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TheKey_of_Kansas_LLC_Policies_and_Procedures_Manual.txt
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TheKey of Kansas, LLC
Policies and Procedures
The policies and procedures contained in this manual have been reviewed and approved.
_______________________________________ ______________________
Administrator Date
_______________________________________ _______________________
Alternate Administrator Date
Alternate Administrator Designation Form
In the absence of the Administrator, ___________________________________
will fulfill all duties of the Administrator.
Administrator Signature
Alternate Administrator Signature
Date
TABLE OF CONTENTS
Page
ADMINISTRATIVE
6
Our Purpose
7
Our Philosophy
8
Our Goals
9
Mission Statement, Vision and Values
10
Our Objectives
11-12
Governing Body
13-14
Agency Administrator/Alternate Administrator
15-17
Client Admission Process
18-19
Services Provided
20-21
Client Assessment
Page
HUMAN RESOURCES
22
Employment Guidelines
23
Reference Checks
24-26
Criminal Background Check
27
Validation of Credentials and/or License for Health Professionals
28-29
Employee Health Screenings
30-31
Personnel Records
32-33
Competency Evaluation
34-36
Performance Evaluation
37-39
Provisional Employment
Page
RIGHTS, RESPONSIBILITIES, & ETHICS
40
Personnel Working Under Hourly or Per Visit Contract
41-43
Client Rights
44-46
Plan of Care
47
Prefilling Insulin Syringes
48-50
Written Assignments
51-54
Assigned Duties of Supportive Care Workers
55-57
Communication and Coordination of Supportive Care Services
58-60
On-Call
61-62
Scope of Practice of Supportive Care Workers
63
Medication Administration
64
Nursing Services
65-68
Reporting Abuse, Neglect, and Exploitation
Page
CLIENT INFORMATION
69-71
Client Records
72-74
Client Record Use, Removal, and Release of Information
75-78
Safeguard and Retrieval of Client Records
79-80
Retention of Records
81
Data Collection and Verification of Service Delivery
82-83
Admission Notes
Page
CLIENT INFORMATION
84
Progress Notes
85-87
Client Transfer, Referral, and Discharge Criteria and Process
Page
CLIENT SERVICES
88-89
Supervision of Services
TheKey of Kansas, LLC
________________
OUR PURPOSE
* To provide client-centered care in the client's home or residence, to minimize the effects of illness, accident, or disability, and to improve client's quality of life.
* To use the Balanced Care Method™ to provide the highest quality personal care, and improve the client's quality of life.
* To use Cognitive Therapeutics Method™ as requested by clients to positively contribute to client's brain health.
* To provide the most qualified caregivers through continuous training, competency checks and assessments, quality review, and care-giver recognition.
* To encourage staff behavior, attitudes, knowledge, and understanding in order to help clients attain and maintain their optimum health and quality of life.
* To provide services that are tailored to assist individuals and families to achieve optimal level of functioning.
TheKey of Kansas, LLC
________________
OUR PHILOSOPHY
We believe that healthcare is a basic human right. It must be available, coordinated, and provided in a comprehensive way, combined with other human services when appropriate. Home healthcare is an important part of the continuous healthcare system, and it will be provided in the most cost-effective way possible.
TheKey shall operate and provide services in compliance with all applicable federal, state, and local laws and regulations. To the best of our knowledge, based on our Quality Improvement Program and professional practices, the services we provide comply with acceptable professional standards and principles.
TheKey philosophy is guided by the following principles:
* We recognize the intrinsic worth of all people including the elderly, diseased and/or disabled. We believe in the value of the contributions of the elderly, diseased and/or disabled to our society. We recognize that everyone is entitled to retain or regain their maximum participation in society.
* We recognize that the aging process is an unavoidable part of life. We understand chronic disease and disability may be part of that process. We believe that maximizing quality of life during all life-stages is vital.
* We believe in client-centered care and recognize that clients and families must determine their needs and requirements. The individual and family should be able to participate in planning care, making on-going care decisions, and assessing the quality of care.
* Advertising or promotional activities will not contain any false, misleading or deceptive statements or claims, nor will they contain any false or misleading disclosures of fees and payments for services.
* Our mission is to Change the Way the World Ages by Helping Seniors Live Well at Home
TheKey of Kansas, LLC
________________
OUR GOALS
* To provide all levels of personal assistance services in collaboration with our client, client’s family, and other care providers thus allowing them to remain in their own homes.
* To provide a broad base of services with client demand governing the scope, allowing clients to be involved in establishing, implementing, and evaluating services.
* To maintain clients in their homes as long as possible and provide services in the least restrictive setting possible.
* To provide cost-competitive, quality services.
* To provide high quality and timely caregiver training and development.
* To develop a relationship with referral sources to effectively meet our clients' home care needs.
* To function as a liaison between our clients and available community resources and assist our clients in coping with their needs and problems.
TheKey of Kansas, LLC
________________
OUR MISSION, VISION, AND VALUES
Our Mission
Our mission is to be the most trusted source of long-term care for aging at home. We are a national home care company with service centers throughout the US and Canada. Our commitment to you is to provide compassion, innovative solutions to improve our service and company, and to go above and beyond for you by always doing the right thing. Our services are distinguished by the caliber of our caregivers, the responsiveness of our staff and our expertise in home care and case management. We are happy you chose us and look forward to working with you.
Our Vision
Change how the world lives and ages at home
Our Values
These four principles guide our actions and reflect our commitment to excellence in our work
Passion
Let caring for others inspire us every day
Compassion
Show kindness and respect to all clients, caregivers, and co-workers
Innovation
Find innovative solutions to improve our service— and our company
Above & Beyond
Go the extra distance and always do the right thing
TheKey of Kansas, LLC
________________
OUR OBJECTIVES
To Provide:
* A coordinated team approach to personal assistance services which allow the client to remain in their own home.
* Personal assistance services and training, which allow caregivers to assume personal responsibility for assisting with the clients’ personal needs.
* Regularly evaluate the care clients are receiving from TheKey.
* Provide educational opportunities for employees through a regular in-service program.
* A work environment conducive to maximum employee performance.
To recruit and retain highly qualified personnel through:
* Screening / Testing
* Evaluation
* Probationary Employment Status
* A competitive compensation Policy: structured to recognize responsibility
TheKey of Kansas, LLC
________________
Category: Administrative Reviewed/Updated: 6.2024
Subject: Governing Body
Applies: All Staff Page: 1 of 2
________________
Purpose:
To ensure lines of authority are established and to ensure clients are provided with safe, professional, and quality services.
Policy:
The Governing Body shall assume full legal authority and responsibility for the management, operation, and fiscal affairs of TheKey of Kansas, LLC. The Governing Body is responsible for the conduct of the TheKey of Kansas, LLC and for the adoption, implementation, enforcement, and monitoring of adherence to the written policies and that they comply with the Statute and are administered to provide safe, professional, quality health care.
Procedure:
The duties and responsibilities of the Governing Body shall include:
* Appoint a qualified Administrator and Alternate Administrator. Delegate to that individual the authority and responsibility for the provision of non-medical supportive care services in accordance with state and federal regulations, accreditation standards, and TheKey mission.
* Performance of the Administrator and Alternate Administrator will be monitored annually through a procedure established by the Governing Body.
* Adopt, revise, periodically review and approve the administrative and personnel policies, client care policies and procedures, bylaws as required by state licensure regulations, and the annual operating budget.
* Oversee the management and fiscal affairs of TheKey of Kansas, LLC. This shall include budget preparation and reviewing/monitoring financial information and organizational operations.
* Define the corporate structure and clearly indicate lines of authority.
* Provide for proper licenses and insurance liability coverage.
* Have bylaws or their equivalent which shall be renewed annually.
TheKey of Kansas, LLC
________________
Category: Administrative
Subject: Governing Body
Applies: All Staff Page: 2 of 2
________________
* Provide the name and address of each officer, director, and owner of the agency to the licensing agency.
* Disclose corporate ownership interests of five percent or more to the department (licensing agency)
* Disclose past home health agency ownership or management, including the name of the agency, its location, and current status, to the department (licensing agency).
* The Governing Body will comply with the organization’s bylaws in relation to:
1. Meeting the notice requirement for scheduled and special meeting
2. Frequency of meetings
3. Appointment of officers and terms of office
4. Attendance requirements at meetings and quorum determination
5. Executive sessions
6. Committee structure and function
TheKey of Kansas, LLC
________________
Category: Administrative Reviewed/Updated: 6.2024
Subject: Agency Administrator/Alternate Administrator
Applies: All Staff Page: 1 of 2
________________
Purpose:
To define the appointment and expectations of the Agency Administrator/Alternate Administrator.
