Table of Contents
Quality Management
POLICIES
Quality Management Plan.................................................................................................. 4.1
Sentinel Event .................................................................................................................... 4.2
Patient/Family Perception of Care ..................................................................................... 4.3
Conducting the Quality Management Program ................................................................. 4.4
Compliance Program ......................................................................................................... 4.5
FORMS/ATTACHMENTS
Patient/Family Perception of Care Survey Tool ................................................................ 4.3A
Patient/Family Perception of Care QM Data Collection and Analysis Summary ............ 4.3B
Patient Record Audit .......................................................................................................... 4.4A
Quarterly Patient Record Audit ......................................................................................... 4.4B
Quarterly Audit Corrective Action Plan ............................................................................ 4.4C
Professional Pediatric Home Care
December 2012
Contents – Chapter 4
ACHC Standard HH1-10B, HH2-7C.01, HH6-1A.01, HH6-4A.02, HH6-4A.03, HH6-4A.04, HH7-1D.01
Quality Management (QM) Plan
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POLICY
The Agency develops implements and maintains an effective, on-going, organization wide
quality assessment and performance management program. The Agency must measure, analyze
and track quality indicators, including adverse patient events, and other aspects of performance
that enable the organization to assess processes of care, efforts address priorities for improved
quality of care and patient safety, and that all improvement actions are evaluated for
effectiveness.
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PURPOSE
To continuously collect and analyze data to improve the Agency’s performance of patient care
and other processes, specifically as follows:
 Continuously improve processes of patient care/services as well as outcomes of care.
 Communicate information to all staff members.
 Use a systematic approach to problem identification and resolution.
 Conform to all applicable federal/state rules/regulations as well as home care standards.
______________________
REFERENCE
Health Facilities and Emergency Medical Services Division, 6 CCR 1011-1, Standards for
Hospitals and Health Facilities, Chapter XXVI – Home Care Agencies
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DEFINITION
The Agency shall establish a quality management program appropriate to the size and type of
agency that evaluates the quality of patient services, care and safety, and that complies with the
requirements set forth in 6 CCR 1011, Chapter II, and section 3.1.
______________________
GOALS/OBJECTIVES
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To collect and analyze data to improve identified processes within the Agency.
To educate and involve appropriate staff in quality management (QM) activities.
To collect and analyze data to improve identified processes of patient care/services as
well as outcomes of patient care, leadership and managerial processes, as indicated.
To establish mechanisms to reprioritize QM activities in response to unusual and/or
urgent events.
To allocate adequate resources for QM.
To create and maintain information systems (manual and/or computer) to support the
collecting, managing and analyzing of data needed to facilitate ongoing QM.
Professional Pediatric Home Care
December 2012
4.1
ACHC Standard HH1-10B, HH2-7C.01, HH6-1A.01, HH6-4A.02, HH6-4A.03, HH6-4A.04, HH7-1D.01
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To endeavor to meet the needs/expectations of staff, patients, families, and caregivers,
physicians, referral sources, third party providers, community agencies, federal and state
agencies.
To apply principles and tools of QM to all aspects of the organization.
______________________
SCOPE OF CARE
1.
Types of patients served: all pediatrics regardless of race, sex, [age], religion, disability,
national origin, sexual preference or whether the patient has an advance directive;
patients residing in Agency’s service area.
2.
Services provided: The Agency primarily serves patients that live within the geographic
area requiring the following care:
 Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Therapy and
Medical Social Services.
 All skilled services are provided under the orders of a licensed physician.
 Service limitations:
o The Agency does not provide the following services at this time: geriatric or
hospice services.
3. Types of practitioners providing care:
 Skilled Nurses
 Physical Therapists
 Occupational Therapists
 Speech Therapists
 Therapy assistants
 Medical Social Workers, Licensed Clinical Social Workers
4. Sites and times of care provision: Administrative office hours are from 9:00 am to 5:30
pm, Monday through Friday. Services can be rendered 24 hours a day/every day.
Service is rendered as agreed upon by the Agency representative and the patient and or
the patient’s representative, at the patient's place of residence.
5. Ongoing: Continuous and periodic collection and assessment of data. Assessment of
such data enables areas of potential problems to be identified and indicates data that
should be collected and assessed in order to identify whether a problem exists
The following areas should be considered within the plan:
 Program objectives.
 All patient care disciplines.
 Description of how the program will be administered and coordinated.
 Methodology for monitoring and evaluating the quality of care.
 Priorities for resolution of problems.
 Monitoring to determine effectiveness of action.
 Oversight responsibility report to governing body.
 Documentation of the review of its own program.
Professional Pediatric Home Care
December 2012
4.1
ACHC Standard HH1-10B, HH2-7C.01, HH6-1A.01, HH6-4A.02, HH6-4A.03, HH6-4A.04, HH7-1D.01
______________________
CONFIDENTIALITY
Confidentiality will be maintained in all QM activities and meetings. Patient or employee data
contained in QM reports will be identified by patient identification number/patient initials or
employee identification numbers only. QM reports will not be available to unauthorized persons
and will be maintained in strict confidence in the Agency office.
__________________________________
RESPONSIBILITY/ACCOUNTABILITY
1.
The Governing Body is ultimately responsible for QM and implementation of the QM plan.
2.
Administrative responsibility for the QM plan is delegated to the Administrator, who, in
turn, assigns certain QM activities to other staff members. The Administrator will be
