POSITION DESCRIPTION / PERFORMANCE EVALUATION

Reference #4001 Home Health 1 of 6 © MCN Healthcare (800) 538-6264

POSITION DESCRIPTION / PERFORMANCE EVALUATION

Job Title: Home Health Administrator Supervised by: Governing Body Prepared by: _ Date: _

Approved by: _ Date:

Job Summary: Organizes and directs the HHA’s day-to-day operations, ensuring compliance with State and Federal regulations. Employs qualified staff and ensures adequate staff education and evaluations. Responsible for an effective budgeting and accounting system. Develops policies and procedures. Develops a system of staff communication that ensures coordinated implementation of plans of treatment and the utilization of necessary services for comprehensive care of patients. Ensures accuracy of public information materials and activities.

DUTIES AND RESPONSIBILITIES:

3 = Exceeds Performance 2 = Expected Performance 1 = Needs Improvement

Demonstrates Competency in the Following Areas:

Meets regularly with the Governing Body. Interprets and implements Governing Body policies for guidance of staff, patients and public.

3 2 1

Maintains ongoing liaison among the Governing Body, the group of professionals and staff.

3 2 1

Plans, coordinates, directs and controls the operations of the HHA. 3 2 1

Maintains effective communication between the Governing Body, professional staff and HHA staff.

3 2 1

Ensures that qualified staff are hired and that such staff receive adequate inservices and evaluations.

3 2 1

Exercises objective and mature judgment in properly controlling all aspects of financial operation by receiving ongoing reports from bookkeeping/accounting staff.

3 2 1

Maintains a system of staff communication that ensures coordinated implementation of plan of care, and the utilization of necessary services for comprehensive patient care.

3 2 1

Participates in the HHA’s Information Management and Quality Assessment and Performance Improvement (QAPI) programs.

3 2 1

Develops the capital and operating budgets. 3 2 1

Develops policies and procedures. 3 2 1

Keeps up-to-date on new developments as related to the HHA in regard to state and federal regulatory agencies.

3 2 1

Provides oversight relative to OASIS data collection and transmission. 3 2 1

Represents and interprets the HHA’s functions to other institutions, the public, government agencies and other organizations.

3 2 1

Supports and maintains a culture of safety and quality. 3 2 1


Professional Requirements:

Adheres to dress code, appearance is neat and clean. 3 2 1

Completes annual education requirements. 3 2 1

Maintains regulatory requirements, including all federal, state, local regulations and accrediting organization standards.

3 2 1

Maintains and ensures patient confidentiality at all times. 3 2 1

Reports to work on time and as scheduled. 3 2 1

Wears identification while on duty. 3 2 1

Attends annual review and performs departmental inservices. 3 2 1

Available during all operating hours, and/or ensures a qualified, pre-designated person is available during all operating hours.

3 2 1

Works at maintaining a good rapport and a cooperative working relationship with physicians, departments and staff.

3 2 1

Represents the organization in a positive and professional manner. 3 2 1

Attends committee, QAPI and management meetings, as appropriate. 3 2 1

Ensures compliance with policies and procedures regarding HHA operations, fire safety, emergency management and infection prevention and control.

3 2 1

Complies with all organizational policies regarding ethical business practices. 3 2 1

Communicates the mission, ethics and goals of the organization. 3 2 1

Total Points


Regulatory Requirements:

Prior to January 13, 2018:

A licensed physician or

A Registered Nurse or

Has training and experience in health service administration and at least one (1) year of supervisory or administrative experience in home healthcare or related health programs.

On or after January 13, 2018:

A licensed physician or

A Registered Nurse or

Holds an undergraduate degree and

Has experience in health service administration with at least one (1) year of supervising administrative experience in home healthcare or a related healthcare program.

Language Skills:

Able to communicate effectively in English, both verbally and in writing.

Additional languages preferred.

Skills:

Knowledge of the duties and functions of the home health HHA and its relationship to the healthcare community.

Comprehensive knowledge of state and federal guidelines and regulations.

Physical Demands:

For physical demands of position, including vision, hearing, repetitive motion and environment, see following description.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising patient care.

=======================================================================================

I have received, read and understand the Position Description/Performance Evaluation above.

Name/Signature Date Signed


DESCRIPTION OF PHYSICAL DEMANDS

JOB TITLE: DEPARTMENT:

NAME: # HOURS/WORKDAY:

DEVELOPED BY: DATE DEVELOPED:

MANAGER SIGNATURE: DATE:

CHECK APPROPRIATE BOX FOR EACH OF THE FOLLOWING ITEMS TO BEST DESCRIBE THE EXTENT OF THE SPECIFIC ACTIVITY PERFORMED BY THE STAFF MEMBERS IN THIS POSITION

PHYSICAL DEMANDS

On-the-job time is spent in the following physical activities Show the amount of time by checking the appropriate boxes below.

Amount of Time

Stand:

Walk:

Sit:

Talk or hear:

Use hands to finger, handle or feel:

Push/Pull:

Stoop, kneel, crouch or crawl:

Reach with hands and arms:

Taste or smell:

This job requires that weight be lifted or force be exerted. Show how much and how often by checking the appropriate boxes below.

Amount of Time

Up to 10 pounds:

Up to 25 pounds:

Up to 50 pounds:

Up to 100 pounds:

More than 100 pounds:

This job has special vision requirements. Check all that apply.

Close Vision (clear vision at 20 inches or less)

Distance Vision (clear vision at 20 feet or more)

Color Vision (ability to identify and distinguish colors)

Peripheral Vision (ability to observe an area that can be seen up and down or to the left and right while eyes are fixed on a given point)

Depth Perception (three-dimensional vision; ability to judge distances and spatial relationships)

Ability to Adjust Focus (ability to adjust eye to bring an object into sharp focus)

No Special Vision Requirements

Specific demands not listed: _

_

_

_

_

_

Note: Reasonable accommodations may be made to enable

individuals with disabilities to perform the essential functions of this position.

WORK ENVIRONMENT

This job requires exposure to the following environmental conditions. Show the amount of time by checking the appropriate boxes below.

Amount of Time

Wet, humid conditions (non- weather):

Work near moving mechanical parts:

Fumes or airborne particles:

Toxic or caustic chemicals:

Outdoor weather conditions:

Extreme cold (non-weather):

Extreme heat (non-weather):

Risk of electrical shock:

Work with explosives:

Risk of radiation:

Vibration:

The typical noise level for the work environment is: (Check all that apply)

Very Quiet Loud Noise Quiet Very Loud Noise Moderate Noise

Hearing: Ability to hear alarms on equipment Ability to hear patient call Ability to hear instructions from physician/department staff

REPETITIVE MOTION ACTIONS

Number of Hours

Repetitive use of foot control 0 1-2 3-4 5-6 7+

A. Right only

B. Left Only

C. Both

Repetitive use of hands

A. Right only

B. Left Only

C. Both

Grasping: simple/light

A. Right only

B. Left Only

C. Both

Grasping: firm/heavy

A. Right only

B. Left Only

C. Both

Fine Dexterity

A. Right only

B. Left Only

C. Both

None up to 1/3

1/3 to 1/2

2/3 and more

None up to 1/3

1/3 to 1/2

2/3 and more

None up to

1/3 1/3 to 1/2

2/3 and more


PERFORMANCE EVALUATION CONTINUATION PAGE

Staff Member: Job Title:

Performance Evaluation Score:

# of total points achieved X 100 = %

(maximum score)

80 - 100%

50 - 79%

0 - 49%

= Exceeds Performance

= Expected Performance

= Needs Improvement

Manager’s Comments:

Recommended Goals/Actions:

Staff Member Comments:

Actions Recommended by Department Manager:

Performance Review Only Salary Increase:

Next Performance Review on: Salary Increase Denied

Staff Member Signature Date

Department Manager Signature Date

Administrative Signature Date


STAFF MEMBER ANNUAL PROFESSIONAL PERFORMANCE AND COMPETENCY EVALUATION

As a member of the organization's staff team, your comments and input are important to both the continuing development and quality provision of patient care and services of the institution. Your continued professional growth and job satisfaction are primary goals of the organization. The administrative team and your department supervisor are interested in your comments regarding the following:

1. How would you rate your current job satisfaction level?

2. How would you rate your current job performance?

1 - 5 (1 = poor, 5 = excellent)

3. How would you rate the organization’s provision of personnel benefits?

4. How would you rate the organization’s provisions for staff continuing education?

5. How would you rate the organization’s physical working environment?

6. How would you rate the organization’s emotional working environment?

7. List your professional goals:

8. List any departmental goals that may differ from professional goals (include educational and performance goals):

9. Is there anything the organization can do to help you achieve any of these goals? Yes No

10. If so, please describe:

11. Comments you feel may assist the organization with improving staff satisfaction levels:

Note: This organization pledges to utilize information provided for the sole purpose of improving staff satisfaction and assisting the author with achievement of advanced personal and/or professional growth.


PERFORMANCE EVALUATION POPULATION-SPECIFIC/AGE-RELATED COMPETENCY

HOME HEALTH ADMINISTRATOR

Name: Date:

Unit: Evaluator:

Age Range of Patients to Whom Service is Provided: Neonate to Geriatric

Population-specific staff competency means considering the populations served by the HHA when assessing and validating the knowledge, skills, and ability of staff members to carry out their job responsibilities.

Each patient care department should define the population they serve.

Population-specific staff competence tells how care, treatment and services are modified to meet the needs of an individual in a specified population.

Populations served can be defined by (not all inclusive): age (neonates to geriatrics); gender; specific disease or condition; point on the wellness-illness spectrum, including conditions considered urgent, acute or chronic; level of physical and mental ability; availability of family and social support; culture; linguistics.

Please add additional population-specific staff competencies that are defined by your HHA.

1 = Cannot Perform Skills Independently

2 = Requires Some Assistance to Perform Skills

3 = Can Perform Skill Independently

NA = Not Applicable

NEONATE/INFANT (Newborn to 2 years)

Ensures staff maintain a safe environment for patients and staff, and staff provides patient/family education.

1 2 3 NA

Maintains patient confidentiality. 1 2 3 NA

Interacts with patient/families/significant others in a calming, caring professional manner.

1 2 3 NA

Provides age specific inservices for staff. 1 2 3 NA

1 2 3 NA

1 2 3 NA

PERFORMANCE EVALUATION - POPULATION-SPECIFIC/AGE-RELATED COMPETENCY -

HOME HEALTH ADMINISTRATOR (continued)


PEDIATRICS (2-11 years)

Ensures staff maintains a safe environment for the patient, family and staff. Provides staff education.

1 2 3 NA

Talks to the child in language that the child can understand. 1 2 3 NA

Talks to patients/families in a calm, caring, professional manner. Allows for privacy needs.

1 2 3 NA


1 2 3 NA

1 2 3 NA

ADOLESCENT (12-21 years)

Ensures staff maintains safe environment. Provides age specific staff education.

1 2 3 NA

Allows patient to have choice and control over situations and environment, as appropriate to condition and situation.

1 2 3 NA

Recognizes the importance of body image. 1 2 3 NA

Allows for privacy needs. 1 2 3 NA

Maintains patient confidentiality with parental/caregiver involvement and education, as appropriate to age and consent of patient.

1 2 3 NA

Avoids use of condescending language. 1 2 3 NA

1 2 3 NA

1 2 3 NA




ADULT

Ensures staff maintains safe environment related to equipment, mental status. Provides age specific staff education.

1 2 3 NA

Involves patient in care. Allows patient to maintain control; involves patient in decision-making as appropriate to condition and situation.

1 2 3 NA

Maintains confidentiality. Respects privacy. 1 2 3 NA

Encourages participation in care, provides education, as appropriate to disease entity and processes.

1 2 3 NA

Encourages family support. 1 2 3 NA

1 2 3 NA

1 2 3 NA

GERIATRIC

Ensures staff maintains safe environment related to equipment, fall precautions, mobility needs, aspiration potential and mental status. Provides age specific staff education.

1 2 3 NA

Allows patient to maintain control; involves patient in decision-making as appropriate to condition and situation.

1 2 3 NA

Allows for possible hearing and/or vision loss, speaking in lower, louder tones as necessary; provides additional or brighter lighting, larger print, etc.

1 2 3 NA

Provides all patient instructions slowly, speaking distinctly and assesses for patient understanding.

1 2 3 NA

Considers mobility needs, maintains ROM, prevents contracture formation. 1 2 3 NA

Encourages family support, involving family in care, education and decisions, as appropriate.

1 2 3 NA

1 2 3 NA

1 2 3 NA




SCORING:

80 to 100% = Exceeds Performance 50 to 79% = Expected Performance

0 to 49% = Needs Improvement

(Note: Be sure to not calculate those skills which have been documented as NA)

Skills rated 3 X the number:



Add the above numbers to obtain the Employee’s Score:

(Employee’s Score ÷ Maximum Score = _ _ X 100 = The Employee’s Score in a Percentage)

EXAMPLE:

77 skills are on the competency; two (2) of those skills are not applicable for this employee. Therefore, the employee was evaluated on 75 skills for a maximum score of 75 X 3 = 225.

The employee received:

Skills rated 3 X the number: (40 Skills X 3) = 120



Add the above numbers to obtain the Employee’s Score: 120 + 60 + 5 = 185

(185 ÷ 225 = .82 X 100 = 82.2%. The employee’s score falls into the category of Exceeds Performance.)

Identified Areas that Require Improvement:

Comments:

Name: Title:

Date:

Signature of Supervisor:

Signature of Staff Member:


ANNUAL COMPETENCY CLINICAL SKILLS ASSESSMENT EVALUATION OF CLINICAL PERFORMANCE

HOME HEALTH ADMINISTRATOR




NA = Not Applicable

Develops and implements procedures to attract qualified staff. 1 2 3 NA

Keeps up-to-date on new developments in regard to state and federal regulatory agencies.

1 2 3 NA

Is a representative of the HHA to the public, government agencies and other organizations.

1 2 3 NA

Develops the capital and operating budgets for the HHA. 1 2 3 NA

Coordinates the treatment plans and the utilization of necessary services to benefit patient care.

1 2 3 NA

Ensures the HHA meets and surpasses accrediting organization standards.

1 2 3 NA

Participates in the HHA's Information Management and Quality Assessment and Performance Improvement (QAPI) plans.

1 2 3 NA

Keeps up-to-date on new methods, products, trends, etc., and communicates this information to staff.

1 2 3 NA

Networks to be able to use peer group as a resource for problem solving. 1 2 3 NA

Demonstrates strong, accurate decision making capabilities. 1 2 3 NA

Demonstrates knowledge of HHA Administrator's role in the Emergency Operations Plan.

1 2 3 NA

Demonstrates knowledge of HIPAA regulations. 1 2 3 NA

Demonstrates knowledge and ability to use the organization’s Electronic Health Record (EHR) system.

1 2 3 NA

Demonstrates knowledge of infection prevention and control policies and procedures, i.e., Standard Precautions, Transmission-Based Precautions, personal protective equipment, aseptic technique, hand hygiene.

1 2 3 NA

ANNUAL COMPETENCY CLINICAL SKILLS ASSESSMENT - HOME HEALTH

ADMINISTRATOR (continued)


Demonstrates knowledge of and follows organization policies regarding the applicable National Patient Safety Goals. (See NPSGs Competency Form)

1 2 3 NA

Demonstrates competency in the knowledge of the delivery of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors.

1 2 3 NA

Demonstrates the knowledge of proper identification and reporting of medical/health care errors. Protects the patient in the event of a medical/health care error and, as appropriate, assists in medical/health care error resolution.

1 2 3 NA

HHA Environment - Able to locate and/or demonstrate knowledge of:

HHA directory 1 2 3 NA

Physician directory 1 2 3 NA

Governing Body directory 1 2 3 NA

Community resources, support services 1 2 3 NA

Government agencies 1 2 3 NA

Fire Equipment:

Alarms 1 2 3 NA

Extinguishers 1 2 3 NA

Exit doors 1 2 3 NA

HHA Organization - Able to describe the roles and functions of:

Governing Body 1 2 3 NA

Patient Care Services Director 1 2 3 NA

Medical Director 1 2 3 NA

Physicians 1 2 3 NA

Ethics Committee 1 2 3 NA

Nursing Staff 1 2 3 NA

Other 1 2 3 NA




HHA Resources - Able to locate and demonstrate the use of:

Home Health Policy and Procedure Manual 1 2 3 NA

Infection Prevention and Control Manual 1 2 3 NA

OASIS Policy and User Manual 1 2 3 NA

Fire/Emergency Management Manual 1 2 3 NA

Safety Data Sheets (SDS) Manual 1 2 3 NA

Community Resources 1 2 3 NA

QAPI Documentation 1 2 3 NA

Patient Teaching Manual 1 2 3 NA

Other 1 2 3 NA

HHA Routines - Able to describe, locate and/or demonstrate knowledge of:

Communication System:

Bulletin boards 1 2 3 NA

Logbooks 1 2 3 NA

Meeting minutes 1 2 3 NA

Reports/memos/statistics 1 2 3 NA

Ordering supplies 1 2 3 NA

Cultural Factors:

Religion 1 2 3 NA

Food preferences 1 2 3 NA

Family/community relationships 1 2 3 NA

Healthcare attitudes/understanding 1 2 3 NA

Trust/privacy needs 1 2 3 NA

Socioeconomic environment 1 2 3 NA




SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





Job Title: Home Health Patient Care Services Director Supervised by: Administrator Prepared by: _ Date: _


Job Summary: Provides overall planning, direction, coordination, management and supervision of all nursing and professional services in conjunction with the Administrator. Assures quality of care by reviewing and assessing each service.




Keeps the Administrator informed on all events which occur. 3 2 1

Advises the Administrator as to basis of contracting health services to be provided. 3 2 1

Provides the Administrator with statistical data involving patients and health services areas.

3 2 1

Develops, evaluates, reviews, revises and implements policies and procedures; goals and objectives; and standards of care relevant to patient services and staff functions.

3 2 1

Performs patient care responsibilities considering needs specific to the standard of care for patient’s age.

3 2 1

Ability to adequately assess and reassess pain. Utilizes appropriate pain management techniques. Educates the patient and family regarding pain management.

3 2 1

Performs all aspects of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors.

3 2 1


Demonstrates knowledge of medications and their correct administration based on age of the patient and the patient’s clinical position.

3 2 1

Follows the seven (7) medication rights and reduces the potential for medication errors. 3 2 1

Addresses and supports cultural practices, as long as such practices do not harm others or interfere with the planned course of medical therapy.

3 2 1

Coordinates all patient services by reviewing plans of treatment, assuring case conferences are conducted, reviewing clinical and progress notes, periodic patient evaluations and determining frequency and/or staffing patterns.

3 2 1

Assists in preparing and controlling the HHA’s annual budget. 3 2 1

Aids in the HHA’s goal of retaining quality staff by appropriately hiring, orienting, training, evaluating and disciplining staff within established policy.

3 2 1



Ensures staff are scheduled to ensure proper coverage within authorized staffing levels. 3 2 1

Ensures orientation and ongoing training programs are developed and provided for HHA staff.

3 2 1

Ensures staff receive timely, complete and documented orientation and training. 3 2 1

Conducts performance evaluations in a timely, measurable and objective manner. Investigates unsatisfactory performance evaluations and plans for remediation. Communicates this information to the Administrator.

3 2 1

Maintains a working knowledge of current Medicare, Medicaid and third party payer requirements for home care reimbursement.

3 2 1

Communicates and coordinates with physician’s offices, payers, patients/families, outpatient services and inpatient coordinator, regarding the care and status of the patient.

3 2 1

Keeps up-to-date on new methods, products, trends, etc., and communicates this information to staff.

3 2 1


3 2 1

Supports and complies with the HHA’s policies. 3 2 1

Possesses understanding of applicable state and federal regulations as applicable to home care and communicates updates to staff.

3 2 1

Possesses understanding of the OASIS data collection and reporting process. 3 2 1





3 2 1

Maintains and ensures patient confidentiality at all times. 3 2 1

Reports to work on time and as scheduled. 3 2 1


Attends annual review and performs departmental inservices. 3 2 1

Works at maintaining a good rapport and a cooperative working relationship with physicians, departments and staff.

3 2 1




Resolves staff concerns at the departmental level, utilizing the grievance process as required.

3 2 1


3 2 1

Effectively and consistently communicates administrative directive to staff and encourages interactive departmental meetings and discussions.

3 2 1


Communicates the mission, ethics and goals of the HHA. 3 2 1

Total Points



Registered Nurse with a Bachelors Degree in Nursing from an accredited program.

Three (3) years nursing experience in community health or home health services in the past five (5) years.

At least one (1) year supervisory and administrative experience.

Public Health Nurse Certificate required.

Current license from the state Board of Registered Nursing.

Current BCLS certification.

Language Skills:



Skills:

Thorough knowledge and understanding of the functions of the HHA.

Ability to plan, coordinate, direct and control the health services of the HHA.

Competency in general nursing theory, techniques and practice.

Physical Demands:



=======================================================================================










PHYSICAL DEMANDS


Amount of Time

Stand:

Walk:

Sit:

Talk or hear:


Push/Pull:



Taste or smell:


Amount of Time

Up to 10 pounds:

Up to 25 pounds:

Up to 50 pounds:

Up to 100 pounds:











_

_

_

_

_



WORK ENVIRONMENT


Amount of Time










Risk of radiation:

Vibration:





Number of Hours


A. Right only

B. Left Only

C. Both


A. Right only

B. Left Only

C. Both


A. Right only

B. Left Only

C. Both


A. Right only

B. Left Only

C. Both

Fine Dexterity

A. Right only

B. Left Only

C. Both

None up to 1/3

1/3 to 1/2

2/3 and more

None up to 1/3

1/3 to 1/2

2/3 and more

None up to

1/3 1/3 to 1/2

2/3 and more






(maximum score)

80 - 100%

50 - 79%

0 - 49%



= Needs Improvement



























PERFORMANCE EVALUATION POPULATION-SPECIFIC/AGE-RELATED COMPETENCY HOME HEALTH PATIENT CARE SERVICES DIRECTOR

Name: Date:

Unit: Evaluator:










NA = Not Applicable


Maintains safe environment: warmth, crib rails in “up” position and locked, no toys with removable parts, no small or sharp objects left out; provides safety education to caregiver/parents.

1 2 3 NA

Involves parents/caregivers in care; ensures return demonstration; encourages parental assistance in provision of care.

1 2 3 NA

Provides information on immunizations. 1 2 3 NA

Demonstrates knowledge of growth and development. 1 2 3 NA

Demonstrates clinical knowledge of expected lab values, vital signs, etc., for the neonatal patient.

1 2 3 NA

Demonstrates knowledge of medicine conversion rates for neonatal/infant dosing.

1 2 3 NA


HOME HEALTH PATIENT CARE SERVICES DIRECTOR (continued)


Recognizes abuse/neglect potential. 1 2 3 NA

Interprets nonverbal communication. 1 2 3 NA

Keeps parents/caregivers in field of vision. 1 2 3 NA

Provides familiar objects (as possible and appropriate). 1 2 3 NA

Uses distraction methods to calm (i.e., visually stimulating objects, bottle, pacifier).

1 2 3 NA

Approaches and provides care in calm, tender manner. 1 2 3 NA

1 2 3 NA

1 2 3 NA


Maintains safe environment: age appropriate toys and/or games; no small or sharp objects left out. Aware of need for peer relationships. Uses age appropriate equipment (i.e., potty chair); ensures safe nutrition (cuts food into small bites to prevent choking).

1 2 3 NA

Involves child in care and educates parents/caregivers at same time. Ensures return demonstration; allows child to have control by allowing choices, as appropriate to situation.

1 2 3 NA

Discusses immunization status with parents. 1 2 3 NA


Demonstrates clinical knowledge of expected lab values, vital signs, etc., for the pediatric patient.

1 2 3 NA

Demonstrates knowledge of medicine conversion rates for the pediatric patient.

1 2 3 NA



Explains all procedures in language that child can understand. 1 2 3 NA




Plans procedures and activities in relation to child’s impulse gratification needs and decreased attention span.

1 2 3 NA

Approaches child in calm manner; uses direct approach with child; allows for privacy needs (ages 9-11); encourages personal hygiene and grooming, as appropriate to condition.

1 2 3 NA

Uses praise as a reward for positive attitude and behavior. Uses touch as a form of comfort, as appropriate to child’s needs and reactions.

1 2 3 NA

1 2 3 NA

1 2 3 NA


Maintains safe environment: assesses for depression/suicidal ideation and keeps dangerous items out of patient’s ability to obtain. Assesses patient’s ability to manage “self-held” and/or “self-operated equipment”.

1 2 3 NA

Involves patient in care, treatments and procedures. Allows time for and encourages questions, explaining issues to patient in language patient can understand. Allows patient to have choice and control over situations and environment, as appropriate to condition and situation.

1 2 3 NA


Demonstrates clinical knowledge of expected lab values, vital signs, etc., for the adolescent patient.

1 2 3 NA

Demonstrates knowledge of medication dosages for the adolescent patient.

1 2 3 NA

Explains all treatments and procedures thoroughly to patient before they are performed.

1 2 3 NA

Avoids using condescending language. 1 2 3 NA



Allows for privacy needs. Encourages and allows for personal hygiene activities.

1 2 3 NA





1 2 3 NA

Encourages verbalization of fears. Discusses options and possible choices patient can make to increase control and foster patient confidence.

1 2 3 NA

1 2 3 NA

1 2 3 NA

ADULT

Maintains safe environment related to equipment and mental status. 1 2 3 NA

Involves patient in care, treatments and procedures. Allows patient to maintain control; involves patient in decision-making and planning of care, as appropriate to condition and situation.

1 2 3 NA

Demonstrates clinical knowledge of expected lab values, vital signs, etc., for the adult patient.

1 2 3 NA

Demonstrates knowledge of medication dosages for the adult patient. 1 2 3 NA

Explains rationale for all treatments and procedures to patient prior to performance.

1 2 3 NA


1 2 3 NA

Facilitates maintenance of body image. 1 2 3 NA

Recognizes/respects concerns over interruption of work, plans, goals, etc. 1 2 3 NA


Recognizes fears of potential life style changes. 1 2 3 NA


Encourages verbalization of fears and anxiety; maintains therapeutic communication with patient.

1 2 3 NA

1 2 3 NA

1 2 3 NA




GERIATRIC

Maintains safe environment related to equipment, fall precautions, mobility needs, aspiration potential and mental status.

1 2 3 NA

Involves patient in care, treatments and procedures. Allows patient to maintain control; involves patient in decision-making and planning of care, as appropriate to condition and situation.

1 2 3 NA

Explains all treatments, tests and procedures, explaining to patient, prior to performance.

1 2 3 NA


1 2 3 NA


1 2 3 NA

Assesses and monitors potential for skin breakdown, decreased bowel function and/or medication absorption.

1 2 3 NA

Recognizes high risk of infection and sepsis. 1 2 3 NA

Recognizes interaction of coexisting health conditions. 1 2 3 NA

Recognizes potential for fluid and electrolyte imbalance. 1 2 3 NA

Demonstrates clinical knowledge of expected lab values, vital signs, etc., for the geriatric patient.

1 2 3 NA

Demonstrates knowledge of medication dosages for the geriatric patient. 1 2 3 NA

Recognizes potential for adverse drug reactions and interactions. 1 2 3 NA


Recognizes importance of autonomy and sense of usefulness. 1 2 3 NA

Considers mobility needs, provides appropriate transportation, maintains ROM, prevents contracture formation.

1 2 3 NA


1 2 3 NA

1 2 3 NA

1 2 3 NA




SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





HOME HEALTH PATIENT CARE SERVICES DIRECTOR




NA = Not Applicable

Demonstrates knowledge of the Patient Care Services Director's role in the absence of the Administrator.

1 2 3 NA

Demonstrates knowledge of the HHA's security plan. 1 2 3 NA

Demonstrates knowledge of the current Medicare requirements for home care reimbursement.

1 2 3 NA

Keeps up-to-date on new developments in regard to state and federal regulatory agencies.

1 2 3 NA


Demonstrates thorough knowledge and understanding of the functions of the HHA.

1 2 3 NA

Demonstrates the ability to plan, coordinate, direct and control the health services of the HHA.

1 2 3 NA

Demonstrates thorough knowledge and understanding of the accrediting organization standards, federal, state and local regulations, and OASIS.

1 2 3 NA

Maintains a good working relationship with the administrator and staff. 1 2 3 NA

Assures quality care by reviewing and assessing each service. 1 2 3 NA

Demonstrates competency in general nursing theory, techniques and practice.

1 2 3 NA

Documentation meets current standards and policies. 1 2 3 NA

Demonstrates the knowledge and ability to be a resource person for the HHA staff.

1 2 3 NA


1 2 3 NA

ANNUAL COMPETENCY CLINICAL SKILLS ASSESSMENT - HOME HEALTH PATIENT CARE

SERVICES DIRECTOR (continued)


HHA Direction:

Oversight of nursing and professional staff 1 2 3 NA

Staffing 1 2 3 NA

Performance evaluations 1 2 3 NA

Staff education: inservices, orientation 1 2 3 NA

Infection prevention and control processes 1 2 3 NA

Safety precautions 1 2 3 NA

Security precautions 1 2 3 NA

Assists with annual budget 1 2 3 NA

Patient complaints 1 2 3 NA

Conflict resolution 1 2 3 NA

Demonstrates knowledge and ability to perform the following:

Intake Service: Admission Record, Orders for Service 1 2 3 NA

Patient Assessments and Reassessments 1 2 3 NA

Nursing process - assessment; intervention; (including pain assessment, reassessment, management and patient/family education regarding pain), etc.

1 2 3 NA

Plan of Care 1 2 3 NA

Discharge Planning 1 2 3 NA

OASIS Data Collection 1 2 3 NA

Waived Testing: Evaluation includes written evaluation of theory; direct observation of test performance by a qualified proctor; direct observation of quality control methodologies (equipment calibration, outdating, troubleshooting, quality control and remedial actions, documentation of quality control measures), if applicable.

1 2 3 NA

List waived testing performed:

Blood glucose monitoring 1 2 3 NA

Fecal occult blood testing 1 2 3 NA

Reagent strips for Urinalysis 1 2 3 NA

Other 1 2 3 NA




List criteria for identification of abuse victims:

Infant/child 1 2 3 NA

Adolescent 1 2 3 NA

Elderly 1 2 3 NA

Domestic abuse 1 2 3 NA

Fiduciary 1 2 3 NA

Neglect 1 2 3 NA

Demonstrates competence in reporting victims of abuse according to established facility standards and state and local laws.

1 2 3 NA


1 2 3 NA


1 2 3 NA


1 2 3 NA

Demonstrates knowledge of role in Emergency Operations Plan. 1 2 3 NA



1 2 3 NA




Telephone system 1 2 3 NA

Beeper system 1 2 3 NA

Fax 1 2 3 NA

Computer system 1 2 3 NA




Charge system 1 2 3 NA

Fire Equipment:

Alarms 1 2 3 NA

Fire extinguishers 1 2 3 NA

Exit doors 1 2 3 NA

HHA Organization - Able to describe roles and functions of:

Home Health Administrator 1 2 3 NA

Governing Body 1 2 3 NA


Physicians 1 2 3 NA


Case Manager 1 2 3 NA

Clinical Supervisor 1 2 3 NA


Pharmacy 1 2 3 NA

Other 1 2 3 NA


Reviews and revises Home Health Policy and Procedure Manual 1 2 3 NA



Fire/Safety Manual 1 2 3 NA

Emergency Management Manual 1 2 3 NA


Patient Teaching Material/Aids 1 2 3 NA

PDR/Drug Reference Manual 1 2 3 NA

Specific Reference Materials/Community Resources 1 2 3 NA





Other 1 2 3 NA

HHA Routines - Able to describe, locate, and/or demonstrate knowledge of:



Logbooks 1 2 3 NA


Reports/memos/statistics 1 2 3 NA


Cultural Factors:

Religion 1 2 3 NA









SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





Job Title: Home Health Clinical Supervisor Supervised by: Patient Care Services Director Prepared by: _ Date: _


Job Summary: Provides direct supervision of all patient services staff; coordinates care services. Collaborates with HHA staff to ensure the submission of accurate OASIS data and assists with reconciling errors. Contributes to operational process development. Represents department on committees as requested.




Directs nursing and home healthcare as prescribed by the attending physician. Reviews all plans of treatments for accuracy, appropriateness and completeness.

3 2 1

Maintains accurate records of all services rendered to patients. 3 2 1

Evaluates and regularly reevaluates the therapy and nursing needs of each patient. 3 2 1

Supervises and trains other nursing services staff. Provides orientation to new staff. 3 2 1

Performs clinical supervisory visits on each Home Health Aide patient every two (2) weeks, as applicable.

3 2 1

Performs initial admission assessment and evaluation of the HHA’s patients, as applicable.

3 2 1


3 2 1


3 2 1


Reports to the physician the patient’s response to treatments, including drugs, and changes in the patient’s physical or emotional condition.