Policy:
The governing body appoints an Administrator who meets the criteria defined by the federal and state regulations and is overseen by the governing body. The Administrator is responsible for all day- to-day operations of TheKey Kansas, LLC and is responsible for ensuring that skilled professional(s) are available during all operating hours.
The Governing Body is responsible to select and pre-designate an alternate administrator, in writing, who assumes the same responsibilities and obligations as the Administrator, including the responsibility to be available during all operating hours.
Procedure:
1. The governing body is responsible for the appointment of the Administrator/Alternate Administrator as the designated responsible party for the ‘day-to-day’ operations of the agency.
2. Administrative functions are not delegated to another person, agency or organization, except for periodic acting duties of the predetermined designee in short periods of the Administrator’s absence. This designee must be authorized in writing by the Administrator.
3. The Administrator of the agency has the following responsibilities:
1. Be responsible for the daily operations of the organization.
2. Have the necessary authority to implement his/her responsibilities for the organization’s operations, as conferred by the Governing Body.
3. Have the education and experience appropriate to fulfill his/her responsibilities and the knowledge of service systems in the community served by the organization, as outlined in the job description.
4. Maintain ongoing liaison among the Governing Body and personnel.
5. Employ qualified personnel and ensure adequate personnel education and evaluations.
TheKey of Kansas, LLC
________________
Category: Administrative
Subject: Agency Administrator/Alternate Administrator
Applies: All Staff Page: 2 of 2
________________
6. Provide written personnel policies and procedures and job descriptions that are made available to all employees
7. Maintain appropriate personnel records, administrative records, and all policies and procedures of TheKey of Kansas, LLC
8. Provide orientation for new staff, regularly scheduled in-service education programs, and opportunities for continuing education for the staff
9. Ensure completion, maintenance, and submission of reports and records as required by the department, and
10. Ensure that each client admitted to TheKey of Kansas, LLC, receives in writing the Client’s Bill of Rights specified in K.A.R. 28-51-111
4. Alternate Administrator:
1. The Governing Body/Administrator will appoint an Alternate Administrator, who will act as the Agency Alternate Administrator should the Administrator be absent from the Agency and assume all the duties/responsibilities of the Administrator as well as be available during all operating hours of the Agency.
1. The Alternate Administrator will have the same qualifications as the Administrator.
2. A written document (Alternative Administrator Designation Form) shall be completed by both parties.
3. The Alternate Administrator will assume the complete duties/responsibilities of the Agency Administrator in their absence and will be available to agency staff at all times the Alternate is in place.
4. This document shall be kept in the personnel file of the designated Alternative Administrator.
5. Should the designated Alternate Administrator be unable to perform their duties, the Governing Body will appoint another qualified Alternate Administrator.
TheKey of Kansas, LLC
________________
Category: Administrative Reviewed/Updated: 6.2024
Subject: Client Admission Process
Applies: Client Success/ Client Solutions Managers Page: 1 of 3
________________
Purpose:
* To establish a consistent admission process for all clients admitted to TheKey.
* To ensure that client-identifying data is obtained and documented.
* To ensure clients are admitted for care according to the admission criteria.
* To determine whether the client’s need for services is appropriate by evaluating the client’s physical, psychological, social, spiritual, and cultural status.
* To identify situations in which the TheKey will not provide services.
Policy:
All clients accepted for service by TheKey will undergo a consistent process to assure appropriate information is exchanged between TheKey and client, all laws and regulations are met and followed, and relevant processes are completed. TheKey of Kansas, LLC shall not discriminate on the basis of religion, race, color, Creed, sex, age, handicap, sexual orientation, or place of national origin, in its acceptance of individuals as clients
Procedure:
1. Admission criteria are standards by which a client can be deemed appropriate for admission.
2. TheKey of Kansas, LLC shall provide supportive care services to a client only when the home health agency reasonably expects that the client’s needs can be met adequately by TheKey of Kansas, LLC in the client’s place of residence.
3. TheKey will not admit client or continue to provide services in the following situations:
a. Scope and complexity of needs cannot be met by TheKey
b. Skills and suitability of agency personnel are not adequate to meet client needs
c. The client's life situation and/or support system does not provide for his/her maintenance/supervision
d. Where the client's activities or environment pose a threat to the safety of TheKey personnel
TheKey of Kansas, LLC
________________
Category: Administrative
Subject: Client Admission Process
Applies: Client Success/ Client Solutions Managers Page: 2 of 3
________________
4. Each client referred to TheKey shall be evaluated by the Administrator or designee to determine the immediate care and support needs of the client. Prior to the initiation of services, the Administrator or designee will:
a. Verify all pertinent information on the Intake Summary with the client.
b. Inform the client about services to be provided.
c. Inform client about supervision by TheKey of services provided.
d. Provide the client or authorized representative with a copy and an explanation of the Client Rights. Receipt shall be acknowledged by the client or authorized representative.
e. Obtain documentation concerning notification to the client of the availability of medical power of attorney for health care, advance directive, or DNR orders in accordance with applicable law.
f. If appropriate, advise the client of the charges and billing procedures and, to the extent possible, the anticipated insurance coverage, the client's financial liability, and other methods of payment. Additionally, advise the client of TheKey process for rate/payment changes and client notification of rate changes before implementation.
g. Explain the concept of assignment of benefits and the liability for payments received from the insurance company for the agency's services.
h. Obtain the client's signature on the Client Consent Agreement, Client Bill of Rights, and other forms required by the agency.
i. Review the Care Plan with the client, placing a signed copy in the client file.
5. A copy of the Intake Assessment form shall be forwarded to the Staffing Specialist, or designee.
TheKey of Kansas, LLC
________________
Category: Administrative
Subject: Client Admission Process
Applies: Client Success/ Client Solutions Managers Page: 3 of 3
________________
6. Upon admission of a client, the Administrator or designee will assign the appropriate caregiver to the client. Whenever possible, services will be initiated within 7 days after
the assessment, unless an alternate date has been agreed upon by the client or client’s responsible party.
7. If TheKey cannot fulfill the required care need, a referral will be made to other appropriate community resources and referral source will be notified.
8. TheKey shall be responsible for the coordination of consumer services with known external and internal agencies providing care and services to the same customer.
a. No agency shall refuse to share consumer care information unless the consumer has chosen to refuse coordination with external agencies.
b. Client's refusal of such coordination shall be documented in the client record.
TheKey of Kansas, LLC
________________
Category: Administrative Reviewed/Updated: 6.2024
Subject: Services Provided
Applies: All Staff Page: 1 of 2
________________
Purpose:
To provide an overview of services provided by the agency, which it is qualified and/or licensed to provide to ensure that client needs are effectively, efficiently, and safely met in the local community.
Policy:
TheKey of Kansas, LLC provides in-home non-medical supportive care services to clients who may require assistance in their own homes and communities to assist in the maintenance and retention of their independence and well-being. These services are responsive to the distinct needs of the client and community and are delivered to by qualified supportive care workers.
1. Non-medical Supportive Care Services delivered by TheKey of Kansas, LLC include:
* Companionship/Accompaniment/Respite Care
* Personal Care
* Assistance with activities of daily living
* Ambulation, positioning and protecting client from falls
* Bathing, Routine hair and skin care
* Dressing
* Meal preparation/ Eating / Feeding
* Light housekeeping
* Personal Hygiene
* Toileting
* Assistance with physical transfer
* Medication Reminders
* Transportation assistance
* Maintaining a safe environment for the client
* Communication with the client
* Providing physical and emotional support
2. Employees and clients shall be informed of , and understand, the extent and limitations of services provided by the agency.
TheKey of Kansas, LLC
________________
Category: Administrative
Subject: Services Provided
Applies: All Staff Page: 2 of 2
________________
3. Services shall be delivered in a caring and respectful manner, in accordance with agency policies and industry standards.
4. Services shall only be assigned to those employees who have the necessary experience, skills, qualifications, certification, or equivalent to meet the needs of the client. Where this is not possible, employees may be trained to perform the necessary tasks required for client care.
5. Services shall be delivered by employees who are able to communicate effectively with clients, using the client’s preferred methods of communication.
TheKey of Kansas, LLC
________________
Category: Administrative Reviewed/Updated: 6.2024
Subject: Client Assessment
Applies: Client Success/ Client Solutions Managers Page: 1 of 2
________________
Purpose:
To provide guidelines for conducting assessments for all services.
