CHAP Core Operational Policies And Procedures And

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Thank you very much for purchasing this Policy Manual. This manual is designed so thatimplementation of the policies will result in compliance with the CHAP standards foraccreditation and Medicare Conditions of Participation for Home Care. The manual is dividedinto two sections:CHAP Core Operational Policies and ProceduresandCHAP Home Health Operational Policies and ProceduresWe know you will find it helpful as you prepare for CHAP accreditation, Medicarecertification and continue to improve your operational practices.This manual has been copyrighted by The Corridor Group, Inc. (TCG) and is thereby protectedby copyright laws of the United States and foreign countries.TCG hereby grants Visiting Nurse & Hospice Care license to use documents therein for allinternal purposes. TCG requires that Visiting Nurse & Hospice Care will not disclose thecontents of such manuals to any third party, or allow any third party to use the manuals for anypurpose.

CORRIDOR MEDIA, INC.MANUAL PURCHASING LICENSE AGREEMENTThis is a legal agreement between the CUSTOMER and CORRIDOR MEDIA, INC. Upon receiving the CD-ROM, theCUSTOMER is agreeing to be bound by the terms of the agreement below.TERMS USED THROUGHOUT THIS AGREEMENTAll references to customer, patient, facility, site, location, or physical location throughout this document will refer to:Visiting Nurse & Hospice Care located at 2821 WEst 33rd Street, Erie, PA 16506.All licensing and usage agreements are assigned specifically to Visiting Nurse & Hospice Care located at 2821 WEst33rd Street, Erie, PA 16506.LICENSE FEEAll fees, taxes, and other applicable charges governed by this agreement are due upon receipt of the CORRIDORMEDIA, INC. invoice, and prior to shipping of said product.TERMS OF AGREEMENTCUSTOMER is entitled to use This CORRIDOR MEDIA MANUAL at the site or location originally purchased for thelife of the product for which CUSTOMER has paid.SITE LICENSEFor each purchase and subject to the terms and conditions of this agreement, CORRIDOR MEDIA, INC. grantsCUSTOMER the nonexclusive, nontransferable right to CORRIDOR MEDIA MANUAL. Use in more than one (1)facility or physical location by any means, including but not limited to intranet or Internet sharing requires one (1) paidlicensed manual per facility or physical location. This license allows use of the product for the internal business of theCUSTOMER only; commercial use is prohibited, as is use by any party other than CUSTOMER and its employees inthe specific site or location originally purchased. CORRIDOR MEDIA, INC. reserves all rights not expressly grantedto CUSTOMER.OWNERSHIP AND CONFIDENTIALITYCORRIDOR MEDIA, INC. retains ownership of the POLICIES AND PROCEDURES MANUAL. Supportingapplications are licensed for use by CUSTOMER and are owned by their respective companies. CUSTOMER agreesnot to reverse-engineer any application provided with the product. CORRIDOR MEDIA, INC. grants CUSTOMER theright to modify the manual to meet the CUSTOMER’S specific needs. CUSTOMER assumes all responsibility for theaccuracy and effectiveness of all such modifications.COPY RESTRICTIONSThis SOFTWARE and the accompanying written materials have copyright protection. These manuals are protectedby copyright laws of U.S. and foreign countries and are licensed for single locations only. Any reproduction of thisdocument other than for specific use within the CUSTOMER single location is strictly prohibited. Any other copying,duplication, or broadcasting of the SOFTWARE or the accompanying written materials is forbidden. No part of thewritten materials may be reproduced, transmitted, transcribed, stored in a retrieval system, shared by computernetworks, intranets, or the Internet, or translated into any magnetic, optical, chemical, manual, or otherwise, withoutthe prior written permission of CORRIDOR MEDIA, INC. CUSTOMER may be held legally responsible for anycopyright infringement that is caused by your failure to abide by the terms of this LICENSE. CORRIDOR MEDIA,INC. requires that the user will not disclose the contents of such materials to any third party, or allow any third party touse the manuals for any purpose.

