SAMPLE - California Association for Health Services at...
Transcript of SAMPLE - California Association for Health Services at...
HOSPICE I Organization’s Name Structure and Function
*Requires organization-specific information.
California CHAP Hospice Manual/Revised October 2015 © 2003 The Corridor Group
SECTION ONE
Structure and Function Policy No.
Philosophy, Mission, and Purpose ....................................................................................... H:1-001
Regulatory Compliance ....................................................................................................... H:1-002
Clinical Policies and Procedures .......................................................................................... H:1-003
Hospice Professional Advisory Committee ......................................................................... H:1-004
Addendum: Hospice Professional Advisory Committee Members* ............................ H:1-004.A
Hospice Administrator ......................................................................................................... H:1-005
Informed Consent for Patient and Family/Caregiver ........................................................... H:1-006
Medicare Hospice Benefit.................................................................................................... H:1-007
Medicaid Hospice Benefit.................................................................................................... H:1-008
Hospice Site Visitor Home Visit Consent ........................................................................... H:1-009
Financial Responsibility and Medicare Written Notices ..................................................... H:1-010
Addendum: Advance Beneficiary Notice (ABN) of Noncoverage .............................. H:1-010.A
Addendum: Notice of Medicare Provider Noncoverage .............................................. H:1-010.B
Addendum: FFS Expedited Review Detailed Notice ................................................... H:1-010.C
Addendum: Additional CMS Resources for ABN and Expedited Notices .................. H:1-010.D
Corporate Compliance Plan* ............................................................................................... H:1-011
Addendum: Sample Compliance Report ...................................................................... H:1-011.A
Corporate Compliance Officer ............................................................................................. H:1-012
Internal Control Systems/Accountabilities .......................................................................... H:1-013
Hospice Patient Bill of Rights.............................................................................................. H:1-014
Whistleblower Protection..................................................................................................... H:1-015
SAMPLE
HOSPICE II Organization’s Name Quality of Services and Products
*Requires organization-specific information.
California CHAP Hospice Manual/Revised October 2015 © 2003 The Corridor Group
SECTION TWO
Quality of Services and Products Hospice Services Policy No.
Scope of Services ................................................................................................................. H:2-001
Listing of Services Provided ................................................................................................ H:2-002
Interdisciplinary group Membership and Responsibilities .................................................. H:2-003
Hospice Nursing Care .......................................................................................................... H:2-004
Hospice Aide Services ......................................................................................................... H:2-005
Psychosocial Services .......................................................................................................... H:2-006
Spiritual Care Counseling Services ..................................................................................... H:2-007
Addendum: Hospice Spiritual Concerns ...................................................................... H:2-007.A
Bereavement Services .......................................................................................................... H:2-008
Volunteer Services ............................................................................................................... H:2-009
Rehabilitative Services......................................................................................................... H:2-010
Speech Therapy Services ..................................................................................................... H:2-011
Nutritional Services ............................................................................................................. H:2-012
Physician Services — Medical Director .............................................................................. H:2-013
Physician Services — Attending Physician’s Role ............................................................. H:2-014
Continuous Care Services .................................................................................................... H:2-015
Addendum: Responsibilities of Continuous Care Personnel ........................................ H:2-015.A
Addendum: Charting Guidelines For Continuous Care ................................................ H:2-015.B
Inpatient Services ................................................................................................................. H:2-016
Pharmacy Services ............................................................................................................... H:2-017
Access to Emergency Room, Pharmacy, Radiology, Laboratory ........................................ H:2-018
Durable Medical Equipment and Supplies .......................................................................... H:2-019
Safe, Operable Equipment ................................................................................................... H:2-020
Transportation Services ....................................................................................................... H:2-021
Hospice Community Education ........................................................................................... H:2-022
Admission to Hospice
Hospice Intake Process* ....................................................................................................... H:2-023
SAMPLE
HOSPICE II Organization’s Name Quality of Services and Products
*Requires organization-specific information.
California CHAP Hospice Manual/Revised October 2015 © 2003 The Corridor Group
SECTION TWO
Quality of Services and Products
Policy No.
