5.A. Organizational Structure and Lines of
Authority
All Home Health Care Services Providers will identify in
writing the services provided, administrative control, and lines of authority
for the delegation of responsibility down to the patient/client care level. A
policy and procedure manual(s), including patient care protocols, for the
organization and operation of the facility shall be established implemented and
reviewed at least annually. Each review of the manual(s) shall be documented
and dated. This written material shall be maintained at the home health care
agency's main office so that Department staff can examine it during monitoring
visits. This material will include:
5.A.1. A statement describing the
organizational goal(s) of the home health care agency, its philosophy and
objectives and the services provided by the agency,
5.A.2. An organizational diagram clearly
outlining the relationship between personnel having responsibility and
accountability within the organization including any sub units of the
provider,
5.A.3. Job description of
the Administrator. The administrator is a person having the authority and
responsibility for the operation of the home health care services agency and
for staff performance in accordance with applicable requirements and policies
of the agency. The administrator is a licensed physician, registered nurse, or
a individual who has training and experience in a health services
administration, with at least one (1) year of supervisory or administrative
experience in home health care services or related health programs.
5.A.4. Job descriptions of employees. These
job descriptions shall include the qualifications necessary for the position,
an outline of the scope of duties, competencies, responsibilities and
accountability required of employees in that position;
5.A.5. A description of the orientation
programs provided for employees directly employed by the home haft care agency.
This orientation information shall indicate:
a. The organization goals of the
agency,
b. The review of the
agency's policies and procedures;
c. Ongoing inservice programs and staff
training;
d. Other community
resources related to the delivery of home health care services;
e. Job duties to be performed by the
employees;
f. Job duties to be
performed by other Home Health Care Services Provider personnel and a
description of the relationship of these duties to patient/client
care
g. Patient/chat care
protocols; and
h. A review of the
agency's written protocols for the identification and reporting of abuse,
neglect, or misappropriation of client's/patient's
property.
5.A.6. If the
organization has an advisory or governing body a set of by-laws specifying the
following will be required:
a.
Membership;
b. Authority;
c. Administration's role,
d. Frequency of meetings, and
e. Recorded minutes.
The by-laws shall be adopted and updated as deemed necessary
by the advisory or governing body.
5.B. Business Records
5.B.1. Business records of the Home Health
Care Services Provider shall be kept and retained in a manner consistent with
all applicable city, state and federal laws, ordinances and regulations with
proper audit trails available. Business records, contracts, and newspaper
advertisements will be retained for a minimum of five (5) years.
5.B.2. If a Home Health Care Services
Provider has sub units, relevant administrative records shall be maintained for
each sub unit.
5.B.3. Copies of the
current licenses of all licensed health professionals employed directly or
through a contractual relationship with the agency shall be maintained by the
agency. Certificates verifying completion of applicable training courses for
all certified nursing assistants ad home health aides employed directly or
through a contractual relationship by the agency shall also be maintained by
the agency.
5.B.4. The Home Health
Care Services Provider shall keep a personnel file for each health care
professional and paraprofessional employed or contracted which shall include,
but not be limited to:
a. An
application;
b. Evidence of current
qualifications;
c. Evidence of
orientation and inservice training;
d. Periodic
evaluations.
5.C. Qualifications for Professional
Personnel
The following health care professionals employed directly or
through a contractual relationship with a home health care agency may provide
home health care services by virtue of possession of a current license to
practice their health care discipline in the State of Maine:
5.C.1. Registered professional
nurses;
5.C.2. Physical
therapists;
5.C.3. Speech
pathologists;
5.C.4. Occupational
therapists,
5.C.5. Social
workers;
5.C.6. Licensed practical
nurses; and
5.C.7.
Dietitians.
5.D. Quality
Assurance
The Home Health Care Services Provider shall establish a
quality assurance program. The program will reflect ongoing objective
assessment of important aspects of patient/client care and the correction of
identified problems. It will consist of a clinical record review at least
quarterly and an overall agency review at least annually, The results of the
review/evaluation are reported to, and acted upon, by those responsible for
operation of the agency.
