Washington, DC Home Health Policy and Procedure Manual
For Washington, DC home care agencies licensed by DC Health under 22-B DCMR Chapter 39: agencies that directly provide skilled nursing and at least one other therapeutic service, whether or not they are Medicare-certified. The manual has 58 policies and 56 forms, with every patient form in English and Spanish, written to Chapter 39, the District's Certificate of Need rules and, where they apply, the home health Conditions of Participation (42 CFR Part 484) and the DC Medicaid personal care aide and EPD Waiver rules. 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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Washington, DC · Home health
58 policies written to the Washington, DC 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
- 58
- Forms
- 56
- Categories
- 13
- 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.
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3 free sample policies, shown in full for a sample agency.
DC-HH-CMP-01Free sample
Client rights
Complaints and Grievances
Lets patients and their representatives complain to any staff member, orally or in writing, in confidence and without fear of reprisal; gives a written summary of the process at acceptance or denial of services; posts the DC Health complaint hotline in the office; answers every complaint within 14 calendar days and, if the patient is not satisfied, in writing within 30 calendar days of the first response with the contact details of every District agency that takes complaints; meets the shorter EPD Waiver time frames where they apply; and reviews all complaints in the governing body’s annual evaluation.
Read the full policy DC-HH-SG-01Free sample SafeguardingAbuse, Neglect, Self-Neglect, and Exploitation of Adults: Reporting to Adult Protective Services
Requires every staff member who suspects that an adult patient (or another vulnerable adult in the home) is being abused, neglected, or exploited, or is neglecting himself or herself, to make the person safe, report at once inside the Agency, and make sure a report reaches Adult Protective Services, which takes reports 24 hours a day. Licensed health professionals, social workers, and the Director are mandatory reporters under D.C. Code §7-1903; the Agency requires every staff member to report and never lets an internal report replace or delay the APS report.
Read the full policy DC-HH-IC-01Free sample Infection controlInfection Prevention and Control and Employee Communicable Disease Screening
Sets out the Agency’s infection prevention and control program: standard and transmission-based precautions in the home, bag technique, surveillance of infections in patients and staff, outbreak response and communicable disease reporting, education for staff, patients, and caregivers, and the communicable disease screening of every employee at hire and every year, with rules on working while ill.
Read the full policy
Washington, DC rules
What the District's rules ask your policies to cover
- Discharge notice. Written notice at least 7 calendar days before a discharge or referral, with oral notice allowed only in the cases the rule lists. For DC Medicaid personal care aide beneficiaries, the notice is generally 30 calendar days. 22-B DCMR §3909.2; 29 DCMR §5007.1
- Complaints. A response within 14 calendar days of receipt. If the patient is not satisfied, a written response within 30 calendar days that gives the contact details of every District agency that takes complaints. 22-B DCMR §3913.5 and §3913.6
- Plan of care and orders. The plan of care is approved and signed within 30 days of the start of care. Telephone orders are put in writing immediately and signed within 30 days. 22-B DCMR §3914.4
- Aide supervision. On-site supervision at least every 2 weeks for patients receiving skilled services, and at least every 62 calendar days for patients receiving other services. 22-B DCMR §3915.7
- Uncompensated care. Every Certificate of Need holder gives uncompensated care worth at least 3 percent of operating expenses, less Medicare and Medicaid reimbursements, posts notices in English and Spanish, and decides eligibility in writing within 10 business days. 22-B DCMR §4400.2; §4405.2; §4408.6(c)
- Background checks. Completed within the 45 days before the first day of work, looking back 7 years, and repeated every 4 years. DC Health is told within 10 days when someone leaves over criminal, unprofessional or unethical conduct. 22-B DCMR §4701; D.C. Code §44-552
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:
Show me the written notice you gave this patient before discharge. How many days before the discharge was it given?DC-HH-DC-02Written Notice of Discharge, Referral, Suspension, or Reduction of Services
This patient was not satisfied with your first answer. Show me your written response and the agency contacts it gave.DC-HH-CMP-01Complaints and Grievances
This patient receives only aide services. When was the last on-site supervisory visit?DC-HH-AID-02Aide Assignment, Duties, Written Instructions, and Supervisory Visits
Show me a written eligibility determination. Was it made within ten business days?DC-HH-BUS-04Certificate of Need Conditions and Uncompensated Care
Where is your District of Columbia operating office, and who staffs it eight hours a day, Monday through Friday?DC-HH-GOV-03Licensure, Certificate of Need, District Operating Office, Insurance, and Inspections
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Browse all 58 policies
Search by title, policy number or rule. Open any policy to see its summary, the rules it follows and what is inside.