3 2 1

Demonstrates knowledge of medications and their correct administration based on age of the patient and patient’s clinical position.

3 2 1


Teaches, supervises and counsels the patient and family members regarding the nursing care needs.

3 2 1


3 2 1


3 2 1

Supports and carries out the HHA’s policies. 3 2 1


3 2 1



Assures that monthly case conferences are done on each patient, recorded and filed in patient’s chart.

3 2 1

Presents weekly report to the Administrator and Patient Care Services Director on activities and visit count.

3 2 1

Performs other administrative duties as assigned by Patient Care Services Director. 3 2 1

Assists Patient Care Services Director in meeting the accrediting organization standards and federal, state and local regulations.

3 2 1

Keeps up-to-date on new methods, products, trends, etc., and communicates this information to other staff.

3 2 1



Completes annual educational requirements. 3 2 1

Maintains regulatory requirements. 3 2 1

Maintains patient confidentiality at all times. 3 2 1

Reports to work on time and as scheduled, completes work within designated time. 3 2 1

Wears identification while on duty, uses computerized punch time system correctly. 3 2 1


Actively participates in QAPI activities. 3 2 1

Represents the organization in a positive and professional manner in the community. 3 2 1


3 2 1

Complies will all organizational policies regarding ethical business practices. 3 2 1

Resolves staff concerns at the departmental level, utilizing the grievance process as required.

3 2 1


3 2 1

Effectively and consistently communicates administrative directives to staff and encourages interactive meetings and discussions.

3 2 1


Total Points



Bachelors Degree in Nursing from an accredited nursing program.

Registered Nurse, currently licensed in the state.

Public Health Nursing experience desirable with minimum of two (2) years in a community health setting.

Language Skills:



Skills:

Comprehensive knowledge of general nursing theory and practice.

Demonstrated ability in supervision and leadership.

Ability to coordinate patient care services.

Physical Demands:



=======================================================================================










PHYSICAL DEMANDS


Amount of Time

Stand:

Walk:

Sit:

Talk or hear:


Push/Pull:



Taste or smell:


Amount of Time

Up to 10 pounds:

Up to 25 pounds:

Up to 50 pounds:

Up to 100 pounds:











_

_

_

_

_



WORK ENVIRONMENT


Amount of Time










Risk of radiation:

Vibration:





Number of Hours


A. Right only

B. Left Only

C. Both


A. Right only

B. Left Only

C. Both


A. Right only

B. Left Only

C. Both


A. Right only

B. Left Only

C. Both

Fine Dexterity

A. Right only

B. Left Only

C. Both

None up to 1/3

1/3 to 1/2

2/3 and more

None up to 1/3

1/3 to 1/2

2/3 and more

None up to

1/3 1/3 to 1/2

2/3 and more






(maximum score)

80 - 100%

50 - 79%

0 - 49%



= Needs Improvement




























HOME HEALTH CLINICAL SUPERVISOR

Name: Date:

Unit: Evaluator:










NA = Not Applicable


Maintains safe environment: warmth, crib rails in “up” position and locked, no toys with removable parts, educates family members.

1 2 3 NA



1 2 3 NA



1 2 3 NA




HOME HEALTH CLINICAL SUPERVISOR (continued)


Demonstrates clinical knowledge of expected lab values, vital signs, etc., for the neonate.

1 2 3 NA

Knows appropriate medication dosages for age and weight of the infant. 1 2 3 NA


1 2 3 NA

1 2 3 NA


Maintains safe environment. Age appropriate toys and/or games. Aware of need for peer relationships (i.e., with visitors); Uses age appropriate equipment (i.e., potty chair); ensures safe nutrition (cuts food into small bites to prevent choking).

1 2 3 NA


1 2 3 NA



1 2 3 NA


1 2 3 NA



Demonstrates clinical knowledge of expected lab values, vital signs, etc., for the child.

1 2 3 NA

Knows appropriate medication dosages for the age and weight of the child.

1 2 3 NA


1 2 3 NA


1 2 3 NA

1 2 3 NA





Maintains safe environment: assesses for depression/suicidal ideation and keeps dangerous items out of patient’s ability to obtain.

1 2 3 NA

Involves patient in care, Allows time for and encourages questions, explaining issues to patient in language patient can understand. Allows patient to have choice and control over situations and environment, as appropriate to condition and situation.

1 2 3 NA


Allows for privacy needs. Encourages patient to perform own personal hygiene if able.

1 2 3 NA


1 2 3 NA



1 2 3 NA


1 2 3 NA



Encourages verbalization of fears. 1 2 3 NA

1 2 3 NA

1 2 3 NA

ADULT

Maintains safe environment related to equipment, mental status. 1 2 3 NA

Involves patient in care. Allows patient to maintain control; involves patient in decision-making and planning of care, as appropriate to condition and situation.

1 2 3 NA

Explains rationale for all treatments, tests and procedures, explaining to patient prior to performance.

1 2 3 NA






1 2 3 NA




1 2 3 NA



1 2 3 NA

1 2 3 NA

1 2 3 NA

GERIATRIC


1 2 3 NA


1 2 3 NA

Explains all treatments to patient, prior to performance. 1 2 3 NA


1 2 3 NA


1 2 3 NA


1 2 3 NA


Recognizes risk of infection and sepsis. 1 2 3 NA





1 2 3 NA





Knowledgeable about medication precautions. 1 2 3 NA




1 2 3 NA

1 2 3 NA

1 2 3 NA




SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





HOME HEALTH CLINICAL SUPERVISOR




NA = Not Applicable

Keeps up-to-date on new products, trends, methods. 1 2 3 NA

Demonstrates knowledge of nursing process - assessment; intervention; (including pain assessment, reassessment, management and patient/family education regarding pain), etc.

1 2 3 NA

Completes initial patient assessments in the established timeframe. 1 2 3 NA

Develops and implements a plan of care for each patient. Updates care plans as needed.

1 2 3 NA

Medical/Surgical Skills:

Indwelling urinary catheter insertion; male and female 1 2 3 NA

IM injection 1 2 3 NA

IV antibiotics protocol 1 2 3 NA

TPN protocol:

Initiating 1 2 3 NA

Maintaining with monitoring of finger stick blood sugars and daily weights

1 2 3 NA

Chemotherapy:

General precautions 1 2 3 NA

Mixing 1 2 3 NA

Administration 1 2 3 NA

Antiemetics 1 2 3 NA

Waste transport and disposal 1 2 3 NA

Extravasation protocol 1 2 3 NA

Drug protocols 1 2 3 NA

Spill kit and protocol 1 2 3 NA

ANNUAL COMPETENCY CLINICAL SKILLS ASSESSMENT - HOME HEALTH CLINICAL

SUPERVISOR (continued)


Morphine Sulfate Infusion:

IV administration 1 2 3 NA

Subcutaneous administration 1 2 3 NA

Calculation of rate 1 2 3 NA

Narcan preparation 1 2 3 NA

Disposal of controlled drugs when they are no longer needed by the patient

1 2 3 NA

Able to respond to anaphylactic reaction to a medication in the patient’s home

1 2 3 NA

Peripheral IV placement 1 2 3 NA

PICC protocol:

Maintenance 1 2 3 NA

Dressing and cap change 1 2 3 NA

View PICC film (10 min.) 1 2 3 NA

Hickman catheter protocol:

Venous 1 2 3 NA

Epidural 1 2 3 NA

Groshong catheter protocol 1 2 3 NA

Portacath protocol 1 2 3 NA

Equipment:

Infusion pump 1 2 3 NA

Laboratory Evaluation:

Peripheral collection 1 2 3 NA

Semipermanent catheter collection 1 2 3 NA

Laboratory requisitions and appropriate tubes 1 2 3 NA

Clot for type and crossmatch 1 2 3 NA

Blood cultures 1 2 3 NA




Wound cultures 1 2 3 NA

Clean-catch urine for culture 1 2 3 NA

Infusion Pump:

Operations 1 2 3 NA

Familiar with manual 1 2 3 NA

Reservoir filling 1 2 3 NA

Inhalation Therapy Visits:

Standard home visit 1 2 3 NA

Supervising home visit 1 2 3 NA

Medicare 1 2 3 NA

Hospice Medicare 1 2 3 NA



Adolescent 1 2 3 NA

Elderly 1 2 3 NA


Fiduciary 1 2 3 NA

Neglect 1 2 3 NA


1 2 3 NA


1 2 3 NA








Other 1 2 3 NA

Documentation: Able to provide thorough knowledge of:

Record of services rendered to patients 1 2 3 NA

Patient reports to physicians 1 2 3 NA

Monthly case conferences 1 2 3 NA

Weekly reports to Administrator and Patient Care Services Director; activities, visit count

1 2 3 NA


1 2 3 NA



1 2 3 NA


1 2 3 NA


1 2 3 NA


1 2 3 NA

Demonstrates knowledge of the HHA's Emergency Operations Plan. 1 2 3 NA

Staff Direction:

Oversight of staff 1 2 3 NA

Orientation training 1 2 3 NA

Inservices 1 2 3 NA

Patient and Staff Safety 1 2 3 NA




Performance evaluations 1 2 3 NA






Fax 1 2 3 NA



Fire Equipment:

Alarms 1 2 3 NA


Exit doors 1 2 3 NA


Administrator 1 2 3 NA



Physicians 1 2 3 NA


Intake Nurse 1 2 3 NA


Aides 1 2 3 NA

Other 1 2 3 NA












Patient Teaching Aids/Materials 1 2 3 NA


Community resources 1 2 3 NA


Other 1 2 3 NA

HHA Routines: Able to describe, locate and/or demonstrate knowledge of:


Demonstrates understanding of the principle of information management.

1 2 3 NA


Logbooks 1 2 3 NA



Care Plans:

Documents appropriately in the medical record, legible with each entry authenticated

1 2 3 NA

Documents psychosocial patient issues 1 2 3 NA

Complete patient acuity 1 2 3 NA

Cultural Factors:

Religion 1 2 3 NA












SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





Job Title: Home Health Intake Nurse Supervised by: Home Health Clinical Supervisor and Patient Care Services Director

Prepared by: _ Date: _


Job Summary: The Intake Nurse is responsible for the screening and recertification of home health referrals.




Responsible for obtaining accurate referral information. 3 2 1

Obtains specific physician orders for recertification of home care services. 3 2 1

Ensures that physician’s orders are communicated to the HHA’s staff with accuracy, thoroughness and understanding.

3 2 1

Communicates patient’s data and observations verbally and through recording. 3 2 1

Plans with the physician to implement changes to improve patient care. 3 2 1


3 2 1


3 2 1


3 2 1



3 2 1


Addresses and supports cultural practices, as along as such practices do not harm others or interfere with the planned course of medical therapy.

3 2 1


3 2 1

Complies with the HHA’s policies. 3 2 1

Assists administration in meeting the accrediting organization standards and federal, state and local regulations.

3 2 1

Possesses thorough knowledge of the OASIS data collection and reporting process and applicable regulatory requirements.

3 2 1









Completes inservices and returns in a timely fashion. 3 2 1

Attends annual review and department inservices, as scheduled. 3 2 1

Attends at least staff meetings annually, reads and returns all monthly staff meeting minutes.

3 2 1


Actively participates in QAPI activities. 3 2 1



Total Points



Graduate of an accredited nursing school/program.

Current state RN or LPN/LVN licensure.

Prior experience in home health.

Language Skills:



Skills:

Understands regulations governing home healthcare.

Physical Demands:



=======================================================================================










PHYSICAL DEMANDS


Amount of Time

Stand:

Walk:

Sit:

Talk or hear:


Push/Pull:



Taste or smell:


Amount of Time

Up to 10 pounds:

Up to 25 pounds:

Up to 50 pounds:

Up to 100 pounds:











_

_

_

_

_



WORK ENVIRONMENT


Amount of Time










Risk of radiation:

Vibration:





Number of Hours


Right only

Left Only

Both


Right only

Left Only

Both


Right only

Left Only

Both


Right only

Left Only

Both

Fine Dexterity

Right only

Left Only

Both

None up to 1/3

1/3 to 1/2

2/3 and more

None up to 1/3

1/3 to 1/2

2/3 and more

None up to

1/3 1/3 to 1/2

2/3 and more






(maximum score)

80 - 100%

50 - 79%

0 - 49%



= Needs Improvement













How would you rate your current job satisfaction level?

How would you rate your current job performance?


How would you rate the organization’s provision of personnel benefits?

How would you rate the organization’s provisions for staff continuing education?

How would you rate the organization’s physical working environment?

How would you rate the organization’s emotional working environment?

List your professional goals:

List any departmental goals that may differ from professional goals (include educational and performance goals):

Is there anything the organization can do to help you achieve any of these goals? Yes No

If so, please describe:

Comments you feel may assist the organization with improving staff satisfaction levels:




HOME HEALTH INTAKE NURSE

Name: Date:

Unit: Evaluator:










NA = Not Applicable



1 2 3 NA



1 2 3 NA



1 2 3 NA




HOME HEALTH INTAKE NURSE (continued)



1 2 3 NA



1 2 3 NA

1 2 3 NA


Maintains safe environment. Age appropriate toys and/or games. Aware of need for peer relationships (i.e., with visitors); Uses age appropriate equipment (i.e., potty-chair); ensures safe nutrition (cuts food into small bites to prevent choking).

1 2 3 NA


1 2 3 NA



1 2 3 NA


1 2 3 NA




1 2 3 NA

Knows appropriate medication dosages for the age and weight of the child. 1 2 3 NA


1 2 3 NA


1 2 3 NA

1 2 3 NA






1 2 3 NA

Involves patient in care. Allows time for and encourages questions, explaining issues to patient in language patient can understand. Allows patient to have choice and control over situations and environment, as appropriate to condition and situation.

1 2 3 NA



1 2 3 NA



1 2 3 NA


1 2 3 NA


1 2 3 NA




1 2 3 NA

1 2 3 NA

ADULT



1 2 3 NA


1 2 3 NA





1 2 3 NA





1 2 3 NA



1 2 3 NA

1 2 3 NA

1 2 3 NA

GERIATRIC


1 2 3 NA


1 2 3 NA



1 2 3 NA


1 2 3 NA


1 2 3 NA







1 2 3 NA









1 2 3 NA

1 2 3 NA

1 2 3 NA




SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





HOME HEALTH INTAKE NURSE




NA = Not Applicable

Intake Service:

Obtains accurate referral information 1 2 3 NA

Completes initial patient intake form (admission record) 1 2 3 NA

Verifies benefits from private insurance company 1 2 3 NA

Completes insurance verification form 1 2 3 NA

Obtains physician's orders for home health services 1 2 3 NA

Communicates physician's orders to HHA care staff with accuracy 1 2 3 NA

Demonstrates knowledge of the HHA’s admitting criteria 1 2 3 NA

Expresses thorough knowledge of the accrediting organization standards, federal, state and local regulations, and state scope of practice.

1 2 3 NA


1 2 3 NA




Adolescent 1 2 3 NA

Elderly 1 2 3 NA


Fiduciary 1 2 3 NA

Neglect 1 2 3 NA


1 2 3 NA

ANNUAL COMPETENCY CLINICAL SKILLS ASSESSMENT - HOME HEALTH INTAKE

NURSE (continued)





1 2 3 NA


1 2 3 NA


1 2 3 NA


1 2 3 NA


1 2 3 NA

Demonstrates understanding of OASIS data collection and submission process and time-specific period associated with data collection.

1 2 3 NA

HHA Environment - Able to locate and/or demonstrate knowledge/use of:



Home Healthcare Agencies 1 2 3 NA



Fax 1 2 3 NA



Fire Equipment:

Alarms 1 2 3 NA



NURSE (continued)


Exit doors 1 2 3 NA





Physicians 1 2 3 NA




Other 1 2 3 NA









Reference Materials/Community Resources 1 2 3 NA


Other 1 2 3 NA



Demonstrates understanding of the principles of information management

1 2 3 NA


Logbooks 1 2 3 NA



NURSE (continued)



Cultural Factors:

Religion 1 2 3 NA







NURSE (continued)


SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





Job Title: Home Health Case Manager Supervised by: Patient Care Services Director and Clinical Supervisor



Job Summary: A Registered Nurse who is responsible for planning, coordinating, providing and documenting care for a geographically assigned caseload of patients from day of admission through day of discharge. Utilizing physicians’ orders and professional skills, the Case Manager RN develops and implements a home health plan that meets each patient’s specific needs and is in compliance with accrediting organization standards, federal and state regulations, reimbursement guidelines as well as HHA policies and procedures.




Performs admission assessment within 24 hours of referral or patient’s return to his/her residence.

3 2 1

Develops a written plan of care for each patient in the assigned geographic caseload. 3 2 1

Collects accurate OASIS data at time appropriate periods. 3 2 1

Assesses patient’s condition, initiates plan of care, re-evaluates and updates as necessary.

3 2 1


3 2 1


3 2 1


3 2 1


Provides skilled nursing care. 3 2 1

Obtains all necessary physician orders and collaborates with physician as patient’s needs dictate.

3 2 1


3 2 1


Initiates case conferences to discuss multidisciplinary team responsibilities, patient progress, plans for continued care, new problems, etc.

3 2 1

Notifies the Intake Coordinator of patients who need to be seen on weekends or holidays and submits updated nursing care plan to the weekend/holiday nurse.

3 2 1

Follows up with obtaining lab results and notifying physician of any significant results. 3 2 1

Establishes patient schedule and indicates which patients may be seen by a part-time RN when caseload prohibits Case Manager from seeing all scheduled patients.

3 2 1

Re-evaluates the need for continued care on an ongoing basis; initiates recertification as necessary.

3 2 1



Provides oversight to HHA LPN/LVN staff and co-signs documentation as needed in accordance with scope of practice.

3 2 1

Plans for discharge from the HHA with the patient and family. Makes referrals for alternative level of care if necessary.

3 2 1


3 2 1

Promotes patient/family education using various verbal and written communication techniques that take into account the patient’s/family’s cultural, ethnic and/or personal needs or preferences.

3 2 1

Supervises Home Health Aides on an every other week basis. 3 2 1

Initiates needed referrals to other disciplines and/or community resources. 3 2 1

Obtains needed supplies and equipment to provide care. 3 2 1

Knowledgeable of current federal, state and HHA regulations concerning patient care. 3 2 1

Participates in HHA’s other mandated activities, i.e., inservices, UR/QAPI committee, staff meetings.

3 2 1

Adheres to all HHA, payroll, billing and documentation policies and procedures. 3 2 1











3 2 1


Actively participates in Quality Assessment and Performance Improvement (QAPI) activities.

3 2 1



Total Points



Graduate of an accredited school of nursing.

Current state licensure as a Registered Nurse.

Experience as an RN commensurate with one of the following:

One (1) year acute care experience within the last two (2) years;

One (1) year home healthcare experience within the last two (2) years;

One (1) year community health or public health experience within the last two (2) years;

One (1) year outpatient facility experience within the last two years;

Credentials in specialty area, i.e., phlebotomy, IV, ET.

Current CPR card.

Current health certificate/physical examination and TB testing.

Valid state driver’s license and reliable automobile.

Proof of current automobile insurance.

Full command of verbal and written communication skills.

Demonstrated leadership capabilities with the ability to relate well to staff and other professionals.

Language Skills:



Skills:

Comprehensive knowledge of general nursing theory and practice.

Physical Demands:



=======================================================================================










PHYSICAL DEMANDS


Amount of Time

Stand:

Walk:

Sit:

Talk or hear:


Push/Pull:



Taste or smell:


Amount of Time

Up to 10 pounds:

Up to 25 pounds:

Up to 50 pounds:

Up to 100 pounds:











_

_

_

_

_



WORK ENVIRONMENT


Amount of Time










Risk of radiation:

Vibration:





Number of Hours


Right only

Left Only

Both


Right only

Left Only

Both


Right only

Left Only

Both


Right only

Left Only

Both

Fine Dexterity

Right only

Left Only

Both

None up to 1/3

1/3 to 1/2

2/3 and more

None up to 1/3

1/3 to 1/2

2/3 and more

None up to

1/3 1/3 to 1/2

2/3 and more






(maximum score)

80 - 100%

50 - 79%

0 - 49%



= Needs Improvement




























HOME HEALTH CASE MANAGER

Name: Date:

Unit: Evaluator:










NA = Not Applicable



1 2 3 NA



1 2 3 NA



1 2 3 NA




HOME HEALTH CASE MANAGER (continued)



1 2 3 NA

Knows appropriate medication dosages for age and weight of the child. 1 2 3 NA


1 2 3 NA

1 2 3 NA


Maintains safe environment. Age appropriate toys and/or games. Aware of need for peer relationships (i.e., with visitors). Uses age appropriate equipment (i.e., potty chair); ensures safe nutrition (cuts food into small bites to prevent choking).

1 2 3 NA


1 2 3 NA



1 2 3 NA


1 2 3 NA




1 2 3 NA



1 2 3 NA


1 2 3 NA

1 2 3 NA






1 2 3 NA


1 2 3 NA



1 2 3 NA



1 2 3 NA


1 2 3 NA


1 2 3 NA




1 2 3 NA

1 2 3 NA

ADULT



1 2 3 NA


1 2 3 NA





1 2 3 NA





1 2 3 NA



1 2 3 NA

1 2 3 NA

1 2 3 NA

GERIATRIC


1 2 3 NA


1 2 3 NA



1 2 3 NA


1 2 3 NA


1 2 3 NA







1 2 3 NA









1 2 3 NA

1 2 3 NA

1 2 3 NA




SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





HOME HEALTH CASE MANAGER




NA = Not Applicable

Completes the admission assessment within the established timeframe. 1 2 3 NA

Updates care plans per established timeframes and when needed. 1 2 3 NA

Keeps current with federal, state and HHA regulations. 1 2 3 NA

Makes referrals to other community resources per established protocols. 1 2 3 NA

Organizes all members of the healthcare team to deliver optimal patient care. 1 2 3 NA

Follows policy and procedure for the disposing of controlled drugs when no longer needed by the patient.

1 2 3 NA


1 2 3 NA


Expresses knowledge of advanced medical-surgical nursing care, including all systems.

1 2 3 NA

Assessments are complete and reflect a total picture of the patient and his/her environment.

1 2 3 NA



Adolescent 1 2 3 NA

Elderly 1 2 3 NA


Fiduciary 1 2 3 NA

Neglect 1 2 3 NA

ANNUAL COMPETENCY CLINICAL SKILLS ASSESSMENT - HOME HEALTH CASE

MANAGER (continued)



1 2 3 NA

Plans of care reflects:

Sound, skilled clinical judgment 1 2 3 NA

Medical necessity 1 2 3 NA

Specific physician's orders 1 2 3 NA

Reasonable behavioral goals 1 2 3 NA

Compliance with accrediting organization, federal, state, HHA and reimbursement regulations

1 2 3 NA

Updates care plans per established timeframes and when needed 1 2 3 NA

Plans of care are submitted with all required admission documents within 48 hours of start of care

1 2 3 NA

Documents psychosocial patient issues. 1 2 3 NA

Documentation meets current policy and standards. 1 2 3 NA


1 2 3 NA

Each entry is legible and authenticated. 1 2 3 NA

Treatment Authorization Requests are submitted within 24 hours of start of care. 1 2 3 NA

Patient visits reflect the provisions of nursing care rendered in accordance with the physician's orders and plan of care.

1 2 3 NA

New problems, changes in problems and/or resolution of problems are identified and followed.

1 2 3 NA

Averages 5 visits a day or 25 visits a week. 1 2 3 NA

Participates in on-call rotation. 1 2 3 NA

Participates in mandated activities which is documented on sign-in sheet. 1 2 3 NA


MANAGER (continued)


Communication/Documentation - Able to provide thorough knowledge of:



Daily itineraries 1 2 3 NA

Admission/Recertification paperwork 1 2 3 NA

Clinical notes and discharge summaries 1 2 3 NA

Projected weekly schedules 1 2 3 NA

Communicates with HHA each morning and evening (minimal) 1 2 3 NA

List of patients needing weekend/holiday care submitted Friday mornings

1 2 3 NA

Attendance at weekly interdisciplinary team meetings 1 2 3 NA

Multidisciplinary Team Conference notes submitted on each patient 1 2 3 NA

Ancillary Services:

Referrals made within 24 hours of start of care 1 2 3 NA

Notified of skilled nursing discharge within 24 hours 1 2 3 NA

Appropriate utilization of all available services 1 2 3 NA


Indwelling urinary catheter insertion: male and female 1 2 3 NA


IV antibiotic protocol 1 2 3 NA

TPN protocol:

Initiating 1 2 3 NA


1 2 3 NA

Chemotherapy:




MANAGER (continued)












Drug reactions 1 2 3 NA


PICC protocol:



Phlebotomy 1 2 3 NA


Venous 1 2 3 NA

Epidural 1 2 3 NA






Medicare 1 2 3 NA




MANAGER (continued)










1 2 3 NA





Other 1 2 3 NA

Discharge Planning 1 2 3 NA

Equipment/Supplies:

Vital signs equipment 1 2 3 NA


Ordering 1 2 3 NA

Infection Prevention and Control:

Hand Hygiene 1 2 3 NA

Standard Precautions 1 2 3 NA

Transmission-Based Precautions 1 2 3 NA

Personal Protective Equipment 1 2 3 NA


1 2 3 NA


MANAGER (continued)



1 2 3 NA


1 2 3 NA


1 2 3 NA







Fax 1 2 3 NA



Fire Equipment:

Alarms 1 2 3 NA


Exit doors 1 2 3 NA





Physicians 1 2 3 NA



MANAGER (continued)




LPN/LVN 1 2 3 NA

Aides 1 2 3 NA

Other 1 2 3 NA













Other 1 2 3 NA




Logbooks 1 2 3 NA



Cultural Factors:

Religion 1 2 3 NA



MANAGER (continued)







MANAGER (continued)


SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





Job Title: Home Health RN Supervised by: Clinical Supervisor Prepared by: _ Date: _


Job Summary: Responsible for planning, coordinating and documenting care for an assigned caseload of patients. Utilizing physicians' orders and professional skills the Home Health RN, in conjunction with the Case Manager, develops and implements a home health plan that meets each patient's specific needs and is in compliance with accrediting organization standards, federal and state regulations, reimbursement guidelines, as well as agency policies and procedures. Participates in Quality Assessment and Performance Improvement (QAPI) activities.




Develops a written plan of care for each patient. 3 2 1

Provides skilled nursing care. 3 2 1

Assesses patient's condition, initiates plan of care, re-evaluates and updates as necessary.

3 2 1


3 2 1


3 2 1


Obtains all necessary physician orders and collaborates with the physician as the patient's needs dictate.

3 2 1

Participates in case conferences to discuss multidisciplinary team responsibilities, patient progress, plans for continued care, new problems, etc.

3 2 1

Submits updated nursing care plans for the weekend/holiday RN. 3 2 1

In coordination with the Case Manager, plans patient discharge from the agency. Recommends referrals for alternative level of care if necessary.

3 2 1

Recommends to Case Manager needed referrals to other disciplines and/or community resources.

3 2 1

Obtains needed supplies and equipment to provide care. 3 2 1

Performs patient care responsibilities considering needs specific to the standard of care for patient's age, pediatric through geriatric.

3 2 1

Plans with the physician to implement changes to improve patient care. 3 2 1

Reports changes in patient's physical and emotional health to the physician. 3 2 1

Communicates patient's data and observations verbally and through documentation. 3 2 1

All documentation, charting and agency forms are completed in the designated time. 3 2 1



Demonstrates knowledge of medications and their correct administration based on age of patient and patient's clinical status.

3 2 1


Addresses and supports cultural practices as long as these practices do not harm the patient/family or interfere with the planned course of medical treatment.

3 2 1

Adheres to all agency, billing and documentation policies and procedures. 3 2 1

Teaches, supervises and counsels the patient and family members regarding nursing care needs.

3 2 1

Follows up with obtaining lab results and notifies the physician of any significant changes. 3 2 1


Adheres to dress code; appearance is neat and clean. 3 2 1

Completes annual educational requirements. 3 2 1


Reports to work on time and as scheduled; completes work within designated time. 3 2 1


Completes inservices. 3 2 1

Participates in the Home Health Agency's continuous quality improvement activities. 3 2 1

Attends a minimum of staff meetings annually; reads and returns all monthly staff meeting minutes.

3 2 1

Total Points



Licensed Registered Nurse in the state of .

Credentials in specialty areas, i.e., phlebotomy, IV, ET.

Current BCLS.

One (1) year acute care nursing experience.

Prior experience in home health preferred.

Valid state driver’s license, current automobile insurance and reliable automobile.

Language Skills:



Skills:

Basic Computer Knowledge

Knowledgeable of current federal, state and agency regulations governing patient home healthcare.

Physical Demands:



=======================================================================================










PHYSICAL DEMANDS


Amount of Time

Stand:

Walk:

Sit:

Talk or hear:


Push/Pull:



Taste or smell:


Amount of Time

Up to 10 pounds:

Up to 25 pounds:

Up to 50 pounds:

Up to 100 pounds:











_

_

_

_

_



WORK ENVIRONMENT


Amount of Time










Risk of radiation:

Vibration:





Number of Hours


Right only

Left Only

Both


Right only

Left Only

Both


Right only

Left Only

Both


Right only

Left Only

Both

Fine Dexterity

Right only

Left Only

Both

None up to 1/3

1/3 to 1/2

2/3 and more

None up to 1/3

1/3 to 1/2

2/3 and more

None up to

1/3 1/3 to 1/2

2/3 and more






(maximum score)

80 - 100%

50 - 79%

0 - 49%



= Needs Improvement




























HOME HEALTH RN

Name: Date:

Unit: Evaluator:










NA = Not Applicable



1 2 3 NA



1 2 3 NA



1 2 3 NA




HOME HEALTH RN (continued)



1 2 3 NA



Provides information on community and financial resources specific to the neonatal population.

1 2 3 NA

Addresses religious and cultural system beliefs and incorporates these into care planning decisions.

1 2 3 NA

1 2 3 NA

1 2 3 NA


Maintains safe environment. Age appropriate toys and/or games. Aware of need for peer relationships (i.e., with visitors); Uses age appropriate equipment (i.e., potty chair); ensures safe nutrition (cuts food into small bites to prevent choking).

1 2 3 NA


1 2 3 NA



1 2 3 NA


1 2 3 NA




1 2 3 NA

Knows appropriate medication dosages for the age and weight of the child.

1 2 3 NA





1 2 3 NA


Provides information on community and financial resources specific to the pediatric population.

1 2 3 NA


1 2 3 NA

1 2 3 NA

1 2 3 NA



1 2 3 NA

Involves patient in care, Allows time for and encourages questions, explaining issues to patient in language patient can understand. Allows patient to have choice and control over situations and environment, as appropriate to condition and situation.

1 2 3 NA



1 2 3 NA


1 2 3 NA



1 2 3 NA


1 2 3 NA







Provides information on community and financial resources specific to the adolescent population.

1 2 3 NA


1 2 3 NA

1 2 3 NA

1 2 3 NA

ADULT



1 2 3 NA


1 2 3 NA



1 2 3 NA




1 2 3 NA



1 2 3 NA

Provides information on community and financial resources specific to the adult population.

1 2 3 NA


1 2 3 NA

1 2 3 NA

1 2 3 NA




GERIATRIC


1 2 3 NA


1 2 3 NA



1 2 3 NA


1 2 3 NA


1 2 3 NA




1 2 3 NA












1 2 3 NA

Provides information on community and financial resources specific to the geriatric population.

1 2 3 NA


1 2 3 NA

1 2 3 NA

1 2 3 NA




SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





HOME HEALTH RN




NA = Not Applicable

Keeps up-to-date on new products, trends, methods. 1 2 3 NA


1 2 3 NA

Completes initial patient assessments in the established timeframe. 1 2 3 NA

Develops and implements a plan of care for each patient. Updates care plans as needed.

1 2 3 NA


Indwelling urinary catheter insertion; male and female 1 2 3 NA


IV antibiotics protocol 1 2 3 NA

TPN protocol:

Initiating 1 2 3 NA


1 2 3 NA

Chemotherapy:








ANNUAL COMPETENCY CLINICAL SKILLS ASSESSMENT - HOME HEALTH RN (continued)







Disposal of controlled drugs when they are no longer needed by the patient

1 2 3 NA

Able to respond to anaphylactic reaction to a medication in the patient’s home

1 2 3 NA


PICC protocol:



View PICC film (10 min.) 1 2 3 NA


Venous 1 2 3 NA

Epidural 1 2 3 NA



Equipment:












Infusion Pump:

Operations 1 2 3 NA

Familiar with manual 1 2 3 NA

Reservoir filling 1 2 3 NA




Medicare 1 2 3 NA




Adolescent 1 2 3 NA

Elderly 1 2 3 NA


Fiduciary 1 2 3 NA

Neglect 1 2 3 NA


1 2 3 NA


1 2 3 NA





Other 1 2 3 NA



Documentation: Able to provide thorough knowledge of:



Monthly case conferences 1 2 3 NA

Weekly reports to Administrator and Patient Care Services Director; activities, visit count

1 2 3 NA



1 2 3 NA

Documents appropriately in the medical record, legible with each entry authenticated


1 2 3 NA


1 2 3 NA


1 2 3 NA


1 2 3 NA







Fax 1 2 3 NA





Fire Equipment:

Alarms 1 2 3 NA


Exit doors 1 2 3 NA





Physicians 1 2 3 NA




Aides 1 2 3 NA

Other 1 2 3 NA















Other 1 2 3 NA

HHA Routines: Able to describe, locate and/or demonstrate knowledge of:


Demonstrates understanding of the principle of information management.

