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["Agency Name: "]
["Agency Contact Name:"]
["Agency Contact E-mail Address:"]
["Agency Contact Phone Number:"]
["Date Submitted: "]
["Date Review Completed:"]
["Review Completed By:"]
[]
["3350 Skilled Home Health Agencies Part 1\nOffice of Health Facilities Licensing and Certification (OHFLC)\nDocument Compliance Checklist"]
[]
[]
["Directions:"]
["Agencies  seeking licensure must provide evidence of compliance through documentation.  This documentation will include, but is not limited to, policies, procedures, handbooks and forms."]
["Please develop your documentation in accordance with the regulations found at: "]
["OHFLC WEBSITE"]
["Prepare your documentation as follows:"]
["· Develop the policy/document which establishes compliance with the regulation."]
[]
["• Number all pages of the submission (i.e. 1, 2, 3, 4, etc.) and organize the submission in numerical order."]
["• In the column of this document entitled \"Page Number\", write the page number of your submission that contains the language that demonstrates compliance with that specific regulation. The Office of Health Facilities Licencing and Certification (OHFLC) will review and mark met or not met the compliance for those specific regulations with comments. "]
[]
[]
["DHSS_DHCQ_OHFLCFax@delaware.gov"]
["Upon receipt of your \"Document Compliance Checklist\" and notification:"]
[]
["· Prepare and deliver your document submission, initial licensure application and initial licensure fee (Certified Check or Money Order) payable to:  State of Delaware "]
["Address:  OHFLC at 263 Chapman Road, Suite 200, Newark, DE 19702"]
["• The OHFLC will retain all of the documents."]
["**** Please note ****"]
["• The initial licensure fee is not refundable"]
["Please update OHFLC with any change of contact information"]
["Do not spend any money on business license, insurance, office space, hiring personnel, etc. until you are recommended for licensure by our office."]

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["Regulation \nNumber ","Licensure Application","Page\n Number(s)","Met","Not\n Met","Comments or Instructions "]
["2.2.2","Application Part 1 for Home Health Agency License  ",null,null,null,"•\n•\n•"]
["2.2.2.1","Names, addresses and types of  agencies  owned or managed by the applicant;",null,null,null,"•\n•\n•"]
["2.2.2.3.4","Identity of: Any officers/directors, partners, or managing members, or members of a governing body who have a financial interest of five percent (5%) or more in a licensee's operation or related businesses;",null,null,null,"•\n•\n•"]
["Regulation Number ","Regulatory Requirement","Page\n Number(s)","Met","Not \nMet","Comments or Instructions "]
[3.9,"Policies and an operational system which assure uninterrupted implementation of the plan of care. The agency shall, at a minimum: 1) maintain a sufficient pool of qualified employees/contractors to fulfill plans of care and provide scheduled services; and 2) develop and maintain a back-up system to provide substitute employees/contractors if regularly scheduled employees/ contractors are unavailable. ",null,null,null,"•\n•\n•"]
["4.2.7","The governing body must develop an organizational structure establishing lines of authority and responsibility (provide organizational chart)",null,null,null,"•\n•\n•"]
[4.4000000000000004,"Written policies and procedures pertaining to each service offered",null,null,null,"•\n•\n•"]
[4.5,"Description of the system for the maintenance of patient records",null,null,null,"•\n•\n•"]
["5.1.3.1","Director duties and responsibilities shall include: Interpretation and execution of the policies adopted by the governing body",null,null,null,"•\n•\n•"]
["5.1.3.2","Director duties and responsibilities shall include: Program planning, budgeting, management and program evaluation",null,null,null,"•\n•\n•"]
["5.1.3.3","Director duties and responsibilities shall include: Maintenance of the agency’s compliance with licensure regulations and standards",null,null,null,"•\n•\n•"]
["5.1.3.4","Director duties and responsibilities shall include: Preparation and submission of required reports",null,null,null,"•\n•\n•"]
["5.1.3.5","Director duties and responsibilities shall include: Distribution of a written plan for the delegation of administrative responsibilities and functions in the absence of the director",null,null,null,"•\n•\n•"]
["5.1.3.6","Director duties and responsibilities shall include: Documentation of complaints relating to the conduct or actions by employees/contractors and action taken secondary to the complaints",null,null,null,"•\n•\n•"]
