This book is intended to aide home health owners, administrators and managers in practicing good, goal directed and efficient care of their patients. It is my intention that if this book is properly put to use, by all home health care professionals, the home health agencies and their patients will benefit immensely. Home Health Care has and will continue to undergo changes. The use of qualified staff and the effective management of the agencies by their owners and administrator through knowledge and understanding of home health rules and regulations is key to coping with the changes.
QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT FOR HOME HEALTH AGENCIES
A Guide for Home Health AgenciesBy Emmanuel C. AneneAuthorHouse
Copyright © 2012 Emmanuel Anene
All right reserved.ISBN: 978-1-4567-6846-1Contents
ABOUT THE AUTHOR.............................................................................13ACKNOWLEDGEMENT..............................................................................14Author's Insight.............................................................................15ADMINISTRATIVE...............................................................................18QUALITY ASSESSMENT & PERFORMANCE IMPROVEMENT (QAPI)..........................................20AGENCY PHILOSOPHY............................................................................25AGENCY GOALS.................................................................................25DAILY STAND UP CONFERENCE / QAPI DATA COLLECTION.............................................26CLINICAL RECORD REVIEW.......................................................................28ADMISSION POLICY.............................................................................32SERVICES PROVIDED............................................................................34CLIENT ASSESSMENT............................................................................36PROVISION OF 24-HOUR RN AVAILABILITY.........................................................38SUPERVISION OF SERVICES......................................................................40ABUSE PREVENTION PLAN........................................................................41SPECIAL CONSIDERATIONS.......................................................................44CLINICAL.....................................................................................48PHYSICIAN ORDERS.............................................................................54MEDICAL SUPERVISION..........................................................................57EMERGENT CARE................................................................................59CLINICAL DOCUMENTATION.......................................................................60DOCUMENTATION TURNAROUND POLICY FOR CLINICAL STAFF...........................................61MEDICARE DOCUMENTATION GUIDE AND CHEAT SHEET.................................................62MEDICATION PROFILE...........................................................................65TABLE 1:.....................................................................................68HOME HEALTH AIDE FLOW SHEET AND DOCUMENTATION................................................74HOME HEALTH AIDE CARE PLAN...................................................................76HOME HEALTH AIDE: ASSIGNMENT.................................................................78HOME HEALTH AIDE DOCUMENTATION POLICY........................................................80COMMUNICATION WITH LIMITED-ENGLISH-PROFICIENT PERSONS........................................81THE PROCESS OF COMMUNICATION IN BUSINESS.....................................................83TEACHING CLIENTS/CAREGIVERS..................................................................87SAFETY MANAGEMENT............................................................................90NEEDLE STICK SAFETY AND PREVENTION POLICY AND PROCEDURE......................................92MISTREATMENT / ABUSE / NEGLECT / MISAPPROPRIATION............................................95CLIENT INCIDENT REPORTING....................................................................98LABORATORY TESTING...........................................................................100CLIENT DISCHARGE PROCESS.....................................................................102DISCHARGE SUMMARY............................................................................105CLIENT TRANSFER..............................................................................107PERSONNEL RECRUITMENT PROCESS................................................................109LICENSE REGISTRATION OR CERTIFICATION REQUIREMENTS...........................................110HOME HEALTH AIDE COMPETENCY EVALUATION.......................................................111EMPLOYEE HEALTH SCREENING....................................................................115PERFORMANCE REVIEW...........................................................................119CARDIOPULMONARY RESUSCITATION (CPR) TRAINING.................................................121EMPLOYEE ORIENTATION.........................................................................122EMPLOYEE TRAINING............................................................................125LICENSE REGISTRATION OR CERTIFICATION REQUIREMENTS...........................................128HOME HEALTH AIDE COMPETENCY EVALUATION.......................................................129FORM 3.......................................................................................132FORM 4: CONFIDENTIAL REFERENCE...............................................................133FORM 5: CONFIDENTIAL REFERENCE...............................................................134FORM 6: APPLICANT PERFORMANCE EVALUATION.....................................................135SUPERIOR:....................................................................................136ABOVE AVERAGE:...............................................................................136FULLY COMPETENT:.............................................................................136DEVELOPMENTAL:...............................................................................136PROVISIONAL/UNSATISFACTORY:..................................................................136FORM 