responsible for: ensuring adequate resources are available, assigning adequate number of
staff, allowing staff sufficient time to participate in QM activities and instituting
appropriate information systems (manual and/or computer) for collecting and analyzing
data.
3.
The Administrator is responsible for appointing the Quality Improvement (QI) Coordinator
and assigning staff to the QM team. The role of QI Coordinator will be the responsibility of
the Director of Clinical Services, unless the Administrator designates an alternate staff
member. The QM team will be responsible for coordinating all QM activities, reviewing
collection of data, analyzing data, assisting staff in developing QM design or improvement
activities, planning actions, collecting data and analyzing the effectiveness of action and
implementing effective actions.
4.
The QM team will meet on a regular basis and will share in reporting to the Administrator,
who, in turn, will report to the Governing Body. Results will also be communicated by the
QM team to staff, including contract staff. The QM team will meet at least quarterly to
aggregate data and will prepare and the action plans for improvement.
___________________________________
PROBLEM SOLVING METHODOLOGY
The Agency will utilize the PDCA (Plan-Do-Check-Act) model for problem solving
methodology and QM.
______________________
DESIGN/REDESIGN
The Agency will strive to design new processes and redesign old processes as needed.
Design/redesign will be based on:
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The Agency’s mission, vision and plan.
Needs/expectations of patients, staff and others.
Up-to-date sources of information (i.e., publications, practice guidelines or parameters).
Performance of processes and outcomes in other organizations, e.g., reference databases.
Professional Pediatric Home Care
December 2012
4.1
ACHC Standard HH1-10B, HH2-7C.01, HH6-1A.01, HH6-4A.02, HH6-4A.03, HH6-4A.04, HH7-1D.01
______________________
DATA COLLECTION
1.
Data collection will include established priorities for improvement, including:
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2.
Referral/intake
Insurance verification, as applicable
Scheduling
Service delivery process: Patient care and compliance
Satisfaction surveys
Occurrence and complaint reporting/resolution
Medication errors
Infection control
Clinical Record and Utilization review
Workers compensation claims
Medical records: documentation, timely filing
Personnel recruitment
Staff orientation, training and competency evaluation
Staff in-servicing
Annual Performance Evaluations
Payroll
Billing and Collection
Accounts payable
Sales/marketing
Review of ethical issues
Monitor all service/care provided under a contract or agreement
Data collection may include:
 High risk processes: patients are placed at risk of serious consequences or deprived of
care if care is not provided correctly, not provided when indicated or provided when
not indicated.
 High volume processes: care/service/process occurs frequently or affects large
numbers of patients/staff.
 Problem prone processes: care/service/process tends to produce problems for patients
or staff.
3.
Data collection asks these questions in prioritizing process:
 Is process, function or service consistent with the Agency's mission, vision and plan?
 Has our Agency listened to customer and staff ideas about a well-designed process,
function or service?
 What industry information is available to assist us in decision making and
comparative analysis?
4.
Data collection includes developing QM indicators, criteria or performance levels for
each major function or process determined to be improved. Data collection will be
Professional Pediatric Home Care
December 2012
4.1
ACHC Standard HH1-10B, HH2-7C.01, HH6-1A.01, HH6-4A.02, HH6-4A.03, HH6-4A.04, HH7-1D.01
ongoing and frequency will be determined by the process improvement activity and the
QM team.
5.
6.
Sources of information from which data may be collected include (but are not limited to):
 Home visits.
 Patient records.
 Patient/caregiver interviews.
 Staff interviews.
 Policies/procedures.
 Incident/Occurrence/Complaint/Infection reports.
 Staffing patterns.
 Supervisory visit observation.
 Peer review.
 Patient perception of care surveys.
 Review of ethical issues
 Workers compensation claims
 Staff, physician, referral source and Home Health Care CAHPS satisfaction surveys,
if applicable
The Agency will consider data collection about the following activities:
 Staff opinions and needs.
 Staff perceptions of risks to individuals and suggestions for improving patient safety.
 Staff willingness to report unanticipated adverse events.
 Conditions in the patient and organization environment.
_____________________________
AGGREGATION AND ANALYSIS
1.
The QM team will aggregate and analyze collected data, which may include detection of
trends, patterns of behavior, and for an action plan to decrease occurrences The Agency
will monitor at least one important aspect of the service/care provided by the Agency, at
least one important administrative/operational aspect of function
2.
Statistical techniques will be utilized, as appropriate, to analyze data. Such techniques
help to focus the Agency's attention and resources on those processes and outcomes for
which more intensive analysis will be most beneficial.
3.
When findings during the analysis of data are relevant to an individual staff member's
performance, the individual is given not only sufficient opportunity to improve his/her
performance, but also education to bring his/her performance to the desired level. If staff
member's performance does not improve, other appropriate action is taken. Whatever
action is taken, the individual's personnel file will contain such documentation. When
relevant, this information is used in evaluating the individual’s performance.
Professional Pediatric Home Care
December 2012
4.1
ACHC Standard HH1-10B, HH2-7C.01, HH6-1A.01, HH6-4A.02, HH6-4A.03, HH6-4A.04, HH7-1D.01
_____________________________
PERFORMANCE EXPECTATION
1.
For each process identified to be improved, mechanisms to identify levels, patterns or
trends in that process that will trigger further evaluation of the process will be identified.
2.
For each established process to be improved, the performance expectation will be
determined. The frequency of data collection and analysis will be specified for each
process. The QM team will analyze the data collected to pursue opportunities for
improvement and identify important problems.
3.
A summary of data collection, analysis, recommendations for improvement and report of
cumulative findings will be prepared by the QM team. The reports are provided to the
Governing Body. Failure to achieve expected levels of performance will be documented
and an explanation delineated to identify opportunities for improvement.
_________________________________________
ACHIEVED AND SUSTAINED IMPROVEMENT
