HOSPICE DME

POLICIES AND PROCEDURES MANUAL

TABLE OF CONTENTS

LEGAL AUTHORITY............................................................................................................................................4NOTIFICATION POLICY OF ORGANIZATION CHANGES........................................................................................5GOVERNING BODY...........................................................................................................................................6GOVERNING BODY STRUCTURE........................................................................................................................7GOVERNING BODY ORIENTATION.....................................................................................................................8CONFLICT OF INTEREST AND DISCLOSURE.........................................................................................................9PRESIDENT.....................................................................................................................................................10ABSENCE OF PRESIDENT.................................................................................................................................11MISSION AND PHILOSOPHY STATEMENT........................................................................................................12STRATEGIC PLANNING....................................................................................................................................13REPORTING OF OUTCOMES............................................................................................................................15SERVICE DESCRIPTION....................................................................................................................................16CLIENT BILL OF RIGHTS AND RESPONSIBILITIES...............................................................................................17CLIENT/PATIENT GRIEVANCE / COMPLAINT....................................................................................................18CONFIDENTIALITY OF CLIENT/PATIENT INFORMATION...................................................................................19CLIENT/PATIENT ABUSE OR NEGLECT..............................................................................................................21ETHICAL ISSUES..............................................................................................................................................23CODE OF ETHICS.............................................................................................................................................24CLIENT/PATIENT CULTURAL BACKGROUND AND RELIGIOUS BELIEFS...............................................................25COMMUNICATION BARRIERS..........................................................................................................................26COMPLIANCE PROGRAM................................................................................................................................28BUDGET PLANNING........................................................................................................................................32BUDGET PLANNING........................................................................................................................................32ACCOUNTING ACTIVITIES................................................................................................................................33FINANCIAL RECORD RETENTION.....................................................................................................................34REIMBURSEMENT DISCLOSURE.......................................................................................................................35PERSONNEL MANAGEMENT...........................................................................................................................36PERSONNEL RECRUITMENT AND INTERVIEW..................................................................................................37JOB DESCRIPTIONS.........................................................................................................................................38PERSONNEL CREDENTIALS..............................................................................................................................39EMPLOYEE REQUIREMENTS............................................................................................................................40PERSONNEL RECORDS.....................................................................................................................................42ORIENTATION PROGRAM...............................................................................................................................43COMPETENCY ASSESSMENT / SUPERVISOR VISITS..........................................................................................44IN-SERVICE / CONTINUING EDUCATION..........................................................................................................45SUPERVISION..................................................................................................................................................46EMPLOYEE PERFORMANCE EVALUATIONS......................................................................................................47CONTRACTED AND PURCHASED SERVICES......................................................................................................48CLIENT/PATIENT RECORD DOCUMENTATION..................................................................................................49CLIENT/PATIENT RECORD MANAGEMENT.......................................................................................................50CLIENT/PATIENT REFERRALS...........................................................................................................................52

ELIGIBILITY ASSESSMENT AND GUIDELINES.....................................................................................................53GEOGRAPHIC AREA SERVED............................................................................................................................54ANTIDISCRIMINATION COMPLIANCE..............................................................................................................55UNMET NEEDS................................................................................................................................................56PERFORMANCE MANAGEMENT PLAN.............................................................................................................57INFECTION CONTROL......................................................................................................................................59TUBERCULOSIS INFECTION CONTROL PLAN.....................................................................................................61HEPATITIS B INFECTION CONTROL PLAN.........................................................................................................66BLOODBORNE PATHOGENS CONTROL PLAN...................................................................................................67INFECTIOUS DISEASE REPORTING...................................................................................................................72SAFETY MANAGEMENT...................................................................................................................................74EMERGENCY PREPAREDNESS PLAN.................................................................................................................78EMERGENCY PREPAREDNESS DRILL.................................................................................................................80UTILITIES MANAGEMENT................................................................................................................................81FIRE SAFETY....................................................................................................................................................82HAZARDOUS WASTE MANAGEMENT..............................................................................................................83IDENTIFICATION, HANDLING AND DISPOSAL OF HAZARDOUS MATERIALS......................................................84HAZARD COMMUNICATION PROGRAM..........................................................................................................85INCIDENT REPORTING.....................................................................................................................................86HME REGULATIONS AND QUALIFICATIONS.....................................................................................................88HME SCOPE OF SERVICES................................................................................................................................89AFTER-HOURS CALLS.......................................................................................................................................90SUPERVISION..................................................................................................................................................91ADMISSION ASSESSMENT AND PLAN OF SERVICE...........................................................................................92EQUIPMENT SERVICES FOLLOW-UP................................................................................................................93CLIENT/PATIENT EDUCATION..........................................................................................................................94HOME SAFETY EDUCATION.............................................................................................................................95CLEANING AND TESTING OF EQUIPMENT PROCEDURE....................................................................................97EQUIPMENT TRANSPORT AND SET-UP............................................................................................................98EQUIPMENT MAINTENANCE AND REPAIR.......................................................................................................99VENDOR REPAIR SERVICE PROCEDURE..........................................................................................................100PRODUCTS TRACKING...................................................................................................................................101HME EQUIPMENT TRACKING........................................................................................................................102PRODUCT INCIDENTS....................................................................................................................................103PRODUCT INCIDENT REPORTING...................................................................................................................104PRODUCT RECALL.........................................................................................................................................105VEHICLE INFECTION CONTROL......................................................................................................................106HME EQUIPMENT CLEANING AND INFECTION CONTROL...............................................................................107EQUIPMENT BACK-UP...................................................................................................................................108MANUFACTURER MANUALS/INSTRUCTION SHEET PROCEDURE....................................................................109VEHICLE MAINTENANCE AND REPAIRS..........................................................................................................110MATERIALS MANAGEMENT QUALITY CONTROL MEASURES..........................................................................111OXYGEN CONCENTRATOR PROCEDURE.........................................................................................................113OXYGEN TANK PROCEDURE..........................................................................................................................114OXYGEN CONSERVING DEVICE PROCEDURE..................................................................................................115OXYGEN DEFINITIONS...................................................................................................................................116OXYGEN: EQUIPMENT STANDARDS..............................................................................................................118OXYGEN: LABELING......................................................................................................................................119

RECORD KEEPING: COMPRESSED MEDICAL GASES........................................................................................120STORAGE AND HANDLING: COMPRESSED GASES..........................................................................................121PRESCRIPTION TRACKING AND ROTATION....................................................................................................122CALIBRATION: DIAGNOSTIC EQUIPMENT......................................................................................................123BATH AND SHOWER AIDS PROCEDURE.........................................................................................................124CANE, QUAD CANE, AND CRUTCHES PROCEDURE.........................................................................................125WALKER PROCEDURE....................................................................................................................................126WHEELCHAIR PROCEDURE............................................................................................................................127COMMODE CHAIR PROCEDURE....................................................................................................................128HOSPITAL BED PROCEDURE..........................................................................................................................129SIDE RAILS PROCEDURE................................................................................................................................130SUPPORT SURFACES PROCEDURE.................................................................................................................131TRAPEZE BAR PROCEDURE............................................................................................................................132PATIENT LIFT PROCEDURE.............................................................................................................................133CPAP, BILEVEL AND NPPV.............................................................................................................................134MEDICATION COMPRESSOR PROCEDURE......................................................................................................135SUCTION MACHINE PROCEDURE...................................................................................................................136HME REFERENCE LIBRARY.............................................................................................................................137