Page 7 – Amity Healthcare Group

Home Health Annual Compliance Check List

WOUND MANAGEMENT PROGRAM POLICY & PROCEDURE MANUAL

Product Disclosure Statement

Wound Management Program Policy Crosswalk

P&P Adoption

Wound Management Program Adoption and Approval Governing Body Review Wound Management Program

01 SECTION I

Program Plan and Description

Attachment 1. A Wound Management Program Coordinator Job Description

Attachment 1. B Wound Management Program Interdisciplinary Team

Attachment 1. C Wound Management Committee Monthly Meeting Minutes

Attachment 1. D Monthly Wound Assessment and Care Summary

Attachment 1. E Wound Management Program Log

Attachment 1. F Monthly Wound Audit Tool

02 SECTION II

Clinical Guidelines

Selection and Approval of Clinical Practice Guidelines

Attachment 2. A Clinical Guidelines Review and Approval

Attachment 2. B Wound Management Program Educational Modules and Competency Quizzes

Attachment 2. B Module 1 Wound Care Basics

Common Terms and Concepts in Wound Assessment

Wound Healing Basics

NPIAP Pressure Injury Stages

Module 1 Quiz

Attachment 2. B Module 2 Wound Assessment

Wound Assessment Guidelines

The Wound Bed Preparation Paradigm

Pressure Injury Assessment and Management

Wound Assessment Procedure

Bates-Jensen Wound Assessment Tool

Module 2 Quiz

Attachment 2. B Module 3 Wound Cleansing, Irrigation, and Product Selection

Wound Cleansing, Irrigation, and Product Selection

Wound Products Overview and Selection

Wound Dressing Application Procedure

Wound Irrigation Procedure

Module 3 Quiz

Attachment 2. B Module 4 Negative Pressure Wound Therapy

Negative Pressure Wound Therapy

Module 4 Quiz

Attachment 2. B Module 5 Nutritional Strategies for Wound Healing

Nutritional Strategies for Wound Healing

Mini Nutritional Assessment

Module 5 Quiz

Patient Education Handouts and Teaching Tools

Attachment 2. B Module 6 Comprehensive Assessment (RN’s only)Comprehensive Assessment Policy Wound

Management Program Addendum

Wound Management Program Comprehensive Assessment Checklist

Patient Education and Health Literacy Assessment

Wound Management Program Policy

Module 6 Quiz

OASIS References for Agencies Completing

OASIS Assessment

OASIS E Section M: Skin Conditions Guidelines

Attachment 2. B Module 7 Infection Control

Infection Control Policy Wound Management Program Addendum

Bag Technique Policy and Procedure

Module 7 Quiz

Attachment 2. B Module 8 Patient Education

Patient Education and Health Literacy

Assessment Policy

Patient Education and Self-Management Plan

Disease Management Policy

Patient Lifestyle Education Handouts

Module 8 Quiz

Attachment 2. B Module 9 Additional Wound Management Program Policies

Wound Management Program Reassessment Policy

Wound Management Program Reassessment Checklist

Plan of Care Policy Wound Management Program Addendum

Coordination of Care Policy Addendum

Discharge and Transfer Policy Addendum

Module 9 Quiz

Attachment 2. C Wound Management Program Nursing Competency Evaluation

Attachment 2. D Wound Management Competency Evaluation Form

Attachment 2. E Wound Management Program In-Service Agenda

Attachment 2. F Policy W2.10 Infection Control Policy

Wound Management Program Addendum

Attachment 2. G Bag Technique Policy and Procedure

Attachment 2. H Clinical Practice Guidelines and References

Attachment 2. I Wound Management Program

03 SECTION III

Assessment of Patients and Risk Factors

Initial Comprehensive Assessment

Reassessments of Patients and Wounds

Attachment 3. A Policy W3.01 Comprehensive Assessment Policy

Attachment 3. B Wound Management Program Comprehensive Assessment Checklist

Attachment 3. C Policy W3.02 Wound Management Program Reassessment Policy

Attachment 3. D Wound Management Program Reassessment Checklist

Bates-Jensen Wound Assessment Tool

04 SECTION IV

Provision and Coordination of Care

Attachment 4. A Policy W4.01 Plan of Care Policy

Attachment 4. B Policy W4.02 Coordination of Care Policy

Attachment 4. C Discharge and Transfer Policy

05 SECTION V

Patient and Family Education

Patient and Family Education Regarding Disease Management

Attachment 5. A Policy W5.01 Patient Education and Health Literacy Assessment Policy

