Louisiana Home Health Policy and Procedure Manual
For Louisiana home health agencies licensed by the Louisiana Department of Health (LDH), Health Standards Section, whether or not they are Medicare-certified. The manual has 57 policies and 56 forms, written to LAC 48:I Chapter 91, the home health licensing rules, and, for certified agencies, the home health Conditions of Participation (42 CFR Part 484). Each policy opens with a plain-English summary and names the rule it follows, and every one is filled in with your agency's details. You get Word and PDF files to keep, and your staff sign off on their phones.
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Louisiana · Home health
57 policies written to the Louisiana rules, with 56 forms. Every one is filled in with your agency's details.
- A plain-English summary first
- The rule each policy follows
- Word and PDF downloads, yours to keep
- Policies
- 57
- Forms
- 56
- Categories
- 14
- Policy Pack · required
- $950one-timeIncludes 90 days in the portal with Premium. To keep it open after that, Premium is $99 a month or $990 a year.
Read before you buy
3 free sample policies, shown in full for a sample agency.
LA-HH-CMP-01Free sample
Client rights
Complaints and Grievances
Sets out how patients, families, caregivers, authorized healthcare providers, staff and the public can complain to the Agency about care that is or fails to be furnished and about lack of respect for property or person (LAC 48:I §9125.A.3), how the Administrator makes sure every complaint is investigated and addressed in a timely manner (§9103.A.2.i) and the clinical manager performs complaint investigations (§9103.B.2.f), the Agency's own acknowledgment and resolution time frames, how patients are told about the state home health hotline (§9125.A.9) and other outside agencies, protection from discrimination or reprisal (§9125.A.11), and the governing body's annual review of complaint resolutions (§9102.B.1); and, if the Agency is Medicare-certified, the investigation and documentation duties in 42 CFR §484.50(e).
Read the full policy LA-HH-SG-01Free sample SafeguardingAbuse, Neglect, and Exploitation of Adults: Recognition and Mandatory Reporting
Sets out how staff recognize abuse, neglect, exploitation, extortion and misappropriation of adult patients and report them: every nurse, aide, therapist and other direct caregiver who knows that a patient's health or welfare has been or may be further adversely affected by abuse, neglect or exploitation reports within 24 hours to the Louisiana Department of Health or local law enforcement (R.S. 40:2009.20), and any person with cause to believe reports to Adult Protective Services, Elderly Protective Services or law enforcement (R.S. 15:1504 and 1505). It also covers protecting the patient, removing accused staff from patient care, the Agency's internal investigation, registry consequences, immunity, penalties and the ban on retaliation; and, if the Agency is Medicare-certified, the immediate reporting and investigation duties in 42 CFR §484.50(e).
Read the full policy LA-HH-IC-01Free sample Infection controlInfection Prevention and Control Program
Sets out the Agency's infection prevention and control program: standard and transmission-based precautions, surveillance of infections in patients and staff as part of QAPI, reporting of reportable diseases to the Louisiana Office of Public Health in the time frames the Sanitary Code sets, employee health, cleaning of equipment, and infection control education for staff, patients and caregivers.
Read the full policy
Louisiana rules
What Louisiana's home health rules ask your policies to cover
- Initial visit. A registered nurse or the appropriate therapist makes the initial visit within 24 hours of referral, unless the order says otherwise. The federal rule for certified agencies allows 48 hours. LAC 48:I.9123.A.1; 42 CFR §484.55(a)
- Plan of care and orders. The initial plan of care is in the record within seven days of the start of care. Plans and verbal orders are signed within 60 days, and the authorized healthcare provider reviews the plan at least once every two months. LAC 48:I.9123.B.2; LAC 48:I.9123.C.1
- Aides. 12 hours of in-service each calendar year. For a patient getting skilled care, a supervisory visit at the residence at least every two weeks. For an aide-only patient, a registered nurse visit at least every 60 days while the aide gives care. LAC 48:I.9103.C.7 and C.8
- Clinical records. Clinical notes are in the record within one week of the visit, and records are kept at least six years from the date the record was established. LAC 48:I.9129.A.8; LAC 48:I.9129.B
- Abuse and neglect. Staff who learn of abuse, neglect or exploitation report it within 24 hours to LDH or local law enforcement, as state law requires of direct caregivers. La. R.S. 40:2009.20
- Emergency preparedness. A plan that conforms to the state model plan, is activated at least once a year by a real event or a drill, and has its updates sent to the parish Office of Emergency Preparedness. It covers evacuation transport and telling families when a patient is evacuated. LAC 48:I.9121
Questions a surveyor may ask
Every policy lists questions a surveyor may ask about it, so your staff can practice the answers. A few from this manual:
When was this patient referred and when was the initial visit made? Who made it?LA-HH-ADM-02Initial Visit, Start of Care, and Admission Documentation
Show me the last three supervisory visits for this patient. Were they made at the residence within 14 days of each other?LA-HH-AID-02Home Health Aide Assignment, Duties, Restrictions, and Supervision
An aide sees a patient's son take money from her purse. What must the aide do, and by when?LA-HH-SG-01Abuse, Neglect, and Exploitation of Adults: Recognition and Mandatory Reporting
Show me the registry and exclusion check printouts for this aide, before hire and for each of the past three months.LA-HH-HR-04Registry Checks and Exclusion Screening of Staff
If your office were destroyed by a hurricane, what would you send to LDH, and by when, to keep your license?LA-HH-EP-02License Inactivation and Temporary Relocation After a Declared or Non-Declared Disaster
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Browse all 57 policies
Search by title, policy number or rule. Open any policy to see its summary, the rules it follows and what is inside.