Policy:
An initial client assessment will be performed prior to providing care. The initial consultation and following assessment will be scheduled at the request of the client. If a referral is made from a clinician (healthcare provider, discharge planner, administrator, etc.) and the client or client representative(s) agrees, the assessment will be scheduled based on the client’s convenience. The Client Success Manager, or designee, will document the assessment in the client record. If appropriate, ongoing, and functional assessments will be determined based on the client’s level of services.
Procedure:
1. The client assessment will include at least the following information (designed to determine the proper level of care has been requested):
1. The client’s functional status including the degree of self-care and the level of assistance needed
2. An assessment of the environment, including, but not limited to:
1. Emergency preparedness
2. Identification of safety and/or health hazards (throw rugs, bathroom safety, etc.)
3. Evaluation of living arrangements
3. The equipment at the site of care and potentially needed by the client
4. The client’s support systems, including emergency contact information
5. Cultural and religious practices as they affect care, or otherwise applicable.
6. Client needs pertinent to the services to be provided
2. The Client Success Manager, or designee shall conduct a functional assessment if appropriate. This shall include, but is not limited to, the following:
1. Level of independence
2. Ability to complete Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL), such as feeding, toileting and problems with continence,
TheKey of Kansas, LLC
________________
Category: Administrative
Subject: Client Assessment
Applies: Client Success/ Client Solutions Managers Page: 2 of 2
________________
transferring, ambulation, shopping, cleaning, laundry, bathing, dressing, meal preparation, use of telephone, money management, ability to take medication (as appropriate) and oral hygiene.
3. Mobility status (including a history of falls and fall risk evaluation if necessary)
4. Ability to use prescribed equipment
5. Ability to communicate needs, memory, cognition level (including emotional responses to health status and orientation) and ability.
3. Clients receiving supportive care services will be reassessed at least every sixty (60) days and upon change of condition to ensure the care provided continues to meet the client’s needs or request.
TheKey of Kansas, LLC
________________
Category: Human Resources Reviewed/Updated: 6.2024
Subject: Employment Guidelines
Applies: All Staff Page: 1 of 1
________________
Policy:
TheKey of Kansas, LLC has established guidelines for the interview, hiring and orientation process to ensure that agency staff is qualified, capable, and competent to meet specific job criteria.
Procedure:
1. At the discretion of the Administrator, applicants who appear qualified and have the appropriate licensure (if required) will be interviewed for available positions without regard to race, color, religion, origin, sex, age, handicap or other lawfully protected status.
2. The selection of staff will be made based upon qualifications, experience and ability to perform specific duties as described in the job description. These qualities and the job description will be discussed during the interview.
3. The prospective employee must provide all necessary documentation for the personnel file.
4. Upon accepting a position with the agency, the employee will be scheduled for orientation prior to first assignment.
TheKey of Kansas, LLC
________________
Category: Human Resources Reviewed/Updated: 6.2024
Subject: Reference Checks
Applies: All Staff Page: 1 of 1
________________
Purpose:
The purpose of this policy is to establish guidelines for conducting reference checks for potential employees of TheKey of Kansas, LLC, a non-medical supportive care agency. This ensures that all hires meet the standards of the agency and maintain the safety and well-being of our clients.
Policy:
TheKey of Kansas, LLC is committed to hiring qualified and reliable staff to provide the highest level of care to our clients. Reference checks are a crucial part of the hiring process, providing insights into a candidate's past performance, reliability, and suitability for the position.
Procedure:
1. The candidates must have completed an application form that contains a release allowing TheKey of Kansas, LLC to validate information contained on the application.
2. A standard reference check form should be used. At least one (1) reference must be obtained, preferably from former supervisors and/or colleagues.
3. If the candidate refuses to allow reference checks or verification of employment, TheKey of Kansas, LLC will then advise the applicant that she or he will no longer be considered for the position.
TheKey of Kansas, LLC
________________
Category: Human Resources Reviewed/Updated: 6.2024
Subject: Criminal Background Check
Applies: All Staff Page: 1 of 3
________________
Purpose:
To ensure the safety and well-being of clients by conducting comprehensive background checks on all employees in accordance with Kansas statute K.S.A 65-5117, K.S.A 39-970, and other relevant regulations. This policy outlines the procedures for conducting, reviewing, and maintaining background checks for a non-medical supportive care agency.
Policy:
1. Compliance with State Laws:
* All background checks will be conducted in compliance with Kansas statute K.S.A 65-5117, K.S.A 39-970, and any other relevant state and federal regulations.
* It is a statutory requirement that any facility licensed under the Kansas Adult Care Home Act or Kansas Home Health Licensure Law must submit criminal record checks through the Kansas Department for Aging and Disability Services (KDADS).
2. Criminal Record Checks:
* Background checks will be performed for all new hires.
* Background checks will include, but are not limited to, criminal history, sex offender registry, and abuse registry checks.
Procedure:
1. Initiating Background Checks:
* TheKey of Kansas, LLC will initiate the background check process during the candidate’s onboarding process and upon receiving a signed consent form from the candidate.
* The consent form will clearly indicate the candidate's agreement to undergo a background check and their understanding of the process.
2. Conducting Background Checks:
* Background checks will be conducted through KDADS as mandated by K.S.A 65-5117 and K.S.A 39-970.
TheKey of Kansas, LLC
________________
Category: Human Resources
Subject: Criminal Background Check
Applies: All Staff Page: 2 of 3
________________
* TheKey of Kansas, LLC will submit the necessary forms and information to KDADS for processing.
* The following offenses, as outlined by the State of Kansas, will be grounds for disqualification:
* Any felony conviction.
* Any crime against a person, including but not limited to murder, manslaughter, assault, battery, kidnapping, or any sex offense.
* Any crime involving fraud, theft, or financial exploitation.
* Any crime related to controlled substances.
* Any other offenses as specified in K.S.A 39-970 and 65-5117.
3. Reviewing Background Check Results:
* If the background check reveals disqualifying offenses, the candidate will be notified in writing and will not be eligible for employment positions.
* If the background check reveals issues that are not automatically disqualifying, TheKey of Kansas, LLC will evaluate the relevance and impact of the findings on the individual's suitability for the position.
4. Maintaining Records:
* Background check records will be maintained in confidential, secure personnel files separate from the general personnel files.
* A copy of the eligibility determination request submitted to KDADS will be maintained in the employee’s personnel file.
* Results of the state and national criminal history record check pursuant to K.S.A. 65 -5117, and amendments thereto, and the findings of any state or national registry, as defined in regulations adopted by the secretary of the department for aging and disability services will be be maintained in confidential, secure personnel files separate from the general personnel files.
* Access to background check information will be limited to HR and other authorized personnel on a need-to-know basis.
TheKey of Kansas, LLC
________________
Category: Human Resources
Subject: Criminal Background Check
Applies: All Staff Page: 3 of 3
________________
5. Ongoing Monitoring:
* Employees are required to immediately report any new criminal charges or convictions to TheKey of Kansas, LLC.
List of Disqualifying Offenses
Per K.S.A 39-970 and K.S.A 65-5117, the following offenses are considered disqualifying:
* Murder in the first or second degree
* Voluntary or involuntary manslaughter
* Kidnapping
* Aggravated kidnapping
* Robbery
* Aggravated robbery
* Sexual battery
* Aggravated sexual battery
* Rape
* Indecent liberties with a child
* Aggravated indecent liberties with a child
* Sexual exploitation of a child
* Abuse, neglect, or exploitation of a child or vulnerable adult
* Any felony involving fraud, theft, or financial exploitation
* Any felony involving controlled substances
TheKey of Kansas, LLC
________________
Category: Human Resources Reviewed/Updated: 6.2024
Subject: Validation of Credentials and/or License for Health Professionals
Applies: All Staff Page: 1 of 1
________________
Purpose:
To ensure that all health professionals, including Home Health Aides (HHAs), Certified Nursing Aides (CNAs), and Licensed Practical Nurses (LPNs), employed by TheKey of Kansas, LLC possess valid and current credentials and/or licenses as required by state regulations and professional standards.
Policy:
1. Verification Requirement:
* All health professionals must have their credentials and/or licenses verified before employment.
2. Continuous Compliance:
* Credentials and licenses must be maintained in good standing throughout the duration of employment period.
3. Documentation:
* Records of all verifications must be maintained in the personnel files and updated regularly.
Procedure:
1. Initial Verification
* During the application process, candidates must submit copies of relevant credentials and/or licenses.
* Primary Source Verification:
* For HHAs and CNAs: Verify certification through the Kansas Nurse Aide Registry via the Kansas Department for Aging and Disability Services (KDADS) website.
* For LPNs: Verify licensure through the Kansas State Board of Nursing (KSBN) website.
* Documentation: Print and file verification results in the candidate’s personnel file.
