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HomeMy WebLinkAbout04/09/1975 626 0063/ MINUTES OF BOARD OF HEALTH MEETING - April 9, 1975 Present: Dr. James Smith, Chairman, Mr. George L'hadwick, Mr. Joe Reeves, Mr. Bruce Freeman, Mr. W. K. Whitmire, Mrs. Vivian Wright and County Manager Dan Eller and County Attorney James Fox Absent: Dr. F. Reynolds, Dr. James TidIer and Mr. R. E. Carter Minutes of the March meeting were approved as presented. Home Health A2enCy Policies: The proposed Home Health Agency Policies were amended to include: "As the members rotate off the Advisory Council, re- placements are to be appointed by Dr. Knox and his Administrative Staff, with approval of the Board of Health." With this amendment, the policies were approved. Mr. Whitmire made the motion, seconded by Mrs. Wright. The motion carried unanimously. (Copy of policies attached to permanent minutes). Tentative Bud2et for 1975-76: After much discussion of the budget as presented by the Health Director, Mr. Chadwick made a motion that the budget be adopted. There was no second to the motion. Mr. Whitmire made a substitute motion that the budget be adopted as presented, but that this board request the County Commissioners to scrutinize the 5% cost of living increase and step increases. The substitute motion was seconded by Mr. Chadwick and carried. Mrs. Wright abstained from voting but asked that it be recorded in the minutes that she appreciates the recommendation from this board to the County Commissioners. Capital Outlay - Equipment: Dr. Knox requested permission to use approxi- mately $2,500 of the money from the capital outlay-equipment account to _~ purchase a new centrifuge for the laboratory and an additional filing cabinet for the clinic area. Motion was made by Mr. Reeves, seconded by Mr. Chadwick that we ask the County Commissioners for permission to purchase these items. Motion carried unanimously. V. D. Control: Mr. Bobby Waters, Public Health Investigator on the staff of the Health Department presented a very interesting program on veneral diseases, giving statistics with graphs, etc. Members present commended Mr. Waters for the good job done and by common consent asked that arrangements be made for Mr. Waters to present this program to the Board of Education since the highest age group involvement seems to be high school students. It was also sug- gested that we should work with UNC-W and Cape Fear Tech. Dr. Knox will contact Dr. Heyward Bellamy, Superintendent of Schools, to arrange for Mr. Waters,to speak to the Board of Education as a beginning point. There being no further business, the meeting was adjourned. Respectfully submitted, Approved: May 7, 1975 /J{~ 73. ;fJ~ ~~k~ NL I-LiilO1lE:? COUNTY H}1,LTH DEPilRT:IENT IILiIHGTON t NOl1TH CAUOLINA POLIG:::~;;S GOvJ.;;nuoo HOlle; H&,LTH SG;1VIC"S i.JURSING S;~TION of the IlULTH DEPARTl mIT :?evised: September, 1971, ~ 7Yz~ 7 -4t '7 ~- POLICES FOR HOt;E m,ALTH AGENCY NEil I-hNOVm COUNTY 1l&\LTH D2PA;'1T::.<:NT 'lIliiINGTOH. NORTH CA:tOLIlIA SEPT.l:idm, 1974 405.1221 Standard a: Home health service is one component of the overall public health nursing program of the Neu Hanover County Health Department. The purpose of this service is to. under orders of a physician or dentist licensed to practice in North Carolina. provide on an intermittent basis certain skilled rmrsir18. physical therapy and home health aide needs, Hhich can be safely met in the home setting. to any homebound patient uithout regard to age. sex, creed, national origin or ability to pay. standard b: The governing body of this ,\gency is the local Board of Health ~:hose members are: Dr. James Smith, Chairman i'urchison BuildinG Dr. James Tidler 1919 South 16th street I~. Bruce R. Freeman llt. 2, Box 21.5 A dr. ij. ~{.:hi tmire P. O. Box 2007 Ix. R. E. Carter 2001 Princess Place Drive dr. Georse Chadllick 32051riehtsville Averme l,r. J. il.. Reaves 2502 South 17th street Dr. Frank Reynolds 1613 Jock street tJrs. Vivian