Pennsylvania Home Health Policy and Procedure Manual
For Pennsylvania home health care agencies licensed by the Department of Health under 28 Pa. Code Chapter 601, whether or not they are Medicare-certified. The manual has 56 policies and 47 forms, written to Chapter 601, the general licensing rules in Chapter 51 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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Pennsylvania · Home health
56 policies written to the Pennsylvania rules, with 47 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
- 56
- Forms
- 47
- 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.
PA-HH-CMP-01Free sample
Client rights
Complaints and Grievances
Gives every patient the right to complain about care or treatment without discrimination or reprisal, tells patients how to complain to the Agency and to outside bodies including the Department of Health home health complaint line (1-800-254-5164), and sets the Agency’s procedure to acknowledge, investigate, document and resolve each complaint within the Agency’s own time frames. Chapter 601 has no complaint procedure section; the Agency applies 42 CFR §484.50(e) to all patients, which is binding if the Agency is Medicare-certified.
Read the full policy PA-HH-SG-01Free sample SafeguardingAbuse, Neglect, and Exploitation of Adults: Mandatory Reporting
Requires every employee and administrator who has reasonable cause to suspect that a patient is a victim of abuse to make an immediate oral report to the local protective services agency ((717) 555-0121) or the 24-hour Statewide Elder Abuse Helpline (1-800-490-8505), to tell the Administrator immediately afterwards, and to make a written report within 48 hours (Older Adults Protective Services Act §701; 6 Pa. Code §15.151; Adult Protective Services Act §501 for adults 18 to 59 with a disability). Sexual abuse, serious physical or bodily injury and suspicious deaths also go immediately to law enforcement and orally to the Department of Aging. The Agency also gives the Department of Health written notice of every complaint of patient abuse.
Read the full policy PA-HH-IC-01Free sample Infection controlInfection Prevention and Control Program
Sets out the Agency’s infection prevention and control program: standard precautions on every visit, bag technique and equipment cleaning, transmission-based precautions, surveillance of infections as part of the quality program, reporting of reportable diseases and outbreaks to the Pennsylvania Department of Health under 28 Pa. Code Chapter 27 (a home health care agency is a "health care facility" under §27.1), restrictions on ill staff, and education of staff, patients and caregivers.
Read the full policy
Pennsylvania rules
What Pennsylvania's home health rules ask your policies to cover
- Aide supervision. A registered nurse or therapist visits the home at least every 2 weeks for every patient who has an aide. This is stricter than the federal rule for patients without skilled care. 28 Pa. Code §601.35(c)
- Verbal orders. The physician countersigns each verbal order within 7 days. 28 Pa. Code §601.31(d)
- Plan of treatment and summary reports. The physician reviews the plan of treatment at least every 60 days, and the agency sends the physician a written summary report for each patient at least every 60 days. 28 Pa. Code §§601.31(c) and 601.21(h)
- Group of professional personnel. At least one physician and one registered nurse who review the core policies every year and take part in a written evaluation of the whole program at least once a year. 28 Pa. Code §601.22
- Quarterly record review. A review at least every quarter of a sample of active and closed clinical records, including services under arrangement. 28 Pa. Code §601.22(d)
- Clinical records. Kept 7 years after discharge, longer than the 5-year federal minimum. 28 Pa. Code §601.36(b)
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 the last supervisory visit for this aide patient? And the one before?PA-HH-AID-02Home Health Aide Assignment, Duties, and Supervision
Show me the last two summary reports sent to this patient’s physician. When were they sent?PA-HH-CC-01Coordination of Patient Services, Case Conferences, and 60-Day Summary Reports
Show me your last four quarterly clinical record reviews. Who did them, how many records, and were services under arrangement included?PA-HH-QA-01Quality Assessment and Performance Improvement and Quarterly Clinical Record Review
What would your aide do if a patient told her that her son hits her?PA-HH-SG-01Abuse, Neglect, and Exploitation of Adults: Mandatory Reporting
If a storm closed the roads tomorrow, how would you reach your patients, and what would you report to the Department?PA-HH-EP-01Emergency Preparedness Program and Patient Emergency Plans
The full pack
Browse all 56 policies
Search by title, policy number or rule. Open any policy to see its summary, the rules it follows and what is inside.