* Expiration dates of all licenses and certifications will be kept in WellSky and employees will be notified 60 days prior to expiration and must provide proof of renewal.
TheKey of Kansas, LLC
________________
Category: Human Resources Reviewed/Updated: 6.2024
Subject: Employee Health Screenings
Applies: All Staff Page: 1 of 2
________________
Policy:
TheKey of Kansas, LLC is committed to ensuring the health and safety of our employees and the clients we serve. As part of this commitment, all employees are required to undergo a comprehensive health screening process before beginning their employment and periodically thereafter. This policy outlines the requirements and procedures for the health screening process.
Procedure:
Initial Health Screening
All new employees must complete the following health screening components before commencing work with clients:
1. Self-Reported Health History
* Employees must complete a self-reported health history form detailing their medical history, including chronic conditions, medications, allergies, and previous illnesses or surgeries.
* The health history form will be reviewed by the agency.
2. Current Health Assessment
* Employees must obtain a health assessment performed by a licensed healthcare provider (physician, nurse practitioner, clinical nurse specialist, physician assistant, or registered nurse).
* The health assessment must certify that the employee is physically able to perform the job functions as listed in their job description.
* A written certification from the healthcare provider must be submitted to the agency.
3. Two-Step Tuberculosis (TB) Skin Test
* Employees must undergo a two-step TB skin test following the U.S. Centers for Disease Control and Prevention (CDC) guidelines for healthcare workers.
TheKey of Kansas, LLC
________________
Category: Human Resources
Subject: Employee Health Screenings
Applies: All Staff Page: 2 of 2
________________
* Documentation of the test results must be submitted to the agency before the employee can start working with clients.
* If an employee has a history of a positive TB test, they must provide documentation of a negative chest X-ray or a note from a healthcare provider stating they are free from active TB.
* Employees will complete a TB screening and receive TB education annually.
Periodic Health Screening
Employees are required to undergo periodic health assessments to ensure ongoing fitness for duty and to monitor any changes in health status. These assessments include:
1. Subsequent Health Assessment
* Employees must undergo a health assessment performed by a licensed healthcare provider (physician, nurse practitioner, clinical nurse specialist, physician assistant, or registered nurse) in accordance with agency policies and procedures.
* This assessment must be completed at least every two years or following a significant health event (e.g., hospitalization, surgery, or the onset of a serious illness).
Documentation and Record Keeping
* All health screening documentation, including self-reported health histories, health assessments, and TB test results, must be maintained in the employee's confidential health file.
* TheKey of Kansas, LLC is responsible for ensuring that all required documentation is complete and up-to-date.
Compliance and Enforcement
* Employees who do not comply with the health screening requirements will not be permitted to work with clients until all requirements are met.
* Failure to comply with periodic health assessments may result in disciplinary action, up to and including termination of employment.
TheKey of Kansas, LLC
________________
Category: Human Resources Reviewed/Updated: 6.2024
Subject: Personnel Records
Applies: All Staff Page: 1 of 2
________________
Purpose:
To specify the content of personnel files for employees.
Policy:
TheKey of Kansas, LLC will maintain accurate and complete personnel files for all employees. Personnel files are confidential files of the organization. Personnel health-related information will be kept in a separate file.
Upon request, the organization will provide employees with a copy of all confidential information from the file. If an employee makes a written request to the Administrator, the employee may review and note information contained in the file under supervision by an authorized employee (i.e., Administrator, Director of Human Resources, etc.).
Personnel files will be accessible and readily retrievable for inspection by the Department of Health and Environment at the time of a survey.
Procedure:
1. The content of the personnel files for employees will include:
1. The title of the employee’s position;
2. A written, signed and dated job description including the employment requirements and job responsibilities for each staff position held;
3. Verification that the employee meets the respective employment requirements for each position held;
4. Evidence of a criminal background check, as required by K.S.A. 65-5117.
5. A copy of the eligibility determination request submitted to the department for aging and disability services regarding adult and juvenile convictions and adjudications pursuant to K.S.A. 65-5117, and amendments thereto;
6. Evidence of licensure or certification if required;
7. Documentation of reference checks for each employee before employment;
8. Performance evaluations made within six months of employment and annually thereafter;
TheKey of Kansas, LLC
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Category: Human Resources
Subject: Personnel Records
Applies: All Staff Page: 2 of 2
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9. A health record, including the following:
1. A self-reported health history;
2. A current health assessment performed by a physician, nurse practitioner, clinical nurse specialist, physician assistant, or registered nurse certifying that the employee is physically able to perform job functions as listed in the employee's job description before working with clients; and
3. a current two-step tuberculosis skin test following the U.S. centers for disease control and prevention testing guidelines for healthcare workers taken before working with clients;
10. A subsequent periodic health assessment performed by a physician, nurse practitioner, clinical nurse specialist, physician assistant, or registered nurse in accordance with home health agency policies and procedures and a subsequent health assessment at least every two years or following a significant health event;
11. Abuse, Neglect, and Exploitation training records;
12. Competency evaluation;
13. Supervision records;
14. Orientation records; and
15. Ongoing training records
2. Personnel files are treated in a confidential manner. Access is restricted and files are stored so as to prevent unauthorized access. It is the responsibility of the Administrator to ensure that personnel files are adequately protected.
TheKey of Kansas, LLC
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Category: Human Resources Reviewed/Updated: 6.2024
Subject: Competency Evaluation
Applies: All Staff Page: 1 of 2
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Policy:
The agency shall give the caregiver a competency evaluation prior to the caregiver's first assignment. The agency shall not give a caregiver an assignment until the caregiver has first passed a competency evaluation given by the agency. The competency evaluation shall ensure that the caregiver is competent to provide the services required for the caregiver's first assignment.
Caregivers who do not successfully demonstrate and verbalize the correct response to all tasks on the on-site competency evaluation may not provide care in a task in which he/she has not satisfactorily demonstrated competence. Competency may be established by retesting on the missed task(s) after receiving the necessary instruction.
Procedure:
1. The competency evaluation must address each of the following areas:
1. Communication skills relating to persons who are hard of hearing, have dementia, or have other special needs;
2. Observing, reporting and documenting client status and the care or service provided, including changes in functional ability and mental status demonstrated by the client;
3. Basic elements of body functioning and changes in body function that must be reported to the supervisor;
4. Assisting in the use of specific adaptive equipment, such as a mechanical lifting device, if the worker will be working with clients who use the device;
5. Basic hygiene and basic infection prevention and control practices;
6. Maintenance of a clean, safe, and healthy environment;
7. Basic personal and environmental safety precautions;
8. Recognizing emergencies and initiating emergency procedures, including basic first aid and implementation of a client's emergency preparedness plan;
9. Safe and appropriate techniques in the provision of care for the safety and well being of both the client and the employee;
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Category: Human Resources
Subject: Competency Evaluation
Applies: All Staff Page: 2 of 2
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10. Physical, emotional, and developmental needs of and ways to work with the populations served by the Agency, including the need for respect for the client, his/her privacy, and his/her property;
11. Confidentiality of client's personal, financial and health information;
12. Performing personal care tasks for clients, including: bathing; skin care; hair care; nail care; mouth care; shaving; dressing; feeding; assistance with ambulation; exercise and transfers; positioning; toileting; and medication reminding;
13. Understanding dementia;
14. Problem solving skills to care for patients with dementia who exhibit challenging behavior;
15. Behaviors that would constitute abuse or neglect and the legal prohibitions against these behaviors, as well as knowledge and understanding of abuse and neglect prevention and reporting requirements;
16. Client Rights; and
17. Any other task that the agency may choose to have the caregiver perform.
TheKey of Kansas, LLC
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Category: Human Resources Reviewed/Updated: 6.2024
Subject: Performance Evaluation
Applies: All Staff Page: 1 of 3
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Purpose:
The purpose of this policy is to establish a consistent and fair process for evaluating employee performance, identifying areas for development, and recognizing accomplishments. This process aims to support employees in achieving their professional goals and enhancing the overall effectiveness of the agency.
Policy:
TheKey of Kansas, LLC is committed to fostering a culture of continuous improvement and professional growth. To ensure high standards of performance and service delivery, all employees will undergo performance evaluations within six months of employment and annually thereafter.
Procedure:
Initial Evaluation (First Six Months)
1. Schedule
* The Human Resources (HR) Department will notify the supervisor and employee of the upcoming initial evaluation at least one month in advance.
* The initial performance evaluation will be conducted no later than six months from the employee’s start date.
2. Evaluation Criteria
* Performance will be assessed based on job-specific competencies, adherence to agency policies and procedures, and achievement of initial job-related goals.