All 58 policies
Client rights5
DC-HH-CMP-01Free sample
Complaints and Grievances
Lets patients and their representatives complain to any staff member, orally or in writing, in confidence and without fear of reprisal; gives a written summary of the process at acceptance or denial of services; posts the DC Health complaint hotline in the office; answers every complaint within 14 calendar days and, if the patient is not satisfied, in writing within 30 calendar days of the first response with the contact details of every District agency that takes complaints; meets the shorter EPD Waiver time frames where they apply; and reviews all complaints in the governing body’s annual evaluation.
22-B DCMR §3913
DC-HH-PR-01
Patient Rights and Responsibilities
Sets out the rights and responsibilities of every patient under 22-B DCMR §3912, the added rights of DC Medicaid personal care aide and EPD Waiver beneficiaries, and, if the Agency is Medicare-certified, the federal patient rights in 42 CFR §484.50; requires one combined written statement given and explained before care starts, a signed acknowledgment, public availability, and daily practices that make each right real.
22-B DCMR §3912
DC-HH-PR-02
Advance Directives, Medical Orders for Scope of Treatment, and Do-Not-Resuscitate Orders
Requires the Agency to give every adult patient written information on advance directives before care starts, record in a prominent place whether the patient has a durable power of attorney for health care or a MOST Form, follow District law on who may decide for an incapacitated patient, keep and transfer MOST Forms, act correctly in an emergency when a MOST Form or do-not-resuscitate order is present or uncertain, and never condition care on whether a patient has an advance directive.
22-B DCMR §3908.1
DC-HH-PR-03
Admission Agreement, Consent, Disclosure of Charges, and Interagency Information Sharing
Requires written admissions policies covering every item in 22-B DCMR §3908.1, a written summary given on admission, a signed services agreement and consent before care, oral and written disclosure of services, coverage, and charges, consent for specialized services and for interagency sharing of information, the uncompensated care notice before services, and, if the Agency is Medicare-certified, advance notice of non-covered care and of reductions or terminations.
22-B DCMR §3908.1
DC-HH-PR-04
Language Access, Communication Accommodations, and Effective Communication
Requires the Agency to find out at referral how each patient communicates, to provide qualified interpreters, translated documents, and auxiliary aids at no cost, to avoid using family members and children as interpreters, to assign staff who can communicate with the patient, and to document in the record the steps taken so that every patient receives all required information.
22-B DCMR §3912.6
Service delivery12
DC-HH-ADM-01
Referral Intake, Acceptance Criteria, and the 48-Hour Availability Notice
Sets out how the Agency receives and logs every referral and request for services, screens it against the 22-B DCMR §3908.3 criteria and its own capacity, decides whether to accept, tells the referral source and the person within 48 hours whether service is available and why, handles DC Medicaid referrals from DHCF, keeps records of requests not accepted for at least one year, and keeps public information about its services accurate.
22-B DCMR §3908.4
DC-HH-ADM-02
Initial Assessment Home Visit and Start of Care
Requires an initial assessment, including a home visit, for every patient before services start; sets the time frames (the Agency’s own start-of-care time frame, the 48-hour federal initial assessment visit if the Agency is Medicare-certified, and the 72-hour RN visit and 24-hour start of DC Medicaid personal care aide services); and sets out who conducts the visit, what it covers, the decision to admit, and what happens when a visit is delayed.
