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Sample Policies and Procedures Manual

The policies listed below are from one of our many policy sets, each customized for a specific accrediting body and set of provider services. These policies are for DME and Oxygen accreditation from the Joint Commission (JCAHO).

Click on any policy name to view a preview of that policy.

Click on the green triangles to view policies in other sections.

All policies Copyright 2008 Accreditation Helper LLC.

1. Ethics, Rights, and Responsibilities

1.1. Commitment to Non-Discrimination

1.2. Code of Conduct

1.3. Ethical Issues

1.4. Complaint Process

1.5. Staff Involvement in Care

1.6. Decision Making with Integrity

1.7. Customer Rights

1.8. Customer Responsibilities

1.9. Patient/Client Communication

1.10. Respect for Patient/Client Property

1.11. Confidentiality of Patient/Client Information

1.12. Abuse, Neglect, and Exploitation

1.13. Corporate Compliance

1.14. Unassigned Policy

1.15. Unassigned Policy

2. Care, Treatment, and Services

2.1. Admission Criteria

2.2. Admission Mechanism

2.3. Admission Acceptance

2.4. Admission Refusal

2.5. Timeliness of Service

2.6. Alternate Service Referral

2.7. Initial Equipment Assessment

2.8. Ongoing Equipment Assessment

2.9. Assessment Qualifications

2.10. Information Pertinent for Care/Service

2.11. Definitions: Abuse and Neglect

2.12. Signs - Abuse, Neglect

2.13. Abuse and Neglect Protocol

2.14. Patient/Client Care Planning

2.15. Care Plan Implementation

2.16. Physician's Orders

2.17. Physician Communication

2.18. Physician Licensure

2.19. Care Coordination

2.20. Staffing Considerations

2.22. Instructions in the Home

2.23. Death and Dying

2.24. Transfer, Referral, and Discharge

3. Infection Control

3.1. Infection Control Master Plan

3.2. Infection Control Protocols

3.3. Universal Precautions

3.4. Cleaning Traditional HME

3.5. Hand Hygiene

3.6. Bloodborne Pathogen Exposure Control Plan

3.7. Tuberculosis Exposure Control Plan

3.8. Reporting of Infectious Diseases

3.9. Influenza Policy

4. Performance Improvement

4.1. Performance Improvement Plan

4.2. Customer Satisfaction Measure

4.3. Patient File Audit Measure

4.4. Personnel File Audit Measure

4.5. Claims Processing Measure

4.6. Patient/Staff Infections Measure

4.7. Complaints and Incidents Measure

4.8. Unfilled Patient Orders Measure

4.9. Timeliness of Rehab Services

4.10. Influenza Vaccination Rate Measure

5. Leadership

5.1. Governing Body

5.2. Leadership and Management

5.3. Contracted Services

5.4. Services at the Organization Site

5.5. Fiscal Policy and Procedure

5.6. Sentinel Events

5.7. National Patient Safety Goals

5.8. Federal, State and Local Regulations

6. Equipment Management

6.1. Safe, Clean, and Operational Equipment

6.2. Receipt of Returned Rental Equipment

6.3. Routine Maintenance

6.4. Product Recall

6.5. Safety Issues

6.6. Incident Occurrence

6.7. Environmental Safety

6.8. Hazard Communication

6.9. Material Safety Data Sheets (MSDS)

6.10. Emergency Preparedness

6.11. Emergency Operations Plan

6.12. DOT Information

7. Management of Human Resources

7.1. Staff Selection and Hiring

7.2. Promotions and Transfers

7.3. Employment Requirements

7.4. Employee Orientation

7.5. Continuing Education

7.6. Performance Appraisals

7.7. Staff Competency

7.8. Content of Personnel Files

8. Management of Information

8.1. Information Management Planning

8.2. Standardized Documentation

8.3. Confidentiality of Information

8.4. Security of Home Care Records

8.5. Documentation Retrieval

8.6. Retention of Patient/Client Records

8.7. Disaster Recovery Plan

8.8. Individual Patient Record Review

8.9. Abbreviations and Terminology

8.10. Identity Theft and Prevention: Compliance with the Red Flags Rule