Accreditation CHECK LIST ADMINISTRATIVE …

1 : 2950 W 84 St. Bay Fl 33018 Accreditation CHECK LISTADMINISTRATIVE:9 Liability/Professional Insurance9 laboratory /CLIA, AHCA,9 Business Licenses9 Waste License Lease9 Regulations/Laws9 Communication/Letters from-to AHCA Minimum Standards, Chapter 400, Surveyors Guide (H-Tag) CMS, Palmetto, Medicaid, DOH, etc9 Contracts (Therapy-ALF)9 Contracts Evaluations9 Workers Compensation 9 Accounting: Budget (3 years), Cash flow, OASIS transmission report, OBQI reports Payroll, W2, taxes9 Quarterly Reports 9 Annual Agency eval/Appraisal9 Board List, PAC, Ethic Cte, Compliance Cte-Fraud, HIPAA-PrivacyCte, Infection Control Cte9 Medicare Conditions of Participation #TopOfPage9 Services to Provide (letter to AHCA if needed, fax: 850-922-5374)Posters.

2 9 Regulation current Year9 Speak Up9 Hand washing9 HIPAA9 Safety Goals9 Emergency ControlJCHO9 Mission and Non-Discrimination9 City/County Licenses9 Organizational Chart9 Exit Route9 Door Sign (Agency Name)9 Fire Safety/Extinguisher9 Abbreviations (Hours, Emergency)9 Agency Board Material (Do not use Abbreviation, Hand washing, PI, Accepted Abbreviations)LOGS: (Surveys Log: Patient-Employee-Physicians) (Incident: all together separates)9 Emergency Log: Including Emergency Plan, Medication, POC, Evacuation Form (if applicable), by Proof of Plan Updates and submissions * ARRAIGNMENT OUTSIDE STATE SUPPLIER (annual)9 Hospitalization Log9 File Movement 9 Visitor Log (HIPAA)9 Minutes Logs (Book)9QA review Log9 Grievance/Complaints/Grievance Form9 Referral Log9On-Call Log (Posted Person On-Call Daily) 9 In-Services(posted Calendar)9 Glucometer Area Cleaning9 Bio-Waste9 Transfer Log9 Infection9 License Verification (Employees, MDs) 9 Inventory Log9 Medical Supplies Log9 Surveys, separated by DIVIDERS.

3 Patients, (Quarterly review, using scale 1-5), Employees, Physicians9 Copy of all Contracts, Eval9 Physician Orders9 Employee Concern (front)9 Utilities Backup 9 Discharge Planning/Forms9 BP Gauge check9 Incident Reports: (Separate by dividers:) Falls, Employee Incident Exposure, Risk Mg, Ethic,9 List of more common infections/disease Accident, Infection, Behaviors, Med. (Board Minute: Minutes are retained for a minimum of 5 years)9 Safety. Fire Drill9 Board of Directors (INITIAL)9 Advisory Committee (Medical Director, Name) (Approval: Mission, Adm., AADM, DON, ADON, PAC members, CFO) 9QA/QI/PI minutes9 Utilization review9 Ethic (Clinical Record Review cte q/3months, must participate each disciple with services)9 Infection Control9 Board (Discussion of Conflict Interest-annual, Non-Discrimination)9 Civil Rights (Non-Discrimination) (Board: Minutes End of Year, Budget, Agency Eval) : 2950 W 84 St.

4 Bay Fl 33018 FORMS*:(must be in Office)9 Agency Forms Book (Nurses Assessment-OASIS)9 DNR order 9 Emergency Evacuation release9 BROCHURE9BS Log with Glucometer Calibration. 9 BP/VS Log9 Staff Change Form9 Referral Form9 DC Instructions, Summary, Letters-DC Packages9 Wound Record, Wound Body chart, Wound photo9 Admission Order, Recert Order, Reinstatement Order, DC Order9 Missed Caregiver Affidavit9 Advance Beneficiary Notices9 Recert Packages9 Medicare Provider Non Coverage9 Case Conference9 Patient Transfer9 Verbal/Modify Orders9 60 Days Summary9 Team Communication9 Medication Form9 Admission Packages (No labels)9 Progress Notes (Nurse, HHA must match HHA Plan)9 Supervision Forms9 Therapy Forms (Including Plan, Eval, SV, Notes, DC)9 Weekly, Itinerary9In-Home Calendar9 MSW forms9 Case manager Report9 OASIS.