Admission Criteria and Process ........................................................................................... H:2-024
Certification of Terminal Illness .......................................................................................... H:2-025
Addendum: Face-to-Face Policy* ................................................................................ H:2-025.A
Hospice Election Statement ................................................................................................. H:2-026
Admission for General Inpatient Services ........................................................................... H:2-027
Admission for Respite Care ................................................................................................. H:2-028
Care Planning
Unit of Care.......................................................................................................................... H:2-029
The Plan of Care .................................................................................................................. H:2-030
Interdisciplinary Group Plan of Care ................................................................................... H:2-031
Verification of Physician Orders ......................................................................................... H:2-032
Availability of Family/Caregiver ......................................................................................... H:2-033
Prioritizing Patient Problems/Needs .................................................................................... H:2-034
Coordination/Continuity of Care
Interdisciplinary Group Coordination of Care ..................................................................... H:2-035
Interdisciplinary Group Meeting .......................................................................................... H:2-036
Physician Responsibility in Managing Hospice Patients ..................................................... H:2-037
Monitoring Patient’s Response/Reporting to Physician ...................................................... H:2-038
Patient Notification of Changes in Care .............................................................................. H:2-039
On-Call/Weekend Services .................................................................................................. H:2-040
Coordination of Care With Contracts/Agreements .............................................................. H:2-041
Continuity of Care Between Inpatient Setting and Home ................................................... H:2-042
Provision of Care to Residents of SNF/NF or ICF/IID........................................................ H:2-043
Addendum: Compliance Tool for Hospices That Provide Care to
Residents of a SNF/NF, ICF/IID or Other Facility ................................. H:2-043.A
Internal Referral Process ...................................................................................................... H:2-044
SAMPLE
HOSPICE II Organization’s Name Quality of Services and Products
*Requires organization-specific information.
California CHAP Hospice Manual/Revised October 2015 © 2003 The Corridor Group
SECTION TWO
Quality of Services and Products Assessments Policy No.
Initial Assessment ................................................................................................................ H:2-045
Comprehensive Assessment ................................................................................................ H:2-046
Ongoing Assessments .......................................................................................................... H:2-047
Functional Assessment......................................................................................................... H:2-048
Nutritional Assessment ........................................................................................................ H:2-049
Pain Assessment .................................................................................................................. H:2-050
Psychosocial Assessment ..................................................................................................... H:2-051
Spiritual Assessment ............................................................................................................ H:2-052
Bereavement Assessment..................................................................................................... H:2-053
Assessment of Possible Abuse/Neglect ............................................................................... H:2-054
Addendum: “Organization List of Private and Public Community
Agencies That Provide or Arrange for Assessment of
Suspected or Alleged Abuse/Neglect Victims”* ..................................... H:2-054.A
Medication Administration
Medication Profile ............................................................................................................... H:2-055
Identification of Medication for Administration.................................................................. H:2-056
Administration and Documentation of Medications ............................................................ H:2-057
Addendum: Drug Classifications and Their Routes ..................................................... H:2-057.A
Addendum: Medications Not Approved For Safe Home Administration*................... H:2-057.B
Addendum: Drug Information for the Nurse* ............................................................... H:2-057.C
Addendum: Advice For the Patient—Drug Information in Lay Language* ................ H:2-057.D
Patient Self-Administration of Medication .......................................................................... H:2-058
Home Use and Disposal of Controlled Substances .............................................................. H:2-059
Addendum: List of Controlled Substances Available* ................................................. H:2-059.A
Addendum: Drug Disposal Instructions * .................................................................... H:2-059.B
Intravenous Administration of Medications/Solutions ........................................................ H:2-060
Addendum: Medications Approved/Not Approved For Intravenous Administration* H:2-060.A
SAMPLE
HOSPICE II Organization’s Name Quality of Services and Products
*Requires organization-specific information.
California CHAP Hospice Manual/Revised October 2015 © 2003 The Corridor Group
SECTION TWO
Quality of Services and Products
Medication Administration (continued) Policy No.
Intravenous Administration of Chemotherapy..................................................................... H:2-061
Addendum: Antineoplastic Medications Approved/Not Approved For Intravenous
Administration* ...................................................................... H:2-061.A
First Dose Policy .................................................................................................................. H:2-062
Crushing of Medications ...................................................................................................... H:2-063
Addendum: Oral Dosage Forms That Should Not Be Crushed* .................................. H:2-063.A
Pulse Rate Determination With Certain Drugs .................................................................... H:2-064
Storage of Medications and Nutritional Products ................................................................ H:2-065
Medication Labeling ............................................................................................................ H:2-066
Adverse Drug Reactions ...................................................................................................... H:2-067
Addendum: Advice About Voluntary Reporting .......................................................... H:2-067.A
Anaphylaxis Protocol ........................................................................................................... H:2-068
Medication Error .................................................................................................................. H:2-069
Medication Monitoring ........................................................................................................ H:2-070
Investigational Medications ................................................................................................. H:2-071
Clinical Care
Identification, Prevention, and Treatment of Secondary Symptoms ................................... H:2-072
Care of the Dying Patient ..................................................................................................... H:2-073
Death at Home ..................................................................................................................... H:2-074
Do Not Resuscitate/Do Not Intubate Orders ....................................................................... H:2-075
Cardiopulmonary Resuscitation ........................................................................................... H:2-076
Withdrawal of Life-Sustaining Care .................................................................................... H:2-077
Emergency Care ................................................................................................................... H:2-078
Suicide…………………….................................................................................................. H:2-079
Home Glucose Monitoring .................................................................................................. H:2-080
SAMPLE
HOSPICE II Organization’s Name Quality of Services and Products
*Requires organization-specific information.
