Howard County Home Health & Hospice



Home Health & Hospice

Annual Agency Review

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|Administration | | | |

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| |Yes |No |Comments |

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|Does the Agency have a current license? | | | |

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|Are the charter by-laws on file? (Administrative Book) | | | |

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|Is a doctor, registered nurse or appropriately credentialed individual designated as | | | |

|Agency advisor or supervisor? (Policies) | | | |

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|Are the responsibilities of the Agency supervisor clearly defined? (Administrator Job | | | |

|Description) | | | |

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|Responsibilities for staffing? | | | |

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|Assigning of personnel? | | | |

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|Evaluation of personnel? | | | |

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|Evaluation of care? | | | |

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|Current physicians orders? | | | |

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|Coverage of local physicians? | | | |

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|Discharge criterium? | | | |

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|Staff development? | | | |

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|Coordination of services? | | | |

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|Objectives | | | |

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|Does the Agency have program objectives? (Policy manual) | | | |

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|Do the objectives cover: | | | |

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|Who is to receive service? | | | |

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|Who is to give service? | | | |

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|Type of additive service available? | | | |

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|Defines skilled nursing? | | | |

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|Defines therapeutic services? | | | |

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|Defines intermittent basis? | | | |

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|Job Descriptions | | | |

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|Are there written job descriptions for each category of personnel? (Job Description Book) | | | |

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|Do the job descriptions define: | | | |

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|Qualifications (Education and experience)? | | | |

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|General functions? | | | |

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|Specific functions? | | | |

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|Do the job descriptions for RN’s and LPN’s concur with state law? (State Nurse Practice | | | |

|Act) | | | |

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|Are all RN’s and LPN’s currently licensed in the state of Missouri? (Personnel files) | | | |

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|Personnel File | | | |

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|Is there a personnel file for each employee? | | | |

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|Does a sampling of personnel files include: | | | |

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|Application for employment? | | | |

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|Evaluations? | | | |

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|Pre-Employment | | | |

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|Are background checks being performed as state requires? | | | |

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|Is there an adequate orientation program for all personnel? | | | |

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|Do all employees have pre-employment physicals? | | | |

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|Ongoing Employment | | | |

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|Is there an active inservice program being carried on for all categories of personnel? | | | |

|(Inservice manual) | | | |

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|Is a record of automobile insurance and current driver’s license kept on file? | | | |

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|Is there a current license for personnel for whom it is required? | | | |

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|Board of Directors | | | |

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|Are there by-laws for the Advisory Committee? (Administrative Manual) | | | |

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|Do these by-laws spell out: | | | |

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|Method of selection of members? | | | |

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|Composition of the committee? | | | |

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|Length of term of committee members? | | | |

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|Recording and filing of minutes? | | | |

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|Functions of the committee? | | | |

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|Do the functions of the Board of Directors include the regular review and approval of | | | |

|policies? | | | |

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|Do the functions of the Advisory Committee include: | | | |

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|Liaison between Agency and community? | | | |

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|Review of utilization of services? | | | |

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|Public relations? | | | |

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|Evaluation of programs? | | | |

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|Contracts | | | |

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|Does the Agency have contracts for additive services, if not provided within the Agency? | | | |

|(Contracts Folders) | | | |

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|With another agency or organization? | | | |

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|With an individual? | | | |

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|Is the contract(s) current? | | | |

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|Does the contract include: | | | |

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|Description of service to be provided? | | | |

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|Specific length of time contract is in effect? | | | |

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|Provision for periodic review of contract? | | | |

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|Defines the role of the Agency in relation to: | | | |

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|Supervision? | | | |

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|Reimbursement? | | | |

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|Billing? | | | |

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|Orientation? | | | |

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|Record keeping? | | | |

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|Defines the role of the agency (or individual) in relation to: | | | |

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|Qualifications? | | | |

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|Following Agency policies? | | | |

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|Maintaining the required records? | | | |

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|Participating in any educational programs? | | | |

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|Providing service(s) as necessary? | | | |

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|Patient Care | | | |

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|Do the admission policies of the Agency take into consideration: (Policy Manual) | | | |

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|Staff competency? | | | |

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|Patient’s ability to meet their responsibilities? | | | |