All 57 policies
Client rights5
LA-HH-CMP-01Free sample
Complaints and Grievances
Sets out how patients, families, caregivers, authorized healthcare providers, staff and the public can complain to the Agency about care that is or fails to be furnished and about lack of respect for property or person (LAC 48:I §9125.A.3), how the Administrator makes sure every complaint is investigated and addressed in a timely manner (§9103.A.2.i) and the clinical manager performs complaint investigations (§9103.B.2.f), the Agency's own acknowledgment and resolution time frames, how patients are told about the state home health hotline (§9125.A.9) and other outside agencies, protection from discrimination or reprisal (§9125.A.11), and the governing body's annual review of complaint resolutions (§9102.B.1); and, if the Agency is Medicare-certified, the investigation and documentation duties in 42 CFR §484.50(e).
LAC 48:I §9125.A.3
LA-HH-PR-01
Patient Rights and Responsibilities
Sets out the 12 patient rights that LAC 48:I §9125 gives every patient of a Louisiana home health agency, how and when the Agency explains them in a language and manner the patient understands, who may exercise them for a patient, the contacts the patient must be given (the state home health hotline and the agency on aging, center for independent living, protection and advocacy agency, aging and disability resource center and quality improvement organization for the patient's area), the patient responsibilities the Agency asks patients to accept, and how staff protect and promote these rights. If the Agency is Medicare-certified, the notice also meets 42 CFR §484.50.
LAC 48:I §9125
LA-HH-PR-02
Advance Directives, LaPOST, and Do-Not-Resuscitate Orders
Sets out how the Agency gives every adult patient written information about the right to accept or refuse treatment and to make an advance directive, documents whether the patient has one, keeps copies of declarations, LaPOST forms and do-not-resuscitate orders in the record and the home, follows them in the home, and never conditions care on whether a patient has one. It applies the Louisiana Natural Death Act (R.S. 40:1151.1 et seq.), the LaPOST law (R.S. 40:1155.1 et seq.) and rule (LAC 48:I Chapter 2), the admission orientation in LAC 48:I §9123.B.3.k, and, if the Agency is Medicare-certified, 42 CFR §489.102.
LAC 48:I §9123.B.3.k
LA-HH-PR-03
Consent for Treatment, Freedom of Choice, and Disclosure of Charges
Sets out how the Agency obtains a signed consent for treatment and, when applicable, a signed release of information from every patient; how it protects the patient's right to choose an authorized healthcare provider and a home health agency without interference and obtains a signed freedom of choice statement; and how it tells each patient, orally and in writing and before care begins, what Medicare, Medicaid or other programs are expected to pay and what the patient may have to pay, with advance written notice of possibly non-covered care and of any reduction or end of care, including the Medicare notices CMS requires if the Agency is Medicare-certified.
LAC 48:I §9129.A.5
LA-HH-PR-04
Language Access, Auxiliary Aids, and Nondiscrimination
Sets out how the Agency accepts patients without discrimination, explains rights and care in a language and manner each patient understands, provides qualified interpreters, translated documents and auxiliary aids and services free of charge, tells patients how to get them, and handles grievances about discrimination. It applies LAC 48:I §9123.A and §9125.A and A.12 to every patient, and Section 1557 of the Affordable Care Act (45 CFR Part 92), the Americans with Disabilities Act and, if the Agency is Medicare-certified, 42 CFR §484.50(f).
