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Case Management Agency- Policies and Procedures- Virginia State Licens – CarePolicy.US
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DocumentDocumentPOLICY AND PROCEDURE MANUAL Case Management Agency Version 1.0 [Month, Year] Policy and Procedure Manual Version 1.0 Table of Contents Introduction ....................................................................................................................................10 Our Mission .....................................................................................................................................10 Our Vision........................................................................................................................................10 Statement of Purpose ......................................................................................................................11 Statement of Policy..........................................................................................................................11 Document Control & Approvals ........................................................................................................11 Pre-Scanning and Discharge Planning ...............................................................................................13 Policy: ..................................................................................................................................................... 13 Procedures:.............................................................................................................................................. 13 Root Cause Analysis .........................................................................................................................16 Policy: ..................................................................................................................................................... 16 Procedures:.............................................................................................................................................. 16 Serious Incident Reporting .......................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Incidents Identification ........................................................................... Error! Bookmark not defined. Classification of Incidents....................................................................... Error! Bookmark not defined. Serious Reportable Incidents .............................................................. Error! Bookmark not defined. Recordable Incidents........................................................................... Error! Bookmark not defined. Procedure for Reporting...................................................................... Error! Bookmark not defined. Fiscal Accountability (Internal Controls)....................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Framework for Internal Control .............................................................. Error! Bookmark not defined. Internal Controls ..................................................................................... Error! Bookmark not defined. Petty Cash/Funds Control ....................................................................... Error! Bookmark not defined. Purchasing Controls ................................................................................ Error! Bookmark not defined. Purchasing Review.................................................................................. Error! Bookmark not defined. Indemnification .......................................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Fee Schedule............................................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Fee schedule:........................................................................................... Error! Bookmark not defined. Document Classification: Confidential_ [AGENCY NAME] Page | 2 Policy and Procedure Manual Version 1.0 Policy on Funds of Individuals Receiving Services ......................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Building Modifications .............................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Weapon Policy.........................................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Criminal Background Check ......................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Employee Verification ............................................................................ Error! Bookmark not defined. Background Check.................................................................................. Error! Bookmark not defined. Recruitment............................................................................................. Error! Bookmark not defined. Job Descriptions.......................................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedure: ............................................................................................... Error! Bookmark not defined. Job Descriptions...................................................................................... Error! Bookmark not defined. Employee Training and Development .......................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedure: ............................................................................................... Error! Bookmark not defined. Employee Notification of Policy Changes ..................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Employee or Contractor Performance Evaluation......................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. What is good performance? .................................................................... Error! Bookmark not defined. Periodical reviews ................................................................................... Error! Bookmark not defined. Rewards .................................................................................................. Error! Bookmark not defined. Training................................................................................................... Error! Bookmark not defined. Frequent communication ........................................................................ Error! Bookmark not defined. Managers' responsibilities ...................................................................... Error! Bookmark not defined. Grievance Policy ......................................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Document Classification: Confidential_ [AGENCY NAME] Page | 3 Policy and Procedure Manual Version 1.0 Procedures:.............................................................................................. Error! Bookmark not defined. Grievance Handling ................................................................................ Error! Bookmark not defined. Filing Complaints.................................................................................... Error! Bookmark not defined. Students and Volunteers ..........................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Risk Management ....................................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Designated Risk Management Specialist ................................................ Error! Bookmark not defined. Intervention for The Agitated or Dangerous Client ................................ Error! Bookmark not defined. Personal Injury and Illness Prevention Plan ........................................... Error! Bookmark not defined. Preventing Missing clients Incidents ...................................................... Error! Bookmark not defined. Raising the Alarm ................................................................................... Error! Bookmark not defined. Risk of Property Damage........................................................................ Error! Bookmark not defined. Procedure for Searching Missing/Loss Clients ....................................... Error! Bookmark not defined. Records and Documentation ................................................................... Error! Bookmark not defined. Emergency Preparedness and Response Plan............................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Emergency Preparedness Plan ................................................................ Error! Bookmark not defined. Emergency Plan ...................................................................................... Error! Bookmark not defined. Emergency Preparedness ........................................................................ Error! Bookmark not defined. Responsibilities of the Management ....................................................... Error! Bookmark not defined. Risk Management ................................................................................... Error! Bookmark not defined. Emergency Management Procedures...................................................... Error! Bookmark not defined. Obtains Written Authorization to seek Emergency Treatment ............... Error! Bookmark not defined. Record Keeping in Employee Personnel Records .................................. Error! Bookmark not defined. Emergency Communications .................................................................. Error! Bookmark not defined. Access to Telephone in Emergencies.........................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Service Description Requirements ............................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Staffing Plan ............................................................................................Error! Bookmark not defined. Document Classification: Confidential_ [AGENCY NAME] Page | 4 Policy and Procedure Manual Version 1.0 Policy: ..................................................................................................... Error! Bookmark not defined. Procedure: ............................................................................................... Error! Bookmark not defined. Nutrition..................................................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedure: ............................................................................................... Error! Bookmark not defined. Community Participation .........................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Monitoring and Evaluating Quality ...........................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Screening Admission and Referrals ...........................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedure: ............................................................................................... Error! Bookmark not defined. Assessment Policy....................................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Individualized Services Plan (ISP)..............................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Orientation..............................................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Transition of Individuals among Services ..................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Discharge Policy.......................................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Discharged Criteria ................................................................................. Error! Bookmark not defined. Crisis or Emergency Interventions.............................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Definitions and Procedures: .................................................................... Error! Bookmark not defined. Crisis intervention ................................................................................... Error! Bookmark not defined. Designated Person................................................................................... Error! Bookmark not defined. Crisis Receiving and Stabilization Services............................................ Error! Bookmark not defined. Document Classification: Confidential_ [AGENCY NAME] Page | 5 Policy and Procedure Manual Version 1.0 Minimum Expectations to Operate a Crisis Receiving and Stabilization Service . Error! Bookmark not defined. Documenting Crisis Intervention and Clinical Emergency Services ...... Error! Bookmark not defined. Healthcare Policy .....................................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Medical Necessity ................................................................................... Error! Bookmark not defined. Individual Services Plan ......................................................................... Error! Bookmark not defined. Medical Care and Identification for Treatment....................................... Error! Bookmark not defined. Client Identification Policy ..................................................................... Error! Bookmark not defined. Physical Examination ...............................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Medical Equipment..................................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Medication Management.........................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Behavior Interventions and Support .........................................................Error! Bookmark not defined. Policy ...................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Procedural Requirements for Behavior Interventions............................. Error! Bookmark not defined. Positive Behavior Support Strategies Include......................................... Error! Bookmark not defined. Manipulation of Rewards........................................................................ Error! Bookmark not defined. Consent ................................................................................................... Error! Bookmark not defined. Planning for Behavior Supports .............................................................. Error! Bookmark not defined. Functional Assessment............................................................................ Error! Bookmark not defined. Monitoring On-going Progress ............................................................... Error! Bookmark not defined. Record Management Policy......................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedures:.............................................................................................. Error! Bookmark not defined. Storage, processing, and handling of active and closed records ............. Error! Bookmark not defined. Storage, processing and handling of electronic records.......................... Error! Bookmark not defined. Strategies for service continuity and record recovery............................. Error! Bookmark not defined. Designation of person responsible for records management .................. Error! Bookmark not defined. Disposition of records ............................................................................. Error! Bookmark not defined. Record management policy will comply with state and federal regulations including:Error! Bookmark Document Classification: Confidential_ [AGENCY NAME] Page | 6 Policy and Procedure Manual Version 1.0 not defined. Documentation Policy ..............................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedure: ............................................................................................... Error! Bookmark not defined. Legibility................................................................................................. Error! Bookmark not defined. Client Identification ................................................................................ Error! Bookmark not defined. Time Documentation .............................................................................. Error! Bookmark not defined. Record Procedures .................................................................................. Error! Bookmark not defined. Correction of documentation .................................................................. Error! Bookmark not defined. Physician Orders ..................................................................................... Error! Bookmark not defined. Documentation ........................................................................................ Error! Bookmark not defined. Filing of Records..................................................................................... Error! Bookmark not defined. Security of Records/Documents.............................................................. Error! Bookmark not defined. Review Process for Records......................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedure: ............................................................................................... Error! Bookmark not defined. Case Management Choice ........................................................................Error! Bookmark not defined. Policy: ..................................................................................................... Error! Bookmark not defined. Procedure: ............................................................................................... Error! Bookmark not defined. Process of Changing a Case Manager..................................................... Error! Bookmark not defined. List of Forms/Annexures: .........................................................................Error! Bookmark not defined. Annexure 01: Financial Information Form Expenditure and Disbursement of Client Funds ........Error! Bookmark not defined. Annexure 02: Staff Orientation Form for Employees, Contractors,.............Error! Bookmark not defined. Volunteers and Students ..........................................................................Error! Bookmark not defined. Annexure 03: Staff Training and Development Form .................................Error! Bookmark not defined. Annexure 04: Performance Evaluation Form .............................................Error! Bookmark