1 2 3 NA


Logbooks 1 2 3 NA



Cultural Factors:

Religion 1 2 3 NA








SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





Job Title: Home Health LPN/LVN Supervised by: Clinical Supervisor, Intake Coordinator and Patient Care Services Director



Job Summary: Provides skilled nursing care to patients in their homes under the supervision of a Registered Nurse. Provides service in accordance with the HHA philosophy, standards, policies and scope of practice.




Provides skilled nursing in the home as ordered on the plan of treatment and nursing care plan.

3 2 1

Evaluates the significance of assessment findings and communicates any pertinent information about the patient’s clinical status and ongoing needs to others in a timely fashion.

3 2 1


3 2 1


3 2 1



3 2 1

Functions as a team member demonstrating collaboration with, and responsibility to patient, physician, interdisciplinary team.

3 2 1

Adheres to all HHA, payroll, billing and documentation policies and procedures. 3 2 1

Participates in HHA’s other mandated activities, as requested by Clinical Supervisor or Patient Care Services Director including inservices and UR/PI committee.

3 2 1

Performs patient care responsibilities considering needs to the standard of care for patient’s age.

3 2 1



3 2 1

Promotes patient/family education using various verbal and written communication techniques that take into account the patient’s/family’s cultural, ethnic and/or personal needs or preferences.

3 2 1

Completes and submits necessary documentation in accordance with HHA policy and applicable regulations.

3 2 1

Submits verification of completed visits in accordance with HHA policy. 3 2 1

Participates in interdisciplinary team conferences in accordance with HHA policy. 3 2 1



Assists the physician and registered nurse to perform specialized procedures. 3 2 1

Collaborates with the patient/family to learn appropriate self-care techniques. 3 2 1

Maintains current knowledge of community resources. Identifies and assesses appropriate external and internal resources to meet patient and/or family needs and to facilitate optimal patient outcomes while home care services are being procedures, and for transfer and discharge processes.

3 2 1

Ensures documentation is co-signed in accordance with state regulations. 3 2 1



Adheres to legal practice standards, including applicable federal, state and local regulations and standards.

3 2 1



Demonstrates effective time management and organizational skills; provides patient visits as scheduled, completes patient care within designated time.

3 2 1

Wears identification while providing patient care. 3 2 1

Attends annual review and inservices, as scheduled. 3 2 1


3 2 1

Articulates HHA grievance/concerns procedure. 3 2 1

Articulates HHA adverse event/incident reporting procedure. 3 2 1

Articulates organization’s emergency management plan. 3 2 1

Maintains currency of professional knowledge by participating in continuing education offerings.

3 2 1

Assures continued competency by maintaining and updating professional performance, knowledge and skills.

3 2 1


3 2 1

Practices in a manner consistent with the professional and HHA code of ethics. 3 2 1




Total Points



Graduate of an accredited nursing program.

Current state licensure as a LPN/LVN.

Experience as an LPN/LVN commensurate with one of the following:

One (1) year experience in an acute care setting within the last 24 months;

Six (6) months home care experience within the last 12 months.

Prior home healthcare experience is preferred.




Current CPR card.

Flexible, yet organized, with ability to exercise sound judgment.

Language Skills:



Skills:

Knowledge of general nursing practice.

Physical Demands:



=======================================================================================










PHYSICAL DEMANDS


Amount of Time

Stand:

Walk:

Sit:

Talk or hear:


Push/Pull:



Taste or smell:


Amount of Time

Up to 10 pounds:

Up to 25 pounds:

Up to 50 pounds:

Up to 100 pounds:











_

_

_

_

_



WORK ENVIRONMENT


Amount of Time










Risk of radiation:

Vibration:





Number of Hours


Right only

Left Only

Both


Right only

Left Only

Both


Right only

Left Only

Both


Right only

Left Only

Both

Fine Dexterity

Right only

Left Only

Both

None up to 1/3

1/3 to 1/2

2/3 and more

None up to 1/3

1/3 to 1/2

2/3 and more

None up to

1/3 1/3 to 1/2

2/3 and more






(maximum score)

80 - 100%

50 - 79%

0 - 49%



= Needs Improvement




























HOME HEALTH LPN/LVN

Name: Date:

Unit: Evaluator:










NA = Not Applicable



1 2 3 NA



1 2 3 NA



1 2 3 NA




PERFORMANCE EVALUATION - POPULATION-SPECIFIC/AGE-RELATED COMPETENCY –

HOME HEALTH LPN/LVN (continued)


1 2 3 NA

Knows appropriate medication dosages for age and weight of the child. 1 2 3 NA


1 2 3 NA

1 2 3 NA


Maintains safe environment. Age appropriate toys and/or games. Aware of need for peer relationships (i.e., with visitors); Uses age appropriate equipment (i.e., potty-chair); ensures safe nutrition (cuts food into small bites to prevent choking).

1 2 3 NA


1 2 3 NA



1 2 3 NA


1 2 3 NA




1 2 3 NA



1 2 3 NA


1 2 3 NA

1 2 3 NA





Maintains safe environment: Monitors for depression/suicidal ideation and keeps dangerous items out of patient’s ability to obtain.

1 2 3 NA


1 2 3 NA



1 2 3 NA



1 2 3 NA


1 2 3 NA


1 2 3 NA




1 2 3 NA

1 2 3 NA

ADULT



1 2 3 NA


1 2 3 NA





1 2 3 NA





1 2 3 NA



1 2 3 NA

1 2 3 NA

1 2 3 NA

GERIATRIC


1 2 3 NA


1 2 3 NA



1 2 3 NA


1 2 3 NA


1 2 3 NA







Assesses and monitors potential for skin breakdown, decreased bowel functions and/or medication absorption.

1 2 3 NA








1 2 3 NA

1 2 3 NA

1 2 3 NA




SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





HOME HEALTH LPN/LVN




NA = Not Applicable

Check state specific LPN/LVN scope of practice.

Possesses knowledge of policies and procedures for proper disposal of sharps/medical waste.

1 2 3 NA

Medication Administration: Provides thorough knowledge of:

Drugs 1 2 3 NA

Dose 1 2 3 NA

Frequency 1 2 3 NA

Route 1 2 3 NA

Documentation 1 2 3 NA

Adverse reactions 1 2 3 NA

Able to demonstrate/describe knowledge of nursing care:

Basic patient assessment (i.e., collects vital signs) - Report's any abnormal findings to the RN

1 2 3 NA

Wound care 1 2 3 NA

Pressure sore care 1 2 3 NA

Stasis ulcer care 1 2 3 NA

Ostomy care 1 2 3 NA

Proper body alignment/positioning techniques 1 2 3 NA

Transfer Techniques:

Bed to chair 1 2 3 NA

Crutches 1 2 3 NA

Walker 1 2 3 NA

Ambulation with assistance 1 2 3 NA

Patient and family/significant other education 1 2 3 NA

ANNUAL COMPETENCY CLINICAL SKILLS ASSESSMENT - HOME HEALTH LPN/LVN

(continued)


Reports changes in patient condition to the RN and the patient’s physician, as appropriate.

1 2 3 NA




Adolescent 1 2 3 NA

Elderly 1 2 3 NA


Fiduciary 1 2 3 NA

Neglect 1 2 3 NA

Demonstrates competence in reporting victims of abuse according to established HHA standards and state and local laws.

1 2 3 NA

Each visit reflects the provision of skilled nursing care rendered in accordance with the physician's orders and nursing care plans.

1 2 3 NA

New problems, changes in problems and/or resolution of problems are identified and followed through with:

Case Manager/Supervisor Notification 1 2 3 NA

Physician Notification (if an emergency) 1 2 3 NA

Documentation of Clinical Notes 1 2 3 NA

Performs specific treatments and medication administering as per plan of care. 1 2 3 NA

Skilled nursing reflects compliance with the accrediting organization, federal, state, HHA and reimbursement regulations.

1 2 3 NA

Visits are according to the frequency and duration ordered on the plan of care. 1 2 3 NA

Patients are notified on the day of each scheduled visit. 1 2 3 NA

Documentation reflects patient collaboration and participation in the development of their plan of care.

1 2 3 NA


(continued)


Requests for modification of orders or additional orders are made based on the patient's clinical status and skilled nursing judgments.

1 2 3 NA

All physician's collaboration is documented in the medical record. 1 2 3 NA

Appropriate utilization of all available services is demonstrated and documented.

1 2 3 NA

Attendance at weekly interdisciplinary team meetings is recommended and is documented on sign-in sheets.

1 2 3 NA

Daily itineraries, admission/paperwork, clinical notes and discharge summaries are completed and submitted per HHA policy and procedure.

1 2 3 NA

All utilized medical supplies are recorded on daily itineraries per policy and procedure.

1 2 3 NA


1 2 3 NA


1 2 3 NA


1 2 3 NA


1 2 3 NA



Care Plans:

Documents appropriately in the medical record, legibly with each entry 1 2 3 NA

Documents psychosocial patient issues 1 2 3 NA


1 2 3 NA


(continued)







Fax 1 2 3 NA



Fire Equipment:

Alarms 1 2 3 NA


Exit doors 1 2 3 NA





Physicians 1 2 3 NA





Aides 1 2 3 NA

Other 1 2 3 NA





(continued)










Other 1 2 3 NA

HHA Routines - Able to describe, locate and /or demonstrate knowledge of:



1 2 3 NA


Logbooks 1 2 3 NA



Cultural Factors:

Religion 1 2 3 NA







(continued)


SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





Job Title: Home Health Physical Therapist Supervised by: Therapy/Clinical Coordinator/ Supervisor/Patient Care Services Director



Job Summary: Evaluates, plans and administers comprehensive physical therapy modalities/regimens to patients in their place of residence for the purpose of developing and restoring function through rehabilitative physical therapy as prescribed by a physician.




Performs accurate and comprehensive assessments. 3 2 1

Completes OASIS data sets for "therapy only" cases. 3 2 1

Obtains physician orders for certification and recertification of home physical therapy services.

3 2 1

Ensures that changes in patients’ clinical status are communicated to other healthcare team members and HHA office staff verbally and in writing in a timely manner.

3 2 1

Ensures that physician orders are communicated to other healthcare team members and HHA staff in a timely, accurate, and thorough manner.

3 2 1

Coordinates care planning and delivery with the physician, patient and family/caregivers, other healthcare team members and HHA staff to facilitate optimal patient outcomes.

3 2 1

Educates patients, their families/caregivers and other staff as appropriate, in appropriate physical therapy modalities.

3 2 1

Delivers physical therapy modalities appropriate to the patient’s clinical status and needs, and in accordance with the standard of care for patient’s age.

3 2 1

Provides, modifies or discontinues physical therapy modalities based upon an ongoing assessment/reassessment of the patient’s clinical status and in accordance with physician orders.

3 2 1

Assesses the patient for the need for durable medical equipment as well as other adaptive equipment needs.

3 2 1

Develops appropriate home exercise programs tailored to the patient’s clinical status, needs and age.

3 2 1

Synthesizes data from the physical examination and analyzes data to make clinical judgments regarding patient management.

3 2 1

Able to appropriately assess and reassess a patient’s pain. 3 2 1

Utilizes appropriate pain management modalities that include, but are not limited to, physical therapy modalities.

3 2 1

Educates the patient and/or caregiver in effective pain management modalities. 3 2 1



Provides physical therapy modalities in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors.

3 2 1


Provides supervision and mentorship to PT assistants. 3 2 1

Identifies risk of injuries or threats to life and health in the patient’s environment, i.e., environmental/safety/mobility risks and implements appropriate interventions to reduce those risks.

3 2 1

Addresses and supports cultural practices providing such practices do not harm the patient or others, and do not interfere with the planned course of physical therapy.

3 2 1

Performs transfer and discharge planning functions in accordance with HHA policy and applicable laws, regulations and standards.

3 2 1

Participates in the organization’s information management program. 3 2 1


Adheres to all applicable laws, regulations and standards. 3 2 1


3 2 1



Maintains current knowledge of community resources. Identifies and accesses appropriate external and internal resources to meet patient and/or family needs and to facilitate optimal patient outcomes while home care services are being provided, and for transfer and discharge processes.

3 2 1


Adheres to HHA dress code; appearance is neat and clean. 3 2 1

Adheres to legal practice standards, including applicable federal, state, and local regulations and standards.

3 2 1



Demonstrates effective time management and organizational skills; provides patient visits as scheduled; completes patient care within the designated time.

3 2 1




3 2 1







3 2 1


3 2 1

Participates in the organization’s Quality Assessment and Performance Improvement (QAPI) activities.

3 2 1





Total Points



Current valid State Physical Therapy license unless licensure does not apply and meets one of the following requirements:

Graduate of a Physical Thearpy curriculum approved by:

The Commission on Accreditation in Physical Therapy Education (CAPTE)

Successor organizations of CAPTE

An education program outside the United States determined to be substantially equivalent to

physical therapist entry level education in the U.S. by a credentials evaluation organization approved by the American Physical Therapy Association or an organization identified in 8 CFR 212.15(e), or

Passed an examination for physical therapists approved by the state in which

physical therapy services are provided.

On or before December 31, 2009:

Graduated after successful completion of a physical therapy curriculum approved by the

Commission on Accreditation in Physical Thearpy Education (CAPTE); or

Meets both of the following:

Graduated after successful completion of an education program determined to be

substaintially equivalent to physical therapist entry level education in the U.S. by a credentials evaluation organization approved by the American Physical Therapy Association or identified in 8 CFR 212.15(e), and

Passed an examination for physical therapists approved by the state in which

physical therapy services are provided.

Graduate of an accredited physical therapy curriculum/school.


Graduate of a physical therapy curriculum approved by:

The American Physical Therapy Association, or

The Committee on Allied Health Education and Accreditation of the American Medical

Association, or

The Council on Medical Education of the American Medical Association and the American

Physical Therapy Association; OR,


Was admitted to membership by the American Physical Therapy Association, or,

Was admitted to registration by the American Registry of Physical Therapists, or,

Has graduated from a physical therapy curriculum in a four (4) year college or university

approved by a State department of education; or


Regulatory Requirements (continued):


Was licensed or qualified as a Physical Thearpist, and

Two (2) years of appropriate work experience as a Physical Therapist, and has achieved a satisfactory grade

on a proficiency examination conducted, approved, or sponsored by the US Public Health Service except.

Was licensed or registered prior to January 1, 1966, and prior to January 1, 1970 had 15 years of full- time

experience in the treatment of illness or injury through the practice of physical therapy in which services were rendered under the order and direction of attending or referring doctors of medicine or osteopathy; or,

If trained outside the United States, prior to January 1, 2008:

Was graduated since 1928 from a physical therapy curriculum approved by the country in which

the curriculum was located and in which there is a member organization of the World Confederation for Physical Therapy.

Meets the requirements for membership in a member organization of the World

Confederation for Physical Therapy.

Two (2) years of work experience.

Prior home health experience preferred.





Criminal background check.

Current liability insurance.

Current CPR card.

Language Skills:





Skills:

Understands regulations/standards applicable to home healthcare.

Knowledge of general physical therapy modalities and scope of physical therapy practice within the state of .


Physical Demands:



=======================================================================================










PHYSICAL DEMANDS


Amount of Time

Stand:

Walk:

Sit:

Talk or hear:


Push/Pull:



Taste or smell:


Amount of Time

Up to 10 pounds:

Up to 25 pounds:

Up to 50 pounds:

Up to 100 pounds:











_

_

_

_

_



WORK ENVIRONMENT


Amount of Time










Risk of radiation:

Vibration:





Number of Hours


Right only

Left Only

Both


Right only

Left Only

Both


Right only

Left Only

Both


Right only

Left Only

Both

Fine Dexterity

Right only

Left Only

Both

None up to 1/3

1/3 to 1/2

2/3 and more

None up to 1/3

1/3 to 1/2

2/3 and more

None up to

1/3 1/3 to 1/2

2/3 and more






(maximum score)

80 - 100%

50 - 79%

0 - 49%



= Needs Improvement




























HOME HEALTH PHYSICAL THERAPIST

Name: Date:

Unit: Evaluator:










NA = Not Applicable


Maintains safe environment: warmth, crib rails in “up” position and locked when therapy not being provided, no toys with removable parts, educates parents/caregivers in adapting the home environment when appropriate. Assesses equipment for safety.

1 2 3 NA

Handles and positions child to optimize function and to minimize detrimental effects of disorder.

1 2 3 NA

Demonstrates and administers age appropriate therapeutic exercises and activities to improve or maintain strength, range of motion and fine-motor coordination; educates parents/caregivers.

1 2 3 NA

Involves parents/caregivers in care; ensures return demonstration; encourages parents/caregivers assistance in provision of care.

1 2 3 NA



HOME HEALTH PHYSICAL THERAPIST (continued)


Uses distraction methods to calm, i.e., visually stimulating objects, bottle, pacifier.

1 2 3 NA


Demonstrates knowledge of growth and development; recognizes delays in reaching major milestones in related areas of development, i.e., language, cognition, psychosocial, visual-motor perception.

1 2 3 NA

Performs developmentally appropriate and comprehensive physical therapy examination based on disease process, parental/caregiver concerns and cultural/ethnic considerations.

1 2 3 NA

Evaluates child’s functional capabilities/limitations and/or disabilities using appropriate valid and reliable standardized test(s).

1 2 3 NA

Verbalizes appropriate medication dosages for age and weight of the child. 1 2 3 NA

Develops a therapeutic exercise program, including appropriate adaptive equipment and mobility devices, based on the child’s clinical status, results of the physical therapy assessment and physician orders.

1 2 3 NA



1 2 3 NA

1 2 3 NA


Maintains safe environment. Uses age appropriate equipment; instructs parents/caregivers in solutions for adapting the home/school environment when appropriate. Assesses equipment for safety.

1 2 3 NA


1 2 3 NA

Involves child and parents/caregivers in care and educates child, as appropriate and parents/caregivers at same time. Ensures return demonstration; allows child to have control by allowing choices, as appropriate to situation.

1 2 3 NA




Uses age appropriate language with child. 1 2 3 NA

Plans procedures and activities in relation to child’s impulse gratification needs, decreased attention span and clinical status.

1 2 3 NA

Performs developmentally appropriate and comprehensive physical therapy examination based on disease process, parenteral/caregiver concerns and cultural/ethnic considerations.

1 2 3 NA


1 2 3 NA

Develops a therapeutic exercise program, including appropriate adaptive equipment and mobility devices, based on the child’s clinical status, results of the physical therapy assessment and physician orders.

1 2 3 NA

Approaches child in calm manner; uses direct approach with child; allows for privacy needs (ages 9-11).

1 2 3 NA


Verbalizes appropriate medication dosages for the age and weight of the child. 1 2 3 NA



1 2 3 NA

1 2 3 NA

1 2 3 NA


Maintains safe environment relative to patient’s physical and mental clinical status and equipment needs. Instructs patient/family in appropriate adaptation of the home environment. Assesses equipment for safety.

1 2 3 NA


1 2 3 NA

Performs developmentally appropriate and comprehensive physical therapy examination based on disease process, patient/family concerns and cultural/ethnic considerations.

1 2 3 NA




Develops a therapeutic exercise program, including appropriate adaptive equipment and mobility devices, based on the patient’s clinical status, results of the physical therapy assessment and physician orders.

1 2 3 NA




1 2 3 NA


1 2 3 NA


1 2 3 NA



1 2 3 NA

1 2 3 NA

1 2 3 NA

ADULT

Maintains safe environment relative to patient’s physical and mental clinical status and equipment needs. Instructs patient/family in appropriate adaptation of the home environment when necessary.

1 2 3 NA


1 2 3 NA


1 2 3 NA

Explains rationale for all treatments, tests and procedures, explaining to patient/family prior to performance.

1 2 3 NA







Encourages participation in care, provides education, as appropriate to disease entity and processes and treatment regimen.

1 2 3 NA


Identifies abuse/neglect potential. 1 2 3 NA


1 2 3 NA

1 2 3 NA

1 2 3 NA

GERIATRIC

Maintains safe environment related to equipment, fall precautions, mobility needs, aspiration potential and mental status. Instructs patient/family in appropriate adaptation of the home environment when necessary. Assesses equipment for safety.

1 2 3 NA


1 2 3 NA


1 2 3 NA

Explains all treatments to patient/family, prior to performance. 1 2 3 NA


1 2 3 NA





1 2 3 NA


Assesses and monitors potential for skin breakdown. 1 2 3 NA






1 2 3 NA

1 2 3 NA

1 2 3 NA




SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





HOME HEALTH PHYSICAL THERAPIST




NA = Not Applicable

Demonstrates the ability to apply therapeutic principles and practice; uses appropriate technical knowledge and clinical judgment in observing patient's reaction to treatments specific to the needs of the patient.

1 2 3 NA

Able to assess patient pain interfering with optimal level of function or participation in rehabilitation; makes appropriate physician contact for intervention.

1 2 3 NA

Demonstrates ability to design treatment programs for patients with varying degrees/types of disabilities and multiple medical problems.

1 2 3 NA

Develops and implements therapy programs specific to each patient in accordance with the prescribed physician treatment.

1 2 3 NA

Demonstrates accuracy in performing patient evaluations; interprets results within scope of licensure.

1 2 3 NA

Demonstrates the ability to formulate realistic and appropriate short and long term treatment goals for patients.

1 2 3 NA

Exhibits ability to design treatment programs for patients with varying degrees/types of disabilities and multiple medical problems.

1 2 3 NA

Always reports significant alterations in patient's condition or behavior to Director and/or patient's physician.

1 2 3 NA

Demonstrates the ability to perform preparatory data gathering necessary to adequately evaluate the patient's needs prior to initial patient contact; reviews patient records; confers with the treating physician; collaborates with the nursing staff and other healthcare team members regarding each patient.

1 2 3 NA

Demonstrates the ability to use all equipment correctly and safely and provides maintenance.

1 2 3 NA

Demonstrates the ability to instruct patient/family in home treatment programs.

1 2 3 NA

Evaluates patient’s functional capabilities/limitations and/or disabilities using appropriate valid and reliable standardized test(s).

1 2 3 NA

ANNUAL COMPETENCY CLINICAL SKILLS ASSESSMENT - HOME HEALTH PHYSICAL

THERAPIST (continued)


Develops patient care plan, including short-term and long-term goals in collaboration with patient/family and other healthcare team members. Identifies factors that may facilitate and those that may hinder attainment of goals and optimal outcomes.

1 2 3 NA


Expresses the knowledge to make home/job modifications. 1 2 3 NA

Demonstrates/provides thorough knowledge of complex evaluation skills:

Manual Muscle Testing 1 2 3 NA

Joint ROM Measurements 1 2 3 NA

Self Care Assessment 1 2 3 NA

Functional Level (transfers, balance, mobility, etc.) 1 2 3 NA

Sensation 1 2 3 NA

Differential diagnosis, and when to refer a patient to a practitioner 1 2 3 NA

Recommends appropriate treatment modalities bases on results of evaluation

1 2 3 NA

Demonstrates the ability/knowledge to instruct patients in use of adaptive/ assistance devices:

Wheelchairs 1 2 3 NA

Braces 1 2 3 NA

Crutches 1 2 3 NA

Walkers 1 2 3 NA

Prosthetic Devices and Adaptations 1 2 3 NA

Other Devices 1 2 3 NA

Accurately implements the patient care program or components of:

Activities of daily living 1 2 3 NA

Adaptive equipment training 1 2 3 NA

Visual perceptual training 1 2 3 NA




Demonstrates the ability to instruct, assist and supervise patients in:

Passive, active and/or resistive exercises 1 2 3 NA

General conditioning 1 2 3 NA

Breathing exercises 1 2 3 NA

Back exercises 1 2 3 NA

Able to demonstrate/describe knowledge of correct:

Stump care 1 2 3 NA

Chest physical therapy (CPT) 1 2 3 NA

Use of electrical stimulation equipment 1 2 3 NA

Use of ultrasound equipment 1 2 3 NA

Body alignment/positioning techniques 1 2 3 NA

Strengthening exercises 1 2 3 NA

Balance training 1 2 3 NA

Range of motion evaluation and exercises 1 2 3 NA

Gait Training:

With contact guarding 1 2 3 NA

Without assistive device 1 2 3 NA

With assistive device 1 2 3 NA


Bed to chair (standard chair and wheelchair) 1 2 3 NA

Crutches 1 2 3 NA

Walker 1 2 3 NA





Patient and family/significant other education:

Develops/describes components of Home Exercise Program

1 2 3 NA

Education takes into consideration:

Language barriers 1 2 3 NA

Physical challenges (hearing/sight) 1 2 3 NA

Education level and reading skills of patient/family/significant others

1 2 3 NA

Demonstrates knowledge of and describes components of comprehensive physical therapy assessment.

1 2 3 NA

Able to verbalize frequency of Physical Therapy Assistant supervisory visits. 1 2 3 NA




Adolescent 1 2 3 NA

Elderly 1 2 3 NA


Fiduciary 1 2 3 NA

Neglect 1 2 3 NA

Demonstrates competence in reporting victims of abuse according to applicable standards and state and local laws.

1 2 3 NA

Each visit reflects the provision of skilled physical therapy modalities rendered in accordance with the physician's orders and patient care plans.

1 2 3 NA



Physician Notification 1 2 3 NA

Documentation on Clinical Notes 1 2 3 NA




Performs specific treatments as per plan of care. 1 2 3 NA

Physical therapy services reflect compliance with accrediting organization, federal, state, HHA and reimbursement regulations.

1 2 3 NA

Visits are provided in compliance with frequency and duration ordered on the plan of care.

1 2 3 NA

Patients are notified of the visit schedule and any changes to the schedule.

1 2 3 NA


1 2 3 NA

Requests for modification of orders or additional orders are made based on the patient's clinical status and skilled physical therapy judgments.

1 2 3 NA

All physician collaboration is documented in the medical record. 1 2 3 NA


1 2 3 NA

Participates in interdisciplinary team meetings. 1 2 3 NA


1 2 3 NA

All utilized medical supplies are recorded per policy and procedure. 1 2 3 NA


1 2 3 NA


1 2 3 NA



1 2 3 NA


1 2 3 NA






1 2 3 NA

Care Plans:

Documents appropriately and legibly in the medical record 1 2 3 NA

Modifies the care plan to reflect changes in patient clinical status and/or needs

1 2 3 NA

Reviews and documents review of care plans per HHA policy and procedure

1 2 3 NA

Uses only HHA approved abbreviations. 1 2 3 NA


Physician director 1 2 3 NA



Fax 1 2 3 NA



Fire Equipment:

Alarms 1 2 3 NA


Exit doors 1 2 3 NA





Physicians 1 2 3 NA








Aides 1 2 3 NA

Other 1 2 3 NA

HHA Resources - Able to locate and/or demonstrate the use of:







Exposure Control Plan 1 2 3 NA

Community Resources File/Manual 1 2 3 NA


Corporate Compliance Program/Manual 1 2 3 NA

Other 1 2 3 NA




1 2 3 NA


Logbooks 1 2 3 NA






Cultural Factors:

Religion 1 2 3 NA









SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





Job Title: Home Health Occupational Therapist Supervised by: Therapy Coordinator/Supervisor Prepared by: _ Date: _


Job Summary: Evaluates, plans and administers occupational therapy modalities/regimens to patients in their place of residence for the purpose of developing and restoring function through rehabilitative occupational therapy as prescribed by a physician. Provides supervision of occupational therapist assistants.





Accurately completes OASIS data sets. 3 2 1

Obtains physician orders for certification and recertification of home occupational therapy services.

3 2 1


3 2 1

Ensures that assessment results, recommendations, and physician orders are communicated to other healthcare team members and HHA staff in a timely, accurate and thorough manner.

3 2 1

Coordinates care planning and delivery with the physician and other healthcare team members and HHA staff to facilitate optimal patient outcomes.

3 2 1

Delivers occupational therapy modalities appropriate to the patient’s clinical status and needs, and in accordance with the standard of care for patient’s age and with applicable laws, regulations and standards.

3 2 1

Assesses the efficiency and effectiveness of occupational therapy services and designs and implements processes to support optimal patient outcomes.

3 2 1

Develops appropriate home exercise programs tailored to the patient’s clinical status, needs and age.

3 2 1


Utilizes appropriate pain management modalities that include, but are not limited to, occupational therapy modalities.

3 2 1

Educates the patient and/or family in effective pain management modalities. 3 2 1

Provides occupational therapy modalities in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors.

3 2 1





3 2 1

Addresses and supports cultural practices providing such practices do not harm the patient or others, and do not interfere with the planned course of occupational therapy.

3 2 1




Provides appropriate supervision of OT assistants. 3 2 1


3 2 1




3 2 1




3 2 1




3 2 1




3 2 1







3 2 1


3 2 1


3 2 1





Total Points



Licensed or otherwise regulated, if applicable, as an occupational therapist by the state in which practicing, unless licensure does not apply;

Graduated after successful completion of an occupational therapist education program accredited by the Accreditation Council for Occupational Therapy Education (ACOTE) of the American Occupational Therapy Association, Inc. (AOTA), or successor organizations of ACOTE; and

Is eligible to take, or has successfully completed the entry-level certification examination for occupational therapists developed and administered by the National Board for Certification in Occupational Therapy, Inc. (NBCOT).


Licensed or otherwise regulated, if applicable, as an occupational therapist by the state in which practicing; or

When licensure or other regulation does not apply:

Graduated after successful completion of an occupational therapist education program accredited by the Accreditation Council for Occupational Therapy Education (ACOTE) of the American Occupational Therapy Association, Inc. (AOTA) or successor organizations of ACOTE; and

Is eligible to take, or has successfully completed the entry-level certification examination for

occupational therapists developed and administered by the National Board for Certification in Occupational Therapy, Inc., (NBCOT).

On or before January 1, 2008:

Graduated after successful completion of an occupational therapy program accredited jointly by the Committee on Allied Health Education and Accreditation of the American Medical Association and the American Occupational Therapy Association; or

Is eligible for the National Registration Examination of the American Occupational Therapy

Association or the National Board for Certification in Occupational Therapy.


Has had two (2) years of appropriate experience as an occupational therapist; and

Has achieved a satisfactory grade on an occupational therapist proficiency examination conducted,

approved, or sponsored by the U.S. Public Health Service.



If educated outside the United States, must meet both of the following:

Graduated after successful completion of an occupational therapist education program accredited as substantially equivalent to occupational therapist entry level education in the United States by one of the following:

The Accreditation Council for Occupational Therapy Education (ACOTE).

Successor organizations of ACOTE.

The World Federation of Occupational Therapists.

A credentialing body approved by the American Occupational Therapy Association.

Successfully completed the entry level certification examination for occupational therapists developed and

administered by the National Board for Certification in Occupational Therapy, Inc. (NBCOT).


Licensed or otherwise regulated, if applicable, as an occupational therapist by the state in which practicing.

Two (2) years of work experience.

Prior home health experience preferred.







Current CPR card.

Language Skills


Additional language proficiency an asset.


Skills


Knowledge of general occupational therapy modalities and scope of occupational therapy practice within the state of _ .


Physical Demands:



=======================================================================================










PHYSICAL DEMANDS


Amount of Time

Stand:

Walk:

Sit:

Talk or hear:


Push/Pull:



Taste or smell:


Amount of Time

Up to 10 pounds:

Up to 25 pounds:

Up to 50 pounds:

Up to 100 pounds:











_

_

_

_

_



WORK ENVIRONMENT


Amount of Time










Risk of radiation:

Vibration:





Number of Hours


Right only

Left Only

Both


Right only

Left Only

Both


Right only

Left Only

Both


Right only

Left Only

Both

Fine Dexterity

Right only

Left Only

Both

None up to 1/3

1/3 to 1/2

2/3 and more

None up to 1/3

1/3 to 1/2

2/3 and more

None up to

1/3 1/3 to 1/2

2/3 and more






(maximum score)

80 - 100%

50 - 79%

0 - 49%



= Needs Improvement




























HOME HEALTH OCCUPATIONAL THERAPIST

Name: Date:

Unit: Evaluator:










NA = Not Applicable



1 2 3 NA

Handles and positions child to optimize function and to minimize detrimental effects of disorder; educates parents/caregivers.