California CHAP Hospice Manual/Revised October 2015 © 2003 The Corridor Group
SECTION TWO
Quality of Services and Products Clinical Care (continued) Policy No.
Waived Testing .................................................................................................................... H:2-081
Addendum: Organization List and Criteria for Waived Tests Performed* .................. H:2-081.A
Transfer and Discharge
Change of Designated Hospice ............................................................................................ H:2-082
Transfer Information ............................................................................................................ H:2-083
Revocation of Hospice Benefit ............................................................................................ H:2-084
Discharge From Hospice Program ....................................................................................... H:2-085
Discharge Summary ............................................................................................................. H:2-086
Clinical Record, Documentation, and Data Collection
Contents of Clinical Record ................................................................................................. H:2-087
Assembly of Clinical Record ............................................................................................... H:2-088
Clinical Record Review ....................................................................................................... H:2-089
External Databases ............................................................................................................... H:2-090
Hospice Item Set .................................................................................................................. H:2-091
Family/Caregiver Experience of Care Survey ..................................................................... H:2-092
Addendum: Family/Caregiver Experience of Care Survey for Exempt or
Non-Participating Hospice ........................................................................................... H:2-092.A
Other
Missed Visits ........................................................................................................................ H:2-093SAMPLE
HOSPICE III Organization’s Name Human, Financial, and Physical Resources
*Requires organization-specific information.
California CHAP Hospice Manual/Revised October 2015 © 2003 The Corridor Group
SECTION THREE
Human, Financial, and Physical Resources Policy No.
Hospice Human Resources .................................................................................................. H:3-001
Hospice Staffing Guidelines ................................................................................................ H:3-002
Responsibilities/Supervision of Clinical Services ............................................................... H:3-003
Supervision .......................................................................................................................... H:3-004
Orientation of Hospice Personnel to Assigned Responsibilities.......................................... H:3-005
Access to Qualified Consultation......................................................................................... H:3-006
Communication With Office................................................................................................ H:3-007
Contracted Service Providers ............................................................................................... H:3-008
Hospice Aide Training ......................................................................................................... H:3-009
Hospice Homemaker Training ............................................................................................. H:3-010
Hospice Aide Supervisory Visits ......................................................................................... H:3-011
Volunteer Staff ..................................................................................................................... H:3-012
Hospice Volunteer Documentation ...................................................................................... H:3-013
Documentation of Volunteer Utilization ............................................................................. H:3-014
Training/Inservice Education ............................................................................................... H:3-015
Team Access to Emotional Support ..................................................................................... H:3-016
Physician Licensure Verification ......................................................................................... H:3-017
Donated Funds ..................................................................................................................... H:3-018
Hospice Contracted Services ............................................................................................... H:3-019
Addendum: Hospice Contracted Services Review* ..................................................... H:3-019.A
Note:
Job Descriptions can be found in Section 6 of this manual.
Clinical Competency Assessment Skills Checklists can be found as Appendices at the end of
Section 6 of this manual.
SAMPLE
HOSPICE IV Organization’s Name Long Term Viability
*Requires organization-specific information.
California CHAP Hospice Manual/Revised October 2015 © 2003 The Corridor Group
SECTION FOUR
Long Term Viability
Policy No.
Hospice Operational Planning ............................................................................................. H:4-001
Hospice Innovation .............................................................................................................. H:4-002
SAMPLE
HOSPICE V Organization’s Name Patient and Family/Caregiver Education
*Requires organization-specific information.
California CHAP Hospice Manual/Revised October 2015 © 2003 The Corridor Group
SECTION FIVE
Patient and Family/Caregiver Education
Policy No.
