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Ohio Home Care Policy and Procedure Manual

For Ohio agencies licensed by the Ohio Department of Health (ODH) to provide nonmedical home health services with their own aides. The manual has 49 policies and 65 forms, with the forms for clients in English and Spanish. It is written to ORC Chapter 3740 and OAC Chapter 3701-60, the licensing rules, and, where your agency takes part, to the Ohio Department of Aging's PASSPORT rules (OAC 173-39) and the Ohio Department of Medicaid's waiver rules (OAC 5160-44). Each policy opens with a plain-English summary and names the rule it follows, and every one is filled in with your agency's name and details. You get Word and PDF files to keep, and your staff read and sign each policy on their phone.

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Ohio · Home care

49 policies written to the Ohio rules, with 65 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
49
Forms
65
Categories
13
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3 free sample policies, shown in full for a sample agency.

OH-HC-CR-01Free sample Client rights

Client Rights and Responsibilities

Sets out the rights and responsibilities of every client of the Agency, the additional rights that Ohio Department of Medicaid rules give clients on an ODM-administered waiver, how and when the written rights notice is given and explained, how staff respect those rights on every visit, and where a client can take a concern inside and outside the Agency.

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OH-HC-ANE-01Free sample Safeguarding

Recognizing and Reporting Abuse, Neglect, and Exploitation of Adults

Makes every employee's legal duty to report suspected abuse, neglect (including self-neglect) and exploitation of adults clear and practical: who is a mandatory reporter under ORC 5101.63, the Ohio definitions, warning signs, how to report immediately to adult protective services through the county department of job and family services, what the written report contains, the separate route for people with developmental disabilities under ORC 5123.61, the one-business-day notice to ODA or its designee and the waiver incident report, protecting the client, protections for reporters, the penalty for not reporting, and what happens when an employee is accused.

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OH-HC-IC-01Free sample Infection control

Infection Prevention and Standard Precautions

Sets the Agency's infection prevention program for care in clients' homes, based on standard precautions: hand hygiene, gloves and other protective equipment supplied free of charge, respiratory hygiene, cleaning and disinfection, laundry and waste, food safety, care of clients with known or suspected infections, staff illness, outbreaks and public health emergencies, and the hand hygiene and PPE competency check on Form OH-HC-IC-01-A.

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Ohio rules

What Ohio's rules ask your policies to cover

  • Background checks. Each direct care applicant is checked against six databases and through a BCII criminal records check, with FBI information where the rule requires it. Employees are re-checked at least every five years. OAC 3701-60-05; OAC 3701-60-06
  • Conditional employment. The BCII check is requested within five business days after conditional employment begins, and the job ends if results other than FBI are not received within sixty days. OAC 3701-60-07
  • The license. It lasts three years. A renewal is on time only if filed at least ninety days before the license expires, and ODH gets written notice within ten days of a change in application information. ORC 3740.05; OAC 3701-60-03
  • Adult abuse reporting. Every employee reports suspected abuse, neglect or exploitation of an adult aged 60 or older immediately to the county department of job and family services. ORC 5101.63
  • PASSPORT aide supervision. For ODA-certified personal care, a supervisory visit at least every sixty days by a registered nurse, or a licensed practical nurse under a registered nurse, with at least two in-person visits a year. ORC 173.525(B); OAC 173-39-02.11(C)(4)
  • Waiver incidents. For clients on an Ohio Medicaid waiver, incidents go to the case management agency or managed care plan immediately on discovery and no later than one business day after. OAC 5160-44-05

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:

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Browse all 49 policies

Search by title, policy number or rule. Open any policy to see its summary, the rules it follows and what is inside.