["5.1.3.7","Director duties and responsibilities shall include: Conducting or supervising the resolution of complaints received from patients in the delivery of care or services by the agency",null,null,null,"•\n•\n•"]
["5.1.3.8","Director duties and responsibilities shall include: Reviewing policies and procedures at least annually and reporting, in writing, to the governing body on the review",null,null,null,"•\n•\n•"]
["5.5.2.1","Written policies regarding: The rights and responsibilities of patients",null,null,null,"•\n•\n•"]
["5.5.2.2","Written policies regarding: The handling and documentation of incidents, accidents and medical emergencies",null,null,null,"•\n•\n•"]
["5.5.2.3","Written policies regarding: Control of the exposure of patients and staff to persons with communicable diseases",null,null,null,"•\n•\n•"]
["5.5.2.4","Written policies regarding: Reporting of all reportable communicable diseases to the Department",null,null,null,"•\n•\n•"]
["5.5.2.5","Written policies regarding: The patient’s (and family or representative, if any) right to have concerns addressed without fear of reprisal. This policy must include the mechanism for informing the patient of her/his right to report concerns/complaints to the Department at a telephone number established for that purpose",null,null,null,"•\n•\n•"]
["5.5.2.6","Written policies regarding: The procedure to be followed in the event that the home health agency is not able to provide services scheduled for any particular day or time. ",null,null,null,"•\n•\n•"]
["5.5.2.6.1","Written policies regarding: The procedure for contacting the patient prior to the missed visit",null,null,null,"•\n•\n•"]
["5.5.2.6.2","Written policies regarding: The procedure for attempts to find a substitute caregiver",null,null,null,"•\n•\n•"]
["5.5.2.6.3","Written policies regarding: Documentation of the missed visit, patient contact, and attempts to find a substitute caregiver",null,null,null,"•\n•\n•"]
["5.5.2.7","Written policies regarding: Infection control",null,null,null,"•\n•\n•"]
["5.5.2.8.1","Written policies regarding: Qualifications, responsibilities and requirements for each job classification",null,null,null,"•\n•\n•"]
["5.5.2.8.2","Written policies regarding: Pre-employment requirements",null,null,null,"•\n•\n•"]
["5.5.2.8.3","Written policies regarding: Position descriptions",null,null,null,"•\n•\n•"]
["5.5.2.8.4","Written policies regarding: Orientation policy and procedure for all employees and contractors",null,null,null,"•\n•\n•"]
["5.5.2.8.5","Written policies regarding: Inservice education ",null,null,null,"•\n•\n•"]
["5.5.2.8.6","Written policies regarding: Annual performance review and competency testing",null,null,null,"•\n•\n•"]
["5.5.2.8.7","Written policies regarding: The process of appointment to the professional staff whereby it can satisfactorily be determined that the individual is appropriately licensed and qualified for the privileges and responsibilities to be given. ",null,null,null,"•\n•\n•"]
["5.5.2.9","Written policies regarding: Referrals received, admission of patients to agency services, delivery of those services and discharge of patients",null,null,null,"•\n•\n•"]
["5.5.2.10","Written policies regarding: The use and removal of records and the conditions for release of information in accordance with statutory provisions pertaining to confidentiality. ",null,null,null,"•\n•\n•"]
["5.8.3.1","Orientation Program must include: Organizational structure of the agency",null,null,null,"•\n•\n•"]
["5.8.3.2","Orientation Program must include: Agency patient care policies and procedures",null,null,null,"•\n•\n•"]
["5.8.3.3","Orientation Program must include: Philosophy of patient care",null,null,null,"•\n•\n•"]
["5.8.3.4","Orientation Program must include: Description of patient population and geographic location served",null,null,null,"•\n•\n•"]
["5.8.3.5","Orientation Program must include: Patient rights",null,null,null,"•\n•\n•"]
["5.8.3.6","Orientation Program must include: Agency personnel and administrative policies",null,null,null,"•\n•\n•"]
["5.8.3.7","Orientation Program must include: Job description",null,null,null,"•\n•\n•"]
["5.8.3.8","Orientation Program must include: Disaster preparedness",null,null,null,"•\n•\n•"]
["5.8.3.9","Orientation Program must include: Applicable state regulations governing the delivery of home health care services ",null,null,null,"•\n•\n•"]