LAC 48:I §9125.A.12
Service delivery10
LA-HH-ADM-01
Admission Criteria, Referral Intake, and Acceptance to Service
Sets out the written criteria the Agency uses to decide whether to accept a referred patient (the ability to provide services on a timely basis and available within 24 hours unless the authorized healthcare provider specifies otherwise; the patient's and caregiver's willingness to take part in the plan of care; needs that can be met safely at home; and payer criteria), how referrals are received at all times and recorded, who decides, how capacity is checked so that no patient is accepted when the Agency cannot care for him or her, and what happens when a referral is not accepted. If the Agency is Medicare-certified, it is also the acceptance-to-service policy required by 42 CFR §484.105(i).
LAC 48:I §9123.A
LA-HH-ADM-02
Initial Visit, Start of Care, and Admission Documentation
Sets out how the Agency makes the initial visit, by a registered nurse or appropriate therapist, within 24 hours of referral unless otherwise ordered by the authorized healthcare provider; what happens at that visit (assessment, instruction about home care services, rights, consent and orientation); how the initial plan of care is completed by an RN or appropriate therapist and placed in the record within seven days from the start of care; and the documentation that Louisiana requires at admission (LAC 48:I §9123.B.3). If the Agency is Medicare-certified, the visit also meets 42 CFR §484.55(a).
LAC 48:I §9123.B
LA-HH-ADM-03
Medicare Eligibility, Certification, Face-to-Face Encounter, and Homebound Status
For a Medicare-certified Agency, sets out how the Agency confirms that each Medicare patient meets the conditions for Medicare home health coverage (confined to the home, under the care of a physician or allowed practitioner, in need of intermittent skilled nursing, physical therapy or speech-language pathology, under a plan of care), obtains a complete certification signed by the certifying physician or allowed practitioner including the face-to-face encounter, documents homebound status at each visit, and obtains recertification at least every 60 days when care continues. For other payers, the Agency meets the payer's own criteria, as LAC 48:I §9123.A.4 requires.
42 CFR §424.22
LA-HH-ASM-01
Comprehensive Assessment and Reassessment
Sets out how each patient receives a patient-specific comprehensive assessment and regular reassessment: who may complete it, when (no later than 5 calendar days after the start of care; the last 5 days of every 60 days; within 48 hours of return home after a hospital admission of 24 hours or more; at discharge; and whenever the patient's condition changes significantly), what it must contain, and how findings feed the plan of care. The timing and content are federal Conditions of Participation if the Agency is Medicare-certified; the Agency applies them to every patient as its own standard, together with the Louisiana admission documentation and RN reassessment duties in LAC 48:I Chapter 91.
42 CFR §484.55
LA-HH-ASM-02
OASIS Data Collection, Accuracy, and Transmission
For a Medicare-certified Agency, sets out how OASIS data is collected as part of each comprehensive assessment, checked for accuracy, encoded and transmitted to the CMS system (iQIES) within 30 days of completing the assessment, using compliant software and the CMS-assigned branch identification number, and kept confidential, and how the Agency meets the Home Health Quality Reporting Program submission threshold. A licensed-only agency that is not Medicare-certified is not subject to these federal OASIS rules.
42 CFR §484.45
LA-HH-CC-01
Coordination of Services, Case Conferences, and Communication with Authorized Healthcare Providers
Sets out how the Agency coordinates the care given by every discipline, employed or under contract, with the patient, caregivers and authorized healthcare providers from admission through discharge: who coordinates, how changes in the patient's condition are reported to the authorized healthcare provider and the supervising RN, case conferences and their records, written instructions given to the patient and caregiver, and ongoing education and training.
LAC 48:I §9123.F
LA-HH-CC-02
Nursing Availability, After-Hours Care, and On-Call
Sets out how the Agency provides nursing services at least eight hours a day, five days a week, makes care available on an emergency basis 24 hours a day, seven days a week, keeps an RN immediately available by telecommunications at all times through an on-call schedule for RNs, posts its hours and emergency contact procedures, answers after-hours calls and referrals, and records every on-call contact. It also covers notice to the Department of any change in the 24-hour contact procedures.
LAC 48:I §9123.F.1
LA-HH-CP-01
Plan of Care, Plan of Care Review, and Continuation of Services
Sets out how each patient's individualized plan of care is developed by an RN or appropriate therapist, signed by the authorized healthcare provider within a timely manner (the Agency's target is within 14 days, never later than 60 days), followed exactly, reviewed by the authorized healthcare provider with the Agency's professional personnel at least once every two months (and, if the Agency is Medicare-certified, at least once every 60 days), updated by the RN as needed or at least every 60 days, and renewed for continuation of services, with each plan in the record within seven days. It covers the content of the plan, patient participation, and tracking signatures and review dates.