All 49 policies

Client rights3

Service delivery13

OH-HC-ADM-01 Referral, Intake, and Acceptance of Clients Sets how the Agency receives referrals and enquiries, gathers intake information, decides whether it can safely serve a person with the nonmedical home health services it is licensed for, in the area it serves and with the staff it has, makes the initial home visit, tells the person the decision, and prepares for the first visit. Adds the acceptance rules for PASSPORT, Ohio Home Care Waiver and MyCare Ohio referrals. OAC 173-39-02.11(C)(2)(a) OH-HC-ADM-02 Client Service Agreement and Disclosure of Charges Requires a written Client Service Agreement, signed before services begin, that sets out the services, schedule, charges and payment terms, how either side may change or end services, how to complain and how to claim for loss or damage; explains how the agreement works for clients whose services Medicaid pays for, who are never billed for covered services; and sets how the agreement is changed, renewed and kept. OAC 5160-1-17.2(C) OH-HC-DC-01 Reduction, Suspension, Transfer, and Discharge Sets when services may be reduced, suspended, transferred or ended, what the Agency tries first, the written notice it gives (thirty days for PASSPORT, thirty calendar days for ODM-administered waivers with the listed exceptions, and an Agency standard for private pay), how it handles hospital stays and safety suspensions, how it helps a client move to another provider, and what the discharge summary records. OAC 173-39-02(B)(3)(d) OH-HC-SAF-01 Client Safety, Falls Prevention, and Safe Transfers Sets how the Agency keeps clients safe at home: a home safety check at the first visit and every in-person supervisory visit (Form OH-HC-SAF-01-A), preventing falls during care, safe walking and transfers using the technique and equipment in the activity plan, what to do when a client falls, follow-up and reporting of falls and injuries (including ODA significant-change and ODM 24-hour notices and waiver incident reports where they apply), and other hazards such as burns, fire, oxygen, wandering and extreme weather. OAC 173-39-02.11(C)(3)(a)(v)(b)(vii) OH-HC-SAF-02 Medical Emergencies, Death in the Home, and DNR Identification Sets how aides respond to a medical emergency (call 911 first, then the supervisor), give first aid within their training, and handle common emergencies; how the Agency records whether a client has Ohio do-not-resuscitate (DNR) identification and what aides do when it is present, based on ORC 2133.21 to 2133.26 and OAC Chapter 3701-62; what to do when a client dies at home; and how emergencies and deaths are recorded on Form OH-HC-SAF-02-A and reported for waiver clients. ORC 2133.21 OH-HC-SAF-03 Staff Safety in the Home and Workplace Violence Prevention Sets how the Agency protects aides and supervisors who work alone in clients' homes: safety information gathered before the first visit, check-in and travel safety, common hazards in the home, safe lifting, the right to leave when unsafe, handling harassment, threats and violence (including the ODM 24-hour notice and the ODA exception to thirty days' notice when the provider is at serious, imminent risk), work injuries and workers' compensation, OSHA reporting and recordkeeping, and reporting concerns without retaliation (Form OH-HC-SAF-03-A). OAC 5160-44-31(B)(17)(g) OH-HC-SP-01 Service Planning and Activity Plans Sets how the Agency plans each client's services with the client: who writes the written activity plan and when, how it follows the person-centered services plan for Medicaid clients, what it contains, how aides use it on every visit, and when it is reviewed and updated. Adds the initial-visit rules for ODA personal care and homemaker and for Ohio Home Care Waiver personal care aide services. OAC 173-39-02.11(C)(4)(b)(i) OH-HC-SP-02 Scheduling, Missed Visits, and Back-Up Plans Sets how the Agency schedules visits, keeps an agency back-up plan and a written back-up plan for each client, handles aide call-offs, late and missed visits and clients who are not at home, and gives the notices that ODA and ODM rules require when an authorized service is not provided as planned. OAC 173-39-02.11(C)(2)(c) OH-HC-SP-03 Changes in Condition, Significant Changes, and Coordination with Case Managers Sets how aides recognize and report changes in a client's condition, home or circumstances, how the supervisor responds and updates the activity plan, and when and how the Agency notifies ODA's designee (one business day), ODM or its designee (twenty-four hours) or the case manager, and, for private-pay clients, the representative. Covers ongoing coordination with case managers. OAC 173-39-02(B)(3)(b) OH-HC-SUP-01 Supervision of Aides and Supervisory Visits Sets who may supervise aides, how supervision is available whenever aides work, and how often supervisors visit each client: at least once every sixty days for PASSPORT personal care (with at least two in-person visits a year), at least every ninety days for ODA homemaker, at least every sixty days face to face with the aide present for Ohio Home Care Waiver personal care, and every ninety days in person for private-pay clients as the Agency's own standard. Covers what happens at each visit, the record each visit needs (Form OH-HC-SUP-01-A), extra visits after complaints or changes, and missed visits. ORC 173.525(B) OH-HC-SVC-01 Scope of Nonmedical Home Health Services and Clients Served Defines the nonmedical home health services the Agency is licensed to provide under Ohio law (home health aide services and personal care services), lists the services the Agency actually offers, states plainly that it does not provide skilled nursing, therapy or medical social services, and sets the types of clients it accepts, the clients it refers elsewhere, and its hours, service area and languages. It is the service list and related policy the Agency files with its license application. ORC 3740.01(N) OH-HC-SVC-02 Personal Care and Home Health Aide Tasks Sets which personal care and home health aide tasks aides may perform, the conditions for each (training and competency evaluation on the task, a current activity plan, and for Medicaid clients an authorized service), the tasks aides never perform because they are nursing tasks outside a nonmedical license, how aides observe and report changes, and how each aide's approved tasks are recorded on Form OH-HC-SVC-02-A. ORC 3740.01(H) OH-HC-SVC-03 Homemaker, Respite, Errand, and Escort Services Sets how the Agency provides homemaker services (only when incidental to personal care or essential to the client's own health and welfare, never for other household members), respite for family caregivers, errands outside the client's presence, and escort and transportation, including the ODA homemaker activity list, handling clients' money on errands, and the driver standards for staff who transport clients. ORC 3740.01(Q)(4) to (6)