S./right 2$()9 Hel/lurk Avenue This board assumes full legal authority and responsibility for the operation of the Agency. It has adopted and periodically reviells these policies and oversees the management and fiscal affairs of the j,gency. It has appointed the health director as the qualified administrator of the program. standard c: As administrator the Ilealth Director directs the Agency's program; maintains liason among the Board of Health, the J~dvisory Council and the staff; employs qu:.:.lified nersonnel and ensures adequate in-service education and evaluations; oversees all other aspects of the program. In the absence of the health director he has designated the rmrsing supervisor or director to act as administrator. Standard d: The services of this Home Health Agency are under the supervision and direction of the health director, the rmrsing director and or supervisors, one of \-Thom is available at all times durinG operating hours. - < - 'ltandard e: The l"Ules and, re~lations in the ~rsonnel ?olicies. !.2E. ]Ecal Goverrunent E1,lploymen! ~.J.e.c~ i~ !d!! 3,tat':. ~rsonn!l.~ ;~ ~rill be follo11ed in em;Jloyill(; staff t establis..'1ing c1.:.ssification, setting salary. hours of lTorlet vacation and sick leave. III enr;>loyees ,rill have a s'dn test and/or Chest X-~t serology c.nd other appropriate tests as indicated anrmally to determine freeLoiU from co,mllunicable disease. Il.ej'JOrts of all such tests shall be ',e;Jt in the confidential ;Jersonnel .rile of each elilployee. J.:uch ne'.! staff member is .:;iven .m orientation cOlllnensurata to eX!1ibited needs. Evaluation of the \!or~, load anri performaTlce of each person ~rill be made in Ilriting alUl\ld.lly (Ol' as necessaL"J) and leept in the individual's confidential personnel rile, alol1[; ,rith the job description of the position Clhicb the person fills. The qualifications and licensure of all staff are com;xl.led and '.e,t up to date and retained in a separate file folder. Professional liability insuranee shall be carried on all professional stafr t the a=l IJreilliu"l beil1[; su;Jportec' 'r1y the county. In-service education is planned ~l offered to leeep staff abreast of ~1 prozrams and developments in the health field in :.;eneral as ,'!ell as fulfilline e::pressed needs of Gl'OUps arrl/or individuals. Standard f: F\Jysical thera;JY services lrill be IJrovide<l on an hourl;v basis under contract ~rith a Licensed ~ysical l~erapist. Part time nursinJ ssrvices to [.I.::le )atients lrill be furnished on a ;:Jer visit basis by a :nale Home Heulth Aicee .::nd a mule Licensed ?r.::ctical llurse as 1011[; as they are dvailable.. These contracts are maintained in a separate file folder. '3tancJ.al"C 5: Coordination of ;Jatient services is rmntained throu@1 inter- chan3e of information, re,'JOrting and recordill(; by all ;Jersonnel involved I-rith the lJatients' care. Tllis is cone by tele)hone, by personal contact and/or 'r1y a ..titten &Ul,ll,l<lry bein,3 sent to the physician at least ever.! 60 cleys, a cow of ~!hich is incor,lOrated in the :>atinets' record. - 3 - 405.1222 The Advisory Council of this Home Health >'gency consists of the following representation: one lic<;:nsed physician, three reeistered professional nurses, one physical therapist, one pharmacist, one social \~orker and t\~O interested citizens. The health director. nursing director and nursing supervisors are permanent ex-officio members of the Council. The chairman of the Council is elected by the members. The term of all members is three years. A member may succeed himself for a second term but should go off the Council for at least one year after each tll0 consecutive terms of service before being considered for re-appointment. Appointment ta the Council shall be made by the Health Director and his administrative staff and approved by the Board of Health. The functions of the Advisory Council shall be to assist the "gency \1ith: 1. Program development 2. Reviet1ing these policies periodically and revising them as necessary. 