* Feedback from colleagues, clients, and supervisors may be incorporated.
3. Evaluation Meeting
* The supervisor will schedule a meeting with the employee to discuss the evaluation.
* The meeting will cover the employee's strengths, areas for improvement, and a development plan for the next evaluation period.
TheKey of Kansas, LLC
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Category: Human Resources
Subject: Performance Evaluation
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4. Documentation
* The completed evaluation form will be signed by both the supervisor and the employee.
* A copy of the evaluation will be provided to the employee, and the original will be filed in the employee’s personnel record.
Annual Evaluation
1. Schedule
* Annual evaluations will be conducted within the same month each year, corresponding to the employee’s anniversary date.
* The HR Department will notify the supervisor and employee of the upcoming annual evaluation at least one month in advance.
2. Evaluation Criteria
* Performance will be assessed based on job-specific competencies, adherence to agency policies and procedures, and achievement of annual goals.
* Feedback from colleagues, clients, and supervisors may be incorporated.
3. Self-Assessment
* Employees will be provided with a self-assessment form to complete prior to the evaluation meeting. This form allows employees to reflect on their achievements and areas for growth.
4. Evaluation Meeting
* The supervisor will schedule a meeting with the employee to discuss the evaluation.
* The meeting will cover the employee's performance over the past year, strengths, areas for improvement, and a development plan for the next year.
5. Documentation
* The completed evaluation form will be signed by both the supervisor and the employee.
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Category: Human Resources
Subject: Performance Evaluation
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* A copy of the evaluation will be provided to the employee, and the original will be filed in the employee’s personnel record.
Handling Disputes
1. Dispute Resolution
* If an employee disagrees with their performance evaluation, they may submit a written appeal to the HR Department within 14 days of the evaluation meeting.
* The HR Department will review the appeal, gather additional information if necessary, and provide a written response within 30 days.
Confidentiality
* All performance evaluations are confidential and will only be shared with individuals who have a legitimate business need to know.
TheKey of Kansas, LLC
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Category: Human Resources Reviewed/Updated: 6.2024
Subject: Provisional Employment
Applies: All Staff Page: 1 of 3
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Policy:
This policy outlines the procedures and guidelines for provisional employment at TheKey of Kansas, LLC. The purpose of this policy is to ensure that all provisional employees meet the necessary qualifications and standards to provide high-quality care to our clients while awaiting the completion of their full background checks and credential verifications.
Definitions:
Provisional Employment: Temporary employment granted to an individual pending the completion of all required background checks and credential verifications.
Provisional Employee: An individual hired on a temporary basis subject to the conditions outlined in this policy.
Procedure:
1. Eligibility for Provisional Employment
* Applicants must have completed an initial application and interview process.
* Applicants must provide consent for all required background checks.
* Applicants must submit copies of necessary credentials (e.g., certifications, licenses).
2. Conditional Offer of Employment
* A conditional offer of employment will be extended to the applicant on a one-time basis, specifying the provisional nature of the employment.
* The offer will outline the duration of the provisional period which shall not exceed 60 days.
3. Background Checks and Credential Verification
* All provisional employees must undergo a criminal background check and reference check.
* Verification of credentials and qualifications must be initiated immediately upon the provisional employment offer.
TheKey of Kansas, LLC
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Category: Human Resources
Subject: Provisional Employment
Applies: All Staff Page: 2 of 3
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4. Training and Supervision
* Provisional employees will undergo an orientation and training program covering the agency’s policies, procedures, and job-specific responsibilities.
* Provisional employees must work under the direct supervision of an employee who has completed all training required by federal regulations, department regulations, and the agency's policies and procedures.
5. Restrictions on Duties
* Provisional employees may not perform tasks that require unsupervised interaction with clients.
* Provisional employees are restricted from handling sensitive client information without supervision.
6. Evaluation and Monitoring
* Supervisors will conduct regular evaluations of provisional employees' performance and compliance with agency standards.
* Any concerns or issues identified during the provisional period must be documented and addressed promptly.
7. Transition to Permanent Employment
* Upon successful completion of all background checks and credential verifications, and based on satisfactory performance evaluations, provisional employees may be offered permanent employment.
* A formal employment contract will be issued, outlining the terms and conditions of permanent employment.
8. Termination of Provisional Employment
* Provisional employment may be terminated at any time if background checks or credential verifications reveal disqualifying information.
* Provisional employment may also be terminated for performance-related issues or non-compliance with agency policies.
TheKey of Kansas, LLC
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Category: Human Resources
Subject: Provisional Employment
Applies: All Staff Page: 3 of 3
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9. Documentation and Record Keeping
* All documents related to the provisional employment process, including consent forms, background check results, and performance evaluations, will be maintained in the employee’s personnel file.
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Category: Rights, Responsibilities, & Ethics Reviewed/Updated: 6.2024
Subject: Personnel Working Under Hourly or Per Visit Contract
Applies: All Staff Page: 1 of 1
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Policy:
TheKey of Kansas, LLC does not contract with any individuals or businesses to provide home health services, HCBS, or supportive care services under hourly or per visit arrangements.
All services to clients are provided by TheKey of Kansas, LLC employees.
In the event TheKey of Kansas, LLC utilizes personnel who work under an “hourly” or “per visit” contract, the following will be included:
1. A statement that clients will be provided supportive care services by TheKey of Kansas, LLC;
2. A description of the supportive care services to be provided by each individual or business;
3. A statement that each individual or business shall conform to all applicable agency policies and procedures, including those related to qualifications;
4. A statement that each individual or business shall be responsible for participating in the development of plans of care;
5. A description of the manner in which supportive care services provided by each individual or business shall be controlled, coordinated, and evaluated by TheKey of Kansas, LLC;
6. The procedures for submitting progress notes, scheduling client care, and conducting periodic client evaluations; and
7. The procedures for determining charges and reimbursement to each individual or business.
TheKey of Kansas, LLC
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Category: Rights, Responsibilities, & Ethics Reviewed/Updated: 6.2024
Subject: Client Rights
Applies: All Staff Page: 1 of 3
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Purpose:
To encourage awareness of client rights and provide guidelines to assist clients in making decisions regarding services, and to actively participate in the plan of care.
Policy:
Each client will be an active, informed participant in the plan of care. To ensure this process, the client will be empowered with certain rights as described and as required by laws and regulations. A client may designate someone to act as a representative. This representative, on behalf of the client, may exercise any of the rights provided by the policies and procedures established by the organization.
To assist with fully understanding the client’s rights, all policies will be available to organization personnel, clients, client representatives, other organizations, and to the public.
Procedure:
1. Each governing body shall establish a bill of rights that shall be equally applicable to all clients.
2. The client, authorized decision-maker or legal representative will be informed at admission and on an ongoing basis, as needed, of their rights, the following provisions shall be included in the clients’ bill of rights:
1. Each client shall have the right to choose care providers and the right to communicate with those providers.
2. Each client shall have the right to participate in planning of the client's care and the right to appropriate instruction and education regarding the plan.
3. Each client shall have a right to request information about the client's diagnosis, prognosis, and treatment, including alternatives to care and risks involved, in terms that the client and the client's family can readily understand so that they can give their informed consent.
4. Each client shall have the right to refuse home health care and to be informed of possible health consequences of this action.
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Category: Rights, Responsibilities, & Ethics
Subject: Client Rights
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5. Each client shall have the right to care that is given without discrimination as to race, color, creed, sex, or national origin.
6. Each client shall be admitted for service only if the agency has the ability to
provide safe, professional care at the level of intensity needed.
7. Each client shall have the right to reasonable continuity of care.
8. Each client shall have the right to be advised in advance of the disciplines that will furnish care and the frequency of visits proposed to be furnished.
9. Each client shall have the right to be advised in advance of any change in the plan of care before the change is made.
10. Each client shall have the right to confidentiality of all records, communications, and personnel information.
11. Each client shall have the right to review all health records pertaining to them unless it is medically contraindicated in the clinical record by the physician.
12. Each client denied service for any reason shall have the right to be referred elsewhere.
13. Each client shall have the right to voice grievances and suggest changes in services or staff without fear of reprisal or discrimination.
14. Each client shall have the right to be fully informed of agency policies and charges for services, including eligibility for, and the extent of payment from third-party reimbursement sources, prior to receiving care. Each client shall be informed of the extent to which payment may be required from the client.
15. Each client shall have the right to be free from verbal, physical, and psychological abuse and to be treated with dignity.
16. Each client shall have the right to have his or her property treated with respect.
17. Each client shall have the right to be advised in writing of the availability of the licensing agency’s toll-free complaint telephone number -- -KDHE Abuse, Neglect, and Exploitation Complaint Hotline 1-800-842-0078.