not defined. Annexure 05: Grievance Procedure Form..................................................Error! Bookmark not defined. Annexure 06: Facility Inspection Checklist Form........................................Error! Bookmark not defined. Annexure 07: Fire Safety Drill Form ..........................................................Error! Bookmark not defined. Annexure 08: Emergency Preparedness Numbers .....................................Error! Bookmark not defined. Annexure 09: Daily Schedule of Services ...................................................Error! Bookmark not defined. Annexure 10: Daily Nutrition Monitoring Form .........................................Error! Bookmark not defined. Annexure 11: Client Screening Form .........................................................Error! Bookmark not defined. Annexure 12: Initial Assessment Form ......................................................Error! Bookmark not defined. Annexure 13: Comprehensive Assessment Form .......................................Error! Bookmark not defined. Document Classification: Confidential_ [AGENCY NAME] Page | 7 Policy and Procedure Manual Version 1.0 Annexure 14: ISP Requirements Form.......................................................Error! Bookmark not defined. Annexure 15: Reassessments and ISP Quarterly Review Form ...................Error! Bookmark not defined. Annexure 16: Sample Daily Progress Notes ...............................................Error! Bookmark not defined. Annexure 17: Client Orientation Form ......................................................Error! Bookmark not defined. Annexure 18: Transfer Form .....................................................................Error! Bookmark not defined. Annexure 19: Discharge Form...................................................................Error! Bookmark not defined. Annexure 20: Crisis Intervention and Emergency Services .........................Error! Bookmark not defined. Annexure 21: Fall Assessment Form .........................................................Error! Bookmark not defined. Annexure 22: Client Physical Examination Form........................................Error! Bookmark not defined. Annexure 23: Emergency (ER) Medical Information Form..........................Error! Bookmark not defined. Annexure 24: Monitoring, Behavior Intervention & Supports Form ...........Error! Bookmark not defined. Annexure 25: Abuse/ Neglect Reporting Form ..........................................Error! Bookmark not defined. Annexure 26: Seclusion and/ or Restraint Documentation Form................Error! Bookmark not defined. Annexure 27: Client Face Sheet Form........................................................Error! Bookmark not defined. Annexure 28: Individual's Service Record Form.........................................Error! Bookmark not defined. Annexure 29: Therapies Individual/ Group Form ....................................Error! Bookmark not defined. Annexure 30: Release of Information Form...............................................Error! Bookmark not defined. Annexure 31: Record Review Form ...........................................................Error! Bookmark not defined. Document Classification: Confidential_ [AGENCY NAME] Page | 8 Policy and Procedure Manual Version 1.0 Copyright 2023 © [AGENCY NAME] Disclaimer: All rights reserved. No part of this publication may be utilized, reproduced, stored in a retrieval system, or transmitted in any form by any means, electronic, mechanical, recording or otherwise, without the prior written consent of the publisher. [Agency Name] [Agency Address] [Contact Number] [Email Address] [Website] Document Classification: Confidential_ [AGENCY NAME] Page | 9 Policy and Procedure Manual Version 1.0 Introduction [Agency Name]is a case management agency based in Virginia that is committed to providing comprehensive services to empower individuals to achieve their goals. Our primary focus is to work with clients to enhance or identify the skills and resources needed to function to their fullest potential in their community. At [Agency Name], we understand the importance of making the best decisions for our clients' well-being. We strive to deliver the highest quality of care to our clients, and our team of compassionate professionals is dedicated to ensuring their satisfaction. We work with our clients to create a personalized plan of care that is specific to their needs and goals. Our services include comprehensive case management, support coordination, and other related services to help our clients achieve their desired outcomes. We are committed to helping our clients achieve greater independence and quality of life. Our Mission Our mission at [Agency Name] is to empower individuals and families to achieve their fullest potential and live healthy, productive lives. We provide comprehensive case management services to those in need, with a focus on connecting our clients to the resources and support they need to thrive. We believe that every individual has the right to quality care and support, and we work tirelessly to ensure that our clients receive the highest level of service possible. Our team of dedicated professionals is committed to providing compassionate, individualized care to each and every client we serve. Through our services, we aim to improve the health and well-being of our clients, strengthen families and communities, and promote greater independence and self-sufficiency. We are passionate about our work and strive to make a positive impact in the lives of those we serve. Our Vision At [Agency Name], our vision is to create a world where every individual has the resources, support, and opportunity to lead a healthy and fulfilling life. We are dedicated to making a positive impact in the lives of those we serve, and we strive to be a leader in the field of case management. We envision a future where our clients have access to the highest quality of care, regardless of their background, circumstances, or challenges. We believe in a world where every