1.
The QM team is responsible for taking appropriate action. If the performance
expectation is not met, the findings will be evaluated by the QM team to determine the
systematic approach for making improvement. The systematic approach will include:
 Identification of potential improvement.
 Implement identified improvement strategy.
 Analyze whether the strategy was effective.
2.
The Agency must conduct monitoring of a least one important aspect of the service/care
provided by the agency. An important aspect of service/care reflects a dimension of
activity that may be high volume (occurs frequently or affects a large number of
patients), high risk (causes a risk of serious consequences if the service/care is not
provided correctly), or problem-prone (has tended to cause problems for staff or patients
in the past).
3.
The Agency must conduct monitoring of at least one important administrative/operational
aspect of function or service/care of the agency. (Examples of QM activities may include,
but are not limited to, monitoring compliance of conducting performance evaluations, inservice hours, or billing audits).
4.
All improved processes will continue to be analyzed for a specified time to determine if
QM strategic action has resulted in sustained improvement.
Professional Pediatric Home Care
December 2012
4.1
ACHC Standard HH6-6A.01
Sentinel Event
______________________
POLICY
The Agency will identify and analyze all sentinel events.
______________________
PURPOSE
To identify processes for responding to sentinel events.
______________________
REFERENCE
Health Facilities and Emergency Medical Services Division, 6 CCR 1011-1, Standards for
Hospitals and Health Facilities, Chapter XXVI – Home Care Agencies
______________________
PROCEDURE
1.
The Agency defines a sentinel event as an unexpected, unanticipated patient death or a
major permanent loss of function or limb that is not related to the natural course of the
patient’s illness or underlying condition. The definition includes any process variation
which does not result in an adverse outcome. However, if such variation occurs again, a
significant chance exists that patient could experience a serious adverse event or outcome
(“near miss”).
2.
For purposes of this policy, the sentinel event definition only applies to Agency’s patients
and not to staff. However, Agency may consider significant events occurring with staff as
sentinel events, e.g., rape, murder, or death in an automobile accident while on duty.
3.
Sentinel events for patients include:
 Unexpected, unanticipated death pursuant to section 3-10-606, C.R.S. as arising from
an unexplained cause or under suspicious circumstances.
 Any occurrence involving physical, sexual, or verbal abuse of a patient as described
in section 18-3-202, 18-3-203, 18-3-204, 18-3-206, 18-3-402, 18-3-403, 18-3-404,
18-3-405, C.R.S.
 Major permanent loss of function or limb not present at time of admission to Agency
that requires continued treatment or lifestyle change.
 Second or third degree burns involving twenty percent or more the body surface area
of an adult patient
 Any occurrence involving neglect of a patient or resident, as described in section 263. 1-101 (4) (b) C.R.S.
 Any occurrence in which drugs intended for use by patient are diverted to use by
another person.
Professional Pediatric Home Care
December 2012
4.2
ACHC Standard HH6-6A.01
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A development, that is, unauthorized departure, of a patient from an around -the clock care setting resulting in death (suicide, accidental death or homicide) or major
permanent loss of function.
Any occurrence involving misappropriation of a patient’s property. This includes,
misappropriation of a patient’s property means a pattern of or deliberately misplacing,
exploiting, wrongfully using, either temporarily or permanently, a patient’s
belongings or money without the patient’s consent.
A patient fall that results in death or major loss of function as a direct result of
injuries sustained from the fall.
4.
All staff will be educated during orientation and on an ongoing basis of the Agency’s
sentinel event policy.
5.
The Agency will identify and respond appropriately to all sentinel events as defined. The
staff member identifying a sentinel event must report the event immediately to the
Administrator or Supervisor. Appropriate emergency services will be initiated.
6.
The Agency Supervisor and/or Administrator will initiate an intensive
assessment/analysis of the sentinel event by performing a thorough and credible root
cause analysis, which will focus on systems and processes.
7.
The Agency will create, document and implement risk-reduction activities and action
plan. The effectiveness of system and/or process improvements will be measured and
analyzed.
8.
Sentinel events will be reported to external organizations as required by applicable
federal or state law.
9.
On an ongoing basis, Agency leaders will monitor published data regarding sentinel
events in home care. Such data will be considered for improvement strategies and risk
reductions within the Agency.
Professional Pediatric Home Care
December 2012
4.2
ACHC Standard HH1-10B
Patient/Family Perception of Care
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POLICY
The Agency will collect data on an ongoing basis from patients and families regarding their
satisfaction and perceptions of care.
______________________
PURPOSE
To gather information about Agency’s performance and to give Agency insight about process
design and functioning.
______________________
REFERENCE
Health Facilities and Emergency Medical Services Division, 6 CCR 1011-1, Standards for
Hospitals and Health Facilities, Chapter XXVI – Home Care Agencies
______________________
RELATED DOCUMENTS
“Patient/Family Perception of Care Survey Tool,” “Patient/Family Perception of Care QM Data
Collection and Analysis Summary” forms
Indicators
Performance Expectations
Satisfied with care provided............................................................................... 90%
Understand Written Notice of Patient Rights .................................................... 90%
Was it easy to access the Agency after hours/weekends for emergencies ......... 90%
Satisfied with staff that provided care ............................................................... 90%
Satisfied with self participation in care .............................................................. 90%
Understood plan of care ..................................................................................... 90%
Agreed to changes in plan of care ..................................................................... 90%
Response to problems/complaints was timely ................................................... 90%
Patient needs/expectations met .......................................................................... 90%