Patient Education Process .................................................................................................... H:5-001
Safe/Effective Use of Medications ...................................................................................... H:5-002
Pain Management Education ............................................................................................... H:5-003
Safe/Effective Use of Equipment and Supplies ................................................................... H:5-004
Basic Home Safety ............................................................................................................... H:5-005
Addendum: Fall Reduction Program* .......................................................................... H:5-005.A
Rehabilitation Techniques ................................................................................................... H:5-006
Storage, Handling, and Access to Supplies and Gases ........................................................ H:5-007
Identification, Handling, and Disposal of Hazardous Waste ............................................... H:5-008
Infection Control Precautions .............................................................................................. H:5-009
Natural Disasters/Emergencies ............................................................................................ H:5-010
Addendum: Guidelines for Emergency Management* ................................................ H:5-010.A
Appropriate Use of Restraints and Supplies ........................................................................ H:5-011
Signs and Symptoms of Approaching Death ....................................................................... H:5-012
Community Resources ......................................................................................................... H:5-013
Educational Resources ......................................................................................................... H:5-014
SAMPLE
HOSPICE VI Organization’s Name Job Descriptions
*Requires organization-specific information.
California CHAP Hospice Manual/Revised October 2015 © 2003 The Corridor Group
SECTION SIX
Job Descriptions Policy No.
Policy Statement .................................................................................................................. H:6-001
Addendum: Job Description (Template) ...................................................................... H:6-001.A
Addendum: Physical Requirements .............................................................................. H:6-001.B
Professional Services Agreement For Medical Director ..................................................... H:6-002
Addendum: Professional Services Agreement for Medical Director (Sample)............ H:6-002.A
Addendum: Medical Director Job Description ............................................................H:6-002.B
Addendum: Sample Evaluation Criteria .......................................................................H:6-002.C
JOB TITLE/POSITION
Executive Director/Administrator
Finance Director
Controller
Human Resources Director
Information Systems Director
Marketing/Community Relations Director
Clinical Director/Director of Patient Care Services
Clinical Records Manager
Clinical Supervisor
Managed Care Coordinator
Referral/Intake Supervisor
Performance Improvement Coordinator
Hospice Nurse Practitioner
Registered Nurse
Addendum A: Performance Evaluation for the Registered Nurse (Template)
Licensed Practical/Vocational Nurse
SAMPLE
HOSPICE VI Organization’s Name Job Descriptions
*Requires organization-specific information.
California CHAP Hospice Manual/Revised October 2015 © 2003 The Corridor Group
SECTION SIX
Job Descriptions Policy No.
Addendum A: Performance Evaluation for the Licensed Practical/Voc. Nurse (Template)
Certified Hospice Aide
Addendum A: Performance Evaluation for the Certified Hospice Aide (Template)
Addendum B: Hospice Aide Training Agreement
Homemaker
Physical Therapist
Physical Therapy Assistant
Speech—Language Pathologist
Occupational Therapist
Certified Occupational Therapy Assistant
Social Services Supervisor
Social Worker
Registered Dietician
Volunteer Coordinator
Volunteer
Hospice Chaplain
Bereavement Coordinator
Secretary/Receptionist
Billing Manager
Accounting Clerk
Data Entry/Computer Operator
Billing/Collections Clerk
Filing/Data Processing Clerk
Office Manager
Payroll and Benefits Coordinator
SAMPLE
HOSPICE VI Organization’s Name Job Descriptions
*Requires organization-specific information.
California CHAP Hospice Manual/Revised October 2015 © 2003 The Corridor Group
SECTION SIX
Job Descriptions Policy No.
Scope of the Program/Process Methodology ....................................................................... H:6-003
Competency Based Orientation ........................................................................................... H:6-004
Addendum: Initial Competency Assessment Skills Checklist/RN ............................... H:6-004.A
Addendum: Initial Competency Assessment Skills Checklist/LPN ............................. H:6-004.B
Addendum: Initial Competency Assessment Skills Checklist/Inf Nurse ..................... H:6-004.C
Addendum: Initial Competency Assessment Skills Checklist/Hosp. Aide .................. H:6-004.D
Addendum: Initial Competency Assessment Skills Checklist/PT ............................... H:6-004.E
Addendum: Initial Competency Assessment Skills Checklist/PTA .............................. H:6-004.F
Addendum: Initial Competency Assessment Skills Checklist/Speech–Lan ................ H:6-004.G
Addendum: Initial Competency Assessment Skills Checklist/OT ............................... H:6-004.H
Addendum: Initial Competency Assessment Skills Checklist/OTA ............................. H:6-004.I
Addendum: Initial Competency Assessment Skills Checklist/MSW ............................ H:6-004.J
Addendum: Initial Competency Assessment Skills Checklist/Reg Dietician .............. H:6-004.K
Addendum: Volunteer Coordinator/Volunteer ............................................................. H:6-004.L
Addendum: Initial Competency Assessment Skills Checklist/Hos. Chaplain............. H:6-004.M
Addendum: Initial Competency Assessment Skills Checklist/Ber. Coord ................... H:6-004.N
Addendum: Initial Competency Assessment Skills Checklist/Hos. Physician ............ H:6-004.O
Core Competency Skills ...................................................................................................... H:6-005
Annual Core Competence .................................................................................................... H:6-006
Addendum: Performance Criteria (Template) .............................................................. H:6-006.A
Addendum: Performance Criteria (Sample) ................................................................. H:6-006.B
Addendum: Performance Criteria (Sample for the Infusion Nurse) ............................. H:6-006.C
Addendum: Performance Criteria (Sample for the Hospice Chaplain) ........................ H:6-006.D
Addendum: Performance Criteria (Sample for the Hospice Physician) ....................... H:6-006.E
Specialized Services............................................................................................................. H:6-007
Requirements for Supervisors/Preceptors ............................................................................ H:6-008
Addendum: Performance Observation Report (Sample) .............................................. H:6-008.A
SAMPLE
HOSPICE VI Organization’s Name Job Descriptions
*Requires organization-specific information.
