- Amity Healthcare Group

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)

ACHC HOME HEALTH POLICY AND PROCEDURE MANUAL

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