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Title: Section 763.4 Policies and procedures of service delivery

Effective Date


763.4 Policies and procedures of service delivery. The agency shall ensure that:

(a) written policies and procedures, consistent with current professional standards of practice, are developed and implemented for each service and are reviewed and revised as necessary;

(b) protocols are developed for each professional discipline to indicate when that service should be included in the patient assessment;

(c) any nursing or therapeutic services, procedures or treatments, not previously carried out in the home by that agency, are first reviewed by the professional advisory committee before being provided regularly. If a patient needs such service, procedure or treatment, it may be provided prior to review by the professional advisory committee, if:

(1) medical consultation has been obtained regarding safety and appropriateness; and

(2) personnel have been trained to provide that specific service, procedure or treatment;

(d) professional personnel are fully informed of, and encouraged to refer patients to, other health and social community resources which may be needed to maintain patients in the home;

(e) policies and procedures for the storage, cleaning and disinfection of medical supplies, equipment and appliances are established;

(f) persons providing care in the home display proper and current identification, including name, title and current photograph of care provider and name of agency providing the service. Such identification shall be returned to the agency upon termination of employment;

(g) supervisory personnel are employed by the agency to assure quality of patient care services. Such supervision shall include:

(1) ongoing review of cases and delegation of assignments;

(2) in-home visits to direct, demonstrate and evaluate the delivery of patient care;

(3) provision of clinical consultation; and

(4) professional guidance on agency policies and procedures; and

(h) all personnel delivering care in patient homes are adequately supervised. The department shall consider the following factors as evidence of adequate supervision:

(1) supervision of nursing personnel is conducted by a supervising community health nurse;

(2) personnel regularly provide services at the frequencies specified in the patient's plan of care, and in accordance with the policies and procedures of their respective services;

(3) personnel are assigned to the care of patients in accordance with their licensure, as appropriate, and their training, orientation and demonstrated skills;

(4) clinical records are kept complete, and changes in patient condition, adverse reactions, and problems with informal supports or home environment are charted promptly and reported to supervisory personnel;

(5) plans of care are revised as needed by the patient, and changes are reported to the authorized practitioner and other personnel providing care to the patient;

(6) supervision of a home health aide or personal care aide is conducted by a registered professional nurse or licensed practical nurse or by a therapist if the aide carries out simple procedures as an extension of physical therapy, occupational therapy or speech/language pathology;

(7) in-home supervision, by professional personnel, of home health aides and personal care aides takes place:

(i) to demonstrate to and instruct the aide in the treatments or services to be provided, with successful re-demonstration by the aide during the initial service visit, or where there is a change in personnel providing care, if the aide does not have documented training and experience in performing the tasks prescribed in the plan of care;

(ii) where any of the changes in paragraph (4) of this subdivision occur, to evaluate the change and initiate any revision in the plan of care which may be needed; and

(iii) to instruct the aide as to the observations and written reports to be made to the supervising community health nurse or therapist;

(8) direct supervision of an advanced home health aide is conducted by a registered professional nurse who:

(i) provides training, guidance, direction and oversight, and evaluation related to the performance of advanced tasks by the advanced home health aide;

(ii) assigns advanced tasks to be performed by the advanced home health aide after completing a nursing assessment to determine the patient’s current health status and care needs;

(iii) provides case specific training to the advanced home health aide to verify and ensure the advanced home health aide can safely and competently perform the advanced tasks for the patient;

(iv) provides written, patient specific instructions for performing advanced tasks, including the criteria for identifying, reporting, and responding to problems, errors or complications;

(v) conducts a comprehensive medication review including evaluation of the patient’s current medication use, and prescribed drug regimen and identifies and resolves any discrepancies prior to assigning the advanced home health aide to administer medications;

(vi) determines direct supervision of the advanced home health aide based on the complexity of advanced tasks, the skill and experience of the advanced home health aide assigned to perform the advanced tasks, and the health status of the patient for whom the advanced tasks are being performed;

(vii) while on duty is continuously available to communicate with the advanced home health aide by phone or other means;

(viii) conducts home visits or arranges for another qualified registered professional nurse whenever necessary to protect the health and safety of the patient;

(ix) performs an initial and ongoing assessments of the patient’s needs; and

(x) conducts a home visit at least every two weeks and more frequently as determined by the registered professional nurse, to observe, evaluate, and oversee services provided by the advanced home health aide;  

(9) a process is in place to document the limitation or revocation of the assignment of advanced tasks by an advanced home health aide when deemed appropriate by a supervising registered professional nurse and to ensure that such information is available to other registered professional nurses that may supervise such aide; and

(10) any failure by a supervising registered professional nurse to comply with the requirements of paragraph eight of this subdivision shall be reported to the department.



VOLUME E (Title 10)