ACHC and CHAP Certified Products and Services

1. SECTION I – ORGANIZATION AND ADMINISTRATION
   1. 1. POLICY
      2. LEGAL AND REGULATORY COMPLIANCE
      3. DISCLOSURE OF OWNERSHIP AND MANAGEMENT
      4. PROFESSIONAL STANDARDS AND PRINCIPLES
      5. GOVERNING BODY RESPONSIBILITIES AND REQUIREMENTS
      6. CONFLICT OF INTEREST
      7. ADMINISTRATOR
      8. LINES OF AUTHORITY
      9. SERVICES PROVIDED
      10. CLINICAL MANAGER
      11. COLLECTION AND TRANSMISSION OF OASIS DATA
      12. REPORTING NEGATIVE AGENCY OUTCOMES
      13. SERVICES FURNISHED UNDER WRITTEN AGREEMENT/CONTRACT
      14. WAIVED TESTS
   1. ATTACHMENT
   2. GOVERNING BODY MEMBERS ROSTER
   3. GOVERNING BODY ORIENTATION CHECKLIST
   4. CONFLICT OF INTEREST ATTESTATION STATEMENT
   5. DESIGNATION OF ALTERNATE ADMINISTRATOR
   6. ORGANIZATIONAL CHART
   7. DESIGNATION OF ALTERNATE CLINICAL MANAGER
   8. CONTRACTOR/PROVIDER AGREEMENT
   9. ANNUAL CONTRACTOR EVALUATION
2. SECTION II – PROGRAM AND SERVICE OPERATIONS
   1. POLICY
   2. DESCRIPTION OF CARE AND SERVICES
   3. PATIENT RIGHTS AND RESPONSIBILITIES
   4. REPORTING AND INVESTIGATING ABUSE AND NEGLECT
   5. REPORTING AND INVESTIGATING ABUSE AND NEGLECT
   6. PATIENT CONFIDENTIALITY AND PROTECTED HEALTH INFORMATION
   7. ADVANCE DIRECTIVES
   8. EMERGENCY CARE AND RESUSCITATION
   9. EMERGENCY CARE AND RESUSCITATION
   10. COMMUNICATION AND LANGUAGE BARRIERS
   11. CULTURAL AWARENESS AND RESPECT
   12. AGENCY COMPLIANCE PROGRAM
   13. SUPERVISOR AND NURSING AVAILABILITY
   14. APPROVED TREATMENTS AND PROCEDURES
   16. ATTACHMENT
   17. PATIENT RIGHTS AND RESPONSIBILITIES
   18. SAMPLE COMPLAINT LOG
   19. SAMPLE COMPLAINT REPORT
   20. NOTICE OF PRIVACY PRACTICES
   21. COMPLIANCE REPORTING POSTER
3. SECTION III – FISCAL MANAGEMENT
   1. POLICY
   2. AGENCY BUDGET PLAN
   3. CAPITAL EXPENDITURE PLAN
   4. FINANCIAL MANAGEMENT AND BUSINESS PRACTICES
   5. FINANCIAL RECORDS RETENTION AND REVIEW
   6. DISCLOSURE OF RATES FOR CARE AND SERVICES
   8. ATTACHMENT
   9. CARE AND SERVICE RATES
4. SECTION IV – HUMAN RESOURCE MANAGEMENT
   1. POLICY
   2. PERSONNEL FILE MANAGEMENT
   3. VERIFICATION OF CREDENTIALING
   4. TB SCREENING AND VACCINATION POLICIES
   5. JOB DESCRIPTION
   6. DRIVER’S LICENSE AND MVR CHECKS
   7. BACKGROUND CHECKS
   8. EMPLOYEE HANDBOOK AND PERSONNEL POLICIES
   9. EMPLOYEE HANDBOOK AND PERSONNEL POLICIES
   10. ORIENTATION
   11. COMPETENCY ASSESSMENT
   12. CONTINUING EDUCATION AND IN-SERVICE REQUIREMENTS
   13. HOME HEALTH AIDE TRAINING, COMPETENCY, AND SUPERVISION
       REQUIREMENTS
   14. PERSONAL CARE ATTENDANTS
   15. TRAINING FOR WAIVED TESTING
   16. SPECIALTY TRAINING AND CERTIFICATION FOR NURSES
   18. ATTACHMENT
   19. PERSONNEL FILE CHECKLIST
   21. SAMPLE JOB DESCRIPTIONS
   22. ADMINISTRATOR
   23. CLINICAL MANAGER
   24. REGISTERED NURSE
   25. LICENSED PRACTICAL/VOCATIONAL NURSE
   26. PHYSICAL THERAPIST
   27. PHYSICAL THERAPIST ASSISTANT
   28. OCCUPATIONAL THERAPIST
   29. OCCUPATIONAL THERAPIST ASSISTANT
   30. SPEECH-LANGUAGE PATHOLOGIST
   31. MEDICAL SOCIAL WORKER
   32. HOME HEALTH AIDE
   33. QUALITY ASSURANCE COORDINATOR/QAPI COORDINATOR
   34. ACKNOWLEDGEMENT OF RECEIPT OF EMPLOYEE HANDBOOK
   36. SAMPLE PERFORMANCE EVALUATIONS
   37. ADMINISTRATOR
   38. CLINICAL MANAGER
   39. REGISTERED NURSE