LAC 48:I §9123.C
LA-HH-DC-01
Discharge Planning, Transfer, and Discharge Summaries
Sets out the reasons for which a patient may be discharged under LAC 48:I §9123.G.1, how discharge planning starts at admission and continues throughout care, the discharge procedures Louisiana requires (notify the authorized healthcare provider, document discharge planning and a discharge summary, and forward the summary to the provider), the discipline discharge summaries due within five business days, the transfer form sent to a receiving facility, and, if the Agency is Medicare-certified, the federal discharge planning standard and the 5-business-day discharge summary and 2-business-day transfer summary.
LAC 48:I §9123.G
LA-HH-DC-02
Discharge Notice, Discharge for Cause, and Reduction or Termination of Services
Sets out the written notice the Agency gives before it reduces or ends a patient's care, when it gives 30 days' advance written notice, how it handles discharge when the home is unsafe or the patient or others in the home are disruptive, abusive or uncooperative (discharge for cause), the steps it must take first, the Medicare notices it uses, and the transfer and discharge rights a patient of a Medicare-certified agency has under 42 CFR §484.50(d). It also explains the summary of these policies given to every patient at the start of care.
LAC 48:I §9123.G.1
Patient care3
LA-HH-CS-01
Scope of Home Health Services and Services Provided Directly
Defines the home health services the Agency offers, which services it provides directly with its own employees and which under written contract, the qualifications behind each service, the rule that skilled nursing plus at least one other service is always available, the rule that administration and one other service are always provided directly, and the safeguards that keep patients from unsafe clinical practices.
LAC 48:I §9101
LA-HH-CS-02
Skilled Nursing Services: Registered Nurse and Licensed Practical Nurse
Sets out the Louisiana qualifications, duties and limits of the registered nurses and licensed practical nurses who provide the Agency's skilled nursing service, the RN's supervision of LPNs (an on-site evaluation at least every six months while the LPN gives care), clinical note time frames, and reporting of changes in the patient's condition.
LAC 48:I §9103.K
LA-HH-CS-03
Therapy Services, Medical Social Services, and Nutritional Guidance
Sets out the Louisiana qualifications and duties of physical, occupational and speech therapists, therapy assistants, medical social workers and dietitians, the supervision therapists must give their assistants (including the physical therapist's reassessment at least every sixth visit and not less than once a month, and face-to-face conferences), discharge summaries, and when a physical therapist may supervise aides.
LAC 48:I §9103.I
Clinical tasks7
LA-HH-AID-01
Home Health Aide Qualifications, Training, Competency, and In-Service
Sets out who may work as a home health aide for the Agency, the competency evaluation every aide passes before giving care, the content of any aide training program the Agency offers, aide orientation, and the 12 hours of in-service training each aide receives every calendar year (and, if the Agency is Medicare-certified, in each 12-month period).
LAC 48:I §9103.C
LA-HH-AID-02
Home Health Aide Assignment, Duties, Restrictions, and Supervision
Sets out how an RN assigns aides and writes their care instructions, what aides do and must never do, and how aides are supervised: a supervisory visit to the patient's residence at least every two weeks (not over 14 days) for patients receiving skilled services, and an RN visit at least every 60 days while the aide is giving care for patients who are not, with no virtual visits counted.
LAC 48:I §9103.C.7
LA-HH-CS-04
Death of a Patient in the Home
Tells staff what to do when a patient dies, or is found dead, during or between home health visits: who to call, how pronouncement of death works in Louisiana, when the coroner must be involved, how to support the family, what to document, and how the Agency discharges the patient after a death.
LAC 48:I §9123.G.3
LA-HH-CS-05
Laboratory Services, Specimen Collection, and Waived Testing
Sets out when the Agency needs a CLIA certificate, how staff collect and send specimens only as ordered, who may draw blood, how referral laboratories are chosen, how waived tests and patient self-tests are handled, and how results reach the authorized healthcare provider.
42 CFR §484.100(c)
LA-HH-DEL-01
Delegation of Nursing Tasks to Home Health Aides
Sets out when an RN may delegate a nursing task to a home health aide under Louisiana law, the six conditions the Louisiana State Board of Nursing requires for any delegation, the tasks that may never be delegated (including medication administration and any sterile or invasive procedure), the Agency's written list of delegable tasks, and how the RN supervises and withdraws delegation.
LAC 48:I §9103.C.2.c
LA-HH-MED-01
Medication Management, Medication Errors, and Drug Regimen Review
Sets out how the Agency protects patients from medication errors: keeping a complete medication list, reviewing the drug regimen, who may administer medications (RNs, LPNs within practical nursing law, never aides beyond the over-the-counter items Louisiana allows), giving only pharmacist-dispensed, properly labeled drugs as ordered, teaching patients and families, intravenous therapy, vaccines, and reporting and learning from medication errors.