1 2 3 NA

Demonstrates and administers age appropriate therapeutic exercises and activities to improve or maintain strength, range of motion and fine-motor coordination; educates parents/caregivers

1 2 3 NA

Evaluates and adjusts age-specific adaptive equipment as necessary. 1 2 3 NA

Instructs parents/caregivers in adaptive techniques and use of adaptive equipment.

1 2 3 NA

Involves parents/caregivers in care; ensures return demonstration; encourages parents/caregivers assistance in provision of care.

1 2 3 NA


HOME HEALTH OCCUPATIONAL THERAPIST (continued)




1 2 3 NA



1 2 3 NA

Performs developmentally appropriate and comprehensive occupational therapy examination based on disease process, parental/caregiver concerns and cultural/ethnic considerations.

1 2 3 NA


1 2 3 NA

Develops a therapeutic exercise program, including appropriate adaptive equipment and mobility devices, based on the child’s clinical status, results of the occupational therapy assessment and physician orders.

1 2 3 NA



1 2 3 NA

1 2 3 NA


Maintains safe environment. Uses age appropriate equipment; instructs parents/caregivers in solutions for adapting the home/school environment when appropriate. Assesses equipment for safety.

1 2 3 NA


1 2 3 NA


1 2 3 NA



1 2 3 NA




Performs developmentally appropriate and comprehensive occupational therapy examination based on disease process, parents/caregiver concerns and cultural/ethnic considerations.

1 2 3 NA


1 2 3 NA

Develops and demonstrates a therapeutic exercise program, including appropriate adaptive equipment and mobility devices, based on the child’s clinical status, results of the occupational therapy assessment and physician orders.

1 2 3 NA

Instructs parents/caregivers in adaptive techniques and use of adaptive equipment.

1 2 3 NA

Provides occupational therapy modalities to maintain/improve child’s functional skills for ADLs, conserve energy, restore/maintain/improve joint function and promote safety. Educates patient/family in these modalities.

1 2 3 NA


1 2 3 NA


Demonstrates effective pain management and respiratory care interventions; educates parents/caregivers.

1 2 3 NA



1 2 3 NA

1 2 3 NA


Maintains safe environment relative to patient’s occupational and mental clinical status and equipment needs. Instructs patient/family in appropriate adaptation of the home environment. Assesses equipment for safety.

1 2 3 NA


1 2 3 NA




Performs developmentally appropriate and comprehensive occupational therapy examination based on disease process, patient/family concerns and cultural/ethnic considerations.

1 2 3 NA

Develops and demonstrates a therapeutic exercise program, including appropriate adaptive equipment and mobility devices, based on the patient’s clinical status, results of the occupational therapy assessment and physician orders.

1 2 3 NA




1 2 3 NA

Instructs patient/family in adaptive techniques and use of adaptive equipment.

1 2 3 NA

Provides occupational therapy modalities to maintain/improve functional skills for ADLs, conserve energy, restore/maintain/improve joint function and promote safety. Educates patient/family in these modalities.

1 2 3 NA

Maintains patient confidentiality with parental involvement and education, as appropriate to age and consent of patient.

1 2 3 NA



1 2 3 NA

1 2 3 NA

1 2 3 NA

ADULT

Maintains safe environment relative to patient’s occupational and mental clinical status and equipment needs. Instructs patient/family in appropriate adaptation of the home environment when necessary.

1 2 3 NA


1 2 3 NA





1 2 3 NA


1 2 3 NA

Evaluates and adjusts adaptive equipment as necessary. 1 2 3 NA

Instructs patient/family in appropriate adaptive techniques and use of adaptive equipment.

1 2 3 NA


1 2 3 NA



1 2 3 NA




1 2 3 NA

1 2 3 NA

1 2 3 NA

GERIATRIC

Maintains safe environment related to equipment, fall precautions, mobility needs, aspiration potential and mental status. Instructs patient/family in appropriate adaptation of the home environment when necessary. Assesses equipment for safety.

1 2 3 NA


1 2 3 NA


1 2 3 NA






1 2 3 NA


1 2 3 NA

Evaluates and adjusts adaptive equipment as necessary. 1 2 3 NA

Instructs patient/family in appropriate adaptive techniques and use of adaptive equipment.

1 2 3 NA


1 2 3 NA







1 2 3 NA

1 2 3 NA

1 2 3 NA




SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:




ANNUAL COMPETENCY CLINICAL SKILLS ASSESSMENT EVALUATION OF CLINICAL PERFORMANCE HOME HEALTH OCCUPATIONAL THERAPIST




NA = Not Applicable

Demonstrates the ability to supervise supportive staff, Occupational Therapy Assistants, Occupational Therapy Aides, etc.

1 2 3 NA

Demonstrates the ability/knowledge to organize daily work schedules allowing appropriate amounts of time for preparation and completion of tasks. Coordinates and reassesses schedule with staff throughout the day.

1 2 3 NA

Demonstrates thorough knowledge of state, federal and accrediting organization standards and regulations.

1 2 3 NA

Demonstrates the ability to correctly apply therapeutic principles and practices.

1 2 3 NA

Uses appropriate technical knowledge and clinical judgment in observing patient's reaction to appropriate treatments specific to the needs of the patient.

1 2 3 NA

Able to assess patient pain interfering with optimal level of function or participation in rehabilitation - makes appropriate physician contact for intervention.

1 2 3 NA

Utilizes a comprehensive approach to patient evaluation and implementation of the therapy program; assesses physical, social, and emotional needs of the patient.

1 2 3 NA


1 2 3 NA


1 2 3 NA

Demonstrates the ability to observe and report significant alterations in the patient's condition or behavior.

1 2 3 NA


OCCUPATIONAL THERAPIST (continued)


Demonstrates the ability to perform preparatory data gathering necessary to adequately evaluate the patient's needs prior to initial patient contact; reviews patient records; confers with the treating physician; collaborates with the nursing staff and other healthcare team members regarding each patient.

1 2 3 NA

Demonstrates the ability to perform patient evaluations and interprets results within scope of licensure.

1 2 3 NA

Demonstrates the ability to formulate realistic and appropriate short and long term goals for each patient.

1 2 3 NA


1 2 3 NA

Exhibits ability to design treatment programs for patients with varying degrees/types of disabilities and multiple medical problems.

1 2 3 NA

Performs treatment programs in accordance with pre-established protocols/procedures, as appropriate, to the provided treatment plan and level of functioning.

1 2 3 NA

Accurately instructs, assists and supervises the medically stable patient in exercise programs of a non-complex nature, such as passive, resistive exercises, general conditioning, breathing or back exercises.

1 2 3 NA

Demonstrates the ability to correctly and safely use adaptive devices for ADLS when educating the patient.

1 2 3 NA

Expresses the knowledge to make home/job modifications. 1 2 3 NA

Develops innovative home programs individualized to meet the needs of the patient/family. Instructs the patient and family in these programs.

1 2 3 NA

Demonstrates the ability to correctly and safely use adaptive devices for ADLS. 1 2 3 NA

Demonstrates knowledge of Occupational Therapy Procedures and Treatments:

Feeding training 1 2 3 NA

Dressing training 1 2 3 NA

Hygiene and grooming training 1 2 3 NA

Homemaking 1 2 3 NA




Coordination and control training 1 2 3 NA

Functional therapeutic exercise 1 2 3 NA

Endurance training and energy conservation 1 2 3 NA

Pain management 1 2 3 NA

Sensory retraining 1 2 3 NA

Edema control 1 2 3 NA

Visual stimulation 1 2 3 NA

Somata-Sensory stimulation 1 2 3 NA

Body scheme/retaining 1 2 3 NA

Prosthesis training 1 2 3 NA

ADL training 1 2 3 NA

Designing, constructing, and fitting of orthotics and self-help devices

1 2 3 NA


Energy conservation techniques 1 2 3 NA

Task oriented activities 1 2 3 NA

Joint protection strategies 1 2 3 NA

Use of electrical stimulation equipment 1 2 3 NA

Use of ultrasound equipment 1 2 3 NA

Body alignment/positioning techniques 1 2 3 NA

Strengthening exercises 1 2 3 NA

Balance training 1 2 3 NA

Range of motion evaluation and exercises 1 2 3 NA

Safety techniques for sensory loss 1 2 3 NA

Use of upper body prosthetic devices 1 2 3 NA





Bed to chair (standard chair and wheelchair) 1 2 3 NA

Crutches 1 2 3 NA

Walker 1 2 3 NA




1 2 3 NA





1 2 3 NA

Demonstrates knowledge of and describes components of comprehensive occupational therapy assessment.

1 2 3 NA

Able to verbalize frequency of Occupational Therapy Assistant supervisory visits. 1 2 3 NA




Adolescent 1 2 3 NA

Elderly 1 2 3 NA


Fiduciary 1 2 3 NA

Neglect 1 2 3 NA


1 2 3 NA

Each visit reflects the provision of skilled occupational therapy modalities rendered in accordance with the physician's orders and patient care plans.

1 2 3 NA









Occupational therapy services reflect compliance with accrediting organization, federal, state, HHA and reimbursement regulations.

1 2 3 NA


1 2 3 NA


1 2 3 NA


1 2 3 NA

Requests for modification of orders or additional orders are made based on the patient's clinical status and skilled occupational therapy judgments.

1 2 3 NA



1 2 3 NA



1 2 3 NA



1 2 3 NA


1 2 3 NA







1 2 3 NA


1 2 3 NA


1 2 3 NA

Care Plans:



1 2 3 NA


1 2 3 NA

Uses only HHA approved abbreviations 1 2 3 NA





Fax 1 2 3 NA



Fire Equipment:

Alarms 1 2 3 NA


Exit doors 1 2 3 NA








Physicians 1 2 3 NA





Aides 1 2 3 NA

Other 1 2 3 NA












Other 1 2 3 NA




1 2 3 NA





Logbooks 1 2 3 NA



Cultural Factors:

Religion 1 2 3 NA









SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





Job Title: Home Health Speech-Language Pathologist Supervised by: Patient Care Services Director Prepared by: _ Date: _


Job Summary: Evaluates, plans and administers comprehensive speech therapy modalities/regimens as prescribed by a physician to patients with speech, voice, language, cognitive-communicative and oral-pharyngeal swallowing disorders in their place of residence for the purpose of improving and/or restoring speech and/or swallowing functions.




Performs accurate and comprehensive speech, language and swallowing assessments. 3 2 1

Obtains physician orders for certification and recertification of home speech therapy services.

3 2 1


3 2 1

Ensures that physician orders are communicated to other healthcare team members and HHA staff in a timely, accurate and thorough manner.

3 2 1

Coordinates care planning and delivery with the physician and other healthcare team members and HHA staff to facilitate optimal patient outcomes.

3 2 1

Delivers speech therapy modalities appropriate to the patient’s clinical status, needs and age.

3 2 1


Utilizes appropriate pain management modalities that include, but are not limited to, physical therapy modalities.

3 2 1

Educates the patient and/or family in effective pain management modalities. 3 2 1

Provides speech therapy modalities in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors.

3 2 1


Addresses and supports cultural practices providing such practices do not harm the patient or others, and do not interfere with the planned course of speech therapy.

3 2 1


3 2 1


Accurately completes OASIS data set. 3 2 1



3 2 1






3 2 1


3 2 1




3 2 1




3 2 1






3 2 1


3 2 1


3 2 1





Total Points



Master’s or Doctoral Graduate in the area of Speech Therapy or Speech Pathology from an accredited university or college.

Certificate of Clinical Competence in Speech-Language Pathology awarded by the American Speech Language and Hearing Association.

Current valid state Speech-Language Pathologist or

In the case of an individual who furnishes services in a state which does not license speech-language pathologists:

Has successfully completed 350 clock hours of supervised clinical practicum (or is in the process of

accumulating surpervised clinical experience)

Performed not less than nine (9) months of supervised full-time speech-language pathology services after

maintining a Master's or Doctoral degree in speech-language pathology or a related field; and

Successfully completed a national examination in speech-language pathology approved by the

Secretary.

One (1) year of work experience.

Prior home health experience preferred. Valid state driver’s license and reliable automobile.





Language Skills:



Skills:


Knowledge of general speech therapy modalities and scope of speech therapy practice within the state of .



Physical Demands:



=======================================================================================










PHYSICAL DEMANDS


Amount of Time

Stand:

Walk:

Sit:

Talk or hear:


Push/Pull:



Taste or smell:


Amount of Time

Up to 10 pounds:

Up to 25 pounds:

Up to 50 pounds:

Up to 100 pounds:











_

_

_

_

_



WORK ENVIRONMENT


Amount of Time










Risk of radiation:

Vibration:





Number of Hours


Right only

Left Only

Both


Right only

Left Only

Both


Right only

Left Only

Both


Right only

Left Only

Both

Fine Dexterity

Right only

Left Only

Both

None up to 1/3

1/3 to 1/2

2/3 and more

None up to 1/3

1/3 to 1/2

2/3 and more

None up to

1/3 1/3 to 1/2

2/3 and more






(maximum score)

80 - 100%

50 - 79%

0 - 49%



= Needs Improvement



























PERFORMANCE EVALUATION POPULATION-SPECIFIC/AGE-RELATED COMPETENCY HOME HEALTH SPEECH-LANGUAGE PATHOLOGIST

Name: Date:

Unit: Evaluator:










NA = Not Applicable



1 2 3 NA

Handles and positions child to optimize function and to minimize detrimental effects of disorder.

1 2 3 NA

Assesses child’s speech and language skills, level of language development, articulation and swallowing ability, and voice and fluency disorders.

1 2 3 NA

Demonstrates and administers age appropriate therapeutic exercises and activities to improve or maintain muscular coordination and sensory stimulation to promote language development and/or swallowing activities; educates parents/caregivers.

1 2 3 NA

Involves parents/caregivers in care; ensures return demonstration; encourages parental/caregiver assistance in provision of care.

1 2 3 NA


HOME HEALTH SPEECH-LANGUAGE PATHOLOGIST (continued)




1 2 3 NA



1 2 3 NA

Performs developmentally appropriate and comprehensive speech/ swallowing therapy examination based on disease process, parental/ caregiver concerns and cultural/ethnic considerations.

1 2 3 NA

Develops a therapeutic exercise program, including appropriate adaptive equipment and mobility devices, based on the child’s clinical status, results of the speech therapy assessment and physician orders.

1 2 3 NA



1 2 3 NA

1 2 3 NA


Maintains safe environment. Uses age appropriate equipment; instructs parents/caregivers in solutions for adapting the home/school environment and in the use of speech-language equipment when appropriate. Assesses equipment for safety and appropriateness.

1 2 3 NA


1 2 3 NA


1 2 3 NA



1 2 3 NA




Performs developmentally appropriate and comprehensive speech therapy examination based on disease process, parental/caregiver concerns and cultural/ethnic considerations.

1 2 3 NA

Assesses child’s speech and language skills, level of language development, articulation and swallowing ability, and voice and fluency disorders.

1 2 3 NA

Develops a therapeutic exercise program, including appropriate equipment, based on the child’s clinical status, results of the speech therapy assessment and physician orders.

1 2 3 NA


1 2 3 NA


Demonstrates effective pain management and respiratory care interventions; educates parents/caregivers.

1 2 3 NA

Verbalizes appropriate medication dosages for the age and weight of the child. 1 2 3 NA



1 2 3 NA

1 2 3 NA

1 2 3 NA


Maintains safe environment relative to patient’s physical and mental clinical status and equipment needs. Instructs patient/family in appropriate adaptation of the home environment and in use of speech-language equipment as necessary. Assesses equipment for safety and appropriateness.

1 2 3 NA


1 2 3 NA




Performs developmentally appropriate and comprehensive speech therapy examination based on disease process, patient/family concerns and cultural/ethnic considerations.

1 2 3 NA

Assesses patient’s speech and language skills, level of language development, articulation and swallowing ability, and voice and fluency disorders.

1 2 3 NA

Develops a therapeutic exercise program, including appropriate equipment, based on the patient’s clinical status, results of the speech therapy assessment and physician orders.

1 2 3 NA




1 2 3 NA

Maintains patient confidentiality with family involvement and education, as appropriate to age and consent of patient.

1 2 3 NA



1 2 3 NA

1 2 3 NA

1 2 3 NA

ADULT

Maintains safe environment relative to patient’s physical and mental clinical status and equipment needs. Instructs patient/family in appropriate adaptation of the home environment when necessary and in use of speech-language equipment as necessary. Evaluates equipment for safety and appropriateness.

1 2 3 NA


1 2 3 NA


1 2 3 NA





1 2 3 NA


1 2 3 NA


1 2 3 NA



1 2 3 NA




1 2 3 NA

1 2 3 NA

1 2 3 NA

GERIATRIC

Maintains safe environment related to equipment, fall precautions, aspiration potential and mental status. Instructs patient/family in appropriate adaptation of the home environment when necessary and in use of speech-language equipment as necessary. Assesses equipment for safety and appropriateness.

1 2 3 NA


1 2 3 NA


1 2 3 NA


1 2 3 NA




Plans and develops remedial programs designed to restore or improve communication and/or swallowing efficiency.

1 2 3 NA



1 2 3 NA


1 2 3 NA






1 2 3 NA

1 2 3 NA

1 2 3 NA




SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





HOME HEALTH SPEECH-LANGUAGE PATHOLOGIST




NA = Not Applicable

Demonstrates knowledge of principles and practice of speech-language pathology.

1 2 3 NA

Demonstrates knowledge and skill to perform technical skills related to speech-language pathology.

1 2 3 NA

Demonstrates knowledge of equipment utilized in the diagnosis, evaluation and treatment of speech-language pathology.

1 2 3 NA

Able to determine appropriate patient procedures and evaluate results. 1 2 3 NA

Performs preparatory data gathering necessary to adequately evaluate the patient's needs prior to initial patient contact:

Reviews patient records 1 2 3 NA

Identifies written physician order 1 2 3 NA

Collaborates with the nursing staff and other members of the healthcare team

1 2 3 NA

Demonstrates accuracy in performing patient evaluations; interprets results within scope of licensure.

1 2 3 NA

Able to assess patient pain interfering with optimal level of function or participation in rehabilitation; makes appropriate physician contact for intervention.

1 2 3 NA

Demonstrates the ability to formulate realistic and appropriate short and long term treatment goals. Discusses these goals with patient/family and other members of the healthcare team.

1 2 3 NA


1 2 3 NA

Demonstrates the ability to design treatment programs for patients with varying degrees/types of deficits and multiple medical problems.

1 2 3 NA


ANNUAL COMPETENCY CLINICAL SKILLS ASSESSMENT - HOME HEALTH SPEECH-

LANGUAGE PATHOLOGIST (continued)


1 2 3 NA


1 2 3 NA

Collaborates with members of the rehabilitation team to develop the most appropriate treatment plan consistent with the needs and level of functioning of each patient.

1 2 3 NA

Develops innovative home programs individualized to meet the needs of the patient/family when appropriate. Instructs the patient and family in these programs.

1 2 3 NA

Initiates discharge recommendations on the day of evaluation to facilitate transition to the home care environment.

1 2 3 NA

Applies therapeutic principles and practices; uses appropriate technical knowledge and clinical judgment in observing patient's reactions to appropriate treatments specific to the needs of the patient.

1 2 3 NA

Utilizes a comprehensive approach to patient evaluation and implementation of the therapy program; assesses physical, social and emotional needs of the patient.

1 2 3 NA

Reports significant alterations in patient's condition of behavior to patient's physician.

1 2 3 NA

Demonstrates appropriate professional judgment in presenting alternative or innovative solutions to problems encountered in the course of speech-language therapy; revises treatments as necessary.

1 2 3 NA

Able to describe/demonstrate knowledge of speech therapy modalities to restore or improve communication and/or swallowing efficiency.

1 2 3 NA

Demonstrates the knowledge and ability to perform evaluation skills:

Selects appropriate screening, diagnostic and evaluation materials and equipment, including swallowing evaluation:

Dysphagia 1 2 3 NA

Voice 1 2 3 NA

Aphasia 1 2 3 NA




Apraxia 1 2 3 NA

Fluency 1 2 3 NA

Cognition 1 2 3 NA

Dysarthria 1 2 3 NA

Administers and scores screening and assessment instruments accurately.

1 2 3 NA

Recommends appropriate treatment interventions based on the results of the evaluation.

1 2 3 NA


Swallowing exercises 1 2 3 NA

Use of electrical equipment as appropriate 1 2 3 NA

Use of voice production exercises 1 2 3 NA

Use of appropriate alternative communication aids 1 2 3 NA

Oral muscle strengthening exercises 1 2 3 NA



1 2 3 NA





1 2 3 NA

Demonstrates knowledge of and describes components of comprehensive speech therapy assessment.

1 2 3 NA

Able to verbalize frequency of Speech Therapy Assistant supervisory visits. 1 2 3 NA







Adolescent 1 2 3 NA

Elderly 1 2 3 NA


Fiduciary 1 2 3 NA

Neglect 1 2 3 NA


1 2 3 NA

Each visit reflects the provision of skilled speech therapy modalities rendered in accordance with the physician's orders and patient care plans.

1 2 3 NA






Speech therapy services reflect compliance with accrediting organization, federal, state, HHA and reimbursement regulations.

1 2 3 NA


1 2 3 NA


1 2 3 NA


1 2 3 NA

Requests for modification of orders or additional orders are made based on the patient's clinical status and skilled speech therapy judgments.

1 2 3 NA






1 2 3 NA



1 2 3 NA



1 2 3 NA


1 2 3 NA


Demonstrates knowledge of HIPAA Regulations. 1 2 3 NA


1 2 3 NA


1 2 3 NA


1 2 3 NA

Care Plans:



1 2 3 NA


1 2 3 NA










Fax 1 2 3 NA



Fire Equipment:

Alarms 1 2 3 NA


Exit doors 1 2 3 NA





Physicians 1 2 3 NA





Aides 1 2 3 NA

Other 1 2 3 NA















Other 1 2 3 NA




1 2 3 NA


Logbooks 1 2 3 NA



Cultural Factors:

Religion 1 2 3 NA









SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





Job Title: Home Health Medical Social Worker Supervised by: Therapy Coordinator/Supervisor Prepared by: _ Date: _


Job Summary: Provides psychosocial assessments, diagnosis and treatment to patients in their place of residence as prescribed by a physician, to assist the patient/family develop effective coping skills in response to the patient’s diagnosis, treatment and/or life situation.





Obtains physician orders for certification and recertification of home medical social work services.

3 2 1


3 2 1

Ensures that physician orders are communicated to other healthcare team members and HHA staff in a timely, accurate, and thorough manner.

3 2 1

Coordinates care planning and delivery with the physician, patient/family, other healthcare team members and HHA staff to facilitate optimal patient outcomes.

3 2 1

Educates patient/family and other staff as appropriate, in appropriate medical social work modalities and interventions.

3 2 1

Delivers medical social work modalities and interventions appropriate to the patient’s clinical status and needs, and in accordance with the standard of care for patient’s age.

3 2 1

Provides, modifies or discontinues medical social work modalities and interventions based upon an ongoing assessment/reassessment of the patient’s clinical status and in accordance with physician orders.

3 2 1

Synthesizes assessment data and analyzes data to make clinical judgments regarding patient management.

3 2 1

Provides medical social work modalities in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors.

3 2 1


Identifies risk of injuries or threats to life and health in the patient’s environment, i.e., environmental/safety/mobility risks and implements appropriate interventions to reduce those risks.

3 2 1

Addresses and supports cultural practices providing such practices do not harm the patient or others, and do not interfere with the planned course of medical social work.

3 2 1


3 2 1







3 2 1



Supervises the work of social work assistants, as applicable 3 2 1


3 2 1




3 2 1




3 2 1




3 2 1





3 2 1


3 2 1


3 2 1





Total Points



Current valid State clinical social worker license

Masters or doctoral degree from an accredited school of social work, and

One (1) year of post-masters experience in a clinical setting

Prior home health experience preferred







Language Skills:



Skills:


Knowledge of general medical social work modalities/interventions and scope of medical social work practice within the state of _.

Physical Demands:



=======================================================================================










PHYSICAL DEMANDS


Amount of Time

Stand:

Walk:

Sit:

Talk or hear:


Push/Pull:



Taste or smell:


Amount of Time

Up to 10 pounds:

Up to 25 pounds:

Up to 50 pounds:

Up to 100 pounds:











_

_

_

_

_



WORK ENVIRONMENT


Amount of Time










Risk of radiation:

Vibration:





Number of Hours


Right only

Left Only

Both


Right only

Left Only

Both


Right only

Left Only

Both


Right only

Left Only

Both

Fine Dexterity

Right only

Left Only

Both

None up to 1/3

1/3 to 1/2

2/3 and more

None up to 1/3

1/3 to 1/2

2/3 and more

None up to

1/3 1/3 to 1/2

2/3 and more






(maximum score)

80 - 100%

50 - 79%

0 - 49%



= Needs Improvement




























HOME HEALTH MEDICAL SOCIAL WORKER

Name: Date:

Unit: Evaluator:










NA = Not Applicable


Maintains safe environment: warmth, crib rails in “up” position and locked, no toys with removable parts, identifies patient by leg/arm band.

1 2 3 NA

Involves parents/caregivers in care; encourages parental assistance in provision of care.

1 2 3 NA


Demonstrates knowledge of neonatal assessment for high-risk psychosocial issues.

1 2 3 NA

Demonstrates knowledge of the neonate with suspected drug withdrawal or exposure to maternal chemical abuse.

1 2 3 NA

Demonstrates knowledge of adoption process. 1 2 3 NA

Demonstrates knowledge of community resources for the neonate. 1 2 3 NA


HOME HEALTH MEDICAL SOCIAL WORKER (continued)



Uses distraction methods to calm, (i.e., visually stimulating objects, bottle, pacifier).

1 2 3 NA


1 2 3 NA

1 2 3 NA


Maintains safe environment. Age appropriate toys and/or games. Aware of need for peer relationships, (i.e., with visitors).

1 2 3 NA

Involves child in care and educates parents/caregivers at same time; allows child to have control by allowing choices, as appropriate to situation.

1 2 3 NA


Uses language that child can understand. 1 2 3 NA


1 2 3 NA

Makes provisions for academic/special education as appropriate. 1 2 3 NA


1 2 3 NA

1 2 3 NA

1 2 3 NA


Maintains safe environment. Assesses for depression/suicidal ideation and keeps dangerous items out of patient’s ability to obtain. Assesses for “gang” relationships and considers appropriateness of visitors.

1 2 3 NA






1 2 3 NA

Recognizes need to control environment/situation. 1 2 3 NA

Does not use condescending language. 1 2 3 NA

Recognizes importance of body image. 1 2 3 NA

Makes provisions for academic/special education as appropriate. 1 2 3 NA

Allows for privacy needs. Encourages and allows for personal hygiene activities.

1 2 3 NA


1 2 3 NA

Encourages verbalization of fears. Discusses options and possible choices patient can make to increase control and foster patient confidence.

1 2 3 NA

1 2 3 NA

1 2 3 NA

ADULT

Maintains safe environment related to mental status. 1 2 3 NA


1 2 3 NA


1 2 3 NA



Recognizes/respects concerns over interruption of work/plans/goals/ separation from family, etc.

1 2 3 NA

Recognizes fears regarding potential life style changes. 1 2 3 NA




Encourages family visitation and support. 1 2 3 NA


1 2 3 NA

1 2 3 NA

1 2 3 NA

GERIATRIC

Maintains safe environment related fall precautions, mobility needs. 1 2 3 NA




1 2 3 NA


1 2 3 NA


1 2 3 NA


1 2 3 NA

1 2 3 NA

1 2 3 NA




SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:




ANNUAL COMPETENCY CLINICAL SKILLS ASSESSMENT EVALUATION OF CLINICAL PERFORMANCE HOME HEALTH MEDICAL SOCIAL WORKER




NA = Not Applicable

Demonstrates knowledge and skill to perform psychosocial assessments and reassessments.

1 2 3 NA

Demonstrates knowledge and skill to determine the patient's discharge planning needs.

1 2 3 NA

Involves the family/caregiver in the patient's plan of care and discharge planning.

1 2 3 NA

Keeps informed about new and existing community resources. 1 2 3 NA

Maintains, updates community resources file. 1 2 3 NA

Demonstrates the ability to act as a liaison between patients, the HHA, and the community.

1 2 3 NA

Demonstrates the ability to aid patients and/or families with personal and social difficulties that predispose illness or interfere with obtaining maximum benefits from medical care.

1 2 3 NA

Demonstrates the ability to refer patients to appropriate resources in the community.

1 2 3 NA

Demonstrates ability to educate the patient and/or family concerning Medicare, Medicaid and private insurance issues.

1 2 3 NA

Demonstrates a good working relationship with outside agencies, skilled nursing facilities and acute care hospitals, etc.

1 2 3 NA

Demonstrates thorough understanding of local, state, federal regulations accrediting organization standards and NASW Standards and Code of Ethics.

1 2 3 NA

ANNUAL COMPETENCY CLINICAL SKILLS ASSESSMENT - HOME HEALTH MEDICAL

SOCIAL WORKER (continued)


Able to describe/demonstrate knowledge of:

Neonatal assessments - High Risk Psychosocial Issues:

Family planning 1 2 3 NA

WIC 1 2 3 NA

High-risk follow-up 1 2 3 NA

Housing 1 2 3 NA

Financial aid 1 2 3 NA

Alcohol/Substance abuse issues 1 2 3 NA

Religious and spiritual needs 1 2 3 NA

Cultural and ethnic adaptations 1 2 3 NA

Counseling Services 1 2 3 NA

Skilled Nursing Facility Referral Process 1 2 3 NA

Assisted Living Referral Process 1 2 3 NA

Transfer Process 1 2 3 NA


Develops/describes components of Special Education Program 1 2 3 NA





1 2 3 NA

Demonstrates knowledge of and describes components of comprehensive Medical Social Worker assessment.

1 2 3 NA

Able to verbalize frequency of Social Worker Assistant supervisory visits. 1 2 3 NA







Adolescent 1 2 3 NA

Elderly 1 2 3 NA


Fiduciary 1 2 3 NA

Neglect 1 2 3 NA


1 2 3 NA

Each visit reflects the provision of medical social work modalities rendered in accordance with the physician's orders and patient care plans.

1 2 3 NA





Performs interventions as per plan of care. 1 2 3 NA

Social services reflect compliance with accrediting organization, federal, state, HHA and reimbursement regulations.

1 2 3 NA


1 2 3 NA


1 2 3 NA


1 2 3 NA

Requests for modification of orders or additional orders are made based on the patient's clinical status and skilled social work judgments.

1 2 3 NA






1 2 3 NA



1 2 3 NA

Stays informed about new and existing community resources. 1 2 3 NA


1 2 3 NA


1 2 3 NA




1 2 3 NA


1 2 3 NA


1 2 3 NA

Documentation - Progress Notes:

Assessment of the situation 1 2 3 NA

Adjustment to the illness and HHA care/services 1 2 3 NA

Possible solutions, options 1 2 3 NA

Action taken 1 2 3 NA




Disposition of case 1 2 3 NA

Any social therapy/rehabilitation provided to patient and/or family 1 2 3 NA

Follow-up notes 1 2 3 NA

Documentation complete and appropriate in the medical record 1 2 3 NA

Each entry is legible and authenticated 1 2 3 NA

Maintains statistical data 1 2 3 NA

Care Plans:


1 2 3 NA


1 2 3 NA







Fax 1 2 3 NA



Fire Equipment:

Alarms 1 2 3 NA


Exit doors 1 2 3 NA








Physicians 1 2 3 NA





Aides 1 2 3 NA

Other 1 2 3 NA












Other 1 2 3 NA







1 2 3 NA


Logbooks 1 2 3 NA



Cultural Factors:

Religion 1 2 3 NA









SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





Job Title: Home Health Aide Supervised by: Clinical Supervisor, Case Manager and Patient Care Services Director



Job Summary: Performs duties essentially of personal care which might be given to convalescent, chronically ill or disabled persons in their homes. Attempts in every possible way, in working with individuals and families, to assist them to assume responsibilities toward self-care. Helps the well family members to carry their share of the responsibilities and encourages the disabled member to participate in the life of the family, in so far as able.




Performs duties as assigned by Clinical Supervisor or Case Manager including baths, oral hygiene, nail care, foot care, skin care, pressure relief, dressing patient, feeding, toileting and elimination, and transferring patient.

3 2 1

Takes accurate vital signs. 3 2 1

Describes the activities of daily living and demonstrates the ability to use techniques to assist the patient to meet these activities.

3 2 1

Notifies appropriate licensed staff when patient complains of pain. 3 2 1

Positions patient in bed with proper body alignment. 3 2 1

Assists patient with ambulation as necessary. 3 2 1


3 2 1


Identifies and communicates findings to the Case Manager or Clinical Supervisor. 3 2 1

Demonstrates the ability to chart according to professional standards. 3 2 1

Works as part of the interdisciplinary team. 3 2 1













3 2 1



3 2 1



Total Points



Home Health Qualifications:

Per CMS regulations, a qualified home health aide is a person who has successfully completed:

A training and competency evaluation program that meets CMS requirements (484.80(b) and

484.80(c))* repectively; or

A competency evaluation program that meets the requirements of CMS 484.80(c); or

A nurse aide training and competency evalution program approved by the state as meeting

the requirements of CMS 484.151 through 483.154 and is currently listed in good standing on the state nurse aide registry; or

The requirements of a state licensure program that meets the provisions of CMS 484.80(b)

and 484.80(c).