person has the ability to reach their fullest potential, and we are committed to helping them get there. Through our work, we aim to build stronger, more resilient communities, where every person is valued and supported. We are driven by a passion for making a difference, and we will continue to work tirelessly to create a brighter future for those we serve Document Classification: Confidential_ [AGENCY NAME] Page | 10 Policy and Procedure Manual Version 1.0 Statement of Purpose The purpose of this policy is to define organization-wide processes and activities that maximize the coordination of quality home services to clients at [Agency Name]. The goal of this plan is to coordinate client's care in a manner that is seamless from the client's perspective. This policy shall be made available for review, upon request, to clients and their designated representatives and shall be readily available for staff use at all times within [Agency Name]. Statement of Policy [Agency Name] prohibits discrimination in all its activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, gender identity, genetic information, and any political beliefs. [Agency Name]is consistent with the: · Federal and State Law of Virginia · Needs of our members and the community we serve; · Our mission, goals and strategic objectives; · Agency policies and procedures We strongly adhere to compliance requirements stated by Virginia Law, Department of Health and follow the best practices implemented in terms of policies and procedures within [Agency Name]. Document Control & Approvals Document Revisions shall be recorded in the table below; Ver. Rev. Page No. No. No. Description of Amendment Approved By Date Document Classification: Confidential_ [AGENCY NAME] Page | 11 Policy and Procedure Manual Version 1.0 Document review and approvals shall be recorded in the table below; Description Title Signature Prepared By Reviewed By Approved By Date Note: All policies and procedures shall be reviewed at least annually, with recommended changes submitted to the governing body for approval, as necessary. Document Classification: Confidential_ [AGENCY NAME] Page | 12 Policy and Procedure Manual Version 1.0 Area/ Title: Pre-Scanning and Policy: 12 VAC 35-105-155.5a Discharge Planning Issued: 02/01/2023 Page: 13-15 of 165 Revised: Pre-Scanning and Discharge Planning Policy: Discharge planning services relevant to Compulsive Sexual Behavior (CSB) should be provided to clients with the involvement of an interdisciplinary team including the client, the client's family/caretaker, and licensed medical providers and staff involved in the client's care, treatment, and services (i.e., nursing, therapy staff). Case Managers (CMs) shall educate and provide clients and families with information about discharge options available in the community in preparation for key points in the transition of a client's care. The policy also serves to reduce avoidable readmissions, and comply with all regulatory guidelines and governing entities. Procedures: Screening 1. All clients are screened as close to time of admission as possible to determine which clients may be likely to suffer adverse health consequences due to Compulsive Sexual Behavior (CSB) upon discharge in the absence of adequate discharge planning. A discharge planning screening shall be initiated upon admission, utilizing the initial Admission Assessment. 2. The admitting RN will complete the discharge planning screening to identify those clients identified as being at risk for adverse health consequences upon discharge without adequate discharge planning a. If the client is identified to be at high risk from the discharge planning screening, Case Management will be notified for further evaluation. b. Reassessment of a client's discharge needs and associated risks using the screening criteria will occur during multidisciplinary rounds and the nurse's daily client assessment. c. A referral to Case Management may be requested by a member of the client's care team, family, or provider at any time during the course of their program. Evaluation 1. The Case Manager will perform an evaluation of a client's post-discharge needs as indicated through the primary RN's admission screening. The discharge planning assessment will be completed in a timely manner to ensure that appropriate arrangements for post-home care will be made before discharge, and to avoid unnecessary delays in discharge. 2. As part of the discharge assessment, the Case Manager will determine the client's risk for readmission. The below risk factors will be identified and addressed for all home clients: · Problem Medications-Is the client on anticoagulants, insulin, digoxin, narcotics, or aspirin & clopidogrel dual therapy? · Psychological-depression screen positive or h/o depression diagnosis, anxiety disorders, and substance abuse? · Poor Health Literacy-inability to do teach back? · Client Support-absence of caregiver to assist with discharge and home care/poor physical Document Classification: Confidential_ [AGENCY NAME] Page | 13 Policy and Procedure Manual Version 1.0 condition? · Palliative Care-Does this client have an advanced or progressive serious illness? · Adverse reactions and dangerous sexual behavior. 3. Discharge planning needs are reassessed during the client's stay in collaboration with all disciplines involved. Revisions are made to appropriately meet the needs of the client, including changes in the client's condition, support system, and/or changes in discharge care needs. 4. An evaluation may be requested at any time by the client and/or family, and/or by a physician or other members of the client's care team. 5. The Case Manager may request assistance from a Social Employee to assist with complex discharge planning needs or concerns due Compulsive Sexual Behavior (CSB). 6. The Case Manager evaluation of the client's post-discharge needs is determined by the assessment and evaluation of the client's medical record, interviews and/or conferences with client/family, and multidisciplinary rounds. 