Medicare's Conditions of Participation (CoP) requires an HHA's Governing Body to regularly evaluate the policies and procedures that regulate the Agency's:
- Agency-wide risk management
- Patient-specific risk management
- Emergency Preparedness
- Employee Management: continuing education, evaluations, health-status requirements, license & education verification, reference verification
- Ethics
- Infection Surveillance and Identification
- Leadership
- Patient care
- Patient complaints
- Patient surveys - CAHPS
- Supervision of nursing and therapy assistants
Agency-wide Risk Management
Are your policies and procedures effective at controlling:
- workplace injuries resulting from musculoskeletal disorders secondary to lifting/lowering, and pushing/pulling, and carrying of patients?
- needlesticks?
- management of hazardous waste? fire and utility safety?
- infection exposure & personal protective equipment?
Patient-specific Risk Management
Do your patient education materials include: home safety? infection control? medications, oxygen, and home medical equipment?
- Do you verify license, reference and education on all field staff?
- Do you have clinical policies and procedures readily available to field staff?
- How often are are patient education materials reviewed?
Emergency Preparedness
- annual update of risk assessment and risk types for the agency secondary to its location
- types of patients served and emergency preparedness for each patient type served
- how patients are prioritized for care
- communication system during emergency
- employee training on emergency preparedness
Employee Management
Are the following verified for all new employees?
- education verification
- experience verification
- license verification
- references and experience verification
How frequently are the following monitored and/or performed during employment?
- health status and vaccinations
- evaluations
- continuing education
- non-proficiency evaluations
Ethics
Any incidences and corrective actions regarding the following?
- Patient rights violations
- Patient confidentiality violations
- Patient care provided according to professional standards
- Patient education regarding advance directives
- Patient liability for payment
- Policies and procedures regarding application of restraints
- Policies and procedures regarding patient non-compliance
Infection surveillance and identification
- How do you monitor for infections in your patient population?
- What training is provided to staff?
- What steps are taken with a suspected infection of a patient? of an employee?
- What steps are taken with an active infection of a patient? of an employee?
Leadership
- How do you solicit feedback from field clinicians and office staff?
- What do you do with feedback from field clinicians and office staff?
- How does your organization solicit your ideas and views about issues like daily operations, educational needs, information management, and so on?
- Describe the budgeting process and its relationship to your organization's planning process.
- Who is involved in budget development?
Patient Care
- What reports do you use to evaluate your HHA's quality of care?
- How often are those reports reviewed?
- Can you provide documentation of the reports and corrective actions?
- What training do you provide on patient care protocols?
Patient Complaints
- What patient complaints were received and what was the corrective action?
- What employee training was provided?
Patient Surveys
- What are the results of the Consumer Assessment of Healthcare Providers and Systems surveys (CAHPS) from the prior reporting period?
- Were corrective actions indicated?
- If yes - were they performed?
Supervision of nursing and therapy assistants
- Documentation of required supervision
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