Home Health Agency ACCS Pre-Licensure Desk Review ...



DEPARTMENT OF HEALTH SERVICESDivision of Quality AssuranceF-62536 (11/2018)STATE OF WISCONSINWis. Admin. Code ch. DHS 133Page PAGE \* MERGEFORMAT 1 of NUMPAGES \* MERGEFORMAT 2HOME HEALTH AGENCY (HHA)ACCS INITIAL APPLICATION / PRE-LICENSURE DESK REVIEW CHECKLISTName – Agency FORMTEXT ?????Name – Agency Contact FORMTEXT ?????Email Address – Agency Contact FORMTEXT ?????Phone No. – Agency Contact FORMTEXT ?????Name – Nurse Surveyor FORMTEXT ?????Surveyor No. FORMTEXT ?????Date – Received (MM/dd/yyyy) FORMTEXT ?????Date – Completed / to ACCS Supv. FORMTEXT ?????All information received must be reviewed within 30 days of receipt by the Acute Care Compliance Section (ACCS) surveyor, unless otherwise directed by the ACCS supervisor.MeetsRegPolicy or Docu-mentationSurveyTagDHSAdmin. CodeRegulation SectionComments FORMCHECKBOX PT107133.05(1)(a)Governance FORMTEXT ????? FORMCHECKBOX DT108133.05(1)(b)Governance FORMTEXT ????? FORMCHECKBOX DT110133.05(1)(d)Governance FORMTEXT ????? FORMCHECKBOX DT111133.05(1)(e)Governance FORMTEXT ????? FORMCHECKBOX DT112133.05(2)(a)Professional Advisory Board FORMTEXT ????? FORMCHECKBOX PT120-21133.06(3)(a-b)Personnel plan FORMTEXT ????? FORMCHECKBOX PT122133.06(4)(a)Orientation FORMTEXT ????? FORMCHECKBOX PT123-27133.06(4)(a)(1-5)Orientation FORMTEXT ????? FORMCHECKBOX EitherT129133.06(4)(c)Evaluation FORMTEXT ????? FORMCHECKBOX PT132133.06(4)(d)3Surveillance FORMTEXT ????? FORMCHECKBOX EitherT133133.06(4)(e)Continuing training FORMTEXT ????? FORMCHECKBOX PT248133.06(4)(g)Background checks, misconduct reporting FORMTEXT ????? FORMCHECKBOX EitherT249-51133.06(5)(a-c)Infection control FORMTEXT ????? FORMCHECKBOX EitherT136133.07(2)HHA Program Evaluation FORMTEXT ????? FORMCHECKBOX EitherT139133.08(1)Patient Rights FORMTEXT ????? FORMCHECKBOX PT140133.08(2)Patient Rights FORMTEXT ????? FORMCHECKBOX PT141-48T252-53133.08(2)(a-j)Patient Rights (prototype required) FORMTEXT ????? FORMCHECKBOX PT149133.08(3)Complaints FORMTEXT ????? FORMCHECKBOX PT150133.09(1)Patient Acceptance FORMTEXT ????? FORMCHECKBOX DT152133.09(2)Service Agreement (prototype required) FORMTEXT ????? FORMCHECKBOX PT153-61133.09(3)(a)(1-5)Patient Discharge FORMTEXT ????? FORMCHECKBOX EitherT170133.13Emergency Notification FORMTEXT ????? FORMCHECKBOX DT202133.17(3)Aide Assignments (prototype required) FORMTEXT ????? FORMCHECKBOX EitherT214-15133.18(1-2)Supervisory Visits FORMTEXT ????? FORMCHECKBOX DT216-22133.19(1)(a-f)Contract Services (if applicable) FORMTEXT ????? FORMCHECKBOX DT223133.19(2)Contract Services (if applicable) FORMTEXT ????? FORMCHECKBOX EitherT224133.20(1)Plan of Care (prototype required) FORMTEXT ????? FORMCHECKBOX EitherT225-26133.20(2)(a-b)Plan of Treatment FORMTEXT ????? FORMCHECKBOX PT231-46133.21(1-6)Medical Records FORMTEXT ????? FORMCHECKBOX PT247133.21(7)Record Abbreviations FORMTEXT ????? FORMCHECKBOX PZ13.05(3)Policy on Misconduct Reporting, Investigation, and documentationSubmission and Review of Job DescriptionsDoneTitleComments FORMCHECKBOX Administrator [§ DHS 133.06(2)(a-c) – T117-19] FORMTEXT ????? FORMCHECKBOX Substitute Administrator [§ DHS 133.06(2) (a-c) – T117-19] FORMTEXT ????? FORMCHECKBOX Director of Nursing / Supervising Nurse (if applicable) FORMTEXT ????? FORMCHECKBOX Registered Nurse (RN) FORMTEXT ????? FORMCHECKBOX Licensed Practical Nurse (LPN), (if applicable) FORMTEXT ????? FORMCHECKBOX Therapists – PT, OT, ST, Other (if applicable) FORMTEXT ????? FORMCHECKBOX Medical Social Worker (if applicable) FORMTEXT ????? FORMCHECKBOX Home Health Aide FORMTEXT ????? FORMCHECKBOX Personal Care Worker (PCW) (if applicable) FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMTEXT ?????Telephone Contact(s) Made with AgencyDate (MM/dd/yyyy)Name of ContactTopic(s) Discussed FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Written CorrespondenceNurse surveyor should attach all written correspondence to and from applicant agency.Date(s) of Written Correspondence TO the Applicant FORMTEXT ?????Date(s) of Written Correspondence FROM the Applicant FORMTEXT ?????Nurse Surveyor Comments and RecommendationAdditional Comments FORMTEXT ?????Recommendation Regarding Provisional Licensure of Applicant FORMTEXT ?????SIGNATURE – Nurse SurveyorDate Signed (MM/dd/yyyy) FORMTEXT ?????ACCS Supervisor Recommendation to Licensing, Certification and CLIA Section (LCCS) FORMTEXT ?????SIGNATURE – ACCS SupervisorRecommended Effective Date FORMTEXT ?????Date Submitted to LCCS FORMTEXT ????? ................
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