Emergency Plan

Same month every year (annually)

Complete the Data Sheet.

Complete the Agreement with another Agency. (Fax to us the information to complete/submit the Plan)

Your License must be renewed every 2 years

Renew License Form: 60 days before to expiration date.    CLIA application form

PRIVACY AND SECURITY NOTICE REGARDING ELECTRONIC FORMS. Our electronic forms are provided solely as a convenience to assist Home Health Agencies in completing required documentation. The forms operate within your web browser and are intended for local use by authorized agency personnel. No patient information entered into these forms (if any) is collected, stored, saved, transmitted, processed, or retained by our website, servers, or systems. The information entered remains under the control of the user and is used only to generate or complete the form for the agency's own records. Because no protected health information (PHI) is received, maintained, saved, or retained by our website, we do not create or maintain a database of patient information from these forms. This website is protected by a valid HTTPS Secure Sockets Layer (SSL/TLS) certificate, which encrypts communications between your web browser and our website to help protect the integrity and security of your connection. Home Health Agencies remain solely responsible for ensuring that any completed forms are handled, stored, transmitted, printed, or incorporated into their medical, administrative record systems in compliance with all applicable federal and state laws, including the Health Insurance Portability and Accountability Act (HIPAA), the Health Information Technology for Economic and Clinical Health (HITECH) Act, applicable Centers for Medicare & Medicaid Services (CMS) Conditions of Participation, and any other applicable state and federal privacy and security requirements. By using these electronic forms, users acknowledge that they are responsible for maintaining the privacy, security, and confidentiality of any patient information after the form has been completed. Please Note: While this website uses industry-standard HTTPS (SSL/TLS) encryption to secure communications, HIPAA compliance ultimately depends on how each Home Health Agency uses, stores, transmits, and safeguards Protected Health Information (PHI) after the form has been completed.

Every year all the following reports must be completed under the supervision of the Administrator/DON or delegate.

Administrator/DON: Survey Ready Check List: Survey Ready Check List

(The template must be updated with your discussion and Agency's reality data)

INFECTION PREVENTION:  

ADD to Infection Control LOG, also discuss in BD meetings:

DON, Clinical Manager-QA Prioritized Infection Risk Report (Monthly)

Prioritized Infection Risk Surveillance of Infections Report                                                              

Infection Control Log       Prevention/Tx Log: Infection Prevention/Tx

DON:  Infection Control Risk Assessment Infection Prev. Risk Assessment   (Quarterly)

Infection Risk Goals Policy

DON-QA Infection Control program effectiveness Report (Quarterly)

Infection Control Effectiveness

Miami Dade EPI Report: Infection EPI Report   Request copy to: Vanessa.Villamil@flhealth.gov

DON, Clinical Manger-QA Hand Hygiene Improvement Intervention (to be posted in the Agency's Information Board) (Quarterly)

Handwashing Improvement (Quarterly) Summary monthly handwashing competency (Monthly)

Hand Hygiene Patient Survey (by patient) Hand Hygiene Pt Survey Summary (Quarterly)

Staffs monthly results handwashing competency (full year): Handwashing Competency by months

FALL PREVENTION:  

Add to Fall Prevention LOG, and BD meeting:

DON-QA Fall Prevention Intervention Plan (Monthly)

Fall Prevention Intervention Plan                      Monthly Fall Tracking

DON, Clinical Manager-QA Fall Prevention Program (Intervention Analyzes Report) (Quarterly)

Fall Prevention leadership Intervention          Agency Fall Prevention Evaluation

DON, Clinical Manager-QA

Fall Prevention Assessment (Quarterly)                   Fall Investigation Report(Quarterly)

Agency Fall Prevention Assessment                        Fall Investigation Report

DON, Clinical Manger-QA Fall Prevention Data Collection (Monthly)

Fall Prevention Data Collection

DON, Clinical Manager: Fall Prevention (Prioritized List) LOG (Must be completed monthly)

Fall Prioritized List

QAPI REPORTS:  

QA/DON/Clinical Manger: Monthly report about hospitalization, emergency care prevention (results of risk assessment)

  (QAPI PROJECT)

DON: Hospitalization LOG (Must be completed monthly)     Hospitalization Log

Hospitalization risk analysis: Hospitalization risk analysis  Emergency care risk analysis: Emergency Care risk analysis

QAPI Project Hospitalization/Emergency Care:  Hospitalization/Emergency care services risk Project   

