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Contact Us
  • About Us
  • Services
    • Home Health Clinical Manager Foundations Certification Program
    • ICD-10 Coding and Clinical Documentation Review
    • Home Health/Home Care Consulting
    • Mock Survey
    • Competency
      • CNA / HHA Competency
      • Nursing Competency
    • Home Health Quality Assessment Performance Improvement (QAPI) Services
    • Home Health Medicare Certification
    • Emergency Preparedness Consulting
    • Startup and Licensure Consulting for Texas and Colorado
  • Manuals/Products
    • ACHC and CHAP Certified Products
    • Colorado
    • Texas
  • Education
    • Colorado
      • Administrators/Managers Training (Home Health/Home Care)
      • Dementia Training (Adult Day Care)
      • Dementia Training (Nursing Home)
      • Dementia Training (Assisted Living)
    • Texas
      • HCSSA Administrator Training
    • Home Health Clinical Manager Foundations Certification Program
    • User Login
  • Events
  • Resources
  • Contact Us
  • About Us
  • Services
    • Home Health Clinical Manager Foundations Certification Program
    • ICD-10 Coding and Clinical Documentation Review
    • Home Health/Home Care Consulting
    • Mock Survey
    • Competency
      • CNA / HHA Competency
      • Nursing Competency
    • Home Health Quality Assessment Performance Improvement (QAPI) Services
    • Home Health Medicare Certification
    • Emergency Preparedness Consulting
    • Startup and Licensure Consulting for Texas and Colorado
  • Manuals/Products
    • ACHC and CHAP Certified Products
    • Colorado
    • Texas
  • Education
    • Colorado
      • Administrators/Managers Training (Home Health/Home Care)
      • Dementia Training (Adult Day Care)
      • Dementia Training (Nursing Home)
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    • Texas
      • HCSSA Administrator Training
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About Us
  • 713-564-5011 (Houston Office)
  • 303-690-2749 (Denver Office)
  • 720-398-6200
  • ig@amityhealthcaregroup.com
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  • Friday
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Copyright © 2025 Amity Healthcare Group. All rights reserved.
Home Health Annual Compliance Check List

    WOUND MANAGEMENT PROGRAM POLICY & PROCEDURE MANUAL

    Product Disclosure Statement

    Wound Management Program Policy Crosswalk

    P&P Adoption

    • Wound Management Program Adoption and Approval
    • Governing Body Review Wound Management Program

    01. SECTION I

    • Program Plan and Description
    • Attachment 1.A – Wound Management Program Coordinator Job Description
    • Attachment 1.B – Wound Management Program Interdisciplinary Team
    • Attachment 1.C – Wound Management Committee Monthly Meeting Minutes
    • Attachment 1.D – Monthly Wound Assessment and Care Summary
    • Attachment 1.E – Wound Management Program Log
    • Attachment 1.F – Monthly Wound Audit Tool

    02. SECTION II

    • Clinical Guidelines
    • Selection and Approval of Clinical Practice Guidelines
    • Attachment 2.A – Clinical Guidelines Review and Approval
    • Attachment 2.B – Wound Management Program Educational Modules and Competency Quizzes

      • Module 1: Wound Care Basics (Common Terms and Concepts in Wound Assessment, Wound Healing Basics, NPIAP Pressure Injury Stages, Module 1 Quiz)
      • Module 2: Wound Assessment (Wound Assessment Guidelines, The Wound Bed Preparation Paradigm, Pressure Injury Assessment and Management, Wound Assessment Procedure, Bates-Jensen Wound Assessment Tool, Module 2 Quiz)
      • Module 3: Wound Cleansing, Irrigation, and Product Selection (Wound Products Overview and Selection, Wound Dressing Application Procedure, Wound Irrigation Procedure, Module 3 Quiz)
      • Module 4: Negative Pressure Wound Therapy (NPWT Overview, Module 4 Quiz)
      • Module 5: Nutritional Strategies for Wound Healing (Mini Nutritional Assessment, Module 5 Quiz, Patient Education Handouts and Teaching Tools)
      • Module 6: Comprehensive Assessment (RN’s only) (Comprehensive Assessment Policy Wound Management Program Addendum, Comprehensive Assessment Checklist, Patient Education and Health Literacy Assessment, Policy, Module 6 Quiz, OASIS References for Agencies Completing OASIS Assessment, OASIS E Section M: Skin Conditions Guidelines)
      • Module 7: Infection Control (Infection Control Policy Wound Management Program Addendum, Bag Technique Policy and Procedure, Module 7 Quiz)
      • Module 8: Patient Education (Patient Education and Health Literacy Assessment Policy, Patient Education and Self-Management Plan, Disease Management Policy, Patient Lifestyle Education Handouts, Module 8 Quiz)
      • Module 9: Additional Wound Management Program Policies (Wound Management Program Reassessment Policy & Checklist, Plan of Care Policy Addendum, Coordination of Care Policy Addendum, Discharge and Transfer Policy Addendum, Module 9 Quiz)
    • Attachment 2.C – Wound Management Program Nursing Competency Evaluation
    • Attachment 2.D – Wound Management Competency Evaluation Form
    • Attachment 2.E – Wound Management Program In-Service Agenda
    • Attachment 2.F – Policy W2.10 Infection Control Policy Wound Management Program Addendum
    • Attachment 2.G – Bag Technique Policy and Procedure
    • Attachment 2.H – Clinical Practice Guidelines and References
    • Attachment 2.I – Wound Management Program

