Governing body

The governing body is legally responsible for the quality of patient care services; for patient safety and security; for the conduct, operation, and obligations of the agency; and for ensuring compliance with all federal, state, and local laws. Contracts, arrangements, or other agreements may not limit the responsibility of the governing body in any way. The governing body shall: 1. Have bylaws or the equivalent, which shall be reviewed annually and be revised as needed. They must be made available to all members of the governing body. The bylaws or equivalent must specify the duties and responsibilities of the governing body. 2. Approve an overall plan and budget for the agency which includes an annual operating budget and capital expenditure plan. 3. Provide and maintain an office facility adequately equipped for efficient work and which provides a safe working environment in compliance with local ordinances and fire regulations. 4. Employ a qualified administrator who is designated in writing as administratively responsible and available for all aspects of agency operation including the employment of qualified staff, accuracy of public information, and implementation of the budget. a. A qualified administrator is: (1) A licensed physician, registered nurse, or college graduate with a bachelor's degree who has a minimum of three years of health care management; or (2) A person without a college degree may qualify by obtaining the equivalent of six years of supervisory experience in health care management. b. The administrator and nurse executive may be the same individual if the individual is dually qualified. c. The administrator must identify in writing an individual who is qualified and authorized to act in place of the administrator when the administrator is not available. 5. Organize agency services to ensure quality of patient care. An organizational chart, from the governing body to the patients, with a written description of the organization, authorities, responsibilities, accountabilities, and relationships must be maintained which must include: a. A description of each service offered; b. Policies and procedures pertaining to each service; c. Job descriptions for each discipline; and d. A description of the system for maintenance of patient records. 6. Ensure the development, implementation, review and revision of policies and procedures as changes in standards of practice occur. Policies and procedures must include the following: a. Operation and administration of the agency, including: (1) Provision of therapeutic and supportive services under the direction of a physician or registered nurse. (2) Acceptance of only patients for whom they can provide the needed services. Acceptance is based on medical, nursing, and social information provided by the patient's physician, the facility the patient is being discharged from, and the staff of the agency, as applicable. (3) Provision of services to patients consistent with the treatment plan established, signed, and regularly reviewed by the physician responsible for the patient's care. Supportive services may be provided, without a physician's order, consistent with the care plan established, signed, and regularly reviewed by the registered nurse when therapeutic services are not needed by the patient. (4) If therapeutic services are ordered, review of the total plan of care by the patient's physician at such intervals as the patient's condition requires, but no less than once every two months. Verbal authorization to change the plan of treatment shall be reviewed and signed by the physician consistent with agency policy. (5) Availability of services to patients regardless of age, sex, religion, or ethnic background. (6) Clinical records that are accurate, concise, and consistent with current medical records standards of practice must be maintained for each patient which cover the services the agency provides directly or through arrangement, and contain pertinent past and current medical, nursing, and social information including the plan of treatment and care. (7) A means to ensure all records must be maintained in a confidential manner. (8) A means to report, investigate, and document action taken on grievances, including follow-through with the patient or the patient's family. b. Personnel records that include the following documentation: (1) Checking of state registries and licensure boards prior to employment for findings of inappropriate conduct, employment, disciplinary actions, and termination; (2) Job descriptions; (3) Orientation records; (4) Training and education records; (5) Disciplinary action records; (6) Verification of current licensure or registration status, if applicable; (7) Documentation of annual performance reviews; and (8) Documentation of competency evaluation of home health aides. c. Notification of each patient in writing of the patient's rights during the initial evaluation visit prior to the initiation of treatment. Patient rights, at a minimum, include the right to: (1) Be given care without discrimination as to race, color, creed, sex, age, or national origin. (2) Exercise the person's right as a patient of the agency. If the patient has been judged incompetent, the patient's family or guardian may exercise the patient's rights. (3) Choose care providers and the right to communicate with those providers. (4) Be fully informed of the patient's medical condition and to have access to the patient's medical record. (5) Be informed, in advance, about the care to be furnished and any changes in the care to be furnished, the disciplines that will furnish the care, the frequency of visits proposed, any changes in the plan of care before the change is made, and of the patient's right to participate in planning the care and planning any changes in the care. (6) Refuse care and to be informed of possible health consequences of this action. (7) Be provided information regarding advanced directives prior to the initiation of treatment. (8) Be informed of the need for transfer, referral, or discharge from the agency. (9) Be treated with dignity, privacy, respect, and consideration as well as freedom from abuse, neglect, or misappropriation of the patient's property. (10) Voice grievances regarding treatment or care that is, or fails to be, furnished or regarding lack of respect for property by anyone who is furnishing services on behalf of the agency and to not be subjected to discrimination or reprisal for doing so. (11) Confidentiality regarding the patient's medical condition and medical records. (12) Advice, before care is initiated, of the extent to which payment for agency services may be expected from Medicare, Medicaid, or other sources and the extent to which payment may be required from the patient. The patient must also be informed orally and in writing of any changes in payment sources no later than thirty calendar days after the agency becomes aware of the changes. (13) Use of the toll-free hotline established by the department to receive complaints or questions about local agencies and the hours of operation of the hotline. 7. Ensure there is a written agreement or contract in place and signed by both parties if arranging for services from individuals not employed directly by the agency or from other agencies. a. The written agreement or contract must at a minimum state the following: (1) Patients may be accepted for care only by the agency; (2) The specific service to be provided; (3) The period of time the contract is in effect; (4) The availability of the service; (5) Financial arrangements; (6) Verification that any individual providing service is appropriately licensed or registered as required by state statute or regulation; (7) Provisions for supervision of contract personnel where applicable; (8) Assurance that individuals providing services under contractual arrangements meet the same requirements as those specified for agency personnel; (9) Provision for the documentation of services rendered in the patient's record; (10) Provision for the sharing of assessment and plan of care data; (11) The geographic area the contractor agrees to serve; (12) Specify that only the contracting agency shall bill for services provided under the written agreements and collect the applicable payments pertaining to the contracted services; and (13) Evaluation of the acceptability of the contracted services. b. Contract services must be provided in accordance with the patient's plan of care. c. The agency shall assure that all contract services are provided in accordance with the agreement. Agreements must be reviewed on an annual basis and updated as necessary. d. The agency that is subcontracting its work must maintain or produce a complete home care record for each patient. 8. Ensure the agency obtains and maintains compliance with the applicable parts of the clinical laboratory improvement amendments of 1988, 42 CFR part 493, if the agency provides any laboratory testing service, regardless of the frequency or the complexity of the testing. 9. Meet with agency administrative staff to review the operation of the agency at a frequency sufficient to ensure safe and effective patient care. 10. Keep minutes of all meetings including actions taken.