A home health aide or nurse aide is not considered to have completed a program if since the individual's most recent completion of the program(s), there has been:

A continuous period of 24 consecutive months during which none of the services furnished by

the individual as described in CMS 409.40 were for compensation.

If there has been a 24-month lapse in furnishing services for compensation, the individual

must complete another training and competency evaluation program before providing services.

On-the-job instruction relative to specific patient needs and continuing inservice training, so that

patient safety may be assured and the personal care and homemaking needs of the patient are adequately met.

Valid state driver’s license and reliable automobile, current automobile insurance and be willing to

operate personal car necessitated by nature of job.


Current CPR card.

* Refer to the Home Health Aide Training policy for requirements of CMS 484.80(b) and the Certified Home Health Aide Competency Evaluation Program for requirements of CMS 484.80(c).

Language Skills:




Physical Demands:



=======================================================================================










PHYSICAL DEMANDS


Amount of Time

Stand:

Walk:

Sit:

Talk or hear:


Push/Pull:



Taste or smell:


Amount of Time

Up to 10 pounds:

Up to 25 pounds:

Up to 50 pounds:

Up to 100 pounds:











_

_

_

_

_



WORK ENVIRONMENT


Amount of Time










Risk of radiation:

Vibration:





Number of Hours


A. Right only

B. Left Only

C. Both


A. Right only

B. Left Only

C. Both


A. Right only

B. Left Only

C. Both


A. Right only

B. Left Only

C. Both

Fine Dexterity

A. Right only

B. Left Only

C. Both

None up to 1/3

1/3 to 1/2

2/3 and more

None up to 1/3

1/3 to 1/2

2/3 and more

None up to

1/3 1/3 to 1/2

2/3 and more






(maximum score)

80 - 100%

50 - 79%

0 - 49%



= Needs Improvement




























HOME HEALTH AIDE

Name: Date:

Unit: Evaluator:










NA = Not Applicable



1 2 3 NA



1 2 3 NA



1 2 3 NA

Demonstrates knowledge of expected vital signs for the neonate. 1 2 3 NA


HOME HEALTH AIDE (continued)




1 2 3 NA

1 2 3 NA


Maintains safe environment. Age appropriate toys and/or games. Aware of need for peer relationships (i.e., with visitors). Uses age appropriate equipment (i.e., potty-chair); ensures safe nutrition (cuts food into small bites to prevent choking).

1 2 3 NA


1 2 3 NA

Demonstrates knowledge of expected vital signs for the child. 1 2 3 NA



1 2 3 NA


1 2 3 NA



1 2 3 NA


1 2 3 NA

1 2 3 NA






1 2 3 NA


1 2 3 NA

Demonstrates knowledge of expected vital signs for the adolescent patient.

1 2 3 NA



1 2 3 NA


1 2 3 NA




1 2 3 NA

1 2 3 NA

ADULT



1 2 3 NA


1 2 3 NA




Demonstrates knowledge of expected vital signs for the adult patient. 1 2 3 NA




1 2 3 NA



1 2 3 NA

1 2 3 NA

1 2 3 NA

GERIATRIC


1 2 3 NA


1 2 3 NA



1 2 3 NA


1 2 3 NA


Demonstrates knowledge of expected vital signs for the geriatric patient. 1 2 3 NA









1 2 3 NA

1 2 3 NA

1 2 3 NA




SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:





HOME HEALTH AIDE




NA = Not Applicable

Demonstrates knowledge of infection prevention and control policies and procedures, i.e., Standard Precautions, Transmission-Based Precautions, personal protective equipment, hand hygiene.

1 2 3 NA

Notifies appropriate licensed staff when patient complains of pain. 1 2 3 NA

Able to describe/demonstrate correct nursing care:

Clean/trim fingernails 1 2 3 NA

Clean/trim toenails 1 2 3 NA

Bed bath, self-help, tub bath, shower 1 2 3 NA

Shave: electric razor, safety razor 1 2 3 NA

Hair shampooing: bed, tub and sink 1 2 3 NA

Oral Hygiene:

Alert patient 1 2 3 NA

Unresponsive patient 1 2 3 NA

Dentures 1 2 3 NA

Dressing:

Bedbound patient 1 2 3 NA

Patient with paralysis 1 2 3 NA

Back rub 1 2 3 NA

Recognizes and reports changes in skin condition to appropriate licensed staff

1 2 3 NA

Peri care 1 2 3 NA

Toileting an elimination 1 2 3 NA

ANNUAL COMPETENCY CLINICAL SKILLS ASSESSMENT - HOME HEALTH AIDE

(continued)


Feedings:

Offer fluid/nutrition appropriate to patient's diet 1 2 3 NA

Feed with spoon 1 2 3 NA

Give liquids with syringe 1 2 3 NA

Encourage self-feeding, if possible 1 2 3 NA

Encourages patient to eat with the family, if possible 1 2 3 NA

Mobility:

Position patient in bed with proper body alignment 1 2 3 NA

Remind family to turn bedridden patient every two (2) hours 1 2 3 NA

Transfers:

Bed to chair/commode/wheelchair 1 2 3 NA

Chair to bed 1 2 3 NA

Assist with ambulation 1 2 3 NA

Cane 1 2 3 NA

Crutches 1 2 3 NA

Pick-up walker 1 2 3 NA

Wheeled walker 1 2 3 NA

Vital Signs:

Blood pressure 1 2 3 NA

Pulse (radial) 1 2 3 NA

Respirations 1 2 3 NA

Temperature:

Oral 1 2 3 NA

Axillary 1 2 3 NA

Rectal 1 2 3 NA


(continued)


Accurate charting/documentation 1 2 3 NA

Notifies supervisor of any changes in patient vital signs, condition, etc.

1 2 3 NA

Always encourages patients to do as much as possible for themselves. 1 2 3 NA



Adolescent 1 2 3 NA

Elderly 1 2 3 NA


Fiduciary 1 2 3 NA

Neglect 1 2 3 NA

Demonstrates competence in reporting victims of abuse according to established agency standards and state and local laws.

1 2 3 NA


1 2 3 NA


1 2 3 NA




1 2 3 NA






(continued)



Fax 1 2 3 NA



Fire Equipment:

Alarms 1 2 3 NA


Exit doors 1 2 3 NA





Physicians 1 2 3 NA





LPN/LVN 1 2 3 NA

Other 1 2 3 NA







(continued)






Community Resources 1 2 3 NA


Other 1 2 3 NA



Demonstrates the understanding of the principles of information management

1 2 3 NA




Cultural Factors:

Religion 1 2 3 NA







(continued)


SCORING:









EXAMPLE:









Comments:

Name: Title:

Date:




ANNUAL COMPETENCY JOINT COMMISSION NATIONAL PATIENT SAFETY GOALS

AND UNIVERSAL PROTOCOL

HOME HEALTH/HOSPICE




NA = Not Applicable

Score those competency statements that are applicable to your department/organization

GOAL #1: IMPROVE THE ACCURACY OF PATIENT IDENTIFICATION:

NPSG.01.01.01:

Uses two (2) patient identifiers that have been defined by the organization.

1 2 3 NA

Uses at a minimum two (2) patient identifiers when administering medications or blood products.

1 2 3 NA

Uses at a minimum two (2) patient identifiers when collecting blood specimens and other specimens for clinical testing. Specimen containers are labeled in the presence of the patient.

1 2 3 NA

Uses at a minimum two (2) patient identifiers when providing other treatments or procedures.

1 2 3 NA

GOAL #3: IMPROVE THE SAFETY OF USING MEDICATIONS:

NPSG.03.06.01: (Competencies for Qualified Clinical Staff)

Obtains and documents a list of the patient’s current medications (scheduled and PRN), with patient/ family/other source involvement upon admission/entry to the organization. Information includes dose, route and frequency of current medications.

1 2 3 NA

Follows the organization’s policy and procedure for medication reconciliation and the procedure for resolving any discrepancies.

1 2 3 NA

Upon discharge, provides the patient/family with written information on the medications the patient will be taking at the time of discharge.

1 2 3 NA

ANNUAL COMPETENCY - JOINT COMMISSION NATIONAL PATIENT SAFETY GOALS AND

UNIVERSAL PROTOCOL (continued)


Explains the importance of managing medication information to the patient/family when he/she is discharged. Reminds patients and families to throw away old medication lists and update records with all medication providers and retail pharmacies.

1 2 3 NA

GOAL #7: REDUCE THE RISK OF HEALTHCARE-ASSOCIATED INFECTIONS:

NPSG.07.01.01:

Complies with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.

1 2 3 NA

GOAL #9: REDUCE THE RISK OF PATIENT/RESIDENT HARM RESULTING FROM FALLS:

NPSG.09.02.01:

Assesses the patient’s/resident’s risks for falls. 1 2 3 NA

Implements interventions to reduce falls based on the patient’s/ resident’s risk assessment.

1 2 3 NA

Follows the organization’s fall reduction program, policies and procedures.

1 2 3 NA

Involves the patient’s family in the fall reduction program and any individual fall reduction strategies.

1 2 3 NA

GOAL #15: THE ORGANIZATION IDENTIFIES SAFETY RISKS INHERENT IN ITS PATIENT POPULATION:

NPSG.15.02.01:

Able to identify risks associated with home oxygen therapy, such as home fires.

1 2 3 NA

Performs a home oxygen safety risk assessment before starting oxygen therapy in the patient’s home and again when home services are initiated that addresses at least the following: whether there are smoking materials in the home; whether there are other fire safety risks in the home, such as the potential for open flames; whether or not the home has functioning smoke detectors.

1 2 3 NA

Documents the home safety risk assessment per policy and procedure.

1 2 3 NA




Informs the patient and family of the findings of the safety risk assessment and educates the patient and family about the causes of fire, fire risks to neighbors and neighboring buildings, precautions that can prevent fire-related injuries, and recommendations to address specific identified risk(s). Documents recommendations/ strategies put into place.

1 2 3 NA

Assesses the patient’s and family’s level of comprehension of identified risks and compliance with suggested recommendations during a home visit; reports any concern to the patient’s physician.

1 2 3 NA

Documents patient/family education given and patient family understanding in the patient’s medical record.

1 2 3 NA

Re-evaluates the patient’s home for potential fire risks in timeframes

established by the organization and as needed. The re-evaluation is documented.

1 2 3 NA




SCORING:




Skills rated 3 X the number: Skills rated 2 X the number: Skills rated 1 X the number:




Comments:

Name: Title:

Date:



Home Health © MCN Healthcare (800) 538-6264

SUBJECT: EMPLOYMENT OF CERTIFIED HOME

HEALTH AIDES/NURSING ASSISTANTS

REFERENCE #4038

PAGE: 1

OF: 1 DEPARTMENT: HOME HEALTH

EFFECTIVE:

APPROVED BY: REVISED:

PURPOSE:

To employ qualified competent staff to provide personal care and services to the population served by HHA and to promote positive patient outcomes.

POLICY:

HHA utilizes only Home Health Aides, certified by the Department of Health Services through an approved training program to provide care to patients, when a physician orders the service and care under the plan of treatment.

Selection and hiring of Certified Home Health Aides adheres to the HHA policy.

PROCEDURE:

All staff personnel files will contain written evidence of either the Home Health Aide certification or the qualifications as a Certified Nursing Assistant (CNA) with additional training as a Home Health Aide.

All policies, procedures and performance standards that relate to Certified Home Health Aides (CHHA) will also be applied to Certified Nursing Assistants (CNA).


SUBJECT: HOME HEALTH AIDE TRAINING REFERENCE #4039

PAGE: 1


EFFECTIVE:


POLICY:

HHA's aide training program shall address each of the following subject areas through classroom and supervised practical training totaling at least75 hours, with at least 16 hours devoted to supervised practical training.

The individual being trained must complete at least 16 hours of classroom training before beginning the supervised practical training.

Supervised practical training shall be provided in a laboratory or other setting in which the trainee demonstrates knowledge while performing tasks on an individual under the direct supervision of a registered nurse or licensed practical nurse who is under the supervision of a registered nurse.

Classroom and supervised practical training shall be based on an instruction plan that includes learning objectives, clinical content, and minimum, acceptable performance standards that meet the requirements of the regulation.

The training of home health aides and the supervision of home health aides during the supervised practical portion of the training shall be performed by or under the general supervision of a registered nurse who possesses a minimum of two (2) years of nursing experience, at least one (1) year of which must be in the provision of home healthcare.

Other individuals may be used to provide instruction under the supervision of a

qualified registered nurse, including healthcare professionals, such as physical therapists, occupational therapists, medical social workers and speech-language pathologists; experienced aides, nutritionists, pharmacists, lawyers.

Subject areas that are addressed during home health aide training include:

Communications skills, including the ability to read, write and verbally report clinical information to patients, representatives and caregivers, as well as the other HHA staff

Observation, reporting and documentation of patient status and the care or service

furnished

Reading and recording temperature, pulse and respiration



PAGE: 2


EFFECTIVE:


Basic infection prevention and control procedures

Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor

Maintenance of a clean, safe and healthy environment

Recognizing emergencies and knowledge of instituting emergency procedures and

their application

The physical, emotional and developmental needs of, and ways to work with, the populations served by the HHA, including the need for respect for the patient, his/her privacy and his/her property

Appropriate and safe techniques in personal hygiene and grooming that include:

Bed bath

Sponge, tub or shower bath

Shampoo - sink, tub or bed

Nail and skin care

Oral hygiene

Toileting and elimination

Safe transfer techniques and ambulation

Normal range of motion and positioning

Adequate nutrition and fluid intake

Recognizing and reporting changes in skin condition

Any other task that the HHA may choose to have the Home Health Aide perform as permitted under state law

The HHA shall be responsible for training Home Health Aides, as needed, for

skills not covered in the basic checklist listed above



PAGE: 3


EFFECTIVE:


All education and training shall be documented in the staff member's personnel file. Documentation shall include:

A description of the training/competency evaluation program, including the

qualifications of the instructors

A record that distinguishes between skills taught at a patient’s bedside, with supervision, and those taught in a laboratory using a volunteer or “pseudopatient” (not a mannequin), and indicators of which skills each aide was judged to be competent

How additional skills (beyond the basic skills listed in the regulation) are taught and tested if the admission policies and case-mix of HHA patients require aides to perform more complex procedures

Eligible Training and Competency Evaluation Organizations:

Eligible training and competency evaluation organizations:

A home health aide training program and competency evaluation program may be offered by any organization except by an HHA that:

Within the previous 2 years:

Was out of compliance with the requirements of CMS 484.80(b) (i.e., content and duration), 484.80(c) (i.e., competency evaluation), 484.80(d)(i.e., in-service training), or 484.80(e)(i.e., instructor qualifications); or

Permitted an individual who does not meet the definition of a “qualified home health aide” as specified in CMS 484.80(a) to furnish home health aide services (with the exception of licensed health professionals and volunteers); or

Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or



PAGE: 4


EFFECTIVE:


Was assessed a civil monetary penalty of $5,000 or more as an intermediate sanction; or

Was found to have compliance deficiencies that endangered the health and safety of the HHA's patients, and had temporary management appointed to oversee the management of the HHA; or

Had all or part of its Medicare payments suspended; or

Was found under any federal or state law to have:

Had its participation in the Medicare program terminated; or

Been assessed a penalty of $5,000 or more for deficiencies in federal or state standards for HHAs; or

Been subjected to a suspension of Medicare payments to which it otherwise would have been entitled; or

Operated under temporary management that was appointed to oversee the operation of the HHA and to ensure the health and safety of the HHA's patients; or

Been closed, or had its patients transferred by the state; or

Been excluded from participating in federal health care programs or debarred from participating in any government program.


SUBJECT: CERTIFIED HOME HEALTH AIDE

COMPETENCY EVALUATION PROGRAM

REFERENCE #4040

PAGE: 1


EFFECTIVE:


PURPOSE:

To ensure that Home Health Aides employed by HHA are and remain qualified and competent to provide care and/or services to the patient population served by the HHA.

POLICY:

In order to comply with state and federal regulations, which mandate that individuals providing home health aide services must have completed a training and competency evaluation program before furnishing home health aide services, the following steps shall be taken:

Only state certified home health aides are employed to provide home health aide services.

A newly hired Home Health Aide shall receive a minimum of hours of

orientation, which shall include information on HHA policies and procedures, documentation, communication and the type of patients served.

Home Health Aides shall receive at least 12 hours of inservice training during each 12-month period.

Home Health Aide inservice training shall be provided by a Registered Nurse (RN):

The RN possesses a minimum of two (2) years of nursing experience, with at least one (1) year in home healthcare.

Note: Inservice training may be furnished while the Home Health Aide is furnishing care to

a patient.

Competency evaluations shall be performed by a RN in consultation with other skilled professionals, as appropriate, prior to the Home Health Aide independently providing patient care or services.

Competency evaluations shall address each of the subject areas listed in CMS 484.80(b)(3) (See Home Health Aide Training Policy).




REFERENCE #4040

PAGE: 2


EFFECTIVE:


Subject areas specified under CMS 484.80(b)(3)(i)(iii), (ix), (x) and (xi) must be evaluated through direct observation of an aide's performance of the task.

All other subject areas listed under CMS 484.80(b)(3) may be evaluated through oral or written examination or direct observation (See Certified Home Health Aide Competency Checklist).

PROCEDURE:

Each newly hired Home Health Aide shall be determined to be competent before being allowed to provide care or services.

The Home Health Aide shall meet minimum standards of competency before

providing any care without the supervision of a nurse.

The Home Health Aide's competency shall be demonstrated in each task to be performed before the Home Health Aide provides the specific care independently.

The Clinical Supervisor/Education Director completes the skills checklist in its entirety upon hire of the CHHA/CNA.

The Registered Nurse assigned to the case completes subsequent skills competency evaluations.

An annual performance review (no less frequently than every 12 months) shall be completed for each Home Health Aide to assure that minimum standards of competency continue to be met.

Information shall be gathered from supervisory visits made by RNs throughout the year, whether by direct observation or verbally.

A Home Health Aide shall be supervised and determined competent in every new task that is to be performed.

The performance review shall be completed within three (3) months of the date of

hire, and annually thereafter according to HHA policy.




REFERENCE #4040

PAGE: 3


EFFECTIVE:


A Home Health Aide shall not perform tasks in which he/she has not demonstrated competency.

If a Home Health Aide receives an unsatisfactory evaluation in more than one (1)

subject area, the Home Health Aide has not passed the competency evaluation program and shall not perform as a Home Health Aide without direct supervision by a registered nurse in any subject area until additional training has been taken and the Home Health Aide is re-evaluated.

Each Home Health Aide shall receive at least hours of inservice training per calendar quarter.

Certified Home Health Aide competency shall be verified by quarterly audits with reports submitted to the Quality Assessment and Performance Improvement (QAPI) Committee.

NOTE:

HHA shall ensure that Home Health Aides under arrangement or contract have the appropriate competency skills. All information shall be documented in the Home Health Aide's personnel file.


CERTIFIED HOME HEALTH AIDE COMPETENCY CHECKLIST

Name:

Date Observed Nurse's Signature

* Communication skills: Able to read, write and verbally report clinical information to patients, representatives and caregivers, as well as to other HHA staff

Observation, reporting and documentation of patient status and the care or service furnished

* Reading and recording temperature, pulse and respiration

Basic infection prevention and control procedures

Basic elements of body functioning and changes in body function that must be reported to an aide's supervisor

Maintenance of a clean, safe and health environment

Recognizing emergencies and knowledge of emergency procedures and their application

The physical, emotional and developmental needs of, and ways to work with, the populations served by the HHA, including the need for respect for the patient, his/her privacy and his/her property

Vital signs:

Blood pressure

* Pulse (radial)

* Respirations

* Temperature:

Oral

Axillary

Rectal

* Appropriate and safe techniques in personal hygiene and grooming that include:

Bath:

Bed bath

Tub bath

Shower


CERTIFIED HOME HEALTH AIDE COMPETENCY CHECKLIST (continued)

Date Observed Nurse's Signature

* Appropriate and safe techniques in personal hygiene and grooming (continued):

Shampoo - sink, tub or bed

Shave:

Electric razor

Safety razor

Oral hygiene:

Alert patient

Unresponsive patient

Dentures

Skin care

Fingernail and toenail care

Toileting and elimination

* Safe transfer techniques and ambulation:

Bed to chair/commode/wheelchair

Chair to bed (i.e., wheelchair to toilet)

Assist with ambulation

Cane

Crutches

Pick-up walker

Wheeled walker

* Normal range of motion and positioning

Adequate nutrition and fluid intake:

Feed with spoon

Give liquids with syringe

Any other task that the HHA may choose to have the Home Health Aide perform

* Skills must be evaluated by a registered nurse through direct observation of an aide's performance of the task with a patient.

Supervisor's Signature : Date:


SUBJECT: HOME HEALTH AIDE ASSIGNMENTS AND

DUTIES

REFERENCE #4042

PAGE: 1


EFFECTIVE:


CHECK STATE-SPECIFIC RULES AND REGULATIONS

PURPOSE:

To ensure patient personal care and services are provided in accordance with best practices.

POLICY:

HHA shall assign Home Health Aides/CNAs to specific patients under the supervision a Registered Nurse (RN) or other appropriate skilled professional (i.e., Physical Therapist, Speech-Language Pathologist and Occupational Therapist).

Home Health Aides/CNAs must follow written Patient Care Instructions as prepared by the RN or other appropriate skilled professional

Home Health Aides/CNAs shall be included as members of the interdisciplinary team

Home Health Aides/CNAs must report changes in the patient’s condition to a RN or other appropriate skilled professional

Home Health Aides/CNAs must complete appropriate records in compliance with the HHA’s policies and procedures

PROCEDURE:

The HHA’s Home Health Aides/CNAs shall provide services that are:

Ordered by the physician

Included in the plan of care

Permitted to be performed under state law

Consistent with the home health aide training


SUBJECT: HOME HEALTH AIDE ASSIGNMENTS AND

DUTIES

REFERENCE #4042

PAGE: 2


EFFECTIVE:


The duties of the HHA’s Home Health Aides/CNAs shall include:

The provision of hands-on personal care

The performance of simple procedures as an extension of therapy or nursing services

Report changes in patient condition to the RN or appropriate other skilled

professional

Assistance in ambulation or exercises

Assistance in administering medications ordinarily self-administered

Appropriate documentation in the patient’s medical record


SUBJECT: PATIENT CARE INSTRUCTIONS REFERENCE #4043

PAGE: 1


EFFECTIVE:


POLICY:

Personal care services provided by Home Health Aides and/or Certified Nursing Assistants (CNAs) shall be delivered according to written Patient Care Instructions developed by a Registered Nurse (RN) or other Licensed Skilled Therapist (i.e., Physical Therapist, Speech-Language Pathologist, or Occupational Therapist).

Individual Patient Care Instructions shall reflect the assessment of the patient’s needs and/or clinical status, and the physician’s orders/Plan of Care.

The Patient Care Instructions shall indicate the specific patient care tasks to be performed by the Aide/CNA and the specific frequency of assigned tasks.

The use of “PRN” or “per patient choice” shall never be allowed for any assigned

personal patient care tasks.

PROCEDURE:

The RN or Licensed Skilled Therapist shall initiate the Personal Care Instructions Form during the admission visit in cooperation with the patient and/or patient’s caregiver.

A copy of the completed Personal Care Instructions Form shall be submitted to the Clinical Supervisor and Aide/CNA.

A copy of the form shall be filed in the patient’s medical record.

The Personal Care Instructions Form shall be reviewed at least every days and updated by the RN or Licensed Skilled Therapist according to the patient’s needs and/or clinical status.

The RN or Licensed Skilled Therapist shall provide education as needed to the patient and/or patient’s caregiver, as appropriate, related to the patient’s Personal Care Instructions.

PATIENT CARE INSTRUCTIONS

Patient Name: MR#:

Home Health Aide Cert. Period From to

Certified Nurse’s Aide HHA/CNA Frequency/Duration

Orders for Services/Treatment (Include Frequency for assigned tasks, No “PRN”)

Obtain TPR every visit BR sitting bath

Personal care/hygiene assistance utilizing Shower with bath

Standard Precautions Shampoo

Bed bath every Shave

Tub with bench Skin care/check pressure areas

Hair comb Lotion rub to back/extremities

Oral hygiene Catheter care - soap and water

Nails - clean/file Peri care

Foot care/tepid water soak Assist patient to dress

Empty drainage bag Assist patient with feeding

Assist with bedpan/commode/urinal Wash/dry dishes

Turn and reposition Make bed

Assist with transferring from to _ Change linen

Assist with ambulation using assistive device Light laundry

Offer fluids Light marketing

Range of Motion exercises Dust/tidy patient's room

Prepare and serve diet

Use of DME

Code Status DNR

Special Instructions:

Problem Goal

Patient needs assistance with: Patient will:

Personal care Maintain adequate hygiene

Mobility Be exempt from avoidable accident or injury

Maintaining safe environment Be exempt from preventable accident, injury or infection

Nutrition/hydration Maintain prescribed food and fluid intake

Light housekeeping Express satisfaction with personal care services

Instructions were developed and discussed with patient and/or family.

Patient/Family Signature: Date:

Signature of Primary Service: Date:




SUPERVISION

REFERENCE #4045

PAGE: 1


EFFECTIVE:


PURPOSE:

To ensure patient personal care and services are provided in accordance with best practices, meet the patient’s needs, and promote positive patient outcomes.

POLICY:

The Registered Nurse and/or Licensed Therapist, as appropriate, shall be responsible for making onsite visits to patients’ homes in order to complete Home Health Aide supervision within appropriate timeframes, as follows:

At least once every 14 days for patients receiving Home Health Aide services and

skilled services (i.e., nursing, physical/occupational therapy, or speech-language pathology).

The aide does not have to be present during this supervisory visit.

If an area of concern is noted by the supervising Registered Nurse/Licensed

Therapist, the supervising individual must make an onsite visit to observe and assess the Aide while he/she is performing care.

At least once every 60 days for patients receiving Home Health Aide services

without skilled services.

The Registered Nurse must make an onsite visit to the location where the patient is receiving care to observe and assess the Aide while he/she performs care.

The Registered Nurse/Licensed Therapist shall make an annual onsite visit to the location where a patient is receiving care to observe and assess each Aide while he/she performs patient care.

If a deficiency in skills is noted by the Registered Nurse or Licensed Therapist during an onsite visit, the Aide must complete a competency evaluation.



SUPERVISION

REFERENCE #4045

PAGE: 2


EFFECTIVE:


PROCEDURE:

The Registered Nurse/Licensed Therapist shall visit the patient’s home during appropriate timeframes, as above, to perform Home Health Aide supervision.

The Registered Nurse/Licensed Therapist shall document supervision of the Home Health Aide’s services, using the appropriate form.

All Home Health Aides, regardless of status of employment (i.e., family hired on own), shall be evaluated.

Home Health Aide supervision must ensure that aides furnish care in a safe and effective manner, including but not limited to:

Following the patient's Plan of Care for completion of tasks assigned to a Home

Health Aide by the Registered Nurse or other appropriately skilled professional

Maintaining an open communication process with the patient representative (if any), caregivers and family

Demonstrating competency with assigned tasks

Complying with infection prevention and control policies and procedures

Reporting changes in the patient's condition

Honoring patient's rights

Should a deficiency in skills be noted, the Aide shall be removed from the case until he/she can demonstrate competency in designated skill. If the Home Health Aide is a personal employee of the patient:

The patient and family shall be notified of the deficiency.

The Agency through whom the Aide is hired shall be notified of the deficiency.



SUPERVISION

REFERENCE #4045

PAGE: 3


EFFECTIVE:


The completed written evaluation of the care provided by the Home Health Aide becomes part of the patient’s medical record.

Deficiencies in skills/care and follow-up shall be communicated verbally or in writing to the appropriate individuals/organizations.

SUPERVISION CHECKLIST

Employee Name: Home Health Aide CNA

Present Not present

Patient Name: MR#: Date:

Purpose of Visit: 14 Day Supervision 60 Day Skills Observation Annual Evaluation

Yes No If no, explain:

Care provided according to Plan of Treatment?

PT/PCG verbalize satisfaction with services provided?

Plan of Care remains appropriate to patient’s needs?

Changes in Plan of Treatment?

Supplemental order submitted Reported to Coordinator

Additional Comments:

Signature of Staff Performing Supervision:



SUBJECT: MONITORING OF HOME HEALTH AIDE AND

CNA INSERVICE HOURS

REFERENCE #4047

PAGE: 1


EFFECTIVE:


PURPOSE:

To provide a permanent record of Home Health Aide/CNA continuing education programs.

POLICY:

Every Home Health Aide and/or CNA shall be required to attend, at a minimum, hours of inservice per quarter in order to meet annual inservice requirements.

Every Home Health Aide and/or CNA must receive at least 12 hours of inservice

training every 12 months.

Inservices shall be given at HHA by a person qualified in the subject presented.

A Registered Nurse with a minimum of two (2) years nursing experience, at least one of which is in home care, shall supervise all inservice training provided to the Home Health Aide/CNA.

PROCEDURE:

The Home Health Aide and/or CNA shall be made aware of inservice dates and times in a timely manner to facilitate attendance.

The Aide shall sign an attendance sheet at each inservice attended.

The date, subject material, instructor’s name, and length of the inservice shall be recorded on a sign-in sheet by the designated inservice coordinator.

The Patient Care Services Director/Home Health Aide Supervisor shall monitor hours of inservice attended to ensure compliance.

A copy of the record of inservice attendance shall be retained in each Aide's or CNA’s personnel file. The original sheet shall be retained in the Education Department.


SUBJECT: STAFFING - GENERAL REFERENCE #4048

PAGE: 1


EFFECTIVE:


POLICY:

The Clinical Supervisor/Patient Care Services Director has overall responsibility and accountability for the development of staffing plans.

The professional accountability for the provision of patient care is addressed in job descriptions, and further defined in the staffing policy statement.

Skilled nursing services are provided by or supervised by a registered nurse.

Supervisory staff is available at all times during operational hours.

Delegation of activities are based on staffing qualifications, competency and requirements for supervision.

Coordination of patient care activities and activities are provided in conjunction with other disciplines through a multidisciplinary plan of care, assuring that interventions/activities are directed at identified patient problems.

Clinical and service indicators will be utilized in combination with human resource screening indicators to assess staffing effectiveness. Revisions in staffing plans and processes will be made according to the evaluation of staff effectiveness.


SUBJECT: QUALIFICATIONS AND COMPETENCY - HHA REFERENCE #4049

PAGE: 1


EFFECTIVE:


PURPOSE:

To ensure that HHA has an adequate number of appropriate qualified staff (employees and contracted staff) to provide quality patient care or services consistent with the mission, vision and goals of the organization, thereby promoting positive patient outcomes and ensuring compliance with State and Federal regulatory requirements.

POLICY:

Every individual selected for employment by HHA shall have the following information verified/completed before the offer of employment is made:

Interviews by appropriate management staff

Current licensure, certification or registration as required by applicable laws, regulations and standards

Verification of education and training as required by applicable laws, regulations and

standards

Employment and personal references and job history, as required by applicable laws, regulations, and standards (verified in writing or verbally):

Compliance with current health requirements, as required by the specific job

description and applicable laws and regulations

Knowledge and experience appropriate for the assigned job responsibilities, as well as an adequate understanding of the corresponding job description

Knowledge regarding State Scope of Practice guidelines,

appropriate for the position

A criminal background check, including sex offender list

Form I-9



PAGE: 2


EFFECTIVE:


Drug testing when required by applicable laws and regulations

A review of the Office of the Inspector General’s (OIG’s) List of Excluded Individual and Entities (LEIE, as applicable

All job offers are contingent upon completion of a satisfactory health examination and satisfactory criminal background checks and drug screening tests, if applicable.

The Human Resources Manager shall be responsible for ensuring that the applicant’s personnel file is complete and accurate.

HHA shall have in place a system to ensure that the licensure, registration and certification required for patient care staff is continually maintained.

HHA shall demonstrate, assess, maintain and improve staff competence on an ongoing basis.

PROCEDURE:

Completed Applications for Employment shall be reviewed by the appropriate department manager/supervisor.

Department managers/supervisors or their designees interview applicants and document the results of the interview and whether the applicant is a suitable candidate on the HHA Interview Form. The completed interview record form shall be submitted to Human Resources.

The Human Resources Department shall verify and document the following:

Status and expiration date of professional license, registration and/or certificates, as appropriate

Possession of Fingerprint Clearance Card

Current pass of Physical

Dates of attendance and/or completion of required education and training

Employment references

Job history



PAGE: 3


EFFECTIVE:


The completed form shall be submitted to the Patient Care Services Director/Administrator for approval to make a job offer to the applicant.

