Policy Manual sample

MDT Home Health Care Agency, Inc. (1) Assure communication with all physicians involved in the plan of care. (2) Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient. (3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. (4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. (5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. Written information to the patient. Our HHA will provide the patient and caregiver with a copy of written instructions outlining: (1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. (2) Patient medication schedule/ instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. (3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. (4) Any other pertinent instruction related to the patient’s care and treatments that the HHA will provide, specific to the patient’s care needs. (5) Name and contact information of the HHA clinical manager. PROCEDURE:  Each discipline, i.e., nursing (nursing Plan of Care included in 485 form, our Agency do not maintain a separated Nursing Care Plan), therapies, social work, including contracted services, contributes to the plan of care, based on the assessment of patient needs and clinical status at the time of the initial/admission visit.  The Case Manager/Clinical Supervisor receives a verbal summary of the plan of care the day of the initial/assessment visit.  The signed original plan of care is submitted to the Agency office within 72 hours of the initial visit. A copy of the plan of care remains in the patient’s home as patient’s request.  The Case Manager/Clinical Supervisor is responsible for overseeing the care planning process. The plan is appropriate and realistic based on the patient’s needs and clinical status, and promotes positive outcomes and avoids duplication of services. Any significant finding is reported to the Agency by the field staff immediately, and Team Communication report is recording in each record with more than one discipline involved in the patient care.  In the event of potential or actual duplication of services, the Case Manager/Clinical Supervisor contacts the disciplines involved and conducts a care conference to correct the situation. The care conference may be conducted via telephone. The results of the care conference are documented and become a permanent part of the patient’s medical record.  Each member of the healthcare team reviews the plan of care at least every two (2) weeks and Home Health Agency Nursing Manual J-55