A Home Health Care Franchise Is Contracting With a Home Health Care Consultant?

Below please find Certified Homecare Consulting’s proposal for bringing XYZ Franchise into full accreditation and Medicare Conditions of Participation compliancy. Full compliance will require dedicated work by all XYZ Franchise management and staff as well as very clear direction provided by the RN Consultants of Certified Homecare Consulting.

Our CHAP Certified Nurse Consultant review team (2) shall review each of the compliance areas listed below during a full day or two Agency review depending on Agency size. Areas of noncompliance shall be identified, and each noncompliant HR or clinical record shall be flagged with compliancy deficiency tags. The Agency shall be given a “clean up” plan with targeted deadlines for reaching full compliance.

After the initial noncompliance findings are determined, one Nurse Consultant will be assigned the “Lead Project Manager” and this nurse shall meet weekly with the Agency Managers for a 2-hour update on the clean-up process. The number of weeks it will actually take is solely dependent on the Agency’s commitment to the clean-up and the dedication of staff to make the corrections

Once full compliance is achieved, the Agency shall be given a proposal for ongoing compliance oversight to maintain the hard achievement of compliance with CHAP Standards and Medicare Conditions of Participation.

Certified Homecare Consulting charges $xxx/hour for each nurse consultant. Any portion of the last hour shall be billed as a full hour.

If this proposal is agreeable to you, please let us know and we will be happy to send you a contract for the work outlined in this proposal.

Policy and Procedure Manuals:

■ XYZ Franchise must assure that the Agency is working with current, revised
Policies and procedures for operating the Home Health Program (manual set).

■ Manuals are kept in locations easily accessible by the departments they provide policy for (i.e. Personnel Manual is kept in the HR Department)

■ Policies are available to staff upon request. How do you assure this?

HR Compliance:

100% audit of all personnel files show:

■ Orientation checklist identifying MDA, False Claims Act, Infection Control education

■ Skills Competency checklist is done at hire during a joint patient visit

■ 90-day eval is done including goal setting for the 1st year of hire

■ Annual eval includes goal setting and Skills Competency checklist is done during a joint
patient visit

■ New hires must have Cori and negative Mantoux on file BEFORE the 1st patient visit

■ ALL new hires must have a fully completed I-9 in a separate file

■ Professional staff have licensure check on file, and it is current

■ Paraprofessionals have 12 in-services each year on file

■ Professional staff have MDA, TB & False Claims Act, Bloodborne Pathogens, and
Infection Control in services completed each year

■ Professionals must have transcript, resume and CPR proof on file

■ All staff have Medicare fraud check on file

■ Every personnel file must have 2 references

■ Every personnel file must have signed confidentiality statement

■ Agency maintains tracking sheet to manage compliance

Clinical Compliance:

■ identify which record system Agency uses ■ paper charts or EMR

■ Identify who scans documents_______________________

■ Identify who manages “orders management” in Kinnser ___________________

■ Every patient has signed “admit to homecare” order in Kinnser

■ Every new admit must have a SOC OASIS completed (error free) within 48h of admission visit

■ Every patient’s SOC OASIS is exported to Medicare within 30 day of admission

■ Every patient has signed SOC 485

■ Indicate specific frequency & duration (no ranges)

■ Every SNV note contains elements of every intervention & goal listed on the 485 (every visit)

■ Every patient has completed SOC med profile

■ Every patient has new med profiles completed as med change (add, DC, inc or dec)

■ Every new treatment/frequency chg./ discipline add/ med chg must have a written order

■ Every admission must have 30 & 60d summaries (include narrative) on file AND a SOC case
conference if there is more than 1 discipline in the case

■ Every patient who goes inpatient must have a Transfer inpatient OASIS done and dated the date
Nurse finds out about the hospitalization

■ Every patient who has been admitted to hospital MUST have a transfer summary dated the same
day as Transfer OASIS completion (NOT a discharge summary) and sent to Unit Manager

■ Every patient discharged from an inpatient facility must have resumption OASIS done AND
orders to include: Discipline and frequency status

Treatment orders per hospital

Med list w dosages per hospital- new med profile

Any other changes to original POC

These resumption orders could use a templated “post hospitalization” order form

When goals are met for a particular discipline, dc the discipline ONLY,

■ get a signed MD order to discharge that discipline.

When ALL goals are met for all disciplines or the patient requests discharge,

■ get a signed MD order to discharge from Agency,

■ complete a Discharge OASIS & a discharge summary (NOT a case conference summary).

■ complete a CAHP survey for EVERY discharged patient dated the day of discharge

■ send summary to MD

If goals are NOT met by day 55,

■ do a Recert OASIS between day 55 thru day 60 (5-day window)

■ Do a 60d summary (case conference)

■ Do a new med profile for this episode

■ Do a new 485 for this episode

■ Do a case conference if more than 1 discipline

■ Export the Recert OASIS to Medicare within 30 days of recert

Travel Charts:

Agency must have some way for clinicians to review the MD POC for each patient. Travel
charts (TC) are a good solution to this. If you will use TC, you must write a policy guiding this
practice. The alternative to TC would be PDA/Table usage in the field

A travel chart (folder) is carried by each clinician for their caseload containing:

■ the current 485’s of all patients serviced

■ most recent SNV note

■ copies of all orders

■ TC must be contained in a closed box in the care. Only the individual patient TC is carried
into the visit (HIPAA)

■ When patient is DCd or SN discipline is DCd, TC is returned to office for shredding

Supervision:

■ HHA POC must be done when service is ordered, and proof must be in the record of how it
was communicated to the service aide

■ HHA supervision must be done q14d or more frequently

■ HHA visit notes must match the HHA POC

■ LPN supervisions are done q30d in each client they service

Performance Improvement Program Compliance

■ 1st PAC mtg is held BEFORE 1st patient admission

■ Ongoing bi-annual PAC mtgs are held 2X/year (Jan & Jul)

■ July PAC is also the Strategic Planning mtg. Minutes reflect this (SWOT)

■ A system exists for collecting and housing raw data between committee meetings

■ Evidence exists that proves Administrator is assuring the collection of raw data

■ Each committee has been assigned 4-5 staff members

■ Each committee meets quarterly to analyze data, determine corrective action & submit such to Administrator

■ Administrator files every set of minutes into PI manuals

■ Administrator addresses findings of committees at monthly staff mtgs and corrects deficiencies found (minutes reflect this)

■ Results of committee findings are compiled into minutes by Administrator for submission to PAC agenda

Corporate Compliance

■ Qualified substitute for CEO is signed and in both the substitute and the CEO’s personnel files

■ Qualified substitute in the Absence of the Administrator form is in both the substitute and the
Administrator ’s personnel files

■ When Administrator will be out personnel file shows above form is dated and signed in the HR files. There is a
separate form for each occurrence

■ Bylaws reflect Board of Directors meeting frequencies and

■ Minutes of Board of Directors mtgs are held accordingly and on file.

■ Board of Directors mtgs held at different times than Bylaws frequency are titled “Special Board of
Directors Meeting” and filed along with other Board of Directors minutes

■ All non-owner members of Board of Directors must have a documented orientation to Agency and
Board of Directors

■ Board of Directors have annual conflict of interest on file for EVERY year

■ Board of Directors mtg minutes reflect that the board reviewed and approved:

■ Policies yearly

■ Legal/business documents yearly (Budget & Bylaws are reviewed q36 months or sooner)

■ Annual Agency Evaluation yearly

■ Hiring of Administrator, alternates and key positions are approved as often as they change

■ PAC minutes

■ Ethics Committee members are approved annually

■ Staffing Contract language is reviewed annually