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As needed Documents

(Complemented documentation)

Training In Our Office

Describe the photo or the page it links to

Every semester we offer 1 or 2 in-office training to your employees.

New Conditions of Participation (CoPs) Implementation date: 01/13/18

Administrator: PATIENT LEGAL REPRESENTATIVE NOTICE (Must be verbally completed before or during SOC, then within 4 days emailed/mailed to the Patient's Legal Representative) Signature proof required.

Representative Statment                       Representative Full Notice 

D/C for Safety issue (Behavioral or other safety problems) : DC Safety Reason

Coordination of Care (Fax/email, orders changes to Involved Physicians): Fax/Email Cover


Administrator: ORGANIZATIONAL CHART (Must be completed as needed and posted in Agency's Board)Organizational Chart                       Agency Activity Calendar


DON: ORDER VERIFICATION/RECONCILIATION (Coordination of Care with Patient's Physician)

(Only for cases where you can not contact by phone the patient's physician)

Order Verification

 

Alert Medication Interaction (Notification/Fax to Patient's Physician as needed)

Meds Interaction Notification

 

FDA approval waived instruments, (glucometers, etc)  Operational Manual enhanced:

Link to FDA to obtain the Operation Manual

 

Home Health Qualification (Patient's qualification, MD who can order, Face to Face, Value Purchased, etc)

Medicare HH Qualifications (Homebound)                  Medicare Conditional level def. (G Tags)

 

AHCA State deficiencies (H Tags)                              Policy on Admission (Homebound)

 

Face to Face guidelines                                             Discharge Planning (CMS)

 

Prior Authorization Info (CMS)                                     Value Purchased items

 

DON: CASE CONFERENCE REPORT FORM (Must be completed at least every 30 days)

Case Conference Report

 

DON: Staff Change Form                              Beneficiary Elected transfer to your Agency

Staff Change Form                                    Beneficiary Elected Transfer

 

Authorization to release Information:              Authorization to Release Information

Authorization to sign on behalf of Pt:              Authorization to Sign

 

DON: Missed Visit Report: (Fax to MD)         DON oversight visits report (AHCA may request)

Missed Visit Report                                   DON Oversight Visits Report

D/C in Office (Used when OASIS DC was not completed)      Federal G-Tag Summary

DC in Office/Agency                                 Federal G-Tags Summary


Survey Documents request:

CHAP - AHCA         JCHO        ACHC


Administrator:

Sample Accountant External Review: Survey required (CHAP)

 Accountant Ext. Rev. Sample

Electronic Signature Authentication

 For Staff who sign by any electronic mean                        For Physician (authentication electronic signature)

Electronic Signature Authentication                               MD Electronic Signature Authentication


Administrator/DON: Survey Ready Check List

Survey Ready Check List


Administrator: Business Associate Contract with all Associated Business with possible access to Patient Information (including voluntary members of the PAC (non employees), Staffing Company, Consultants, Billing Agent, Waste pickup company, etc)

Business Associate Contract                        Staffing Company Contract

Contract with ALF, Nursing Home or Hospice:

ALF Contract


POLICY:

Record Retention Information                  Board Members Name/Title

Record Retention                                      Board Members       

PAC members Name/Title                          Ethic Committee Members Name/Title

PAC Members                                           Ethic Committee Members       

Compliance Cte members Name/Title   Policy Named Administrator/DON

Compliance Committee                             Administrator & DON names     

Executive: GB, PAC,etc Name/Title         Policy on Admission (Homebound)

Executive Staff                                           Policy on Admission (Homebound)          

Policy Wages and Charges:                        Policy on Charges:                            

Wages & Charges                                      Charges for Services      

Back Up / Contingency Policy:

BackUp Contingency Policy


CASPER Report Manual (OBQI):   CASPER (OBQI) Manual

ICD10 Tips:   TIPS/Samples ICD10    ICD10 Guidelines

HHCAHPS Web: HHCAHPS Enrollment


Common Survey Questions                              Common Errors                                       

Common Survey Qt                                         Common Errors

Common Staff Qt

Disclaimer: Every log/form template is only your guide to complete each log/form, your Agency Officials must assure that every member had active participation in the discussion and confection of the Log, Reports, Evaluations, Documents.

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