7: HEALTH STATEMENT.....................................................................137FORM 8: PERFORMANCE APPRAISAL REPORT.........................................................138FORM 9: EMPLOYEE EVALUATION (optional).......................................................140FORM 11: PEER REVIEW.........................................................................142NURSES ORIENTATION...........................................................................143FORM 12: PATIENT/FAMILY GRIEVANCE FORM.......................................................145FORM 13: GRIEVANCE/COMPLAINT INVESTIGATION REPORT............................................146COMPETENCY EVALUATION AND TEST FOR REGISTERED NURSE..........................................147COMPETENCY EVALUATION AND TEST FOR LICENSED PRACTICAL (VOCATIONAL) NURSE.....................156ADDITIONAL RESOURCES.........................................................................164FORM 13: QAPI FORM...........................................................................188FORM 14: QUALITY INDICATOR...................................................................189Quality Indicator............................................................................189FORM 15: STAFF RETENTION.....................................................................192DIAGRAM 1: THE ANENE SERVICE & CARE MANAGEMENT CIRCLE........................................194REFERENCES...................................................................................195
Chapter One
ADMINISTRATIVE Business Development Department (MARKETING)
Home health agencies are becoming aggressive marketers of their business because marketing is very important for the sustenance of any home health agency. Operating an agency without an aggressive and effective marketing plan will be self defeating. The marketing efforts of any home health agency will be directed at ensuring that the most cost effective methods are applied and that the marketer understands the scope of the agency and the totality of the agency's capabilities in terms of skills and personnel.
In marketing a home health agency the marketer must be equipped with adequate information about the agency regarding what sets the agency apart from other home health agencies. (What does your agency offer that sets it above and beyond other agencies) For example: staff at TRANSITIONAL HOME HEALTH CARE in Arlington, Texas and the Business Development Specialist (Marketer) pride themselves in skills and knowledge in the following areas of care, for example:
• Management of Dialysis patients
• Wound/ostomy care and management
• Wound VAC
• Venupuncture
• TPN
• Intravenous Therapy,
• Tube feeding
• Drainage tubes (JP and Penrose)
• Ports access and management
• Supra Pubic and Urethra catheter care and management
• Patient education
• Skilled assessment, observation
• Case management,
• and other services that most agencies do not provide.
The primary function of the Business Development Department is the GROWTH of THE AGENCY through contacts with other businesses, community organizations and individuals within the community; and developing and creating the image that is uniquely THE AGENCY'S. One of the ways to achieve this objective is through hiring community liaisons and encouraging employees to participate in community awareness.
It must be noted however, that marketing home health agencies is very tasking and competitive.
QUALITY ASSESSMENT & PERFORMANCE IMPROVEMENT (QAPI)
Introduction
1. The agency shall maintain a quality assessment and assurance committee consisting of the Administrator, the Director of Professional Services or Supervising Nurse, the Medical Director, Aide/Attendant Representative, and the Field Supervisor.
2. It is recommended that the QAPI committee (a) Meet at least twice annually or more frequently as determined by the agency or as required by the State regulatory agency and accreditation agency to identify issues with respect to which quality assessment and assurance activities are necessary; and (b) Develop and implements appropriate plans of action to correct identified quality deficiencies.
3. A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with requirements of this section and the agency determines that the disclosure of such document will impact positively to the benefit of the agency.
4. Good faith attempts by the committee to identify and correct quality deficiencies may not be used as basis for sanctions.
Definitions
• Quality Assessment: an evaluation of a process and/or outcome of a process to determine if a defined standard of quality is being achieved.
• Quality Assurance: the organizational structure, processes, and procedures designed to ensure that care practices are consistently applied and the agency meets or exceeds an expected standard of quality. This shall include CQI.
• Quality Improvement/Continuous Quality Improvement (CQI): is an ongoing interdisciplinary process that is designed to improve the delivery of services and patient outcomes.
• Quality Deficiencies: are potential markers of quality that the agency considers to be in need of investigating-not synonymous to surveyor's deficiencies.
Defining quality in home health is not a one step approach because it has many different components. Quality can be viewed as clinical effectiveness and in a broader sense as issues characteristic of the medical care process that the patients value.
The word quality to a great extent is subjective. Meaning is giving to the word quality by the participants. In the home health industry the definition varies based on the person or group providing the response. Each patient, care provider and regulatory body may define quality based on their perspective of the word and they determine the tools for measurement. For example, quality to the client or patient receiving home health care may be the promptness of service and thoroughness of the individual performing the service and achieving the desired outcome. To the physician who ordered the home health care, it may be the agency's ability to carry through with the physician's orders, and to the home health agency (provider), it may be the financial viability and the satisfaction of the patient and client and also satisfying the surveyors (regulatory) requirements.
