Admission Policy

All Admission/initial visits shall be done by a Registered Nurse and a plan of care thereafter is discussed and established with the patient’s physician when a patient is found to have the need for home health services.

PROCEDURE

1. Upon receipt of referral, the patient/caregiver is contacted by phone to inform of the date and approximate time of skilled visit.
2. After the initial visit, plan of care is discussed with the patient’s physician and established thereafter specific to the patient’s individualized needs.
   The RN Case Manager shall ensure that the patient has a face-to-face encounter with her PCP ninety (90) days prio and/or scheduled to see her PCP thirty (30) days following admission.
   Submission of SOC packets shall be done within a week; and/or in the case of PT referrals, initial evaluation.
   All medications shall be reviewed and revalidated with the PCP.
   *Schedule of visits shall be discussed and planned with the patient and caregiver; and succeeding plan of visits scheduled for the entire episode.
   *The need of Telehealth shall be documented as specific related to patient’s need in the assessment. Telehealth monitoring may be scheduled as the need arises with corresponding physician order.
3. An RN Case Manager shall assess the patient prior to the end of the 60-day episode and upon findings that indicate a medical necessity, the RN Case Manager shall do a conference with the patient’s PCP regarding patient’s status and discuss continuance of home health service(s). A recertification order shall be generated and patient shall be recertified for the next succeeding 60-day episode for treatment on the basis of reasonable expectation.
   All medications shall be reviewed and revalidated with the PCP.

ADMISSION REFERRAL POLICY

All patients referred to Compassionate Professional Home Care, Inc. must be ordered by a physician.

All referrals will be forwarded to the Agency Director for review and evaluation. If the referral(s) meet the criteria for home health service, the Agency Director will forward the referral(s) to the Administrator and/or Supervisor/Case Manager for admission within 48 hours.

The plan of treatment must be verified by the attending physician.

All patients placed on hold due to hospitalization, upon referral from the hospital shall have a Resumption of Care (ROC) OASIS date set and shall have a Resumption of Physician’s orders regarding patient’s plan of care for the remainder of the certfication period.