Emergency Plan
Same month every year (annually)
Complete the Agreement with another Agency. (Fax to us the information to complete/submit the Plan)
Quality Assurance (QAPI) 
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.
(The templates must be updated with your discussion during
preparation of your PI and QA program, and Agency's data and
reality, your DON must review/approve the reports and data
collection.)
Also: Please complete to be ready for new CoPs:
1) The Clinical Record review minute and support documents
2) ALL monthly/quarterly report
3) ALL Logs
DON/QA Staff: Template for Performance Improvement Data Collection/Analyzes:
QAPI Data collection (al year long) PI Monitoring Log (Quarterly)
DON: Performance Improvement Plan: Target for Improvement or Replication (quarterly)
Performance Improvement Plan (annual) PI target for improvement report Pediatric PT target for improvementMeasurable Improvement report: (DON-quarterly) Care Plan Compliance problem PI Report
Measurable improvement report Care Plan compliance Problem PI report
DON, Clinical Manager/QA: Performance Levels, Patterns, Trends, Variations: (Quarterly)
PI: Performance, Patterns, Trends PI: Performance Tracking Report
DON, Clinical Manager: OBQI Analyzes LOG (OBQI report must be analyzed by the Agency on Regular BD meeting, this log documented the review of the OBQI (Casper) reports) (Quarterly)
OBQI Analyzes Log Adverse Event (OBQI Analyzes)
QAPI PROJECT (CoPs):
QA/DON/Clinical Manger: Monthly report about hospitalization, emergency care prevention (results of risk assessment)
DON: Hospitalization LOG (Must be completed monthly) Hospitalization Log
Hospitalization risk analysis: Hospitalization risk analysis Emergency care risk analysis: Emergency Care risk analysis
QAPI Project Hospitalization/Emergency Care: Hospitalization/Emergency care services risk Project
QAPI Plan-Do-Study-Act (PDSA) Hospitalization/Emergency Care PDSA
Decreasing Hospitalization, Improvement report: Decreasing hospitalization/Improvement Report
Cardio Vascular Disease Project: CVD Project CVD Plan-Do_Study (PDSA) CVD PDSA
(Complete the DC Planning control log, and have the Total DC patients with High BP)
QAPI TOOLS:
DON/QA staff: Progress Note review form Sign Up Package check up form Improve Documentation:
Progress Notes Review Form Sign Up Package Check list Prevent Conditionals Defficieny
DON/QA Staff: Chart Audit check list Q60 days (On Recert or Discharge)
Record review tool:
QA Audit Form
Private Duty:
QA
audit Form
(PD)
Pediatric:
QA Audit Form
(Ped.)
Artificial intelligence is no longer a future concept for home health care—it is becoming an important tool for improving quality, strengthening patient safety, supporting clinical and administrative staff, enhancing documentation, streamlining operations, and promoting more effective coordination of care in the home setting. As AI adoption continues to expand, Home Health Agencies have an important opportunity to use these technologies responsibly and strategically. AI should support—not replace—the professional judgment, clinical decision-making, and responsibilities of qualified healthcare personnel. Its implementation must include appropriate human oversight, protection of patient privacy and health information, documentation integrity, staff education, and ongoing quality monitoring. When implemented appropriately, AI can help Home Health Agencies improve efficiency and consistency while preserving the personal interaction, professional accountability, and patient-centered approach that are essential to providing safe, high-quality care in the patient’s home. (Call our office to order your (AI) Implementation Manual, to be in compliance with (AI) professional standards (Content, price can be reviewed in our webasite at https://pnsystem.com/Consulting.htm))
(AI) Documentation Review Checklist (AI) Documentation review Use this checklist to review (AI)-assisted clinical or administrative documentation before it becomes part of the legal medical record.
(AI) Clinical Validation Checklist (AI) Clinical Validation Complete this checklist before implementing or significantly modifying any Artificial Intelligence (AI) application used to support clinical care, documentation, or clinical decision support
(AI) Corrective Action Plan (CAP) (AI) Corrective Action Plan Use this form to document corrective actions resulting from AI-related audits, incidents, QAPI reviews, privacy events, security findings, vendor issues, or regulatory deficiencies.
DON/QA Staff: POC Tips POC TIPS (Orders/Goals) Prevention Conditional level defficiency Assement/POC
Nurses Teaching tools at: https://www.hsag.com/zone-tools
PANIC VALUE list: (Verify that if any parameter is out of normal limit, the patient's physician was notified)
* Please be sure to add to the 485 Goals (box 22) realistics End Point goals
* Add Hospitalization & Emergency visit risks, Patient's identified goals, care preferences
* Add Advance Directives information in details to 485 (as was collected during sign up)
PANIC VALUE (Can be customized, if changed please replace that page in your Policy Manual)
QA Staff: Verification of visits/services patients random calls (Monthly)
Monthly QA Phone Calls Patient Satisfaction Survey Patient Survey Patient Survey Summary Summary
MD Survey MD Survey
QA Staff: Performance Improvement Bar Graphic Study sample:
BAR Graphic Hospitalization Risk BAR Graphic Generic
SURVEY DOCUMENTS REQUEST:
Survey Documents request:
CHAP - AHCA CHAP - Policy 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 Home Visit items
Prevent Conditionals Defficieny Survey Ready Check List Home Visit (ACHC) items
Administrator/DON: Survey Ready Check List
Survey Ready Check List Value Base Purchase VBP Information VBP Information 2
Covid-19 QAPI Report (Quarterly): COVID-19 PI Report *** no longer mandatory after 05/11/2023
For use by External QAPI RN only:
Consultant Report (After visit as applicable)
External RN QAPI review Business Associate contract: Business Associate RN QAPI Contract
Disclaimer: Every template is only your guide/AGENDA to type the Minutes of your meeting, your Agency Officials must assure that the meeting occur, the quorum is acceptable, and every member had active participation in the discussion
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