Emergency Plan
Same month every year (annually)
Complete the Agreement with another Agency. (Fax to us the information to complete/submit the Plan)
Same month every year (annually)
Complete the Agreement with another Agency. (Fax to us the information to complete/submit the Plan)
Renew License Form: 60 days before to expiration date. CLIA application form
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)
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)
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)
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): EVV Policy Policy on Staff Background/Verifications: Verification
Medically Fragile Children Policy Policy Notes Delivery: Delivery Notes 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.
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