QAPI Plan-Do-Study-Act (PDSA) Hospitalization/Emergency Care PDSA

Decreasing Hospitalization, Improvement report: Decreasing hospitalization/Improvement Report

Cardio Vascular Disease Project: CVD Project                     CVD Plan-Do_Study (PDSA) CVD PDSA

(Complete the DC Planning control log, and have the Total DC patients with High BP)

DON, Clinical Manager/QA: Performance Levels, Patterns, Trends, Variations:  (Quarterly)

PI: Performance, Patterns, Trends

DON, Clinical Manager: OBQI Analyzes LOG (OBQI report must be analyzed by the Agency on Regular BD meeting, this log documented the review of the OBQI (Casper) reports) (Quarterly)

OBQI Analyzes Log                              Adverse Event (OBQI Analyzes)

(AI) QUARTERLY AUDIT TOOL (AI) Audit tool  Use this tool to perform quarterly Quality Assurance and Performance Improvement (QAPI) audits of Artificial Intelligence (AI) technologies and AI-assisted processes.

(AI) QAPI MONITORING DASHBOARD (AI) QAPI Monitoring Dashboard    Quarterly Quality Assessment and Performance Improvement (QAPI) monitoring tool for Artificial Intelligence (AI) implementation and oversight.

MEDICATION MANAGEMENT:  

DON, Clinical Manager: Medical Error Management Analyzes

Medical Error Management Analyzes  Quarterly  Medical Error Incident Report  Complete report as needed

Total Medical Error Incidents (%)    (Monthly)       Medication Management Analyzes   Quarterly 

Clinical Referencias:  BEERS Criteria Medication List  Agency Clinical Referencia: Clinical Ref. BEERS

DON: Patient on OXYGEN therapy LOG (Must be completed quarterly)    Patients on Oxygen Log

MULTIPLE REPORTS:  

DON: Coordination of Care Compliance/Tracking LOG (Quarterly)        Coordination of Care

Administrator/DON: Complaints Log (Monthly)

Complaints Log Summary                            Complaints Log (detail) Summary

Administrator/DON/QA: Total of Incidents Summary/Occurrence Report  (Monthly)

Incidents/Occurrence Report

ADMINISTRATOR/HR: Staff Influenza Declination Analyzes, Report to BD (Quarterly): Influenza Declination Analyzes

DON, Clinical Manager: Home Health Value Based Purchased report: CMS pulls the required quality metrics directly from standard data sources like the OASIS assessment tool, Medicare claims, and patient surveys.

DON, Clinical Manager: Total Monthly Discharge Patients by reasons Report Must be completed (Monthly)

Total Discharge Patients                    Discharge Planning Log

DON, Clinical Manager-Administrator Following Policy Log (Quarterly), Compliance Report  (Quarterly)

Following Policy Log                             Compliance Report                                        

Safety Tracking LOG (All year long)        Safety Tracking Log     (Complete all reports in Safety Minutes)

DON, Clinical Manager: Diabetes/Insulin Administration (PI Data Control List) LOG Must be completed (Quarterly)

Diabetes Control Log

Add to QAPI meeting (Quarterly)

DON, Clinical Manager/Administrator: INCIDENT Occurrence Report Must be completed (Monthly)

Incident Occurence Report

Administrator Financial and Billing Report to BD (Quarterly)       Financial/Billing Reports

DON, Clinical Manager: More Common Diseases report by counties: (Monthly)

Florida:

Any Foridal County

Miami Dade    Monroe County (Keys)    Broward

Palm Beach    Duval County    Indian River           

Seminole County    Orange County    Brevard County

Osceola County    Hardee County    Highlands County

Hillsborough County    Manatee County    Polk County

Charlotte County    Collier County    DeSoto County

Glades County    Hendry County    Lee County

Sarasota County    Pasco County    Pinellas County

California:

Los Angeles County CA

Illinois:

Cook County IL

Pennsylvania:

Bucks County PA

Texas:

Fort Bend County TX    Harris County TX

CMS Medicare Balance Report: Due on 1 - 30 of January, April, July and October (Quarterly)

  Medicare Balance Report   You can fax the report to: (803) 419-3277

***Starting December 1, 2024, providers aren’t required to submit Credit Balance Reports (CMS-838) (PDF) on a quarterly basis. You’re still required to report self-identified overpayments, but you should only use a Credit Balance Report when they occur.

Disclaimer: Every template is only your Guide/Agenda to complete each report, your Agency Officials must assure that the meeting occur, the quorum is acceptable, and every member had active participation in the discussion and confection of the Reports, Evaluations, Documents.