addendum: Hospice Competence Report (Sample) ..................................................... H:6-009.A

SAMPLE

Organization’s Name Attachments


ATTACHMENTS

Attachment I: ........................................................................................................ CHAP Crosswalk Attachment I: ......................................................................... Medicare Conditions of Participation

Attachment II: ................................................................................ Hospice Interpretive Guidelines

Attachment III: ........................................................................................................ Hospice Manual

Attachment IV:................................................................................................ Additional Resources

SAMPLE

CORE I Organization’s Name Structure and Function


California CHAP Core Manual/Revised October 2015 © 2003 The Corridor Group

SECTION ONE

Structure and Function Policy No.

Mission Statement ................................................................................................................ C:1-001

Governing Body ................................................................................................................... C:1-002

Addendum: Governing Body Members*...................................................................... C:1-002.A

Addendum: Governing Body Orientation Checklist* .................................................. C:1-002.B

Conflict of Interest ............................................................................................................... C:1-003

Referral Disclosure and Care Decisions .............................................................................. C:1-004

Administrative Qualifications and Responsibilities............................................................. C:1-005

Appointment of Executive Director/Administrator ............................................................. C:1-006

Designation of Individual in Absence of Executive Director/Administrator ...................... C:1-007

Use of Organizational Chart ................................................................................................ C:1-008

Addendum: Organizational Charts* ............................................................................. C:1-008.A

Policy Decisions................................................................................................................... C:1-009

Development of Policies and Procedures ............................................................................ C:1-010

Addendum: Required Policy Checklist ........................................................................ C:1-010.A

Addendum: Administrative Policy Renewal/Revision Flow Sheet .............................. C:1-010.B

Facilitating Communication*............................................................................................... C:1-011

Addendum: Organization List of Interpreters* ............................................................. C:1-011.A

Ethical Issues ....................................................................................................................... C:1-012

Nondiscrimination Policy and Grievance Process* ............................................................. C:1-013

Uniform Quality of Care ...................................................................................................... C:1-014

Experimental Research and Investigational Studies ............................................................ C:1-015

Record Retention ................................................................................................................. C:1-016 SAMPLE

CORE II Organization’s Name Quality of Services and Products



SECTION TWO

Quality of Services and Products Policy No.

Public Disclosure Statement ................................................................................................ C:2-001

Admission Documents ......................................................................................................... C:2-002

Patient Bill of Rights ............................................................................................................ C:2-003

Informed Consent/Refusal of Treatment ............................................................................. C:2-004

Addendum: Sample Informed Consent for Medical Photography ....................................C:2-004.A

Financial Responsibility....................................................................................................... C:2-005

Advance Directives .............................................................................................................. C:2-006

Addendum: Advance Directive Information Statement ............................................... C:2-006.A

Addendum: Durable Power of Attorney for Health Care* ........................................... C:2-006.B

Addendum: POLST Policy* ......................................................................................... C:2-006.C

Complaint/Grievance Process .............................................................................................. C:2-007

Care/Service Coordination ................................................................................................... C:2-008

Availability of Services........................................................................................................ C:2-009

Emergency Management Plan ............................................................................................. C:2-010

Addendum: Pyramid Phone Communication Plan* ..................................................... C:2-010.A

Addendum: Weather Report/Road Conditions* ........................................................... C:2-010.B

Fostering Internal Communication ...................................................................................... C:2-011

Interface of Patient Data and Management Systems ........................................................... C:2-012

Access to Information .......................................................................................................... C:2-013

Principles of Information Management ............................................................................... C:2-014

Patient Privacy Rights .......................................................................................................... C:2-015

Addendum: Notice of Privacy Practices ....................................................................... C:2-015.A

Minimum Necessary Uses of PHI........................................................................................ C:2-016

Minimum Necessary Disclosures of PHI ............................................................................. C:2-017

Uses and Disclosures of PHI................................................................................................ C:2-018

Authorization for Use or Disclosure of PHI ........................................................................ C:2-019

Minimum Necessary Requests For PHI ............................................................................... C:2-020

Privacy of Health Information of Deceased Individuals ...................................................... C:2-021

SAMPLE




SECTION TWO


Patient Requests for Privacy Restrictions ............................................................................ C:2-022

Patient Requests for Confidential Communications ............................................................ C:2-023

Patient Requests for Access to PHI ..................................................................................... C:2-024

Patient Requests to Amend PHI ........................................................................................... C:2-025

Patient Requests for Accounting of PHI Disclosures .......................................................... C:2-026

Fundraising and PHI ............................................................................................................ C:2-027

Marketing and PHI ............................................................................................................... C:2-028

Privacy Training................................................................................................................... C:2-029

Sanctions for Privacy and Security Violations .................................................................... C:2-030

Safeguarding/Retrieval of Clinical/Service Record ............................................................. C:2-031

Computer Access to Information ......................................................................................... C:2-032

Clinical/Service Data Collection.......................................................................................... C:2-033

Retention of Clinical/Service Records ................................................................................. C:2-034

Branch/Subunit Documentation Control.............................................................................. C:2-035