DATA SOURCES AND COLLECTION METHOD: SAMPLING
Telephone and/or written survey will be conducted on an ongoing basis with current and
discharged patients on a random sample of patients. Survey will be conducted by the
Administrator or Supervisor. Survey interview will be conducted with the patient and/or
caregiver. The collective results will be tabulated and the performance expectations actually
achieved for each indicator computed.
Professional Pediatric Home Care
December 2012
4.3
ACHC Standard HH1-10B
ANALYSIS AND ACTIONS
The Quality Management team are responsible for comparing the data against the established
performance expectations, taking actions, analyzing the effectiveness of the actions, integrating
information, problem tracking and communicating findings. All comments of the surveys will be
noted and action taken immediately, if necessary. Individual employees who receive comments
on the surveys may have copies of the surveys placed in employee personnel records for
assistance in performance appraisal/evaluation.
COMMUNICATION
The results of the data collection and analysis will be collected and reported to the QM team and
then to the Governing Body. The staff will also receive results during staff meetings.
Professional Pediatric Home Care
December 2012
4.3
ACHC Standard HH1-10B
Professional Pediatric Home Care
2 Inverness Drive East, Suite 101, Englewood, CO 80112 (303)759-1342
CLIENT SATISFACTION SURVEY
Please let us know how we are doing. Survey results will be kept confidential and will be shared with your child’s
therapists and/or nurses in a statistical format and not in an individualized manner.
To better serve our patients, we have a Medical Social Worker that provides resources and research assistance to
families. We also have a website that offers information at www.pediatrichomecare.com.
Scale:
Rate on a scale from 1 to 5, with 5 being Strongly Agree
I am pleased with services provided by PPHC.
I am pleased with my child’s nursing services.
I am pleased with my child’s physical therapy services.
I am pleased with my child’s occupational therapy services.
I am pleased with my child’s speech therapy services.
N/A
Agree
5
4
3
Comments about my child’s services:
(Optional)
I would appreciate a call to discuss the issues above in a confidential manner.
Name:____________________________________________________________________________________
Phone Number:_____________________________________________________________________________
Finally, please contact Jennifer Rahrer at 303.747.4021 or jrahrer@pediatrichomecare.com and let her know if you
have had any changes to your private insurance policy in the past year.
THANK YOU
Professional Pediatric Home Care
December 2012
4.3
Disagree
2
1
ACHC Standard HH1-10B
Professional Pediatric Home Care
December 2012
4.3
PATIENT/FAMILY PERCEPTION OF CARE
QM Data Collection and Analysis Summary
Time Period: __________________________________
Percent
Rate on a scale from 1 to 5, with 5 being
strongly agree
pleased w services.
pleased w nursing
pleased w PT
pleased w OT
pleased w ST
Scale:
Sample Size:
Agree
%5-4
Disagree
5
4
3
2
Summary of comments on needs/expectations and improvements for patient safety:
Step #2:
Was performance expectation met?
Yes ____
No
Step #3:
A problem or opportunity exists to improve
care/service?
Yes ____
No
If yes, explain
Step #4:
Cause of problem related to: _____ Knowledge
_____ Systems
_____ Behavior/Performance
_____ Other (specify)
Step #5:
Recommendation for action:
Step #6:
Actions to be taken/date/by whom:
Step #7:
Reported to QM committee and date?
Signature
Professional Pediatric Home Care
Yes ____
Date
December 2012
4.3B
Date
1
ACHC Standard HH1-10B, HH6-4A, HH6-4A.01, HH6-4A.05, HH6-5A.01
Conducting the Quality Management Program
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POLICY
The Quality Management program will include all departments, disciplines, divisions and services.
______________________
PURPOSE
To define additional QM requirements.
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REFERENCE
Health Facilities and Emergency Medical Services Division, 6 CCR 1011-1, Standards for Hospitals
and Health Facilities, Chapter XXVI – Home Care Agencies
______________________
RELATED DOCUMENTS
“Patient Record Audit” and “Quarterly Patient Record Audit,” and “Quarterly Audit Performance
Plan” forms
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PROCEDURE
1. Patient/Family Perception of Care Surveys
 Satisfaction surveys are mailed to randomly selected patients annually.
 When satisfaction surveys are returned via mail they are read and any immediate issues are
addressed by the Administrator.
 Returned surveys are reviewed annually and tallied on the Customer Satisfaction Audit.
Based on the results, action items may be written on the Audit Performance Plan.
 Threshold for this area is 90%; any area that falls below 90% will be tracked.
2. Patient Record Audit
 Each quarter 10% or fifteen (15) total patient charts will be reviewed using the Patient
Record Audit tool.
 An adequate sampling of open and closed records is selected to determine the completeness
of documentation
 Quarterly the patient record audits will be tallied on the Quarterly Patient Record Audit tool.
Based on the tallied results, action items may be written on the Quarterly Audit Performance
Plan.
 Threshold for each area of this audit is 85%. Any area that falls below will be tracked.
3. Patient Complaints and/or Incidents/Occurrence and/or Infection Audit
 Quarterly the logs will be reviewed and, based on the results, action items may be written on
the Quarterly Audit Performance Plan.
Professional Pediatric Home Care
December 2012
4.4
ACHC Standard HH1-10B, HH6-4A, HH6-4A.01, HH6-4A.05, HH6-5A.01
4. Each quality improvement activity must include the following items:
 A description of indicator(s) activities to be conducted
 Frequency of activities
 Designation of who is responsible for conducting the activities
 Methods of data collection
 Acceptable limits for findings
 Who will receive the reports
 Plans to re-evaluate if findings fail to meet acceptable limits in addition to any other
activities required under state or federal laws or regulations
 Any other activities required under state or federal laws or regulations
5. A written plan of correction/activity plan is developed in response to any quality improvement
activity that does not meet an acceptable threshold. The plan of correction/activity plan may
identify changes in policy, procedure, or processes that will improve performance.
6. A written summary describes changes made as a part of a corrective action plan. This summary
may be a separate document, or a part of the minutes of the governing body meetings, or as a
part of the QM reports.
Professional Pediatric Home Care
December 2012
4.4
Patient Record Audit
Patient ID#
Auditor Name
Audit Date
Requirement
Identification data.