7. The evaluation also incorporates the client's need for post home care services such as home health, hospice or palliative care, respiratory services, rehabilitation services, dialysis services, pharmaceutical related supplies, nutritional consultation and related supplies, and durable medical equipment (DME). Development 1. The client and/or family shall be notified as soon as possible regarding the identified discharge needs, as appropriate, so the client and/or family can be involved in the decision-making and ongoing discharge planning. The discussion must disclose to the client the relationship, if any, between the transferring provider and any entity affiliated with the facility before the client makes his or her decision as to who the receiving service/provider will be. 2. The Case Manager will collaborate on developing a coordinated discharge plan using the evaluations and assessments of the interdisciplinary team, along with the goals of the client and/or family/representative. 3. If a client/family exercises the right to refuse to participate in the discharge planning or to implement a discharge plan, documentation of the refusal will be recorded in the client's medical record, and the physician will be made aware of the refusal. 4. If a client and/or family/representative choose a discharge plan that is considered to be unsafe or suboptimal, the Case Manager shall discuss the risks associated with the plan. Documentation shall include the client and/or family teach back regarding their understanding of the risks discussed. 5. Case Management will communicate regularly with the attending care provider regarding the status of the current discharge plan and update other members of the healthcare team as necessary. Implementation 1. The interdisciplinary team will communicate with client and/or family/representative as early as possible regarding the client's expected discharge date. 2. Case Management will facilitate the client's transfer of care to appropriate facilities, agencies, or client services, as ordered. For clients who are transferred from the facility should be provided with necessary information that includes, but is not limited to: Document Classification: Confidential_ [AGENCY NAME] Page | 14 Policy and Procedure Manual Version 1.0 a. Brief reason; b. Brief description of course of treatment; c. Client's condition at discharge, including cognitive and functional status and social supports needed; d. Medication list (reconciled to identify changes made during the client's hospitalization if any) including prescription and herbal supplements. e. List of allergies (including food as well as drug allergies) and drug interactions; f. For transfer to other facilities, a copy of the client's advance directive, if the client has one. g. Brief description of care instructions reflecting training provided to client and/or family or other informal caregiver(s); h. If applicable, list of all follow-up appointments with practitioners with which the client has an established relationship and which were scheduled before discharge, including who the appointment is with, date, and time. i. If applicable, referrals to potential primary care providers, such as health clinics, if available, for clients with no established relationship with a practitioner. 3. The transition plan will be updated as needed during the facility stay based upon changes to the Client's health, psychosocial, financial status, and the availability of services postdischarge. Reassessment 1. As part of the Quality Assessment & Performance Improvement (QAPI) program, Care Management department will reassess the effectiveness of the discharge planning process on a quarterly basis. The following reassessment processes will be performed to ensure that the discharge plans are responsive to the client's discharge needs: a. Immediately identify those clients who are readmitted within 30 days of their index stay and complete a focus assessment to identify potential reason for readmission. b. Develop action plans for trends identified through the analysis of readmissions. c. Action plans shall address factors contributing to potentially preventable readmissions and incorporate improvement strategies and the ongoing (reassessment) monitoring of results to achieve improvements. Action plans may include revisions to the discharge planning process to achieve improvement. Document Classification: Confidential_ [AGENCY NAME] Page | 15 Policy and Procedure Manual Version 1.0 Area/ Title: Root Cause Analysis Policy: 12 VAC 35-105-160.E.2 Issued: 02/01/2023 Page: 16-18 of 165 Revised: Root Cause Analysis Policy: "Root cause analysis" (RCA), as defined by 12 VAC 35-105-160.E.2, is "a method of problem solving designed to identify the underlying causes of a problem. The focus of a root cause analysis is on systems, processes, and outcomes that require change to reduce the risk of harm." The purpose of this policy is to establish a consistent approach to conducting root cause analysis for any identified incident or event that could potentially impact the health, safety, or well-being of the individuals we serve. A root cause analysis shall be conducted by the provider within 30 days of discovery of Level II serious incidents and any Level III serious incidents that occur during the provision of a service or on the provider's premises. [Agency Name] shall develop and implement a root cause analysis policy for determining when a more detailed root cause analysis, including convening a team, collecting and analyzing data, mapping processes, and charting causal factors, should be conducted. At a minimum, the policy shall require for the provider to conduct a more detailed root cause analysis when: a) A threshold number, as specified in the provider's policy based on the provider's size, number of locations, service type, number of individuals served, and the unique needs of the individuals served by the provider, of similar Level II serious incidents occur to the same individual or at the same location within a six-month period; b) Two or more of the same Level III serious incidents occur to the same individual or at the same location within a six-month period; c) A threshold number, as specified in the provider's policy based on the provider's size, number of locations, service type, number of individuals served, and the unique needs of the individuals served by the provider, of similar Level II or Level III serious incidents occur across all of the provider's locations within a six-month period; or d) A death occurs as a result of an acute medical event that was not expected in advance or based on a person's known medical condition. Procedures: 1. [Agency Name]is committed to conducting a thorough and effective root cause analysis for any incident or event that could potentially impact the health, safety, or well-being of the individuals we serve. 