Basic Agency Functions

(1) An agency shall provide at least one of the qualifying home health services directly through agency employees, but may arrange with another licensed organization or health care professional to provide any additional home health services. Home health services provided under arrangements with another licensed home care organization or professional organization shall be subject to a written contract conforming with the requirements of this chapter. (2) All personnel providing home health services shall assure that their efforts effectively complement one another and support the objectives outlined in the plan of care. The medical record or minutes of case conferences shall establish that effective interchange, reporting, and coordinated patient evaluation does occur. A written summary report for each patient shall be sent to the attending physician at least every sixty-two (62) days. (3) Plan of Care. (a) The written plan of care, developed in consultation with the organization staff, shall cover all pertinent diagnoses, including mental status, types of services and equipment required, frequency of services, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items. If a physician refers a patient under a plan of care which cannot be completed until after an evaluation visit, the physician shall be consulted to approve additions or modifications to the original plan. Orders for home health therapy services shall include the specific treatment or modalities to be used and their amount, frequency and duration. The therapist and other organization personnel shall participate in developing the plan of care. (b) The total plan of care shall be reviewed by the attending physician and agency personnel involved in the patient’s care as often as the severity of the patient’s condition requires, but at least once every sixty-two (62) days. Evidence of review by the physician must include the physician’s signature and date of the review on the plan of care. A facsimile of the physician’s signature is acceptable. Professional staff shall promptly alert the physician to any changes that suggest a need to alter the plan of care. (4) Drugs and treatments shall be administered by appropriately licensed agency personnel, acting within the scope of their licenses. Oral orders for drugs and treatments shall be given to appropriately licensed personnel acting within the scope of their licenses, immediately recorded, signed and dated, and countersigned and dated by the physician. (5) Skilled Nursing Services. (a) The agency shall provide skilled nursing services by or under the supervision of a registered nurse who has no current disciplinary action against his/her license, in accordance with the plan of care. This person shall be available at all times during operating hours and participate in all activities relevant to the professional home health services provided, including the development of qualifications and assignment of personnel. (b) The registered nurse’s duties shall include but are not limited to the following: make the initial evaluation visit, except in those circumstances where the physician has ordered therapy services as the only skilled service; regularly evaluate the patient’s nursing needs; initiate the plan of care and necessary revisions; provide those services requiring substantial specialized nursing skill; initiate appropriate preventive and STANDARDS FOR HOME CARE ORGANIZATIONS PROVIDING HOME CHAPTER 0720-27 HEALTH SERVICES rehabilitative nursing procedures; prepare clinical and progress notes; coordinate services; inform the physician and other personnel of changes in the patient’s condition and needs; counsel the patient and family in meeting nursing and related needs; participate in in-service programs; supervise and teach other nursing personnel. The registered nurse or appropriate agency staff shall initially and periodically evaluate drug interactions, duplicative drug therapy and non-compliance to drug therapy. (c) The licensed practical nurse shall provide services in accordance with agency policies, which may include but are not limited to the following: prepare clinical and progress notes; assist the physician and/or registered nurse in performing specialized procedures; prepare equipment and materials for treatments; observe aseptic technique as required; and assist the patient in learning appropriate self-care techniques. (d) A registered nurse may make the actual determination and pronouncement of death under the following circumstances: 1. The deceased was receiving the services of a licensed home care organization; 2. The death was anticipated, and the attending physician has agreed in writing to sign the death certificate. Such agreement by the attending physician must be present with the deceased at the place of death; 3. The nurse is licensed by the state; and 4. The nurse is employed by the home care organization providing services to the deceased. (6) Therapy Services. (a) All therapy services offered by the agency directly or under arrangement shall be planned, delegated, supervised or provided by a qualified therapist in accordance with the plan of care. A qualified therapist assistant may provide therapy services under the supervision of a qualified therapist in accordance with the plan of care. The therapist shall assist the physician in evaluating the level of function, helping develop the plan of care (revising as necessary), preparing clinical and progress notes, advising and consulting with the family and other agency personnel, and participating in in-service programs. (b) Speech therapy services shall be provided only by or under supervision of a qualified speech language pathologist in good standing, or by a person qualified as a Clinical Fellow subject to Tennessee Board of Communications Disorders and Sciences Rule 1370-01-.10. (c) A qualified therapist may make the initial evaluation visit when therapy is the only skilled service ordered. (7) Home Health Aide Services. (a) Aides shall be selected on the basis of such factors as: a sympathetic attitude toward the care of the sick; the ability to read, write and carry out directions; and the maturity and ability to deal effectively with the demands of the job. Aides shall be formally and carefully trained in: methods of assisting patients to achieve maximum self-reliance in nutrition and meal preparation; the aging process and emotional problems of illness; procedures for maintaining a clean, healthy and pleasant environment; changes in a STANDARDS FOR HOME CARE ORGANIZATIONS PROVIDING HOME CHAPTER 0720-27 HEALTH SERVICES patient’s condition that should be reported; work of the agency and the health team; ethics; confidentiality; respect for human dignity and the awareness of individual differences; and record keeping. Any home health aide training programs must comply with the federal home health aide training and competency regulations. Copies of these regulations may be obtained from the department. (b) The home health aide shall be assigned to a particular patient by a registered nurse. Written instructions for patient care shall be prepared by a registered nurse or therapist as appropriate. Duties may include the performance of simple procedures as an extension of therapy services, personal care, ambulation and exercises, household services essential to health care at home, assistance with medications that are ordinarily self-administered, reporting changes in the patient’s condition and needs, and completing appropriate records. (c) The registered nurse, or appropriate professional staff member if other home health services are provided, shall make a supervisory visit to the patient’s residence at least monthly, either when the aide is present to observe and assist or when the aide is absent (preferably alternating visits), to assess the aide’s competence in providing care and determine whether goals are being met. (d) There shall be continuing in-service programs on a regularly scheduled basis with on- the-job training during supervisor visits and more often as needed. (8) Medical Social Services, when provided, shall be given by a certified master social worker, a licensed clinical social worker, or by a social work assistant employed by the agency and under the supervision of a certified master social worker or licensed clinical social worker, and in accordance with the plan of care. The medical social services provider shall assist the physician and other team members in understanding the significant social and emotional factors related to the health problems, participate in the development of the plan of care, prepare clinical and progress notes, work with the family, utilize appropriate community resources, participate in discharge planning and in-service programs, and act as a consultant to other agency personnel. (9) Performance Improvement. (a) An agency shall have a committee to review, at least annually, past and present home health services including contract services, in accordance with a written plan, to determine their appropriateness and effectiveness and to ascertain that professional policies are followed in providing these services. (b) The objectives of the review committee shall be: 1. To assist the agency in using its personnel and facilities to meet individual and community needs; 2. To identify and correct deficiencies which undermine quality of care and lead to waste of agency and personnel resources; 3. To help the agency make critical judgments regarding the quality and quantity of its services through self-examination; 4. To provide opportunities to evaluate the effectiveness of agency policies and when necessary make recommendations to the administration as to controls or changes needed to assure high standards of patient care; STANDARDS FOR HOME CARE ORGANIZATIONS PROVIDING HOME CHAPTER 0720-27 HEALTH SERVICES 5. To augment in-service staff education; 6. To provide data needed to satisfy state licensure and certification requirements; 7. To establish criteria to measure the effectiveness and efficiency of the home health services provided to patients; and 8. To develop a record review system for the agency to evaluate the necessity or appropriateness of the home health services provided and their effectiveness and efficiency. (10) Infection Control. (a) There must be an active performance improvement program for developing guidelines, policies, procedures and techniques for the prevention, control and investigation of infections and communicable diseases. (b) Formal provisions must be developed to educate and orient all appropriate personnel and/or family members in the practice of aseptic techniques such as handwashing and scrubbing practices, proper hygiene, use of personal protective equipment, dressing care techniques, disinfecting and sterilizing techniques, and