22-B DCMR §3908.6
DC-HH-ADM-03
Eligibility, Physician Certification, Face-to-Face Encounter, and DC Medicaid Authorization
Sets out how the Agency confirms, before and during care, that each patient is eligible for the payer’s benefit and that the required certification, face-to-face encounter, orders, and authorizations are in place: Medicare home health eligibility and certification if the Agency is Medicare-certified, DC Medicaid personal care aide orders and PCA Service Authorizations, EPD Waiver service plans, and other payers.
42 CFR §424.22
DC-HH-AID-03
DC Medicaid Personal Care Aide Services and EPD Waiver Homemaker Services
For an Agency enrolled with DC Medicaid: sets out the State Plan and EPD Waiver personal care aide services the Agency may provide and those it may not, who may be a paid aide, the registered nurse’s duties, the plan of care visit within 72 hours of the DHCF referral, the start of services within 24 hours of the plan, the RN visit within 48 hours of starting and at least every 60 days, reporting service failures to DHCF within three business days, and EPD Waiver homemaker services.
29 DCMR §5008
DC-HH-ASM-01
Comprehensive Assessment, Reassessment, and the 62-Day Skilled Services Review
Sets the schedule, content, and responsibility for assessing and reassessing each patient: the nurse’s and each discipline’s evaluations, the review and evaluation of skilled services at least every 62 calendar days with a summary report to the physician, the federal comprehensive assessment and its updates if the Agency is Medicare-certified, the DC Medicaid 60-day plan reviews and annual evaluation of continued need, and the reassessments a change in condition requires.
42 CFR §484.55
DC-HH-ASM-02
OASIS Data Collection, Accuracy, and Transmission
Applies only if the Agency is Medicare-certified. Sets out how the Agency collects OASIS data as part of the comprehensive assessment, checks it for accuracy, encodes and transmits it to CMS within 30 days of completing the assessment, corrects errors, gives the OASIS privacy notice, and protects patient identifiable OASIS information. The District has no OASIS rule of its own.
42 CFR §484.45
DC-HH-CC-01
Coordination of Services, Interagency Coordination, and Summary Reports to the Physician
Sets the Agency’s written policies for documenting how different services are coordinated, inside the Agency and with other agencies, through written communication, case conferences, and interagency agreements; sets the progress notes, summary notes, and summary reports to the physician required every 30 and 62 calendar days; and sets what the Agency tells DHCF about DC Medicaid personal care aide beneficiaries.
22-B DCMR §3916.2
DC-HH-CC-02
After-Hours Availability, On-Call, Missed Visits, and Contingency Staffing
Makes sure patients can reach the Agency at all hours: a District office staffed at least eight hours a day Monday through Friday, a registered nurse on call at all other times, named employees and protocols for emergencies in each plan of care, prompt handling of late and missed visits, contingency staffing so a patient is not left without care when an assigned worker cannot come, and reports to DHCF within three business days when an authorized DC Medicaid PCA visit is not delivered.
22-B DCMR §3914.3(l)
DC-HH-CP-01
Plan of Care: Content, Patient Participation, and Practitioner Approval
Requires a written, individualized plan of care for every patient, developed with the patient, containing every item in 22-B DCMR §3914.3 (and, if the Agency is Medicare-certified, 42 CFR §484.60(a)(2)), approved and signed by the physician or other practitioner DC Health allows within 30 days of the start of care, followed by all staff, reviewed and revised as the patient’s condition requires, and explained to the patient in written care instructions.
22-B DCMR §3914
DC-HH-CS-01
Scope of Services and Services Offered
Defines the services the Agency offers, makes sure it directly provides skilled nursing and at least one other therapeutic service as the District licensing law requires, keeps a written policy for every service, and tells patients, referral sources, and the public accurately what is and is not available.