California CHAP Hospice Manual/Revised October 2015 © 2003 The Corridor Group
SECTION SIX
Job Descriptions Policy No.
Report to the Governing Body ............................................................................................. H:6-009
Addendum: Hospice Competence Report (Sample) ..................................................... H:6-009.A
SAMPLE
Organization’s Name Attachments
California CHAP Hospice Manual/Revised October 2015 © 2003 The Corridor Group
ATTACHMENTS
Attachment I: ........................................................................................................ CHAP Crosswalk Attachment I: ......................................................................... Medicare Conditions of Participation
Attachment II: ................................................................................ Hospice Interpretive Guidelines
Attachment III: ........................................................................................................ Hospice Manual
Attachment IV:................................................................................................ Additional Resources
SAMPLE
CORE I Organization’s Name Structure and Function
*Requires organization-specific information.
California CHAP Core Manual/Revised October 2015 © 2003 The Corridor Group
SECTION ONE
Structure and Function Policy No.
Mission Statement ................................................................................................................ C:1-001
Governing Body ................................................................................................................... C:1-002
Addendum: Governing Body Members*...................................................................... C:1-002.A
Addendum: Governing Body Orientation Checklist* .................................................. C:1-002.B
Conflict of Interest ............................................................................................................... C:1-003
Referral Disclosure and Care Decisions .............................................................................. C:1-004
Administrative Qualifications and Responsibilities............................................................. C:1-005
Appointment of Executive Director/Administrator ............................................................. C:1-006
Designation of Individual in Absence of Executive Director/Administrator ...................... C:1-007
Use of Organizational Chart ................................................................................................ C:1-008
Addendum: Organizational Charts* ............................................................................. C:1-008.A
Policy Decisions................................................................................................................... C:1-009
Development of Policies and Procedures ............................................................................ C:1-010
Addendum: Required Policy Checklist ........................................................................ C:1-010.A
Addendum: Administrative Policy Renewal/Revision Flow Sheet .............................. C:1-010.B
Facilitating Communication*............................................................................................... C:1-011
Addendum: Organization List of Interpreters* ............................................................. C:1-011.A
Ethical Issues ....................................................................................................................... C:1-012
Nondiscrimination Policy and Grievance Process* ............................................................. C:1-013
Uniform Quality of Care ...................................................................................................... C:1-014
Experimental Research and Investigational Studies ............................................................ C:1-015
Record Retention ................................................................................................................. C:1-016 SAMPLE
CORE II Organization’s Name Quality of Services and Products
*Requires organization-specific information.
California CHAP Core Manual/Revised October 2015 © 2003 The Corridor Group
SECTION TWO
Quality of Services and Products Policy No.