3. Program evaluation 4. Public relations The council shall meet quart:.erly. Special meetin3s may be called at the discretion of the chairman. Dated minutes of all meetings shall be kept. on file. 405.1223 Home Health Services provided to homebound patients on an intermittent basis are skilled nursing physical therapy and home health aide. A Homebound patient is one who i.s essentially confined to his place of residence due to an illness or injury and, if ambulatory or otheI'l'lise mobile, is unable to be absent from his residence except for periods of relatively short duration, e.g., fer visit to doctor's office. to barber shop, for a short ~lalk prescribed as therapeutic exercise. Intermittent basis means that service ~rill require a fe~' hours a day, several times a l'Ieek. Some patients may require longer service on one day than on other days and such adjustments are to be encouraged. Occasionally, because of special circumstances occurring during a brief period, service for a full day may need to be provided. - h - I. Admission Policies and i'jedical SU1)0rvisioi1 --- ---- - - ----- ,.. The patient shall be u11<1er the su,1ervision of a physician ,Iho provides and or coorclinates orders for his care. ll. The res')onsibility for seeJd113 medical care belongs :>rimariJ.;r to the i'al:1iJ.;r. :-!ealth Department personnel, uhile in the home, do not summon D. physician except in the case of a real emersency. c. ,.n alternate physician ma;)' be named by the family to ;Jrovide care :Ihen the reGUlar :;X1Ysician is not avdilable. -). If the i'arson ,~ivin7> care finds th&.-c._ the patient has chan3ed medical supervision, she may not S"ive fU1'ther C2re until neH !!I'itten orders have been obtaine~. :~. If, on first visit, the nurse finds that the ')/itient is not under meclical SU;Jervision, she should explain to :'Jatisnt and family that raer1ical su,10rvision is essential for continued service, and that she crill return U"lOn request 0-' patient's olJ.c'sician. II. z.~.2! !r.~~tl:.1..ent. I. Rec,uest for s"'''vice and 01,(1ers for care lrill be acce'Jt,ed from :>l1ysicLms el11L. "~n+.ists licensed to ;:>ractice in the state of ..lorth '~LrolinOi and IJro,,+,icinr\ ,.rithin a reasona.1Jle radius of the Iiealth Departr'lent. ll. [,adicul orders uill be acce;Jted f,'om p.'1ysicians in hospitals and nursin:> homes uhich Lre beyond r",",sonable radius of the c.~:;ency. (3uch as Veterans "c!ministration H03pitals and out- patient clinics at Duke and Iiemorial lIosj11tal in Chapel lIill). Ii', hOHaver, the referrinG :mysician is not responsible for the ;Jatiant's l:laclical care at home, the local family ph~'dciun should. be contacted for a?proval of orders "cfore, or j romediately, follman,; the fir,,+. visit. Ii' no local physiciau h~s been selected by the family, this shou.ld be done befora a ".."one! visit is made. ,rhen ;z>s"ible, the ;>Q.t.ient or the fumil::l tAll be res"9Qnsi.ble for securin.:; or..-lers froin the physician. c. 'lritten Ol''(lers for patient eare era to be procured from the }h'lld.cLm and sif_~ne(1. b~r him. ~'1.. rec;istered. nurne may accept verbal oroe:6 'l.'rom a phyn;_ci~n in some instances, Ol1.t t.hese are to hq fo1.1o''I(,;;u. \'nt.h11. three days 1~' l~ltten orders an0 before the service is repeated. '1. Orders for nurcoti"" and dangerous dr\J.[;s trust be received in ~!I'iting and signerl by the physic'i~n 'J~Ti'0rv~ beinr; d.