Names of next of kin/legal guardian/emergency contact with phone numbers.
Name of primary caregiver(s) with phone numbers.
Source of referral.
Admission and discharge dates from hospital or other institution (if applicable).
Hospital and emergency room records for known episodes or documentation of
efforts to obtain the information.
Advance directives.
Names of power of attorney and/or healthcare power of attorney.
Name of physician responsible for care.
Diagnosis.
Physician orders, including medications and dietary, treatment and activity orders.
Signed release of information and other documents for protected health
information.
Admission and informed consent documents (including signed notice of Bill of
Rights and election of Hospice services (if applicable).
Assessment of the home.
Medical equipment provided by the Agency or related to the care, treatment
and services provided including assessment of patient and family
comprehension of appropriate use and maintenance.
Patient and family education and training on services or treatments and the use
of equipment at the time of delivery to the home.
Documentation of safety measures taken to protect the patient from harm
including fall risk assessments, and documentation why any identified or planned
safety measures were not implemented or continued.
Diagnostic and therapeutic procedures, treatments, tests and their results where
known to have occurred.
Initial assessments.
Ongoing assessments (if applicable).
Initial written plan of care.
Updated written plans of care (if applicable).
Transfer summaries/records (if any) received from transferring organizations.
Discharge planning and/or prognosis.
Evidence of coordination of service/care provided by the organization with
others who may be providing service/care.
Referrals to and names of known home care agencies, individuals and
organizations involved in the patient’s care.
Professional Pediatric Home Care
December 2012
4.4A
Met
Not N/A
Met
Patient Record Audit (continued)
Requirement
Documentation of communications with the patient or authorized
representative regarding care, treatment and services (phone calls, emails, etc).
Signed and dated clinical notes.
Copies of summary reports sent to physicians.
Patient/family response to service/care provided.
Discharge summary (when applicable).
Professional Pediatric Home Care
December 2012
4.4A
Met
Not N/A
Met
Quarterly Patient Record Audit
Patient ID#
Auditor Name
Audit Date
Requirement
Identification data.
Names of next of kin/legal guardian/emergency contact with phone numbers.
Name of primary caregiver(s) with phone numbers.
Source of referral.
Admission and discharge dates from hospital or other institution (if applicable).
Hospital and emergency room records for known episodes or documentation of
efforts to obtain the information.
Advance directives.
Names of power of attorney and/or healthcare power of attorney.
Name of physician responsible for care.
Diagnosis.
Physician orders, including medications and dietary, treatment and activity orders.
Signed release of information and other documents for protected health
information.
Admission and informed consent documents (including signed notice of Bill of
Rights and election of Hospice services (if applicable).
Assessment of the home.
Medical equipment provided by the Agency or related to the care, treatment
and services provided including assessment of patient and family
comprehension of appropriate use and maintenance.
Patient and family education and training on services or treatments and the use
of equipment at the time of delivery to the home.
Documentation of safety measures taken to protect the patient from harm
including fall risk assessments, and documentation why any identified or planned
safety measures were not implemented or continued.
Diagnostic and therapeutic procedures, treatments, tests and their results where
known to have occurred.
Initial assessments.
Ongoing assessments (if applicable).
Initial written plan of care.
Updated written plans of care (if applicable).
Transfer summaries/records (if any) received from transferring organizations.
Discharge planning and/or prognosis.
Evidence of coordination of service/care provided by the organization with
others who may be providing service/care.
Referrals to and names of known home care agencies, individuals and
organizations involved in the patient’s care.
Professional Pediatric Home Care
December 2012
4.4B
Met
Not N/A
Met
Quarterly Patient Record Audit (continued)
Requirement
Met
Not N/A
Met
Documentation of communications with the patient or authorized
representative regarding care, treatment and services (phone calls, emails, etc).
Signed and dated clinical notes.
Copies of summary reports sent to physicians.
Patient/family response to service/care provided.
Discharge summary (when applicable).
Scoring:
# Met: _______ / # Applicable (Met + Not Met): _______
Professional Pediatric Home Care
December 2012
4.4B
= Percentage: _______
Quarterly Audit Corrective Action Plan
Qtr/Year
Area of Concern
Professional Pediatric Home Care
Plan of Correction Steps
December 2012
4.4C
Date
Completed
Outcome
ACHC Standard HH2-9A.01
Compliance Program
______________________
POLICY
The Agency has a Compliance Program that provides both general and specific guidance as to
various internal anti-fraud and abuse controls.
______________________
PURPOSE
The Compliance Program identifies and discusses numerous compliance risk areas
particularly susceptible fraud, waste and abuse.
 To advance the prevention of fraud, abuse and waste in health care while simultaneously
furthering the fundamental mission of the agency to provide quality care, treatment and
services to patients.
 To establish a culture that promotes the prevention, detection and resolution of potential
violations of laws, regulations and standards, and company policies and procedures.
 To identify and discuss potential compliance risk areas susceptible to fraud and abuse.
 To increase the likelihood of preventing, or at least identifying unlawful and unethical
behavior.
 This document is a description of the agency’s Compliance Program that reflects not only
policies and procedures, program activities, but also the commitment of senior
management and the support of all employees, vendors and agents to make the program
effective.
 The agency recognizes that although an effective compliance program may not entirely
eliminate fraud, waste, and abuse, it significantly reduces the risk of unlawful, unethical,
or otherwise improper conduct. The agency supports the program with financial and
staffing resources, to the successful implementation of an effective Compliance Program
that addresses the following elements:
 Establishment of compliance standards and procedures.
o Development and distribution of written standards of conduct.
o Policies and procedures that promote compliance and address areas of potential fraud,
waste and abuse.

