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Our job is to help health care organizations, such as yours, achieve accreditation from The Joint Commission (formerly JCAHO).  We have never had a client fail to get their full accreditation in the 28 years that we have been in business.

 Your company’s prestige in the health care community will soar, not to mention your bottom line if you are awarded full accreditation and The Joint Commission’s “Gold Seal of Approval”.  This gives deemed status for Medicare and Medicaid reimbursement, plus eligibility for reimbursement from third party payers.   Could it be that those who are getting the lion’s share of the Home Care Providers’ business are accredited by The Joint Commission?  That would be the case. Do you want more business for 2009 and the years beyond? 

 The Joint Commission’s accreditation will allow you to enjoy a competitive edge.  Fast-Tracking your accreditation is our specialty. Call  us for more details and a cost proposal.

 John Dow, Director of Marketing, 800-950-4410
Healthcare Quality Improvement Resources, Inc

  If you are in need of any of these policies and procedures, please send E-mail. Be sure to include the name and # of the policies that you desire.  The first 5 policies are free.  Additional policies will be made available for a fee.  A CD of all of the policies will be available in the near future on our website.  If you are interested in the CD, please contact us by E-mail so that we have an idea of the approximate number of CD’s needed for possible purchase. 

2005 HC-POLICY JCAHO REF

POLICY NAME

SECTION & POLICY #

POLICY CROSS REFERENCE # JCAHO STANDARD(S)
RIGHTS & ETHICS

SECTION I

 

 

Patient Information Packet

1001

 

RI.2.60

RI.2.20

Patient Rights & Responsibilities

Procedural Aspects

1002

 

HR.2.10

RI.2.70

RI.2.10

RI.2.30

Home Care Patient Rights &
Responsibilities

1003

 

HR.2.10

RI.2.30

RI.2.10

RI.2.70

HIPPA Regulations & Patient Information

 

1003 A

 

RI.2.20

RI.2.30

RI.2.10

HIPPA

 

1003 B

 

RI.2.30

HR.2.10

Advance Directive Policy

1004

  

 

RI.2.20-ER.2-3

RI.2.80-ER.1-9

Patient Information on Advance Directives

1004 A

 

RI.2.20

RI.2.80

Durable Power of Attorney

1005

 

RI.2.70

Declaration

1006

 

RI.2.30

Patient Informed Decision Making

1007

1003

RI.2.30

Consents

1008

 

 

Patient Consents & Authorizations Form 

1009

10007

 

Clinical Documentation

1010

10007

 

Destruction and Disposal of Protected Health Information Media

1010 A

 

 

Photographing or Videotaping of Clients

1011

 

RI.2.50

Consent to Photograph/Video
Form

1011 A

10007

RI.2.50

IM.6.20

Emergency Intervention

1012

 

 

Do Not Resuscitate/Do Not Intubate

1013

 

 

DNR/DNA Request Form

1014

10007

 

Withholding/Withdrawing Life Support

1015

 

RI.2.10

RI.2.30

RI.2.70

Patient Complaints

1016

 

RI.2.120

About the Right to Express Grievances

1017

 

RI.2.120

Patient Complaint Form

1018

 

RI.2.120

 Confidentiality of Information

 1019

 10003

 IM.2.10

IM.6.10

RI.2.130

Confidentiality Statement Form

1020

10003 A

IM.1.20

Sensory Impaired Patients

1021

 

RI.2.100

Non-English Speaking Patients-Cultural Considerations

1022

 

RI.2.100

Code of Ethics

1023

 

RI.1.10

Ethics Committee

1024

 

RI.1.10

Conflict Resolution

1025

 

RI.2.30

Acceptance of Patients

1026

 

 

Conflict of Interest

1027

 

RI.1.10

RI.1.20

Conflict of Interest Disclosure Statement

 1028

 

 RI.1.20

Ethical Practices-New Life

1029

 

RI.1.10

Integrity Of Clinical Decision-Making

1030

 

RI.1.30

RI.1.40

Protecting Patients from Abuse

1031

 

RI.2.150

Protective Services

1032

 

RI.2.170

 

 

 

 

ASSESSMENT OF PATIENTS 

SECTION II

 

 

Intake Services

2001

 

PC.2.20

Admission Record Form

2002

10007

PC.2.20

IM.6.10

Intake/Referral Form

2003

10007

PC.2.20

IM.6.10

Orders for Service Form

2004

10007

IM.6.10

Patient Assessment Functions & Qualifications

2005

 

