As Needed

New Conditions of Participation (CoPs) Implementation date: 01/13/18

CoPs State Interpreation Manual 2019

Administrator: PATIENT LEGAL REPRESENTATIVE NOTICE (Must be verbally completed before or during SOC, then within 4 days emailed/mailed to the Patient's Legal Representative) Signature proof required.

Representative Statment Representative Full Notice

D/C for Safety issue (Behavioral or other safety problems) : DC Safety Reason

Non Compliance D/C (Not Follow POC, Medication Plan, etc) : DC Non Comp.

D/C in Office (Used when OASIS DC was not completed) DC in Office/Agency

Coordination of Care (Fax/email, orders changes to Involved Physicians): Fax/Email Cover

Administrator: ORGANIZATIONAL CHART (Must be completed and posted in Agency's Board)Organizational Chart Agency Activity Calendar

DON: ORDER VERIFICATION/RECONCILIATION (Coordination of Care with all involved Patient's Physician)

Plan of Care (485) for Non Skilled Cases: POC (485)

(Only for cases where you can not contact by phone the patient's physician)

Order Verification

Non Admission Notice form: Non Admission

Alert Medication Interaction (Notification/Fax to Patient's Physician as needed)

Meds Interaction Notification (Also notify any detected medication discrepancy)

FDA approval waived instruments, (glucometers, etc) Operational Manual enhanced:

Link to FDA to obtain the Operation Manual

REGULATIONS:

Home Health Qualification (Patient's qualification, MD who can order, Face to Face, Value Purchased, etc)

Medicare HH Qualifications (Homebound) Medicare Conditional level def. (G Tags)(2018 G-Tags)

AHCA State deficiencies (H Tags) Policy on Admission (Homebound)

Face to Face guidelines Discharge Planning (CMS)

Prior Authorization Info (CMS) Value Purchased items

Federal G-Tag Summary Federal G-Tags Summary

DON: CASE CONFERENCE REPORT FORM (Must be completed at least every 30 days)

Case Conference Report Anticoagulation Management: Anticoagulation Program

DON: Staff Change Form Beneficiary Elected transfer to your Agency

Staff Change Form Beneficiary Elected Transfer

AUTHORIZATIONS/CONSENTS:

Authorization to release Information: Authorization to Release Information

Authorization to sign on behalf of Pt: Authorization to Sign

Specialty Shelter Refuse Registration: Shelter Refuse Registration

Consent to assistance of Self Administered Meds Consent to assistance with self adm. meds

Against Medical Advice (AMA) report: AMA report English AMA report Spanish

REPORTS:

DON: Missed Visit Report: (Fax to MD) DON oversight visits report (AHCA may request)

Missed Visit Report DON Oversight Visits Report

SURVEY:

Survey Documents request:

CHAP - AHCA JCHO ACHC Assessment/POC req. Survey Tips

Common Survey Questions Common Errors JCHO Safety Goals Poster

Common Survey Qt Common Errors Patient Safety Goals Poster

Common Staff Qt Total Patients visits

Prevent Conditionals Defficieny Survey Ready Check List

Administrator:

Sample Accountant External Review: Survey required (CHAP only)

Accountant Ext. Rev. Sample

Electronic Signature Authentication

For Staff who sign by any electronic mean For Physician (authentication electronic signature)

Electronic Signature Authentication MD Electronic Signature Authentication

Electronic Health Record Staff Access Authorization: Electronic HR Authorization

CONTRACTS: STAFFING COMPANY, BUSINESS ASSOCIATED, ALF

Administrator: Business Associate Contract with all Associated Business with possible access to Patient Information (including voluntary members of the PAC (non employees), Staffing Company, Consultants, Billing Agent, Waste pickup company, etc)

Business Associate Contract Staffing Company Contract

Contract with ALF, Nursing Home or Hospice: (not mandatory)

ALF Contract

POLICY/MANUALS/PLANS:

POLICY MANUAL INDEX to search Policy page: Policy Index/content

Policy Manual Orientation Survey common policy request (pages)

Manual Orientation Common Policy request

Record Retention Information Staff Competency Policy Update

Record Retention Staff Competency

Generic Cover Manual Emerging Infectious Disease (like Coronavirus)

Manual Cover Emerging Infectious Disease Policy

Pandemic Management Plan Policy Manual Signature page

Pandemic Plan DON/Administrator signature

Risk Management Plan Drug Free Workplace program

Risk Mgm Plan Drug Free Program

Patient Educational Materials Agency Compliance Plan

Patient Educational Materials Agency Compliance Plan

Staff Health Policy RN task delegation to CNA/HHA

Staff Health Policy RN task delegation Criteria Delegation of Tasks Policy

Agency Influenza Vaccination Improvement Plan: Agency Influenza Vaccination Plan

Influenza Vaccine Goals Policy: Influenza Vaccine Goals Policy Alzheimer's Training: Alzheimer's

EVV (Electronic Visit Verification Policy): EVV Policy

NAME CHANGES POLICY, FORMS:

Ethic Committee Members Name/Title Board Members Name/Title

Ethic Committee Members Board Members

Compliance Cte members Name/Title Policy Named Administrator/DON

Compliance Committee Administrator & DON names

Executive: GB, QAPI,etc Name/Title HIPAA Authorities (Name/Titles)

Executive Staff HIPAA Authorities

Safety Committee Name/Title Infection Control Committee members (Name/Title)

Safety Committee Infection Committee

____________________________________________________________________

Policy Wages and Charges: Policy on Charges:

Wages & Charges Charges for Services

Back Up / Contingency Policy: Policy on Admission (Homebound)

BackUp Contingency Policy Policy on Admission (Homebound)

Influenza and pneumococcal vaccine administration Policy

Influenza & Pneumococcal Vaccine

CASPER Report Manual (OBQI): CASPER (OBQI) Manual

ICD10 Tips: TIPS/Samples ICD10 ICD10 Guidelines

HHCAHPS Web: HHCAHPS Enrollment

Disclaimer: Every log/form template is only your guide to complete each log/form, your Agency Officials must assure that every member had active participation in the discussion and confection of the Log, Reports, Evaluations, Documents.

As needed Documents

(Complemented documentation)

Emergency Plan

Your License must be renewed every 2 years