LAC 48:I §9123.E
LA-HH-ORD-01
Authorized Healthcare Provider Orders, Verbal Orders, and Signatures
Sets out who may order home health services, who at the Agency may take a verbal or telephone order, how orders are written down, read back and recorded in the plan of care, and how the Agency gets every plan of care and verbal order signed by the authorized healthcare provider within its own target and never later than the 60 days Louisiana allows.
LAC 48:I §9123.C.1
Safeguarding2
LA-HH-SG-01Free sample
Abuse, Neglect, and Exploitation of Adults: Recognition and Mandatory Reporting
Sets out how staff recognize abuse, neglect, exploitation, extortion and misappropriation of adult patients and report them: every nurse, aide, therapist and other direct caregiver who knows that a patient's health or welfare has been or may be further adversely affected by abuse, neglect or exploitation reports within 24 hours to the Louisiana Department of Health or local law enforcement (R.S. 40:2009.20), and any person with cause to believe reports to Adult Protective Services, Elderly Protective Services or law enforcement (R.S. 15:1504 and 1505). It also covers protecting the patient, removing accused staff from patient care, the Agency's internal investigation, registry consequences, immunity, penalties and the ban on retaliation; and, if the Agency is Medicare-certified, the immediate reporting and investigation duties in 42 CFR §484.50(e).
R.S. 40:2009.20
LA-HH-SG-02
Child Abuse and Neglect: Mandatory Reporting
Sets out how Agency staff, who are mandatory reporters as health practitioners or social service practitioners under Children's Code Art. 603, recognize and report suspected abuse or neglect of a child, whether the child is a patient or lives in or visits a patient's home: a report is made immediately (Art. 610(A)) to the Department of Children and Family Services when the suspected perpetrator is a parent, caretaker or other person listed in Art. 610(A)(1), and otherwise to local or state law enforcement, with the information Art. 610(B) lists. It also covers the ban on employer policies that delay reports, protection from retaliation, and the penalties in R.S. 14:403.
Children's Code Art. 610
Infection control3
LA-HH-IC-01Free sample
Infection Prevention and Control Program
Sets out the Agency's infection prevention and control program: standard and transmission-based precautions, surveillance of infections in patients and staff as part of QAPI, reporting of reportable diseases to the Louisiana Office of Public Health in the time frames the Sanitary Code sets, employee health, cleaning of equipment, and infection control education for staff, patients and caregivers.
42 CFR §484.70
LA-HH-IC-02
Bloodborne Pathogens Exposure Control Plan
This is the Agency's written exposure control plan under the OSHA Bloodborne Pathogens Standard: which jobs have occupational exposure, the controls and protective equipment used, hepatitis B vaccination offered within 10 working days of initial assignment at no cost, what to do after an exposure, training at assignment and at least every year, and the records the standard requires.
29 CFR §1910.1030
LA-HH-IC-03
Sharps, Medical Waste, and Patient and Caregiver Instruction
Sets out how staff handle, package, label, carry and dispose of sharps and potentially infectious medical waste they generate in patients' homes under the Louisiana Sanitary Code and OSHA, how household-generated sharps are packaged under the Sanitary Code, and how the Agency teaches patients and caregivers to handle sharps, soiled dressings and spills safely.
42 CFR §484.70(c)
Emergency preparedness2
LA-HH-EP-01
Emergency Preparedness Plan and Program
Sets out the Agency's emergency preparedness plan and program: a written plan that conforms to the current Office of Emergency Preparedness model plan and the Louisiana Model Home Health Emergency Preparedness Plan (LAC 48:I §§9121.A and 9115.B.1.l) and covers at least the five subjects in §9121.B; an emergency plan and at risk evaluation for each patient; activation of the plan at least once a year by a real event or a planned drill, with the performance evaluated and documented (§9121.C); submission of updates to the parish Office of Emergency Preparedness (§9121.D); review by the governing body each year (§9102.B.1); and, if the Agency is Medicare-certified, the risk assessment, policies, communication plan, training and testing in 42 CFR §484.102.
LAC 48:I §9121
LA-HH-EP-02
License Inactivation and Temporary Relocation After a Declared or Non-Declared Disaster
Sets out how the Agency may ask LDH to inactivate its license when an emergency or disaster interrupts its services, so that the license is not lost under LAC 48:I §9110.A: for a declared disaster, written notice to the Health Standards Section within 60 days of the executive order or proclamation with the statements and attestations §9116.A.1 lists, and resumption of operation in the same service area within one year; for a non-declared disaster, written notice within 30 days, plans for repairs within 90 days of approval, and resumption within one year (§9117); reinstatement requests and surveys; the conditions that apply while the license is inactive; and a waiver of up to 90 days to operate outside the licensed area after a parish evacuation order (§9121.E).
