Virginia home care policies and procedures: what 12VAC5-381 requires

Approved written policies, reviewed annually

Implement written policies approved by the governing body; review all policies at least once a year and send changes to the governing body for approval.

"All policies and procedures shall be reviewed at least annually, with recommended changes submitted to the governing body for approval, as necessary."

Governing body

A governing body legally responsible for management, operations and finances; it decides the services, ensures staffing and equipment, complies with the law and sets up a quality improvement committee.

"The organization shall have a governing body that is legally responsible for the management, operation and fiscal affairs of the organization."

Administrator

Appoint a qualified administrator responsible for day-to-day management, with the eight listed duties.

"The administrator shall be responsible for the day-to-day management of the organization, including but not limited to:"

Alternate administrator and availability

Designate someone able to act when the administrator is absent; the administrator or designee is available at all times during operating hours and for emergencies.

"The individual designated to perform the duties of the administrator when the administrator is absent from the organization shall be able to perform the duties of the administrator as identified in subsection B of this section."

License posting and change notices

Post the license; tell OLC 30 days ahead of the eight listed changes, and give 30 working days’ written notice of changes needing a reissued license.

"The current license from the department shall be posted for public inspection."

Advertising

No false, misleading or deceptive advertising or disclosures of fees.

"The organization shall not use any advertising that contains false, misleading or deceptive statements or claims, or false or misleading disclosures of fees and payment for services."

Discontinuing services

Written notice to clients and OLC 30 days before discontinuing services; return the license within five working days; tell OLC and clients where records will be kept.

"Policies shall specify arrangements for retention and protection of records if the organization discontinues operation and shall provide for notification to the OLC and the client of the location of the records."

Inspections and access

Let OLC inspect, give access to records, and allow interviews with staff, agents and contractors.

"The home care organization shall make available to the OLC's representative any necessary records and shall allow access to interview the agents, employees, contractors, and any person under the organization's control, direction or supervision."

Plans of correction

Submit an acceptable plan of correction with the four listed parts within 15 working days of an inspection or complaint report; finish corrections within 45 working days of the last inspection day.

"The administrator shall submit, within 15 working days of receipt of the inspection report, an acceptable plan for correcting any deficiencies found."

Inspector home visits

Arrange OLC home visits with clients, families and caregivers, and explain that consent is voluntary and will not affect care.

"The organization shall explain clearly to the client, family or caretaker that the permission for the representative's home visit is voluntary and that consent to the home visit will not affect the client's care or other health benefits."

Approved variances

Administrative policies cover approved variances. The topic is listed without "if applicable"; an organization with none can say so.

"18. Approved variances."

Requesting and monitoring variancesif the organization requests or holds a variance

Request a variance in writing to the Director, OLC, showing special hardship; monitor any approved variance and collect data for OLC reports.

"The home care organization shall develop procedures for monitoring the implementation of any approved variances to assure the ongoing collection of any data relevant to the variance and the presentation of any later report concerning the variance as requested by the OLC."

Administrative records

Policies on keeping administrative records.

"Administrative and operational policies and procedures shall include, but are not limited to: 1. Administrative records;"

Admission and discharge criteria

Criteria for admission and for discharge or termination from service.

"2. Admission and discharge or termination from service criteria;"

Informed consent

Policies on informed consent.

"3. Informed consent;"

Advance directives and DDNR orders

Policies on advance directives, including Durable Do Not Resuscitate Orders; give clients advance directive information before services start.

"4. Advance directives, including Durable Do Not Resuscitate Orders;"

Client rights

Written client rights policies and procedures covering the ten listed rights; review rights with each client at admission and document it.

"Client rights shall be reviewed with clients or client designees upon admission to the organization. The review shall be documented in the client's record."

Contract services

Policies on contract services. The topic is listed for every organization; one that uses no contractors can say so.

"6. Contract services;"

Medication managementif staff assist with or administer clients’ medications

Medication management policies where applicable. Personal care may include administering normally self-administered drugs as allowed by § 54.1-3408.

"7. Medication management, if applicable;"

Quality improvement

Policies on quality improvement.

"8. Quality improvement;"

Mandated reporting of abuse, neglect and exploitation

Policies on mandated reporting under § 63.2-1606.

"9. Mandated reporting of abuse, neglect and exploitation pursuant to § 63.2-1606 of the Code of Virginia;"

Communicable and reportable diseases

Policies on communicable and reportable diseases; encourage and facilitate flu shots for staff and clients.