["5.8.12","Mandatory annual dementia specific training must include: communicating with persons diagnosed as having Alzheimer’s disease or other forms of dementia; the psychological, social, and physical needs of those persons; and safety measures which need to be taken with those persons. ",null,null,null,"•\n•\n•"]
["6.1.3.1","Written Agreement must: Specify the services to be provided by the agency, including but not limited to: frequency of visits including scheduled days and hours, transportation agreements as appropriate, emergency procedures and conditions for discharge and appeal.",null,null,null,"•\n•\n•"]
["6.1.3.2","Written Agreement must: Specify the procedure to be followed when the agency is not able to keep a scheduled patient visit. ",null,null,null,"•\n•\n•"]
["6.1.3.3.1","Written Agreement must: Specify a description of services purchased and the associated cost;",null,null,null,"•\n•\n•"]
["6.1.3.3.2","Written Agreement must: Specify an acceptable method of payment(s) for these services",null,null,null,"•\n•\n•"]
["6.1.3.3.3","Written Agreement must: Specify an outline of the billing procedures.",null,null,null,"•\n•\n•"]
["6.1.3.3.4","Written Agreement must: Specify that all payments by the patient for services rendered shall be made directly to the agency or its billing representative and no payments shall be made to or in the name of individual employees/contractors of the agency. ",null,null,null,"•\n•\n•"]
["6.1.3.4","Written Agreement must: Be signed by the patient, if (s)he is able, or representative, if any, and the representative of the home health agency. ",null,null,null,"•\n•\n•"]
["6.1.3.5","Written Agreement must: Be given to the patient or representative, if any, and a copy shall be kept at the agency in the patient record. ",null,null,null,"•\n•\n•"]
["6.1.3.6","Written Agreement must: Be reviewed and updated as necessary to reflect any change in the services or the financial arrangements. ",null,null,null,"•\n•\n•"]
["6.3.5","Policies and procedures describing the method to obtain and incorporate the licensed independent practitioner’s orders into the plan of care. ",null,null,null,"•\n•\n•"]
["6.7.11","Policies for authentication of any computerized records. ",null,null,null,"•\n•\n•"]
["10.2.1","The comprehensive emergency management plan must: Provide for continuing home health services during an emergency that interrupts patient care or services in the patient's home ",null,null,null,"•\n•\n•"]
["10.2.2.1","The comprehensive emergency management plan must: Describe how the home health agency establishes and maintains an effective response to emergencies and disasters including: Notification of staff when emergency response measures are initiated",null,null,null,"•\n•\n•"]
["10.2.2.2","The comprehensive emergency management plan must: Describe how the home health agency establishes and maintains an effective response to emergencies and disasters including: Provision for communication with and between staff members, local emergency management agencies, the State emergency management agency and patients; ",null,null,null,"•\n•\n•"]
["10.2.2.3","The comprehensive emergency management plan must: Describe how the home health agency establishes and maintains an effective response to emergencies and disasters including: Provision for a backup system;",null,null,null,"•\n•\n•"]
["10.2.2.4","The comprehensive emergency management plan must: Describe how the home health agency establishes and maintains an effective response to emergencies and disasters including: Identification of resources necessary to continue essential care and services; ",null,null,null,"•\n•\n•"]
["10.2.2.5","The comprehensive emergency management plan must: Describe how the home health agency establishes and maintains an effective response to emergencies and disasters including: Prioritization of patient care needs and services",null,null,null,"•\n•\n•"]
[null,"Please also e-mail your emergency management plan to: DHSS_DHCQ_OHFLCFax@delaware.gov ",null,null,null,"•\n•\n•"]
[null,"Additional Notes:"]
[]
[]
[null,null,null,null,null,"•\n•\n•"]

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["\nItems marked \"not met\" did not demonstrate the required regulatory compliance for licensure.  These items must be resubmitted for review no later than _______________________.  If your submission remains non-compliant after the second review, you will have to restart the licensure process and a license will not be issued. "]
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["_____________________________________________          __________________________"]
["                  OHFLC Representative                                                                  Date"]