All 56 policies
Client rights5
PA-HH-CMP-01Free sample
Complaints and Grievances
Gives every patient the right to complain about care or treatment without discrimination or reprisal, tells patients how to complain to the Agency and to outside bodies including the Department of Health home health complaint line (1-800-254-5164), and sets the Agency’s procedure to acknowledge, investigate, document and resolve each complaint within the Agency’s own time frames. Chapter 601 has no complaint procedure section; the Agency applies 42 CFR §484.50(e) to all patients, which is binding if the Agency is Medicare-certified.
42 CFR §484.50(e)
PA-HH-PR-01
Patient Rights and Responsibilities
Sets out the rights and responsibilities of every patient of the Agency, how and when they are explained and given in writing, who may exercise them for a patient, and how staff protect them day to day. 28 Pa. Code Chapter 601 has no patient-rights section, so the Agency applies 42 CFR §484.50 to every patient as its own standard; the federal rule is legally binding if the Agency is Medicare-certified. Pennsylvania confidentiality, nondiscrimination, advance directive and protective services laws apply to every patient in all cases.
42 CFR §484.50
PA-HH-PR-02
Advance Directives and Out-of-Hospital Do-Not-Resuscitate Orders
Sets out how the Agency gives every adult patient written information about the right under Pennsylvania law to accept or refuse treatment and to make an advance directive, records whether the patient has one, keeps copies in the clinical record, respects living wills, health care powers of attorney, health care representatives and out-of-hospital do-not-resuscitate orders, never conditions care on having a directive, and protects staff who decline to take part in withholding or withdrawing life-sustaining treatment.
20 Pa.C.S. Chapter 54
PA-HH-PR-03
Patient Agreement, Consent, and Disclosure of Charges
Sets out the written service agreement and consent each patient signs before care begins, the consent to release information outside the Agency that 28 Pa. Code §601.36(c) requires, the patient’s right to refuse, how the Agency tells each patient orally and in writing what Medicare, Medical Assistance or another payer is expected to cover and what the patient may have to pay, and the written notices given in advance of non-covered care or of reducing or ending care.
42 CFR §484.50(c)
PA-HH-PR-04
Language Access, Accessibility, and Effective Communication
Sets out how the Agency identifies each patient’s language and communication needs, provides qualified interpreters, translated documents and auxiliary aids and services free of charge, limits the use of family members and children as interpreters, gives the notice of free language assistance, and makes reasonable modifications for patients with disabilities, so that every patient receives information in plain language and in a manner that is accessible and timely.
42 CFR §484.50(f)
Service delivery9
PA-HH-ADM-01
Referral Intake and Patient Acceptance
Sets out how the Agency receives and records referrals, decides whether it can accept a patient on the basis of a reasonable expectation that the patient’s medical, nursing and social needs can be met adequately in the patient’s place of residence, applies the same acceptance criteria consistently to every referral, logs every referral not accepted with the reason, respects the patient’s free choice of provider, and keeps its public information about services accurate.
28 Pa. Code §601.31(a)
PA-HH-ADM-02
Time Frames for Initiation of Care
Sets the time within which the Agency makes the initial evaluation visit after accepting a referral, requires a registered nurse to make that visit as 28 Pa. Code §601.32(b) provides, explains how this compares with the federal 48-hour standard and therapy-only rule, and sets out what staff do when a visit is requested for a later date, when the patient returns home from a hospital, or when the time frame cannot be met.
42 CFR §484.55(a)
PA-HH-ADM-03
Eligibility, Certification, Face-to-Face Encounter, and Prior Authorization
Sets out how the Agency confirms, before and during care, that each patient meets the conditions of their payer: for Medicare, the homebound, skilled need, plan of care and physician or allowed practitioner requirements, the face-to-face encounter, certification and recertification; for Medical Assistance, the attending physician’s certifications, the 60-day review, and prior authorization; and for licensure, the attending physician’s supervision under 28 Pa. Code §601.31(a).