D.C. Code §44-501(a)(7)
DC-HH-DC-01
Discharge Planning, Transfer, and Discharge Summaries
Sets the Agency’s written criteria and procedures for transfer, discharge, and referral; requires discharge planning from admission, documented in the record; sets how transfers to other providers, unplanned hospital admissions, and DC Medicaid provider changes are handled; and requires a discharge summary stating the reason and effective date, sent (if the Agency is Medicare-certified, and as the Agency’s standard for all patients) within 5 business days of discharge, or a transfer summary within 2 business days.
22-B DCMR §3909.1
DC-HH-DC-02
Written Notice of Discharge, Referral, Suspension, or Reduction of Services
Sets the notice the Agency gives before it discharges, refers, suspends, or reduces a patient’s services: at least 7 calendar days’ written notice for every patient, with the five District exceptions that allow oral notice; at least 30 calendar days for DC Medicaid personal care aide and EPD Waiver beneficiaries, with the immediate-threat and eligibility exceptions; the federal advance notices if the Agency is Medicare-certified; the steps before a discharge for cause; and the Agency’s duty to keep the patient safe until other care is in place.
22-B DCMR §3909.2
Clinical tasks8
DC-HH-AID-02
Aide Assignment, Duties, Written Instructions, and Supervisory Visits
Sets out how aides are assigned, the duties the Agency allows personal care aides and home health aides, the tasks aides never do, the written instructions every aide receives, and on-site supervisory visits at least every two weeks for patients receiving skilled services and at least every 60 days for all other patients (the District minimum is 62 calendar days), with the federal annual and semi-annual observations of each aide.
22-B DCMR §3915.7
DC-HH-CS-02
Skilled Nursing, Psychiatric Nursing, and Monitoring Services
Sets out who may provide skilled nursing, the duties every Agency nurse carries out, on-site supervision of licensed practical nurses at least every 62 calendar days, progress notes every 30 and summary notes every 62 calendar days, the limits on wound care and tube feeding by aides, and the extra requirements for psychiatric nursing, monitoring services, and ventilator-dependent patients.
22-B DCMR §3917
DC-HH-CS-03
Therapy, Nutritional Support, and Medical Social Services
Sets out the qualifications, orders, evaluations, documentation, and supervision for occupational therapy, physical therapy, speech language pathology, medical social services, and nutritional support services, including the summary statement to the physician every 62 calendar days for nutritional support.
22-B DCMR §3923
DC-HH-CS-04
Intravenous Therapy and Infusion Services
Sets out the written policies 22-B DCMR §3920.5 requires for intravenous therapy: who may give it, patient selection, the intravenous therapy service plan, consent, monitoring and emergency care, the anaphylactic kit rule for first doses of antibiotics and chemotherapy, 24-hour availability, storage, infection control, disposal, equipment, supplies, blood transfusions, adverse reactions, and the 30-day progress notes and 62-day summary reports.
22-B DCMR §3920
DC-HH-CS-05
Laboratory Services, Specimens, and Diagnostic Results
Sets out how the Agency collects, labels, and sends specimens, performs any testing in the home, records the type and frequency of diagnostic services and the dates and times of specimen collection, and makes sure results reach the physician, especially results outside ordered limits.
42 CFR §484.100(c)
DC-HH-CS-06
Death of a Patient at Home and Pronouncement of Death
Tells staff what to do when a patient dies at home or is found dead: CPR and 911 unless a valid MOST Form says not to resuscitate, reporting every death at home to the Office of the Chief Medical Examiner and leaving the body undisturbed until it decides, pronouncement of an expected death by the registered nurse under D.C. Code §7-231.12(r), notifying the physician, family and funeral home, the death certificate duties District law gives to the funeral director, the physician and the medical examiner, care of the body, medications and equipment, documentation, discharge, the Agency's own incident and adverse event reporting, and support for the family.
