Structure and Function Policy No.cahsah.org/EmailImages/Bookstore/ResourceTOC/CA_CHAP_HH_TOC.… ·...

HOME HEALTH I Organization’s Name Structure and Function

*Requires organization-specific information.

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

SECTION ONE

Structure and Function Policy No.

Scope of Services .............................................................................................................. HH:1-001

Listing of Services Provided ............................................................................................. HH:1-002

Regulatory Compliance .................................................................................................... HH:1-003

Professional Advisory Committee ................................................................................... HH:1-004

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

Home Health Organizational Chart .................................................................................. HH:1-005

Addendum: Organizational Charts* .......................................................................... HH:1-005.A

Home Health Administrator .............................................................................................. HH:1-006

Home Health Clinical Policies and Procedures ................................................................ HH:1-007

Home Health Record Retention ........................................................................................ HH:1-008

Scope of the Behavioral Health Program.......................................................................... HH:1-009

Scope of the Pediatric Program......................................................................................... HH:1-010

Scope of the Obstetrical Program ..................................................................................... HH:1-011

Telemedicine Program ...................................................................................................... HH:1-012

Telemedicine—Patient Privacy ........................................................................................ HH:1-013

Telemedicine—Admission Criteria .................................................................................. HH:1-014

Telemedicine—Plan of Care ............................................................................................. HH:1-015

Telemedicine—Patient Education .................................................................................... HH:1-016

Telemedicine—Discharge Criteria ................................................................................... HH:1-017

Financial Responsibility and Medicare Written Notices .................................................. HH:1-018

Addendum: Advance Beneficiary Notice of Noncoverage (ABN) ........................... HH:1-018.A

Addendum: Home Health Change of Care Notice (HHCCN) .................................. HH:1-018.B

Addendum: Generic Expedited Determination Notice ............................................. HH:1-018.C

Addendum: FFS Expedited Review Detailed Notice ................................................ HH:1-018.D

Addendum: Additional CMS Resources for Expedited Notices ............................... HH:1-018.E

Corporate Compliance Plan* ............................................................................................ HH:1-019

Addendum: Sample Compliance Report ................................................................... HH:1-019.A

SAMPLE

HOME HEALTH I Organization’s Name Structure and Function



SECTION ONE


Corporate Compliance Officer .......................................................................................... HH:1-020

Internal Control Systems/Accountabilities ....................................................................... HH:1-021

Whistleblower Protection.................................................................................................. HH:1-022

SAMPLE

HOME HEALTH II Organization’s Name Quality of Services and Products



SECTION TWO

Quality of Services and Products

Admission to Home Health Policy No.

Home Health Patient Bill of Rights .................................................................................. HH:2-001

Intake Process ................................................................................................................... HH:2-002

Admission Criteria and Process ........................................................................................ HH:2-003

Addendum: Face-to-Face Encounter Procedure * ...................................................... HH:2-003.A

Care Planning

Care Planning Process....................................................................................................... HH:2-004

Physician Participation in Plan of Care ............................................................................ HH:2-005

Verification of Physician Orders ...................................................................................... HH:2-006

Rehabilitation Care Planning ............................................................................................ HH:2-007

Nutrition Care Planning .................................................................................................... HH:2-008

Home Health Aide Plan of Care ....................................................................................... HH:2-009

Orientation of Assigned Home Health Aide ..................................................................... HH:2-010

Support/Chore Worker Service Plan ................................................................................. HH:2-011

Discharge Planning ........................................................................................................... HH:2-012

Coordination/Continuity of Care

Continuity of Care............................................................................................................. HH:2-013

Case Conference/Progress Summary ................................................................................ HH:2-014

Monitoring Patient’s Response/Reporting to Physician ................................................... HH:2-015

60-Day Summary Report ................................................................................................. HH:2-016

Patient Notification of Changes in Care ........................................................................... HH:2-017

On-Call/Weekend Staffing................................................................................................ HH:2-018

Coordination of Services With Other Providers .............................................................. HH:2-019

Internal Referral Process ................................................................................................... HH:2-020

SAMPLE




SECTION TWO


Assessment Policy No.