REVISION OF WRITTEN MATERIALSCORRIDOR MEDIA, INC. reserves the right to revise this publication and to make periodic content changes.CORRIDOR MEDIA, INC. will notify any person of such revision or changes to be purchased for a fee.VISITING NURSE & HOSPICE CARE RESPONSIBILITIESCUSTOMER is responsible for installing the CD-ROM and setting up hardware, for maintaining its computer system,and for keeping network and software in good working condition. CUSTOMER is also responsible for ensuring thatcomputers meet the minimum system configuration.NO OTHER WARRANTIESTo the maximum extent permitted by applicable law, CORRIDOR MEDIA, INC. disclaims all other warranties, eitherexpress or implied, including but not limited to implied warranties of merchantability and fitness for a particularpurpose, with respect to the program, the related product manual and written materials, and any accompanyinghardware and/or software. This limited warranty gives CUSTOMER specific legal rights. CUSTOMER may haveothers that vary from state/jurisdiction to state/jurisdiction.NO LIABILITY FOR CONSEQUENTIAL DAMAGESTo the maximum extent permitted by applicable law, in no event shall CORRIDOR MEDIA, INC. or its suppliers beliable for any other damages whatsoever (including, without limitation, pecuniary loss) arising out of the use of orinability to use the software, even if CORRIDOR MEDIA, INC. as been advised of the possibility of such damages. Inany case, CORRIDOR MEDIA, INC. entire liability under any provision of this agreement shall be limited to the feepaid by CUSTOMER for the product. Because some states/jurisdictions do not allow the exclusion of limitation ofliability for consequential or incidental damages, the above limitation may not apply to CUSTOMER.BREACHCUSTOMER's failure to comply with the provisions of this license agreement constitutes a breach and will be causefor CORRIDOR MEDIA, INC. to require return of the POLICIES AND PROCEDURES MANUAL and removal fromCUSTOMER's computers of all components thereof. Certain breaches may result in CORRIDOR MEDIA, INC.pursuing legal remedies against CUSTOMER, specifically, but not limited to, unauthorized and unpaid use at multiplesites, copying and/or reverse engineering the program, commercial use of the product, and/or abuse of Help Deskservices by continued requests for assistance with problems unrelated to the POLICIES AND PROCEDURESMANUAL.APPLICABLE LAWThis agreement is governed by the laws of the state of Kansas. If any provision(s) of this agreement are found to belegally invalid, the other provisions shall remain in effect.RECOMMENDED HARDWARE/SOFTWARECORRIDOR MEDIA, INC.'s Recommended Hardware/Software Configuration for the POLICIES AND PROCEDURESMANUAL: Microsoft Windows 98 or higherMicrosoft Word 97 with postscript fonts installedPentium II processor 350 MHz or higherTo install POLICIES AND PROCEDURES MANUAL for Microsoft Word, CUSTOMER must accept this agreement. IfCUSTOMER does not agree to the license agreement, please EXIT setup now.

INSTALLATION INSTRUCTIONSThe Corridor Manuals have been provided to you on CD-ROM for use as a tool in customizing and updating the information to meet the needs of your individual program. You must have a CR-ROM drive and Windows to installthis product.These instructions only address installing the information from the CD-ROM onto your computer.If you need information about how to insert, delete, or search/replace information, please consult the user'smanual that accompanied your word processing software. Information is easily added and/or deleted using thecut/copy/paste function of the software. Since everyone’s computer may read converted data differently, you maynotice some changes in spacing, character formats, and, in some cases, where page breaks fall.Following the instructions below, the files containing your manuals will be automatically installed on your computerinto the following path: C:\ Program files\Corridor Products\Windows 95 and above using Windows Explorer:1.Insert the CD-ROM into your CD-ROM drive. On most computers, the CD-ROM should start automatically2.If the install program does not start automatically, open Windows Explorer.3.Select your CD-ROM Drive.4.Double click on the setup.exe file.5.Follow the prompts.To Access Information after Installation: 1.Go into Microsoft Word.2.Select File.3.Select Open.4.Under Drives, select C:.5.Open the path: Program files\Corridor Products\.6.Select which file you would like to open.7. Press Enter.Please note: We have attempted to make these instructions as simple as possible. However, we understand that some computer systems, i.e., Windows 95 may vary in the steps taken to create a directory, open a file from aCD-ROM, or copy files. If your system differs from these instructions, please retrieve and use these files according toyour computer’s specifications.NAVIGATION INSTRUCTIONSHypertext links are tools that facilitate navigation within a document. The user is able to go directly to a locationwithin the document without manually scrolling through the pages. Hypertext links are located within this document.While the user always has the ability to navigate the document with the scroll bar, these tools allow easier movementwithin the document.All items that are “linked” to another part of the document appear in color on the computer screen. Locate the sectionof the document that you want to find, click on the colored text and the hyperlink will take you directly to that section.