PC.2.20

PC.2.120

Assessment

2006

 

PC.2.20

PC.2.120

PC.8.10

Nursing Assessment/Medical History Form

2007

10007

PC.2.20

PC.2.120

PC.8.10 (Pain)

Nursing Progress Report Form

2008

10007

IM.6.10

PC.8.10 (Pain)

Nursing Diagnosis Form

2009

10007

IM.6.10

Proposed Plan of Treatment Form

2010

10007

PC.4.10

Patient Abuse

2011

 

PC.3.10

Patient Abuse-Child

2012

 

PC.3.10

Suspected Adult or Child Abuse Report Form

2013

10007

PC.3.10

IM.6.10

Reassessment

2014

 

PC.2.150

 

 

 

 

 CARE, TREATMENT & SERVICES

 SECTION III

 

 

On-Call Coverage

3001

 

 

Care Planning

3002

 

PC.4.10

Patient Identifiers

3002 A

 

PC.5.10

Home Health Certification and Plan of Treatment Form

3003

10007

IM.6.10

MM.1.10

PC.2.150

PC.4.10

Skilled Nursing Plan of Care Form

3004

10007

IM.6.10

MM.1.10

PC.4.10

Personal Care Instructions

3005

 

IM.6.10

Personal Care Instructions Form

3006

10007

IM.6.10

Confirmation of Physician Telephone/Verbal Orders Policy

3007

10007

IM.6.10

Confirmation of Physician Telephone/Verbal Orders Form

 3008

 10007

IM.6.10

Guidelines for Medical Management &b Physician’s Responsibilities

3009

 

 

Pain Management

3010

 

RI.2.160

PC.8.10

Pain Management Assessment Tools

3010 A

10007

PC.8.10

Care of Terminally Patient

3011

 

PC.8.70

Home Antimicrobial First Dose & Management of Anaphylaxis

3012

 

MM.5.10

MM.6.10

Use of Investigational Treatments/Trials

3013

 

MM.7.40

Adverse Responses to Medication

3014

 

MM.5.10

MM.6.20

Possible Drug Reaction Sheet

3015

 

MM.5.10

MM.6.20

Medication Profile “A” Form

3016

10007

IM.6.10

MM.1.10

Medication Profile “B” Form

3016 A

10007

IM.6.10

MM.1.10

Controlled Drug Disposal

3017

 

 

Medication Errors

3018

 

MM.6.10

Nutritional Assessment

3019

 

PC.2.20  EP # 5

 Nutrition Assessment Form

 3020

 10007

 PC.2.20  EP # 5

Waived Testing

3021

6012

 

PC.16.10

PC.16.20

PC.16.30

PC.16.40

PC.16.50

PC.16.60

Discharge/Transfer/Referral of Patients

3022

 

PC.5.60

PC.15.10

PC.15.20

PC.15.30

EDUCATION

SECTION IV

 

 

Multidisciplinary Patient Education

4001

 

PC.6.10

PC.6.20

Patient Education

4002

 

LD.3.120

PC.6.10

PC.6.30

Pain Management Education

4002 A

 

RI.2.160

LD.3.120

PC.6.10

IM.6.10

PC.6.30 

PC.8.10

Patient/Family Education Form

4003

10007

LD.3.120

IM.6.10

PC.6.30

Use of Restraint Devices

4004

 

PC.4.10

Emergency Preparedness

4005

 

 

Emergency Checklist

4006

 

 

Home Safety

4007

 

 

Waste Disposal

4008

 

 

Infection Control-Patient/Family Education

4009

 

LD.3.120

IC STANDARDS

CONTINUUM OF CARE

SECTION V

 

 

Coordination of Services

5001

 

 

Monthly Medical Update Form

5002

10007

 

Discharge/Transfer of Patients

5003

 

 

Criteria for Discharge-Discharge Summary

5004

 

 

Discharge Summary-Final Note

5005

 

 

Skilled Nursing Discharge Summary Form

5006

10007

 

 

 

Discontinuance of Service Against Medical Advice Form

 

 

5007

 

 

10007

 

Physician Discharge Summary Form

5008

10007

 

IMPROVING ORGANIZATIONAL PERFORMANCE

SECTION VI

 