the handling and storage of patient care equipment and supplies. (c) Continuing education shall be provided for all agency patient care providers on the cause, effect, transmission, prevention and elimination of infections, as evidenced by the ability to verbalize/or demonstrate an understanding of basic techniques. (d) A Home Care Organization Providing Home Health Services shall have an annual influenza vaccination program which shall include at least: 1. The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The Home Care Organization Providing Home Health Services will encourage all staff and independent practitioners to obtain an influenza vaccination; 2. A signed declination statement on record from all who refuse the influenza vaccination for reasons other than medical contraindications (a sample form is available at http://tennessee.gov/health/topic/hcf-provider); 3. Education of all employees about the following: (i) Flu vaccination, (ii) Non-vaccine control measures, and (iii) The diagnosis, transmission, and potential impact of influenza; 4. An annual evaluation of the influenza vaccination program and reasons for non- participation; and 5. A statement that the requirements to complete vaccinations or declination statements shall be suspended by the administrator in the event of a vaccine shortage as declared by the Commissioner or the Commissioner’s designee. STANDARDS FOR HOME CARE ORGANIZATIONS PROVIDING HOME CHAPTER 0720-27 HEALTH SERVICES (e) The agency shall develop policies and procedures for testing a patient’s blood for the presence of the hepatitis B virus and the HIV (AIDS) virus in the event that an employee of the agency, a student studying at the agency or other health care provider rendering services at the agency is exposed to a patient’s blood or other body fluid. The testing shall be performed at no charge to the patient, and the test results shall be confidential. (f) The agency and its employees shall adopt and utilize standard precautions (per CDC) for preventing transmission of infections, HIV and communicable diseases. (g) Precautions shall be taken to prevent the contamination of sterile and clean supplies by soiled supplies. Sterile supplies shall be packaged and stored in a manner that protects the sterility of the contents. (11) Medical Records. (a) A medical record containing past and current findings in accordance with accepted professional standards shall be maintained for every patient receiving home health services. In addition to the plan of care, the record shall contain: appropriate identifying information; name of physician; all medications and treatments; signed and dated clinical notes. Clinical notes shall be written the day on which service is rendered and incorporated no less often than weekly; copies of summary reports shall be sent to the physician; and a discharge summary shall be dated and signed within 7 days of discharge. (b) A home care organization providing home health services is authorized to receive and appropriately act on a written order for a plan of care for a patient concerning a home health service signed by a physician that is transmitted to the agency by electronically signed electronic mail. Such order that is transmitted by electronic mail shall be deemed to meet any requirement for written documentation imposed by this regulation. (c) All medical records, either written, electronic, graphic or otherwise acceptable form, must be retained in their original or legally reproduced form for a minimum period of at least ten (10) years after which such records may be destroyed. However, in cases of patients under mental disability or minority, their complete agency records shall be retained for the period of minority or known mental disability, plus one (1) year, or ten (10) years following the discharge of the patient, whichever is longer. Records destruction shall be accomplished by burning, shredding or other effective method in keeping with the confidential nature of the contents. The destruction of records must be made in the ordinary course of business, must be documented and in accordance with the agency’s policies and procedures, and no record may be destroyed on an individual basis. (d) Even if the agency discontinues operations, records shall be maintained as mandated by this chapter and the Tennessee Medical Records Act (T.C.A. § 68-11-308). If a patient is transferred to another health care facility or agency, a copy of the record or an abstract shall accompany the patient when the agency is directly involved in the transfer. (e) Medical records information shall be safeguarded against loss or unauthorized use. Written procedures govern use and removal of records and conditions for release of information. The patient’s written consent shall be required for release of information when the release is not otherwise authorized by law. STANDARDS FOR HOME CARE ORGANIZATIONS PROVIDING HOME CHAPTER 0720-27 HEALTH SERVICES (f) For purposes of this rule, the requirements for signature or countersignature by a physician or other person responsible for signing, countersigning or authenticating an entry may be satisfied by the electronic entry by such person of a unique code assigned exclusively to him or her, or by entry of other unique electronic or mechanical symbols, provided that such person has adopted same as his or her signature in accordance with established protocol or rules.