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| Policy and Procedure Manual |
The Policies and Procedures of The Cherokee Home Health Service
Table of Contents
Health and Medical Division SUBJECT: Absenteeism EFFECTIVE DATE: May 5, 1997 DATE REVIEWED OR REVISED: August 6, 1999 DISTRIBUTION: Home Health Service personnel POLICY: For purpose of consistency, an incident is considered any consecutive
amount of time for the same illness. Six incidences of tardiness or leaving early in a 12 month period
is considered acceptible attendance. Fewer than six exceeds expectations,
and more than six indicates a need for improvement.
Health and Medical Division PURPOSE: To provide education to our patients about advanced directives STAFF GOVERNED BY THIS POLICY: RN EFFECTIVE DATE: August 27, 1997 DATE REVIEWED OR REVISED: DISTRIBUTION: Home Health Service personnel POLICY: A large print instruction sheet about advanced directives is in
each admission packet. The nurse is to go over this with the patient
and/or family on the first visit and leave this information in the
home. Our role is for instruction only. Encourage patients to ask
questions and reinstruct as you feel is warranted or when patient/family
expresses interest. The tribe has an interpreter available for the
Cherokee language when needed. Make requests for the interpreter
to the Director.
Health and Medical Division SUBJECT: Annual Leave Requests PURPOSE: To maintain adequate patient coverage STAFF GOVERNED BY THIS POLICY: All personnel EFFECTIVE DATE: 07/01/95 DATE REVIEWED OR REVISED: August 6, 1999 DISTRIBUTION: Home Health Service personnel POLICY: Staff members are requested to make their annual leave requests at least three weeks in advance so that adequate patient coverage can be planned. During the Christmas and New Year holiday period, no more than one week’s vacation will be permitted per employee, to allow other staff time to be with their families. Requests for vacation will be processed in the order submitted, with consideration given to previous vacations taken during the holiday period. Twenty-four to forty-eight hours notice is usually adequate if only one day off is needed. Emergency leave requests will be reviewed by the appropriate Supervisor.
Health and Medical Division PURPOSE: Guidance for decision-making concerning ethical matters STAFF GOVERNED BY THIS POLICY: All personnel EFFECTIVE DATE: 10/00 DATE REVIEWED OR REVISED: DISTRIBUTION: Home Health Service personnel POLICY: Cherokee Home Health recognizes the need to incorporate concern for ethical aspects of care in their day-to-day practice. The agency values health and well being for all persons, and strives to assist patients in achieving their optimal level of health. We respect and promote the rights of patients, and help them to express their health needs to obtain appropriate information and services. We involve patients and their families in health planning and health care decision-making, including choices concerning Advance Directives and the acceptance or refusal of Home Health services. We are committed to providing quality care performed by employees
who demonstrate a high level of competence, in a compassionate,
supportive manner. We support staff efforts to increase their professional
knowledge through continued education, training, and experience. We acknowledge the importance of the spirit, and are sensitive to the cultural beliefs of patients, caregivers, and employees. We safeguard the trust of patients by using confidential information in the context of a professional relationship, and share such information outside the health care team only with the patient’s permission. We apply and promote principles of equity and fairness to assist clients in receiving unbiased treatment, health services and resources proportionate to their needs, regardless of ethnicity, religion, gender, or ability to pay for services. We value honesty and integrity in serving our patients, and abide by all policies of the Eastern Band of Cherokee Indians.
Health and Medical Division SUBJECT: Changes in Management PURPOSE: Describe procedure for dealing with changes in agency ownership and management STAFF GOVERNED BY THIS POLICY: All personnel EFFECTIVE DATE: DATE REVIEWED OR REVISED: 10/00 DISTRIBUTION: Home Health Service personnel POLICY: This agency is a non-profit program of the Health and Medical Division of the Eastern Band of Cherokee Indians, a federally recognized tribal entity. As such, ownership of this agency cannot be transferred to another entity. Changes in the management structure of the Health and Medical Division must be approved by the Chief and/or Tribal Council through the passing of a Tribal Resolution or Ordinance, which would be included in the public records of the EBCI. Tribal Council members are selected by enrolled members of the EBCI through an election process, serving for a term of four years. Changes in personnel in all Home Health positions, including management positions, must be approved in writing by the Health Operations Director, Executive Director of the HMD, Human Resources Manager, and the Executive Committee, which is comprised of the Principal Chief and Vice Chief of the EBCI.
