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
PRIVACY AND SECURITY NOTICE REGARDING ELECTRONIC FORMS.
Our electronic forms are
provided solely as a convenience to assist Home Health Agencies in
completing required documentation. The forms operate within your web browser
and are intended for local use by authorized agency personnel. No patient
information entered into these forms (if any) is collected, stored, saved,
transmitted, processed, or retained by our website, servers, or systems. The
information entered remains under the control of the user and is used only
to generate or complete the form for the agency's own records. Because no
protected health information (PHI) is received, maintained, saved, or
retained by our website, we do not create or maintain a database of patient
information from these forms. This website is protected by a valid HTTPS
Secure Sockets Layer (SSL/TLS) certificate, which encrypts communications
between your web browser and our website to help protect the integrity and
security of your connection. Home Health Agencies remain solely responsible
for ensuring that any completed forms are handled, stored, transmitted,
printed, or incorporated into their medical, administrative record systems
in compliance with all applicable federal and state laws, including the
Health Insurance Portability and Accountability Act (HIPAA), the Health
Information Technology for Economic and Clinical Health (HITECH) Act,
applicable Centers for Medicare & Medicaid Services (CMS) Conditions of
Participation, and any other applicable state and federal privacy and
security requirements. By using these electronic forms, users acknowledge
that they are responsible for maintaining the privacy, security, and
confidentiality of any patient information after the form has been
completed. Please Note: While this website uses industry-standard HTTPS
(SSL/TLS) encryption to secure communications, HIPAA compliance ultimately
depends on how each Home Health Agency uses, stores, transmits, and
safeguards Protected Health Information (PHI) after the form has been
completed.
Medical Record: Clinical Record Entry Log: Clinical Record entry Log
(by authorized staff only)
DON: Referral Log (Admitted / Non Admission): Referral Log
DON: High Risk/Alert Medication LOG (This log document the control of High Alert Medications) Section 1557: Language Assistance Language Log
High Alert/Risk Medications Auxiliary Aide Log Auxiliary Log
DON: Medication Reconciliation LOG (This log document the Medication reconciliation)
Medication Reconciliation Hospitalization Log: Hospitalization
Medication/Drugs/Supplies list:
DON: Sound/Look alike: Supplies Inventory/Cleaning Storage
Sounds/Looks Alike Supplies Inventory/Cleaning Storage
Equipment Maintenance: Log EM
DON: Fall Injury review tool LOG
Fall Injury Review Tool (as needed) OSHA’s Form 300 Osha's 300
Ass needed:
ON CALL: Report: ON Call Report On Call Log/Calendar: ON Call Log
Visitor Log: Visitor Log (Front desk clip board)
Administrator/DON: Emergency Control Log (Monthly) Hazard Vulnerability
(Included in the Safety Minutes reports)
Emergency Control Log (All reports in the Safety minutes must be completed)
Hazard Vulnerability Analyzes Hazard Vulnerability Log
Administrator/DON: Safety Tracking LOG (All year long) Safety Tracking Log
Administrator/DON: Complaints
Complaint, ON-CALL report: Complaints Report
Med Watch 3500 Log Med Watch Log
Administrator/DON: Orders Movement Log (needed if late signed focus detected)
Administrator/DON: INCIDENT REPORTS (Must be completed as applicable)
DON: FALL INCIDENT Report (Must be completed as applicable)
DON: MEDICAL ERROR Report Anti-coagulant Incident
Medical Error Report Anti Coagulant Report
DON: SHARP INJURY INCIDENT Report (Must be completed as applicable)
Multiple incident report forms: Multiple Incident Report forms
(AI) INCIDENT REPORT FORM
(AI) Incident Report
Use this form to report any actual o
r
suspected Artificial Intelligence (AI)-related incident
affecting patient care, documentation, privacy, cybersecurity,
regulatory compliance, or Agency operations.
(AI) PRIVACY BREACH REPORT FORM (AI) Privacy Breach Report Use this form to report any actual or suspected privacy breach involving an Agency approved Artificial Intelligence (AI) application or AI-assisted process.
DON: Adverse Event Incident Report Form: (if needed, fall, severe patient's health impact, etc.)
Adverse Event Incident UTI: Adverse UTI Event Incident
Abuse:
Abuse Incident Report Plan to Prevent Abuse Incident
Administrator/DON/QA: Patients/MD Survey Summary Table Analyzes (Quarterly)
(HCAPS reports can replace this sumaries) Patients Survey Form
Physicians survey (at least yearly): Physicians Survey Form
Results of Patients survey analyzes, possible Adverse Event
Patients Survey Summary Adverse Event Patient Survey
Administrator: Extinguisher Log (Monthly-Yearly)
Administrator: Visitor Log (all year long, front desk)
Visitor Log
Disclaimer: Every log template is only your Guide/Agenda to complete each log, your Agency Officials must assure that every member had active participation in the discussion and confection of the Log, Reports, Evaluations, Documents.
This service reflects the author’s own opinions about Home Health Care services. Although the information and Policies are from sources deemed very reliable, they are not guaranteed. PN System © owner disclaims any personal liability for loss incurred as a result of the applications of any information offered in this application process, or in the use of our services. If expert, professional, medical, clinical assistance is required, the services of a component professional person should be sought. Your Director of Nursing, MUST review/approve the Policies / Procedures/ Forms.
Also you and your Agency guarantees to comply with all Federal/Local/State laws to use our services.
Please take a moment to comment about our services:
We are Proud Member of the Home Health Association of Florida:
Experience:
Over 30 years serving more than 2000 Home Health Agencies nationwide.
CMS Education/Seminars
ACHC Education/Seminars
CHAP Education/Seminars
FULL ADMISSION PACKAGE:
(One Patient's Signature only)
$5.00 each
Minimal Order 25
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