42 CFR §424.22
PA-HH-CC-01
Coordination of Patient Services, Case Conferences, and 60-Day Summary Reports
Sets out how all staff and contractors caring for a patient keep in touch so that their work fits together and supports the plan of treatment, how case conferences are held and recorded, how the registered nurse coordinates services and informs the physician, how services under arrangement are integrated, and how a written summary report for each patient is sent to the attending physician at least every 60 days, as 28 Pa. Code §601.21(h) requires.
28 Pa. Code §601.21(h)
PA-HH-CC-02
After-Hours Care, On-Call, and Supervisor Availability
Sets out how a qualified supervising nurse and a person in charge are available at all times during the Agency’s operating hours, how patients and staff reach a nurse outside office hours through (717) 555-0199, how on-call calls are answered, handled and recorded, how missed and late visits are prevented and handled, and how emergencies are escalated.
28 Pa. Code §601.21(e)
PA-HH-CS-01
Scope of Services and Services Offered
Sets out the home health services the governing body has approved, how the Agency meets the Pennsylvania definition of a home health care agency (skilled nursing plus at least one other therapeutic service, at least one of them provided directly by employees, on a part-time or intermittent basis), how services are added or stopped with 60 days’ written notice to the Department of Health, the annual review of the scope of services and the emergency scope of services, and the basic safety rules for staff working in patients’ homes.
28 Pa. Code §601.21(b)
PA-HH-CS-04
Laboratory Services and Waived Testing
Makes sure no Agency staff member tests a patient’s specimen unless the Agency holds a current CLIA certificate covering the test and has settled with the Pennsylvania Department of Health whether a state clinical laboratory permit is also needed. Covers waived tests, helping patients test themselves, collecting specimens for certified referral laboratories, and recording and reporting results.
42 CFR Part 493
PA-HH-DC-01
Discharge Planning, Transfer Summaries, and Transitions of Care
Sets out how the Agency plans each patient’s discharge from the start of care, helps patients choose a post-acute provider using quality and resource use data, sends the information the next provider needs, prepares the discharge summary that 28 Pa. Code §601.36(a) requires, sends a copy of the record or an abstract with a patient transferred to another home health agency (§601.36(b)), and, if the Agency is Medicare-certified, sends discharge and transfer summaries within the time frames in 42 CFR §484.110(a)(6).
42 CFR §484.58
PA-HH-DC-02
Patient Transfer and Discharge, Including Discharge for Cause
Sets out the only reasons for which the Agency transfers or discharges a patient, the written notice the patient receives and when, the Medicare notice of termination and the right to an expedited Quality Improvement Organization review, the Agency’s policy for discharge for cause under 42 CFR §484.50(d)(5), what happens when staff safety is at risk, and the steps after transfer or discharge. Pennsylvania’s home health rules set no discharge notice period; the advance notice for patients who are not Medicare beneficiaries is the Agency’s own standard.
42 CFR §484.50(d)
Patient care3
PA-HH-ASM-01
Initial Evaluation Visit and Comprehensive Assessment
Sets out what the registered nurse does at the initial evaluation visit, what the comprehensive assessment covers and when it is completed and updated, how medicines are reviewed, who may assess (registered nurses and, for therapy-only patients, therapists; licensed practical nurses contribute focused assessments only), and how each patient’s individual emergency plan is built into the assessment. The federal content and time frames in 42 CFR §484.55 are the Agency’s standard for every patient and are binding if the Agency is Medicare-certified.
42 CFR §484.55
PA-HH-ASM-02
OASIS Data Collection, Accuracy, and Transmission
Applies only if the Agency is Medicare-certified. Sets out how OASIS items are collected as part of the comprehensive assessment, how the data is checked for accuracy, encoded and transmitted to the CMS system within 30 days of completing the assessment, how errors are corrected, how the OASIS privacy notice is given, and how patient-identifiable OASIS information is kept confidential. A licensed-only Agency does not collect or transmit OASIS.