   40. LICENSED PRACTICAL/VOCATIONAL NURSE
   41. PHYSICAL THERAPIST
   42. PHYSICAL THERAPIST ASSISTANT
   43. OCCUPATIONAL THERAPIST
   44. OCCUPATIONAL THERAPIST ASSISTANT
   45. SPEECH-LANGUAGE PATHOLOGIST
   46. MEDICAL SOCIAL WORKER
   47. HOME HEALTH AIDE
   48. QUALITY ASSURANCE COORDINATOR/QAPI COORDINATOR
   49. SAMPLE COMPETENCY ASSESSMENTS
   50. REGISTERED NURSE
   51. LICENSED PRACTICAL/VOCATIONAL NURSE
   52. PHYSICAL THERAPIST
   53. PHYSICAL THERAPIST ASSISTANT
   54. OCCUPATIONAL THERAPIST
   55. OCCUPATIONAL THERAPIST ASSISTANT
   56. SPEECH-LANGUAGE PATHOLOGIST
   57. MEDICAL SOCIAL WORKER
   58. HOME HEALTH AIDE
   59. SAMPLE ANNUAL EDUCATION/INSERVICE AGENDA
5. SECTION V – PROVISION OF CARE AND RECORD MANAGEMENT
   1. POLICY
   2. PATIENT RECORD REQUIREMENTS
   3. STORAGE AND ACCESS OF PATIENT RECORDS
   4. INITIAL ASSESSMENT AND PLAN OF CARE DEVELOPMENT
   5. COMPREHENSIVE ASSESSMENTS
   6. THERAPY AND MEDICAL SOCIAL WORK SERVICES ASSESSMENTS
   7. THERAPY AND MEDICAL SOCIAL WORK SERVICES ASSESSMENTS
   8. FIRST DOSE IN THE HOME SETTING
   9. PLAN OF CARE REQUIREMENTS
   10. WRITTEN INSTRUCTIONS FOR PATIENTS AND CAREGIVERS
   11. CARE COORDINATION
   12. TRANSFER/DISCHARGE CRITERIA AND PROCESS
   13. VERBAL ORDERS
   14. CHANGES IN PATIENT CONDITION
   15. SKILLED PROFESSIONAL SERVICES
   16. HOME HEALTH AIDE SERVICES
   17. PATIENT AND CAREGIVER EDUCATION
   18. REFERRAL AND ACCEPTANCE PROCESS
   19. FACE-TO-FACE ENCOUNTER AND CERTIFICATION
   20. CREDENTIAL VERIFICATION FOR PHYSICIANS AND
       ALLOWED PRACTITIONERS
   21. OUTPATIENT SERVICES
   23. ATTACHMENT
   24. PHYSICIAN AND ALLOWED PRACTITIONER LICENSE VERIFICATION
6. SECTION VI – QUALITY OUTCOMES AND PERFORMANCE IMPROVEMENT
   1. POLICY
   2. QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT
      (QAPI) PLAN
   3. OVERSIGHT AND APPROVAL OF THE QAPI PROGRAM
   4. INCIDENTS AND OCCURRENCES REPORTING AND DOCUMENTATION
   5. SAFE MEDICAL DEVICE REPORTING
   6. OASIS DATA REPORTS
   8. ATTACHMENT
   9. AGENCY QAPI PLAN
   10. ANNUAL QAPI REPORT
   11. SAMPLE INCIDENT/OCCURRENCE REPORT
   12. SAMPLE INCIDENT LOG
7. SECTION VII – RISK MANAGEMENT: INFECTION CONTROL, SAFETY AND EMERGENCY PREPAREDNESS
   1. POLICY
   2. INFECTION CONTROL PROGRAM
   3. EXPOSURE CONTROL AND STANDARD PRECAUTIONS
   4. TUBERCULOSIS SCREENING AND PREVENTION PLAN
   5. COVID-19 STANDARD
   6. EMPLOYEE AND PATIENT INFECTION CONTROL TRAINING
   7. EMPLOYEE AND PATIENT INFECTION CONTROL TRACKING
   8. BLOODBORNE PATHOGENS STANDARD
   9. EMPLOYEE PERSONAL SAFETY EDUCATION
   10. BASIC HOME SAFETY
   11. OFFICE AND WORKPLACE SAFETY PLAN
   12. HAZARDOUS WASTE AND MATERIALS USE, STORAGE, AND DISPOSAL
   13. HAZARD COMMUNICATION STANDARD
   14. INCIDENT AND OCCURRENCE REPORTING FOR PERSONNEL
   15. POINT-OF-CARE LABORATORY TESTING: PT/INR
   16. POINT-OF-CARE LABORATORY TESTING: BLOOD GLUCOSE MONITORS
   17. EMERGENCY PREPAREDNESS
   18. SAFE USE OF EQUIPMENT AND SUPPLIES
   19. EXPERIMENTAL THERAPIES AND CLINICAL RESEARCH
   21. ATTACHMENT
   22. AGENCY TB SCREENING ASSESSMENT
   23. EMPLOYEE TB SCREENING ASSESSMENT
   24. PATIENT INFECTION LOG
   25. EMPLOYEE INFECTION LOG
   26. FIRE DRILL LOG
   27. ANNUAL OFFICE ENVIRONMENT ASSESSMENT
   28. INCIDENT/OCCURRENCE LOG
   29. INCIDENT/OCCURRENCE REPORT
   30. EMERGENCY PREPAREDNESS PLAN

