Policies and Procedures Manual for Hospice by bak27323

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									Policies and Procedures Manual for Hospice

                        UPDATE : 1st Period 2010
                            January 2010



                                                                                 Product #: HSPMANL


What information does this update contain?                              Tips for Filing Updates…
This manual has been updated to reflect recent changes in regulatory
and clinical guidelines. This update reflects:                             File this update as soon as
                                                                           possible to prevent loss of
     The Joint Commission 2010 Comprehensive Accreditation Standards      important information.
      for Home Care and Hospice
                                                                           Remove all pages that are
                                                                           replaced by this update and
     “Measuring Hand Hygiene Adherence: Overcoming the Challenges”        retain all removed information
      (Joint Commission)                                                   indefinitely. (See Archiving
                                                                           Removed Pages.)

                                                                           File updates in the order in
                                                                           which you receive them.

                                                                           Do not file updates out of
                                                                           sequential order.



                                                                          Need assistance with this
                                                                          update or have questions
                                                                           about our subscription
                                                                                 services?

                                                                        Contact:
                                                                               Customer Service
                                                                                MED-PASS, Inc.
                                                                              10800 Industry Lane
                                                                             Miamisburg, OH 45342

                                                                                or call toll-free

                                                                            1-800-438-8884
                                                                           (8:00 a.m. to 7:00 p.m. EST)




       See Reverse Side for Filing Instructions
The following docum ents have been updated to reflect chang es to regulatory or clinical guidelines. These documents
have undergo ne content changes that must be reviewed a nd noted and staff training sho uld occur where applicable.
Documents that are included in the u pdate pages but do not appear on this li st have onl y undergone repagination or
small typographical changes.

   Document
                       Status                            Title                                   Chapter
     Type

 Policy              New        Guidelines for H1N1 Virus                           Infection Prevention and Control

 Policy              Revised    Hand Hygiene Policy and Compliance Program          Infection Prevention and Control
                                Patient Education of Infection Precautions and
 Policy R             evised    Infection Control Practices                         Infection Prevention and Control
                                Central-Line Associated Bloodstream Infections
 Policy Deleted                 Policy                                              Infection Prevention and Control

 Form                Deleted    Hand Hygiene Compliance                             Infection Prevention and Control

 Form                New        Hand Hygiene Monthly Monitoring                     Infection Prevention and Control
                                Central-Line Associated Bloodstream Infections
 Guideline Deleted              (CABSIs) Work Plan                                  Infection Prevention and Control

 Policy              New        HIPAA Breach Notification                           Information Management

 Policy R             evised    Prohibited Abbreviations                            Information Management

 Form                Deleted    Prohibited Abbreviations Record Review              Information Management
                                Sentinel Event (moved from Quality Assessment and
 Policy New                     Performance Improvement chapter)                    Leadership

 Policy              Deleted    Look-Alike/Sound-Alike Drugs                        Medication Management

 Policy              Deleted    Anticoagulant Therapy Management Plan               Medication Management
                                                                                    Provision of Care, Treatment and
 Policy R             evised    Patient Education                                   Services
                                Critical Test Order and Critical Test Results       Provision of Care, Treatment and
 Policy Deleted                 Reporting                                           Services
                                                                                    Provision of Care, Treatment and
 Form                Deleted    Critical Test Results Log                           Services
                                                                                    Provision of Care, Treatment and
 Form                Deleted    Critical Test Order: Digoxin Level                  Services
                                                                                    Quality Assessment and
 Policy              Deleted    Sentinel Event (moved to Leadership chapter)        Performance Improvement
                                                                                    Record of Care, Treatment and
 Policy R             evised    Record Review                                       Services
                                                                                    Record of Care, Treatment and
 Policy              Revised    Physician Orders – Verbal Orders                    Services
                                                                                    Record of Care, Treatment and
 Form                Deleted    Verbal Order Read-Back                              Services
                                                                                    Rights and Responsibilities of the
 Policy              Revised    Patient Bill of Rights                              Individual
                                                                                    Rights and Responsibilities of the
 Policy Rev             ised    Complaint Resolution                                Individual

								
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