42 CFR §484.45
PA-HH-CP-01
Plan of Treatment and Care Planning
Sets out how each patient’s written plan of treatment is developed with the patient and all disciplines, what it must contain under 28 Pa. Code §601.31(b), 42 CFR §484.60(a) and, for Medical Assistance recipients, 55 Pa. Code §1249.42(2), how it is established, signed and reviewed by the attending physician at least every 60 days, how the physician is alerted to changes, how revisions are communicated, and the written instructions the patient receives.
28 Pa. Code §601.31
Clinical tasks8
PA-HH-AID-01
Home Health Aide Selection, Training, and Competency
Sets out how home health aides are selected, trained and evaluated before they care for patients, and kept competent afterwards. The Agency meets the Pennsylvania standard (selection factors, at least 60 hours of classroom instruction in the subjects in 28 Pa. Code §§601.6 and 601.35(a), close supervision) and, for every aide, the stricter federal standard: a qualifying training and competency program, an RN competency evaluation before any assignment, the 24-month lapse rule, and at least 12 hours of in-service training each year.
28 Pa. Code §601.35(a)
PA-HH-AID-02
Home Health Aide Assignment, Duties, and Supervision
Sets out how home health aides are assigned to a patient by a registered nurse with written instructions, which duties they may perform under 28 Pa. Code §601.35(b), and how they are supervised: an in-person RN (or therapist) supervisory visit to the patient’s residence at least every 2 weeks for every aide patient under §601.35(c), plus the federal on-site observations of each aide and retraining after deficiencies.
28 Pa. Code §601.35
PA-HH-CS-02
Skilled Nursing Services and Pennsylvania Nursing Practice
Sets out how skilled nursing is provided by or under the supervision of a registered nurse under 28 Pa. Code §601.32: what the registered nurse and the licensed practical nurse each do, how licensed practical nurses are supervised, practice within the scope set by the State Board of Nursing (49 Pa. Code Chapter 21), the nursing standards of conduct, clinical notes, reporting changes, and why nursing tasks are not delegated to home health aides in Pennsylvania.
28 Pa. Code §601.32
PA-HH-CS-03
Therapy and Medical Social Services
Sets out how physical therapy, occupational therapy, speech pathology and audiology, and medical social services are provided under 28 Pa. Code §§601.33 and 601.34: who may provide them, the duties of therapists and social workers, supervision of therapy assistants and social work assistants, therapy orders, evaluations for therapy-only patients, and documentation and coordination.
28 Pa. Code §601.33
PA-HH-CS-05
Pronouncement of Death and Care at the Time of Death
Tells staff what to do when a patient appears to have died or dies during a visit: emergency response, out-of-hospital do-not-resuscitate orders, expected and unexpected deaths, the county coroner, notifying the physician and family, care of the body, and records. Sets out, as a governing body choice, whether Agency registered nurses pronounce death under section 507 of the Vital Statistics Law of 1953.
35 P.S. §450.507
PA-HH-MED-01
Medication Management and Drug Regimen Review
Makes sure every patient has a current medication profile, that Agency staff check the medicines a patient may be taking for ineffective drug therapy, adverse reactions, significant side effects, drug allergies and contraindicated medication and promptly report problems to the physician (28 Pa. Code §601.31(d)), that nurses administer only ordered medications within their scope, that aides only assist with medications ordinarily self-administered, and that adverse reactions and errors are reported the same day.
28 Pa. Code §601.31(d)
PA-HH-MED-02
Intravenous Therapy and Infusion Services
Applies only if the governing body has added intravenous therapy to the Agency’s services. Sets the conditions under which registered nurses perform venipuncture and give intravenous fluids and medications (49 Pa. Code §21.12), including the list of intravenous medications kept by a committee of physicians, pharmacists and nurses; what licensed practical nurses may and may not do in IV therapy and how they are supervised (§§21.145(f)-(g), 21.145a, 21.145b); and safe infusion care in the home.
