Table of Contents - JC

1 Table of Contents Page ADMINISTRATIVE Federal Tag JOINT COMMISSION California Regs Definition of Organization 74600 74652 74677 74703 74705 Mission Statement, Goals, and Philosophy Services Offered 74652 74693 Service Area Payment for Services Fee Schedule Target Population Service Limitations Hours of Operation Administrative Control G123, G128 74703 74705 74717 74718 Ethics Committee Corporate Compliance Plan Branch Offices 74675 Professional Advisory Committee G152, G153 74721 74742 Page ADMINISTRATIVE Cont. Federal Tag JOINT COMMISSION California Regs Annual Evaluation G153 74719 74721 74742 Admission Criteria 74695 74707 74721 Face to Face Encounter Discharge/Transfer from Service G303 74721 Contingency Plan 74731 Agency Closure Procedures 74681 74731 Backup Coverage of Services 74693 Business Associate Contract Anti Fraud Program Professional Standards & Principles G117,118,121 74689 74693 74695 74707 Financial Records Financial Planning Capital Expenditures Services Provided under Contract 74719 Research Activities/Investigational Studies Page ADMINISTRATIVE Cont.

2 Federal Tag JOINT COMMISSION California Regs Public Disclosure 74675 74677 Disclosure to Licensing Authority 74665 74671 74729 Change of Ownership/Administrative Control 74667 74673 74731 Plan of Correction 74744 Information Management Page HUMAN RESOURCES Federal Tag JOINT COMMISSION California Regs Reasonable Accommodations Personnel Records Employment References Time Records OIG Excluded List Selection of Personnel 74721 Classification of Personnel 74721 Volunteers Ethics Employee Dress Code Employee Health Assessments 74723 Payday Benefits & Wages Page HUMAN RESOURCES Cont. Federal Tag JOINT COMMISSION California Regs Confidentiality Orientation & Staff Development Policy & Procedure Agreement Competency Evaluation Cell Phone and Texting Performance Evaluation Employee Discipline Termination/Separation of Employment Employee Grievances Smoking Professional Peer Review Professional Reporting Drug Testing Conflict of Interest Knowledge/Resource Center 74721 Page RIGHTS RESPONSIBILITIES ETHICS Federal Tag JOINT COMMISSION California Regs Client Conduct Responsibility & Rights 74743 Non Discrimination 74717 Program Accessibility Solicitation/Distribution for Referrals Ethical Complaints Patients Complaints & Grievances

3 G105,106,107,116 Reporting Abuse Neglect or Exploitation Criminal History Checks Nurse Aide Registry National Sex Offender Registry Out-of-Hospital Do Not Resuscitate Order Advanced Directives G110 Declaration for Mental Health Treatment Coordination of Client Care 74707 Advance Beneficiary Notice (ABN) Home Health Change of Care Notice (HHCCN) Patient Privacy Rights G102 Facilitating Communication sec. 504 Rehab Act After Hours Care 74693 74703 Generic & Expedited Review Process Page PATIENT INFORMATION Federal Tag JOINT COMMISSION California Regs Security of Clinical Information G111, 310 74731 Data Backups Retention of Clinical Records 74731 Timeliness of Entries in Clinical Record 74731 Client Records 74697 74731 74735 Patient Identification Physician Orders/Plan of Care 74697 74701 Physician Signatures Physician Delegation Physician Verification RN Delegation 74709 Clinical Record Review/Quarterly Review G250 74742 Abbreviations Prohibition on Transporting Patient Data Entry/Transmission OASIS Info Medication Profile Page PATIENT INFORMATION Cont.

4 Federal Tag JOINT COMMISSION California Regs Medication Administration Record Medication Storage Emergency Medication Medication/Prescriptions Orders 74701 Confused Medications Administration of Blood Adverse Drug Reactions Vaccine Storage and Transportation Medication Reminding Page NON-CLINICAL Federal Tag JOINT COMMISSION California Regs Billing Referrals Medical Supplies Verification of Primary Payer OASIS Corrections Staffing Issues 74707 Faxing Protected Health Information Password/Usernames Red Flag Rules Page CLINICAL Federal Tag JOINT COMMISSION California Regs In Service Education G208,209,215,117 Patient Education 74707 Wound Care Management Pain Management Page CLINICAL Cont.

5 Federal Tag JOINT COMMISSION California Regs Reporting Emergencies in the Home 74721 Cardiopulmonary Resuscitation (CPR) Sharp Debridement of non viable tissue Clinical Procedures 74721 Care Planning 74697 74701 74707 RN Pronouncement Assessment of Patients (OASIS) Nurse Supervision 74703 74709 Registered Nurse 74693 74707 Licensed Practical Nurse 74707 Certified Nursing Aide 74709 74710 74745 Therapy Services 74711 Therapy Evaluation Medical Social Worker 74713 Medical Social Worker Evaluation Dietician 74715 Page SAFETY/INFECTION CONTROL Federal Tag JOINT COMMISSION California Regs Infection/Exposure Control Plan 74721 CLIA Waiver , , , , Universal Body Substance Precautions Management of Infections/Exposures in Personnel Personal Protective Equipment Hand washing Aseptic Technique Sterile Technique Respiratory & Tuberculosis Precautions Tuberculosis Exposure Control Plan Contaminated Reusable Materials Disposition Contaminated Waste Disposal Therapy Bag Techniques Page SAFETY/INFECTION CONTROL Cont.

6 Federal Tag JOINT COMMISSION California Regs Multidrug-Resistant Organisms Communication of Hazards to Personnel Hepatitis B Vaccination Influenza Vaccination Influenza Vaccination Compliance Information & Training Evaluating & Maintaining Records of infections Reporting of Communicable Diseases 74725 74727 Record Keeping Medical Equipment Malfunction 74693 Hazardous Waste Handling & Labeling OSHA Bloodborne Pathogen Training Incident/Accident Reporting 74721 Sentinel Events Agency Personnel Safety Personal Safety Agency Personnel Safety/ Unsafe Home Visits Accidental Exposure Accidental Prevention Fall Prevention Page SAFETY/INFECTION CONTROL Cont. Federal Tag JOINT COMMISSION California Regs Car Accident Reporting Disaster/Emergency Preparedness 74721 Material Safety Data Sheet Fire Safety Utilities/Equipment Management Page QUALITY MANAGEMENT Federal Tag JOINT COMMISSION California Regs Quality Assessment/Performance Plan 74707 74721 74742 Patient Satisfaction Survey Non Patient Satisfaction Survey Data Quality Audits Page PROVISIONS OF INTRAVENOUS THERAPY Federal Tag JOINT COMMISSION California Regs Provisions of Intravenous Therapy Administration of IV Therapy Nurse Responsibility Patient Education Anaphylaxis Protocol Possession of Supplies Possession of Dangerous Drugs