18. Each client shall have the right to be free from the use of restraints in the home setting.
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Category: Rights, Responsibilities, & Ethics
Subject: Client Rights
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3. Client/responsible party/family responsibilities will be explained upon admission and on
an ongoing basis as needed.
4. The client/responsible party/family is responsible for:
1. Reporting unexpected changes in the client’s status
2. Feedback regarding services, needs and expectations
3. Following instructions and asking questions regarding care or services
4. Following the organization’s policies and procedures concerning client care and conduct
5. Showing respect and consideration for the organization’s personnel and property
6. Meeting financial commitments by promptly meeting any financial obligation agreed to with the organization
5. The client will be requested to sign a Client Rights Form. The original will be kept in the
client record. A copy will be maintained by the client. Should a client refuse to sign the
form, the client’s refusal, including the reason for the refusal, will be documented in the
client record.
6. The family or guardian may exercise the client’s right when a client is incompetent.
7. If a client’s representative signs the Client Rights Form, an explanation of the
representative’s relationship to the client will be documented in the client record.
8. TheKey of Kansas, LLC shall ensure that the client, authorized decision-maker or legal
representative is given oral and/or written rights information.
9. TheKey of Kansas, LLC personnel will be oriented to the client’s rights during orientation
and annually thereafter.
TheKey of Kansas, LLC
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Category: Rights, Responsibilities, & Ethics Reviewed/Updated: 6.2024
Subject: Plan of Care
Applies: All Staff Page: 1 of 3
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Purpose:
To develop a Plan of Care based on the client’s identified needs and to outline each task/activity to be performed by the caregiver.
Policy:
A written plan of care will be initiated immediately following the client’s admission and reviewed by the manager at least every sixty (60) days. The client plan of care is revised as needed. Personnel involved in the delivery of client services, either directly or indirectly, may contribute to the plan of care and will be oriented to the client’s specific plan prior to providing services. The client and responsible party/primary family member(s) will participate in decisions regarding the plan of care whenever possible.
Procedure:
1. At the time of the initial evaluation, the manager, or designee will develop the plan of care based upon the client’s identified needs or requests and will review it with the client and responsible party/primary family member(s).
2. The manager, or designee will consider all findings of the initial and ongoing client evaluations, assessments and interviews in the care planning process, including, but not limited to:
1. Individualized client needs and problems related to service, functional status, and support systems
2. Changes in the client’s status
3. Based upon the interviews and conclusions, the plan of care will include, but will not be limited to:
1. Start of care date
2. Frequency and duration of services provided
3. Client demographics
4. Cognitive status of client
5. Type of services provided
6. Equipment and supplies
7. Functional limitations
8. Diet and nutritional needs
TheKey of Kansas, LLC
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Category: Rights, Responsibilities, & Ethics
Subject: Plan of Care
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9. Safety measures to protect against injury, if applicable
10. Client or responsible party/family’s expectations and special requests
4. Decisions will be reflected in the services provided and the actions implemented to meet individualized client needs or requests for services, including after-hours aide services.
5. The plan of care will be reviewed by the Manager or designee a minimum of every sixty (60) days unless state laws require more frequent review.
6. The plan of care, and any changes to the plan of care, will be signed by the appropriate organization personnel and the client and/or client representative(s). A copy of the plan of care, and any changes will be provided to the client and placed in the client record.
7. Changes to the plan of care must be documented in the plan of care. Changes must be written, dated, and signed by the professional making the changes.
8. The care staff will understand their duties and the arrangements for providing services as stated in the plan of care.
1. The manager and care staff will receive training on following the Plan of Care, which includes ensuring competency in the following:
1. Communication skills, with special focus on communicating with clients with hearing deficits, dementia, or other special needs;
2. Observation, reporting, and documentation of client status and documenting supportive care services provided to the client;
3. Basic infection control procedures;
4. Basic elements of body functioning and changes in body function and when to report changes in bodily functions to the manager;
5. Maintenance of a clean, safe, and healthy environment;
6. Recognizing emergencies and knowledge of the agency’s emergency procedures;
7. Recognizing physical, emotional, and developmental needs of the clients served by the agency;
8. Working with clients, including respect of the client and the client’s privacy and property;
9. Appropriate and safe techniques in personal hygiene and grooming; and
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Category: Rights, Responsibilities, & Ethics
Subject: Plan of Care
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10. Knowledge of client’s bill of rights
2. The plan of care will be reviewed with the appropriate care team, including the client, care staff, responsible party/family, and hands on orientation of the care staff will be provided as needed.
3. Care staff will document services provided to each client when services occur and submit documentation on a weekly basis (or more often as organization needs dictate) for incorporation into the client record if the documentation is not made directly into the client record.
TheKey of Kansas, LLC
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Category: Rights, Responsibilities, & Ethics Reviewed/Updated: 6.2024
Subject: Prefilling Insulin Syringes
Applies: All Staff Page: 1 of 1
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Policy:
No unlicensed person employed by TheKey of Kansas, LLC, in the course of their employment with the agency, shall prefill insulin syringes for any client served by the agency.
Only licensed healthcare professionals are authorized to prefill insulin syringes.
Unlicensed personnel are strictly prohibited from prefilling insulin syringes under any circumstances.
TheKey of Kansas, LLC
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Category: Rights, Responsibilities, & Ethics Reviewed/Updated: 6.2024
Subject: Written Assignments
Applies: All Staff Page: 1 of 3
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Purpose:
To ensure that supportive care workers provide high-quality, consistent, and compliant care to clients, adhering to the regulations set forth for Non-medical Supportive Care Services agencies in Kansas.
Policy:
1. Preparation of Written Assignments and Instructions
* All written assignments and instructions for supportive care workers shall be prepared by a manager.
* These assignments and instructions must be based on the client's individualized plan of care.
2. Contents of Written Assignments and Instructions
* Procedures for Meeting Client's Needs:
* The written instructions shall clearly outline the specific procedures the supportive care worker is to follow to meet the client's needs as identified in the plan of care.
* Reporting Requirements:
* The instructions shall specify the circumstances under which the supportive care worker is required to report to their supervisor. This includes, but is not limited to, any changes in the client's condition, incidents, or emergencies.
* Documentation Requirements:
* Supportive care workers are required to document all supportive care services provided during each visit. This documentation must be accurate, thorough, and submitted as per the agency’s protocol.
3. Review of Written Assignments and Instructions
* Each manager shall review the written assignments and instructions at least once every three months.
TheKey of Kansas, LLC
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Category: Rights, Responsibilities, & Ethics
Subject: Written Assignments
Applies: All Staff Page: 2 of 3
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* Reviews shall also be conducted more frequently if there are any changes in the client’s status or needs.
* The review process shall ensure that the instructions remain relevant and effective in meeting the client’s current needs.
Procedure:
1. Preparation of Assignments
* The manager will review the client's plan of care and develop specific written instructions for the supportive care worker.
* These instructions will be documented and provided to the supportive care worker prior to the commencement of care.
2. Contents Detailing
* Meeting Client's Needs:
* The supportive care worker will be provided detailed step-by-step procedures for the care tasks needed to be performed.
* The supportive care worker will be provided with any special instructions or considerations unique to the client.
* Reporting Requirements:
* Clear guidelines will be given to the supportive care worker on when and how to report to the supervisor.
* The supportive care worker will be provided emergency contact numbers and steps to follow in case of an urgent situation.
* Documentation Requirements:
* Supportive care workers will be provided instructions on what needs to be documented (e.g., activities performed, client’s response, any changes noticed).
* Supportive care workers will be provided instructions on the format and timelines for submitting documentation.
TheKey of Kansas, LLC
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Category: Rights, Responsibilities, & Ethics
Subject: Written Assignments
Applies: All Staff Page: 3 of 3
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3. Ongoing Review and Updates
* Scheduled Review:
* Every three months, the manager will schedule a review of all written assignments and instructions.
* This review will be documented, and any necessary updates will be made to the written instructions.
* Unscheduled Review:
* If the client’s status or needs change, the manager will immediately review and update the written instructions to reflect these changes.
* Supportive care workers will be promptly informed of any updates.
4. Documentation and Compliance
* Supportive care workers must ensure that all documentation is completed accurately and submitted timely.
* Managers will periodically audit documentation to ensure compliance with this policy.
Responsibilities
* Manager:
* Prepare and review written assignments and instructions.
* Ensure instructions are based on the plan of care and reviewed regularly.
* Update instructions as needed and communicate changes to supportive care workers.