D.C. Code §5-1406
DC-HH-MED-01
Medication Management, Assistance with Self-Administration, and Drug Regimen Review
Sets out how the Agency keeps an accurate medication profile and allergy history for every patient, reviews the drug regimen, gives medications only as ordered and only by licensed nurses, limits aides to assisting with self-administration, teaches patients with a written medication schedule, gives vaccines only under an approved protocol, and handles medication errors and adverse drug reactions.
22-B DCMR §3914.3(d)
DC-HH-ORD-01
Physician, APRN, and Physician Assistant Orders and Telephone Orders
Sets out who may give orders for the Agency’s patients, how plans of care and orders are approved and signed within 30 days of the start of care, how telephone orders are taken, read back, reduced to writing immediately, and signed within 14 days (never more than the 30 days the rule allows), and the order rules for DC Medicaid personal care aide services.
22-B DCMR §3914.4
Safeguarding3
DC-HH-SG-01Free sample
Abuse, Neglect, Self-Neglect, and Exploitation of Adults: Reporting to Adult Protective Services
Requires every staff member who suspects that an adult patient (or another vulnerable adult in the home) is being abused, neglected, or exploited, or is neglecting himself or herself, to make the person safe, report at once inside the Agency, and make sure a report reaches Adult Protective Services, which takes reports 24 hours a day. Licensed health professionals, social workers, and the Director are mandatory reporters under D.C. Code §7-1903; the Agency requires every staff member to report and never lets an internal report replace or delay the APS report.
D.C. Code §7-1903
DC-HH-SG-02
Child Abuse and Neglect: Mandatory Reporting
Treats every staff member as a mandatory reporter of child abuse and neglect, as District law requires for registered and practical nurses, social services workers, and individuals involved in the care and treatment of patients: when staff know or have reasonable cause to believe that a child they know through their work has been abused or neglected, or is in immediate danger of abuse, they immediately make an oral report to the Child and Family Services Agency or the Metropolitan Police Department, tell the Director, and make a written report if asked.
D.C. Code §4-1321.02
DC-HH-SG-03
Allegations Against Staff: Investigation, Protection of the Patient, and Reports to DC Health and Licensing Boards
When anyone alleges that an Agency employee or contractor mistreated, neglected, abused, or stole from a patient, the Agency protects the patient at once (removing the staff member from patient contact and sending alternate staff), makes the outside reports the law requires, investigates and documents the allegation and its resolution, prevents retaliation, acts on the findings, and tells DC Health within 10 days and the licensing board within 10 business days when a person leaves or is disciplined for the conduct.
42 CFR §484.50(e)
Infection control3
DC-HH-IC-01Free sample
Infection Prevention and Control and Employee Communicable Disease Screening
Sets out the Agency’s infection prevention and control program: standard and transmission-based precautions in the home, bag technique, surveillance of infections in patients and staff, outbreak response and communicable disease reporting, education for staff, patients, and caregivers, and the communicable disease screening of every employee at hire and every year, with rules on working while ill.
22-B DCMR §3905.2(h)
DC-HH-IC-02
Bloodborne Pathogens Exposure Control Plan and Hepatitis B Vaccination
This is the Agency’s written Exposure Control Plan under the OSHA Bloodborne Pathogens Standard: who is exposed and when, engineering and work practice controls, personal protective equipment, hepatitis B vaccination within 10 working days of initial assignment, what to do after an exposure, training at assignment and every year, the annual plan review with frontline input, and the records OSHA requires.
29 CFR §1910.1030
DC-HH-IC-03
Sharps, Medical Waste, and Equipment Cleaning
Sets out how staff handle and dispose of sharps and regulated medical waste generated by Agency care, teach patients to dispose of household sharps safely, clean up blood spills, and clean and disinfect reusable equipment between patients.