When the applicant accepts the job offer his/her name shall be submitted for a criminal background check and he/she shall be asked to complete a drug screening test, if applicable.

Applicants for clinical or technician positions shall be required to complete a competency test (written and/or demonstration), as outlined by the HHA's clinical competency policies.

The Human Resources Manager shall inform the appropriate department manager/supervisor when the applicant’s file is complete.

The Human Resources Manager, in conjunction with the department manager/supervisor, shall notify the applicant of the date of hire either in writing or verbally.

Competence assessments for staff, students and volunteers who work in the same capacity as staff providing care, treatment and services shall be based on the following:

Populations Served:

Staff members must successfully complete competency assessments specific

to the age ranges, cultural, ethnic and clinical conditions associated with the population serviced by the department.

The specific competencies required by the services provided and departmental

scope in the department in which the staff member works (i.e., treatment provided, infection prevention and control issues, medications, equipment).

The competencies that are to be assessed during orientation.

The specified competencies that need to be assessed and reassessed on an

ongoing basis, based on techniques, procedures, technology, equipment and/or skills needed to provide care, treatment and services within the given department to the specific patient population served by that department.

Staff shall have a documented competency assessment completed as a part of their orientation; after the 90-day period of probation, and once every years, or more frequently as defined by HHA policy or law and regulation.



PAGE: 4


EFFECTIVE:


Assessment methods that are used shall correspond to the skill being assessed (i.e., theory may be assessed through written testing, practical skills may be assessed through direct observation/demonstration). Methods include, but may not be limited to:

Written exam

Return demonstration

Use of simulations

Direct observation by qualified supervisor or preceptor:

Successful completion of general and department-specific skills checklist

Successful performance of identified procedure

Peer review

Only those individuals who are qualified through licensure, experience and training to assess specific skills shall conduct competency assessments:

When an individual is not found to assess staff competency,

shall be used (individual outside of the organization) or

Competency guidelines from the appropriate professional organization shall be used to perform staff competency

When improvement activities lead to a determination that a person with performance problems is unable or unwilling to improve, the staff member’s work assignment may be revised, further education and training may be required or other appropriate corrective action(s) may be taken.

The competence assessment program shall be continuous and ongoing, with reports of competency outcomes forwarded to the Governing Body on a regular basis.

NOTE:

CHAP Core Standards require evidence of two (2) reference checks for each staff member.


SUBJECT: LICENSURE, CERTIFICATION AND

REGISTRATION VERIFICATION AND

CONTROL SYSTEMS

REFERENCE #4050

PAGE: 1


EFFECTIVE:


POLICY:

HHA shall employ only those individuals who have proper licensure, certification or registration by the appropriate agency in those jobs requiring such status.

Furthermore, licensure, certification or registration shall be maintained current by those staff. The staff member shall furnish the original of license, certification or registration documentation before employment begins and shall provide a photocopy of the document(s) to the HHA which shall be placed on permanent record in the personnel file.

At each time the status requires updating and/or renewal, the staff member shall provide original documentation and further photocopies to the HHA Human Resources Department as proof of update and/or renewal.

Human Resources Department staff shall verify each individual’s license, certification or registration through the primary source via telephone or secure electronic communication.

Two (2) photocopies of the license/certification/registration shall be made and the license/ certification/registration verification form shall be completed. The Human Resources Department staff shall contact the appropriate primary source and verify the new hire’s current license/ certification/registration status and document this directly on the copy of the individual’s license/certification. One (1) copy shall be placed in the staff member’s personnel file, and one (1) copy shall be sent to the department manager.

This process shall be completed at the time of hire and at the time of renewal for the

license, certification or registration.

Failure on the part of the staff member to provide such documentation or proof of current status shall result in one (1) or more of the following actions on the part of the HHA:

Demotion to an available position closest to that normally held which does not

require licensure, certification or registration

Suspension without pay until such documentation is received

Disciplinary action as deemed appropriate by the department manager




CONTROL SYSTEMS

REFERENCE #4050

PAGE: 2


EFFECTIVE:


PROCEDURE:

At the Time of Employment:

All newly hired staff whose job requires licensure by the state or other proof of registry or certification shall provide a photocopy of such document to Administration/ Human Resources. Verification is due upon demand by the HHA before the staff member may assume duties associated with such a license.

Human Resources Department staff shall verify the individual’s licensure, certification or registration with the primary source via telephone or secure electronic communication. Verification shall be documented directly on the individual’s licensure, certification or registration.

A primary source of information may designate another agency to

communicate credentials information. The designated agency may then be used as a primary source.

An external organization, such as a Credential Verification Organization

(CVO), may be used to collect credentials information.

The CVO must meet the accrediting organization guidelines.

One (1) copy shall be placed in the staff member’s personnel file, and one (1) copy shall be sent to the department manager.

Failure on the part of the staff member to provide this document shall relieve the HHA of any employment obligations. The staff member shall be considered unable to perform duties of the job requiring the document, or the date of hire shall be adjusted to reflect the date the document is received.

Periodic Renewal:

It is again the responsibility of the staff member to provide an original for review and a photocopy of the required document at each date or time of renewal. Human Resources Department staff shall again verify the renewed licensure, certification or registration through the primary source.




CONTROL SYSTEMS

REFERENCE #4050

PAGE: 3


EFFECTIVE:


The following procedure shall be followed to assure current status:

At the date of hire, the original shall be reviewed by Human Resources and a photocopy of the document shall be received in Administration/Human Resources.

License monitoring shall be done within the department where the staff member

works.

The staff member shall be notified by the department manager of impending expiration before the first day of the month in which the expiration shall occur.

If an original is not provided for review and/or a photocopy of the document is not

received by the last day of the month of expiration, the staff member’s status shall be considered to have changed. At this time, one (1) or more of the following actions may be implemented:

Demotion to an available position closest to that normally held which does not

require licensure; termination if no position is available

Suspension without pay until such documentation is received

Disciplinary action as deemed appropriate by the department manager

A telephone call from the Administrative Secretary/Human Resources Department to the state licensing agency may confirm the renewal of said license. The hardcopy of the license shall be presented to Administration/Human Resources within a reasonable period of time.

In case of clerical or procedural error on the part of the licensing agency,

documentation from that agency must be provided in lieu of the actual license.


SUBJECT: CRIMINAL BACKGROUND CHECKS REFERENCE #4051

PAGE: 1


EFFECTIVE:



PURPOSE:

To provide an increased level of safety, thereby reducing risk for patients and staff of the HHA.

POLICY:

HHA shall obtain a background screening on all final candidates and contracted entities for employment upon a conditional offer of employment in accordance with HHA policy. See Qualifications and Competency policy.

Background checks shall include the Office of Inspector General (OIG) exclusion list and National Sex Offender Registry.

Background screenings performed for another healthcare facility or retirement community within the past years are accepted by this HHA. Another background screening does not have to be performed if a copy of a letter from the screening agency can be provided.

This HHA will accept screening documents transferred from another home care agency, providing the transferred documents are no more than two (2) years old and the applicant did not have a break in service longer than 180 days.

A final offer of employment will not be offered to the candidate until the criminal background check clearance results have been received and reviewed by the HHA.

Unwillingness to consent to a criminal background check shall result in withdrawal of the conditional offer of employment.

Failure to disclose criminal history shall result in withdrawal of the conditional offer of employment.

Results of criminal background checks are confidential and are retained within the staff member's confidential personnel file.

Criminal background history and the National Sex Offender Registry shall be checked every years for all staff providing direct patient care, treatment and/or services.



PAGE: 2


EFFECTIVE:


PROCEDURE:

The applicant is asked at the time of a conditional offer of employment to sign an authorization and consent form that allows this HHA to process a criminal background check of the applicant.

The criminal background check includes a state and national criminal history check and fingerprint processing, as required by state law.

Criminal conviction records are evaluated on an individual basis including, but not limited to:

The time and nature of the offense and its relationship to the position sought

The age of the individual when the crime was committed

The length of time that has elapsed since the conviction

The individual’s criminal history since the conviction

The degree to which the applicant has demonstrated rehabilitation

The individual’s work history

The individual’s current employment and character references

Any other pertinent information useful to making an informed employment decision

The following convictions are automatic causes for not making a final employment offer to candidates:

Felony conviction within the past seven (7) years

Convictions for sex crimes or violent crimes

Convictions for possession and/or trafficking of controlled or illegal substances

Convictions for embezzlement, larceny or related charges within the past five (5) years



PAGE: 3


EFFECTIVE:


The applicant shall be informed of the results of the criminal background check; however, the applicant will not be provided a copy of the criminal background check results, and shall be afforded the opportunity to submit proof within 30 days that any adverse findings are inaccurate.

NOTE:

It is the organization’s responsibility to ensure that this policy adheres to all applicable state and local laws and regulations.

CRIMINAL BACKGROUND CHECK RELEASE OF INFORMATION AUTHORIZATION FORM

SAMPLE

By my signature below, I authorize the (state) through the State Bureau of Investigation, Division of Criminal Information to perform a (state) criminal history record information check relative to my application for employment or volunteer services with HHA pursuant (cite the applicable law).

Please print legibly or type the following information:

Name: Last First Middle Maiden

Previous Name(s) including previous married name(s) and aliases:

Address:

If applicant has lived at the above address for less than two (2) years, please list previous address(es) below:

Social Security #: Date of Birth: Sex:

Place of Birth:

City County State Country

I understand that the (state) Bureau of Investigation, Division of Criminal Information and its official and employees shall not be held legally accountable in any way for providing this information to the above named healthcare provider, and I hereby release said HHA and persons from any and all liability which may be incurred as a result of furnishing such information. I further understand that the healthcare provider cannot provide me with a copy of the results of this criminal history record check.

Applicant’s Signature: Date:

This request form must be accompanied by a transmittal letter from the authorized official or individual requesting criminal history record information. This request must be mailed to:

State Bureau of Investigation DCI/Identification Section (Insert appropriate address)



SUBJECT: REFERENCE CHECKING REFERENCE #4053

PAGE: 1


EFFECTIVE:


PURPOSE:

To validate the appropriateness of an applicant’s education, experience and employment background in a consistent manner.

POLICY:

A satisfactory background check acceptable to meet standards for employment consists of an absence of a criminal history record.

HHA shall verify and validate background factors of applicants for employment. These factors may include, but are not limited to the following:

Education pertinent to the job applied for

Formal or informal training received related to the job applied for

Past work record, including dates of previous employment in a similar position

Past work record indicating patterns of attendance and/or reliability from previous employment

Verification of licensure and/or registration

HHA shall release past employment information as requested and only upon written authorization of the staff member concerned. Only that information which has been duly verified and documented in the personnel file will be released to outside parties, upon receipt of proper authorization.

Without written authorization, the only information that will be released is the dates of employment and job title or position held during employment.

Employment information will be released by this HHA only through the Human

Resources Director.


SUBJECT: REFERENCE CHECKING REFERENCE #4053

PAGE: 2


EFFECTIVE:


PROCEDURE:

Reference Checking - External:

Once an applicant has been deemed acceptable for employment by the interviewer, the reference request will be initiated.

During the interview, the interviewer will have the applicant sign the Reference

Request to authorize release of the desired information from the proper source.

The interviewer will indicate the Reference Request on the Application and return the request to the Human Resources Department.

A telephone request will be made only at the discretion of the Human Resources

staff in order to verify dates of employment, position, etc.

The Reference Request Form will be completed by the Human Resources staff and forwarded to the proper parties. This action is documented on the application, or in the personnel file if that person is employed.

When the information is received, the interviewer may review the completed form

upon request. The form will be filed with the application, or in the personnel file if that person is employed.

Reference Checking - Internal:

Upon receipt of the authorization signed by the staff member involved, the Human Resources Director will provide the requested information.

Without proper authorization, only the dates of employment and position held will be

provided.

When an employment inquiry is made by telephone, this is considered to be a request without proper authorization.

If any staff member, supervisor or department manager receives a request for

employment information from an outside party, all such inquiries are to be referred to the Human Resources Director and no information is to be divulged.


SUBJECT: PHYSICIAN LICENSURE VERIFICATION REFERENCE #4054

PAGE: 1


EFFECTIVE:


PURPOSE:

To implement a standardized process to verify and document that physicians and/or licensed independent practitioners providing orders or prescriptions for care, treatment and/or services are licensed in the state in which he/she is practicing.

POLICY:

HHA verifies and documents that each physician and/or licensed independent practitioner providing orders and/or prescriptions for patient care, treatment and/or services has a current and valid license in good standing to practice in the state of (enter name of state).

PROCEDURE:

The Clinical Supervisor/Intake Nurse should obtain the physician’s/independent licensed practitioner’s license number at the time of the first referral to the HHA.

The Patient Care Services Director or his/her designee shall call the Medical Board of (enter name of state) and provide the license number of the physician/licensed independent practitioner.

The issue, effective date(s) and status of the license are recorded on a license verification form.

The license verification form is dated and signed by the Patient Care Services Director.

When a physician/licensed independent practitioner is identified as having his/her license inactivated:

The physician’s/practitioner’s office will be notified by the Patient Care Services

Director that this HHA cannot accept referrals and orders from him/her.

The physician/practitioner will be asked to provide the name of another physician/practitioner who will provide orders/prescriptions for his/her patients.

HHA clinical staff and management staff are notified of the physician’s licensure status.

Completed License Verification Forms are retained in the office of the Patient Care Services Director.


SUBJECT: ORIENTATION PROGRAM REFERENCE #4055

PAGE: 1


EFFECTIVE:


PURPOSE:

To provide an organizationwide effective and systematic orientation program for all newly-hired staff, including supervisory and management staff, volunteers and members of the Governing Body.

POLICY:

All staff, volunteers and members of the Governing Body new to this HHA shall participate in a general orientation program before assuming any job responsibilities or duties.

The HHA Patient Care Services Director shall be responsible for coordinating the agency’s monthly general orientation program.

Department orientation and appropriate job training shall be provided to anyone new to a department and includes content not covered during general orientation as well as content that is unique to the role of the new, transferred or cross-trained staff member.

Cross-training for staff members starting in a new position with new responsibilities may include only job orientation for the features/tasks of the new position with which the staff member is not familiar in the new department.

The following areas of orientation shall be completed before staff, volunteers and licensed independent practitioners perform patient care, treatment and services:



PAGE: 2


EFFECTIVE:


Development of the orientation programs shall take into consideration the following:

The design of the programs is based on sound adult educational principles.

Content is based on identified needs assessments, program evaluations and competency assessments, as well as applicable local, state and federal laws, regulations and standards.

Results/outcomes of the general and department orientation programs are assessed, validated and documented as part of the organizationwide Quality Assessment and Performance Improvement (QAPI) program.

Content of the general orientation program includes the following topics as applicable and appropriate to the care or services provided:

Introduction to the Organization:

History

Corporate structure

Mission, vision, values, goals and customer service perspective

Types of care or services provided

Corporate compliance plan

Organization’s Policies and Procedures:

Abuse, neglect, mistreatment

Body Mechanics and Transfer Techniques

Complaint/Grievance Procedure

Ethics

Patient Rights and Responsibilities, including Advance Directives, Conflict of

Interest, Grievance Process



PAGE: 3


EFFECTIVE:


Advance Directives/Living Wills/Healthcare Surrogate

Death and Dying

Record Keeping and Reporting

OASIS

Quality Assessment and Performance Improvement

Confidentiality of Patient, Staff and Organization Information (HIPAA)

Care or Service Responsibilities - Roles and Responsibilities of Interdisciplinary Healthcare Team Members

Cultural Diversity and Sensitivity, Ethical Issues

Staff Policies:

Hours of work/pay period

Holidays, sick/personal time

Insurance and other benefits

Infection/Exposure Control:

Personal hygiene

Aseptic procedures

Hand hygiene procedures

Communicable infections

OSHA/Bloodborne Pathogens Training

Standard Precautions, Transmission-Based Precautions



PAGE: 4


EFFECTIVE:


Personal protective equipment

Cleaning, disinfection and sterilization of equipment and supplies

Disposal of hazardous materials

Fire Safety and Prevention within the HHA Office and patient’s home

Safe Medical Devices Act

Personal Safety/Security on the Job, in the Automobile, in the Home

Safety within the Patient’s Place of Residence:

Bathroom

Fire

Environmental

Electrical

Emergency Management

Communication with Supervisors

Other topics that may be included:

Principles of Reimbursable Documentation

Public Relations

Tour of HHA



PAGE: 5


EFFECTIVE:


PROCEDURE:

The orientation program shall:

Take into consideration the educational experiences and learning of the participants.

Be presented in a variety of formats, adhering to adult principles of teaching and learning including:

Group participation

Case Studies

Self-Studies

Interactive activities

Audio, video, and computer enhancement

Staff members sign their name on an orientation sign-in sheet for each day of general orientation attended.

Record of staff attendance at orientation is maintained in their respective personnel files.

Staff members shall be assessed for his/her ability to carry out assigned responsibilities safely, competently and in a timely manner upon completion of orientation by his/her department manager/director/supervisor. Successful completion of orientation will be documented in the staff member’s personnel file.

All staff members participating in orientation should complete an evaluation at the end of the general and department orientation programs.

The results of the evaluations are aggregated and evaluated.



PAGE: 6


EFFECTIVE:


Summary reports are submitted to the QAPI Committee.

Results of orientation programs are utilized to improve or otherwise modify the programs.

Mandatory staff forms, such as Acknowledgement of HIPAA Privacy and Security Training, are signed and maintained in the staff member's personnel file.


SUBJECT: ORIENTATION - CERTIFIED HOME

HEALTH AIDE SERVICES

REFERENCE #4056

PAGE: 1


EFFECTIVE:


PURPOSE:

To provide a consistent and formalized orientation program to Certified Home Health Aides by HHA.

POLICY:

All Certified Home Health Aides hired by HHA shall participate in an orientation program before receiving patient care assignments.

Orientation of new Certified Home Health Aide staff members shall be the joint responsibility of the Patient Care Services Director or his/her designee/Home Health Aide Supervisor and nursing staff.

PROCEDURE:

The Patient Care Services Director or his/her designee shall be responsible for orienting newly hired Certified Home Health Aides to HHA benefits, rights and responsibilities of staff, basic home health services provided by the HHA, and operating policies and procedures of the HHA.

The Education Director/Home Health Aide Supervisor shall be responsible for ensuring that newly hired Certified Home Health Aides demonstrate knowledgeable of and/or are competent in the following:

Basic verbal and written English communication skills

Able to use medical terminology accurately and appropriately

Demonstrate the ability to document in the patient record according to professional standards and HHA policies and procedures

Able to identify and communicate significant findings to the supervisor

HHA Home Health Aide policies and procedures


SUBJECT: ORIENTATION - CERTIFIED HOME

HEALTH AIDE SERVICES

REFERENCE #4056

PAGE: 2


EFFECTIVE:


Medicare/Medicaid or other third party coverage of Home Health Aides services in home health

Activities of daily living and demonstrate the ability to use techniques to assist the

patient to meet these activities

Social, cultural, ethnic, economic and psychological factors that influence adjustment to illness and disability

The effect of illness, disability and aging on family role relationships

The role of the Certified Home Health Aide as a member of an interdisciplinary team


SUBJECT: PERFORMANCE EVALUATIONS REFERENCE #4057

PAGE: 1


EFFECTIVE:


PURPOSE:

To ensure a consistent process by which the competency of HHA staff and contract staff, as appropriate, shall be assessed, demonstrated and maintained.

POLICY:

Performance evaluations shall be conducted, by the department manager or supervisor, upon completion of the probationary period, approximately 90 days following hire. In the case of a job transfer or change in job classification, an evaluation shall be conducted approximately 90 days after the change.

A new hire shall receive a performance evaluation one (1) year from the hire date. A classification or job change shall receive a performance evaluation one (1) year from the change.

Ongoing performance evaluations shall be conducted at the minimum of once every three(3) years, or more frequently according to the organization’s policies, state laws or regulations.

The purpose of the performance evaluation is to let each staff member know how well they are performing their assigned job duties, providing the staff member with positive and negative feedback (if necessary) and informing them whether they have any performance problems. Evaluations shall be reviewed with the staff member in private with the opportunity for the staff member to comment. The staff member signs the form to acknowledge that an evaluation has been done on this date and receives a copy of the evaluation.

The performance evaluation is generally conducted concurrently or after the staff member’s competency assessment of his or her abilities to carry out assigned responsibilities has been completed. However, the performance evaluation may be completed at a separate time, if necessary.

The Patient Care Services Director shall be responsible for reviewing and investigating any report of individual staff member’s unsatisfactory performance and shall establish an appropriate remediation plan.

All performance evaluations shall be documented.



PAGE: 2


EFFECTIVE:


PROCEDURE:

Each month, the Human Resources Department shall notify all department managers of those staff members due for their performance evaluation.

The Human Resources Department shall communicate with the individuals or departments utilizing Allied Health Practitioners, and support the individuals/departments with evaluation tools commensurate with the position held.

Department managers shall utilize the criteria based job evaluation tool relating to the position being evaluated.

Department managers shall submit documentation of the completed evaluation (a copy of the actual evaluation form) to the Human Resources Department, along with the Personnel Action Form (PAF) recommending any salary or status change. The evaluation and PAF shall be submitted to the Human Resources Department on a timely basis in order to meet all payroll deadlines and avoid delays in rate changes or raises.

The Human Resources Department shall obtain appropriate administrative approval for all evaluations and action forms and forward to the Payroll Department for processing.

Competency Evaluations:

Competency evaluations shall be used in conjunction with the 90-day and annual performance evaluations to determine the staff member’s level of performance and to identify areas of improvement.

Competency evaluations shall be completed prior to the performance evaluation

date to allow sufficient time for training/education.



PAGE: 3


EFFECTIVE:


The format of competency evaluations may include, but shall not be limited to, the following:

Demonstration

Direct observation/checklist

CD/DVD review and written/oral test

Skills lab

Self-study and written/oral test


SUBJECT: EMPLOYEE EDUCATION PROGRAMS REFERENCE #4058

PAGE: 1


EFFECTIVE:


PURPOSE:

To provide planned ongoing educational activities for HHA staff that:

Develop and enhance staff's skills

Broaden and increase staff's knowledge base

Maintain and improve staff competency

POLICY:

This HHA shall provide educational programs appropriate to the staff’s patient care, treatment and services responsibilities specific to the needs of the patient population served, and as required by applicable laws, regulations and standards.

Educational programs shall be provided to those staff members whose responsibilities have changed.

An annual educational program shall be planned and implemented based on identified staff needs.

HHA Aides shall receive a minimum of 12 hours of inservice training every 12 months. Inservice training may occur when an aide is furnishing care to a patient under the supervision of an RN.

All staff shall be surveyed biannually to identify educational needs.

Patient care, treatment and services staff shall be required to attend or produce evidence of having attended the appropriate number of continuing education programs required by law and regulation to maintain currency of licensure and/or certification.

ACHC requires at least eight (8) hours of in-service education per year for non-direct

care personnel and at least 12 hours of in-service education for direct care personnel each year.



PAGE: 2


EFFECTIVE:


All staff members are required to attend, or provide proof of having participated in, mandatory inservice programs. These mandatory inservice training programs shall include, but not be limited to:

OSHA/Bloodborne Pathogens

Infection Prevention and Control

Domestic Violence

Workplace Violence Prevention

Personal Safety

CPR

Communication Barriers

Cultural Diversity

Ethics

Fire Safety

Emergency/Disaster Management

Pain Management

Patient Rights and Responsibilities

Death and Dying

The need to report unanticipated adverse events and how to report these events

Handling Grievances/Complaints

Organizational Compliance Program

HHA administration retains the right to designate other inservice programs as mandatory programs.



PAGE: 3


EFFECTIVE:


INSERVICE RESPONSIBILITIES:

The Patient Care Services Director/designee shall be responsible for providing current and factual information to his/her staff regarding performance of their job duties. New processes, procedures or policies governing such duties shall be conveyed to the staff in a manner that is understandable and reasonable to all involved. Records of such programs shall be retained as described in this policy.

At minimum, the following staff members, including staff members providing services under contract, shall be responsible for participating in the HHA’s inservices (not all inclusive):

Home Health Aides

Licensed Practical Nurses

Medical Social Workers

Physicians

Registered Nurses

Therapy Services (i.e., Physical Therapists, Occupational Therapists, Speech

Language Pathologists, Therapy Assistants)

A Registered Nurse, either the Patient Care Services Director or RN designee, shall supervise all inservice training provided to Home Health Aides.

The Administration shall provide up-to-date and factual information to all staff regarding policies, procedures and benefits. In most cases, policies and procedures shall be conveyed to department managers who shall convey such information to their staff.



PAGE: 4


EFFECTIVE:


PROCEDURE - INSERVICE ATTENDANCE:

Mandatory Inservice Meetings: Those meetings which have been determined necessary for staff within a particular department or group of common interest shall be considered to mandatory. Mandatory attendance shall be at the discretion of the Patient Care Services Director with approval of the Administrator.

Mandatory meetings are generally those which will provide vital and necessary

information to staff involved, and attendance will be requested with prior notice to all those required to attend. Staff shall receive their regular rate of pay for attendance at mandatory meetings, unless their attendance is not specifically requested. If attendance at a mandatory meeting will involve overtime for staff during that work week, specific approval from the department manager shall be required if an alternate attendance time cannot be arranged.

Voluntary Inservice Meetings: Those meetings for which attendance is not deemed necessary and vital to a particular department or group of common interest are considered to be voluntary. Attendance at voluntary meetings shall be at the discretion of the staff member, based on his/her interest in the subject being presented.

Credit for Attendance at Inservice Programs:

In order to receive proper credit for attendance, the staff member shall sign his/her name on the sign-in sheet provided at each meeting.

The staff member must attend the entire program and complete an evaluation form

in order to receive credit for attendance.

Continuing Education Credits:

Programs for which continuing education credits are offered shall be advertised as such.

The number of credit hours shall be listed with the program information.



PAGE: 5


EFFECTIVE:


In order to receive appropriate continuing education credits and a certificate, participants shall:

Attend the entire program

Sign the attendance sheet

Complete an evaluation form

Internal Scheduling of Inservice Programs:

Equipment and Supplies: All audiovisual and other inservice equipment shall be maintained by the Education Department. Those who desire use of this equipment should submit a written request as early in advance as possible.

Supplies necessary for inservice programs shall be the responsibility of the

individual conducting the program. Prior administrative approval shall be required for expenditures made for inservice program supplies.

Meeting Room Availability: Meeting rooms must be reserved in advance as early as possible through administration.

Record Keeping for Education Programs:

Records of education programs shall be maintained in a central location, i.e., Education Department, HHA Clinical Supervisor or Administration. Proper record keeping shall contain the following information:

Names and signatures of all staff who attended the program.

Title of the program, name of the individual conducting the program, dates

and times the program was conducted and the location of the program.

A description of the content of the program, its relation to the department and/or staff and voluntary/mandatory status of the program.

Results of education program evaluation shall be compiled and summarized by the

Education Department.



PAGE: 6


EFFECTIVE:


Summary reports shall be evaluated monthly to determine the quality and appropriateness of the education provided and to develop and/or modify future educational programs.

Summary reports of educational activities and the results of program evaluations

shall be submitted to the Quality Assessment and Performance Improvement (QAPI) Committee quarterly.

Education records for individual staff members shall be considered valid on either a

card made for that staff member showing dates and subjects of programs attended, or on a written form or other sheet of paper containing such information placed in the staff member's personnel file.

CONTINUING EDUCATION/INSERVICE ATTENDANCE RECORD

Date: Presenter:

Topic:

Location:

Signature

RN/LPN/LVN/ HHA/PT/etc.

Professional License #

(If appropriate)

Print Name



SUBJECT: EQUAL OPPORTUNITY EMPLOYMENT REFERENCE #4060

PAGE: 1


EFFECTIVE:


PURPOSE:

Establish and maintain a working environment free of any and all forms of discrimination as prescribed by law.

POLICY:

HHA is an Equal Opportunity Employer and shall provide equal employment opportunities with regard to race, color, religion, sex (including pregnancy, childbirth or related medical conditions), national origin, physical disability, mental disability, age, sexual orientation, veteran status or marital status.

Employment shall be offered and continued based on an individual’s ability to perform essential job functions as defined by the requirements within each job description.

Reasonable accommodation shall be made for known physical or mental limitations and/or disabled employees at all levels of employment who can perform the essential functions of the job.

HHA shall provide an outlet of complaint to all staff if they feel they have been subjected to a violation of this policy. Each staff member may request an Employee Grievance Form (from Administration). Each grievance received shall be handled according to the procedures outlined in the current Employee Handbook provided to all staff.

REFERENCE:

U.S. Equal Employment Opportunity Commission (EEOC). (n.d.) Equal Employment Opportunity is the Law. Retrieved from http://www1.eeoc.gov/employers/poster.cfm

http://www1.eeoc.gov/employers/poster.cfm


SUBJECT: APPLICATIONS FOR EMPLOYMENT REFERENCE #4061

PAGE: 1


EFFECTIVE:



PURPOSE:

To implement a consistent and nondiscriminatory process for selecting staff members.

POLICY:

HHA selects qualified staff members without regard to gender, race, age, creed, handicap or national origin.

It is the policy of this HHA to provide all qualified individuals with the opportunity to seek employment with this organization. Applications for employment are available from the Human Resources Department. No individual will be considered for employment without first submitting a completed Application for Employment.

Although it is HHA policy to accept these Applications for Employment, there may be those times when no employment opportunities exist. In this case, the HHA reserves the right not to accept the applications until position vacancies occur, but does encourage the interested party to return at another time to complete the form.

Completed Applications for Employment will be maintained in Human Resources and are considered to be the sole property of the HHA and its authorized agents. Applications for Employment are considered to be "active" for a period of 30 days, during which time the document may be sent to one (1) or more interviewers. After this period, the application is filed according to the area of employment desired, and kept in storage areas for a period of one (1) year.

Qualified individuals currently employed by this HHA may apply for position openings within the HHA by completing an Application for Employment.


SUBJECT: ATTENDANCE AND TARDINESS REFERENCE #4062

PAGE: 1


EFFECTIVE:



PURPOSE:

To ensure that timely and consistent care, treatment and services are provided to the patient population served by HHA.

POLICY:

Any absenteeism or tardiness is to be communicated to the staff member’s supervisor in a timely manner.

Excessive absenteeism and/or tardiness may result in disciplinary action, up to and including termination, and may have an adverse effect on a staff member's future salary increase, transfer request, promotion or continued employment.

PROCEDURE:

Each staff member, including contracted staff, is responsible for reporting any absence or tardiness to his/her immediate supervisor in a timely manner (according to departmental guidelines) to allow the supervisor to plan for staff coverage.

At the time of notification of absence or tardiness, the supervisor shall determine and discuss with the staff member the appropriate use of or denial of paid leave or extended illness time.

Administration may, at their discretion, request a staff member to submit proof of illness, including the request of the staff member to obtain a physician's statement. Administration may also request the attending physician examine a staff member who has been ill for more than three (3) days.

If a staff member is absent one (1) day without notification of the supervisor, he/she is considered to have "quit without notice" and termination measures are undertaken.

Absences and tardiness records are available to each department manager and shall be properly maintained and placed in the personnel file upon termination of employment.

The department manager or supervisor shall also maintain accurate documentation of all absences and tardiness on the staff member’s time record.


SUBJECT: PERSONAL INFORMATION - CHANGE OF REFERENCE #4063

PAGE: 1


EFFECTIVE:


POLICY:

It shall be the responsibility of staff to notify the Human Resources Department, through their supervisor, of a change in personal information on the appropriate form.

A change in personal information shall include, but not be limited to, a change in the following:

Name

Address

Telephone/Pager/Cell Phone Number

E-mail Address

Beneficiary (Life Insurance)

Person to Notify in Case of Emergency

Marital Status

Personal Physician

Number of Dependents

Automobile Insurance


SUBJECT: CLASSIFICATION OF EMPLOYEES REFERENCE #4064

PAGE: 1


EFFECTIVE:



POLICY:

record keeping.

All employees will be informed of their classification status at the time of employment, change of status when changed from nonexempt to exempt status or from exempt to nonexempt status or a change in internal classification status.

DEFINITIONS - INTERNAL CLASSIFICATION OF EMPLOYEES:

Regular Full-Time Employees: A regular full-time employee is one who is regularly scheduled to work a minimum of 32 hours per week on a routine basis. This employee is entitled to all nonlegislated employee benefits.

Regular Part-Time Employees: All employees who work part-time (less than 32 hours per week) will receive no nonlegislated employee benefits. At the HHA's convenience, an employee may be asked to adjust his/her hours, but this will not affect his/her nonlegislated employee benefits.

Temporary Employees: Any employee who is hired for a limited period of time to fill a temporary position. This employee is not entitled to any nonlegislated benefits, regardless of the number of hours worked each pay period.