Initial and Comprehensive Assessment ............................................................................ HH:2-021

Ongoing Assessments ....................................................................................................... HH:2-022

Reassessments/Recertification .......................................................................................... HH:2-023

Functional Assessment...................................................................................................... HH:2-024

Nutritional Assessment ..................................................................................................... HH:2-025

Pain Assessment................................................................................................................ HH:2-026

Assessment of Possible Abuse/Neglect ............................................................................ HH:2-027

Addendum: Organization List of Private & Public Community Agencies That

Provide or Arrange for Assessment of Suspected or Alleged

Abuse/Neglect Victims* ........................................................................ HH:2-027.A

Medication Administration

Medication Profile ............................................................................................................ HH:2-028

Identification of Medication for Administration............................................................... HH:2-029

Administration and Documentation of Medications ......................................................... HH:2-030

Addendum: Drug/Classifications and Their Routes ................................................. HH:2-030.A

Addendum: Medications Not Approved for Safe Home Administration* ................ HH:2-030.B

Addendum: Drug Information for the Nurse* ........................................................... HH:2-030.C

Addendum: Advice for the Patient—Drug Information in Lay Language* ............. HH:2-030.D

Patient Self-Administration of Medication ....................................................................... HH:2-031

Home Use and Disposal of Controlled Substances........................................................... HH:2-032

Intravenous Administration of Medications/Solutions ..................................................... HH:2-033

Addendum: Medications Approved/Not Approved for Intravenous Administration HH:2-033.A

Intravenous Administration of Chemotherapy.................................................................. HH:2-034

Addendum: Antineoplastic Medications Approved/Not Approved for Intravenous

Administration* ..................................................................................... HH:2-034.A

First Dose Policy ............................................................................................................... HH:2-035

SAMPLE




SECTION TWO


Medication Administration (continued) Policy No.

Crushing of Medications ................................................................................................... HH:2-036

Addendum: Oral Dosage Forms That Should Not Be Crushed* ............................... HH:2-036.A

Pulse Rate Determination With Certain Drugs ................................................................. HH:2-037

Storage of Medications and Nutritional Products ............................................................. HH:2-038

Medication Labeling ......................................................................................................... HH:2-039

Adverse Drug Reactions ................................................................................................... HH:2-040

Addendum: Advice About Voluntary Reporting ....................................................... HH:2-040.A

Anaphylaxis Protocol ........................................................................................................ HH:2-041

Medication Error .............................................................................................................. HH:2-042

Medication Monitoring ..................................................................................................... HH:2-043

Investigational Medications .............................................................................................. HH:2-044

Clinical Care

Waived Testing ................................................................................................................. HH:2-045

Addendum: Organization List and Criteria for Waived Tests Performed* ............... HH:2-045.A

Home Glucose Monitoring ............................................................................................... HH:2-046

Do Not Resuscitate/Do Not Intubate Orders .................................................................... HH:2-047

Cardiopulmonary Resuscitation ........................................................................................ HH:2-048

Withdrawal of Life-Sustaining Care ................................................................................. HH:2-049

Care of the Dying Patient .................................................................................................. HH:2-050

Transfer and Discharge

Transfer/Referral Criteria and Process .............................................................................. HH:2-051

Transfer Summary ............................................................................................................ HH:2-052

Discharge Criteria and Process ......................................................................................... HH:2-053

Discharge Summary .......................................................................................................... HH:2-054

SAMPLE




SECTION TWO


Clinical Record, Documentation, and Data Collection Policy No.

Contents of Clinical Record .............................................................................................. HH:2-055

Assembly of Clinical Record ............................................................................................ HH:2-056

Clinical Record Review .................................................................................................... HH:2-057

External Databases ............................................................................................................ HH:2-058

OASIS Reporting

OASIS Data Transmission ................................................................................................ HH:2-059

Experience of Care

Patient and Family/Caregiver Experience of Care Survey ............................................... HH:2-060

Addendum: Patient and Family/Caregiver Experience of Care Survey for Exempt

or Non-Participating Home Health Agency .............................................................. HH:2-060.A

Other

Missed Visits ..................................................................................................................... HH:2-061

SAMPLE

HOME HEALTH III Organization’s Name Human, Financial, and Physical Resources



SECTION THREE

Human, Financial, and Physical Resources

Policy No.