22-B DCMR §3920.5(f)
Emergency preparedness1
Records2
DC-HH-REC-01
Clinical Records: Content, Authentication, Storage, and Retention
Defines what goes into every patient’s clinical record, how entries are written, signed, corrected, and kept secure, where records are held (the District operating office, or produced within 24 hours), how long they are kept (at least five years after discharge under Chapter 39, ten years for DC Medicaid records, and ten years after discharge for every record as the Agency’s own standard), and how they are destroyed or transferred if the Agency closes.
22-B DCMR §3910.4
DC-HH-REC-02
Patient Access to Records, Copies, and Release of Information
Gives patients access to their own clinical records (a free copy at the next visit or within 4 business days as the Agency’s standard for every patient, and within the HIPAA limit of 30 days for formal requests), sets out how records are amended, and controls every release of information to others, which needs the patient’s signed authorization unless the law allows the disclosure without one.
22-B DCMR §3912.2(m)
Privacy3
DC-HH-PRV-01
HIPAA Privacy, Confidentiality, and the EPD Waiver Privacy Plan
Names the privacy official, gives every patient the Notice of Privacy Practices at the first visit, limits uses and disclosures of patient information to what HIPAA and District law allow, protects privacy in patients’ homes and on phones, honors patients’ privacy rights, serves as the privacy plan required for EPD Waiver services, and sanctions staff who break the rules.
45 CFR Part 164 Subpart E
DC-HH-PRV-02
HIPAA Security
Protects the Agency’s electronic patient information under the HIPAA Security Rule: a named security official, a written risk analysis and risk management plan, role-based access, unique logins, encryption of every device that holds patient information, audit log review, backup and disaster recovery, secure OASIS transmission, rules for phones and EVV devices in the field, and security incident response.
45 CFR §§164.302-164.318
DC-HH-PRV-03
Breach Notification Under HIPAA and District Law
Sets out how the Agency finds, assesses, and reports breaches of patient information: staff report at once, the privacy official completes a documented four-factor risk assessment, patients are notified without unreasonable delay and no later than 60 calendar days after discovery, HHS (and for large breaches the media) is notified, and under District law the Attorney General for the District of Columbia is notified in writing whenever a breach of computerized personal information affects 50 or more District residents.
45 CFR §§164.400-164.414
Human resources6
DC-HH-AID-01
Home Health and Personal Care Aide Qualifications, Training, Competency, and In-Service
Sets out who may work as a home health aide or personal care aide: a current District aide certification, 75 hours of classroom and supervised practical training with 16 classroom hours before 16 hours of supervised practical training, a competency evaluation before any assignment, at least 12 hours of in-service training a year with a disability care component, and the extra qualifications for DC Medicaid personal care aides and EPD Waiver homemakers.
22-B DCMR §3915.2
DC-HH-HR-01
Personnel Policies, Position Descriptions, Orientation, In-Service Training, and Annual Evaluation
Sets out the Agency’s written personnel policies: terms and conditions of employment, a position description for every job, orientation before patient contact, periodic training and competency evaluation, an annual performance evaluation for every employee, and fair discipline, termination, and grievance procedures.
22-B DCMR §3907.1
DC-HH-HR-02
Personnel Records, Employee Health Screening, and Fitness for Duty
Lists what every personnel record must contain, keeps records available to DC Health within 24 hours, screens every employee for communicable disease before hire and every year, and keeps anyone impaired or with a communicable disease that poses a confirmed risk away from patients.
22-B DCMR §3907.2
DC-HH-HR-03
Criminal Background Checks and Registry Checks
Requires a fingerprint-based criminal background check, sex offender and Nurse Aide Abuse Registry checks, and a sworn statement before anyone with direct patient access starts work, repeats the checks every four years, bars people convicted of listed offenses, and tells DC Health when someone leaves for criminal, unprofessional, or unethical conduct.
D.C. Code §44-552
DC-HH-HR-04
Professional Licensure, Aide Certification, Credential Verification, Agency Identification, and Reports to Licensing Boards
Makes sure every nurse, therapist, social worker, and aide holds a current District of Columbia license or certification that the Agency has verified, that every staff member shows Agency identification before entering a home, and that the Agency reports health professionals to their licensing board within 10 business days when District law requires it.