Health and Medical Division PURPOSE: Appropriate services will be provided to patients with communication needs. STAFF GOVERNED BY THIS POLICY: All personnel EFFECTIVE DATE: Nov 2000 DATE REVIEWED OR REVISED: DISTRIBUTION: Home Health Service personnel POLICY: All patients have the right to participate in their plan of care. Skilled staff are responsible for identifying patients with communication needs which could interfere in their quality of care. These needs could include language barriers, or barriers to vision or hearing. Assessment will be performed upon initial visit, and will be reevaluated with each visit. Staff members will be sensitive to these issues, incorporate them into the plans of care for the individual patient as needed, and provide appropriate information to all staff who care for this patient. Patients with special communication needs will be assisted with obtaining the appropriate method to facilitate communication as necessary. The following guidelines are provided:
Skilled staff will make the appropriate referrals to obtain necessary equipment to assist patients with their communication needs.
Health and Medical Division SUBJECT: Communication with Physicians PURPOSE: To ensure efficiency and continuity of care when notifying physicians of a change in the patient’s condition STAFF GOVERNED BY THIS POLICY: Nursing and Therapy staff EFFECTIVE DATE: 03/16/01 DATE REVIEWED OR REVISED: DISTRIBUTION: Home Health Service personnel POLICY: For physicians at Cherokee Indian Hospital: 1. Phone the hospital and ask the operator to page the patient’s
primary physician Do not fax lab results that require immediate attention. Instead, phone the results to the physician using the procedure listed above. To contact doctors other than those with Cherokee Indian Hospital, phone their office and ask to speak to the patient’s primary physician. If they are unavailable to come to the phone, leave a message with the nurse or office manager explaining the reason for the call. In either case, if you do not receive an order and need for the physician to return your call, complete pertinent information in the “Clinical Facts” section on a “Changes in Orders, Medical Update” form and leave it with the nursing supervisor, so when the doctor calls back the order can be completed.
Health and Medical Division SUBJECT: Confidentiality Agreement PURPOSE: To insure the confidentiality of all tribal correspondent data or financial information; patient/client/employee records, including medical, dental, mental health, substance abuse, other and various types of confidential information. STAFF GOVERNED BY THIS POLICY: All personnel EFFECTIVE DATE: DATE REVIEWED OR REVISED: DISTRIBUTION: Home Health Service personnel POLICY: As an employee, volunteer, contractor, or student of Eastern Band of Cherokee Indians, you must safeguard all tribal correspondent data or financial information; patient/client/employee records, including medical, dental, mental health, substance abuse, other and various types of confidential information from misuse. PROCEDURE: All employees must read and sign the
Confidentiality
Agreement.