"10. Communicable and reportable diseases;"

Client records and confidentiality

Policies on client records, including confidentiality.

"11. Client records, including confidentiality;"

Record retention

Policies on record retention, including on termination of services.

"12. Record retention, including termination of services;"

Supervision and delivery of services

Policies on how services are delivered and supervised.

"13. Supervision and delivery of services;"

Emergency and on-call services

Policies on emergency and on-call services.

"14. Emergency and on-call services;"

Infection control

Policies on infection control.

"15. Infection control;"

Handling consumer complaints

Policies on handling consumer complaints.

"16. Handling consumer complaints;"

Telemonitoring

Policies on telemonitoring. The topic is listed without "if applicable"; an organization that does not telemonitor can say so.

"17. Telemonitoring; and"

Admission agreements

Financial policies cover admission agreements.

"Financial policies and procedures shall include, but are not limited to: 1. Admission agreements;"

Data collection and verification of services

Collecting data on, and verifying, the services delivered.

"2. Data collection and verification of services delivered;"

Billing methods

How the organization and its contractors bill for services.

"3. Methods of billing for services by the organization and by contractors;"

Notice of fee changes

Tell clients orally and in writing of fee changes they pay, no later than 30 calendar days after the organization learns of the change.

"4. Client notification of changes in fees and charges;"

Billing errors and refunds

Correcting billing errors, and the refund policy.

"5. Correction of billing errors and refund policy; and"

Delinquent accounts

Collecting delinquent client accounts.

"6. Collection of delinquent client accounts."

Budget, accounting and theft controls

A working budget; GAAP records; an independent CPA audit at least every three years; documented controls against theft or embezzlement.

"The organization shall have documented financial controls to minimize risk of theft or embezzlement."

Job descriptions

A written job description for each position with title, duties, supervisor’s title and entry qualifications; employees can see theirs and are told of changes.

"Written job description that specifies authority, responsibility, and qualifications for each job classification;"

Personnel records

Keep an accurate, complete and current personnel record for each employee, with the ten listed items, in a system that protects confidentiality.

"Process for maintaining an accurate, complete and current personnel record for each employee;"

Verifying licenses, certifications and training

Verify current professional licenses, certifications and training of employees and independent contractors.

"Process for verifying current professional licensing or certification and training of employees or independent contractors;"

Annual performance and competency evaluation

Evaluate each employee’s performance and competency every year, including their development needs and plans.

"Process for annually evaluating employee performance and competency;"

Contractor qualifications

Verify that contractors and their employees meet the organization’s personnel qualifications.

"Process for verifying that contractors and their employees meet the personnel qualifications of the organization;"

Criminal background checks and drug-free workplace

A process for criminal background checks and for maintaining a drug-free workplace under § 32.1-162.9:1.

"Process for obtaining a criminal background check and maintaining a drug-free workplace pursuant to § 32.1-162.9:1 of the Code of Virginia; and"

Reporting licensed staff to their boards

Report licensed and certified medical personnel who violate their licensing or certification to the right board within the Department of Health Professions.

"Process for reporting licensed and certified medical personnel for violations of their licensing or certification to the appropriate board within the Department of Health Professions."

Criteria for accepting clients

Criteria for accepting clients; accept a client only when the organization can meet their needs at home.

"The organization shall accept a client only when the organization can adequately meet that client's needs in the client's place of residence."

Obtaining a plan of care or service

The process for obtaining a plan of care or service at admission.

"The process for obtaining a plan of care or service;"

Discharge criteria and referral

Criteria for discharge or termination from each service, and referral to other agencies or community services.

"Criteria for determining discharge or termination from each service and referral to other agencies or community services; and"

Notice of discharge or referral

Oral and written notice with the reason, the referral organization’s contact details, and documentation in the record; at least five days’ written notice when the organization ends services.

"Process for notifying clients of intent to discharge/terminate or refer, including:"

Policies available to clients and staff

Policies available to clients and their representatives on request, and to staff at all times.

"Policies and procedures shall be readily available for staff use at all times."

Business hours and 24-hour on-call

Regular posted business hours, fully operational during them, and services provided or arranged on call 24 hours a day, seven days a week.

"The organization shall have regular posted business hours and be fully operational during such business hours."

Emergency operations plan

A plan for inclement weather or natural disaster covering contact with and essential care for clients, coordination with community agencies, and a current list of clients needing specialized help.