Haven Home Health shall abide by all regulations and interpretations of requirements for qualifying an employee as an exempt or nonexempt from Wage and Hour overtime regulations and for the administration of payroll procedures for hourly paid employees, in accordance with the Fair Labor Standards Act as amended and in conformance to the Code of Federal Regulations. Furthermore, the HHA shall maintain an internal classification of employees for purposes of benefits administration and payroll



PAGE: 2


EFFECTIVE:


On-Call, Per Diem or Relief Employees: Any employee who is hired on an on-call, per diem or relief basis works only at the discretion of the HHA and is entitled to no nonlegislated employee benefits. When hired under this agreement, no work is guaranteed and the employee reports to duty at the direction of supervisory staff.

Probationary Employees: Any employee who is within the first three (3) months(90 calendar days) of employment. An employee in this status is not entitled to vacation, sick time or bereavement leave and will not receive insurance benefits until the "effective date" has been met and an acceptable probationary review has been submitted by the Supervisor.

PROCEDURE FOR TRANSFER OR CHANGE IN CLASSIFICATION:

A transfer in the classification of employment may be available, depending upon needs. Recommendations for change in status are made by the department manager and must be approved in concert with Human Resources.

DEFINITIONS - FEDERAL CLASSIFICATION OF EMPLOYEES:

Definitions:

Nonexempt Employees: Nonexempt employees are those who do not meet the requirements for exempt status as outlined by Federal Wage and Hour Requirement, or those who are not considered to be exempt employees by mutual agreement with the HHA.

Exempt Employees: An exempt employee is considered to be "salaried" and

qualifies for exempt status as an executive, professional or administrative employee. Employees are placed in this classification by mutual agreement with the HHA.



PAGE: 3


EFFECTIVE:


Benefits and Compensation - Exempt Employees:

Overtime: No compensation for overtime will be paid to administrative or executive employees. Compensation for overtime will be paid to professional exempt employees only if it is necessary due to the request of the HHA and approved by the department manager and administration.

Sick Leave: It is our policy to allow every full-time employee to accumulate a

reserve of sick leave which can be used for time off with pay when necessitated. Falsification of sick leave may be grounds for dismissal. Time off reimbursed by Workers' Compensation is not considered sick leave.

Educational Leave: Paid educational leave may be granted upon the approval of the department manager and Administrator for attending approved seminars. These days will be noted on the employee's time record and paid at the regular rate of pay and, under no circumstances, may create overtime.

Personal Leave of Absence: Personal LOAs are discouraged. However, if

management determines there are justifiable reasons, a personal leave of up to 30 days may be granted.

Vacation: Ten (10) working days will be allowed per year after the first year of

full-time employment. Vacation time accumulation will be subject to limitations as outlined in the vacation policy.

Holidays: Exempt employees are entitled to receive the same number of paid

holidays, eight (8) a year as are all other employees. These are scheduled at the convenience of the organization, and are not to be accumulated. Holidays are paid according to current organization policies.


PAGE: 4


EFFECTIVE:


Benefits and Compensation - Nonexempt Employees (40-hours work week):

Overtime: o Overtime for care providers including HHA, LPN and RN staff shall be calculated based on

any hours worked over 40 hours in a scheduled workweek. o Any and all overtime must be approved by the department supervisor prior to the overtime

shift being worked. o Overtime shall be paid at the rate of time and one-half the employee’s usual base salary

for all hours worked past the scheduled 40 hours in a workweek. Excluding calculation of shift differential for determination of overtime rate. In certain areas, employees who have signed 12-hour shift agreements will be paid according to that policy.

o Salaried employees are not eligible for overtime payment. Salaried Directors, Assistant Directors, and other Nurse Managers who are required

to fill in a weekend shift that is over 4 hours for call offs/ no-call no-shows to cover a primary shift will be paid the current market nursing rate as a secondary rate. At NO time will this be considered a long term solution to staffing.

o Overtime is granted on a case by case basis dependent on the patient need and the following factors:

Patient choice of staff member. Ascending order of total hours worked for workweek, i.e. per diem staff will be offered first,

then part time staff, followed by full time staff to minimize corporate total overtime. Seniority First response to overtime availability, i.e. “first come, first serve” following above

requirements.

o Haven Home Health Care is committed to providing the best care for our disabled patients. Overtime will be worked by staff on an approved basis and in the interest of corporate fiscal responsibility. Patient care is the primary objective for the necessity of overtime and shall take precedence over associated staffing issues including but not limited to the above factors or situations. Management reserves the right to staff for overtime as necessary to provide appropriate nursing care to patients following accepted standards of care. Management shall continue to make every effort to honor the above factors when approving overtime.

Sick Leave: Payment for sick leave will commence on the first day of an excused absence due to illness. Sick days are accumulated at a rate of one (1) day per month, up to a maximum of 30 days or 240 hours. Probationary employees are not eligible for sick leave pay, however, hours will be accrued.

Inservice Meetings: Time off with pay may be granted with approval of the department manager and Administrator to attend meetings. In general, there are two types of internal meetings that will be encountered during employment. Those types are explained below, with explanation of pay for attendance:

Mandatory: Those meetings which have been determined necessary for employees within a particular department or group of common interest are considered mandatory. When non-exempt employees are required to attend meetings of this type, time spent in the meeting is considered to be "time worked" and will be compensated at straight time.




PAGE: 5


EFFECTIVE:


Voluntary: For those meetings where attendance is not deemed necessary and vital to a particular department or group of employees with common interest, time spent in the meeting is not considered to be "time worked". Attendance to this type of meeting is at the choice of the employee, and will most generally be held at a time convenient to all work shifts. Voluntary meetings may include, but are not limited to, those outlining or introducing benefits, or "public service" meetings conducted by outside law enforcement or governmental agencies.

Vacation: Ten (10) working days will be allowed after the first year of employment,

to be scheduled and approved at the convenience of the HHA. Fifteen (15) working days will be allowed per year after the fifth year of employment is completed. This time is not considered "time worked."

Holidays: All nonexempt employees will receive eight (8) paid holidays per year, as outlined in the current Employee Handbook. These will be compensated at the regular rate of pay, and are not considered to be "time worked". Holiday pay is subject to terms and conditions contained in the Employee Handbook.

Record of Time: Nonexempt employees must record their time worked each day by

the use of time cards which are provided prior to the beginning of the new pay period. The time card shall reflect an accurate account of time in and time out each day, with an entry made for lunch or meal time. Incorrect recordings of hours worked on a time card may be grounds for immediate termination. Each time card must be signed by the employee and approved by the supervisor.

Part-Time, Temporary, Relief Employee Classifications:

All employees, whose internal classification places them in one of the above categories, are considered to be nonexempt employees and are subject to benefits and compensation related to their status.

OVERTIME APPROVAL FORM

This form is to be used to approve all overtime.

Your Supervisor or Manager must approve overtime PRIOR to the beginning of the overtime work.

Name of Employee:______________________________ Employee Payroll NO:____________

State of Employer: WA AZ NM

Why work cannot be completed during regular hours:

____________________________________________________________________________

Supervior/ Manager Approval:_________________________________

Employee Signiture:_________________________________________

Employee Printed Name:_____________________________________

Date:_____________________________________________________

Overtime Approval Policy:

I. Purpose: The purpose is to control labor cost by managing the expense of overtime pay for non-

exempt employees.

II. Compliance: Company pays time and one-half to non-exempt employees who exceed 40 hours

of work time ina workweek.

III. Overtime Approval: Supervisors are required to obtain approval from managers prior to the use

of overtime. Employees who anticipate the need for overtime to complete the weeks work must

notify their supervisor in advance and obtain approval prior to working hours that extend beyond

their normal schedule.

IV. Mandatory Overtime: During busy periods, the Company may require employees to work

extended hours.

V. Consquences of Overuse of Overtime: Supervisors who authorize staff members to work

overtime without prior approval from management will be ubject to dsplinary action. Superviors

who continually rely on the us of overtime hours in order to complete a weeks work without being

deemed as extebuating by management will be palced on a performance improvement plan.

VI. Cosequences of Unauthorized Overtime: Employees who fail to obtain approval prior to

working hours that extend beyond their normal 40-hour workweek will be subject to disciplinary

action. Repeated offenses may result in termination.

Form Instructions: This form must be completed in its entirety. The Supervisor/ Manager must keep the

completed form in his/her pending payroll file, then include the form in the applicable pay periods regular

time and attendance record sent to human resources. Forms should be maintianed in the employee’s

payroll file on site.

a. Paid leave such as holiday, sick, or vacation pay does not apply toward work time.

b. The workweek begins at 12:00 am on Sunday and ends 11:59 pm on Saturday night.


SUBJECT: BCLS RESUSCITATION CERTIFICATION REFERENCE #4065

PAGE: 1

OF: 2 DEPARTMENT: ORGANIZATIONWIDE

EFFECTIVE:


POLICY:

All staff who have direct patient contact shall maintain CPR skills as evidenced by an annual update review or recertification class. All new healthcare staff who have direct patient care shall be required to present verification of a current BCLS certification card upon hire.

Cardiac resuscitation training must be completed through an evidence-based training program, such as those programs provided by the American Heart Association and the American Red Cross.

New Staff:

Shall present a current American Heart Association (AHA) or American Red

Cross CPR card for photocopying.

A copy of the card shall be kept in the employee's file and shall be updated according to policy and procedure.

It shall be the responsibility of the employee to maintain a current BCLS

certification and provide evidence of recertification according to policy and procedure.

Existing Employees:

It shall be the responsibility of the employee to maintain a current BCLS

certification and provide evidence of recertification according to policy and procedure.

A copy of the card shall be kept in each employee's file current and updated

according to policy and procedure.


SUBJECT: BCLS RESUSCITATION CERTIFICATION REFERENCE #4065

PAGE: 2

OF: 2 DEPARTMENT: ORGANIZATIONWIDE

EFFECTIVE:


PROCEDURE:

BCLS Initial Certification:

Any employee having direct patient contact shall be required to be BCLS certified according to the AHA Course C standards.

If the employee has never been certified, then the employee shall attend an eight (8)

hour Initial Certification class.

BCLS Recertification:

Each direct patient contact employee shall recertify his/her BCLS card every two (2) years, at least 30 days before expiration.

Recertification can be satisfied by any one of the following methods:

Attend a four (4) hour BCLS recertification class.

Complete the CPR Recertification take-home study.

Participate in a mock CPR drill and verify participation on the sign-in sheet.


SUBJECT: DISCIPLINARY ACTION REFERENCE #4066

PAGE: 1


EFFECTIVE:



POLICY:

HHA shall administer fair and reasonable methods of disciplinary action to those staff members whose job performance or behavior does not meet the standards of the HHA as outlined in this policy.

When the staff member’s job performance or work behavior does not meet those standards for continued employment, the HHA shall initiate disciplinary action for corrective purposes in the following manner:

Verbal Reprimand: Considered to be a notice to the staff member that his/her job

performance or work behavior does not meet standards of employment.

Written Reprimand: Considered to be further notice to the staff member of undesirable work behavior or unacceptable job performance, submitted in writing and placed in the personnel file for permanent record.

Suspension Without Pay: Considered to be the final notice to the staff member that

undesirable work behavior or unacceptable job performance must be corrected at once.

Discharge: Considered to be the most extreme form of disciplinary action and the

final step in this process. This will occur when all previous steps have been followed or in the event that immediate discharge is considered to be justifiable by the Supervisor, Patient Care Services Director and Administrator.

Furthermore, the HHA shall ensure that all staff shall have the right to initiate the internal grievance procedure in connection with any aspect of this policy.



PAGE: 2


EFFECTIVE:


STANDARDS OF CONDUCT:

The following standards of conduct are prescribed to assure continuation of employment. Staff are at all times expected to:

Give primary consideration to the welfare of patients, staff and visitors

Respect established authority

Use HHA equipment and supplies judiciously and with utmost care

Perform all duties and responsibilities in an acceptable manner

Be honest

Seek help in resolving problems

Develop care in personal appearance and confidence in the individual’s ability

Comply with HHA and departmental rules and regulations

Conduct oneself as a responsible member of the staff and as a good citizen

Unacceptable Behavior includes, but is not limited to:

Excessive absenteeism;

Use, possession or being under the influence of illegal substances or alcohol while on company premises or otherwise engaged in company business;

Insubordination;

Falsification of company records including the employment application form;

Negligent or unauthorized use of company equipment;

Physical or verbal abuse of fellow associates, clients/patients or visitors;

Misappropriation of company property;



PAGE: 3


EFFECTIVE:


Violation of safety rules and common safety practices;

Failure to promptly report any accident or incident on company property;

Failure to observe department working hours and schedules, including scheduled overtime;

Unsatisfactory work performance;

Delaying or restricting production or inciting others to do so;

Disclosure of confidential company information to unauthorized persons;

Possession of weapons;

Failure to report potential or actual violations of the Corporate Compliance Program thereby increasing the agency’s vulnerability fraud, abuse and waste.

PROCEDURE:

Initiation of Disciplinary Action: When a staff member’s job performance or work behavior ceases to meet acceptable standards for continued employment, disciplinary action procedures are initiated by persons in authority. Those persons having this authority are as follows:

The staff member’s immediate Supervisor

The Patient Care Services Director

The Administrator

The supervisor or department manager, not directly associated with the staff member, in the case of an event occurring while the staff member’s supervisor and/or department manager are not present

Verbal Reprimand: The first step in the process is the verbal reprimand issued to the staff member as an initial warning. Although this reprimand is not officially documented and placed in the staff member’s personnel file, it is noted and maintained by the Patient Care Services Director for future reference.



PAGE: 4


EFFECTIVE:


Written Reprimand: The next step in the process is the written reprimand issued to the staff member as the second warning. This reprimand is presented to the staff member in writing and is documented on a Disciplinary Action Form requiring the signature of the counselor and the staff member.

The staff member is asked to sign this document, not as admission of guilt, but to

acknowledge that the counseling did occur.

The document is placed in the staff member’s personnel file as a part of the permanent employment record regardless of signature.

Failure to sign the form must be documented on the Disciplinary Action Form.

Suspension Without Pay: The next step in the process is suspension without pay issued to the staff member as the third and final warning. This action is presented to the staff member in writing and is documented on a Disciplinary Action Form requiring the signature of the counselor and the staff member.

The staff member is asked to sign this document, not as an admission of guilt, but to

acknowledge that the event did occur.

This document is placed in the staff member's personnel file as a part of the permanent employment record.

The staff member will not be allowed to return to work until the suspension period

has expired.

Discharge: The final step in the process is discharge. At this time, the employment status is terminated and termination documents are processed.

When the decision is made to enter into this step of the process, it has been fully

determined through previous steps that the staff member does not intend to correct the undesirable work behavior, or unacceptable job performance, and thus fails to meet those standards required for continued employment.

This action is documented on the Disciplinary Action Form requiring the signature of the counselor and the staff member.

The staff member is asked to sign the document, not as a direct admission of guilt,

but to acknowledge that the event did occur.



PAGE: 5


EFFECTIVE:


Immediate Suspension: Automatic suspension occurs when it is determined by those persons having authority that the staff member has:

Violated HHA and/or department policy to the extent that damage was done, or the

results and consequences of the action will be severely detrimental to the HHA.

Exhibited extremely undesirable work behavior and/or job performance or neglect of job performance.

Substantially violated those standards of conduct set forth in the Disciplinary Action policy to the extent that damage was done, or the results and consequences of the violation will be severely detrimental to the HHA and/or the department.

Other undesirable actions as deemed sufficient to justify automatic and immediate

discharge.

Those persons having the authority to execute immediate suspension are as follows:

The staff member’s immediate Supervisor, upon the direction and approval of the Patient Care Services Director

The Administrator

The Nursing Supervisor on duty after normal office hours, or on weekends and holidays, who is in charge of HHA operations during those times



PAGE: 6


EFFECTIVE:


GENERAL PROCEDURES INVOLVING DISCIPLINARY ACTION:

The staff member, at all times, shall have the right to initiate the internal grievance procedure for matters related to the disciplinary action process. The staff member may obtain information regarding the grievance Human Resources and will be assisted by Human Resources throughout the grievance procedure.

The disciplinary action process is to be administered fairly and consistently to all staff at all times and in a manner consistent with HHA policy, rules and regulations to assure equal treatment to all staff.

Staff shall be informed of their status throughout the disciplinary action process of the following items:

What the staff member can expect to occur next if the problem is not corrected.

What actions the staff member can take to correct the problem.

What specifically led to the disciplinary action.

Specifically, what is necessary for the staff member to meet standards for continued

employment.

What is a reasonable period of time in which corrective action is to occur.

PROCEDURE - STAFF GRIEVANCE REPORTING METHODS:

Problems arise in any group of people working together. It is important to all that these problems be solved as quickly and as fairly as possible so that small problems do not grow out of proportion. Occasionally, however, it may be necessary to investigate certain problems in greater detail. The grievance procedure enables a staff member to have a fair review of any work-related controversy, dispute or misunderstanding.



PAGE: 7


EFFECTIVE:


If a staff member believes he/she has a valid grievance, the following procedure should be used:

Step One: A staff member may submit, in writing or orally, the problem to his/her

immediate supervisor or department manager within three (3) days after the problem is recognized by the staff member. The supervisor or department manager will attempt to resolve the staff member’s grievance during the initial meeting. If unable to reach a mutually agreed upon settlement, the supervisor or department manager will investigate the situation further and within three (3) working days, meet with the staff member with a proposed solution to the grievance. If the staff member is still not satisfied, then he/she may request a step two meeting.

Step Two: If the staff member is not satisfied with the results of step one, he/she must submit in writing within five (5) working days the problem or grievance. Human Resources will investigate the problem with all involved parties and schedule a meeting with the staff member and the supervisor or department manager. The staff member may elect to have a fellow staff member accompany him/her to this meeting to assist in the presentation of the problem. A concerted effort will be made at this meeting to resolve the problems. Human Resources will be responsible for preparing a written report of this meeting. If the staff member does not believe the solution presented is satisfactory, the step three procedure may be requested.

Step Three: The staff member may request within five (5) working days, a review of

the proceeding by the Administrator or his/her designee. The Administrator or his/her designee will, within five (5) working days after receipt of the grievance, thoroughly investigate the problem and considering every aspect of the staff member’s and the supervisor or department manager's position, as well as information described in steps one and two, make a final and binding determination on the grievance.

Staff who are discharged for cause may appeal that decision by using the grievance procedure. However, discharged staff shall appeal to Human Resources as step one and the appeal must be in writing. Any discharge appeal must be received in Human Resources within seven (7) working days of the discharge to be considered.

DISCIPLINE FORM

Employee Name:

Date of Violation: Offense: First Second Third

Description of Violation:

Employee Comments:

Supervisor Comments:

Disciplinary Action(s):

Employee Signature: Date:

Supervisor Signature: Date:



SUBJECT: DRUG-FREE WORKPLACE POLICY REFERENCE #4068

PAGE: 1


EFFECTIVE:


POLICY:

The organization adheres to a zero-tolerance of use or abuse of alcohol and drugs by its employees.

The unlawful manufacture, distribution, dispensing, possession, sale, purchase or use of a controlled substance on organization property is prohibited.

Being under the influence of alcohol, inhalants or other drugs on organization premises or while representing the organization off premises is prohibited.

The unauthorized use or possession of prescription or over-the-counter drugs on organization premises or while representing the organization off premises is prohibited.

Employees who violate the drug policy are subject to appropriate disciplinary action up to and including termination of employment.

This policy applies to all employees of the organization regardless of rank or position, and includes temporary and part-time employees and independent contractors.

PROCEDURE:

It shall be the responsibility of each and every organization employee to report known use, sale, possession, or distribution of drugs on organization property, in organization vehicles or in patients' homes to his/her immediate supervisor.

Employees are required to inform their supervisors of the use of any prescribed medication that could affect their performance. When reporting such use, the employee shall be required to present the supervisor with a written statement from his/her physician regarding the prescription's potential effect on the employee's job performance. When there is a distinct risk of workplace accidents, the employee shall be reassigned to other tasks or shall be required to take a leave of absence until the use of the medication is no longer required, or the risk of accidents is alleviated.



PAGE: 2


EFFECTIVE:


Pre-employment Testing

All job applicants, regardless of the position offered, shall undergo drug testing following an offer of employment that is contingent upon the results of the screening.

An independent Medical Review Officer, not affiliated with the laboratory performing

the screening, reviews all test results.

The following procedure shall be followed in the event of positive test results:

The Medical Review Officer contacts the tested individual to review the results confidentially and determine if other factors may have affected the outcome.

Laboratory confirms the results by subjecting the original specimen to a

second test of higher quality (gas chromatography).

Confirmation is sent to the Medical Review Officer and the final test results shall be sent to the organization CEO.

If the test is confirmed positive, the employment offer must be withdrawn, and the

applicant shall not be eligible for employment with the organization.

To be considered for employment in the future, the individual must provide proof that they have completed a rehabilitation program and have been drug free for no less than six (6) months.



PAGE: 3


EFFECTIVE:


Reasonable Suspicion Testing (Random Testing):

Any employee may be tested for drug or alcohol use without warning based on reasonable suspicion when:

The employee is observed to display symptoms of drug abuse, impairment or

intoxication during the performance of his/her job responsibilities. Symptoms/observations may include slurred speech, dilated pupils, loss of balance, unsteady gait, inability to perform ordinary physical tasks or unusual risk-taking behavior.

Such behavior is not reasonably explained as resulting from causes other than the use of these substances (e.g., fatigue, lack of sleep, side effects of authorized prescription or over-the-counter drugs, etc).

The employee's supervisor shall complete a report and submit same to the CEO or

his/her designee prior to sending the employee for testing.

Drug Testing Procedure:

The employee shall complete a pretesting consent form at the organization's collection site.

The organization shall utilize a NIDA-approved laboratory to perform urinalysis for

drug/alcohol detection. The laboratory shall provide chain-of-custody procedure documentation.

The reporting of positive test results to employees, job applicants or managers shall be based only on written results from the laboratory.

Individuals with positive test results shall be notified confidentially.

In an effort to preserve confidentiality and provide information on a "need to know"

basis, the results of confirmed positive drug screening shall be sent to the CEO or his/her designee.

Disciplinary action shall be based on confirmed, documented test results.



PAGE: 4


EFFECTIVE:


When an employee tests positive, he/she shall be referred for treatment, counseling or rehabilitation. The employee shall be suspended from work until all required testing and treatment is completed.

To be reinstated to a position, the employee must present a signed release from a

medical doctor stating that he/she is fit for work. The employee must submit to another screen test and have a negative result within six (6) weeks from the date he/she was suspended, otherwise the employee shall be discharged.

Any employee who has been suspended for a positive drug test and allowed to

return to work shall be immediately terminated for a positive result on any subsequent drug screen.

Violation of Policy:

Any employee suspected of violating this policy shall be immediately suspended without pay pending completion of an investigation.

The employee shall be provided an opportunity to explain his/her actions.

In the event a determination is made that the employee violated this policy,

appropriate disciplinary action shall be taken.

Should it be determined that no violation occurred, the employee shall be reinstated and shall be paid any lost wages.

Any employee who undertakes a rehabilitation program and does not complete it or

who cannot maintain a drug free status on the job is subject to disciplinary action, up to and including discharge.

This policy is not intended to and shall not limit testing or search for drugs by authorized law enforcement personnel in the performance of their duties.


SUBJECT: DRESS REGULATIONS REFERENCE #4069

PAGE: 1


EFFECTIVE:



PURPOSE:

Assure standards of dress by HHA staff that present a professional appearance to our visitors, co-workers and others who may enter the HHA.

POLICY:

Uniforms:

Those departments which require specific types of uniforms to be worn by staff will be notified by their department managers.

Uniforms must be appropriate as determined by the department manager,

must be neat, clean and appropriate for professional work and the image that the HHA must project to others.

General Dress Code:

All clothing worn by the HHA staff must be neat, clean and appropriate for professional work. Hair styles, clothing and jewelry shall conform to the best business and professional standards. Blue jeans, clog-type shoes, jean jackets, etc., are not acceptable.

Name Tags:

The HHA will provide a name tag for each staff member upon employment. When received, the name tag is considered a part of the uniform and is to be worn at all times by the staff member when on duty. The name tag is to be worn on the outside of the clothing and in plain and obvious view.


SUBJECT: DRESS REGULATIONS REFERENCE #4069

PAGE: 2


EFFECTIVE:


Penalty for Improper Attire:

Due to our contact with patients and the public, it is imperative that the work attire of all staff be appropriate and identify them as HHA staff. For this reason, the staff member may be sent home by the supervisor or department manager for reporting to duty in a substandard uniform, or otherwise subject to disciplinary action.

Reasonable Period of Time for Obtaining Proper Uniform:

It is expected that each staff member will obtain a proper uniform before beginning employment. The staff member will be informed of uniform requirements before beginning work and be allowed ample time in which to acquire the proper attire, which is considered to be a part of the requirements for employment.


SUBJECT: EMPLOYEE ASSISTANCE PROGRAM REFERENCE #4070

PAGE: 1


EFFECTIVE:



PURPOSE:

To promote, foster and maintain the health and well-being of staff, both in the workplace and in their personal and family lives by focusing on prevention, early intervention and education.

To provide a confidential avenue of assistance for staff of the HHA to identify and resolve problems/areas concern that may affect their work performance and/or home life. These areas include, but are not limited to, health, marital, family, financial, alcohol, drug, legal and/or emotional issues.

To maintain effective and productive work processes, functions and outcomes of the HHA and to decrease costs related to turnover, absenteeism, accidents and stress related disability.

POLICY:

HHA shall offer referrals to appropriate counseling and/or rehabilitation through an outside independent Employee Assistance Program to full-time staff and/or immediate families of all staff who suspect or know they may have an alcohol, drug, emotional, family or other personal problem. Identification of the need for assistance may come from management and/or supervisory staff, or from the staff member him/herself.

Although staff are encouraged to use this referral system, participation in the program is voluntary and confidential, and does not relieve staff of their obligation to perform their work in a satisfactory manner and to comply with the HHA's rules and regulations. However, staff jobs, futures and reputations will not be jeopardized by using this service.

The Employee Assistance Program is provided at no cost to all full-time non-probationary staff and their dependents.

Staff should make every effort to schedule appointments during nonworking hours. Appointments scheduled during work hours will be treated as medical appointments and may be charged against sick leave.


SUBJECT: EMPLOYEE ASSISTANCE PROGRAM REFERENCE #4070

PAGE: 2


EFFECTIVE:


For inpatient rehabilitation programs, a medical leave of absence may be granted.

The Human Resources Department is responsible for generating referrals for staff assistance and all services and records are treated confidentially.

Staff may enter the Employee Assistance Program independent of the HHA.

PROCEDURE:

The request for a staff assistance referral may be submitted to the Human Resources Department.

The formal referral process is used for diminished work performance or inappropriate workplace behavior issues that may have resulted in a substandard performance evaluation or a disciplinary action.

The HHA receives quarterly utilization reports of usage patterns from the Employee Assistance Program. The reports include only the following information:

Number of HHA staff served

Number of sessions

Number of family members served

Types of treatment or referral provided

This information shall be tracked and trended as an integral part of the organizationwide Quality Assessment and Performance Improvement (QAPI) program.

The contracted Employee Assistance Program provides in-house education and training during orientation and on an ongoing basis as needed to address the specific requirement of the HHA.


SUBJECT: EMPLOYEE GRIEVANCE PROCESS REFERENCE #4072

PAGE: 1


EFFECTIVE:


POLICY:

The organization has in place a process allowing each employee the opportunity to initiate a fair and equitable review of any work-related controversy, dispute or misunderstanding related to the disciplinary action process.

The employee may obtain information related to the grievance from the Human Resources/ Personnel Department.

PROCEDURE:

Step One:

The employee may submit his/her dispute orally or in writing, to his/her immediate supervisor or manager within three (3) business days after being informed of the situation and subsequent disciplinary action.

The supervisor or manager shall attempt to resolve the employee’s grievance during

the initial meeting.

If unable to reach a mutually agreed upon settlement, the supervisor or manager shall investigate the situation further and within three (3) working days, meet with the employee with a proposed solution to the grievance.

If the employee is not satisfied with the proposed solution, he/she may proceed to

Step Two.


SUBJECT: EMPLOYEE GRIEVANCE PROCESS REFERENCE #4072

PAGE: 2


EFFECTIVE:


Step Two:

The employee must submit a written detailed description of the problem or grievance within five (5) working days of Step One of the process having been completed.

The Human Resources/Personnel Department shall investigate the problem,

conferring with all involved parties and schedule a meeting with the employee and the supervisor or manager. The employee may elect to have a fellow employee accompany him/her to this meeting to assist in the presentation of the issues.

A concerted effort shall be made at this meeting to resolve the situation.

Employees who are discharged for cause may appeal that decision by using the grievance procedure. However, discharged employees shall appeal as in Step One and the appeal must be in writing. Any discharge appeal must be received within seven (7) working days of the discharge in order to be considered for review.


SUBJECT: EMPLOYEE HANDBOOK REFERENCE #4073

PAGE: 1


EFFECTIVE:


POLICY:

An Employee Handbook shall be given to every new employee at the time of orientation.

The Employee Handbook shall include (not all inclusive):

Benefits

Complaints and Grievances

Conflict of Interest

Disciplinary Action

Performance Expectations and Reviews

Professional Boundaries

Recruitment, Hiring and Retention of Personnel

Termination of Employment

Wages

Each staff member shall sign a form stating that he/she received the Employee Handbook. This form shall be kept in the employee's personnel file.

HHA's Employee Handbook and Human Resources policies and procedures shall be reviewed annually and updated as needed.


SUBJECT: EMPLOYEE REQUESTS FOR TIME OFF REFERENCE #4074

PAGE: 1


EFFECTIVE:



POLICY:

HHA shall consider all properly submitted requests for time off, with or without pay, from all staff.

When such requests are made in connection with earned or accrued benefit time, proper considerations will be given to the employee, with the welfare of the patients foremost in mind. Initial approval of all such requests is required by supervisory staff in the employee's department, but may be subject to administrative approval if the benefit time is in question.

When requests for time off are made by the employee who has not earned or accrued proper benefit time off, such requests when granted, will be without pay and subject to supervisory and administrative approval.

PROPERLY SUBMITTED REQUESTS FOR TIME OFF:

For all purposes and uses of this policy, a request for time off will only be considered when it meets the following conditions:

The request is made in writing by use of the proper form and contains an accurate

account of all regularly scheduled working days off desired by the employee.

In cases of extreme and unexpected emergency, the request is made in writing on a sheet of paper, other than forms provided, containing accurate information as to the reason for the request, as well as the regularly scheduled working days off desired.

The request is made verbally to the supervisor and/or department manager and is

made at least 24 hours before the regularly scheduled working day off desired.

In cases of extreme and unexpected emergency, the request is made via telephone (only when the employee is unable to appear in person) to the supervisor and/or department manager and is made sufficiently early so that adequate staffing may be arranged.

Requests for time off which do not meet one or more of the following conditions will be considered improper and may lead to disciplinary action.



PAGE: 2


EFFECTIVE:


PROCEDURE: REQUEST FOR EARNED BENEFIT TIME OFF:

Vacation Time:

The employee shall obtain the appropriate form from his/her supervisor. The form shall be completely filled out by the employee and returned to the supervisor as soon as possible.

The Payroll Department will consult the most recent benefit report in regards to

earned time off to make sure the employee has the proper amount accrued and has fulfilled length of service requirements. This information is conveyed to the supervisor who may either approve or deny the request.

If approved, the request will be sent to the Payroll Department for processing with the employee's time card. A copy of the request along with approval or denial is retained by the Payroll Department and a copy is returned to the supervisor. The original is placed in the employee's personnel file.

If the request is denied, further discussion with the employee will occur to agree on a

more suitable time off.

Sick Leave:

Although no form is required for an employee to take earned sick leave time, proper notification to the supervisor and/or department manager must be made according to the following conditions:

If the employee has advanced knowledge of physical incapacity to perform

work, written request may be made on the Request for Leave of Absence Form or by another written method chosen by the employee. Written documentation from a physician may be required before approval is given for time off.

If injury or illness occurs without advanced knowledge or warning, verbal

notification is sufficient, if made directly to the supervisor and/or department manager and with notification made as soon as possible. Only in severe instances will notification made by someone other than the employee be sufficient.



PAGE: 3


EFFECTIVE:


In all cases, staff are expected to provide notification with a proper period of time allowed to arrange for adequate staffing in their absence. Only in extreme instances will notification later than two (2) hours before the regularly scheduled working shift be acceptable.

Written documentation from a physician may be necessary before time off is

approved due to illness. In all absences of more than 72 hours (beginning with employee's regularly scheduled time for reporting to duty) a written release from a physician may be required before the employee will be allowed to return to duty.

Leave of Absence Without Pay:

Requests for leave of absence must be made in accordance with categories outlined in the current Employee Handbook and are subject to benefit rules and regulations as stated.