Clinical tasks1

Safeguarding4

OH-HC-ANE-01Free sample Recognizing and Reporting Abuse, Neglect, and Exploitation of Adults Makes every employee's legal duty to report suspected abuse, neglect (including self-neglect) and exploitation of adults clear and practical: who is a mandatory reporter under ORC 5101.63, the Ohio definitions, warning signs, how to report immediately to adult protective services through the county department of job and family services, what the written report contains, the separate route for people with developmental disabilities under ORC 5123.61, the one-business-day notice to ODA or its designee and the waiver incident report, protecting the client, protections for reporters, the penalty for not reporting, and what happens when an employee is accused. ORC 5101.63 OH-HC-ANE-02 Reporting Suspected Child Abuse or Neglect Makes clear that every employee of the Agency is a mandated reporter of child abuse and neglect under ORC 2151.421, as an employee of a home health agency and of an entity that provides homemaker services; that the duty covers any child under 18 and any person under 21 with a developmental disability or physical impairment, including clients and children staff see in clients' homes; and sets out how to report immediately to the public children services agency or a peace officer, the written report, the protections for reporters, the penalty for not reporting, and the waiver incident report. ORC 2151.421 OH-HC-INC-01 Incident Management and Waiver Incident Reporting Sets how staff recognize, respond to, document and report incidents for every client, and how the Agency meets the Ohio Medicaid incident management rule for waiver and managed care clients: the critical and reportable incident categories, immediate action, the report to the case management agency or managed care plan immediately upon discovery and no later than one business day after discovery, the minimum report contents, the one-business-day significant change notice to ODA or its designee, cooperation with investigations, internal review and trend analysis, and the written acknowledgment of the rule by staff. OAC 5160-44-05 OH-HC-SVC-05 Responding to Challenging Behaviors and Prohibition of Restraint and Seclusion Prohibits any use of restraint, seclusion or restrictive intervention by Agency staff, sets how aides understand and respond to challenging behaviors (including dementia-related distress, aggression, wandering and self-harm) with respect and de-escalation, when to leave and call for help, and how behaviors are recorded, planned for and reported, including the Ohio waiver incident rule that treats unauthorized restraint as abuse. OAC 5160-44-05(B)(1)(a)