Oversight of the compliance program by high-level personnel.
o Designation of a compliance officer who reports directly to the Administrator and
Governing Body of the organization
o Establishment of other appropriate systems/processes such as a compliance
committee.
o Prompt responses to detected violations/offenses through corrective action plans.

No discretionary authority given to individuals either known to engage in or suspected of
engaging in criminal action.
o Policies addressing the non-employment or retention of sanctioned individuals.

Effective communication of the compliance standards and procedures to all employees
and/or agents of the organization.
o Development of regular, effective education and training programs.
Professional Pediatric Home Care
December 2012
4.5
ACHC Standard HH2-9A.01

Monitoring, auditing and reporting systems which encourage the reporting of criminal
conduct without retaliatory consequences.
o Implementation of a system/process such as a hotline to report and respond to
allegations of improper/illegal activities.
o Adoption of policies to protect the anonymity of reporters and protect them from
retaliation/retribution.
- Use of audits and other evaluative techniques to monitor compliance and reduce
risk in identified problem areas.

Establishing and disseminating Agency disciplinary guidelines for failing to comply with
the organization’s standards and procedures, and applicable statutes and regulations.
- Use of appropriate and consistent discipline of employees and/or agents who have
violated internal compliance standards, applicable statutes, regulations, or federal
health care program requirements will not be tolerated.