Visiting Nurse & Hospice CarePOLICY NUMBERING AND REFERENCESPolicies have been numbered to identify the manual name, section, policy number and page.Example:HH:2-043.1 The HH: represents the Home Health Manual The 2 represents Section Two The 043 represents policy 43 within the section .1 represents page 1 of that policyPOLICY CODESMANUAL REFERENCEDC:CoreHH:Home HealthH:HospicePolicies in each manual have been “crosswalked” to the corresponding Community HealthAccreditation Program (CHAP) standards and Medicare Conditions of Participation. Thecrosswalk also contains a legend identifying the evidence required by CHAP.CHAP Home Health Manual/revised February 2011 2003 The Corridor Group, Inc.

Visiting Nurse & Hospice CareCROSSWALK OF POLICIES AND PROCEDURESWITH CHAP STANDARDS ANDMEDICARE CONDITIONS OF PARTICIPATIONCHAP Home Health Manual/revised February 2011 2003 The Corridor Group, Inc.

Visiting Nurse & Hospice CareSECTION ONEStructure and RECOP1.Scope of ServicesD, IHHI.1a2.Listing of Services ProvidedD, IHHI.1b3.Regulatory ComplianceDHHI.2a484.12, 484.12(a-b)4.Professional Advisory CommitteeD, I, OHHI.2c-g484.16, 484.525.Home Health Organizational ChartDHHI.3a484.146.Home Health AdministratorHHI.4a-c484.14(c-d)7.Home Health Clinical Policies and ProceduresDHHI.5b484.14(g), 484.18(bc), 484.36(e)8.Home Health Record RetentionD, OHHI.5d484.48(a)9.Scope of the Behavioral Health ProgramDHHI.5c10. Scope of the Pediatric ProgramDHHI.5c11. Scope of the Obstetrical ProgramDHHI.5c12. Telemedicine ProgramDHHI.5e (3)13. Telemedicine—Patient PrivacyDHHI.5e (3)14. Telemedicine—Admission CriteriaDHHI.5e (1)15. Telemedicine—Plan of CareDHHI.5e (1)16. Telemedicine—Patient EducationDHHI.5e (2)17. Telemedicine—Discharge CriteriaDHHI.5e (1)18. Medicare Written NoticesDCII.1b(11)D, I, O484.14(a), 484.18484.10(e)19. Not in Use20. Not in Use21. Internal Control Systems/AccountabilitiesLegend of Evidence for CHAP Accreditation:D DocumentsI InterviewCHAP Home Health Manual/revised February 2011O ObservationS Survey 2003 The Corridor Group, Inc.

Visiting Nurse & Hospice CareSECTION TWOQuality of Services and RECOP1.Home Health Patient Bill of RightsDHHII.1484.102.Intake ProcessDHHII.4484.183.Admission Criteria and ProcessDHHII.4a484.184.Care Planning ProcessD, IHHII.4b, HHII.5a484.18, 484.18(a),484.18(b),484.30(a), 484.325.Physician Participation in Plan of CareD, IHHII.4c484.18, 484.18(b)6.Verification of Physician OrdersHHII.5g, h484.18(b, c)7.Rehabilitation Care PlanningD, IHHII.5a484.18(a)8.Nutrition Care PlanningD, IHHII.5a484.18(a)9.Home Health Aide Plan of CareD, OHHII.5m, n484.36(c)D10. Orientation of Assigned Home Health AideD, I, OHHII.5n484.14(e)11. Support/Chore Worker Service PlanD, I, OHHII.5o, p484.36(d)12. Discharge PlanningD, IHHII.4c484.14(g)13. Continuity of CareD, IHHII.4c484.14(g)DHHII.4d484.14(g)HHII.4c, HHII.5i484.14(g), 484.18,484.18(b)DHHII.5j484.14(g)17. Patient Notification of Changes in CareD, IHHII.4c484.14(g)18. On-Call/Weekend StaffingD, IHHII.319. Coordination of Services with Other ProvidersD, IHHII.4c20. Internal Referral ProcessD, IHHII.4c14. Case Conference/Progress Summary15. Monitoring Patient’s Response/Reporting toPhysician16. 60-Day Summary Report21. Initial and Comprehensive AssessmentD, ID484.14(g)HHII.5c, d22. Ongoing Assessments484.14(g), 484.32,484.34484.18, 484.18(a),484.55(a),484.55(b),484.55(c), 484.55(e)484.18, 484.55Legend of Evidence for CHAP Accreditation:D DocumentsI InterviewCHAP Home Health Manual/revised February 2011O ObservationS Survey 2003 The Corridor Group, Inc.