Infection control2

Emergency preparedness1

Records2

Privacy3

OH-HC-PRV-01 Privacy and Confidentiality of Client Information Sets how the Agency protects client information: when HIPAA applies, the privacy official, the minimum necessary rule, when information may be shared with family, case managers and others, the Notice of Privacy Practices, the client's rights to see, copy, amend and get an accounting of their information with the federal time limits, personal representatives, privacy in the client's home, business associates, complaints, sanctions and the Medicaid confidentiality rules that bind ODA and ODM providers. 45 CFR §164.502 OH-HC-PRV-02 Information Security, Devices, and Electronic Records Sets how the Agency protects electronic client information and the devices that hold it: the security official, a written risk analysis, unique logins and strong passwords, automatic lock and encryption, rules for Agency and personal phones used for EVV and visit notes, electronic signatures that meet ORC 3701.75, email and texting, backups and an emergency plan for systems, device loss, disposal, and reporting security incidents. 45 CFR §164.308 OH-HC-PRV-03 Breach Notification Sets how the Agency recognizes, investigates and reports a breach of client information: the HIPAA risk assessment, notice to clients without unreasonable delay and in no case later than 60 calendar days after discovery, notice to the Secretary of Health and Human Services and, for more than 500 residents of a state, the media; and, for an Agency that is not a HIPAA covered entity, Ohio's breach notice law for computerized personal information (no later than forty-five days after discovery). 45 CFR §164.404

Human resources8

OH-HC-HR-01 Recruitment, Hiring, and Minimum Qualifications of Staff Sets the Agency's recruitment and hiring steps and the minimum qualifications for each position: the age, identification, communication and screening requirements that apply to every direct care worker, the personal care aide and homemaker aide qualifications that apply when the Agency is ODA-certified, the aide qualifications for the Ohio Home Care Waiver, the qualifications of aide supervisors, and job descriptions for every position. ORC 3740.11(B) OH-HC-HR-02 Criminal Records Check Policy: Database Review, BCII and FBI Checks, and Conditional Employment The Agency's written criminal records check policy, filed with its nonmedical home health services license application. It covers who is checked, the notices given to applicants, the six-database review, the BCII criminal records check with FBI information where required, conditional employment with the five-business-day request and sixty-day limit, the disqualifying offenses and exclusionary periods, certificates and pardons, the five-year re-checks of employees, and the confidentiality, roster and attestation requirements of OAC 3701-60-10. ORC 3740.11 OH-HC-HR-03 Employee Health Screening, Tuberculosis, and Fitness for Duty Sets the Agency's own health screening program for staff who visit clients (a post-offer health statement, baseline tuberculosis screening and testing based on CDC recommendations, annual tuberculosis education, and follow-up after an exposure) and the fitness-for-duty rules, including the Ohio Medicaid and Department of Aging bans on working while unfit or impaired. OAC 5160-44-31(E)(7) OH-HC-HR-04 Personnel Files and Qualification Records Sets out what is kept in each personnel file, how criminal records reports and medical information are kept confidential and separate, how the Agency proves each aide's qualifications for ODA, and how long personnel, qualification, training, employment eligibility and OSHA records are kept. OAC 3701-60-10(B) OH-HC-HR-05 Orientation and Annual In-Service Training Sets the orientation every employee completes before any direct, in-person contact with a client, including the topics the Ohio Department of Aging requires, and the annual in-service training: six hours of ODA-approved in-service every twelve months for ODA personal care and homemaker aides, twelve hours for Ohio Home Care Waiver aides of accredited agencies, the Agency's own minimum for all other staff, bloodborne pathogens training, and the annual written acknowledgment of the Ohio incident management rule. OAC 173-39-02.11(C)(3)(b) OH-HC-HR-06 Exclusion Screening, Employment Eligibility, and Employer Obligations Makes sure no one the Agency employs or contracts with is excluded from federal or Ohio health care programs, by checking the federal exclusion lists at hire and monthly and the Ohio Medicaid exclusion and suspension list, and sets the Agency's duties as an employer: employment eligibility verification, Ohio workers' compensation through the state insurance fund, wage-and-hour compliance, taxes, and the attestations ODA requires. OAC 5160-1-17.2(H) OH-HC-HR-07 Staff Referred by Employment Services, Contractors, and Volunteers Sets the rules for direct care workers referred to the Agency by an employment service (who count as Agency employees for the background check law), the confirmations and letters the Agency must receive before relying on the employment service's database review and criminal records check, and the Agency's standards for contractors and volunteers, including supervision of volunteers under ODA rules. ORC 3740.11(F) OH-HC-TRN-01 Aide Training, Competency Evaluation, and Qualifications Sets how aides qualify before serving clients: the five ODA routes for PASSPORT personal care aides (state tested nurse aide, Medicare home health aide, one year of experience plus competency evaluation, a vocational program, or a training and competency evaluation program of at least thirty hours covering ten listed subjects), the homemaker aide route, the Ohio Home Care Waiver certificate and first aid requirements, and the Agency's own standard applying the ODA routes to private-pay aides. Covers competency evaluation by written or electronic test and in-person return demonstration, additional training before new tasks, and verification records (Forms OH-HC-TRN-01-A and OH-HC-TRN-01-B). ORC 173.525(A)