LAC 48:I §9116
Records2
LA-HH-REC-01
Clinical Records: Content, Clinical Notes, Authentication, and Retention
Sets out what every clinical record must contain under LAC 48:I §9129.C, how each visit is documented in a clinical note that is incorporated into the record within one week of the visit, how entries are authenticated, dated and timed, where original records are kept at the parent and branch offices, how records are protected and corrected, and how long they are retained: not less than six years from the date the record was established (§9129.A.8) and, if the Agency is Medicare-certified, at least five years after discharge (42 CFR §484.110(c)), whichever is later.
LAC 48:I §9129
LA-HH-REC-02
Patient Access to Records and Release of Information
Sets out how a patient, a personal representative and other persons the law allows can see or obtain copies of health records, the time limits that apply (for a Medicare-certified agency, free of charge at the next home visit or within 4 business days, whichever comes first, under 42 CFR §484.110(e); under HIPAA, action within 30 days; under R.S. 40:1165.1, a reasonable period not to exceed fifteen days after the request and written authorization), the Louisiana copy charge limits, when access may be denied, and how information is released to others with a signed authorization under 45 CFR §164.508 and LAC 48:I §9129.A.6.
R.S. 40:1165.1
Privacy3
LA-HH-PRV-01
HIPAA Privacy and OASIS Confidentiality
Sets out how the Agency protects the privacy of patient health information under the HIPAA Privacy Rule (45 CFR Part 164, Subpart E) and Louisiana's right to a confidential clinical record (LAC 48:I §9125.A.6): the privacy official, permitted uses and disclosures, authorizations, the minimum necessary rule, the Notice of Privacy Practices, patient privacy rights and their time limits, privacy in the home and the office, business associates, complaints, sanctions and documentation, and, if the Agency is Medicare-certified, the confidentiality of OASIS information under 42 CFR §484.40.
45 CFR §164.530
LA-HH-PRV-02
HIPAA Security and Electronic Records
Sets out the administrative, physical and technical safeguards the Agency uses to protect electronic protected health information under the HIPAA Security Rule (45 CFR §§164.306 to 164.316): the security official, risk analysis and risk management, unique logins and electronic signatures that authenticate record entries under LAC 48:I §9129.A.2, mobile devices and encryption, audit controls, secure transmission (including OASIS transmission under 42 CFR §484.45(c)(2) if Medicare-certified), backups and downtime, security incidents, vendors, disposal, and documentation kept for six years.
45 CFR §164.308
LA-HH-PRV-03
Breach Notification Under HIPAA and Louisiana Law
Sets out how the Agency recognizes, reports, investigates and documents a possible breach of patient information and gives the notices that the HIPAA Breach Notification Rule (45 CFR §§164.400 to 164.414) and the Louisiana Database Security Breach Notification Law (R.S. 51:3071 et seq.; LAC 16:III.701) require: to each affected person without unreasonable delay and no later than 60 calendar days after discovery, to the media and the Secretary of Health and Human Services where the rule requires, and to the Louisiana Attorney General's Consumer Protection Section.
45 CFR §164.404
Human resources6
LA-HH-HR-01
Personnel Policies, Job Descriptions, Orientation, and Performance Evaluation
Sets out the Agency's personnel policies, reviewed every year, covering each subject LAC 48:I §9119.A lists: hours of work, the organizational chart, job descriptions with realistic performance expectations, annual employee health screening, a written orientation outline with its length, annual evaluations and license verification, continuing education, discipline, grievances, employee health and safety, payroll, criminal background checks and registry checks.
LAC 48:I §9119.A
LA-HH-HR-02
Personnel Records and Annual Employee Health Screening
Sets out where the Agency keeps original personnel files, the 11 items LAC 48:I §9119.B requires in the record of every employee and contract staff member, how records are kept confidential and available to surveyors, how long they are kept, and how the annual employee health screening required by §9119.A.4 is carried out under the clinical manager's supervision of the employee health program.
LAC 48:I §9119.B
LA-HH-HR-03
Criminal History and Security Checks
Sets out how the Agency requests a criminal history and security check from the Louisiana State Police or an authorized agency upon an offer of employment or contract, gives the required notice and obtains written consent, uses temporary or conditional employment only as R.S. 40:1203.2 (as amended by Act 802 of 2026) allows, applies the hiring bar and termination duty in R.S. 40:1203.3 (as amended effective October 1, 2026), and keeps criminal history records confidential.