* Supportive Care Workers:
* Follow the written assignments and instructions as provided.
* Report to the supervisor as specified in the instructions.
* Document all services provided during each visit accurately and submit documentation timely.
Compliance
Failure to adhere to this policy may result in disciplinary action, up to and including termination of employment.
TheKey of Kansas, LLC
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Category: Rights, Responsibilities, & Ethics Reviewed/Updated: 6.2024
Subject: Assigned Duties of Supportive Care Workers
Applies: All Staff Page: 1 of 4
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Policy:
This policy outlines the assigned duties and procedures for supportive care workers employed by TheKey of Kansas, LLC. The purpose of this policy is to ensure that all supportive care services are provided consistently, ethically, and in accordance with Kansas state regulations.
Procedure:
1. Assisting with Medication
Supportive care workers may assist clients with medication only under the following conditions:
* Preselection: Medications must be preselected by the client, a family member, a nurse, or a pharmacist and stored in containers other than prescription bottles, such as medication reminder containers clearly marked with day and time of dosage.
* Assistance Includes:
* Inquiring whether medications were taken.
* Verbal prompting to take medications.
* Handing the appropriately marked medication reminder container to the client.
* Opening the medication reminder container if the client is physically unable to do so.
* Prescription and Nonprescription Medications: The above applies to all types of medications.
* Reporting: Any irregularities in medication intake (e.g., taken too often or not as scheduled) must be reported immediately to the manager.
* Prohibitions: Supportive care workers shall not participate in medication administration.
2. Skin Care
* Scope of Assistance: Provide assistance only if the client's skin is unbroken and they do not have active chronic skin problems.
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Category: Rights, Responsibilities, & Ethics
Subject: Assigned Duties of Supportive Care Workers
Applies: All Staff Page: 2 of 4
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* Prohibitions: No application of medication, wound care, or dressing changes.
3. Ambulation
* Conditions: Assist clients who can balance and bear weight, as determined by a qualified health professional.
* Prohibitions: No assistance beyond what is determined by the professional assessment.
4. Bathing
* Assistance: Allowed unless the client has wounds requiring bandage changes before, during, or after bathing, in which case home health agency services are required.
5. Dressing
* Allowed Assistance: Help with ordinary clothing and over-the-counter support stockings.
* Prohibitions: No assistance with elastic bandage wraps or prescription-only stockings.
6. Exercise
* Permissible Assistance: Normal bodily movement as tolerated by the client.
* Encouragement: Encouraging clients to comply with a prescribed exercise program is allowed.
* Prohibitions: No assistance with exercises prescribed by health professionals.
7. Feeding
* Conditions: Assist clients who can independently chew and swallow and maintain an upright position.
* Prohibitions: No syringe, tube, or intravenous feedings. High-risk clients must be under home health agency care.
8. Hair Care
* Permissible Actions: Shampooing (non-prescription shampoo), drying, combing, and styling hair.
TheKey of Kansas, LLC
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Category: Rights, Responsibilities, & Ethics
Subject: Assigned Duties of Supportive Care Workers
Applies: All Staff Page: 3 of 4
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9. Mouth Care
* Permissible Actions: Basic oral hygiene and denture care.
* Prohibitions: Mouth care for clients who are unconscious, have swallowing difficulties, or are at risk for choking or aspiration, or have had recent oral surgery, must be performed by a licensed home health agency.
10. Nail Care
* Permissible Actions: Soaking nails, pushing back cuticles (without utensils), and filing nails.
* Prohibitions: Nail trimming is restricted to workers from a home health agency licensed to provide such services.
11. Positioning
* Permissible Actions: Assist clients with repositioning if they can communicate the need for change. Simple alignment in bed, wheelchair, or other furniture is allowed.
* Prohibitions: No positioning if it involves skin care requirements.
12. Shaving
* Permissible Equipment: Electric or safety razors only.
13. Toileting
* Permissible Actions:
* Assisting to and from the bathroom.
* Assistance with bedpans, urinals, and commodes.
* Personal hygiene assistance for incontinence care.
* Emptying urinary collection devices and ostomy bags.
* Prohibitions: No insertion or removal of catheters, care of external catheters, suppository insertion, or enema administration.
14. Transfers
* Permissible Actions: Assisting with transfers if the client can assist. Adaptive and safety equipment use is allowed with proper training.
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Category: Rights, Responsibilities, & Ethics
Subject: Assigned Duties of Supportive Care Workers
Applies: All Staff Page: 4 of 4
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* Prohibitions: No assistance if the client cannot assist in the transfer.
15. Respiratory Care
* Prohibitions: No respiratory care is allowed by supportive care workers as it is considered skilled care.
16. Masks and Oxygen Flow
* Permissible Actions: Temporary removal and replacement of oxygen masks or cannulas for face washing or shaving. Setting oxygen flow during tank changes if trained and competent.
Training and Competency
* All supportive care workers must undergo training and demonstrate competency in each permitted task before performing it independently.
* Regular refresher training and evaluations will be conducted to ensure ongoing compliance and proficiency.
Reporting and Documentation
* Immediate reporting to the manager for any irregularities, incidents, or changes in client conditions.
* Detailed documentation of all assistance provided, adhering to confidentiality and privacy standards.
TheKey of Kansas, LLC
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Category: Rights, Responsibilities, & Ethics Reviewed/Updated: 6.2024
Subject: Communication and Coordination of Supportive Care Services
Applies: All Staff Page: 1 of 3
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Purpose:
The purpose of this policy is to establish a clear procedure for communication and coordination among personnel providing supportive care services, ensuring that all services promote the client’s plan of care and comply with Kansas regulations.
Policy:
All personnel providing supportive care services must maintain consistent communication with the manager to ensure that all services align with the client's plan of care and adhere to the regulations for Non-medical Supportive Care Services agencies in Kansas.
Procedure:
1. Communication Protocol
1. Initial Coordination Meeting
* Prior to beginning services, the manager will schedule an initial coordination meeting with all personnel assigned to the client.
* The meeting will review the client's plan of care, specific tasks, schedules, and any special considerations.
2. Regular Check-ins
* Personnel must participate in check-in meetings with the manager to discuss the client's status, any changes in their condition, and any adjustments needed in the plan of care.
* These meetings can be conducted in person, via phone, or through a secure digital platform.
3. Daily Reporting
* Personnel must provide daily reports summarizing the services delivered, the client's response, and any issues encountered.
* Reports should be submitted by the end of each day through the designated reporting system (WellSky).
TheKey of Kansas, LLC
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Category: Rights, Responsibilities, & Ethics
Subject: Communication and Coordination of Supportive Care Services
Applies: All Staff Page: 2 of 3
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4. Incident Reporting
* Any incidents, including accidents, injuries, or significant changes in the client's condition, must be reported to the manager immediately.
* An incident report form must be completed and submitted within 24 hours of the incident.
2. Documentation and Record Keeping
1. Service Logs
* Personnel must maintain accurate and up-to-date service logs detailing the care provided, including dates, times, tasks performed, and observations.
2. Client Records
* All client records must be maintained in a secure and confidential manner, in compliance with state regulations and agency policies.
* Updates to the client's plan of care must be documented promptly and communicated to all personnel involved in the client's care.
3. Adherence to Plan of Care
1. Plan of Care Review
* The manager will ensure that the plan of care is reviewed and updated regularly, at least every 60 days or as needed based on the client's condition.
* All personnel will be informed of any changes to the plan of care immediately.
2. Compliance with Regulations
* Personnel must adhere to all Kansas state regulations for Non-medical Supportive Care Services, including those related to training, documentation, and client rights.
* The agency will provide regular training and updates on regulatory requirements to all personnel.
TheKey of Kansas, LLC
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Category: Rights, Responsibilities, & Ethics
Subject: Communication and Coordination of Supportive Care Services
Applies: All Staff Page: 3 of 3
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4. Confidentiality and Privacy
1. Confidential Information
* Personnel must handle all client information with the highest level of confidentiality and privacy.
* Any breach of confidentiality must be reported to the manager immediately and will be subject to disciplinary action.
2. Secure Communication
* All communication regarding client care should be conducted through secure channels approved by the agency to ensure the confidentiality of client information.
Responsibilities
* Manager
* Coordinate initial and regular meetings.
* Review and update the plan of care.
* Ensure compliance with regulations.
* Provide support and training to personnel.
* Personnel
* Attend scheduled meetings and provide reports.
* Maintain accurate service logs.
* Adhere to the plan of care and regulatory requirements.
* Maintain client confidentiality and use secure communication channels.
