This is for informational purposes only. Following this guidance does not guarantee you will pass the survey visit. What follows are examples of some, but not all causes for deficient practice. This guidance is not intended to be the best or the only way to be compliant.
Governing Body Regulations for Class A Agencies
6 CCR 1011, Chapter 26, Section 7.1
"(A) A home care agency shall have an organized governing body.
(1) The body shall consist of members who singularly or collectively have business and healthcare experience sufficient to oversee the services provided by the home care agency.
(B) The governing body shall have a process for review of agency operations at least quarterly and meet at least annually.
(C) The governing body shall assume responsibility for:
(1) Compliance with all federal regulations, state rules, and local laws,
(2) Quality consumer care,
(3) Policies and procedures which describe and direct functions or services of the home care agency and protect consumer rights,
(4) Bylaws that shall include, at a minimum:
(a) A description of functions and duties of the governing body, officers, and committees,
(b) A statement of the authority and responsibility delegated to the administrator,
(c) Meet as stated in bylaws, at least annually,
(d) Appoint in writing a qualified administrator who is responsible for the agency's overall functions.
(5) Review of the written agency evaluation report and other communications from the administrator or group of professional personnel with evidence of written response,
(6) Establish and ensure the maintenance of a system of financial management and accountability, and
(7) Organization, services furnished, administrative control and lines of authority for the delegation of responsibility down to the consumer care level that are clearly set forth in writing and are readily identifiable."
Policy and Procedure Requirements
A common cause of deficient practice by the governing body is failure to assume responsibility for the agency's policies and procedures which describe and direct its functions. Chapter 26 requires the agency have a policy or procedure on a number of topics. The governing body may be cited with deficient practice when an agency does not have a required written policy at all, a policy is in place but is inadequate, a policy is in place but is not followed by staff, or a policy has not been reviewed as a part of an annual agency evaluation.
Below is a list of written policies and procedures required in Chapter 26 rules for home care. Although these are minimum requirements, each agency is advised to compose policies, procedures, protocols and other formal documents to describe and direct the numerous aspects of its operations.
At a minimum, a Class A agency should have written policies on the following general topics and topics specific to Class A agencies.
General Policy Requirements:
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Section 6.3(E): Policy or procedure regarding the employment of any individual who is convicted of a felony or misdemeanor to ensure that the individual does not pose a risk to the health, safety and welfare of the consumer.
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Section 6.4: Policy or procedure regarding the rights of consumers, how they will be informed of their rights, how they will be protected from discrimination and how the agency will protect and promote consumer rights.
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Section 6.9: Policy regarding complaint processing.
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Section 6.11(A): Policy directing services provided directly or under arrangement be provided in accordance with each consumer's plan of care.
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Section 6.12(A): A written emergency preparedness plan including elements required in the rule, reviewed on an annual basis and after an incident response.
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Section 6.16: Policy concerning pre-employment physical examinations and employee health including work restrictions for sick employees.
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Section 6.17: Policy regarding missed visits and how coverage will be assured in the event of employee illness, vacation, holidays, etc.
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Section 6.19: Policy or procedure regarding effective paper and electronic information management systems that assure privacy, confidentiality, organization of the record, how accuracy of documentation is validated, and how record recovery plans in the event of a system failure.
Requirements Specific to Class A Agencies:
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Section 7.2(C): For agencies that provide equipment to consumers, policies and procedures for the management of medical equipment including selection, acquisition, delivery and maintenance of equipment.
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Section 7.2(E): Policy describing how consumers will contact the agency after hours and how on-call staff will have access to consumer information when needed.
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Section 7.3(C): Policy and procedure to establish criteria for calling a meeting of the group of professional personnel more frequently than the annual minimum.
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Section 7.9(C): Policy regarding nurse delegation, delineating what tasks can and cannot be delegated, the process for delegation and how delegation will be supervised. If the agency prohibits delegation, there shall be a policy that specifies such prohibition.
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Section 7.10(E): Policy about how the agency will intervene with an attending physician care provider cannot be contacted or does not respond timely.
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Section 7.11(C): A policy for how controlled drugs will be administered and monitored.
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Section 7.13: Develop an orientation plan for staff providing extended care involving highly technical services and a contingency plan in case staff are unavailable.
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Section 7.16(C): A process for standardized, step-by-step observation and evaluation of nurse aide competency in a variety of subject areas prior to the assignment of tasks.
Governing Body Composition Requirements
The Work of the Governing Body
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In addition to annually reviewing policies and procedures and evaluating operations, the governing body is responsible for ongoing oversight of agency operations.
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In order to monitor services and maintain administrative control, some governing bodies meet more frequently than annually and do more than a quarterly review of operations.
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Engaged governing bodies require frequent reports from Administrators on incidents like complaints, occurrences, enrollments, discharges, missed visits etc. They may require quality management activities be carried out based on what is reported and may monitor the outcome of improvement efforts during future meetings.
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Following a troubling event, some governing bodies convene to draft new policies that direct agency and employee action in order to avoid similar events in the future.
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To show they are aware of agency operations and overseeing services, governing bodies retain documentation of their discussions as well as the directions they give the Administrator and others. Often times the governing body will request updated reporting from the administrator and others in order to monitor progress and the effectiveness of corrective actions.
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The governing body does not have to always meet in person. Ongoing oversight and collaboration can occur remotely. Administrators may send routine emailed reports to each member of the governing body on predetermined topics or as issues come to light. Emailed responses with input and direction are retained to demonstrate ongoing direction. Collaboration is important under these circumstances.