(JJ:d.nis-tercd. C. Ver':>al or('.er5 cannot be accarrr.ed from the patient or family. - 5 - F. Uhen obtaining orders from the physicians. specific information shall be requested l1ith regard to: Diagnosis and treatment [iedications and dressings Dosage and interval Nutritional requirements ;rethod preferred for administering medication or treatment Frequency of treatment Precautions, if any Prognosis G. All orders for patient care must be reviel1ed by the physician and reneued in uriting every tllO months. R.ene~lal forms trill be provided for the physician by the aGency at the appropriate time. III. Request!2r Service A. '!be agency reserves the right to make discretionary judgment if and llhen adequate staff is not available. aec;uest from physician for service trill be ans',rered I'lith a minimum of delay. Requests received before 9:00 a.m. lrill be made the same day uhen possible. Rec,uests received later than 9:00 a.m. trill be ansllered the follotring day, or on the nurse's first visit to the area. Nell orders for treatment lrill not be initiated betlleen Friday noon and Iionday 8:00 a.m., nor on holidays. B. The nursinG staff \rill call the office betl'leen 12:00 and 2:00 p.m. to receive calls that need more immediate attention. C. Frequency and duration of visits trill be determined according to medical orders, needs of patient and availability of staff. D. forking hours of the nursing staff lrill conform to the regular agency schedule - i-londay through Friday. 1. Nursing service on Saturday, Sunday, and holidays lrill be extremely limited. All orders for medication and treatments trill be scheduled for regular l'yorking days '-mENEVER roSSIBill. E. The nursing staff ,.rill receive compensatory time for \'Ieek-end and holiday service. They trill be expected to take this time the follolring ueek. - 6 - l1'. A s;Jecific hour for visits cannot be Jivenj atteln,?ts !Iill be made to foll~'1 a practicable schedule for patient and staff. IV.'tesponsibilitz f,. Patient lJi.ll be expected to select a ph~rsician and to remain under medical supervision. 0. Patients I.rill be expected to secure all medications and dressi~"ls and as milch equipment as is feasible. c. .\ member of the householC. must be 'rilling and able to assume responsi- bility for care of the patient bettTeen nursing visits. J. The patient, c.rhen possible, or a household member lrill be expected to learn to assume responsibility for procedures "Ihich, in the opinion of the physician, can be safely t;;.ue;ht the individual. v. payment.J2!. ~ Health Services ". Philosophy of fee collection 1. The family's financial status doos not determi.ne the pat.~nt' s need for home health services. 2. The charGe for home visits ~Ji.ll be based on a cost established by an annual cost report. 3. !hen families aloe unable to ,)Uy full fee and are ineligible for contract services \'lith insurance Cor.lpanies, the fee is adjusted in accordance ,dth the (juir:e for'urses (Fee Scale) and/or abilit~' of the fami~ to ;x.y. Tho fee uill be l'e-evaluated annually or sooner, if the fa,rl.J.;f situ&tion chan~es. " t.... iethod of fee collection: The person ma!dll3 the visit every effort to collect fees at the time of the visit. unable to do this, the patient may be billed. lrill ma'ce If she is _r. Jischarge ~l:i.cies ''lervice trill be terIilinatec1. Nhan on consultation lrith physician, nurse, supenisor, physical thera7i.st, and other professional ;>ersonnel involved, it is cletermined that the: 1. Patient has reached his md;;it:n.Jm benefit from services. 2. Patient's condition halO sl.,mili.7.ad ",nd other suitable arrall3efflnts can be made. 3. Patients alli'./or fD.l'rl.ly have ?I'oven not to M acc"r'''.i.nr: or cooperatinG :dth '11an for c<lI'e. h. Sldllcd care is no 101l3er necessary. - 7 - 5. Patient's condition has deteriorated so that intermittent care is no longer sufficient and other arrangements should be made. 6. Physical environment is no longer suitable for patient's care. 7. other demands for agency service have higher priority based on medical and nursing needs and resources of agency are inadeCluate to continue this care. VII. Nursillf, ~ a. ( 1) ( 2) ( 3) ( 4) ( 5) ( 6) ( 7) ( S) ( 9) (10) (11) (12) (13 ) (14) (15) b. Examples of nursing care uhich the agency ,lill provide in the home are: subcutaneous and intramuscular injections (excluding drugs for treatment of allergies, immunizing, and first injections of penicillin). catherization of female patients (except first catheterization tlhen there is a history of obstruction