R.S. 40:1203.2
LA-HH-HR-04
Registry Checks and Exclusion Screening of Staff
Sets out the checks the Agency makes before hiring and every month after that: the Direct Service Worker Registry, the Louisiana Certified Nurse Aide Registry and the Louisiana adverse actions list, and the federal List of Excluded Individuals/Entities, as LAC 48:I Chapters 91, 92 and 100 require, together with the age and English requirements for non-licensed staff and what happens when a finding is found.
LAC 48:I §9120
LA-HH-HR-05
Licensure Verification, Continuing Education, Competency, and Impaired Personnel
Sets out how the Agency verifies the license or certification of every professional before employment and every year, confirms that staff are competent in each treatment and procedure before they perform it, makes sure the Administrator, clinical manager, professionals and aides complete the continuing education Louisiana requires, and refers impaired personnel to the proper authorities.
LAC 48:I §9103.B.2
LA-HH-SAF-01
Staff Safety in the Home and Workplace Violence Prevention
This is the Agency's workplace violence prevention plan under Louisiana's healthcare workplace violence law, together with its field safety procedures: the required sign at the office, annual interactive training for direct care staff, an annual risk assessment, how staff stay safe on home visits, how violent incidents are reported (within 24 hours when there is injury, a weapon or an urgent threat), protection from retaliation, and what happens when a home is unsafe.
R.S. 40:2199.15
Governance7
LA-HH-GOV-01
Governing Body, Organization Chart, and Lines of Authority
Sets out how the governing body of the Agency holds full legal authority and responsibility for its operation, designates the person responsible for day-to-day management, completes the annual documented review that LAC 48:I §9102.B.1 requires, keeps signed minutes, receives the written notifications and QAPI results the rule lists, and maintains an organizational chart that shows lines of authority down to the patient care level.
LAC 48:I §9102
LA-HH-GOV-02
Administrator, Alternate Administrator, Clinical Manager, and Alternate Clinical Manager
Sets out the qualifications, written designation, availability, duties and continuing education of the Administrator and the clinical manager, and the written designation of the persons who act for each of them when they are unavailable, as LAC 48:I §9103.A and B require; for a Medicare-certified agency it also applies 42 CFR §484.105(b) and (c) and §484.115.
LAC 48:I §9103.A
LA-HH-GOV-03
Licensure, Surveys, Plans of Correction, and Appeals
Explains how the Agency keeps its Louisiana home health license current, displays it, cooperates with unannounced surveys and complaint investigations, submits an acceptable plan of correction so that LDH receives it within 10 days, uses the informal dispute resolution process and appeal rights, and avoids the grounds for a provisional license, denial or revocation in LAC 48:I Chapter 91 and R.S. 40:2116.32 and 40:2116.36.
LAC 48:I §9105
LA-HH-GOV-04
Notice of Changes, Change of Ownership, Relocation, and Branch Offices
Sets out the written notices the Agency gives LDH no later than five days before a change of address, name, telephone or fax, hours, 24-hour contact procedures, administrator or clinical manager, controlling ownership or closure; how a change of ownership and a relocation are handled; and the approval, identification, records and operating rules for a branch office under LAC 48:I §9118.
LAC 48:I §9109
LA-HH-GOV-05
Hours of Operation, Agency Premises, Geographic Service Area, and Operational Requirements
Sets out the Agency's posted business hours (fully operational at least eight hours a day, five days a week between 7 a.m. and 6 p.m.), 24-hour availability of patient care and of a registered nurse by telecommunications, the rules for the Agency's premises, the 50-mile geographic service area, and the other operating requirements in LAC 48:I §9115.B that keep the Agency operational and lawfully licensed.
LAC 48:I §9115
LA-HH-GOV-06
Contract Services and Services Under Arrangement
Sets out when the Agency may contract with other companies or individuals to provide services to patients, the written contract and its required terms under LAC 48:I §9127.A.1, the Agency's continuing responsibility for the patient's care and the contractor's compliance, annual documented contract review, coordination of contract services, and the rule that administration and one other service are always provided directly.
LAC 48:I §9127
LA-HH-GOV-07
Cessation of Business, Agency Closure, and Disposition of Records
Sets out what the Agency does before and after it closes or stops providing services: 30 days' advance written notice to every patient, each patient's authorized healthcare provider and the Health Standards Section; a safe and orderly discharge and transition of every patient; a written plan for disposition of patient records approved by LDH, with a named custodian and newspaper notice at least 15 days before closure; and return of the license.
LAC 48:I §9110
Quality2
LA-HH-QA-01
Quality Assessment and Performance Improvement and Quarterly Clinical Record Review
Sets out the Agency-wide, data-driven quality assessment and performance improvement (QAPI) program that LAC 48:I §9131 requires: quarterly evaluations made up of an overall policy and administrative review and a quarterly clinical record review, an assessment of whether the program is appropriate, adequate, effective and efficient, quarterly reports to the governing body which receives and acknowledges them (§9102.B.4), and the annual program evaluation (§9102.B.1); and, if the Agency is Medicare-certified, the program scope, data, activities, performance improvement projects and executive responsibilities in 42 CFR §484.65.