Governance4

OH-HC-GOV-01 Governing Body, Organization, and Adoption of Policies Identifies the governing body of the Agency and what it is responsible for, lists every written policy that an Ohio or federal rule requires (including the criminal records check policy and the service policies filed with the nonmedical home health services license application), and sets the procedure for adopting, issuing, reviewing and withdrawing policies, including the ten-day notice to the Department of Health when a filed document changes. ORC 3740.03(B)(1) OH-HC-GOV-02 Administrator and Alternate Administrator Sets out how the governing body appoints the Administrator, who is the Agency's "chief administrator" under ORC 3740.11, and an Alternate Administrator; the qualifications the Agency requires; the duties Ohio law places on the chief administrator (database reviews, criminal records checks, notices to applicants and designation of direct care positions); and what happens when the Administrator changes. ORC 3740.11 OH-HC-GOV-03 Nonmedical Home Health Services License: Application, Renewal, Changes, and Closure Explains what the Ohio nonmedical home health services license covers and how the Agency applies for it, renews it at least 90 days before it expires, reports changes to the Department of Health within ten days, handles a change of ownership or relocation, and closes safely, together with the matching notices to ODA and ODM for waiver providers. ORC 3740.02(A)(2) OH-HC-GOV-04 Oversight by the Department of Health, Program Reviews, and Plans of Correction Sets out how the Agency cooperates with the Ohio Department of Health, the Ohio Department of Aging and its designee, the Ohio Department of Medicaid and auditors: giving immediate access and records, keeping the criminal records check roster ready for the director, responding to findings, and sending plans of correction within the time each program sets, together with the Department of Health's grounds for denial, suspension and revocation and the hearing rights. ORC 3740.07

Quality2

Business3

Ethics3

Questions

Questions about this manual

Is this the right manual for my license?

It is for agencies with an ODH nonmedical home health services license that employ their own aides, including those certified by ODA for PASSPORT or serving Ohio Medicaid waiver clients. Agencies with a skilled home health services license need the Ohio home health manual, and hospices need the Ohio hospice manual. Self-employed (nonagency) providers are not covered.

Ohio's license rules say little about client care. What does the manual do?

Ohio's nonmedical license rules (OAC 3701-60) cover licensing and background checks. Where Ohio sets no rule, such as which tasks an aide may do, the policy states an agency standard and labels it as your agency's own choice, so you can change it. ODA and ODM rules are added where your agency takes part in PASSPORT or a Medicaid waiver.

What do the 49 policies cover?

Client rights (3), service delivery (13), clinical tasks (1), safeguarding (4), infection control (2), emergency preparedness (1), records (2), privacy (3), human resources (8), governance (4), quality (2), business (3) and ethics (3).

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