Appropriate response to a known violation of the compliance standards, applicable
statutes, regulations, or federal health care program requirements, and development of
corrective action plans to prevent and detect future violations.
______________________
REFERENCE
Health Facilities and Emergency Medical Services Division, 6 CCR 1011-1, Standards for
Hospitals and Health Facilities, Chapter XXVI – Home Care Agencies
http://www.cms.gov/FraudAbuseforProfs/
______________________
POLICY/ PROCEDURE
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
The agency’s Compliance Program is dynamic evolving process that reflects the
company’s commitment to the highest standards of corporate conduct.
The development, implementation and distribution of written policies and procedures and
standards of conduct that are in compliance with applicable laws, regulations and federal
health care program requirements is an integral part of the Agency’s Compliance
Program.
Agency staff and management personnel receive compliance training during orientation
and at least annually, or more frequently if there are changes in applicable statutes,
regulations, or federal health care program requirements.
The Compliance Program is reviewed at least annually and more often if necessary to
ensure that Agency risks are addressed appropriately and effectively.
Copies of the Compliance Program are available to patients, referral sources and/or the
general public upon request.
Written Standards

The Code of Ethics articulates the fundamental principles, values, standards and ethical
principles that guide the company’s daily operations and provide a framework for action.
Professional Pediatric Home Care
December 2012
4.5
ACHC Standard HH2-9A.01
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The Code of Ethics is very clear that management and staff are expected to behave in
compliance with applicable laws, regulations, standards and company policy.
Upon hire, reference checks include verification of employment history and education.
Criminal background investigations, and national sex registry investigations as
appropriate, are conducted that search for any felony or misdemeanor on both a county
and federal level.
If deemed appropriate to the position, checks are also conducted of professional
certifications and licenses and motor vehicle records.
Leadership and Structure
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There is a designated Compliance Officer charged with oversight of the Compliance
Program, who along with the Agency’s leadership regularly monitors the program to
ensure appropriate responsiveness to the company’s compliance risks.
The Compliance Officer has the authority to review all documents and other information
that are relevant to compliance activities, including, but not limited to, patient and billing
records, contracts and any other obligations that may contain referral and payment
provisions that could violate the anti-kickback statute, as well as the Stark physician selfreferral prohibition and/or any other legal or regulatory requirements.
The Agency’s Professional Advisory Committee functions as the Compliance Committee,
and advises the Compliance Officer and assists in the implementation of the program. The
Office of the Inspector General (OIG) recognizes that a home health agency may tailor the
structure of the Compliance Committee in consideration of the size and design of the
home health agency while endeavoring to address and accomplish the responsibilities of
the Compliance Officer and Compliance Committee. As the Agency grows, the
Compliance Committee shall include individuals with varying responsibilities in the
organization, such as operations, finance, audit, human resources, and clinical
management, as well as employees and managers in key operating positions. These
individuals should have significant professional experience working with billing, clinical
record, and documentation and auditing principles.
The Compliance Officer is responsible for ensuring that a culture of compliance is
sustained throughout the company, for providing strategic guidance for oversight of the
processes, training, and implementation strategies to ensure compliance with applicable
laws and regulations, and company policies.
The Compliance Officer’s primary responsibilities include:
o Overseeing and monitoring the implementation of the compliance program;
o Reporting at least quarterly or more often if necessary to the Agency’s Board of
Directors about the implementation of the program, and assisting in establishing
methods to improve the Agency’s efficiency and quality of care, treatment and
services, and to reduce the Agency’s vulnerability to fraud, abuse, and waste;
o Periodically revising the program in light of changes in the Agency’s needs, and in
applicable laws, regulations, and policies and procedures of government and private
payer health plans;
o Reviewing employee personnel files to ensure that they have received, read, and
understood the standards of conduct;
o Developing, coordinating, and participating in a multifaceted educational and training
program that focuses on the elements of the compliance program, and seeks to ensure
that all relevant employees and management are knowledgeable of, and comply with,
pertinent federal and state standards;
Professional Pediatric Home Care
December 2012
4.5
ACHC Standard HH2-9A.01
o
o
o
o
o
o

Ensuring that independent contractors and agents who provide health care services to
the patients of the agency or provide billing services to the Agency, are aware of the
Agency’s compliance program requirements, including but not limited to: coverage
issues, billing and marketing.
Ensuring that the National Practitioner Bank and Cumulative Sanction Report have
been checked with respect to all employees, referring physicians, and independent
contractors (as appropriate).
Coordinating compliance review and monitoring activities of the Agency’s financial
management;
Independently investigating and acting on matters related to compliance, and any
resulting corrective actions relative to all departments, subcontracted providers and
health care professionals, and any other agents if appropriate;
Monitoring the OIG web site to ensure compliance with all applicable laws,
regulations and OIG recommendations; and,
Continuing to monitor and evaluate the momentum of the compliance program and
whether or not the goals and objectives of the program are being met.
The agency conducts ongoing assessments/internal audits of the Compliance Program to
monitor identified potential risk areas and to identify new and emerging areas of risk and
to develop processes and/or systems to address those areas.
Education and Training
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The agency is committed to taking all necessary and appropriate steps to communicate
agency standards and procedures to all personnel and business associates.
Agency’s employees are educated and trained about their legal and ethical obligations in
order to be in compliance with company policy and applicable laws, regulations, and
standards.
Education and training is provided during orientation, at least annually, and more often if
necessary.
The content of all training is evaluated on a regular basis to ensure that the content and the
training are effective. The training is updated as necessary to reflect current laws,
regulations and standards.
Internal Communications

