Policy Manual sample

MDT Home Health Care Agency, Inc. All appropriate documentation must be completed in the specific incident report form, and delivery to the office within established time frame (6 hours) The guidelines for notifying the physician must be followed by all of our staff, copy of the incident must be faxed to the patient’s physician, immediately after the Incident Report is received by the Agency. Follow-up reporting to the administration/board/owner will be completed by the official receiving the staff report. Our Agency investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develop a plan of correction to prevent the same or similar event from occurring again. Events include, but are not limited to: • Unexpected death, including suicide of patient • Any act of violence • A serious injury • Psychological injury • Significant adverse drug reaction • Significant medication error • Other undesirable outcomes as defined by the HHA • Adverse patient care outcomes • Patient injury, (witnessed and un-witnessed) including falls Upon notification of a potential or actual sentinel event occurrence, MDT Home Health Care Agency, Inc. will conduct a “Root Cause Analysis” in an effort to determine the basic, causative factor(s) that led to the event. Sentinel event reports will be reviewed by Administration and the Director of Performance Improvement within 24 hours of incident identification to determine whether a sentinel event has occurred, pursuant to preestablished criteria (indicators) which define actual or near occurrence of sentinel events. When it is determined that a sentinel event has occurred, this information will be reported to the Accreditation Company/State Regulatory Agency within 45 days of occurrence or event. A root cause analysis is initiated as per Agency policy and procedure. The root cause analysis, conclusions and corrective action plan process is completed within five (5) business days of the initial report. The effectiveness of the corrective action plan is monitored and evaluated in accordance with Agency policy and procedure, and a report is submitted to the Performance Improvement Committee, Administration and the Board of Directors within 30 days of plan implementation. The following is an established list of sentinel events criteria. It is understood that all high-risk events are reviewed by Administration and Director of Performance Improvement, and at the direction of Administration a root cause analysis may be requested for events that do not fall under the sentinel event criteria. Home Health Agency Nursing Manual J-67