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If you are Accredited with The Joint Commission or are seeking Accreditation and have Compliance Review Services, Inc. “start up” product you should have this update package. By inserting the changes/updates into your already purchased product your agency will be compliant with The Joint Commission 2010 standards . Replace the revised pages once purchased and remove the original outdated material . Updates include revisions to the following : Admit Pack., Application Binder, Incident Binder, Equipment Management, Safety Binder ,Infection Control Binder ,Electronic documents and policy and procedure manual

This is the update to the policy manual based upon the 2012 TJC standards. If you previously purchased TJC set of hospice manuals Volume I and II this is the updated version of Volume I, there are NO changes for Volume II.

This is the policy that includes the national patient safety goals and the agency’s compliance with such. It is an update policy to the 2012 one previously produced by Compliance Review Services, Inc.


Job description for Administrative Assistant

This form allows the client to designate a person who is competent to care for them in the event the agency staff is unavailable. This form can be used for Pediatrics and/or Primary Home Care recipients. It can also be used for any other situation in which the family or friends are providing some of the care to the client outside of the agency staff.

This policy update reflects the DADS requirement Chapter 97,97.301(b) related to Retention of Client Records and will replace your current TJC section entitled, Record of Care Treatment and Services.(RC)

This home health and hospice form is when the nurse is requesting something of the physician such as permission to get an air-mattress for a patient. When the physician reviews the top portion of the form (the nurse request portion) and then completes his/her section it becomes a physician order. So many nurses document telephone orders when they never spoke to the doctor's office. This tool allows the nurse to truly request orders and document the request legally and within the scope of her practice.

 This policy is intended to meet the requirement for a DRFCA policy and procedure for those agencies who net 5 million dollars or more and must institute such a policy. 

This version was updated August 2011 to incorporate the new changes that became effective 8/1/11. This version meets DADS (97.256) requirements in the State of Texas and Accreditation Standards.

This policy, procedure and form has been created to ensure the hospice agency is compliant with CMS’ face-to-face encounter requirement effective January 1, 2011. 

This product is a written test for Glucometer and a written test for PT/INR targeted for your nurse competency evaluations. This meets the accreditation and State requirements to show that your nurses are competent in these two areas by written testing, you will also need to observe their skills visually to complete the competency.

This product updates your current HIPAA manual with the newest federal requirements. Track breaches to confidential information. Included is: Policy on breaches, investigative form, breach log, and breach risk assessment tool.


 This includes the most recent Conditions of Participation updates, revised 1/2020. 

This is an updated drug disposal policy based on the latest federal guidelines.

This form has been updated from the previous version to include assisting with medications per the COP’s.

Influx Risk Analysis for Infection Control Accredited form: This is the influx report form required by accredited bodies for home health and hospices. This form has all the elements required within the report to be compliant.

This policy addresses the use of internet within a business. It also addresses acceptable behavior by employees when using the internet for work and addresses employees using the internet during work hours for personal use. The policy addresses only on break time can an employee access the internet for personal use.

The policies in this package address intravenous therapy services as required by the Department of Aging and Disability Services in the State of Texas for home health and hospice. These are basic policies on intravenous infusion. If your agency is providing IV services, you MUST have policies and procedures in place. In addition to these policies, the agency must also purchase a clinical manual on IV therapy to adopt with their clinical policies and procedures. We recommend the following text: Principles & Practice of Intravenous Therapy by Sharon M. Weinstein (Lippincott)

This policy is for all DADS agencies that have a Medicaid contract in place. It is required that all DADS agencies who contract with Medicaid have policies and procedures in place to ensure that their employees/contractors are not on the Medicaid list forbidding them to provide services to Medicaid clients.

MSW Field Competency Form
This form is designated to show that a social worker is competent in the skills for their profession by being checked off in the field by another social worker. This form meets TJC and CHAP requirement for social work competency in the field.

Attention All Non-Accredited Home Health and Hospice Agencies.  Make sure that your agency meets the minimum requires related to DADS HCSSA Rule 97.287 Quality Assessment and Performance Improvement (QAPI).  As a part of your QAPI Program refer to HCSSA rule 97.287(a)(1)(A)(ii)(V)(a), you as an agency must ensure effective and safety of all services provided including the competency of the agency's clinical staff.  In order to meet this requirement you must ensure that all your clinical staff are competency evaluated. We now offer Competency Evaluation Forms for Therapy & Social work on our site, bundled together for $50. You’ll find these on our Online Store under General Forms.

This policy is a policy that meets the Board of Nurse Examiner’s requirement passed in 2008 that if a nurse has multiple employers how many hours they can work combined per week. Compliant with the Board of Nurse Examiners Rules for the State of Texas.

This policy incorporates LVN/RN peer review processes since the 2 boards joined together in the State of Texas.

This policy covers the mandatory requirement to check employees to make sure that they are not on the OIG exclusion list prior to hire.

To ensure that the agency follows the State laws regarding the screening of all employees, contractors/entities for exclusion from participation in federal healthcare programs. This requirement for screening extends to include administrative and management services not directly related to patient care

Physician Narrative of Terminal Diagnosis- Medicaid
This policy has been developed to incorporate Title 42 Code of Federal Regulations CFR 418.22 & Department of Aging and Disability Services (DADS) requiring the physician narrative addendum to form 3074 for Hospice Medicaid patients effective July 1, 2011.

This form for home health or hospice is when the nurse receives actual orders from the physician himself or his representatives.

Therapist Field Competency Form
This form is designated to show that a PT,OT, SLP is competent in the skills for their profession by being checked off in the field by another Pt/OT/SLP. The discipline must be checked off by the same discipline i.e. PT by a PT. This form meets TJC and CHAP requirement for therapist competency in the field.

This is an updated abuse policy based upon the revised Texas DADS rule Chapter 97.249. This policy is specifically for CHAP accredited agencies.

This is an updated abuse policy based upon the revised Texas DADS rule Chapter 97.249. This policy is for all non-accredited agencies Licensed and Certified, PAS, Licensed Home Health, Hospice and also JCAHO accredited agencies.

This policy is an update to reflect recent changes in the Act.

 This policy is an update to reflect recent changes in the Act.

Effective September 14, 2016: Updated barr form to employment in home health and hospice agencies. This meets the 9-14-16 update which added Bars pursuant to Texas Administrative Code, Title 40, Part 1, Chapter 3, §3.201 Texas Health and Safety Code Chapter 481 and Texas Penal Codes.

Effective September 1st 2011 DADS Convictions barring employment update to 42.09 of penal code with the addition of 42.092 and 36.06. This Verification of Employability policy meets the new DADS requirements from House bill 2609 and applies to all current and prospective employees.

This form allows the QA department to log and track each patient’s wounds and document the measurements on a weekly log to assess progress, lack of progress, and to notify the physician of a summary of measurements for the best treatment options available.

This form allows the agency to designate someone other than the Administrator/Alternate Administrator, Supervising Nurse/Alternate Supervising Nurse to greet the surveyor and begin the surveying process. It must be posted by your license. This meets the DADS requirement for the State of Texas.