49 Pa. Code §21.12
PA-HH-ORD-01
Physician Orders and Verbal Orders
Makes sure every drug, device and treatment Agency staff give follows the physician’s written orders, sets who may take a verbal (oral) order and how it is read back, recorded and signed at once, and requires the physician’s countersignature within 14 days, which may not be longer than the 7 days 28 Pa. Code §601.31(d) allows. Covers documented follow-up of late countersignatures under the Department of Health survey guidelines, the Medical Assistance and Medicare countersignature rules, and faxed and electronic orders.
28 Pa. Code §601.31(d)
Safeguarding3
PA-HH-SG-01Free sample
Abuse, Neglect, and Exploitation of Adults: Mandatory Reporting
Requires every employee and administrator who has reasonable cause to suspect that a patient is a victim of abuse to make an immediate oral report to the local protective services agency ((717) 555-0121) or the 24-hour Statewide Elder Abuse Helpline (1-800-490-8505), to tell the Administrator immediately afterwards, and to make a written report within 48 hours (Older Adults Protective Services Act §701; 6 Pa. Code §15.151; Adult Protective Services Act §501 for adults 18 to 59 with a disability). Sexual abuse, serious physical or bodily injury and suspicious deaths also go immediately to law enforcement and orally to the Department of Aging. The Agency also gives the Department of Health written notice of every complaint of patient abuse.
35 P.S. §10225.701
PA-HH-SG-02
Suspected Child Abuse: Mandated Reporting
Makes every Agency employee who is engaged in the admission, examination, care or treatment of individuals, every licensed health professional, the people they supervise who have direct contact with children, and independent contractors mandated reporters of suspected child abuse under 23 Pa.C.S. §6311, who must immediately make an oral report to ChildLine (1-800-932-0313) or an electronic report, follow an oral report with a written report within 48 hours, and then immediately notify the Administrator (23 Pa.C.S. §§6311(c), 6313).
23 Pa.C.S. §6311
PA-HH-SG-03
Employee Alleged to Have Committed Abuse: Plan of Supervision and Suspension
Requires the Agency, on notification that an employee is alleged to have committed abuse, to immediately develop and implement an individual plan of supervision or, when appropriate, suspend the employee; to submit the plan to the protective services agency and the Department of Health for approval; to include in the plan periodic, random direct observation and evaluation by an individual employed by the Agency continuously for at least one year; and, on notice of criminal charges, to inform the Department of Health, which orders the employee’s access to patients denied (OAPSA §704; 6 Pa. Code §15.156; Adult Protective Services Act §504).
35 P.S. §10225.704
Infection control4
PA-HH-IC-01Free sample
Infection Prevention and Control Program
Sets out the Agency’s infection prevention and control program: standard precautions on every visit, bag technique and equipment cleaning, transmission-based precautions, surveillance of infections as part of the quality program, reporting of reportable diseases and outbreaks to the Pennsylvania Department of Health under 28 Pa. Code Chapter 27 (a home health care agency is a "health care facility" under §27.1), restrictions on ill staff, and education of staff, patients and caregivers.
42 CFR §484.70
PA-HH-IC-02
Bloodborne Pathogens Exposure Control Plan
The Agency’s written Exposure Control Plan under the OSHA bloodborne pathogens standard (29 CFR §1910.1030), which applies to private employers in Pennsylvania: exposure determination, engineering and work practice controls, protective equipment, hepatitis B vaccination within 10 working days of initial assignment, post-exposure evaluation and follow-up, labels, training at assignment and at least annually, the annual plan review with frontline input, and records.
29 CFR §1910.1030
PA-HH-IC-03
Medical Waste and Sharps Disposal
Sets out how the Agency handles regulated medical (infectious) waste and sharps under the Pennsylvania Department of Environmental Protection rules (25 Pa. Code §271.1 and Chapter 284) and OSHA: waste staff generate while giving care is regulated medical waste, while waste from the patient’s own self-care is not; segregation, red or orange bags and puncture-resistant sharps containers, labeling, storage of no more than 30 days after a container is full or sealed, transport by a licensed transporter or under the small-generator or mail-back exemptions, and teaching patients safe sharps disposal.