Within the agency is a commitment to a culture of open communication between
employees and management. To that end, the company has adopted open-door policies, as
well as confidentiality and non-retaliation policies. Procedures have been established to
report incidents/issues anonymously.

Employees are encouraged to bring workplace issues of any type to the attention of
management/the Compliance Officer without fear of retaliation or recrimination.
Employees are encouraged to first discuss workplace issues with their immediate
supervisors. If the matter is not successfully resolved, an employee may pursue the matter
with the next level of management or the Compliance Officer.

Professional Pediatric Home Care
December 2012
4.5
ACHC Standard HH2-9A.01
Responding to Violations
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Although a compliance program decreases the likelihood of unlawful and unethical
behavior, DHHR-OIG recognizes that even an effective Compliance Program cannot
prevent all violations. In the event that the company becomes of aware of violations of
law or company policy, the issues will be promptly investigated, disciplinary action shall
be taken if appropriate, and plans of correction will be implemented, if necessary, to
prevent future violations.
The Agency will not conduct business with persons or organizations that have been
excluded, debarred, suspended or otherwise ineligible to participate in Federal healthcare
programs.
If an Agency employee violates the law or regulations and/or company policy, the Agency
has implemented a disciplinary process that outlines the potential consequences up to and
including termination that addresses these violations.
The Agency also assesses whether identified violations may be due in part, to the structure
of company policies, procedures, processes and/or systems, and if so, develops
appropriate corrective plans of action to decrease the possibility of violations occurring in
the future.
If credible evidence is discovered of misconduct from any source and after reasonable
inquiry the Agency has determined there is credible evidence the misconduct has possibly
violated any criminal, civil, or administrative law, the Agency shall report the existence of
such misconduct to the appropriate federal and state authorities and regulatory bodies
within a reasonable period of time, but no more than sixty (60) days after the
determination.
Auditing and Monitoring


Audits conducted at regular intervals address, but are not limited to, the Agency’s
compliance with anti-kickback laws, claim processing, cost reporting, marketing, the
Medicare Conditions of Participation, as well any areas that have been identified by OIG,
any federal or state entity, or internally by the Agency itself.
Internal audits of the Agency’s processes and systems and adherence to the Compliance
Program’s elements are conducted at regular intervals and at least during the company
annual evaluation. Reports of the audits are submitted to the Board of Directors and
Professional Advisory Committee, and analyzed to determine the necessity for
improvements to be made, and if so, plans of correction are developed and implemented
to improve the Agency’s operations. Internal audits are an integral part of the
organization’s Performance Improvement program.
COMPLIANCE PROGRAM EDUCATION


Agency provides Corporate Compliance Program education to all employees during
orientation, annually, and more often if necessary as indicated by changes in applicable
laws, regulations, standards or guidelines or as required due to the sensitivity of the work.
The Compliance Officer is responsible for:
o Assuring that the information provided during any Compliance Program training, and
information disseminated to employees and any agents of the Agency, is accurate,
current and reflects applicable laws, regulations, and standards; and
o Ensuring appropriate documentation of any compliance training
Professional Pediatric Home Care
December 2012
4.5
ACHC Standard HH2-9A.01

All employees shall receive formal training in at least the following:
o Organization Policies and Procedures;
o Ethics, including the Agency’s Code of Ethics; and,
o Procedures for notifying senior management of problems and concerns

Targeted training is provided to corporate officers, managers, clinicians and other
employees whose actions impact the claims submission process to the government and
other third party payors.
The contents of the Compliance Program training shall include, but is not limited to:
o Federal, state and private payer reimbursement rules, regulations and guidelines
o Organization Policies and Procedures
o Stark Laws
o Anti-kickback Laws
o Fraud and Abuse Laws
o Prohibitions related to inducing referrals
o Appropriate admission and discharge of patients
o Claims development and submission process:
- Confirming and prioritizing diagnoses
- Accurate and appropriate coding principles
- Physician signatures
- Visit verification
- Equipment/supplies verification
o Documentation requirements for services rendered and items provided
o Altering medical records
o Misrepresenting services and/or items provided
o Reporting misconduct/potential violations
o Cost Reports
o Waiver of Co-payments/Accepting Assignment
o Marketing Practices
o Standards of Practice
o Scope of Practice


A variety of teaching methods may be used to present the information in a manner that is
understandable to the employees.
Professional Pediatric Home Care
December 2012
4.5