Health and Medical Division SUBJECT: Confidentiality of Personnel Files PURPOSE: Assure the confidentiality of all employee personnel files STAFF GOVERNED BY THIS POLICY: All personnel EFFECTIVE DATE: Nov 2000 DATE REVIEWED OR REVISED: DISTRIBUTION: Home Health Service personnel POLICY: Each employee will have a personnel file maintained in a secure area in the Director’s office. Copies are kept in secure areas of the office of the Executive Director of the Health and Medical Division, and in the Tribal Human Resources Department. The employee may request a copy of any information in this file by contacting the Human Resources Department (see Tribal Policy). The files may be reviewed with the Director’s permission by the employee’s supervisor, during normal business hours. Information concerning the application, dated and signed withholding statements, and verification of citizenship will be kept in the Personnel files at the Human Resources Department of the EBCI. Health and Medical Division PURPOSE: To establish guidelines for patient discharge STAFF GOVERNED BY THIS POLICY: All personnel EFFECTIVE DATE: 06/2000 DATE REVIEWED OR REVISED: DISTRIBUTION: Home Health Service personnel POLICY: Patients will have services terminated in a planned and appropriate manner consistent with their condition and the status of their needs. It is important that there is appropriate consultation and communication prior to the patient’s discharge that involves the patient and caregiver, case manager, other patient care services, Patient Care Services Supervisor, and the patient’s primary physician. PROCEDURE: A patient may be deemed ready for discharge upon establishment of one or more of the following criteria:
Health and Medical Division PURPOSE: To reduce the risk of musculoskeletal disorder injuries to Home Health employees STAFF GOVERNED BY THIS POLICY: All personnel EFFECTIVE DATE: DATE REVIEWED OR REVISED: DISTRIBUTION: Home Health Service personnel POLICY: This policy is presently under development PROCEDURE:
Health and Medical Division SUBJECT: Employee Injury - Work Related PURPOSE: To have a plan for Home Health employees to follow in the event of injury while working. STAFF GOVERNED BY THIS POLICY: All personnel EFFECTIVE DATE: DATE REVIEWED OR REVISED: DISTRIBUTION: Home Health Service personnel POLICY: This policy is presently under development PROCEDURE: Employee is to immediately report any incident of injury to the
respective supervisor. That supervisor must complete an Employee
Injury form.
Health and Medical Division SUBJECT: Ethical issues related to client care PURPOSE: Describe procedure for the identification and recommendation of ethical concerns STAFF GOVERNED BY THIS POLICY: All personnel EFFECTIVE DATE: DATE REVIEWED OR REVISED: DISTRIBUTION: Home Health Service personnel POLICY: An ethical concern is defined as a situation where it is clear that action or lack of action would involve a violation of the agency’s Code of Ethics. Any employee who faces such a situation is to share the ethical
concern with the appropriate supervisor, who will schedule a regular
case conference to discuss possible solutions. If the problem is
not resolved, the Director of Home Health will be notified, and
a case conference will be arranged whose members may include the
patient and family/caregiver, the patient’s physician, the
Medical Director of Home Health, the Director of Home Health, the
nurse, nursing assistant, or therapist involved, the Executive Director,
Operations Director, and Medical Director of the Health & Medical
Division, and a representative of Behavioral Health, as deemed appropriate
by the Director of Home Health.
Health and Medical Division
SUBJECT: Focused Medical Review PURPOSE: To establish a procedure for responding to requests for medical records information as part of Focused Medical Review. STAFF GOVERNED BY THIS POLICY: All personnel EFFECTIVE DATE: 07/01 DATE REVIEWED OR REVISED: DISTRIBUTION: Home Health Service personnel POLICY: It is the policy of Cherokee Home Health to comply with all governmental regulations including those pertaining to requests from CMS (formerly HCFA) for medical records information to support Medicare claims. PROCEDURE:
Health and Medical Division Each month, the Fiscal Coordinator will print a claim for each
patient who has the Indigent Grant as payor. The Director will use these to complete the documents required
for the grant.
Health and Medical Division
Transportation of hazardous waste, including lab samples containing body fluids. Monthly report of infections developed after admission to Home Health Transportation of medical supplies in privately owned vehicles Annual training required for all field staff Cleaning bags each month by each employee.