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1. PRODUCT DISCLOSURE STATEMENT
2. PLACE HOLDER [INSERT AGENCY’S QAPI POLICY AND PROCEDURE]
3. QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM
4. QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT AND HOME HEALTH VALUE-BASED PURCHASING
5. GUIDE TO PERFORMANCE IMPROVEMENT PROJECTS (PIPS) FOR THE QAPI PROGRAM
6. SAMPLES
   1. ONGOING MONITORING INDICATORS AND THRESHOLDS (SAMPLE)
   2. PIP – WOUND ASSOCIATED INFECTIONS (SAMPLE#1)
   3. PIP – WOUND ASSOCIATED INFECTIONS AUDIT TOOL (SAMPLE#1)
   4. PIP – ADHERENCE TO POC (SAMPLE #2)
   5. PIP – ADHERENCE TO POC AUDIT TOOL (SAMPLE #2)
   6. PIP- KEY ASPECT OF ADMINISTRATIVE FUNCTION (SAMPLE #3)
   7. PIP- KEY ASPECT OF ADMINISTRATIVE FUNCTION AUDIT TOOL (SAMPLE #3)
7. TEMPLATES
   1. PERFORMANCE IMPROVEMENT PROJECT (TEMPLATE)
   2. QAPI COMMITTEE MEETING MINUTES (TEMPLATE)
   3. ANNUAL PERFORMANCE IMPROVEMENT (PI) REPORT (TEMPLATE)
   4. GOVERNING BODY QAPI REVIEW (TEMPLATE)
   5. GOVERNING BODY ORIENTATION CHECKLIST
   6. QAPI SELF-ASSESSMENT TOOL (TEMPLATE)
   7. PATIENT RECORD AUDIT TOOL (TEMPLATE)
   8. PERSONNEL FILE AUDIT FORM (TEMPLATE)
   9. PATIENT SATISFACTION SURVEYS (TEMPLATE)
   10. EMPLOYEE SATISFACTION SURVEY (TEMPLATE)
   11. PHYSICIAN/REFERRAL SOURCE/COMMUNITY PARTNER SATISFACTION SURVEY (TEMPLATE)
   12. ETHICS REPORTS LOG (TEMPLATE)
   13. ETHICS REPORT FORM (TEMPLATE)