Home Health Human Resources ....................................................................................... HH:3-001

Home Health Staffing Guidelines ..................................................................................... HH:3-002

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

Supervision ....................................................................................................................... HH:3-004

Access to Qualified Consultation...................................................................................... HH:3-005

Consultation for Specialty Services .................................................................................. HH:3-006

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

Home Health Contracted Services .................................................................................... HH:3-008

Addendum: Home Health Contracted Services Review* .......................................... HH:3-008.A

Contracted Service Providers ............................................................................................ HH:3-009

Training/Inservice Education ............................................................................................ HH:3-010

Competency Assessment .................................................................................................. HH:3-011

Home Health Aide Training.............................................................................................. HH:3-012

Home Health Aide Supervisory Visits .............................................................................. HH:3-013

Physician Licensure Verification ...................................................................................... HH:3-014

Home Health Capital Expenditure Plan ............................................................................ HH:3-015

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

HOME HEALTH IV Organization’s Name Long Term Viability



SECTION FOUR

Long Term Viability

Policy No.

Home Health Annual Evaluation ...................................................................................... HH:4-001

Home Health Innovation ................................................................................................... HH:4-002

SAMPLE

HOME HEALTH V Organization’s Name Patient and Family/Caregiver Education



SECTION FIVE

Patient and Family/Caregiver Education

Policy No.

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

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

Drug–Food Interactions .................................................................................................... HH:5-003

Pain Management Education ............................................................................................ HH:5-004

Rehabilitation Techniques ................................................................................................ HH:5-005

Appropriate Use of Restraints and Supplies ..................................................................... HH:5-006

Safe/Effective Use of Equipment and Supplies ................................................................ HH:5-007

Storage, Handling, and Access to Supplies and Gases ..................................................... HH:5-008

Identification, Handling, and Disposal of Hazardous Waste ............................................ HH:5-009

Infection Control Precautions ........................................................................................... HH:5-010

Natural Disasters/Emergencies ......................................................................................... HH:5-011

Addendum: Guidelines for Emergency Management* ............................................. HH:5-011.A

Basic Home Safety ............................................................................................................ HH:5-012

Addendum: Fall Reduction Program* ....................................................................... HH:5-012.A

Patient Education Related to Discharge Planning ............................................................ HH:5-013

Educational Resources ...................................................................................................... HH:5-014

Community Resources ...................................................................................................... HH:5-015

SAMPLE

HOME HEALTH VI Organization’s Name Job Descriptions



SECTION SIX

Job Descriptions Policy No.

Policy Statement ...................................................................................................................... 6-001

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

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

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

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

JOB TITLES/POSITIONS

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/Nursing Supervisor

Managed Care Coordinator

Referral/Intake Supervisor

Performance Improvement Coordinator

Home Care Coordinator

Home Health Nurse Practitioner

Infusion Therapy Nurse Coordinator

OASIS Review Nurse

Registered Nurse

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

Licensed Practical/Vocational Nurse

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

SAMPLE




SECTION SIX

Job Descriptions

Job Titles/Positions (Continued)

Certified Home Health Aide

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

Addendum B: Home Health Aide Training Agreement (Sample)

Nurse Assistant

Rehabilitation Supervisor

Physical Therapist

Physical Therapy Assistant

Speech–Language Pathologist

Occupational Therapist

Certified Occupational Therapy Assistant

Social Services Supervisor

Medical Social Worker

Registered Dietician

Secretary/Receptionist

Billing Manager

Accounting Clerk

Data Entry/Computer Operator

Billing/Collections Clerk

Filing/Data Processing Clerk

Office Manager

Payroll and Benefits Coordinator

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

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

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

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

Addendum: Initial Competency Assessment Skills Checklist/Infusion Nurse .......... HH:6-004.C

Addendum: Initial Competency Assessment Skills Checklist/HHA ......................... HH:6-004.D

SAMPLE




SECTION SIX

Job Descriptions

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

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

Addendum: Initial Competency Assessment Skills Checklist/Speech/Language ..... HH:6-004.G

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

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

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

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

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

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

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

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

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

Specialized Services.......................................................................................................... HH:6-007

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

Addendum: Performance Observation Report ........................................................... HH:6-008.A

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

Addendum: Organization Competence Report .......................................................... HH:6-009.A

SAMPLE

Organization’s Name ATTACHMENTS


ATTACHMENTS

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

Attachment II: ........................................................................ Medicare Conditions of Participation

Attachment III: .......................................................... Home Health Agency Interpretive Guidelines

Attachment IV:.................................................................................. Home Health Agency Manual

Attachment V .................................................................................................. Additional Resources

SAMPLE

CORE I Organization’s Name Structure and Function


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

SECTION ONE


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

Human, Financial, and Physical Resources Policy No.

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

Structure and Function Policy No.cahsah.org/EmailImages/Bookstore/ResourceTOC/CA_CHAP_HH_TOC.… ·...

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