25 Pa. Code Chapter 284
PA-HH-IC-04
Employee Health Examinations and Tuberculosis Screening
Sets the Agency’s own standard for employee health examinations (28 Pa. Code §601.21(f) requires health examinations in personnel records but sets no content or frequency): a pre-assignment health examination, baseline tuberculosis screening with an individual risk assessment following current CDC guidance for health care personnel, annual TB education and symptom review, testing after exposure, vaccinations, work restrictions for communicable disease under 28 Pa. Code §27.155, and confidential health records.
28 Pa. Code §601.21(f)
Emergency preparedness1
Records1
Privacy3
PA-HH-PRV-01
HIPAA Privacy and Pennsylvania Confidentiality Laws
Names the Agency’s HIPAA Privacy Official, sets out when patient information may be used and shared, protects OASIS data, gives patients their HIPAA rights within the federal time frames, and applies the Pennsylvania rule that the clinical record is privileged and confidential and released outside the Agency only with the patient’s written consent unless law or a third-party contract provides otherwise (28 Pa. Code §601.36(c)).
45 CFR Part 164 Subpart E
PA-HH-PRV-02
HIPAA Security
Sets out how the Agency protects electronic patient information under the HIPAA Security Rule: a named security official, a documented risk analysis and risk management plan, safeguards for laptops, tablets and phones used in patients’ homes, access controls, audit review, backup and contingency plans, business associate agreements, and secure OASIS transmission, supporting the Pennsylvania duty to safeguard clinical record information "against loss or unauthorized use" (28 Pa. Code §601.36(c)).
45 CFR §§164.302-164.318
PA-HH-PRV-03
HIPAA and Pennsylvania Breach Notification
Sets out how the Agency recognizes, contains, assesses and reports a breach of patient or staff information: the HIPAA breach notification rule (individuals within 60 calendar days of discovery at the latest; media for more than 500 residents of a State; the HHS Secretary), and the Pennsylvania Breach of Personal Information Notification Act (notice without unreasonable delay; the Attorney General when more than 500 Pennsylvania residents must be notified; consumer reporting agencies when more than 500 persons are notified at one time; free credit report and credit monitoring where certain identifiers are involved).
45 CFR §§164.400-164.414
Human resources4
PA-HH-HR-01
Personnel Policies, Qualifications, Orientation, Staff Education, and Evaluation
Supports the Agency’s personnel practices with written personnel policies: a job description and qualifications for every position, license verification, orientation before patient contact, ongoing staff education and in-service training, identification tags, and documented performance evaluations, as 28 Pa. Code §601.21(d)-(f) and, for a Medicare-certified agency, 42 CFR §484.115 require.
28 Pa. Code §601.21(f)
PA-HH-HR-02
Personnel Records
Lists what each personnel record must contain under 28 Pa. Code §601.21(f) and the Older Adults Protective Services Act regulations, keeps criminal history and health information confidential, and sets how long records are kept.
28 Pa. Code §601.21(f)
PA-HH-HR-03
Criminal History Checks, Child Abuse Clearances, and Provisional Hiring
Requires every applicant, and every administrator or operator with patient contact, to submit a Pennsylvania State Police criminal history record obtained within the past year, and an FBI fingerprint check with a Department of Aging determination if not a Pennsylvania resident for the past two years; sets the conditions and time limits for provisional hiring; requires an individualized assessment of any conviction in line with the Peake decision; and requires child abuse clearances for staff who care for children.
35 P.S. §10225.502
PA-HH-HR-04
Volunteers
Sets the rules for volunteers: what they may and may not do, screening before patient contact (which the Agency requires as its own standard although Pennsylvania exempts volunteers from the OAPSA criminal history rule), orientation, supervision, documentation, and their role in emergencies.
