As needed Documents

Emergency Plan

Same month every year (annually)

Complete the Data Sheet.

Complete the Agreement with another Agency. (Fax to us the information to complete/submit the Plan)

Your License must be renewed every 2 years

Renew License Form: 60 days before to expiration date.    CLIA application form

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 Form) :    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

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 DOCUMENTS REQUEST:

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 UPDATES / 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

Policy on Non Discrimination (Section 1557)    Non-Discrimination    V.O. read back VO read back

(Section 1557, pamphlet mandatory)                         Acceptance of patients (2025) Policy acceptance Pt

EVV (Electronic Visit Verification): EVV Policy  Policy on Staff Background/Verifications: Verification

Medically Fragile Children  Policy     Policy Notes Delivery:  Delivery Notes Policy

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

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

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                                         

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

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.