Rule 111-8-31-.07 - Administrative Standards(1) Organizations, Services, Administration. Organizations, services provided, administrative control, and lines of authority for the delegation of responsibility down to the patient care level shall be clearly set forth in written policies and procedures. Administrative and supervisory functions shall not be delegated to another agency or organization. Services not provided directly shall be monitored and controlled by the primary agency, including services provided through subunits of the parent agency. If an agency has subunits, appropriate administrative records shall be maintained for each subunit.(2) Governing Body. There shall be a governing body which assumes full legal authority and responsibility for the operation of each home health agency. The governing body shall appoint a qualified administrator, arrange for professional advice, adopt and periodically review written bylaws and oversee the management and fiscal affairs of the agency. The name and address of each officer, directors, and owner shall be disclosed to the Department. If the agency is a corporation, all ownership interests of five (5) percent or more (direct or indirect) shall also be disclosed.(3) Group of Professional Personnel.(a) A group of professional personnel, which shall include at least one physician and one registered nurse, with appropriate representation from other professional disciplines, shall establish and annually review the policies of each home health agency governing scope of services offered, admission and discharge policies, medical supervision and plans of treatment, emergency care, clinical records, personnel qualifications, and program evaluation. There must be at least one member of the group who is neither an owner nor an employee of the agency.(b) The group of professional personnel shall meet at least once per quarter unless circumstances require more often to advise the agency on professional issues, to participate in the evaluation of the agency's program, and to assist the agency in maintaining liaison with other health care providers in the community and in its community information program. The minutes shall be documented by dated minutes.(4) Administrator. The administrator (who may also be the supervising physician or registered nurse), is responsible for organizing and directing the agency's ongoing functions; maintaining ongoing liaison among the governing body, the group of professional personnel, and the staff; employing qualified personnel and ensuring adequate staff education and evaluations; ensuring the accuracy of public information, materials and activities; and implementing an effective budgeting and accounting system. A qualified person shall be authorized in writing to act in the absence of the administrator.(5) Supervising Physician or Registered Nurse. Skilled nursing and other therapeutic services provided shall be under the supervision and direction of a physician or a registered nurse. This person or similarly qualified alternate shall be available at all times during operating hours and: participate in all activities relevant to the professional services provided, including the developing of qualifications and assignments of personnel.(6) Personnel Policies. Personnel practices shall be supported by appropriate, written personnel policies. Individual personnel records shall include job descriptions, qualifications, licenses, performance evaluations, and health examinations, and shall be kept current. If personnel under hourly or per visit contracts are utilized by the home health agency, there shall be a written contract between such personnel and the agency clearly designating: (a) that patients are accepted for care only by the primary home health agency;(b) the services to be provided;(c) the necessity to conform to all applicable agency policies including personnel qualifications;(d) the responsibility for participating in developing plans of treatment;(e) the manner in which services will be controlled, coordinated, and evaluated by the primary agency;(f) the procedures for submitting clinical and progress notes, scheduling of visits, periodic patient evaluation; and(g) the procedure for determining charges and reimbursement.(7) Planning and Budget. A home health agency, under the direction of the governing body, shall prepare an overall plan and budget which provides for an annual operating budget. If capital expenditures are anticipated, a three-year capital expenditure plan shall be provided and updated annually. The overall plan, budget and capital expenditure plan shall be reviewed and updated at least annually. (8) Evaluation. (a) A home health agency shall have written policies requiring an overall evaluation of the agency's total program at least once a year by the group of professional personnel (or a committee of this group), home health agency staff, and consumers; or by professional people outside the agency working in conjunction with consumers. The evaluation shall consist of an overall policy and administrative review and a clinical record review. The evaluation shall assess the extent to which the agency's program is appropriate, adequate, effective and efficient. Results of the evaluation shall be reported to the governing body and maintained separately as administrative records. Mechanisms shall be established in writing for the collection of pertinent data to assist in this evaluation. This data to be considered may include but is not limited to: 1. number of patients receiving each service offered;2. number of patient visits;3. reasons for discharge;4. breakdown by diagnosis;6. number of patients not accepted with reasons; and7. total staff days for each service offered.(b) At least quarterly, appropriate health professionals representing at least the scope of the program, shall review a sample of both active and closed clinical records to assure that established policies are followed in providing services (direct services as well as services under arrangement). Evidence of this review shall be documented by dated minutes.Ga. Comp. R. & Regs. R. 111-8-31-.07
O.C.G.A. §§ 31-2-4et seq. and 31-7-150 et seq.
Original Rule entitled "Administrative Standards" adopted. F. Feb. 20, 2013; eff. Mar. 12, 2013.