28 Pa. Code §601.21(f)
Governance7
PA-HH-GOV-01
Governing Body, Bylaws, Organization, and Lines of Authority
Sets out how the governing body of the Agency holds full legal authority and responsibility for its operation, adopts and reviews written bylaws, appoints the Administrator, arranges professional advice, oversees management and fiscal affairs, and keeps a written description of the organization, services and lines of authority down to the patient care level, as 28 Pa. Code §601.21 and, for a Medicare-certified agency, 42 CFR §484.105 require.
28 Pa. Code §601.21
PA-HH-GOV-02
Administrator, Alternate Administrator, and Supervising Nurse
Names the qualifications and duties of the Administrator, requires a qualified person to be authorized in writing to act in the Administrator’s absence, requires a supervising physician or registered nurse with at least one year of nursing experience, or a similarly qualified alternate, to be available at all times during operating hours, and sets out how a change of Administrator is reported to the Department.
28 Pa. Code §601.21(d)
PA-HH-GOV-03
Licensure, Ownership, Notices to the Department, and Branch Offices
Explains how the Agency keeps its Pennsylvania license current, posts it, files the yearly statistical report, discloses ownership, and gives the Department the written notices Chapters 51 and 601 require before or after changes in ownership, management, services and locations, and how it handles branch offices, exceptions and enforcement.
28 Pa. Code §601.11
PA-HH-GOV-04
Group of Professional Personnel, Annual Policy Review, and Annual Program Evaluation
Sets up the group of professional personnel that Pennsylvania requires, with at least one physician and one registered nurse, to establish and review the Agency’s core policies every year, meet at least once a year with dated minutes, and take part in a written overall evaluation of the Agency’s total program at least once a year.
28 Pa. Code §601.22
PA-HH-GOV-05
Services Under Arrangement and Contracted Services
Requires a written contract for every service the Agency provides under arrangement, keeps at least one qualifying service provided directly by Agency employees, keeps administrative and supervisory control and monitoring with the Agency, and requires contracted caregivers to meet the same criminal history, competency and confidentiality standards as employees.
28 Pa. Code §601.21(b)
PA-HH-GOV-06
Agency Closure and Continuity of Records
Sets out how the Agency would close or stop a service in an orderly way: notice to the Department at least 60 days before ceasing a service, immediate reporting of a sudden interruption, safe transfer of every patient, and a plan that keeps clinical records for seven years after each patient’s discharge even after the Agency stops operating.
28 Pa. Code §601.36(b)
PA-HH-GOV-07
Nondiscrimination and Civil Rights Compliance
Adopts the nondiscriminatory policy Pennsylvania requires of every licensed health care facility, covering patients and staff, and sets out the records the Agency keeps to show compliance: the dated admission policy, a signed and dated notice to employees, publicity in the community at least every three years, posting, and a copy to the Department within 30 days of any change.
28 Pa. Code §51.12
Quality3
PA-HH-QA-01
Quality Assessment and Performance Improvement and Quarterly Clinical Record Review
Sets up the Agency’s quality assessment and performance improvement (QAPI) program and the Pennsylvania clinical record reviews: a review at least quarterly of a sample of active and closed records, covering direct services and services under arrangement, and a continuing review of each patient’s record for every 60-day period of care (28 Pa. Code §601.22(d)). If the Agency is Medicare-certified, the program also meets every element of 42 CFR §484.65; the Agency runs it for every patient either way.
42 CFR §484.65
PA-HH-QA-02
Incident Reporting, Serious Event Notices to the Department, and Investigations
Requires staff to report every incident at once, sets out how the Agency investigates and learns from incidents, and makes sure the Agency gives the Department of Health the notices Pennsylvania requires: immediate written notice of any event that could seriously compromise quality assurance or patient safety, including the events listed in 28 Pa. Code §51.3(g) such as deaths in unusual circumstances, medication error injuries, transfers to a hospital after an accident, and complaints of patient abuse whether or not confirmed, and an immediate telephone report with written follow-up of a catastrophic incident or interruption of services (§601.13(c)).