LAC 48:I §9131
LA-HH-QA-02
Incident Reporting, Investigation, and Adverse Events
Sets out how staff report, and how the Agency responds to, investigates, documents and learns from incidents and adverse patient events such as falls, injuries, injuries of unknown source, medication errors, equipment failures, exposures and property loss. Louisiana has no home health incident report to LDH, but an agency that has placed a patient at risk according to a documented incident may receive a provisional license (LAC 48:I §9105.B.2.c), and failing to notify an appropriate governmental agency of suspected neglect, criminal activity or abuse is a ground for immediate revocation (§9111.C.4). Abuse, neglect and exploitation are reported outside the Agency under Policy LA-HH-SG-01 within 24 hours (R.S. 40:2009.20). If the Agency is Medicare-certified, adverse patient events are tracked and analyzed under 42 CFR §484.65.
LAC 48:I §9111.C
Business3
LA-HH-BUS-01
Budget, Accounting, Insurance, and Financial Viability
Sets out how the Agency keeps an ongoing, accurate and effective budgeting and accounting system, prepares an annual budget that the governing body reviews, keeps the line of credit and the general liability, professional liability and workers' compensation insurance required by LAC 48:I §9105.A.1 in force at all times, and, if Medicare-certified, prepares the overall plan, annual operating budget and capital expenditure plan required by 42 CFR §484.105(h).
LAC 48:I §9103.A.2.h
LA-HH-BUS-02
Charges, Billing, Claims, and Overpayments
Sets out how the Agency tells patients about payment sources and charges, bills only for services that were ordered, provided and documented, meets Medicare conditions for payment if certified, follows Louisiana Medicaid and other payer rules, reviews claims before they are sent, and reports and returns overpayments, in line with the Louisiana Medical Assistance Programs Integrity Law and federal rules.
R.S. 46:438.3
LA-HH-BUS-03
Electronic Visit Verification for Louisiana Medicaid Home Health Services
Sets out how the Agency uses electronic visit verification for Louisiana Medicaid nursing and therapy visits rendered in the home, as the 21st Century Cures Act and the LDH EVV Policy and Procedures (revised March 9, 2026) require, including the written internal policies LDH requires, clocking in and out, credentials, manual entries and edits, the connectivity test form, the utilization threshold, and ending access.
42 U.S.C. §1396b(l)
Ethics2
LA-HH-ETH-01
Compliance Program, Exclusion Screening, and Fraud Prevention
Sets out the Agency's compliance program: oversight, a code of conduct, ways to report concerns without retaliation, monthly exclusion screening of staff and contractors, auditing and monitoring, investigation and correction, education on the federal False Claims Act and the Louisiana Medical Assistance Programs Integrity Law, and cooperation with government investigations.
R.S. 46:438.3
LA-HH-ETH-02
Advertising, Patient Solicitation, Referrals, and Kickbacks
Sets out the Agency's rules on truthful advertising and public information, the ban on harassing, bribing, coercing or intimidating patients to choose or change agencies, the ban on paying or receiving anything of value for referrals under Louisiana and federal law, permitted activities such as health fairs and free blood pressure screenings, and the patient's right to choose an authorized healthcare provider and agency without interference.
LAC 48:I §9115.B.3
Questions
Questions about this manual
Is this the right manual for my license?
It is for home health agencies licensed by LDH, whether or not they are Medicare-certified. Providers with an HCBS license for personal care attendant services need the Louisiana home care manual, and hospices need the Louisiana hospice manual.
Where is Louisiana stricter than Medicare?
On the initial visit (within 24 hours of referral, not 48), the plan of care review by the authorized healthcare provider (at least once every two months), aide supervisory visits (made at the residence), record retention (six years from the date the record was established) and registry checks (before hire and every month). Each policy follows the stricter rule.
Does it cover workplace violence prevention?
Yes. Louisiana's healthcare workplace violence law covers licensed home health agencies. Policy LA-HH-SAF-01 sets out the prevention plan, a risk assessment and interactive staff training at least once a year, and reporting a violent incident that causes injury, involves a weapon or is an urgent threat within 24 hours (La. R.S. 40:2199.15 and 2199.16).
What do the 57 policies cover?
Client rights (5), service delivery (10), patient care (3), clinical tasks (7), safeguarding (2), infection control (3), emergency preparedness (2), records (2), privacy (3), human resources (6), governance (7), quality (2), business (3) and ethics (2).
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