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1. PRODUCT DISCLOSURE STATEMENT
2. PLACE HOLDER [INSERT AGENCY’S QAPI POLICY AND PROCEDURE]
3. PERFORMANCE IMPROVEMENT PROGRAM
4. GUIDE TO PERFORMANCE IMPROVEMENT PROJECTS (PIPS) FOR THE PI PROGRAM
5. SAMPLES
   1. ONGOING MONITORING INDICATORS AND THRESHOLDS
   2. PIP – ADHERENCE TO THE PLAN OF CARE
   3. PIP FOCUS AUDIT- ADHERENCE TO POC/PROVIDER ORDERS
   4. PERFORMANCE IMPROVEMENT ACTIVITY TRACKING SHEET
6. TEMPLATES
   1. PERFORMANCE IMPROVEMENT PROJECT
   2. PERFORMANCE IMPROVEMENT COMMITTEE MEETING MINUTES
   3. ANNUAL PERFORMANCE IMPROVEMENT (PI) REPORT
   4. GOVERNING BODY PI REVIEW
   5. GOVERNING BODY ORIENTATION CHECKLIST
   6. PI SELF-ASSESSMENT TOOL
   7. CLIENT/PATIENT RECORD AUDIT TOOL
   8. CLIENT/PATIENT SATISFACTION SURVEY
   9. EMPLOYEE SATISFACTION SURVEY
   10. PHYSICIAN/REFERRAL SOURCE/COMMUNITY PARTNER SATISFACTION SURVEY

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1. PRODUCT DISCLOSURE STATEMENT
2. PLACE HOLDER [INSERT AGENCY’S PI POLICY AND PROCEDURE]
3. HOME HEALTH AGENCY EMERGENCY PREPAREDNESS PLAN
4. SAMPLES
   1. ABBREVIATED ASSESSMENT
   2. ALL HAZARD VULNERABILITY ASSESSMENT
   3. BUSINESS CONTINUITY PLAN
   4. DISASTER PHONE TREE
   5. EMERGENCY CONTACTS
   6. EMERGENCY PREPAREDNESS RESOURCES FOR PATIENTS AND FAMILIES
   7. EXERCISE PLANNING WORKSHEET
   8. EXERCISE AFTER ACTION REPORT
   9. EXERCISE EVALUATION GUIDE
   10. HOME ENVIRONMENT AND EMERGENCY PREPAREDNESS ASSESSMENT
   11. HOME HEALTH AGENCY EMERGENCY PREPAREDNESS PLAN ASSESSMENT
   12. MEMORANDUM OF UNDERSTANDING
   13. PATIENT EVACUATION TRACKING FORM
   14. PATIENT EVACUATION TRACKING LOG
   15. PATIENT ROSTER
   16. PHYSICIANS/ALLOWABLE PRACTITIONERS ROSTER
   17. READY.GOV FACT SHEETS
   18. STAFF ROSTER
   19. STRATEGIES TO ADDRESS EMERGENCY EVENTS
   20. SUPPLIER ROSTER
   21. VOLUNTEER ROSTER