28 Pa. Code §51.3
PA-HH-QA-03
Reporting Professional Misconduct to Licensing Boards
Requires the Agency to report to the State Board of Medicine or the State Board of Osteopathic Medicine, within 60 days, the termination or curtailment of a physician’s association for reasonable cause to believe malpractice or misconduct occurred, a resignation to avoid discipline, or written information that a physician has been convicted of a felony (Health Care Facilities Act §806.1); requires written notice to the Department of Health of any unlicensed practice (28 Pa. Code §51.3(g)(13)); and sets the Agency’s own standard for reporting nurse, therapist and other licensee conduct that endangers patients to the licensing board.
Health Care Facilities Act §806.1
Business3
PA-HH-BUS-01
Budget, Institutional Planning, and Business Records
Requires the Agency, under the direction of the governing body and with administrative and health professional staff, to prepare an overall plan and budget each year, to run an effective budgeting and accounting system, and to keep business and fiscal records available to the Department of Health and the Medical Assistance program; adds the federal operating budget and three-year capital expenditure plan for a Medicare-certified agency.
28 Pa. Code §601.21(i)
PA-HH-BUS-02
Billing, Claims, and Payment Conditions
Requires accurate billing to every payer, sets out the Pennsylvania Medical Assistance payment conditions for home health services (orders and plan of treatment, certification, oral order countersignature, 60-day review, prior authorization, aide supervision documentation), the Medicare conditions for a certified agency, and how billing errors and overpayments are found, corrected and repaid.
55 Pa. Code §1249.52
PA-HH-BUS-03
Electronic Visit Verification for Medical Assistance Home Health Care Services
Requires electronic visit verification for every Medical Assistance home health care visit in a patient’s home, using the Department of Human Services EVV system or an approved alternate system that sends the six federally required data items to the DHS Aggregator, and sets out how staff record visits, how exceptions are corrected, and how the Agency trains staff and protects visit data.
42 U.S.C. §1396b(l)
Ethics2
PA-HH-ETH-01
Referral Payments, Kickbacks, and Patient Solicitation
Prohibits the Agency and its staff from offering, paying, soliciting or receiving anything of value for patient referrals, from soliciting Medical Assistance recipients from other providers, and from inducing patients to choose the Agency, and requires accurate public information about the Agency’s services.
55 Pa. Code §1101.51(c)
PA-HH-ETH-02
Compliance Program, Exclusion Screening, and Fraud Prevention
Sets up the Agency’s compliance program, built on the HHS-OIG elements, with a code of conduct, a way to report concerns without retaliation, screening of every employee and contractor against the Pennsylvania Medicheck List and the federal exclusion list at hire and every month, auditing, investigation and correction, and information on the False Claims Act.
62 P.S. §1407
Questions
Questions about this manual
Is this the right manual for my license?
It is for home health care agencies licensed under Chapter 601. Agencies licensed only for non-medical home care need the Pennsylvania home care manual, and hospices need the Pennsylvania hospice manual.
Does it suit both Medicare-certified and licensed-only agencies?
Yes. Chapter 601 treats a Medicare-certified agency as meeting it once it files the license application, fee and yearly statistical report (28 Pa. Code §601.2(c)). The policies still write in every Chapter 601 duty and add the federal Conditions of Participation. Chapter 601 has no patient rights section, so the federal rights rule (42 CFR §484.50) is applied to every patient as your agency's own standard.
How much training does a home health aide need?
Chapter 601 asks for at least 60 hours of classroom instruction, which may be finished during the first 3 months (28 Pa. Code §601.6). The federal rule asks for 75 hours before an aide is assigned. The policy applies the federal standard to every aide and labels it as your agency's own choice.
What do the 56 policies cover?
Client rights (5), service delivery (9), patient care (3), clinical tasks (8), safeguarding (3), infection control (4), emergency preparedness (1), records (1), privacy (3), human resources (4), governance (7), quality (3), business (3) and ethics (2).
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