    03. SECTION III

    • Assessment of Patients and Risk Factors
    • Initial Comprehensive Assessment
    • Reassessments of Patients and Wounds
    • Attachment 3.A – Policy W3.01 Comprehensive Assessment Policy
    • Attachment 3.B – Wound Management Program Comprehensive Assessment Checklist
    • Attachment 3.C – Policy W3.02 Wound Management Program Reassessment Policy
    • Attachment 3.D – Wound Management Program Reassessment Checklist & Bates-Jensen Wound Assessment Tool

    04. SECTION IV

    • Provision and Coordination of Care
    • Attachment 4.A – Policy W4.01 Plan of Care Policy
    • Attachment 4.B – Policy W4.02 Coordination of Care Policy
    • Attachment 4.C – Discharge and Transfer Policy

    05. SECTION V

    • Patient and Family Education Regarding Disease Management
    • Attachment 5.A – Policy W5.01 Patient Education and Health Literacy Assessment Policy
    • Attachment 5.B – Patient Education and Self-Management Plan

    06. SECTION VI

    • Disease Management
    • Attachment 6.A – Wound Management Program Disease Management Policy Patient Education Handouts and Teaching Tools

    07. SECTION VII

    • Performance Measurement and Improvement
    • Attachment 7.A – PI/QAPI Policy
    • Attachment 7.B – Wound Management Program Performance Improvement Project (Blank form)
    • Attachment 7.C – Wound Management Program Performance Improvement Project (Samples 1 and 2)