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1. PRODUCT DISCLOSURE STATEMENT
2. PLACE HOLDER [INSERT AGENCY’S EMERGENCY PREPAREDNESS PROGRAM POLICY AND PROCEDURE]
3. HOME CARE AGENCY EMERGENCY PREPAREDNESS PLAN
4. SAMPLES
   1. ALL HAZARD VULNERABILITY ASSESSMENT
   2. BUSINESS CONTINUITY PLAN
   3. EMERGENCY PHONE COMMUNICATION TREE
   4. EMERGENCY CONTACTS
   5. EMERGENCY PREPAREDNESS RESOURCES FOR PATIENTS AND FAMILIES
   6. EXERCISE PLANNING WORKSHEET
   7. EXERCISE AFTER ACTION REPORT
   8. EXERCISE EVALUATION GUIDE
   9. HOME ENVIRONMENT AND EMERGENCY PREPAREDNESS ASSESSMENT
   10. HOME CARE AGENCY EMERGENCY PREPAREDNESS PLAN ASSESSMENT
   11. MEMORANDUM OF UNDERSTANDING
   12. PATIENT EVACUATION TRACKING FORM
   13. PATIENT EVACUATION TRACKING LOG
   14. PATIENT ROSTER
   15. PHYSICIANS/ALLOWABLE PRACTITIONERS ROSTER
   16. READY.GOV FACT SHEETS
   17. STAFF ROSTER
   18. SUPPLIER ROSTER
   19. VOLUNTEER ROSTER
5. TEMPLATES
   1. PERFORMANCE IMPROVEMENT PROJECT (TEMPLATE)
   2. QAPI COMMITTEE MEETING MINUTES (TEMPLATE)
   3. ANNUAL PERFORMANCE IMPROVEMENT (PI) REPORT (TEMPLATE)
   4. GOVERNING BODY QAPI REVIEW (TEMPLATE)
   5. GOVERNING BODY ORIENTATION CHECKLIST
   6. QAPI SELF-ASSESSMENT TOOL (TEMPLATE)
   7. PATIENT RECORD AUDIT TOOL (TEMPLATE)
   8. PERSONNEL FILE AUDIT FORM (TEMPLATE)
   9. PATIENT SATISFACTION SURVEYS (TEMPLATE)
   10. EMPLOYEE SATISFACTION SURVEY (TEMPLATE)
   11. PHYSICIAN/REFERRAL SOURCE/COMMUNITY PARTNER SATISFACTION SURVEY (TEMPLATE)
   12. ETHICS REPORTS LOG (TEMPLATE)
   13. ETHICS REPORT FORM (TEMPLATE)

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1. PRODUCT DISCLOSURE STATEMENT
2. CONSENT FOR TREATMENT
3. EMERGENCY PREPAREDNESS RISK ASSESSMENT
4. HOME ENVIRONMENT AND EMERGENCY PREPAREDNESS ASSESSMENT
5. PATIENT AUTHORIZATION FOR DISCLOSURE OF PHI
6. CARE COORDINATION WITH EXTERNAL AGENCIES
7. PATIENT PLAN OF CARE SUMMARY AND CARE INSTRUCTIONS
8. STATE SPECIFIC FORMS
9. ADVANCE BENEFICIARY NOTICE OF NON-COVERAGE (ABN_EXP. 06. 30.23)
10. HOME HEALTH CHANGE OF CARE NOTICE (HHCCN EXP. 12.31.24)
11. NOTICE OF MEDICARE NON-COVERAGE (NOMNC)
12. PATIENT HANDBOOK

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1. PRODUCT DISCLOSURE STATEMENT
2. ADMISSION AGREEMENT
3. EMERGENCY PREPAREDNESS RISK LEVEL
4. HOME ENVIRONMENT AND EMERGENCY PREPAREDNESS ASSESSMENT
5. AUTHORIZATION FOR DISCLOSURE OF PHI
6. CARE COORDINATION WITH EXTERNAL AGENCIES
7. PLAN OF CARE SUMMARY AND CARE INSTRUCTIONS
8. STATE SPECIFIC FORMS
9. CLIENT/PATIENT HANDBOOK

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1. HOME HEALTH SKILLED NURSING COMPETENCY PROGRAM DESCRIPTION
2. EXHIBITS
   1. EXHIBIT I: SKILLED NURSING COMPETENCY ASSESSMENT CHECKLIST
   2. EXHIBIT II: SKILLED NURSING COMPETENCY WRITTEN ASSESSMENT
   3. EXHIBIT III: CEU CERTIFICATE/CERTIFICATE OF COMPLETION
   4. EXHIBIT IV: COURSE EVALUATION-FEEDBACK SURVEY
   5. EXHIBIT V: HANDOUTS
3. SAMPLES
   1. HOME HEALTH SKILLED NURSING COMPETENCY DOCUMENTATION SAMPLE – 2022

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