"The organization must have a prepared plan for emergency operations in case of inclement weather or natural disaster to include contacting and providing essential care to clients, coordinating with community agencies to assist as needed, and maintaining a current list of clients who would require specialized assistance."

Staffing plan

A staffing plan reflecting the services offered, with enough qualified staff to meet clients’ assessed needs.

"The organization shall design and implement a staffing plan that reflects the types of services offered and shall provide qualified staff in sufficient numbers to meet the assessed needs of all clients."

Orientation

Orient new employees and contract staff on the nine listed topics, from the organization’s philosophy to cultural awareness.

"New employees and contract individuals shall be oriented commensurate with their function or job-specific responsibilities."

Staff development

Provide staff development activities and record participation.

"The organization shall provide opportunities for and record participation in staff development activities designed to enable staff to perform the responsibilities of their positions."

Staff identification

Everyone entering a client’s home for the organization is identifiable by name tag, uniform or other visible means.

"All individuals who enter a client's home for or on behalf of the organization shall be readily identifiable by employee nametag, uniform or other visible means."

Personnel record retention and security

Keep personnel records three years after employment ends, safeguarded against loss and misuse, with health information kept separately.

"Each employee personnel record shall be retained in its entirety for a minimum of three years after termination of employment."

Drug-free workplace and positive results

Drug-free workplace policies, which may include testing for cause and periodic testing; report all positive results to the person’s health regulatory board, if any.

"All positive results from drug testing administered pursuant to this section shall be reported to the health regulatory boards responsible for licensing, certifying, or registering the person to practice, if any."

Barrier crimes

Do not hire for paid work anyone convicted of a barrier crime, except one misdemeanor not involving abuse or neglect after five years.

"It shall be the responsibility of the organization to ensure that its employees have not been convicted of any of the barrier crimes listed in § 32.1-162.9:1 of the Code of Virginia."

Criminal record report timing

Obtain the State Police report within 30 days of employment, dated no more than 90 days before; no direct client contact until it arrives unless directly supervised by a checked employee.

"The organization shall not accept a criminal record report dated more than 90 days prior to the date of employment."

Sworn disclosure statement

Every applicant completes a sworn disclosure statement, filed with the criminal record report.

"A sworn disclosure statement shall be completed by all applicants for employment. The sworn disclosure statement shall be attached to and filed with the criminal record report."

Temporary staff, transfers and rehires

Original reports only, except a letter from a temporary staffing agency with the three listed items; new report and statement when someone moves between organizations, except transfers within 30 days to the same owner and leave of up to six consecutive months.

"A new criminal record report and sworn statement shall be required when an individual terminates employment at one home care organization and begins work at another home care organization."

Denied applicants and confidentiality

Give an applicant denied for convictions a copy of the report; keep reports confidential in locked files for the administrator or designee; no further dissemination except as the law requires.

"All criminal record reports shall be confidential and maintained in locked files accessible only to the administrator or designee."

Indemnity coverage

Malpractice insurance under § 8.01-581.15, $1 million per occurrence general liability, and $50,000 crime insurance or blanket fidelity bond, at all times; contractors also covered.

"The organization shall purchase and maintain the following types and minimum amounts of indemnity coverage at all times:"

Written contract agreementsif any services are provided by contractors rather than employees

A written agreement with the six listed elements for services not provided by employees; contractors follow the organization’s policies, including the sworn statement and criminal record check.

"There shall be a written agreement for the provision of services not provided by employees of the organization."

When a contractor cannot deliverif any services are provided by contractors rather than employees

A written plan for providing care when a contractor is unable to deliver services.

"The organization shall have a written plan for provision of care or services when a contractor is unable to deliver services."

Information before care starts

Before care starts, tell the client orally and in writing the nature and frequency of services, fees, billing and third-party payment, charges they may pay, cancellation notice rules and refund policies.

"Before care is initiated, the home care organization shall inform the client, orally and in writing, of:"

Complaint procedures and staff

A system for logging, investigating and resolving complaints and recording findings; designated staff for intake, investigation and review; proposed resolution to the complainant within 30 days.

"The organization shall establish and maintain complaint handling procedures that specify the:"

Complaint information for clients

At admission, give the client the complaint procedures and the name, mailing address and phone number of the organization’s contact person, the State Ombudsman (Office of the State Long-Term Care Ombudsman, DARS, 5620 Cox Rd, Glen Allen, VA 23060, 804-662-7000) and the OLC Complaint Unit (9960 Mayland Drive, Suite 401, Henrico, VA 23233-1463; 1-800-955-1819 or (804) 367-2106).