2. All employees are responsible for reporting any incident or event that could potentially impact the health, safety, or well-being of the individuals we serve to their supervisor immediately. Document Classification: Confidential_ [AGENCY NAME] Page | 16 Policy and Procedure Manual Version 1.0 3. The Director of Quality Assurance will be responsible for overseeing the root cause analysis process and ensuring that it is conducted in a timely and effective manner. 4. The root cause analysis will be conducted using the following steps: a. Collecting data related to the incident or event b. Identifying the root cause(s) of the incident or event c. Developing corrective actions to prevent future occurrences d. Implementing the corrective actions e. Monitoring the effectiveness of the corrective actions 5. The Director of Quality Assurance will be responsible for ensuring that corrective actions are implemented and monitoring their effectiveness. 6. [Agency Name] will maintain documentation of all root cause analyses, including the incident or event, the data collected, the root cause(s), and the corrective actions developed and implemented. 7. [Agency Name] will review and revise this policy and the root cause analysis process as necessary to ensure its continued effectiveness. 8. [Agency Name] will comply with all applicable Virginia state regulations related to incident management and reporting, including 12VAC35-105-160.E.2. 9. All employees of [Agency Name] will receive training on the root cause analysis process and their responsibilities related to incident management and reporting. 10. [Agency Name] will ensure that individuals we serve and their families are informed of the root cause analysis process and its purpose. We will provide them with regular updates regarding the status of any root cause analysis conducted as a result of an incident or event that impacted them or their loved one. 11. [Agency Name] will provide a copy of this policy to all employees and will ensure that it is readily accessible to all employees and individuals we serve. 12. [Agency Name] will maintain confidentiality of all information related to incident or event reports, root cause analyses, and corrective actions taken. 13. Identification and Reporting of Incidents: [Agency Name] shall establish a policy for identifying and reporting incidents to ensure that any actual or potential incident or event that adversely affects the health, safety, or welfare of a participant is identified and reported to the appropriate agency. The policy shall include clear definitions of incidents, reporting timelines, and responsibilities for reporting and follow-up actions. 14. Investigating Incidents: [Agency Name] shall establish a policy for investigating incidents to determine the root cause(s) and any contributing factors. The policy shall include clear definitions of incident severity levels, procedures for conducting investigations, and a timeline for completing investigations. 15. Corrective Actions: [Agency Name] shall establish a policy for implementing corrective actions to address any identified root cause(s) and contributing factors of incidents. The policy shall include a process for developing and implementing corrective actions, tracking and monitoring the effectiveness of corrective actions, and reporting on the status of corrective actions. 16. Training: [Agency Name] shall provide training to all staff on incident reporting, investigation, and corrective action policies and procedures. Training shall include information on the importance of identifying and reporting incidents, the investigation process, and the implementation of corrective actions. 17. Quality Assurance and Performance Improvement (QAPI): [Agency Name] shall establish a QAPI program that includes ongoing monitoring and evaluation of incident reporting, investigation, and corrective action policies and procedures. The QAPI program shall include a process for identifying trends and implementing improvements to reduce the incidence of incidents. 18. Confidentiality and Privacy: [Agency Name] shall establish policies and procedures to ensure the confidentiality and privacy of participants and staff involved in incident reporting, investigation, Document Classification: Confidential_ [AGENCY NAME] Page | 17 Policy and Procedure Manual Version 1.0 and corrective action processes. The policies shall include clear guidance on the use and disclosure of incident-related information, including who has access to the information and under what circumstances. 19. Recordkeeping: [Agency Name] shall establish policies and procedures for maintaining accurate and complete incident-related records. The policies shall include clear guidance on the documentation of incidents, investigations, and corrective actions, including what information is required and how it should be recorded. The policies shall also include a process for the retention and destruction of incident-related records in accordance with state and federal regulations. *This is only a preview of the Original Document *For inquiries or assistance, please reach out to us at www.carepolicy.us Document Classification: Confidential_ [AGENCY NAME] Page | 18 Policy and Procedure Manual Version 1.0 Document Classification: Confidential_ [AGENCY NAME] Page | 19