Attachment 5. B Patient Education and Self-Management Plan

06 SECTION VI

Disease Management

Attachment 6. A Wound Management Program Disease Management Policy Patient Education Handouts and Teaching Tools

07 SECTION VII

Performance Measurement and Improvement

Attachment 7. A PI/QAPI Policy

Attachment 7. B Wound Management Program Performance Improvement Project (Blank form)

Attachment 7. C Wound Management Program Performance Improvement Project (Samples 1 and 2)

08 SECTION VIII

Information Management

09 SECTION IX

Safety and Emergency Planning

HOME HEALTH ADMISSION PACKET

01. Product Disclosure Statement

02. Consent for treatment

03. Emergency Preparedness Risk Assessment

04. Home Environment And Emergency Preparedness Assessment

05. Authorization for disclosure of PHI

06. Care Coordination with External Agencies

07. Patient Plan of Care Summary and Care Instructions

08. State Specific Forms

09. Advance Beneficiary Notice of Non-coverage (ABN_exp. 01. 31.26)

10. Home Health Change of Care Notice (Hhccn Exp. 11.30.27)

11. Notice of Medicare Non-coverage (Nomnc Exp. 11/30/2027)

12. Patient Handbook

HOME CARE ADMISSION PACKET

01. Product Disclosure Statement

02. Admission Agreement

03. Emergency Preparedness Risk Level

04. Home Environment And Emergency Preparedness Assessment

05. Authorization for disclosure of PHI

06. Care Coordination with External Agencies

07. Plan of Care Summary and Care Instructions

08. State Specific Forms

09. Client/Patient Handbook

HOME HEALTH EMERGENCY PREPAREDNESS PLAN

01. Product Disclosure Statement

02. Place Holder [Insert Agency’s PI Policy and Procedure]

03. Home Health Agency Emergency Preparedness Plan

04. Samples

a. Abbreviated Assessment

b. All Hazard Vulnerability Assessment

c. Business Continuity Plan

d. Disaster Phone Tree

e. Emergency Contacts

f. Emergency Preparedness Resources for Patients and Families

g. EXERCISE PLANNING WORKSHEET

h. EXERCISE AFTER ACTION REPORT

i. EXERCISE EVALUATION GUIDE

j. Home Environment and Emergency Preparedness Assessment

k. Home Health Agency Emergency Preparedness Plan ASSESSMENT

l. Memorandum of Understanding

m. Patient Evacuation Tracking Form

n. Patient Evacuation Tracking Log

o. Patient Roster

p. Physicians/Allowable Practitioners Roster

q. gov Fact Sheets

r. Staff Roster

s. Strategies to Address Emergency Events

t. Supplier Roster

u. Volunteer Roster

HOME CARE EMERGENCY PREPAREDNESS PLAN

01. Product Disclosure Statement

02. Place Holder [Insert Agency’s Emergency Preparedness Program Policy and Procedure]

03. Home Care Agency Emergency Preparedness Plan

04. Samples

a. All Hazard Vulnerability Assessment

b. Business Continuity Plan

c. EMERGENCY PHONE COMMUNICATION TREE

d. Emergency Contacts