Visiting Nurse & Hospice CareSECTION TWOQuality of Services and RECOP484.18(b), 484.55(b),484.55(c), 484.55(d),484.55(e)484.30(a), 484.32,484.5523. Reassessments/RecertificationDHHII.5d, e24. Functional AssessmentDHHII.5d25. Nutritional AssessmentDHHII.5d484.5526. Pain AssessmentDHHII.5d484.5528. Medication ProfileDHHII.7a484.18(c), 484.55(c)29. Identification of Medication for AdministrationDHHII.7b484.18(c)30. Administration and Documentation of MedicationsDHHII.7b484.55(c)33. Intravenous Administration ofMedications/SolutionsDHHII.7b484.55(c)34. Intravenous Administration of ChemotherapyDHHII.7bDHHII.7c42. Medication ErrorDHHII.7c43. Medication MonitoringDHHII.7a27. Assessment of Possible Abuse/Neglect31. Patient Self-Administration of Medication32. Home Use and Disposal of Controlled Substances35. First Dose Policy36. Crushing of Medications37. Pulse Rate Determination with Certain Drugs38. Storage of Medications and Nutritional Products39. Medication Labeling40. Adverse Drug Reactions41. Anaphylaxis Protocol484.18(c), 484.55(c)Legend of Evidence for CHAP Accreditation:D DocumentsI InterviewCHAP Home Health Manual/revised February 2011O ObservationS Survey 2003 The Corridor Group, Inc.

Visiting Nurse & Hospice CareSECTION TWOQuality of Services and RECOP44. Investigational Medications47. Do Not Resuscitate/Do Not Intubate OrdersD, IHHII.5a484.10(c)48. Cardiopulmonary ResuscitationD, IHHII.5a49. Withdrawal of Life-Sustaining CareD, IHHII.5a51. Transfer/Referral Criteria and ProcessDHHII.5k484.34, 484.48(a)52. Transfer SummaryDHHII.5k484.14(g), 484.48(a)53. Discharge Criteria and ProcessDHHII.5l484.34, 484.48(a)54. Discharge SummaryDHHII.5l484.14(g), 484.4855. Contents of Clinical RecordDHHII.8a, b484.4856. Assembly of Clinical RecordDHHII.8d484.48HHII.9a, b484.52(b)50. Care of the Dying Patient57. Clinical Record ReviewD, I58. External Databases484.20(c)59. OASIS Data TransmissionD, I, OHHII.5d,e,f484.20Legend of Evidence for CHAP Accreditation:D DocumentsI InterviewCHAP Home Health Manual/revised February 2011O ObservationS Survey 2003 The Corridor Group, Inc.

Visiting Nurse & Hospice CareSECTION THREEHuman, Financial, Physical ARECOP484.12(c), 484.14(de), 484.36, 484.36(ad)1.Home Health Human ResourcesD, I2.Home Health Staffing GuidelinesD, IHHIII.1b3.Responsibilities/Supervision of Clinical ServicesD, I, OHHIII.1e484.14(d), 484.36(d)4.SupervisionD, I, OHHIII.1e484.14(d), 484.36(d)5.Access to Qualified ConsultationD, I, OHHIII.1e484.14(d), 484.36(d)6.Consultation for Specialty ServicesD, I, OHHIII.1e484.14(d),484.30(a), 484.36(d)7.Communication With OfficeD, I, OHHIII.1e484.14(d), 484.36(d)8.Home Health Contracted ServicesDHHIII.2a9.Contracted Service ProvidersD, IHHIII.2aHHIII.1a484.11, 484.14,484.14(f), 484.36(d)484.11, 484.14,484.14(f), 484.36(d)10. Training/Inservice EducationDHHIII.1f, h11. Competency AssessmentDHHIII.1g12. Home Health Aide TrainingD, I13. Home Health Aide Supervisory Visits14. Physician Licensure Verification15. Home Health Capital Expenditure PlanHHIII.1c, d484.36(b)484.30(a), 484.32,484.36(b)484.36(a),484.36(b), 484.36(c)D, I, OHHIII.1e484.36(d)D, OHHII.1i484.18DHHIII.3Legend of Evidence for CHAP Accreditation:D DocumentsI InterviewCHAP Home Health Manual/revised February 2011O ObservationS Survey 2003 The Corridor Group, Inc.