"The client or his designee shall be given a copy of the complaint procedures at the time of admission to service."

Complaint records

Document every complaint and its status through to resolution; keep records from the last inspection and for at least three years.

"The organization shall maintain documentation of all complaints received and the status of each complaint from date of receipt through its final resolution."

Quality improvement program

An ongoing self-assessment of care quality, including contracted services, evaluating the nine listed data areas and acting on problems found.

"The following data shall be evaluated to identify unacceptable or unexpected trends or occurrences:"

Quality improvement committee and annual report

A committee with the four listed members oversees the program; results are reported to the governing body and administrator every year and acted on.

"Results of the quality improvement program shall be reported annually to the governing body and the administrator and available in the organization."

Infection control program

A program to reduce infection risk with the five listed activities, and disposal of sharps and infectious waste under the OSHA Bloodborne Pathogens standard.

"The organization shall implement a program to reduce the risk of infection."

Drop sitesif the organization uses drop sites

No assigned staff, referrals or advertising at a drop site; records there safeguarded and available to inspectors; operating one as a business office needs a separate license.

"Any client records located at the site shall be safeguarded against loss or unauthorized use."

Client record system

An organized client record system; written policies on retention, reproduction, access, storage, content and completion; confidential and safeguarded records.

"Written policies and procedures shall specify retention, reproduction, access, storage, content, and completion of the record."

Client record content

Each record holds the eight listed items, from identifying information and the initial assessment to the plan and discharge summary.

"An accurate and complete client record shall be maintained for each client receiving services and shall include, but shall not be limited to:"

Service notes and entries

Signed, dated notes written on the day of service and filed in the record within seven working days; entries current, legible, dated and authenticated; errors struck through and initialed.

"Signed and dated notes on the care or services provided by each individual delivering service shall be written on the day the service is delivered and incorporated in the client record within seven working days."

Client record retention

Keep client records at least five years after discharge or last contact; minors’ records until at least five years after age 18.

"Records of minors shall be kept for at least five years after the minor reaches 18 years of age."

Home attendant qualifications

Home attendants speak, read and write English and meet one of the six listed qualifications.

"Home attendants shall be able to speak, read and write English and shall meet one of the following qualifications:"

RN responsible for personal care

Designate a registered nurse responsible for supervising personal care services.

"The organization shall designate a registered nurse responsible for the supervision of personal care services."

Personal care tasks

ADL help; administering normally self-administered drugs as § 54.1-3408 allows; vital signs if in the plan; reporting changes to the supervisor; documenting services; IADLs as needed.

"Recording and reporting to the supervisor any changes regarding the client's condition, behavior or appearance; and"

Plan of services

An RN-written plan, with the client and family, covering the six listed elements; kept in the record, given to the client and reviewed with the assigned home attendant before services start.

"Copies of the plan shall be provided to the client receiving services and reviewed with the assigned home attendant prior to delivering services."

Supervision at least every 90 days

Supervision as often as needed, set by the client’s needs, the RN’s assessment and written policies, never more than 90 days apart.

"Supervision of services shall be provided as often as necessary as determined by the client's needs, the assessment of the registered nurse, and the organization's written policies not to exceed 90 days."

Nurse available during care hours

An RN or LPN available during all hours that personal care is provided.

"A registered nurse or licensed practical nurse shall be available during all hours that personal care services are being provided."

12 hours of annual in-service

At least 12 hours of in-service training a year for home attendants providing personal care.

"Home attendants providing personal care services shall receive at least 12 hours annually of inservice training and education."

Report suspected adult abuse immediately

Staff paid to care for adults are mandated reporters and must report suspected abuse, neglect or exploitation immediately to the local department of social services or the APS hotline (888-832-3858, 24/7), orally or in writing, with all information behind the suspicion.

"Matters giving reason to suspect the abuse, neglect or exploitation of adults shall be reported immediately upon the reporting person's determination that there is such reason to suspect."

Employer duties to mandated reporters

Do not prohibit staff from reporting directly; tell employees about the duty to report when they are hired.

"An employer of a mandated reporter shall not prohibit a mandated reporter from reporting directly to the local department or to the adult protective services hotline."