or tumor). catherization of, or enema for male patients (as long as services of a male nurse or aide are available). irrigation and care of retention catheter dressings colostomy care enema douche bed or tub bath sldn care feedinG positionill[; simple exercises care of tracheoto~J blood pressure 3xamp1es of nursilll> care ~lhich the agency does !!2i provide in the home: ( 1) giving blood transfusions ( 2) gi vill[; intravenous fluids ( 3) Giving fluids by hypodermoclysis ( 4) removill3 suture s (5) insertion and removal of outer tracheotomy tube ( 6) first injection of penicillin (7) imriRlnizing agents and drugs for the treatment of allergies. n v ( 3) visits to ;JOtentially violent ~tients ( 9) insertion of Levine tube (10) insertion or removal of supra}Ubic catheter c. The follouinG nursing activities are a part of all public heD.lth nursin::; visits and trill be continued in the home nursing cnre program: (1) instruction and ~uidance in relation to diseases (2) instruction and Guidance in General health ;JI'omotion ( :3) emotional sup;JOrt, 3Ui(~ance and counseling in acceptin;.; D.nd adjusting to illness and its limitations. (4) guid~nce in use of community resources VIII. ~ndinc. Orc:.ers <.."1.. PurrlO so: stanrling orders are authorized by the Health Director. These orders [;uic:.e the nursin;~ staff of the agency in givinG nursing care lIhen: (1) Services lIhich may be renderec' '1ithout a medical Ol'c:.ei" on a first visit include: (11) te''''Jei'ature, :rulse, res)iration and blood ;)ressure (1)) S')Qn;;e bath or partial care if not contraindicated. (no tub bath t1ithout 'lhysician's order) (c) cure of ",)l"'0SSUre sore - cleo.nse uell .dth soa'') 2.nc~ ", Tater _ relieve .I)1"'cssure - instruct in !(cepin.'3 areQ clenn and dry - chan3c position. (2) Emer,~ency orc1.;)rs for severe druC reaction (a) the public health rn.li'se \1ill contact the patient's physic inn for er.:er;~~cncy or(ers if l)()ssible (b) if physician cannot be reached, or if reaction is so sudtlen and severE: that dekJr is not feasi"ule, the public health nurse .rill administer 3 - 5 minil.lS of aclre=lin chloride 1: 1000 solution, :rhich she ~rl.ll carry in her nursing bo.:::;. (c) the nurse lrill contact su~)()rvisory personnel c.t th0 IIec.lth 'Jepartment as soon "-s :x>ssible to notifj' them of the C1Jer.:;ency and 2..ction ta1"en. Su)ervisory personnel 1:111 help obtain or advise about emergency mec'icd supervision fo"' the patient if this has not been arran.1ed for. 9 - (d) in an emer:::;ency the nurse should remain crith the :w.tient until medical sU;JOrvision can be obtained. In some instances, the most :::>ractical means of obtainin;; emer::;ency medicDl supervision may be havin;; the patient moved to the hospital emergency room. The nursinij staff, hO'Jever, does not trans- ;JOrt patients and/or families. IX. Licensed Practical Nurse - 405.' ??';) I.. Supervisory ~elationships betueen the ReGistered Nurse and the Licensed Practical Nurse in the Home Health Care Program. A. The Licensed Practical llurse is clirectl,y res:x>nsible to the llegistered Nurse. 3. Initial visit <:nd evaluation to all nel/ patients /.1V.<".e by the .1e::;istered ;lurse. The case record is o;xmed at this time and relative information obtained. C. The ite::;istered Nurse is res;JOnsible for carrying out the follo:ril1G: 1. Co-ordinates the duties of the L.P .li. in the Home Health G;;:;.re Progrm:l. 2. j~valuates :::>atient's care plan and proGress. 3. j;v<:luates the duties and lJOrformance of the L.P.N. as they relate to the patient's care plan and progress. 4. The n.ll. ;rill make a nursing visit to the patient uhen needed as indicated and also uhen rec;uested by L.P.N. D. Rec;istered Burse is res'X)nsible for nursillG care of the Home Health Care ProGram patients IIhich are assigned to the Licensed 'Tactical :.iurse. 1. n.ll. and 1.;>.11. confer at regular intervals concernin,; p~tient cuTe and proGress. 