 

Performance Improvement Plan

6001

 

PI.1.10

LD.4.10

LD.4.50

LD.4.60

Performance Measurement

6002

 

LD.4.10

LD.4.50

LD.4.60

Healthcare Topic Methods

6003

 

 

Special Performance Improvement Studies

6004

 

 

Sentinel Events

6005

 

PI.2.30

LD.4.40

PI.3.10

Framework for a Root Cause Analysis

6006

 

PI.2.30

LD.4.60

Root Cause Analysis Flowchart

6007

 

LD.4.60

PI.2.30

Fiscal Planning

6008

7007

LD.4.60

Performance Measures

6009

 

 

Trending Sheet

6010

 

 

Medical Record Review Sheet

6011

 

 

Glucose Monitor Operator Proficiency Record

6012

 

PC.16.10 - PC.16.60

Home Health Service Questionnaire

6013

 

 

Home Health Medical Records Audit Form

6014

 

IM

 

 

 

 

LEADERSHIP

SECTION VII

 

 

Mission & Vision Statement

7001

 

LD.3.10

LD.3.20

Goals & Objectives

7001 A

 

LD.2.50

LD.3.10 

Philosophy

7002

 

LD.3.10

Provision of Services Plan

7002 A

 

LD.3.20

LD.3.10

LD.1.20

LD.3.50

Strategic Plan

7002 B

 

LD.1.20

Scope of Services

7002 C

 

LD.1.20

Annual Agency Evaluation

7003

 

LD.1.20

 Annual Report to the Board

 7003 A

 

 LD.4.40

Non-Discrimination Policy

7004

 

 

Agency Supervision

7005

 

LD.1.10

Organization Chart

7006

 

LD.1.10

Annual Operating Budget

7007

 

LD.2.50

Capital Expenditure Plan

7008

 

LD.2.50

Patient Safety Program

7009

 

LD.4.40

LD.4.60

LD.4.70

MANAGEMENT OF THE ENVIRONMENT OF CARE

SECTION VIII

 

 

Statement of Policy

8001

 

 

Letter of Appointment

8002

 

 

Duties of Safety Director

8003

 

 

Duties of Department Manager in Safety Program

8004

 

 

Safety-Hazard Surveillance Program

8005

 

 

Home Hazard Analysis Checklist Form

8006

 

 

Initial Home Safety Evaluation and Instruction Form

 8007

 

 

Safety Precautions When Using Oxygen

8008

 

 

Safety Education

8009

 

 

Safety and Security Training for Home Health Personnel

8010

 

 

Employee Safety Information Form

8011

 

HR.2.20

Safety When Moving Objects

8012

 

 

Security Plan

8013

 

 

Security Education

8014

 

 

Hazardous Materials and Waste Plan

8015

 

 

Infectious Waste Management Plan

8016

 

 

Antineoplastic Waste Management

8017

 

 

Chemotherapy Liquid Spills

8018

 

 

Fire Safety Plan

8019

 

 

Fire Drill Report Form

8020

 

 

Emergency Preparedness Plan

8021

 

 

Incident Reports

8022

 

HR.2.20

HR.2.30

Incident Report Form

8023

 

HR.2.20

HR.2.30

Utility Systems Management Plan

8024

 

 

Durable Medical Equipment

8025

 

 

Medical Device Problem Recall

8026

 

 

Safe Medical Devices

8027

 

 

 

 

 

 

MANAGEMENT OF HUMAN RESOURCES

SECTION IX

 

 

Staff Recruitment-Retention-education

9001

 

LD.2.10

Applications for Employment

9002

 

 

Attendance and Tardiness

9003

 

 

Change in Personal Information

9004

 

 

Classification of Employees

9005

 

 

Current Licensure/Certification and Registration

9006

 

HR.1.20

 

Competence Assessment

9006 A

 

HR.3.10

Performance Evaluations

9007

 

HR.3.20

Summary Report to Board re: Performance Evaluations

9007 A

 

 

LD.2.10

Equal Opportunity Employment

9008

 

 

Orientation-New Employment

 

9009

 

HR.2.10

HR.2.20

LD.3.60

Position Description/Performance Evaluation-Administrator

9010

 

LD.2.20

Position Description/Performance Evaluation-Director of Patient Care Services

9011

 

LD.2.20

Position Description/Performance Evaluation-Intake Nurse

9012

 

