Policy Manual sample

MDT Home Health Care Agency, Inc. (5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. (6) The patient’s primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; 7) The patient’s representative (if any); (8) Incorporation of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items, as specified by the Secretary. The OASIS data items determined by the Secretary must include: clinical record items, demographics and patient history, living arrangements, supportive assistance, sensory status, integumentary status, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, medications, equipment management, emergent care, and data items collected at inpatient facility admission or discharge only. (d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than— (1) The last 5 days of every 60 days beginning with the start-of care date, unless there is a— (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. PROCEDURES: 1. Home health care registered nurses attempt to contact every client within 48 hours of the client's admission to the home health care agency in order to arrange an appointment for the client's initial nursing assessment (including all discipline ordered). 2. The home health care registered nurse: a. Documents the initial client nursing assessment on a Home Health Care client Nursing Assessment form. b. Begins the client plan of care based on the initial client nursing assessment, following Policy and Client Plan of Care. c. Provides information regarding the initial client nursing assessment and care plan at a client case/team conference. d. Consults with the client's attending physician, as appropriate. e. Does subsequent home health care client nursing assessments, as appropriate f. Consults with the Director of Nursing, Clinical Manager of Home Health Care, as appropriate. 3. Complete OASIS Assessment, if required (48 hrs) (for Medicare patients, adults Medicaid patients with skilled services) Also, the following information is collected in the patient’s assessment and reassessments: - Patient diagnoses - Pertinent physical findings - Pertinent medical history - Functional status, activities permitted - Psychosocial status - Cultural or religious practices that may affect care - Care the family or support system is capable of and willing to provide - Educational needs, including the abilities, motivation, and readiness to learn L-2 Home Health Agency Client Assessments