2. aecord should reflect the consultation of R.N. and the L.P.l1. re~ard.iUG the patient. ~1!Y_~ica! 1!leI2I'Y 2!"!.YJ.ces Physical therapy services :rl11 be provided by a Licensed Physical Therapist under a contract. Physical thernpy ,rill be a<lministered onl,y by a person registered to practice :i1ysic2.1 therapy in the state of North Carolina. 1. Physical then,py visits IIi n be made to carr"J out physician's orders. 2. Procedures j.rill be <>t\ministe!'ed a.cc<>-rding to accepted physical therapy practices. !hen indic3-ted and feasib:v-" and '.rith the consent of the :Jhysician, many yrocedures n..y bo tau::;ht to a member of the famil,y or other responsible )e.,,()n ion the '.ousehold. ~ J. - 10 - 4. it \1!'itten report of visits 'Jill be maintained in the aeency office and periodic reports ,lill be transmitted to the physician. l~mples of procedures ~hich the physical therapist must administer: 1. MUscle testinz, joint range, ambulation and other )hysical evaluation procedures. 2. therapeutic exercises. 3. selecting and teaching proper gait pattern(s). h. determinil15 proeression of treatment ?lan. 5. application of any modality involving the therapeutic use of electricity. SJ:ar.lples of procedures uhich the phynical therapist may tcach and su~rvise : 1. application of heat or cold. 2. TJOsitioning. 3. therapeutic pro~ram of passive and active e;mrcises. h. supervise nractice of transfer and ambulation activities. Consultation and cooTJeration in planninG and implementing services: 1. participation on advisory committees. 2. assist :lith traininG and utilization of non-professional l:>ersonncl. -11- I'ffiSOihL CJh'U AND F.'liiILY "IDS SffiVICE DEFINITIOn: The Health Aide is a non-professional member of the nursing team uho uorks directly under the su;JCrvision of the Public Health Nurse. The Health Aide is administratively responsible to the Health Director through the Director of Nurses. f}UALIFIC"TIONS: * As home health aides are employed, they I-rill be carefully screened and must meet the fol101ring qualifications: 1. Education: Graduate of an accredited high school or meet equivalency qualification. i1Ust have the ability to understand directions and to communicate inforraation about the patient's needs and progress. (Experience in porviding non-technical assistance to professional personnel in a health department may be substituted for the high school education on a year for year basis - lierit System.) 2. Age: ;.ge is a factor only as it relates to the expected degree of maturity. The candidate should behave like an adult uho is capable of follolrin" instructions, observing reactions, and change, and communicating lrith the patient, nurse, and others concerned lrith the care of the patient. :3. Appearance: Good personal GTooming is expected of the Home Health Aide since she may be called upon at any time to provide direct personal care to patients in any class of home. 4. Attitudes: The candidate should communicate a belief in the uorth and dignity of the patient, as uell as the job. 5. Health status: The Aide must be free from health problems that may be injurious to the patient, or to herself as she performs deleGated tasks. Also, she must shOll evidence of the practice of good personal health habits. 6. Previous Training and/or Experience: It is preferable for the candidate to have successfully completed the course for Home Health Aides in Public Health uhich is approved by the Public Health Nursing Section of the state Board of Health. HO\'lever, consideration ,-Jill also be Biven to applicants uho have trained and \'lorked in a hospital setting \'lhen quality references are given. PRRSONNEL POLICIES: Same as for all staff members. * Alamance County Health Department. Burlington. North Carolina October 1967, paees 2.3. - 12 - OI3Ji';CTIVSS: 1. To extend services in the home by G~VJ.~ )Crsonal care 1~hich does not require the sldlled serviccs of a public health nurse I thereby giving the professional personnel more time to car~J out those duties and responsibilities I.lhich require their sJdll and judGment. 