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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

CoPs State Interpreation Manual 2019

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

Non Compliance D/C (Not Follow POC, Medication Plan, etc) : DC Non Comp.

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 all involved Patient's Physician)


Plan of Care (485) for Non Skilled Cases:    POC (485)


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

Order Verification

Non Admission Notice form:   Non Admission

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

Meds Interaction Notification  (Also notify any detected medication discrepancy)


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)(2018 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


Specialty Shelter Refuse Registration:              Shelter Refuse Registration


Consent to assistance of Self Administered Meds   Consent to assistance with self adm. meds 


Against Medical Advice (AMA) report:  AMA report English           AMA report Spanish



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   Assessment/POC req.  Survey Tips


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

Electronic Health Record Staff Access Authorization: Electronic HR Authorization

Administrator/DON: Survey Ready Check List, Med Watch Log

Survey Ready Check List                     Med Watch 3500 Log Med Watch Log

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 Manual Orientation                            Survey common policy request (pages)

Manual Orientation                                      Common Policy request

Record Retention Information                     Staff Competency Policy Update         

Record Retention                                           Staff Competency     

Generic Cover Manual                                     Emerging Infectious Disease (like Coronavirus)      

Manual Cover                                                Emerging Infectious Disease Policy

Pandemic Management Plan                         Policy Manual Signature page

Pandemic Plan                                               DON/Administrator signature

Risk Management Plan                                    Drug Free Workplace program

Risk Mgm Plan                                               Drug Free Program

Patient Educational Materials                     Agency Compliance Plan

 Patient Educational Materials                    Agency Compliance Plan

 Staff Health Policy

 Staff Health Policy


 Agency Influenza Vaccination Improvement Plan: Agency Influenza Vaccination Plan


Influenza Vaccine Goals Policy:   Influenza Vaccine Goals Policy



Ethic Committee Members Name/Title     Board Members Name/Title

 Ethic Committee Members                          Board Members

Compliance Cte members Name/Title      Policy Named Administrator/DON

Compliance Committee                                Administrator & DON names     

Executive: GB, QAPI,etc Name/Title           HIPAA Authorities  (Name/Titles)       

Executive Staff                                              HIPAA Authorities                                         

Safety Committee Name/Title                    Infection Control Committee members (Name/Title)        

Safety Committee                                         Infection Committee                                         


Policy Wages and Charges:                        Policy on Charges:                            

Wages & Charges                                      Charges for Services      

Back Up / Contingency Policy:                  Policy on Admission (Homebound)

BackUp Contingency Policy                      Policy on Admission (Homebound)

 Influenza  and  pneumococcal  vaccine  administration Policy

Influenza & Pneumococcal Vaccine

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

ICD10 Tips:   TIPS/Samples ICD10    ICD10 Guidelines


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.