Abbreviations and Symbols ................................................................................................. C:2-036

Addendum: Approved Home Care/Service Abbreviations* ........................................ C:2-036.A

Addendum: Unacceptable Home Care/Service Abbreviations* ................................... C:2-036.B

Responsibilities in Improving Performance......................................................................... C:2-037

Patient Focused Performance Improvement ........................................................................ C:2-038

Patient and Family/Caregiver Experience of Care Survey .................................................. C:2-039

Infection Control Plan .......................................................................................................... C:2-040

Tuberculosis Exposure Control Plan ................................................................................... C:2-041

Bloodborne Pathogens and Hepatitis B Exposure Control Plan .......................................... C:2-042

Addendum: Hepatitis B Vaccination Documentation Form ......................................... C:2-042.A

SAMPLE




SECTION TWO


Addendum: Hepatitis B Vaccination Declination Form ............................................... C:2-042.B

Addendum: Recognizing the Dangers ........................................................................... C:2.042.C

Addendum: Occupational Exposure Risk By Job Classification ................................. C:2-042.D

Management of Exposures in Personnel .............................................................................. C:2-043

Record Keeping ................................................................................................................... C:2-044

Occupational Exposure Information and Training .............................................................. C:2-045

Standard Precautions ............................................................................................................ C:2-046

Addendum: Standard Precautions Information for Personnel ...................................... C:2-046.A

Personal Protective Equipment ............................................................................................ C:2-047

Addendum: Protective Device Checklist ...................................................................... C:2-047.A

Addendum: Required Personal Protective Equipment Form ........................................ C:2-047.B

Hand Hygiene ...................................................................................................................... C:2-048

Clean vs. Aseptic Technique ................................................................................................ C:2-049

Infection Control/Expanded Precautions ............................................................................. C:2-050

Addendum: Bed Bug Guidance* ................................................................................ C:2-050.A

Contaminated Materials Disposition.................................................................................... C:2-051

Contaminated Waste Disposal ............................................................................................. C:2-052

Hazardous Waste Handling.................................................................................................. C:2-053

Addendum: Hazardous Waste Disposal State and Local Regulations* ....................... C:2-053.A

Accidental Exposure to Blood ............................................................................................. C:2-054

Bag Technique ..................................................................................................................... C:2-055

Evaluating and Maintaining Records of Infections Among Patients ................................... C:2-056

Addendum: Infection Identification—Patient Report .................................................. C:2-056.A

Evaluating and Maintaining Records of Infections Among Personnel ................................ C:2-057

Addendum: Infection Identification—Personnel Report .............................................. C:2-057.A

Reporting of Communicable Diseases ................................................................................. C:2-058

Communication of Hazards to Personnel ............................................................................ C:2-059

SAMPLE




SECTION TWO


Environmental Safety Program ............................................................................................ C:2-060

Environmental Safety—Office ............................................................................................ C:2-061

Addendum: Office Environment Checklist .................................................................. C:2-061.A

Fire Safety—Office .............................................................................................................. C:2-062

Utilities Management—Office ............................................................................................. C:2-063

Equipment Management—Office ........................................................................................ C:2-064

Environmental Safety—Patient ........................................................................................... C:2-065

Fire Safety—Patient ............................................................................................................. C:2-066

Utilities Management—Patient ............................................................................................ C:2-067

Equipment Management—Patient ....................................................................................... C:2-068

Safe and Appropriate Use of Home Medical Equipment and Supplies ............................... C:2-069

Storage of Medications and Nutritional Therapies .............................................................. C:2-070

Medical Equipment Malfunction ......................................................................................... C:2-071

Safe Medical Device Act ..................................................................................................... C:2-072

Organization Personnel Safety—Personal Safety ................................................................ C:2-073

Organization Personnel Safety—Unsafe Home Visits ........................................................ C:2-074

Vehicle Accident Reporting ................................................................................................. C:2-075

Incident Reporting ............................................................................................................... C:2-076

Addendum: Examples of Specific Events or Occurrences

That Must Be Reported ............................................................................ C:2-076.A

Serious Adverse Events ....................................................................................................... C:2-077

Root Cause Analysis/Action Plan ........................................................................................ C:2-078

Addendum: Root Cause Analysis/Action Plan Form ................................................... C:2-078.A

Aggregation of Data/Information ........................................................................................ C:2-079

Identity Theft Prevention Program ...................................................................................... C:2-080

Addendum: Identity Theft Risk Assessment Worksheet .............................................. C:2-080.A

SAMPLE




SECTION TWO


Addendum: Identity Theft Risk Response Matrix ........................................................ C:2-080.B

Pandemic Influenza Preparedness ........................................................................................ C:2-081

Addendum: Reference for Pandemic Influenza Preparedness ...................................... C:2-081.A

Security of PHI .................................................................................................................... C:2-082

Breach Analysis ................................................................................................................... C:2-083

Breach Notification .............................................................................................................. C:2-084

Security Management Process ............................................................................................. C:2-085

Workforce Security .............................................................................................................. C:2-086

Information Access Management ........................................................................................ C:2-087

Security Awareness and Training ........................................................................................ C:2-088

