Section 11-97.1-6 - Policies and procedures and standards(a) A satisfactory statement of policy of the home health agency, including the scope of services, the conditions under which they are offered, and the geographic coverage, shall be available to the department upon request.(b) Services provided by the home health agency shall be available to any qualified patient in a home setting in the geographic area of the home health agency regardless of race, color, or national origin. Contracts with other agencies to provide services shall be approved by authorized persons of agencies involved,(c) The basic services of nursing shall be provided by the home health agency.(d) Policies governing medical services shall be provided through a governing body or designated persons functioning as a governing body.(e) Policies governing nursing and other therapeutic services shall be provided through the governing body or an advisory committee which shall include a minimum of at least a practicing physician or APRN or physician's assistant, and a registered nurse, a representative of other professional services such as dietary, occupational therapy, physical therapy, social work, or speech therapy, and community members who are aware of the needs of the community. The policies recommended by such committee shall meet current and acceptable professional practices. Minutes shall be kept of all meetings.(f) Nursing and other therapeutic service policies shall be established and include but not be limited to: (1) Nursing and other therapeutic services provided shall be in accordance with the physician's or APRN's or physician's assistant's written order and plan of treatment.(2) The nurses, therapists, social workers, aide, or staff members rendering services shall meet qualifications prescribed in the definitions of this chapter.(3) A home health agency provides nursing services, and at least one other therapeutic service such as physical therapy, occupational therapy, or speech therapy consistent with the definition of home health services.(4) When a home health agency does not provide all the nursing or therapeutic services specified above. it shall include in its written policies which govern such services, a plan for identifying, utilizing and cooperating with other resources and facilities including community social agencies for the purpose of providing such services to patients. The home health agency may arrange for the services which it does not provide by written agreements with other licensed home health agencies or by contracts with health professionals who shall meet the requirements of this chapter.(g) Medical records. (1) A clinical record for each patient shall be maintained based on standards acceptable to the department;(2) All staff responsible for specific professional aspects of care to a patient shall record in the patient's record information about the services rendered.(h) Establishment and review plan of treatment.(1) A home health agency shall establish policies and procedures for assuring that care services to be provided are specified under the plan of treatment ordered, established, and regularly signed by the physician or APRN or physician assistant responsible for the care of the patient.(2) The plan of treatment ordered by the physician or APRN or physician assistant shall be signed by the physician or APRN or physician assistant responsible for the patient and incorporated into the patient's medical record.(3) The total plan shall be reviewed by the attending physician or APRN or physician assistant, in consultation with the agency's professional personnel at such intervals as the severity of the patient's condition may require, but not less than once every two months.(4) The professional staff shall bring to the attention of the patient's physician or APRN or physician assistant changes in the patient's condition which may indicate the need for altering the treatment plan or for the termination of service or services.(5) Only the attending physician or APRN or physician assistant shall terminate services. Upon termination of services, the physician or APRN or physician assistant shall prepare or approve a written discharge summary which includes reasons for termination of services, the patient's medical condition upon discharge and a summary of the course of the patient's illness.(6) All orders shall be signed by the physician or APRN or physician assistant.(7) When verbal orders are received by the professional nurse or other professional disciplines they shall be signed by the physician or APRN or physician assistant within a reasonable period of time.(i) Home health agency shall provide:(1) Written job descriptions which specify the qualifications and experience of each category of health personnel and the type of activity each category of health personnel may perform;(2) Written personnel policies to each staff member; and(3) A plan for a pre-employment and periodic medical examination, tuberculosis testing and/or chest x-ray and other appropriate tests and immunizations for all home health agency personnel(j) Home health agency shall provide for all personnel rendering service to patients, a planned program of orientation to the agency's policies and objectives and a continuous in service education program.(k) Maintenance of records and reports. (1) Clinical records, service reports, fiscal reports, job descriptions, personnel reports, personnel policies and rosters, cost accounting data, committee reports, statements of policies, and such other records and reports as may be required shall be kept on file in the agency's office.(2) When a home health agency is a subdivision of a parent agency or organization, the fiscal accounting system shall be maintained in such a method to permit the costs of the home health agency to be easily identifiable.(3) Home health agency shall keep confidential all medical, nursing, paramedical, therapeutical, personnel, and financial information relating to each patient and make such available only to authorized persons. (l) A home health agency shall develop, implement, evaluate, and maintain an effective, ongoing, agency-wide, data-driven quality assessment and performance improvement program that reflects the complexity of its organization and services, involves all services including those services provided under contract or arrangement, focuses on indicators related to improved outcomes, and shall maintain documentary evidence of its quality assessment and performance improvement program.(m) A home health agency shall follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases.(n) A home health agency shall provide a periodic evaluation of employee performance.(o) The director may approve a modification of standards for a home health agency when exceptional circumstances warrant such modification.[Eff 9/16/2022] (Auth: HRS Sec. 321-11) (Imp: HRS Sec. 321-11)