e. Emergency Preparedness Resources for Patients and Families

f. EXERCISE PLANNING WORKSHEET

g. EXERCISE AFTER ACTION REPORT

h.EXERCISE EVALUATION GUIDE

i. Home Environment and Emergency Preparedness Assessment

j. Home CARE Agency Emergency Preparedness Plan Assessment

k. Memorandum of Understanding

l. Patient Evacuation Tracking Form

m. Patient Evacuation Tracking Log

n. Patient Roster

o. Physicians/Allowable Practitioners Roster

p. Ready.gov Fact Sheets

q. Staff Roster

r. Supplier Roster

s. Volunteer Roster

HOME CARE PERFORMANCE IMPROVEMENT PROGRAM

01. Product Disclosure Statement

02. PLACE HOLDER [INSERT AGENCY’S PI POLICY AND PROCEDURE]

03. Performance Improvement Program

04. Guide to Performance Improvement Projects (PIPs) for the PI Program

05. Samples

a. Ongoing Monitoring Indicators and Thresholds

b. PIP – Adherence to the Plan of Care

c. PIP Focus Audit- Adherence to POC/Provider Orders

d. Performance Improvement Activity Tracking Sheet

06. Templates

a. Performance Improvement Project

b. Performance Improvement Committee Meeting Minutes

C. Annual Performance Improvement (PI) Report

D. Governing Body PI Review

E. Governing Body orientation checklist

F. PI Self-Assessment tool

G. Client/Patient Record Audit Tool

H. Client/Patient Satisfaction Survey

I. Employee satisfaction survey

J. Physician/Referral Source/Community
Partner Satisfaction Survey

HOME HEALTH QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT (QAPI)

01. Product Disclosure Statement

02. Place Holder [Insert Agency’s QAPI Policy and Procedure]

03. Quality Assessment and Performance Improvement Program

04. Quality Assessment and Performance Improvement and Home Health Value-Based Purchasing

05. Guide to Performance Improvement Projects (PIPs) for the QAPI Program

06. Samples

Ongoing Monitoring Indicators and Thresholds (sample)PIP – Wound Associated Infections (sample#1)

PIP – Wound Associated Infections Audit Tool (sample#1)

PIP – Adherence to POC (sample #2)

PIP – Adherence to POC Audit Tool (sample #2)

PIP- Key Aspect of Administrative Function (sample #3)

PIP- Key Aspect of Administrative Function Audit Tool (sample #3)

07. Templates

A. Performance Improvement Project (template)
B. QAPI Committee Meeting Minutes (template)
C. Annual Performance Improvement (PI) Report (template)
D. Governing Body QAPI Review (template)
E. Governing BOdy orientation checklist
F. QAPI Self-Assessment tool (template)
G. Patient Record Audit Tool (template)
H. Personnel File Audit Form (template)
I. Patient Satisfaction Surveys (template)
J. Employee satisfaction survey (template)
K. Physician/Referral Source/Community Partner Satisfaction Survey (template)
L. Ethics Reports Log (template)
M. Ethics Report form (template)