22-B DCMR §3907.9
DC-HH-HR-05
Staff Safety in the Home and Workplace Violence Prevention
Protects staff who work in patients’ homes and in the office: safety assessment at intake and before each visit, Agency identification, check-in when working alone, escorts and joint visits, leaving an unsafe situation without abandoning a patient, reporting and investigating every threat or act of violence, support after an incident, and the District and DC Medicaid rules that allow discharge or suspension when staff are threatened.
29 U.S.C. §654(a)(1)
Governance7
DC-HH-GOV-01
Governing Body, Bylaws, Organization, and Lines of Authority
Names the governing body as the body responsible for the operation of the Agency, requires it to adopt bylaws and policies, appoint a qualified Director, and review every policy each year, and requires a written organizational chart that shows the lines of authority from the governing body to the person giving care in the patient’s home.
22-B DCMR §3903
DC-HH-GOV-02
Director, Alternate Director, Clinical Manager, and Supervising Nurse
Sets the qualifications and duties of the Director, requires a written designation of an alternate Director, names the supervising nurse (and, if the Agency is Medicare-certified, the clinical manager) who oversees patient care, and requires prompt notice to DC Health when the Director changes.
22-B DCMR §3904
DC-HH-GOV-03
Licensure, Certificate of Need, District Operating Office, Insurance, and Inspections
Keeps the Agency licensed as a District of Columbia home care agency and covered by a Certificate of Need, with a staffed operating office in the District, its license posted, the insurance the rule requires, the notices DC Health requires, and full cooperation with inspections and surveys.
22-B DCMR §3900
DC-HH-GOV-04
Written Policies and Procedures and the Governing Body’s Annual Evaluation
Requires a complete written policy manual approved by the governing body and available to staff, patients, and the public as the rules require, and sets out the governing body’s annual review and evaluation of all policies, including feedback from a sample of District patients and a review of every complaint.
22-B DCMR §3903.2(c)
DC-HH-GOV-05
Contractor Agreements, Staffing Agencies, and Services Under Arrangement
Requires a written agreement with every contractor or staffing agency that provides home care services to the Agency’s patients, with the contents 22-B DCMR §3906.1 requires, and makes the Agency control, coordinate, and evaluate contracted services as if they were its own.
22-B DCMR §3906.1
DC-HH-GOV-06
Agency Closure, Change of Ownership, and Disposition of Clinical Records
Plans for a closure, sale, or change of control so that no patient is left without care, gives SHPDA, DC Health, DC Medicaid, and patients the notices District law requires, and keeps clinical records safe and retrievable after the Agency stops operating.
22-B DCMR §3910.1(b)
DC-HH-GOV-07
Nondiscrimination, Civil Rights, and Accessibility
Prohibits discrimination against patients, applicants, and staff on any ground protected by the D.C. Human Rights Act and federal civil rights laws, sets out how the Agency makes its services accessible, and tells patients how to raise a discrimination concern.
D.C. Code §2-1402.31
Quality2
DC-HH-QA-01
Quality Assessment and Performance Improvement
Runs one agency-wide, data-driven quality assessment and performance improvement (QAPI) program, required by 42 CFR §484.65 for a Medicare-certified agency and applied to every patient as the Agency’s own standard: the governing body approves what data is collected and how often, the QAPI committee tracks indicators and adverse events, focuses on high-risk, high-volume, and problem-prone areas, runs documented performance improvement projects, and feeds the governing body’s annual evaluation under 22-B DCMR §3903.2(c).