Security Incident Procedures ............................................................................................... C:2-089

Contingency Plan ................................................................................................................. C:2-090

Evaluation ............................................................................................................................ C:2-091

Facility Access Controls ...................................................................................................... C:2-092

Workstation Use and Security ............................................................................................. C:2-093

Device and Media Controls ................................................................................................. C:2-094

Access Controls: Technical Safeguards ............................................................................... C:2-095

HIPAA Security Audit Controls .......................................................................................... C:2-096

Integrity Controls ................................................................................................................. C:2-097

Person or Entity Authentication ........................................................................................... C:2-098

Transmission Security .......................................................................................................... C:2-099

SAMPLE

CORE III Organization’s Name Human, Financial, and Physical Resources



SECTION THREE


Personnel Policies ................................................................................................................ C:3-001

Recruitment, Retention, Development, and Continuing Education ..................................... C:3-002

Categories/Qualifications of Personnel................................................................................ C:3-003

Selection/Hiring of Personnel .............................................................................................. C:3-004

Licensure/Certification/Registration .................................................................................... C:3-005

Equal Opportunity Employer ............................................................................................... C:3-006

Standards of Care, Service, and Practice ............................................................................. C:3-007

Scope of Assessments/Qualifications .................................................................................. C:3-008

Job Descriptions ................................................................................................................... C:3-009

Termination .......................................................................................................................... C:3-010

Personnel Turnover .............................................................................................................. C:3-011

Attendance and Absenteeism ............................................................................................... C:3-012

Personnel Grievance Process ............................................................................................... C:3-013

Personal Vehicle Use/Mileage Requirements ...................................................................... C:3-014

Dress and Appearance.......................................................................................................... C:3-015

Sexual Harassment ............................................................................................................... C:3-016

Standards of Conduct/Ethical Behavior ............................................................................... C:3-017

Personnel Record Contents .................................................................................................. C:3-018

Performance Evaluations ..................................................................................................... C:3-019

Orientation ........................................................................................................................... C:3-020

Addendum: Personnel Orientation Checklist ............................................................... C:3-020.A

Personnel Development ....................................................................................................... C:3-021

Addendum: Personnel Development/Inservice Needs Assessment ............................. C:3-021.A

Resource Information........................................................................................................... C:3-022

Competency Program........................................................................................................... C:3-023

Initial Competency Assessment ........................................................................................... C:3-024

SAMPLE




SECTION THREE


Competency Requirements for Supervisors/Preceptors ....................................................... C:3-025

Addendum: Performance Observation Report .............................................................. C:3-025.A

Competency Report to the Governing Body ........................................................................ C:3-026

Addendum: Organization Competency Report ............................................................ C:3-026.A

Written Agreements for Contracted Services ...................................................................... C:3-027

Addendum: Written Agreement for Home Care Services* .......................................... C:3-027.A

Business Associates ............................................................................................................. C:3-028

Annual Operating Budget .................................................................................................... C:3-029

Certificates of Insurance ...................................................................................................... C:3-030

Financial Management and Control ..................................................................................... C:3-031

Fiscal Solvency .................................................................................................................... C:3-032

Financial Reports ................................................................................................................. C:3-033

Fee Determination ................................................................................................................ C:3-034

Charity Care ......................................................................................................................... C:3-035

Charge Verification .............................................................................................................. C:3-036

Billing and Collections ........................................................................................................ C:3-037

Accounts Receivable Review .............................................................................................. C:3-038

Bad Debt Policy ................................................................................................................... C:3-039

Contractual Allowances ....................................................................................................... C:3-040

Cash Receipts ....................................................................................................................... C:3-041

Purchasing Authorization and Accounts Payable ................................................................ C:3-042

Fixed Assets and Depreciation............................................................................................. C:3-043

Payroll Processing ................................................................................................................ C:3-044

Allocation of Time Worked ................................................................................................. C:3-045

SAMPLE




SECTION THREE


Social Media ........................................................................................................................ C:3-046

Addendum: Social Media and Blog Guidelines ........................................................... C:3-046.A

Progressive Discipline Policy .............................................................................................. C:3-047

SAMPLE

CORE IV Organization’s Name Long Term Viability



SECTION FOUR

Long Term Viability Policy No.

Organizational Planning....................................................................................................... C:4-001

Program Planning................................................................................................................. C:4-002

Marketing Plan ..................................................................................................................... C:4-003

Contingency Planning .......................................................................................................... C:4-004

Contingency Plan if Organization Closes ............................................................................ C:4-005

Measuring Performance of the Environmental Safety Program .......................................... C:4-006

Annual Organization Evaluation.......................................................................................... C:4-007

Addendum: Self-Assessment of Health Care

Organizational Performance ..................................................................... C:4-007.A

SAMPLE

CORE MANUAL Organization’s Name Attachments


ATTACHMENTS

Attachment I: ........................................................................................................ CHAP Crosswalk

Attachment II: ...................................................................................................... Glossary of Terms

SAMPLE

SAMPLE - California Association for Health Services at...

Documents

Transcript of SAMPLE - California Association for Health Services at...