5 SOC, Recert (Follow Up), DC, Transfer9 Emergency Evacuation (En-Sp)9 Hurricane Guide (En-Sp)9 Personal Health Records* in Green for the 1st Survey (AHCA License ) POC signed within 30 *, including all necessary Manuals: 9 Psychiatric manual 9 Compliance Fraud manual (including S/U-Notes-Service-Chart review, Utilization review, DC planning-Performance Imp.)9 Patient Safety Goals(JCHO)9 Face to Face9 HIPAA Manual9 Wound Protocol9 laboratory Manual9 Infection Control/OSHA9 Biomedical waste9 Bloodborne Manual9 Civil Rights (advertising Brochure)9 Emergency Plan current9 Pandemic Manual9 Fall Safety Manual9 Alzheimer s Training Curriculum (2 hrs training for all Employees, with Approved Material)9 Pain Management Manual9 Orientation In-Service manual & Calendar9 Clinical Procedures9 OASIS test9 Employee Safety Manual9 Ethic Manual9 Medical Device 9 Medication Management (JCHO)9 Policy Manual9 Nursing Manual9 IV Manual9 Respiratory Manual9 Agency Forms9 Employee manual (Forms)

6 9 Execute Strategic Plan9 Business Plan9 Risk Management Plan 9 Execute Accreditation Guide/Training(Agency)9 Execute Surveyors Guide (Agency)9 Educational Materials: - Advance Directives, Alzheimer s, Fall prev., Emergencies(Patient-Family Book)- HIPAA Privacy, Diabetes, Pain, Medications, Infection* in Green for the 1st Survey (AHCA License ) : 2950 W 84 St. Bay Fl 330189 Labels: - Biomedical waste9 TB Mask- Confidential (Emp. and Patients)TB_FLU ARMOUR - PANDEMIC - Resources Guide, Fall PreventionINFLUENZA INFECTION CONTROL - QA review, DM, WoundSUPPLIES INCLUDING N95 - Allergies, Anticoagulant therapyRESPIRATORS System: 9 Manila Folders & Dividers 9 Numerical labels9 Year label9 Self Study done: Home Care & Core (CHAP)9 Biohazard Contract/License 9 Regulations Folder, H-Tag, Minimum Standards9 Florida Nursing Board (NursingChapter 400, Civil Rights Practice Act).

7 9 Conflict Interest (Minute, Board, Employee)9 Initial/Exit Interview9 Handbooks9 Ids (Visitors, Temporary)9 Job Descriptions each position9 Surveys, Concerns (reception area)9 Probation - Annual Evaluation - Leader Eval (GOALS-Self Eval) GOALS setting, Self Eval, Joint visit, competency9 In-Services: 9 HIPAA9 HIV, OSHA, Dom. Violence9 Alzheimer s (8 months)9 Patients Rights9 Fraud & Abuse9 Emergency(annual) 9 TB Training-Mask9 Fall Prevention9 Safety9 Pain Management9 Bloodborne9 Infection (Hand washing, Bag)(annual)9 Biomedical waste 9 Medical Device (annual)9 Verification license (Professional staff Copy of Title)9 Calendar of Inservices9 Up to date documents/chart9 Initial Orientation (Employees, Board, Advisory)9 Key Employees: Resume9 Agreement/Contract 9 Liability InsuranceAny Employee POSITION CHANGE, must has new ORIENTATION.

8 If using a Therapy company,each therapist MUST have a full Personnel chart with the Agency forms. Member of PAC must Services include:9 AGENCY visit for checkup (as needed) (outside Miami-Broward area the visit expense is responsibilities of the Agency)9 Unlimited phone calls 9 Accreditation training classes 9 9 9 9 (3 minimum)9 Full Medical Record review (QA training), including OASIS, S/U, D/C, Recert procedures (DON) (is requestedby clinical personnel at extra cost)FIELD SERVICES: Handwashing using employee soap (before/after procedure, before to use the NursingBag), no bag in floor, gloves before/after procedures. HHA Plan > note exact.

9 Medication Updates (Rx andOTC). Schedulle/Calendar compliance (PRN if needed, ). POT Signed within 30 days (LOG).