42 CFR §484.65
DC-HH-QA-02
Unusual Incidents, Serious Adverse Events, and EPD Waiver Incident Reporting
Requires every unusual incident to be made safe, reported inside the Agency at once and in writing before the end of the shift, reviewed by the supervising nurse, investigated, and tracked; and sets out the outside reports that apply: adverse events to DC Health’s reporting system no later than 60 days after they occur (D.C. Code §7-161), EPD Waiver incidents to DHCF within 24 hours or the next business day, abuse to Adult Protective Services or the Child and Family Services Agency, and the DC Health incident form when the Agency or DC Health decides a report is needed. Chapter 39 sets no incident reporting deadline; the Agency’s internal time frames are its own standards.
22-B DCMR §3905.2(i)
Business4
DC-HH-BUS-01
Overall Plan, Annual Operating Budget, and Capital Expenditure Plan
Requires an overall plan, an annual operating budget, and a capital expenditure plan prepared under the governing body’s direction and reviewed every year, checks every planned capital expenditure and new service against the Certificate of Need law first, and keeps the admissions and financial data District agencies require.
42 CFR §484.105(h)
DC-HH-BUS-02
Charges, Billing, Refunds, Claims, and Overpayments
Tells patients what each service costs and how they will be billed before care starts, bills every payer only for services that were authorized, delivered, and documented, never bills a Medicaid beneficiary for covered personal care, and returns any overpayment within 60 days of identifying it.
22-B DCMR §3908.1
DC-HH-BUS-03
Electronic Visit Verification for DC Medicaid Services
Requires every DC Medicaid personal care aide visit, and every other DC Medicaid home health visit for which DHCF requires it, to be recorded in the electronic visit verification system DHCF uses, with the six federal data elements, and controls manual corrections, missed visits, and the related records.
42 U.S.C. §1396b(l)
DC-HH-BUS-04
Certificate of Need Conditions and Uncompensated Care
Meets the uncompensated care obligation that comes with the Agency’s Certificate of Need: at least three percent of annual operating expenses (less Medicare and Medicaid reimbursements) in free or reduced-charge care to eligible people, with the required public and posted notices in English and Spanish, written eligibility decisions within 10 business days, an annual report to SHPDA, and the records to prove it.
22-B DCMR §4400.2
Ethics2
DC-HH-ETH-01
Compliance Program, Exclusion Screening, False Claims, and Fraud Reporting
Sets up the Agency’s compliance program: a code of conduct, training on federal and District false claims laws and whistleblower protections, monthly exclusion screening of staff and contractors, a way to report concerns without retaliation, prompt investigation and correction, and immediate reporting of suspected Medicaid fraud to DHCF.
29 DCMR §5012.7
DC-HH-ETH-02
Referrals, Kickbacks, Patient Inducements, and Marketing
Forbids paying or receiving anything of value for patient referrals, controls every financial relationship with physicians and other referral sources, limits gifts to patients, keeps marketing truthful, and applies the DC Medicaid rules that deny claims arising from staffing agency marketing or from prohibited physician relationships.
42 U.S.C. §1320a-7b(b)
Questions
Questions about this manual
Is this the right manual for my license?
It is for agencies licensed by DC Health as a home care agency, the license for home health. An agency that gives only non-medical personal care holds a home support agency license and needs the Washington, DC home care manual. Hospices need the Washington, DC hospice manual.
Do we need a Certificate of Need?
Yes. A home health or home nursing service needs a Certificate of Need from SHPDA (D.C. Code §44-406), and DC Health requires one for initial licensure (22-B DCMR §3102.3). Before closing, the agency notifies SHPDA at least 90 days ahead and obtains its approval (D.C. Code §44-406(c)).
Does it suit agencies that are not Medicare-certified?
Yes. Chapter 39 applies to every patient. The federal Conditions of Participation apply if the agency is Medicare-certified, and the DC Medicaid personal care aide and EPD Waiver rules apply if it is enrolled. Where the rules differ, the policies tell staff to follow the strictest one that applies to the patient.
What do the 58 policies cover?
Client rights (5), service delivery (12), clinical tasks (8), safeguarding (3), infection control (3), emergency preparedness (1), records (2), privacy (3), human resources (6), governance (7), quality (2), business (4) and ethics (2).
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