Additionally, the administrator and management team define what quality means in any home health agency by creating an atmosphere that sends powerful messages throughout the organization. These messages communicate a set of core values and commitment that influence the employees to strive for improvement.
Policy
The agency shall maintain a planned systematic organization-wide approach to designing, measuring, assessing, and improving its performance. Outcome based measurement of these performance improvement activities should be monitored on a continuous basis and all results should be reported at least annually to the Advisory Board.
Purpose
To provide a system in which the agency's performance is systematically measured, assessed and improved. This is an effort to improve the quality of care provided and client health outcomes, and to ensure proper utilization of services.
The purpose also involves continuous evaluation of agency's systems with the objective of (1) keeping systems functioning well (2) preventing problems (3) when problem arises, correcting them.
Responsibilities
Communication is essential. Agency shall establish a system by which information is disseminated to staff who is not members of the committee. Collecting and analyzing data to find and correct root causes of potential or actual care issues. The agency should communicate such issues and methods of correcting the problem by means of meetings, education, training, and memos/ bulletin board postings.
Determination of Compliance
If the committee (1) is aware of a problem or care issue deficit, (2) had an action plan and or a system in place to correct the problem, (3) implemented the action plan, and (4) evaluated the effectiveness of the action plan.
The regulatory or the accreditation body performs initial survey, annual survey, and periodic surveys to determine compliance.
The agency's group of professional personnel should on a regular basis to not exceed one year perform mock surveys, review and update policies and procedures to determine compliance.
Objectives of the Program
1. To assess and evaluate the quality of client care services and appropriateness of care using structural process and outcome based measures.
2. To identify deviations from agency and professional standards.
3. To address and resolve problems identified.
4. To recommend methods of improving care.
Special Instructions
1. The program should reflect participation by all service categories and disciplines and levels of staff and should subscribe to compliance with internal and external standards including the Medicare Conditions of Participation. If accredited, the agency must also comply with standards of excellence of the accreditation agency.
2. Data will be collected on all services including those provided under contract. This will be done by direct involvement of contracted staff in the quality improvement process or by obtaining information from the contracted organization.
3. The program will reflect participation by all services and levels of staff. A collaborative approach will be used.
4. The Quality Improvement Program will address client service areas that are high volume, high risk, or problem prone.
5. Methods of organizational review and data collection will include, but are not limited to:
a. Quarterly clinical record review
b. Client satisfaction surveys
c. Annual program evaluations
d. Utilization review
e. Incident reports
f. Client complaints
g. Evaluation of clinical competence
h. Monitoring and review of client outcomes
6. A summary of findings, actions, and outcomes is reported at least annually to the Professional Advisory Committee.
AGENCY PHILOSOPHY
Agency should formulate a philosophy or a set of philosophies reflecting that health care is a basic human right, and it must be available, coordinated, and provided in a comprehensive manner, combined with other human services when appropriate. Home Health care is an important part of the continuous health care system, and it shall be provided in the most cost-effective way possible.
Agency and its staff shall operate and provide services in compliance with all applicable federal, state, and local laws and regulations. The agency shall provide a disclosure of ownership information. The agency ownership must reflect in the policy that it's Quality Improvement Program and professional personnel practices, shall comply with professional standards and principles.
AGENCY GOALS
1. To provide all levels of home care service in collaboration with physicians, family and patient, allowing patient to remain in his/her own homes.
2. To provide a broad base of services based on client's needs, involving client in establishing, implementing, and evaluating services.
3. To maintain clients in their homes as long as possible by providing nursing care and related healthcare services.
4. To assist clients in using all restorative methods, tools, and procedures to return to their normal pattern of living as soon as possible.
5. To provide cost-competitive, quality services.
6. To develop a relationship with referral sources to effectively meet the home care needs of clients.
7. To serve as a link between clients and available community resources.
DAILY STAND UP CONFERENCE / QAPI DATA COLLECTION
A brief weekly or daily conference consisting of key staff is highly recommended for an effective quality assurance program. The purpose of the conference is to set the plan for the week or day, identify issues that require action plan and develop a system of addressing pertinent issues. The conference should be brief and all immediate concerns must be addressed, if possible. Individuals are assigned to address issues identified in their departments and report to the supervisor. The supervisor must review and assess the situation to ensure the issue has been addressed and correction made to resolve whatever problems were identified. The data collected over time during these meetings should be used during the agency's scheduled quality improvement and assurance meetings as required by the regulatory agencies.