Public Disclosure Statement ................................................................................................ C:2-001
Admission Documents ......................................................................................................... C:2-002
Patient Bill of Rights ............................................................................................................ C:2-003
Informed Consent/Refusal of Treatment ............................................................................. C:2-004
Addendum: Sample Informed Consent for Medical Photography ....................................C:2-004.A
Financial Responsibility....................................................................................................... C:2-005
Advance Directives .............................................................................................................. C:2-006
Addendum: Advance Directive Information Statement ............................................... C:2-006.A
Addendum: Durable Power of Attorney for Health Care* ........................................... C:2-006.B
Addendum: POLST Policy* ......................................................................................... C:2-006.C
Complaint/Grievance Process .............................................................................................. C:2-007
Care/Service Coordination ................................................................................................... C:2-008
Availability of Services........................................................................................................ C:2-009
Emergency Management Plan ............................................................................................. C:2-010
Addendum: Pyramid Phone Communication Plan* ..................................................... C:2-010.A
Addendum: Weather Report/Road Conditions* ........................................................... C:2-010.B
Fostering Internal Communication ...................................................................................... C:2-011
Interface of Patient Data and Management Systems ........................................................... C:2-012
Access to Information .......................................................................................................... C:2-013
Principles of Information Management ............................................................................... C:2-014
Patient Privacy Rights .......................................................................................................... C:2-015
Addendum: Notice of Privacy Practices ....................................................................... C:2-015.A
Minimum Necessary Uses of PHI........................................................................................ C:2-016
Minimum Necessary Disclosures of PHI ............................................................................. C:2-017
Uses and Disclosures of PHI................................................................................................ C:2-018
Authorization for Use or Disclosure of PHI ........................................................................ C:2-019
Minimum Necessary Requests For PHI ............................................................................... C:2-020
Privacy of Health Information of Deceased Individuals ...................................................... C:2-021
SAMPLE
CORE II Organization’s Name Quality of Services and Products
*Requires organization-specific information.
California CHAP Core Manual/Revised October 2015 © 2003 The Corridor Group
SECTION TWO
Quality of Services and Products Policy No.
Patient Requests for Privacy Restrictions ............................................................................ C:2-022
Patient Requests for Confidential Communications ............................................................ C:2-023
Patient Requests for Access to PHI ..................................................................................... C:2-024
Patient Requests to Amend PHI ........................................................................................... C:2-025
Patient Requests for Accounting of PHI Disclosures .......................................................... C:2-026
Fundraising and PHI ............................................................................................................ C:2-027
Marketing and PHI ............................................................................................................... C:2-028
Privacy Training................................................................................................................... C:2-029
Sanctions for Privacy and Security Violations .................................................................... C:2-030
Safeguarding/Retrieval of Clinical/Service Record ............................................................. C:2-031
Computer Access to Information ......................................................................................... C:2-032
Clinical/Service Data Collection.......................................................................................... C:2-033
Retention of Clinical/Service Records ................................................................................. C:2-034
Branch/Subunit Documentation Control.............................................................................. C:2-035
Abbreviations and Symbols ................................................................................................. C:2-036
Addendum: Approved Home Care/Service Abbreviations* ........................................ C:2-036.A
Addendum: Unacceptable Home Care/Service Abbreviations* ................................... C:2-036.B
Responsibilities in Improving Performance......................................................................... C:2-037
Patient Focused Performance Improvement ........................................................................ C:2-038
Patient and Family/Caregiver Experience of Care Survey .................................................. C:2-039
Infection Control Plan .......................................................................................................... C:2-040
Tuberculosis Exposure Control Plan ................................................................................... C:2-041
Bloodborne Pathogens and Hepatitis B Exposure Control Plan .......................................... C:2-042
Addendum: Hepatitis B Vaccination Documentation Form ......................................... C:2-042.A
SAMPLE
CORE II Organization’s Name Quality of Services and Products
*Requires organization-specific information.
California CHAP Core Manual/Revised October 2015 © 2003 The Corridor Group
SECTION TWO
Quality of Services and Products Policy No.
Addendum: Hepatitis B Vaccination Declination Form ............................................... C:2-042.B
Addendum: Recognizing the Dangers ........................................................................... C:2.042.C
Addendum: Occupational Exposure Risk By Job Classification ................................. C:2-042.D
Management of Exposures in Personnel .............................................................................. C:2-043
Record Keeping ................................................................................................................... C:2-044
Occupational Exposure Information and Training .............................................................. C:2-045
Standard Precautions ............................................................................................................ C:2-046
Addendum: Standard Precautions Information for Personnel ...................................... C:2-046.A
Personal Protective Equipment ............................................................................................ C:2-047
Addendum: Protective Device Checklist ...................................................................... C:2-047.A
Addendum: Required Personal Protective Equipment Form ........................................ C:2-047.B
Hand Hygiene ...................................................................................................................... C:2-048
Clean vs. Aseptic Technique ................................................................................................ C:2-049
Infection Control/Expanded Precautions ............................................................................. C:2-050
Addendum: Bed Bug Guidance* ................................................................................ C:2-050.A
Contaminated Materials Disposition.................................................................................... C:2-051
Contaminated Waste Disposal ............................................................................................. C:2-052
Hazardous Waste Handling.................................................................................................. C:2-053
Addendum: Hazardous Waste Disposal State and Local Regulations* ....................... C:2-053.A
Accidental Exposure to Blood ............................................................................................. C:2-054
Bag Technique ..................................................................................................................... C:2-055
Evaluating and Maintaining Records of Infections Among Patients ................................... C:2-056
Addendum: Infection Identification—Patient Report .................................................. C:2-056.A
Evaluating and Maintaining Records of Infections Among Personnel ................................ C:2-057
Addendum: Infection Identification—Personnel Report .............................................. C:2-057.A
Reporting of Communicable Diseases ................................................................................. C:2-058
Communication of Hazards to Personnel ............................................................................ C:2-059
SAMPLE
CORE II Organization’s Name Quality of Services and Products
*Requires organization-specific information.