Health and Medical Division SUBJECT: Professional licensure/certification PURPOSE: Describe procedure for the verification of professional licensure/certification STAFF GOVERNED BY THIS POLICY: All personnel EFFECTIVE DATE: 10/00 DATE REVIEWED OR REVISED: DISTRIBUTION: Home Health Service personnel POLICY: The Director of Home Health or designee will verify the professional licensure of any physician referring patients for services, prior to admission of the patient. This will be accomplished through the use of the internet web site for the North Carolina Medical Board home page (ww.docboard.org). The results are printed and maintained in a notebook in the office of the Fiscal Coordinator. Physicians assigned to the Cherokee Service Unit (Cherokee Indian Hospital) are commissioned officers or civil service employees, whose credentials are verified through the United States Public Health Service. See attached Articles III and IV of Cherokee Indian Hospital Policy. The Director of Home Health or designee will verify the certification of each Certified Nursing Assistant as part of the hiring process, and will recheck annually during their employment. This will become part of the personnel file kept in the Director’s office. Each employee whose job description requires professional licensure will submit a copy of the current license as part of the hiring process. The Director will be responsible for the tracking of expiration dates for each employee whose job description requires licensure/certification. It is the responsibility of each employee to maintain current licensure/certification without interruption, and to furnish such information including copies of professional license/certification to the Director as requested. Tribal policy concerning disciplinary action will be followed if an employee fails to comply.
Health and Medical Division PURPOSE: To provide instruction for obtaining Medical Supplies used for patient care STAFF GOVERNED BY THIS POLICY: All personnel EFFECTIVE DATE: 07/11/01 DATE REVIEWED OR REVISED: DISTRIBUTION: Home Health Service personnel POLICY: Policy: Field staff will obtain Medical Supplies used for patient care in accordance with physician orders.
Health and Medical Division SUBJECT: Reimbursement of Nursing Visits PURPOSE: Conformity with Compliance Plan STAFF GOVERNED BY THIS POLICY: Staff RNs EFFECTIVE DATE: 10/1/00 DATE REVIEWED OR REVISED: 07/01 DISTRIBUTION: Staff RNs POLICY: To ensure conformity with the Compliance Plan for Cherokee Home Health, nursing visits performed outside of regular working hours will be paid at the regular hourly wage for that employee. If working greater than forty hours during that week, the employee will be paid at 1 and ½ times the hourly rate. This includes visits made while “On-Call.” If the schedule permits, the nurse may take time off during the same week. If while On-call, a nurse receives a page, the nurse will use professional judgement and home health experience to determine if a visit to the patient’s home is necessary. If the nurse needs additional advice to make this determination, he/she is to contact either the Director or Director of Nursing to discuss the particular needs of the patient. If it is necessary for the “Prn RN” to make a visit,
the following rates will apply: If it is necessary for a regular Full-Time Staff RN to make a home visit, he/she will be reimbursed at that employee’s regular hourly rate. If leaving from home, travel time will begin at the nurse’s home, and end when the nurse returns home. For both prnRN and regular nursing staff, mileage reimbursement will begin at the Cherokee Home Health office or nurse’s home, whichever is closer to the patient’s home. On-call pay will be paid at the rate of $2.00 per hour, whether for Staff RN or Prn RN services.
Health and Medical Division SUBJECT: Requests for Agency Information PURPOSE: Describe procedure for disclosing agency ownership and management STAFF GOVERNED BY THIS POLICY: All personnel EFFECTIVE DATE: DATE REVIEWED OR REVISED: 10/00 DISTRIBUTION: Home Health Service personnel POLICY: This agency is a non-profit program of the Health and Medical Division of the Eastern Band of Cherokee Indians, a federally recognized tribal entity. Persons requesting information concerning the organization and management of the agency will be given copies of the organizational chart for the Health and Medical Division by the next day of business following the request (see attached).