2. 3y helpin,r; family 11ith care of the patient at home, institutional care may be avoided. 3. To assist in rehabilitating the patient to his fullest potential. OnBl!T!\TION: 1\11 ;JroGrams or the aGency, their purposes, are covered. The role of the Aide in relation to the total prOGram is tau~~t. 2!LTI~S : (The assiGnment of duties ~1ill be made b;' the Director of Nurses and/or su)Jervisor.) 1. The health aide is tauGht (and supervised) by the public health nurse to take blood ~~ressures and to car~J out procedures in the home uhich a family member could be klUGht to <10 I except injections. Supervisory visits are mac.e by the nurse every t\!O :leeJ:s. not necessarily at the same tit:le the aide is in the home. 2. The male health aide Iii ves :>f)rsonal care to male patients only I includinG challGillG catheters, Gi vine'; enemas, etc. He is approved by the urolOGists at ['leI 1 Hanover lIemorial Hospital before being employed. The actual procedures of changinG catheters of male i1atients or :jiving enemas to male patients are not observed or sU;JOrvised by the Public Health Burse. 3. The adie has conferences l1ith the ?ublic Health Nurse before and after making home visits, ancc recor(;.s visits. h. Attends in-service education .JroGrams 11hen a)J[llicable. - 13 - 405.122f.l CLINICAL'tCCO:WS: Clinical records containinc all pertinent information are maintained on all patients receiving nursing and/or other services from the Agency. Included in the record are: 1. Identifying information on the patient 2. Name of physician and the plan of treatment signed by hir.l 3. Progress notes dated and signed by the person giving service 4. Copies of summary reports sent to the physician every t1l0 months 5. SiGned release of information 6. Discharge information STANDful.JS !l f: !!: These records are removed from the Agency by nurses only l1hen service is being rendered. The aides record their visits after they return to the office. The records are retained by the Agency at least five years after the month the cost report to \'lhich they apply is filed lrith the intermediary. Should the Agency discontinue service the records trill be kept by the Health Department for the length of time as stated above. - 14 - 405.1229 A(I~NCY l':VAIDATION: There lIill be an annual eValuation of the Horne Health Agency Program of the lie'. 1 Hanover County Health De?artment by this agency in accordance l"lith 405.1229 Condition of Participation - liedicare. A subcommittee of the advisory committee including the agency administrator and the nursing supervisor I.Jill be responsible for the administrative evaluation of the agency. This evaluation '.Till include the follO\ling elements. A. 1. 2. 3. Cost audit (annual) Statistical report huarterly and annually) Policy and administrative revie'l B. Clinical Case record revieu (quarterly) 1. Clinical revieu committee structure There lJill be established a comnittee of professionals representing at least those services offered by the aGency to do a (;uarterly revieH of clinical records. This comrnittee shall consist of: (a) Supervising nurse (b) Coordinator of IlOIJe Health Services (c) Physical therapist (contract of state consultant) (d) ~10 staff nurses ( e) One HOine Health "ide 2. Selection of cases for clinical review Cases to be reviewed lnay be: (a) Randot1 sample of active and discharged (b) Problem cases referred from the field case s 3. Purpose of the clinical review shall be: Determine if plan of treatment is being implemented Assure that established policies are followed in providill!3: service (c) Document noeds for services not presently provided (d) Assist in agency evaluation ~~~ 4. The revieu forms used shall be those furnished by the ne"ional Office and these shall HOT be filed uith patient folder but in a se~rate confidential folder for such forms for agency use only. CI_ _ JJ --',-"7'-'0''-,'" ~ if;:! - - -, Dr. Joseph C. ;(nox, li.D., n.p.H. Health Director