California CHAP Core Manual/Revised October 2015 © 2003 The Corridor Group
SECTION TWO
Quality of Services and Products Policy No.
Environmental Safety Program ............................................................................................ C:2-060
Environmental Safety—Office ............................................................................................ C:2-061
Addendum: Office Environment Checklist .................................................................. C:2-061.A
Fire Safety—Office .............................................................................................................. C:2-062
Utilities Management—Office ............................................................................................. C:2-063
Equipment Management—Office ........................................................................................ C:2-064
Environmental Safety—Patient ........................................................................................... C:2-065
Fire Safety—Patient ............................................................................................................. C:2-066
Utilities Management—Patient ............................................................................................ C:2-067
Equipment Management—Patient ....................................................................................... C:2-068
Safe and Appropriate Use of Home Medical Equipment and Supplies ............................... C:2-069
Storage of Medications and Nutritional Therapies .............................................................. C:2-070
Medical Equipment Malfunction ......................................................................................... C:2-071
Safe Medical Device Act ..................................................................................................... C:2-072
Organization Personnel Safety—Personal Safety ................................................................ C:2-073
Organization Personnel Safety—Unsafe Home Visits ........................................................ C:2-074
Vehicle Accident Reporting ................................................................................................. C:2-075
Incident Reporting ............................................................................................................... C:2-076
Addendum: Examples of Specific Events or Occurrences
That Must Be Reported ............................................................................ C:2-076.A
Serious Adverse Events ....................................................................................................... C:2-077
Root Cause Analysis/Action Plan ........................................................................................ C:2-078
Addendum: Root Cause Analysis/Action Plan Form ................................................... C:2-078.A
Aggregation of Data/Information ........................................................................................ C:2-079
Identity Theft Prevention Program ...................................................................................... C:2-080
Addendum: Identity Theft Risk Assessment Worksheet .............................................. C:2-080.A
SAMPLE
CORE II Organization’s Name Quality of Services and Products
*Requires organization-specific information.
California CHAP Core Manual/Revised October 2015 © 2003 The Corridor Group
SECTION TWO
Quality of Services and Products Policy No.
Addendum: Identity Theft Risk Response Matrix ........................................................ C:2-080.B
Pandemic Influenza Preparedness ........................................................................................ C:2-081
Addendum: Reference for Pandemic Influenza Preparedness ...................................... C:2-081.A
Security of PHI .................................................................................................................... C:2-082
Breach Analysis ................................................................................................................... C:2-083
Breach Notification .............................................................................................................. C:2-084
Security Management Process ............................................................................................. C:2-085
Workforce Security .............................................................................................................. C:2-086
Information Access Management ........................................................................................ C:2-087
Security Awareness and Training ........................................................................................ C:2-088
Security Incident Procedures ............................................................................................... C:2-089
Contingency Plan ................................................................................................................. C:2-090
Evaluation ............................................................................................................................ C:2-091
Facility Access Controls ...................................................................................................... C:2-092
Workstation Use and Security ............................................................................................. C:2-093
Device and Media Controls ................................................................................................. C:2-094
Access Controls: Technical Safeguards ............................................................................... C:2-095
HIPAA Security Audit Controls .......................................................................................... C:2-096
Integrity Controls ................................................................................................................. C:2-097
Person or Entity Authentication ........................................................................................... C:2-098
Transmission Security .......................................................................................................... C:2-099
SAMPLE
CORE III Organization’s Name Human, Financial, and Physical Resources
*Requires organization-specific information.
California CHAP Core Manual/Revised October 2015 © 2003 The Corridor Group
SECTION THREE
Human, Financial, and Physical Resources Policy No.