ACHC HOME HEALTH POLICY AND PROCEDURE MANUAL

Section 1 – Organization and Administration

Legal and Regulatory Compliance Disclosure of Ownership and Management

Professional Standards and Principles

Governing Body Responsibilities and Requirements

Conflict of Interest

Administrator

Lines of Authority

Services Provide

Clinical Manage

Collection and Transmission of OASIS Data

Reporting Negative Agency Outcomes

services furnished underwritten agreement/contract

Waived Tests

Attachment

Governing Body Members roster

Governing Body Orientation checklist

Conflict of Interest Attestation Statement

Designation of Alternate Administrator

Organizational Chart

Designation of Alternate Clinical Manager

Contractor/Provider Agreement

Annual Contractor Evaluation

Section 2 – PROGRAM AND SERVICE OPERATIONS

Description of Care and Services

Patient Rights and Responsibilities

Reporting and Investigating Abuse and Neglect

Patient Grievances and Complaints

Patient Confidentiality and Protected Health Information

Advance Directives

Emergency Care and Resuscitation

Ethical Issues

Communication and Language Barriers

Provision of Patient-Centered Care

Agency Compliance Program

Supervisor and Nursing Availability

Approved Treatments and Procedures

Attachment

Patient Rights and Responsibilities

Sample Complaint Log

Sample Complaint Report

Notice of Privacy Practices

Compliance Reporting Poster

Section 3 – Fiscal Management

Agency Budget Plan

Capital Expenditure Plan

Financial Management and Business Practices

Financial Records Retention and Review

Disclosure of Rates for Care and Services

Attachment

Care and Service Rates

Section 4 – Human Resource Management

Personnel File Management

Verification of Credentialing

TB Screening and Vaccination Policies

Job Description

Driver’s License and MVR Checks

Background Checks

Employee Handbook and Personnel Policies

Annual Performance Evaluations

Orientation

Competency Assessment

Continuing Education and In-Service Requirements

Home Health Aide Training, Competency, and Supervision Requirements

Personal Care Attendants

Training for Waived Testing

Specialty Training and Certification for Nurses

Attachment

Personnel File Checklist

Sample Job Descriptions

Administrator

Clinical Manager

Registered Nurse

Licensed Practical/Vocational Nurse

Physical Therapist

Physical Therapist Assistant

Occupational Therapist

Occupational Therapist Assistant

Speech-Language Pathologist

Medical Social Worker

Home Health Aide

Quality Assurance Coordinator/QAPI Coordinator

acknowledgement Of receipt of Employee Handbook

Sample Performance Evaluations

Administrator

Clinical Manager

Registered Nurse

Licensed Practical/Vocational Nurse

Physical Therapist

Physical Therapist Assistant

Occupational Therapist

Occupational Therapist Assistant

Speech-Language Pathologist

Medical Social Worker

Home Health Aide

Quality Assurance Coordinator/QAPI Coordinator

Sample Competency Assessments

Registered Nurse

Licensed Practical/Vocational Nurse

Physical Therapist

Physical Therapist Assistant

Occupational Therapist

Occupational Therapist Assistant

Speech-Language Pathologist

Medical Social Worker

Home Health Aide

Sample Annual Education/In-service Agenda

Section 5 – Provision of Care and Record Management

Patient Record Requirements

Storage and Access of Patient Records

Initial Assessment and Plan of Care Development

COMPREHENSIVE ASSESSMENTS

Therapy and Medical Social Work Services Assessments

Drug Regimen Review and Medication Management

First Dose in the Home Setting

Plan of Care Requirements

Written Instructions for Patients and Caregivers

Care Coordination

Transfer/Discharge Criteria and Process

Verbal Orders

Changes in Patient Condition

Skilled Professional Services

Home Health Aide Services

Patient and Caregiver Education

Referral and Acceptance Process

Face-to-Face Encounter and Certification

Credential Verification for Physicians and

Allowed Practitioners

Outpatient Services

Attachment

drugs and solutions approved for home administration

patient referral and acceptance process policy revision flow sheet

Home health referral and admission availability assessment tool

Physician and Allowed Practitioner License Verification

Section 6 – QUALITY OUTCOMES AND PERFORMANCE IMPROVEMENT

Quality Assessment and Performance Improvement (QAPI) plan

Oversight and approval of the QAPI Program

Incidents and Occurrences Reporting and Documentation

Safe Medical Device Reporting

OASIS Data Reports

Attachment

Agency QAPI Plan

Annual QAPI Report

Sample Incident/Occurrence Report

Sample Incident Log

Section 7 – RISK MANAGEMENT: INFECTION CONTROL,
SAFETY and emergency preparedness

Infection Control Program

Exposure Control and Standard Precautions

Tuberculosis Screening and Prevention Plan

COVID-19 Standard

Employee and Patient Infection Control Training

Employee and Patient Infection Control Tracking

Blood-borne Pathogens Standard

Employee Personal Safety Education

Basic Home Safety

Office and Workplace Safety Plan

Hazardous Waste and Materials Use, Storage, and Disposal

Hazard Communication Standard

Incident and Occurrence Reporting for Personnel

Point-of-Care Laboratory Testing: PT/INR

Point-of-Care Laboratory Testing: Blood glucose monitors

Emergency Preparedness

Safe Use of Equipment and Supplies

Experimental Therapies and Clinical Research

Workplace violence prevention plan

Attachment

Agency TB Screening Assessment

Employee TB Screening Assessment

Patient Infection Log

Employee Infection Log

Fire Drill Log

Annual Office Environment Assessment

Incident/Occurrence Log

Incident/Occurrence Report

EMERGENCY PREPAREDNESS PLAN

RISK FACTORS FOR WORKPLACE VIOLENCE

WORKPLACE VIOLENCE PREVENTION PROGRAM ASSESSMENT CHECKLIST

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