Health and Medical Division PURPOSE: To introduce various new staff members to policies, procedures, and forms. STAFF GOVERNED BY THIS POLICY: All personnel EFFECTIVE DATE: DATE REVIEWED OR REVISED: DISTRIBUTION: Home Health Service personnel POLICY: DAY 1 All new staff 7:45 – 10:00 Welcome, introduction to staff 10:00 – 10:15 Break 10:15 – Noon Mission/philosophy, Agency history Noon – 12:45 Lunch 12:45 – 2:00 Forms shelf 2:00 – 2:15 Break 2:15 – 4:30 Read & sign PCS Manual RN ORIENTATION 7:45 – 9:45 Issue Nursing supplies 9:45 – 10:00 Break 10:00 – Noon Begin reading Policy & Procedures Manual Noon - 12:45 Lunch 12:45 – 1:45 Scavenger Hunt 1:45 – 2:00 Break 2:00 – 4:30 Finish reading and sign Policy & Procedure Manual
RN ORIENTATION 7:45 – 10:00 Read & Sign Infection Control Policy 10:00 – 10:15 Break 10:15 – Noon Admission packet Noon – 12:45 Lunch 12:45 – 1:45 Discharge packet 2:00 – 2:15 Break 2:15 – 4:30 OASIS training CNA ORIENTATION 7:45 – 9:45 Issue CNA bag & supplies 9:45 – 10:00 Break 10:00 – Noon Begin reading Policy & Procedures Manual Noon - 12:45 Lunch 12:45 – 1:45 Scavenger Hunt 1:45 – 2:00 Break 2:00 – 4:30 Finish reading and sign Policy & Procedure Manual
CNA ORIENTATION 7:45 – 10:00 Read & Sign Infection Control Policy 10:00 – 10:15 Break 10:15 – Noon Review information gives patient during admission visit Noon – 12:45 Lunch 12:45 – 1:45 Community resources available to assist with patient care 2:00 – 2:15 Break 2:15 – 4:30 Review Signs & Symptoms of stroke, heart attack and action
to take
ADMINISTRATIVE STAFF ORIENTATION 7:45 – 9:45 Instructions on how to answer the phone and relaying messages 9:45 – 10:00 Break 10:00 – Noon Rounds Noon - 12:45 Lunch 12:45 – 1:45 Scavenger Hunt 1:45 – 2:00 Break 2:00 – 4:30 Finish reading and sign Policy & Procedure Manual
ADMINISTRATIVE STAFF ORIENTATION 7:45 – 10:00 Read & Sign Infection Control Policy 10:00 – 10:15 Break 10:15 – Noon Rounds Noon – 12:45 Lunch 12:45 – 1:45 Read & sign MSDS Manual 2:00 – 2:15 Break 2:15 – 4:30 Mail WRITE DOWN THE LOCATION FOR THE FOLLOWING: BRING THE FOLLOWING TO SHARON: Blank 485 CNA WRITE DOWN THE LOCATION FOR THE FOLLOWING: BRING THE FOLLOWING TO VIVIAN: WRITE DOWN THE LOCATION FOR THE FOLLOWING: BRING THE FOLLOWING TO CATHEY: Daily activity sheet WRITE DOWN THE LOCATION FOR THE FOLLOWING: BRING THE FOLLOWING TO SUZETTE:
Health and Medical Division SUBJECT: Contract Aide Orientation PURPOSE: To introduce new Contract Aides to policies, procedures, and forms. STAFF GOVERNED BY THIS POLICY: Contract Aides EFFECTIVE DATE: DATE REVIEWED OR REVISED: DISTRIBUTION: Contract Aides POLICY: Contract Aide 7:45 – 8:00 Meet with Supervisor 8:00 – 10:00 Signing of Confidentiality policy, sign SBI background check form 10:00 – 10:15 Break 10:15 – Noon Meet with Director (Cathey) Noon – 12:45 Lunch 12:45 – 2:00 Read & sign PCS & CAP Manuals 2:00 – 2:15 Break 2:15 – 4:30 Read and sign Policy & Procedure Manual CNA ORIENTATION 7:45 – 9:45 Blood borne pathogen video or instructions Read & sign MSDS Manual Issue CNA bag & supplies Scavenger Hunt Home visit accompanied by Supervisor Question/answer period WRITE DOWN THE LOCATION FOR THE FOLLOWING: BRING THE FOLLOWING TO DEBBIE: |