Personnel Policies ................................................................................................................ C:3-001
Recruitment, Retention, Development, and Continuing Education ..................................... C:3-002
Categories/Qualifications of Personnel................................................................................ C:3-003
Selection/Hiring of Personnel .............................................................................................. C:3-004
Licensure/Certification/Registration .................................................................................... C:3-005
Equal Opportunity Employer ............................................................................................... C:3-006
Standards of Care, Service, and Practice ............................................................................. C:3-007
Scope of Assessments/Qualifications .................................................................................. C:3-008
Job Descriptions ................................................................................................................... C:3-009
Termination .......................................................................................................................... C:3-010
Personnel Turnover .............................................................................................................. C:3-011
Attendance and Absenteeism ............................................................................................... C:3-012
Personnel Grievance Process ............................................................................................... C:3-013
Personal Vehicle Use/Mileage Requirements ...................................................................... C:3-014
Dress and Appearance.......................................................................................................... C:3-015
Sexual Harassment ............................................................................................................... C:3-016
Standards of Conduct/Ethical Behavior ............................................................................... C:3-017
Personnel Record Contents .................................................................................................. C:3-018
Performance Evaluations ..................................................................................................... C:3-019
Orientation ........................................................................................................................... C:3-020
Addendum: Personnel Orientation Checklist ............................................................... C:3-020.A
Personnel Development ....................................................................................................... C:3-021
Addendum: Personnel Development/Inservice Needs Assessment ............................. C:3-021.A
Resource Information........................................................................................................... C:3-022
Competency Program........................................................................................................... C:3-023
Initial Competency Assessment ........................................................................................... C:3-024
SAMPLE
CORE III Organization’s Name Human, Financial, and Physical Resources
*Requires organization-specific information.
California CHAP Core Manual/Revised October 2015 © 2003 The Corridor Group
SECTION THREE
Human, Financial, and Physical Resources Policy No.
Competency Requirements for Supervisors/Preceptors ....................................................... C:3-025
Addendum: Performance Observation Report .............................................................. C:3-025.A
Competency Report to the Governing Body ........................................................................ C:3-026
Addendum: Organization Competency Report ............................................................ C:3-026.A
Written Agreements for Contracted Services ...................................................................... C:3-027
Addendum: Written Agreement for Home Care Services* .......................................... C:3-027.A
Business Associates ............................................................................................................. C:3-028
Annual Operating Budget .................................................................................................... C:3-029
Certificates of Insurance ...................................................................................................... C:3-030
Financial Management and Control ..................................................................................... C:3-031
Fiscal Solvency .................................................................................................................... C:3-032
Financial Reports ................................................................................................................. C:3-033
Fee Determination ................................................................................................................ C:3-034
Charity Care ......................................................................................................................... C:3-035
Charge Verification .............................................................................................................. C:3-036
Billing and Collections ........................................................................................................ C:3-037
Accounts Receivable Review .............................................................................................. C:3-038
Bad Debt Policy ................................................................................................................... C:3-039
Contractual Allowances ....................................................................................................... C:3-040
Cash Receipts ....................................................................................................................... C:3-041
Purchasing Authorization and Accounts Payable ................................................................ C:3-042
Fixed Assets and Depreciation............................................................................................. C:3-043
Payroll Processing ................................................................................................................ C:3-044
Allocation of Time Worked ................................................................................................. C:3-045
SAMPLE
CORE III Organization’s Name Human, Financial, and Physical Resources
*Requires organization-specific information.
California CHAP Core Manual/Revised October 2015 © 2003 The Corridor Group
SECTION THREE
Human, Financial, and Physical Resources Policy No.
Social Media ........................................................................................................................ C:3-046
Addendum: Social Media and Blog Guidelines ........................................................... C:3-046.A
Progressive Discipline Policy .............................................................................................. C:3-047
SAMPLE
CORE IV Organization’s Name Long Term Viability
*Requires organization-specific information.
California CHAP Core Manual/Revised October 2015 © 2003 The Corridor Group
SECTION FOUR
Long Term Viability Policy No.
Organizational Planning....................................................................................................... C:4-001
Program Planning................................................................................................................. C:4-002
Marketing Plan ..................................................................................................................... C:4-003
Contingency Planning .......................................................................................................... C:4-004
Contingency Plan if Organization Closes ............................................................................ C:4-005
Measuring Performance of the Environmental Safety Program .......................................... C:4-006
Annual Organization Evaluation.......................................................................................... C:4-007
Addendum: Self-Assessment of Health Care
Organizational Performance ..................................................................... C:4-007.A
SAMPLE
CORE MANUAL Organization’s Name Attachments
California CHAP Core Manual/Revised October 2015 © 2003 The Corridor Group
ATTACHMENTS
Attachment I: ........................................................................................................ CHAP Crosswalk
Attachment II: ...................................................................................................... Glossary of Terms
SAMPLE