    08. SECTION VIII

    • Information Management

    09. SECTION IX

    • Safety and Emergency Planning
    HOME HEALTH ADMISSION PACKET

    01. Product Disclosure Statement

    02. Consent for treatment

    03. Emergency Preparedness Risk Assessment

    04. Home Environment And Emergency Preparedness Assessment

    05. Authorization for disclosure of PHI

    06. Care Coordination with External Agencies

    07. Patient Plan of Care Summary and Care Instructions

    08. State Specific Forms

    09. Advance Beneficiary Notice of Non-coverage (ABN exp. 01.31.26)

    10. Home Health Change of Care Notice (HHCCexp. 11.30.27)

    11. Notice of Medicare Non-coverage (NOMNC exp. 11/30/2027)

    12. Patient Handbook

    HOME CARE ADMISSION PACKET

    01. Product Disclosure Statement

    02. Admission Agreement

    03. Emergency Preparedness Risk Level

    04. Home Environment And Emergency Preparedness Assessment

    05. Authorization for disclosure of PHI

    06. Care Coordination with External Agencies

    07. Plan of Care Summary and Care Instructions

    08. State Specific Forms

    09. Client/Patient Handbook

    HOME HEALTH EMERGENCY PREPAREDNESS PLAN

    01. Product Disclosure Statement

    02. Place Holder [Insert Agency’s PI Policy and Procedure]

    03. Home Health Agency Emergency Preparedness Plan

    04. Samples

    • a. Abbreviated Assessment
    • b. All Hazard Vulnerability Assessment
    • c. Business Continuity Plan
    • d. Disaster Phone Tree
    • e. Emergency Contacts
    • f. Emergency Preparedness Resources for Patients and Families
    • g. Exercise Planning Worksheet
    • h. Exercise After Action Report
    • i. Exercise Evaluation Guide
    • j. Home Environment and Emergency Preparedness Assessment
    • k. Home Health Agency Emergency Preparedness Plan Assessment
    • l. Memorandum of Understanding
    • m. Patient Evacuation Tracking Form
    • n. Patient Evacuation Tracking Log
    • o. Patient Roster
    • p. Physicians/Allowable Practitioners Roster
    • q. Gov Fact Sheets
    • r. Staff Roster
    • s. Strategies to Address Emergency Events
    • t. Supplier Roster
    • u. Volunteer Roster
    HOME CARE EMERGENCY PREPAREDNESS PLAN

    01. Product Disclosure Statement

    02. Place Holder [Insert Agency’s Emergency Preparedness Program Policy and Procedure]

    03. Home Care Agency Emergency Preparedness Plan

    04. Samples

    • a. All Hazard Vulnerability Assessment
    • b. Business Continuity Plan
    • c. Emergency Phone Communication Tree
    • d. Emergency Contacts
    • e. Emergency Preparedness Resources for Patients and Families
    • f. Exercise Planning Worksheet
    • g. Exercise After Action Report
    • h. Exercise Evaluation Guide
    • i. Home Environment and Emergency Preparedness Assessment
    • j. Home Care Agency Emergency Preparedness Plan Assessment
    • k. Memorandum of Understanding
    • l. Patient Evacuation Tracking Form
    • m. Patient Evacuation Tracking Log
    • n. Patient Roster
    • o. Physicians/Allowable Practitioners Roster
    • p. Ready.gov Fact Sheets
    • q. Staff Roster
    • r. Supplier Roster
    • s. Volunteer Roster
    HOME CARE PERFORMANCE IMPROVEMENT PROGRAM

    01. Product Disclosure Statement

    02. PLACE HOLDER [INSERT AGENCY’S PI POLICY AND PROCEDURE]

    03. Performance Improvement Program

    04. Guide to Performance Improvement Projects (PIPs) for the PI Program

    05. Samples

    • a. Ongoing Monitoring Indicators and Thresholds
    • b. PIP – Adherence to the Plan of Care
    • c. PIP Focus Audit – Adherence to POC/Provider Orders
    • d. Performance Improvement Activity Tracking Sheet

    06. Templates

    • a. Performance Improvement Project
    • b. Performance Improvement Committee Meeting Minutes
    • c. Annual Performance Improvement (PI) Report
    • d. Governing Body PI Review
    • e. Governing Body Orientation Checklist
    • f. PI Self-Assessment Tool
    • g. Client/Patient Record Audit Tool
    • h. Client/Patient Satisfaction Survey
    • i. Employee Satisfaction Survey
    • j. Physician/Referral Source/Community Partner Satisfaction Survey
    HOME HEALTH QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT (QAPI)

    01. Product Disclosure Statement

    02. Place Holder [Insert Agency’s QAPI Policy and Procedure]

    03. Quality Assessment and Performance Improvement Program

    04. Quality Assessment and Performance Improvement and Home Health Value-Based Purchasing

    05. Guide to Performance Improvement Projects (PIPs) for the QAPI Program

    06. Samples

    • Ongoing Monitoring Indicators and Thresholds (sample)
    • PIP – Wound Associated Infections (sample #1)
    • PIP – Wound Associated Infections Audit Tool (sample #1)
    • PIP – Adherence to POC (sample #2)
    • PIP – Adherence to POC Audit Tool (sample #2)
    • PIP – Key Aspect of Administrative Function (sample #3)
    • PIP – Key Aspect of Administrative Function Audit Tool (sample #3)

    07. Templates

    • A. Performance Improvement Project (template)
    • B. QAPI Committee Meeting Minutes (template)
    • C. Annual Performance Improvement (PI) Report (template)
    • D. Governing Body QAPI Review (template)
    • E. Governing Body Orientation Checklist
    • F. QAPI Self-Assessment Tool (template)
    • G. Patient Record Audit Tool (template)
    • H. Personnel File Audit Form (template)
    • I. Patient Satisfaction Surveys (template)
    • J. Employee Satisfaction Survey (template)
    • K. Physician/Referral Source/Community Partner Satisfaction Survey (template)
    • L. Ethics Reports Log (template)
    • M. Ethics Report Form (template)
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