 

Position Description/Performance Evaluation-Clinical Supervisor

9013

 

 

Position Description/Performance Evaluation-Case Manager

9014

 

 

Position Description/

Performance Evaluation-Home Health Aide

9016

 

 

Employment of Certified Home Health Aides/Nursing Assistants

9017

 

 

Certified Home Health Aide Supervision

9018

 

 

Supervision Checklist

9019

 

 

Certified Home Health Aide Competency Evaluation Program

9020

 

HR.2.10

Certified Home Health Aide Skills Checklist

9021

 

HR.2.10

Certified Home Health Aide Skills Checklist Form

9022

 

HR.2.10

Monitoring of CHHA & CNA

In-service Hours

9023

 

 

Orientation-Certified Home Health Aide Services

9024

 

HR.2.10

Employee Education Programs

9025

3011

HR.2.30

Education re: Needs of Dying Patients

9025 A

 

PC.8.70

Education re: Pain Management

9025 B

 

RI.2.160

Continuing Education/In-service Attendance Record Form

9026

 

HR.2.30

Medical/Surgical Staff Skills Checklist Form

9027

 

 

Ethical Dilemmas in Patient Car-Staff Rights

9028

 

RI.1.10

HR.

Disciplinary Action

9029

 

HR.3.10

Dress Regulations

9030

 

 

Employee Assistance Program

9031

 

 

Employee Communications

9032

 

 

Employee Photo Identification

9033

 

 

Employee Requests for Time off

9034

 

 

Employment of Foreign Applicants

9035

 

 

Employment of the Disabled

9036

 

 

Employment of Relatives

9037

 

 

Exit Interviews

9038

 

 

Exit Interview Form

9039

 

 

Garnishment of Wages

9040

 

 

Holiday Policy

9041

 

 

Payroll Distribution/Time Verification

9042

 

 

Personnel Files:  Contents and Originations

9043

 

IM.2.10

Position Control

9044

 

 

Personnel Requisition Form

9045

 

 

Re-Employment

9046

 

 

Reference Checking/Criminal Background Checks

9047

 

HR.1.20

Harassment, Sexual (Either Sex)

9048

 

 

Sick Leave Policy

9049

 

 

Termination of Employment

9050

 

 

Vacation Policy

9051

 

 

Workers’ Compensation

9052

 

 

 

 

 

 

MANAGEMENT OF INFORMATION

SECTION X

 

 

Information Management Plan

10001

 

IM.1.10

IM.1.20

IM.3.10

LD.1.20

LD.2.10

Patient Access to Medical Records

10002

 

 

Confidentiality of Information

10003

1020

1019

IM.2.10

IM.6.10

Confidentiality Statement

10003 A

1020

IM.2.10

Approved & Unapproved Symbols and Abbreviations

10004

 

IM.2.30

Disaster Recovery Plan for Information Systems

10005

 

IM

Medical Record Entries & Information

10006

 

IM.6.20

IM.6.10

Medical Record Approved Forms

10007

 

IM.6.10

Medical Record Review

10008

 

IM.6.10

 

 

 

 

 

 

 

 

SURVEILLANCE, PREVENTION, & CONTROL OF INFECTION

SECTION XI

 

 

Infection Control Guidelines in the Home Setting

11001

 

IC.1.10

Standard Precautions

11002

 

 

Tuberculosis Screening Program

11003

 

HR.1.20

Health Questionnaire for Positive TB Skin Test Reactions

11004

 

HR.1.20

Employee Health

11005

 

HR.1.20

Employee Health Program

11006

 

HR.1.20

Exposure Control Plan

11007

 

 

Employee Exposure to Blood and Body Fluids Form

11008

 

 

Handwashing

11009

 

 

Employee Health-Employee Illness

11010

 

 

Employee Absence Report Form

11011

 

 

Employee Health-Immunizations

11012

 

 

Employee Health-Injury of the Job Reporting

11013

 

 

AIDS/HIV Positive Guidelines

11014

 

 

Post-exposure Prophylaxis Hepatitis

11015

 

 

Informed Consent for Hepatitis B Vaccine Form

11016

 

 

Hepatitis B Vaccine-Declination Form

11017

 

 

Exposure to HIV

11018

 

 

Infection Control Plan

11019

 

 

 

 

 

 

 

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This page last updated: 08/21/2008