CLINICAL RECORD REVIEW
Policy
At least quarterly, appropriate health professionals, representing the scope of the program, shall review active and closed clinical records, to determine whether established policies are being followed in furnishing services to the patient directly or under arrangement, and also to update existing policies as needed..
Purpose
1. To evaluate for appropriateness of admissions and discharges.
2. To evaluate the formulation and implementation of the plan of care.
3. To study appropriate use of personnel and coordination of services.
4. To make effective use of community resources in continuity of care and services.
5. To identify over or under-utilization of services.
6. To identify gaps in agency service, need for in service education, consultation services, and/or policy development or modification.
7. To ensure that records reflect care or service provided, the client's condition, and client response or progress towards established goals.
8. To ensure that documentation is complete, accurate, and timely. Quality Assurance And Performance Improvement For Home Health
Special Instruction
1. The membership of the Clinical Record Review Committee shall consist of health care professionals representing each service provided by the agency, as applicable. It may include, but not be limited to:
a. Director of Nursing
b. Nursing Supervisor
c. Registered Nurse
d. Physical Therapist
e. Occupational Therapist
f. Speech Therapist
g. Medical Social Worker
2. The responsibility for the review program is primarily that of the Director of Nursing or a designee.
3. The Clinical Record Review Committee is responsible for client care evaluation. It shall make the recommendations to the Administrator concerning individual cases for review.
4. Whenever possible, no committee member shall review a case in which he/she is professionally involved.
5. Committee records are confidential. They will conform to the agency's position on client information and confidentiality.
6. The committee shall review, if possible, all clients' records that received care during the quarter. The committee shall review a sampling of each service offered. A client receiving multiple services may be included in the sample of each service. Selection of cases shall include active and discharged cases by:
a. Random sampling to give a picture of total services;
b. Specific evaluation studies to focus on a problem, diagnosis, discipline, number of visits, length of stay, specific time periods, etc.;
c. Cases questioned or limited by the intermediary;
d. Cases presenting management problems.
7. Committee reviews and evaluates client care as reflected in the clinical record to identify issues related to utilization of staff, availability of services, and compliance with agency policies. This will include evaluation of prevailing professional standards, including their necessity, appropriateness, adequacy, and effectiveness.
8. The committee shall routinely examine the finding s of previous records, reviews to maintain focus on problem areas and assure follow-up in areas which impact the quality of client care and services.
9. Specific studies may be requested by the Medical Director, Administrator, or member of the Quarterly Clinical Record Review Committee.
10. Identified concerns in the areas of quality of care or client safety shall be referred to the appropriate person for action and a report submitted to the committee at its next meeting.
11. Regular minutes shall be kept of the committee's meetings, along with summaries of its activities. This shall include cases reviewed, diagnosis or category, reason for review, findings, recommendations, and actions taken. The meeting minutes, including attendance, will be retained and made available for the annual agency evaluation conducted by the Professional Advisory Board (committee).
12. The Director of Nursing or designee shall report findings and results of the quarterly review to the Professional Advisory Board as needed.
13. There shall be an ongoing review of clinical records by agency staff for each 60 day period that a client receives home health services to determine adequacy of the plan of care and appropriateness of ongoing services.
ADMISSION POLICY
(1) The agency shall formulate a policy that reflects that the agency shall accept patients for care, services and treatment based on a reasonable explanation that the patient's medical, nursing, and social needs can be met adequately by the agency in the patient's home or place of residence and the patient meets the criteria for qualification for home health care.
Admission assessment shall be determined based on the acuity of the patient's illness and order of the physician.
All admissions shall be carried out within guidelines and per agency policy and procedure Care follows a written plan of care established and periodically reviewed by a physician. The plan of care shall cover all pertinent information regarding the reason the patient is receiving home health care
(2) The agency's policy should reflect the agency shall not discriminate against any patient or potential patient on the grounds of race, color, national origin, disability, age or sexual orientation in admission to, participate in, or receive care, services and benefits provided by the agency.
(Continues...)
Excerpted from QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT FOR HOME HEALTH AGENCIESby Emmanuel C. Anene Copyright © 2012 by Emmanuel Anene. Excerpted by permission of AuthorHouse. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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