Policy Manual sample

MDT Home Health Care Agency, Inc. INITIAL COMPREHENSIVE ASSESSMENT POLICY: The comprehensive assessment is performed on patients referred for services and documented in the patient’s record. The comprehensive assessment is conducted and documented whether services continue or not, and must be completed in 48 hrs. The comprehensive assessment is appropriate to the patient age and diagnosis (e.g., infant, older adult, prenatal, post-partum, and mental health patient). The comprehensive assessment must identify the patient’s continuing need for home care and meet the patient’s medical, nursing, rehabilitative, social, and discharge planning needs. PURPOSE: 1. To assess the client's physical, psychological, social, and spiritual status. 2. To collect baseline data about the client's condition. Comprehensive assessment of patients . Each patient must receive, and our HHA will provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. (a) Standard: Initial assessment visit. (1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician-ordered start of care date. (2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician who is responsible for the home health plan of care, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. (b) Standard: Completion of the comprehensive assessment . (1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. (2) Except as provided in paragraph (b)(3) of this section, a registered nurse must complete the comprehensive assessment and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. (3) When physical therapy, speech language pathology, or occupational therapy is the only service ordered by the physician, a physical therapist, speech-language pathologist or occupational therapist may complete the comprehensive assessment, and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. The occupational therapist may complete the comprehensive assessment if the need for occupational therapy establishes program eligibility. (c) Standard: Content of the comprehensive assessment . The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; (2) The patient’s strengths, goals, and care preferences, including information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; (3) The patient’s continuing need for home care; (4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; L-1 Home Health Agency Client Assessments