Clinical Manager Availability, After-Hours Care, and On-Call

Sets out how the Agency makes sure a clinical manager, and the Administrator or a pre-designated person, is available during all operating hours; how patients can reach a clinician at any hour through the after-hours line; who takes on-call duty and what on-call staff must do; the Agency's own response-time standards for after-hours calls; and how after-hours calls, visits and orders are documented and handed over.

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About this policy

Policy number: MI-HH-CC-02
Version: 1.0
Main rule: 42 CFR §484.105(b)(3) and (c)
Library: Michigan home health · 57 policies
Category: Service delivery
Sections: 18

In short

A clinical manager and the Administrator, or the person acting for the Administrator, are available during all office hours.
Outside office hours, call the on-call nurse at (517) 555-0199. Calls are answered or returned within 15 minutes.
In an emergency, call 911 first, then the on-call nurse.
On-call nurses record every call and visit and hand over to the clinical manager by the next business morning.
Every patient gets the clinical manager's name and phone in writing.

What's inside

18 sections. The full text comes with the One-time Policy Pack.

Full text with a package

Terms of Reference
1. Purpose
2. Scope
3. Definitions
4. Policy Statement (42 CFR §484.105(b)(3) and (c))
5. Availability During Operating Hours
6. On-Call Coverage Outside Operating Hours
7. Handling an After-Hours Call
8. Staff in the Field
9. Telling Patients How to Reach the Agency
10. Monitoring
11. Responsibilities
12. Records and Compliance Monitoring
13. Staff Training
14. References
15. Related Policies and Forms
16. Approval
17. Revision History

An inspector may ask

Who is the clinical manager today, and how would a nurse in the field reach that person right now?
Who acts for the Administrator when the Administrator is away? Show me the written authorization.

Michigan home health

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Rules it follows

42 CFR §484.105(b)(3) and (c)Michigan Medicaid Provider Manual, Home Health, Section 10.242 CFR §484.105(b)(1)(iii)42 CFR §484.105(b)(2)42 CFR §484.105(b)(3)42 CFR §484.105(c)42 CFR §484.60(e)(5)42 CFR §484.80(h)42 CFR §484.102(c)

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