The employee desiring a leave of absence shall obtain a Request for Leave of

Absence Form from his/her supervisor as far in advance as possible.

All requests for leave of absence are subject to administrative approval when made for a period of time exceeding four (4) weeks without pay.

If the employee will experience any change in employment status or benefit levels as

a result of the leave of absence, an appointment with Human Resources shall be made to discuss these changes as well as eligibility for reassignment at the end of the approved leave.

Any leave of absence over 30 days will require an appropriate adjustment in the

anniversary date.

Family Care Leave:

Staff with at least one (1) year of continuous service are entitled to family care leave in connection with the birth or adoption of a child or the serious illness of a child, parent, spouse, brother, sister or grandparent.

Spouses who are both employed by the company may take a maximum combined

total of 12 weeks of family care in a 12-month period.



PAGE: 4


EFFECTIVE:


The employee must exhaust any other leave (other than sick leave) to which the employee is entitled before receiving additional family care leave. An employee may be granted up to four (4) months of family care leave in any 12-month period.

If the employee has been on maternity leave, the total of family leave and maternity

leave granted shall not exceed five (5) months in any 24-month period.

During medical or family care leave, the HHA shall continue to pay for the employee’s participation in the HHA's group health plan.

The HHA may deny reinstatement to any key employee who is among the highest

paid 10% of the HHA's staff and whose return to work after leave would cause grievous economic injury to the HHA.

Jury Duty, Bereavement Leave, Time off to Vote:

Jury Duty:

The employee shall notify his/her supervisor of the summons for jury duty as soon as it is received. The supervisor will then refer the summons to Human Resources, who will write a letter for the employee, indicating that the HHA does not pay for jury service.

Bereavement Leave:

The employee shall notify his/her supervisor as soon as possible after having

experienced a death in the family before time off with pay will be granted. The number of days granted off with pay are defined in the current Employee Handbook with regards to members of the immediate family.

Time Off to Vote:

If an employee is unable to vote before or after regular working hours, that employee will be allowed reasonable time off with pay to discharge this civic duty. The employee must schedule this time off with his/her supervisor or department manager.



PAGE: 5


EFFECTIVE:


Workers' Compensation:

For those individuals properly released from duty by a physician due to injury sustained on-the-job, leave of absence is granted in the same manner as any other medical leave of absence.

A staff member is to notify his/her supervisor and/or department manager at least

once weekly to advise them of his/her current status. Written release from the physician is required before the employee is allowed to return to duty. For those absences requiring more than three (3) consecutive days of absence, all pay received will be that in accordance with workers' compensation laws as processed by the HHA's workers' compensation insurance carrier.

Other Requests for Time Off:

Any request to other topics contained in this procedure will be considered individually by the supervisor and/or department manager and will require final approval by the Administrator before time off is granted.

REFERENCE:

U.S. Department of Labor. (n.d.). Wage and Hour Division (WHD). Family and Medical Leave Act, Retrieved from http://www.dol.gov/whd/fmla/

http://www.dol.gov/whd/fmla/


SUBJECT: EMPLOYMENT OF FOREIGN APPLICANTS REFERENCE #4075

PAGE: 1


EFFECTIVE:


CHECK FEDERAL AND STATE-SPECIFIC RULES AND REGULATIONS

POLICY:

HHA shall follow requirements listed below in regards to foreign applicants for employment. In order to be considered for employment, a foreign applicant must first submit the following:

Application of Employment provided by the HHA

Certified copy of applicant's I-94 form (back and front)

Copy of passport indicating expiration date

Copy of educational records from the country where training or education was received

Current License, Registration or Certification, if applicable

In addition, the following requirements shall be made:

Working visa (H-1) must be valid for at least six (6) months from date of employment.

A contract must be signed for the time which each visa or extension is requested.

A background check must be completed by the HHA

In the event a foreign employee with a working visa should submit his/her resignation, the Immigration Department shall be notified unless prior arrangements have been made for release of sponsorship of the H-1 visa.

It shall be the responsibility of the employee to maintain current H-1 visa status.


SUBJECT: EMPLOYMENT OF THE DISABLED REFERENCE #4076

PAGE: 1


EFFECTIVE:


PURPOSE:

To abide by the Americans with Disabilities Act (ADA) of 1990 and provide a consistent and nondiscriminatory process for selecting staff for the HHA.

POLICY:

HHA shall select staff without regard to gender, race, age, creed, handicap or national origin.

The HHA shall make every attempt to employ physically and/or mentally disabled individuals in jobs that they are capable of performing providing the applicant is able to perform essential job functions as defined in the position requirements.

In employing the disabled, this HHA shall provide these workers with on-the-job training as needed making every effort to comply with requirements as spelled out in the statutes and regulations for "reasonable accommodation."

Those staff with documented histories of substance abuse shall be considered individually with appropriate medical recommendation.


SUBJECT: EMPLOYMENT OF RELATIVES REFERENCE #4077

PAGE: 1


EFFECTIVE:



PURPOSE:

To provide a consistent and nondiscriminatory process for selecting and retaining staff for the HHA

To maintain efficient and ethical business practices

POLICY:

HHA permits the employment of close relatives except in those cases where a direct supervisory relationship exists. Such cases include, but may not be limited to situations that:

Require one relative to review or process the work of the other

Provide one relative the opportunity to review or recommend salary levels or

increases of the other

Permit one relative to occupy a position that has access to confidential information about the other

Care must be exercised in the evaluation, selection and placement of candidates for employment and/or transfer, who are relatives of staff members, to ensure that family ties do not interfere with the efficient operation and prudent financial control checks and balances of the HHA and that staff are not subjected to unfair or preferential treatment as a result of their relationship to other HHA staff. This policy applies to all regular full and part- time positions.

BECOMING RELATED AFTER EMPLOYMENT:

When staff members become related by marriage after they have been employed, they may continue their employment with the approval of administration except as restricted in the provisions above.


SUBJECT: EXIT INTERVIEWS REFERENCE #4078

PAGE: 1


EFFECTIVE:



PURPOSE:

To provide a consistent process to identify issues that influence staff members to terminate employment with the HHA.

POLICY:

HHA shall encourage staff members who have terminated their employment with the HHA to schedule an exit interview with the Human Resources Department.

Monthly summary reports of the results of exit interviews are submitted to administration for review and revision of policies, procedures or working conditions, if applicable and appropriate.

Quarterly summary reports of the results of exit interviews shall be submitted to the Quality Assessment and Performance Improvement (QAPI) Committee.


EXIT INTERVIEW FORM SAMPLE

Employee Name: Interview Date:

Interviewer:

Exit Interview Results:

Summarize below employee’s opinions, both positive and negative, of any factors in the topic areas listed below:

The Job:

Employee’s Supervisor and Co-workers:

Communications, Policies and Practices:

Working Conditions and Benefits:

Are there any personal problems causing this termination? Yes No

If yes, option to explain:

Do you recommend the HHA as a place to work? Yes No Neutral

Comments:


EXIT INTERVIEW FORM - SAMPLE (continued)

Conclusion - Interviewer:

What were the major reasons for leaving?

Is this employee recommended for rehire? Yes No

Explain basis for response:

What action(s) would have retained him/her as an employee?

Additional Comments:


SUBJECT: GARNISHMENT OF WAGES REFERENCE #4080

PAGE: 1


EFFECTIVE:



PURPOSE:

To comply with the decisions of local, state or federal government agencies.

POLICY:

HHA shall comply with the requests for garnishment of wages when properly executed and delivered by a lawful federal, state or local government or their authorized agents upon presentation of valid identification.

Compliance with such lawful garnishment requests will be carried out by the Administrator only, and proper notification will be given to the staff member involved in advance of the action in all cases.

The Administrator will confer with and abide by the advice of the HHA’s legal counsel before initiating any action to garnishee a staff member’s wages.

PROCEDURE:

Upon receipt of the Summons of Garnishment or other lawfully executed document, the Administrator will note on the document the following information:

Date received

Amount or estimate of garnishment

Signature

The staff member's personnel file and data card are retrieved with the request for garnishment noted therein and the staff member is immediately contacted.

In such cases which may require consultation with HHA legal counsel, the Administrator is notified immediately.


SUBJECT: GARNISHMENT OF WAGES REFERENCE #4080

PAGE: 2


EFFECTIVE:


If the staff member is unable to obtain a proper release from garnishment in written form, instructions will be given to the Payroll Department for execution. Withdrawal of those instructions will be made upon receipt of proper release.

In such cases requiring consultation of HHA's legal counsel, such advice received will be considered to supersede this policy.


SUBJECT: HOLIDAY POLICY REFERENCE #4081

PAGE: 1


EFFECTIVE:



POLICY:

HHA will grant time off with pay for authorized holidays without loss of income to full-time nonprobationary staff. The compensation will be at the staff member's regular base rate of pay.

Holiday time off is scheduled so as to not compromise the care, treatment and services provided to patients of the HHA.

ELIGIBILITY:

Regular full time staff, as defined under "Classification of Employee" in the manual, are eligible for paid holidays. Eligibility begins with hire. The observed holidays are scheduled by management and are posted each calendar year.

Staff may be asked to volunteer to work on an observed holiday in order to maintain continuity of care, treatment and services to the patient population served by the HHA.

If a staff member must work on the observed holiday, or if it falls on a staff member's day off, a substitute day within the pay period may be granted. Exceptions can be granted only when business conditions prevent the scheduling of this day as approved by the department manager.

It is the intent of this HHA to pay off the holiday within the pay period in which the holiday falls.

Personal holidays must be scheduled on days mutually satisfactory to management and the staff member. This also applies to substitute holidays. Holidays that fall during approved vacation may be used to extend the vacation if approved by the Patient Care Services Director.

To be eligible for a holiday, the staff member must work the full scheduled workday prior to and the full scheduled workday after the holiday (scheduled vacation days are counted in satisfying this requirement) unless alternate arrangements have been approved by administration.


SUBJECT: HOLIDAY POLICY REFERENCE #4081

PAGE: 2


EFFECTIVE:


DESIGNATED HOLIDAYS:

New Year's Day Independence Day Christmas Day

President's Day Labor Day Staff Member's Birthday

Memorial Day Thanksgiving Day

Holidays do not accrue to staff who are on leave of absence. Whenever a staff member returns from an approved leave of absence, the staff member will NOT be eligible for past holidays occurring during the leave of absence.


SUBJECT: PAYROLL DISTRIBUTION/TIME

VERIFICATION

REFERENCE #4082

PAGE: 1


EFFECTIVE:



POLICY:

HHA shall distribute pay to staff on a biweekly basis. Paydays are every other and paychecks are available after PM.

Those persons who are considered to be staff, and who have successfully completed any and all pre-employment requirements as set forth in the HHA policies, will receive pay for hours worked as set forth in Federal Wage and Hour Regulations.

Furthermore, the HHA shall remain in compliance with Federal Wage and Hour Regulations in all facets of the payroll program.

The pay period will begin and end as follows:

Beginning Sunday at 0001 and continuing for 14 consecutive days ending on Saturday at 2400 after the 14 day period.

The Payroll Department will process only those time records which are maintained according to policies. Verification of time worked will be provided by supervisory staff and department managers, according to policies, and each staff member is required to acknowledge his/her entries to the time record by signature.

Records of hours worked will be maintained by use of a time record provided to the staff member at the beginning of each pay period. Records of time worked will be maintained for a period of time not less than three (3) years and are not to be removed from the building without prior written approval of the Administrator or unless lawfully required or requested.

Time records for use by staff in the daily recording of time worked are provided by HHA.



VERIFICATION

REFERENCE #4082

PAGE: 2


EFFECTIVE:


PROCEDURE - PAYROLL DISTRIBUTION:

Routing of Prepared Payroll Checks:

After proper verification of payroll checks, the Payroll Department forwards unsigned checks to administration for signature.

All checks are placed in envelopes which are sealed and placed in alphabetical

order according to department.

At the time designated for distribution, the department manager may obtain checks for his/her staff from Human Resources Department. If the department manager is unable to obtain the checks in person, a written authorization must be provided to another party to do this in his/her place.

The department manager may distribute checks to all staff upon receipt, or at such

time designated and approved by the Administrator.

If a staff member is unable to pick up his/her own check, written authorization must be obtained before the check will be released to another party. Proper identification of this individual will be required. The department manager will forward the written authorization to the Payroll Department as soon as possible.

Date and Time of Payroll Distribution:

Payroll checks are distributed on the following the end of each pay period after PM.

Time Verification:

The Payroll Department will process only those time records each pay period which are considered valid. A valid time card will contain the following:

Accurate daily entries made by the staff member in ink.

Any and all written entries on the time record are approved in writing by the

staff member's supervisor.



VERIFICATION

REFERENCE #4082

PAGE: 3


EFFECTIVE:


The time record is signed by the staff member and initialed by the supervisor or department manager.

The staff member's number and accurate totals of regular time, overtime or

other paid hours are entered in the appropriate areas.

The staff member's name, department number, number and the dates of the pay period are recorded on the time record.

Time records without staff member signature may be processed with the

approval of the department manager; however, the time card must be signed by the staff member before the check is released. If the time card is not signed, a third party will not be allowed to obtain the staff member's check until signature of the staff member is obtained, unless approved by the Administrator.


SUBJECT: PERSONNEL FILES - CONTENTS AND

ORIGINATIONS

REFERENCE #4083

PAGE: 1


EFFECTIVE:



POLICY:

HHA shall initiate and maintain a personnel file on all staff members. The Human Resources Department initiates the personnel file at the time of hire.

It is appropriate for Human Resources to originate and maintain personnel files according to that information which is required by federal, state or local regulations or information otherwise required by the HHA to commence employment.

PROCEDURE:

The personnel file will contain the documents listed below, but not limited to those documents solely. Other information placed in the personnel file will be included at the discretion of the Patient Care Services Director/Administrator and in accordance with other related HHA policies.

Application for Employment, previously completed by the staff member, including:

Staff member's full name and address

Employment classification

Hire date

Termination date

Documentation of reference requests made or the documents themselves.

Documentation of verification of current licensure/certification/registration from the primary source.

Photocopy of license/registration as required (should be clearly marked "copy" on its

face).

Photocopies of automobile insurance and professional liability insurance, if appropriate.



ORIGINATIONS

REFERENCE #4083

PAGE: 2


EFFECTIVE:


Documents required for setup on payroll with pertinent information as contained on the form itself, with required signatures.

"Employee's Withholding Allowance Certificate" (W-4) completed with Social

Security number and signed by staff member.

Enrollment form for benefit plans as required.

Authorization of the staff member, in writing, for any payroll deductions to be made which are extraneous to those required by law.

Other documents, or photocopies thereof, as deemed useful and necessary by administration (may include resume, special awards or certificates, etc.)

Staff medical records shall be considered confidential and will be maintained in a file

separate from staff personnel records.

RETENTION OF PERSONNEL FILES:

HHA shall retain current personnel files for the duration of employment. When the employment status is terminated, the file will be retained in the "terminated" files on the premises for a period of time no less than three (3) years. When removed from the "terminated" file, they will be removed to the HHA storage area where they will remain indefinitely. Personnel files may not be destroyed or removed from storage areas without written authorization of the Administrator.

ACCESS TO PERSONNEL FILES:

Staff:

A staff member will be allowed to review the contents of his/her personnel file at a time convenient to the Human Resources Department. No document will be removed from the file without the approval of the Human Resources Director. A staff member may request, in writing, photocopies of documents contained in his/her personnel file. Such a written request must contain the reason for the request, specific documents requested, date of the request and the staff member's signature. The request will be given to the Human Resources Department and is subject to the approval of the Administrator. If granted, the document photocopies will be mailed to the staff member's home address within 10 working days of the date the request was received.



ORIGINATIONS

REFERENCE #4083

PAGE: 3


EFFECTIVE:


Supervisor/Department Manager:

When it becomes necessary for review of certain documents in the personnel file, these individuals will be allowed limited access to the staff member's personnel file. Such access will be limited to that information necessary to the reason for the request; such review will be done in the Human Resources Department.

Administrator and Patient Care Services Director:

Due to the need of documents and information from personnel files in order to conduct daily operations, these individuals shall have unlimited access to contents of all personnel files.

Outside Parties:

No information or document from any personnel file will be released to any outside party without the written consent of the staff member, unless required by law or regulations and requested in a lawful manner. In such cases, the staff member will be notified.

Regulatory organizations shall have access to personnel files to conduct business,

upon notification of the Patient Care Services Director/Administrator.

CONFIDENTIALITY OF PERSONNEL FILES:

HHA assures the total confidentiality of personnel files maintained in the Human Resources Department. Strict adherence to rules of access as outlined in this policy is required. Deviations or alterations of these rules will occur only at the direction of the Administrator.

OWNERSHIP OF PERSONNEL FILES:

Ownership of all personnel files is that of HHA. No personnel file is to be removed from the Human Resources Department without approval of the Administrator unless otherwise stipulated by this policy. No personnel file will be removed from the premises unless approved by the Administrator.

PERSONNEL FILE LOG

Employee Name: Employee Number:

Position: Date of Hire:

Document Yes No Expiration

Date Comments

Employment Application Form completed

Resumé

Interview completed

References (3) verified

Background check

Drug screening

Salary Form signed

Job Description signed

Employee Handbook

Skills Checklist completed

Competency Form within three (3) months

Performance evaluation - three (3) months

Annual competency

Annual performance evaluation

Orientation completed

I-9 Form

Driver’s license

Automobile insurance

Professional license verified

Malpractice insurance

Specialty practice certificates/verification

CPR

OSHA/AIDS/bloodborne pathogens

Domestic violence

Physical exam

TB/PPD/chest x-ray

Hepatitis B

Confidentiality statement

W-4

Company pager # _

Office key


SUBJECT: PROCUREMENT OF EMPLOYEES REFERENCE #4085

PAGE: 1


EFFECTIVE:


POLICY:

Provide an efficient method and centralize procurement of employees.

PROCEDURE:

To obtain an additional employee or replacement for an employee of this HHA, the department manager will obtain written administrative approval through the use of the Personnel Requisition Form and will forward the signed Personnel Requisition Form to the Human Resources Department. The Personnel Requisition Form will outline the particulars/qualifications necessary to fill the position. On receipt of this information, Human Resources will start the recruitment process.

See Personnel Requisition Form.


PERSONNEL REQUISITION FORM SAMPLE

Request Date: Date Required:

Title: Department:

Exempt Nonexempt Permanent Temporary

Addition Replacement for

Hours: Rate Range: Budget Position: FTE:

To Be Interviewed By: Phone Ext.:

Description of Duties to be Performed:

Experience and/or Education Desired:

Special Qualifications and Remarks:

Is there an employee under your supervision who may be considered for this position? Yes No

Name:

Is there an employee within the HHA who may be considered for this position? Yes No

Name:

Requested by: Date:

Departmental Approval: Administrative:

Human Resources Use Only:

Date Received: Human Resources Representative:

Sources Contacted:



SUBJECT: RE-EMPLOYMENT REFERENCE #4087

PAGE: 1


EFFECTIVE:



POLICY:

Consideration will be given to the application of former full-time or per diem employees, who left employment of HHA in good standing after having completed the probationary period.

Re-employment is based on the same needs and qualifications as are needed in the employment of any other applicant.

For the purpose of establishing beginning wage or salary, except for employees covered by veteran's re-employment rights, a rehired employee is one who returns within one (1) year of termination. All rehired employees are regarded as new employees and must serve a new probationary period of 90 days.

The application of any former employee is processed in the same manner as that of a new employee.

Any employee rehired in the same or related position and assigned to the same pay

grade will have the salary determined in the same manner as a new employee.

An employee rehired into a position unrelated to any position formerly held, even though in the same pay grade, will have the salary determined in the same manner as a new employee.

Those re-employed will qualify for employee benefits in the same way that other new employees qualify except:

Employees leaving their jobs to perform training or service in the Armed Forces will

be re-employed in accordance with the re-employment rights program as stated in Section 9 of the Military Training and Service Act

Employees rehired as non-benefited employees, i.e., staffing pool, per diem


SUBJECT: SICK LEAVE POLICY REFERENCE #4088

PAGE: 1


EFFECTIVE:



PURPOSE:

To establish uniform procedures under which sick leave may be granted and taken.

To ensure that a system is in place for the reporting and accurate recording of absenteeism due to illness of or injury to, staff members of HHA.

POLICY:

All regular, full-time staff shall accrue sick days. Eligibility for sick days is granted after the probationary period at the rate of one (1) sick day (eight [8] hours) for each month of service to a maximum of 12 sick days (96 hours) per year. Paid sick leave shall not be granted as vacation leave and is to be used when the staff member is unable to work because of illness or injury, or for medical or dental appointments.

Sick leave will accrue when a staff member is on vacation, sick leave or on professional or other approved leave; however, it will not accrue while a staff member is on unpaid leave of absence.

Unused sick days may be accumulated from year to year to a maximum of 30 sick days (240 hours). Sick days are paid at the regular base rate for regularly scheduled hours that are missed when the sick days are approved by the department manager. A physician's statement shall be requested if absent for five (5) or more consecutive days.

Sick days are considered an unearned benefit and are granted to staff only for personal illness or injury. It is not intended to be used for other personal time off, care of ill family members, etc. No payment value is carried over and unused days are not payable upon termination.

Staff who miss work excessively cannot fulfill their working responsibilities. If excessive absence is caused by illness, a medical leave of absence should be considered to allow the time to correct any health problems.


SUBJECT: SICK LEAVE POLICY REFERENCE #4088

PAGE: 2


EFFECTIVE:


PROCEDURE:

Staff members are required to notify their immediate supervisor/department manager in a timely manner of any absences due to illness or injury.

The supervisor/department manager should complete the HHA’s Sick Leave Form and submit the form to the Human Resources/Payroll Department.


SUBJECT: TERMINATION OF EMPLOYMENT REFERENCE #4089

PAGE: 1


EFFECTIVE:



PURPOSE:

To provide a procedural guide for a standardized approach to issues of staff termination of employment.

POLICY:

HHA shall provide all staff with one means of terminating their employment relationship, at their request. Upon receipt of the appropriate documents, the HHA will recognize the staff member’s intent to cease employment, and proper procedures will be initiated by the Human Resources Department.

Additionally, the HHA has the right to initiate termination of the employer/staff relationship when justified, and in accordance with applicable laws and regulations. Methods utilized for that purpose will be executed in a manner that is deemed fair and equitable to all parties, under the law. The Human Resources Department at the direction of the Patient Care Services Director/Administrator will carry out proper termination procedures.

Staff are to return all HHA property to the Human Resources Department before the final day of employment. Final paychecks/severance pay is withheld until all HHA property is returned.

Final paychecks are available to all terminating staff at the end of the complete two (2) week pay period following the termination date.

The HHA is committed to and is determined to abide by the nondiscrimination and job- protection assurances contained in all applicable federal and state laws and as such will verify only employment dates and salary information for prospective employers.



PAGE: 2


EFFECTIVE:


PROCEDURE:

All staff who are terminating employment with the HHA for any reason are asked to participate in an exit interview with the Human Resources Director.

Procedure for Termination of Employment - Staff Member Request:

The staff member should submit, in writing, a letter of resignation to his/her immediate supervisor at least two (2) weeks prior to the resignation date. The letter should contain the following information:

Name, department and position of the departing staff member

Date the letter of resignation is written

Effective date of the resignation (the staff member's last day of work)

Specific reasons for the resignation

Forwarding address information

The letter of resignation will be forwarded to the Human Resources Department immediately upon receipt, accompanied by a completed Personnel/Payroll Action form.

The Human Resources staff will begin closure of the staff member's

personnel file in the following manner:

The personnel file and staff member's data card are removed from the files, and the termination date is noted appropriately.

The staff member's insurance records are removed from the files, and the termination date is noted appropriately. Notices of conversion privilege for insurance plans are then prepared and mailed to the staff member.



PAGE: 3


EFFECTIVE:


The Human Resources staff will indicate termination pay or benefits in the Personnel/Payroll Action Form, distribute parts of the form to Payroll and to the department manager of the staff member, and maintain the original in the personnel file.

All other activities associated with termination (withdrawal from other benefit plans, etc.) will be carried out by the Human Resources Department.

Procedure for Termination of Employment:

When deemed necessary, and after completion of the HHA's disciplinary

action policy and procedure, termination information will be forwarded to Human Resources by the department manager.

When all documentation is deemed adequate for termination activities by the

department manager and Human Resources, the procedure outlined above in Procedure for Termination of Employment - Staff Member Request will be initiated.

When termination is to be at the HHA's request, the staff member's final

paycheck will be available to the staff member at the time of dismissal, if possible.


SUBJECT: STAFF RECRUITMENT, RETENTION AND

EDUCATION

REFERENCE #4090

PAGE: 1


EFFECTIVE:


PURPOSE:

To ensure that an adequate number of qualified and competent staff are available to meet the care, treatment and/or service needs of the patient population served by the HHA and to fulfill the mission, vision and goals of the organization.

POLICY:

Programs shall be developed/maintained to promote recruitment, retention, development and continuing education of all staff members.

PROCEDURE:

The following factors are considered in developing programs that promote the recruitment, retention, development and continuing education of all staff:

HHA's mission, vision, goals and scope of care

The case mix of patients and complexity of care, treatment and/or services required

The technology employed in the care of patients

Areas identified by State and Federal regulatory requirements, such as Scope of Practice Guidelines and OASIS Data Collection and Reporting

Identified staffing levels required

Use of direct and/or contract staff

The expectations of the HHA, medical staff and patients and their significant others

for the type and degree of patient care provided

The stated, perceived or otherwise identified learning needs of patient care staff members

Those issues identified or stated by staff members that influence their decision to

continue or terminate employment with the organization

Areas identified by Quality Assessment and Performance Improvement (QAPI) activities


SUBJECT: STAFF RECRUITMENT, RETENTION AND

EDUCATION

REFERENCE #4090

PAGE: 2


EFFECTIVE:


REFERENCE:

Centers for Medicare and Medicaid Services (CMS). (September 6, 2017). OASIS User Manuals. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/HomeHealthQualityInits/HHQIOASISUserManual.html

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIOASISUserManual.html

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIOASISUserManual.html


SUBJECT: VACATION POLICY REFERENCE #4091

PAGE: 1


EFFECTIVE:



POLICY:

HHA shall grant annual vacations with pay to all eligible staff based upon length of service as defined herein.

ELIGIBILITY:

All full-time regular employees are eligible for an annual paid vacation. See Classification of Employees policy.

Vacation benefits are accrued for each 12 months (1 year) of continuous service and are to be taken in the following year. The amount of vacation benefits granted is according to the schedule of benefits. First year employees may be advanced up to five (5) days of vacation from the first year accumulation, after six (6) months of continuous employment. The amount of vacation benefit granted is according to the schedule of benefits.

Vacation request forms may be obtained from the Supervisor or from the Human Resources Department. Vacation requests will be approved on a first come, first serve basis providing conditions allow the absence of the employee at the requested time. Conflicting requests submitted within the same week will be determined by seniority.

A day of vacation shall be computed at the base rate of pay. Only regular full-time employees are eligible for vacation benefits. Earned vacation not taken will be paid upon termination.

Accrued but unused vacation time shall be paid upon termination only if the employee has given a minimum of two (2) weeks notice and if the employee has completed six (6) full months of employment.

Total vacation time advanced may not exceed five (5) days and requires specific advance written approval from the employee’s immediate supervisor/Patient Care Services Director. If an employee who terminates employment for any reason has used more vacation than has been accrued, a deduction will be made from the final paycheck for the excess vacation.

Employees cannot receive pay in lieu of vacation hours except at termination as described above.


SUBJECT: VACATION POLICY REFERENCE #4091

PAGE: 1


EFFECTIVE:



POLICY:

HHA shall grant annual vacations with pay to all eligible staff based upon length of service as defined herein.

ELIGIBILITY:

All full-time regular employees are eligible for an annual paid vacation. See Classification of Employees policy.

Vacation benefits are accrued for each 12 months (1 year) of continuous service and are to be taken in the following year. The amount of vacation benefits granted is according to the schedule of benefits. First year employees may be advanced up to five (5) days of vacation from the first year accumulation, after six (6) months of continuous employment. The amount of vacation benefit granted is according to the schedule of benefits.

Vacation request forms may be obtained from the Supervisor or from the Human Resources Department. Vacation requests will be approved on a first come, first serve basis providing conditions allow the absence of the employee at the requested time. Conflicting requests submitted within the same week will be determined by seniority.

A day of vacation shall be computed at the base rate of pay. Only regular full-time employees are eligible for vacation benefits. Earned vacation not taken will be paid upon termination.

Accrued but unused vacation time shall be paid upon termination only if the employee has given a minimum of two (2) weeks notice and if the employee has completed six (6) full months of employment.

Total vacation time advanced may not exceed five (5) days and requires specific advance written approval from the employee’s immediate supervisor/Patient Care Services Director. If an employee who terminates employment for any reason has used more vacation than has been accrued, a deduction will be made from the final paycheck for the excess vacation.

Employees cannot receive pay in lieu of vacation hours except at termination as described above.


SUBJECT: WORKERS’ COMPENSATION REFERENCE #4092

PAGE: 1


EFFECTIVE:



POLICY:

HHA shall be committed to minimizing the risk of work-related injury and illness.

When work-related injury and illness do occur, the HHA has a legal and moral obligation to provide compensation and assistance to staff members who have suffered an injury or illness arising out of or in the course of their employment.

Any staff bloodborne pathogen exposure shall be handled in a confidential manner. Staff who contract HIV shall be covered under Workers' Compensation if it is determined that they were infected at work.

REPORTING PROCEDURES:

First Aid Cases:

Those injuries requiring minor medical attention or only first aid, generally are not "recordable" under OSHA; however, a location record of all injuries must be kept.

Physician's Cases:

If the staff member sees a physician and the injury is considered reportable, an Employee Claim Form for Workers' Compensation Injury must be prepared and copies forwarded immediately to the Human Resources Department. This report must be submitted immediately. Benefits cannot be paid until paperwork has been completed.

Serious Medical Claims:

In serious injuries or fatalities, the Administrator shall be notified immediately. OSHA notification shall be the responsibility of the Human Resources Department in conjunction with the Safety Officer.



PAGE: 2


EFFECTIVE:


Investigations and Questionable Claims:

Every claim involving lost time shall be investigated immediately, and will include interviewing witnesses, the injured staff member (as soon as health permits), examination of the injury scene and photographs, if appropriate. Any physical evidence (broken machine parts) shall be retained. Should there be any information uncovered that would cause a question as to the validity of the claim, this information shall be communicated immediately and fully to the Administrator. This shall be by phone call initially and then followed by a letter, either attached to the Injury Report, or sent later.

Medical Care:

For any injury, the staff member shall receive prompt and appropriate medical treatment. If referred to a physician, the staff member shall take with him/her a "physician's referral slip" which authorizes the physician to treat the person as a work-related injury.

Treatment of Pre-Existing Conditions:

Departments shall direct their staff accordingly and consideration given when assigning a prospective or current staff member, with a known pre-existing injury which could be aggravated while doing the work assigned.

Documentation of prior injuries shall be placed in staff member's medical files. Documentation may be in the form of group insurance information, preemployment physical or as a result of a claim examination or prior Worker's Compensation claim.

Contact with Injured Staff:

It is very important to maintain close contact and open communications with an injured staff member, but particularly if he/she is away from work more than a week. This shall include phone calls and home visits by the staff member's immediate supervisor and other members of management, as deemed necessary.



PAGE: 3


EFFECTIVE:


Rehabilitative Work:

It is recommended that every effort be made to accommodate a staff member who may return to work on a restricted activity basis. This may be accomplished by discussion with the department manager, the treating physician and the staff member. Rehabilitation is most effective when initiated as soon as medical conditions stabilize (usually within six [6] weeks).

Return to Work:

Authorization for the staff member to return to work must be in writing by the attending physician and presented to the immediate supervisor or department manager.

Even though the physician returns the staff member to "full work" status, caution

shall be exercised for all staff returning after a prolonged disability period.

If a staff member does not report to work on the day he/she is designated, the supervisor shall attempt to reach the staff member to see if the disability period was extended. If the disability period has not been extended, disciplinary action shall be taken in accordance with standard procedures for not reporting to work.

If there are any restrictions noted by the physician on the return to work

authorization, advise the supervisor of such and determine if the staff member can return to work with the restrictions noted.

OSHA Reporting Responsibilities:

Reports of fatalities or hospitalization of three (3) or more employees from a single cause must be made to the local OSHA offices within eight (8) hours of the injury; contact the Human Resources Department for specific instructions.

Maintenance of the OSHA Log and supplemental report shall be the responsibility of

the Human Resources Director.

Quarterly reports of staff injuries and Workers’ Compensation claims shall be submitted to the Quality Assessment and Performance Improvement (QAPI) Committee for review and possible modification of existing processes and/or functions. Staff injuries shall be tracked as part of the organizationwide QAPI program.