Visiting Nurse & Hospice CareSECTION FOURLong Term ViabilityPOLICY/PROCEDURE1.Home Health Annual Evaluation2.Home Health InnovationEVIDENCEDD, I, OCHAPSTANDARDMEDICARECOP484.14(i), 484.16,484.16(a), 484.52,484.52 (a-b)HHIV.1HHIV.2a–cLegend of Evidence for CHAP Accreditation:D DocumentsI InterviewCHAP Home Health Manual/revised February 2011O ObservationS Survey 2003 The Corridor Group, Inc.

Visiting Nurse & Hospice CareSECTION FIVEPatient and Family/Caregiver ient Education ProcessD, IHHII.5a2.Safe/Effective Use of MedicationsD, IHHII.5a3.Drug–Food InteractionsD, IHHII.5a4.Pain Management EducationD, IHHII.5a5.Rehabilitation TechniquesD, IHHII.5a6.Appropriate Use of Restraints and SuppliesD, IHHII.5a7.Safe/Effective Use of Equipmentand SuppliesD, IHHII.5a8.Storage, Handling, and Access toSupplies and GasesD, IHHII.5a9.Identification, Handling, and Disposalof Hazardous WasteD, IHHII.5a10. Infection Control PrecautionsD, IHHII.5a11. Natural Disasters/EmergenciesD, IHHII.5a12. Basic Home SafetyD, IHHII.5aD, IHHII.5a14. Educational ResourcesD, IHHII.5a15. Community ResourcesD, IHHII.5a13. Patient Education Related toDischarge PlanningMEDICARECOPLegend of Evidence for CHAP Accreditation:D DocumentsI InterviewCHAP Home Health Manual/revised February 2011O ObservationS Survey 2003 The Corridor Group, Inc.

Visiting Nurse & Hospice CareSECTION SIXJob DICARECOP1.Policy Statement2.Scope of the Program/Process MethodologyDHHI.5c, HHIII.1g,.1h3.Competency Based OrientationDHHIII.1g, .1h484.364.Core Competency SkillsDHHIII.1g, .1h484.365.Annual Core CompetenceDHHIII.1g, .1h484.366.Specialized ServicesDHHIII.1g, .1h7.Requirements for Supervisors/PreceptorsDLegend of Evidence for CHAP Accreditation:D DocumentsI InterviewCHAP Home Health Manual/revised February 2011O ObservationS Survey 2003 The Corridor Group, Inc.

Visiting Nurse & Hospice CareSECTION SIXJob DescriptionsATTACHMENTSAttachment I: . CHAP CrosswalkAttachment II: . Medicare Conditions of ParticipationAttachment III:.Home Health Agency Interpretive GuidelinesAttachment IV:. Home Health Agency ManualAttachment V . Additional ResourcesCHAP Home Health Manual/revised February 2011 2003 The Corridor Group, Inc.

HOME HEALTH IStructure and FunctionVisiting Nurse & Hospice CareSECTION ONEStructure and FunctionPolicy No.Scope of Services. HH:1-001Listing of Services Provided.

MEDICARE COP 1. Home Health Patient Bill of Rights D HHII.1 484.10 2. Intake Process D HHII.4 484.18 3. Admission Criteria and Process D HHII.4a 484.18 . CHAP MEDICARE . CHAP MEDICARE . Visiting Nurse & Hospice Care CHAP 4. Visiting Nurse & Hospice Care CHAP .

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