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|Agency’s ability to meet the patient’s needs? | | | |

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|Safety of the patient’s residence? | | | |

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|Availability of patient’s physician? | | | |

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|Geographical limitations? | | | |

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|Have the reasons for refusal of referrals been studied? | | | |

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|Were refusals justified by admission policies? | | | |

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|Are there established policies and procedures ensuring that service will be provided only | | | |

|under a physician’s plan of treatment? | | | |

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|Do the policies require: | | | |

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|An original plan of treatment signed by the patient’s physician? | | | |

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|Agency reporting the patient’s progress to the patient’s physician as necessary and/or | | | |

|at least every two months? | | | |

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|Orders are reviewed and recertified at least every two months? | | | |

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|All verbal orders are signed by a physician? | | | |

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|Is there a clinical record for each patient? | | | |

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|Are the clinical records regularly reviewed to check completeness, accuracy and quality? | | | |

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|Nursing Services | | | |

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|Is there a current written plan of care for each patient? | | | |

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|Is there a nursing procedure manual? | | | |

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|Date written | | | |

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|Date reviewed | | | |

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|Are patient progress notes and 60 day summary current and do they give an accurate picture| | | |

|of the patient’s condition and progress? | | | |

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|Does an RN make every 14 day supervisory visits with home health aides? | | | |

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|Is there a regular staff conference? | | | |

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|Home Health Aide | | | |

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|Does the job description and/or Agency policies for the selection of a home health aide | | | |

|require: | | | |

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|Help patient with bath? | | | |

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|Help patient to ambulate? | | | |

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|Help patient with prescribed exercises? | | | |

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|Record activities and observations in the patient’s clinical record? | | | |

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|Does the job description provide that the home health aide work under the direct | | | |

|supervision of a registered nurse or, where applicable, a qualified physical therapist? | | | |

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|Does the Agency provide formal training for the home health aide? | | | |

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|Is there a copy of the home health aide written test in each aide’s personnel file? | | | |

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|Is there a copy of the home health aide’s practice portion of certification in each | | | |

|aide’s personnel file? | | | |

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|Is there a home health aide specific planned orientation to the Agency? | | | |

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|Have the aides received the required twelve hours of inservices for the year? | | | |

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|Do the Agency policies call for regular supervision of the home health aides? | | | |

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|How often? | | | |

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|Is a supervised visit recorded? | | | |

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|Is the home health aide included in regular staff conferences? | | | |

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|Therapy Services | | | |

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|Are the physical therapy treatments incorporated into the plan of care? | | | |

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|Are therapy services provided under a physician’s plan of treatment? | | | |

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|Are the therapists qualified and currently licensed in the state of Missouri? | | | |

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|Does the physical therapist regularly supervise the home health aides who assist in | | | |

|physical therapy? | | | |

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|Do the therapists maintain current progress notes in the patient’s clinical record? | | | |

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|Does the job description or contract for service include the physical therapist | | | |

|instructing the patient on the use of braces, crutches, etc.? | | | |

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|Does the physical therapist regularly report to the Administrator or the Team Leader(s)? | | | |

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|Are the speech therapy plans incorporated in the Agency’s patient care plan? | | | |

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|Is the occupational therapist qualified and registered by the AOTA? | | | |

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|Does the job description or contract for service include the occupational therapist | | | |

|applying diagnostic and prognostic procedures? | | | |

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|Does the job description or contract for service include the occupational therapist | | | |

|guiding the use of therapeutic creative and self-care devices? | | | |

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|Does the job description or contract for service include the following functions of the | | | |

|medical social worker: | | | |

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|Assisting in understanding significant social and emotional factors. | | | |

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|Assessing social and emotional factors. | | | |

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|Helping patients and family follow medical recommendations. | | | |

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|Assisting patients and family with personal and environmental difficulties. | | | |

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|Utilizing community resources. | | | |

Summary of Evaluation

Strengths Found

Weaknesses Found

Signature of person completing report Date

Howard County Home Health & Hospice

Summary of Agency Evaluation

The following strengths were found during the Agency evaluation:

The following weaknesses were found during the Agency evaluation:

Immediate and Long-Range improvement plans:

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