TheKey of Kansas, LLC
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Category: Rights, Responsibilities, & Ethics Reviewed/Updated: 6.2024
Subject: On-Call
Applies: All Staff Page: 1 of 3
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Purpose:
To ensure the availability of agency management support to staff providing non-medical supportive care services for clients.
Policy:
The agency manager or a designated senior staff member will be on-call at all times to assist supportive care workers with any issues or emergencies that arise while providing care services to clients. This policy outlines the procedures for on-call duties to ensure compliance with Kansas state regulations and to provide continuous support to both staff and clients.
Procedure:
1. On-Call Schedule
* Designated On-Call Manager:
* The agency manager or an appointed senior staff member will be on-call.
* Availability:
* The on-call manager must be reachable via phone 24/7.
* A backup manager will also be designated in case the primary on-call manager is unavailable.
2. On-Call Duties
* Supportive Care Worker Assistance:
* Provide guidance and support to staff for any issues related to client care, including but not limited to service delivery concerns, client emergencies, and logistical problems.
* Ensure compliance with the care plans and agency policies.
* Emergency Response:
* Address any emergencies promptly, including contacting emergency services if necessary.
* Provide immediate direction and support to staff handling client emergencies.
TheKey of Kansas, LLC
________________
Category: Rights, Responsibilities, & Ethics
Subject: On-Call
Applies: All Staff Page: 2 of 3
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* Documentation:
* Document all calls and issues addressed during on-call periods, including the nature of the issue, advice given, and any actions taken.
3. Communication Protocol
* Contact Information:
* The On-call manager must ensure their contact information is up-to-date and accessible to all staff.
* Staff will be instructed to contact the on-call manager via phone for urgent issues and via email or text for non-urgent matters.
* Issue Escalation:
* Issues that cannot be resolved by the on-call manager should be escalated to the regional director or other appropriate personnel.
* The on-call manager is responsible for initiating the escalation process if needed.
4. Training and Compliance
* Training:
* All managers and designated senior staff must undergo training on the on-call procedures and emergency response protocols.
* Regulatory Compliance:
* The on-call system and all related activities must comply with Kansas regulations for Non-medical Supportive Care Services agencies.
5. Quality Assurance
* Feedback Mechanism:
* The agency will implement a feedback mechanism for staff to report on the effectiveness of the on-call support they receive.
* The agency will use feedback to improve on-call procedures and address any identified gaps.
TheKey of Kansas, LLC
________________
Category: Rights, Responsibilities, & Ethics
Subject: On-Call
Applies: All Staff Page: 3 of 3
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* Continuous Improvement:
* The agency will regularly review and update the on-call policy and procedures to ensure they meet the needs of the staff and clients, as well as comply with regulatory requirements.
6. Documentation and Reporting
* Incident Reporting:
* All incidents addressed during on-call periods must be documented and reported using the agency’s incident report form.
* Reports must be reviewed by the agency administrator or designee and used to inform any necessary policy changes or staff training.
TheKey of Kansas, LLC
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Category: Rights, Responsibilities, & Ethics Reviewed/Updated: 6.2024
Subject: Scope of Practice of Supportive Care Workers
Applies: All Staff Page: 1 of 2
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Purpose:
The purpose of this policy is to define the scope of practice for supportive care workers, ensuring they perform tasks within their qualifications and adhere to state regulations. This policy aims to protect clients' well-being, maintain professional standards, and ensure legal compliance.
Policy:
Supportive care workers shall provide non-medical supportive care services that are within their training and competence, under the supervision and direction of TheKey of Kansas, LLC. These services are designed to enhance the quality of life for clients by supporting their independence and well-being.
Procedure:
Scope of Practice
Supportive care workers are permitted to perform the following tasks:
1. Activities of Daily Living (ADLs):
* Bathing and personal hygiene assistance
* Dressing assistance
* Grooming (combing hair, nail care, etc.)
* Toileting assistance and incontinence care
* Ambulation and mobility assistance
* Transferring and positioning within the home
2. Instrumental Activities of Daily Living (IADLs):
* Meal planning, preparation, and serving
* Light housekeeping and laundry
* Assistance with shopping and errands
* Accompanying to appointments and social activities
* Medication reminders (non-administration)
* Pet care assistance
TheKey of Kansas, LLC
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Category: Rights, Responsibilities, & Ethics
Subject: Scope of Practice of Supportive Care Workers
Applies: All Staff Page: 2 of 2
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3. Companionship:
* Providing conversation and emotional support
* Engaging in activities such as reading, playing games, or hobbies
4. Observation and Reporting:
* Monitoring client's condition and reporting changes to the supervisor
* Documenting services provided and any significant observations
Prohibited Activities
Supportive care workers shall not engage in any medical or health care tasks, including but not limited to:
* Administering medications or injections
* Performing wound care or dressing changes
* Providing tube feeding or catheter care
* Taking and recording vital signs for medical purposes
* Providing any form of medical diagnosis or treatment
Orientation and Training:
* All supportive care workers must complete an orientation and training program covering the scope of practice, company policies, and procedures.
* Ongoing training sessions will be provided to ensure compliance with regulatory changes and best practices.
Supervision:
* Supervisors will regularly review the performance of supportive care workers to ensure adherence to the scope of practice and agency policies.
* Supportive care workers will report to their supervisors regularly and immediately for any incidents or significant changes in the client's condition.
Documentation:
* Supportive care workers must accurately document all services provided in the client's record.
* Any observations or incidents must be promptly reported and documented as per agency policy.
TheKey of Kansas, LLC
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Category: Rights, Responsibilities, & Ethics Reviewed/Updated: 6.2024
Subject: Medication Administration
Applies: All Staff Page: 1 of 1
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Policy:
Supportive care workers employed by TheKey of Kansas, LLC are strictly prohibited from setting up or administering medications to clients. This policy adheres to the regulations set forth by the state of Kansas to ensure that medication administration is conducted only by licensed healthcare professionals.
Definitions:
Supportive Care Worker: An individual employed by TheKey of Kansas, LLC to provide non-medical assistance to clients, including activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
Medication Administration: The direct application of a medication to a client, including oral, topical, inhalation, or injection routes.
Medication Setup: The preparation of medication doses, including organizing, sorting, and placing medications in a medication organizer or similar device.
Procedure:
1. Education and Training:
* All supportive care workers will receive training on the scope of their role, emphasizing the prohibition of medication setup and administration.
2. Client Assessment and Care Planning:
* During the initial assessment and development of the care plan, clients will be informed that supportive care workers cannot set up or administer medications.
* Clients will be encouraged to arrange for medication administration assistance from licensed healthcare professionals if needed.
TheKey of Kansas, LLC
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Category: Rights, Responsibilities, & Ethics Reviewed/Updated: 6.2024
Subject: Nursing Services
Applies: All Staff Page: 1 of 1
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Purpose:
To ensure that TheKey of Kansas, LLC operates in compliance with Kansas regulations, providing only non-medical supportive care services and not engaging in nursing or medical services.
Policy:
TheKey of Kansas, LLC is committed to providing high-quality non-medical supportive care services to clients while strictly adhering to Kansas state regulations. Under K.S.A. 65-5109 and K.S.A. 65-5104, effective May 20, 2022, the agency will not provide any form of nursing services.
TheKey of Kansas, LLC
________________
Category: Rights, Responsibilities, & Ethics Reviewed/Updated: 6.2024
Subject: Reporting Abuse, Neglect, and Exploitation
Applies: All Staff Page: 1 of 4
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Purpose:
This policy outlines the definitions of abuse, neglect, and exploitation according to Kansas statutes, the responsibilities of employees in reporting suspected incidents, and the procedures for making such reports.
Policy:
TheKey of Kansas, LLC is committed to providing a safe and respectful environment for all individuals in our care. We strictly prohibit any form of abuse, neglect, or exploitation. It is the responsibility of every employee to report any suspected incidents of abuse, neglect, or exploitation immediately.
Definitions:
According to Kansas Statutes Annotated (KSA), the following definitions apply:
Abuse: any act or failure to act performed intentionally or recklessly that causes or is likely to cause harm to an adult, including:
1. Infliction of physical or mental injury;
2. Any sexual act with an adult when the adult does not consent or when the other person knows or should know that the adult is incapable of resisting or declining consent to the sexual act due to mental deficiency or disease or due to fear of retribution or hardship;
3. Unreasonable use of a physical restraint, isolation or medication that harms or is likely to harm an adult;
4. Unreasonable use of a physical or chemical restraint, medication or isolation as punishment, for convenience, in conflict with a physician's orders or as a substitute for treatment, except where such conduct or physical restraint is in furtherance of the health and safety of the adult; or
5. A threat or menacing conduct directed toward an adult that results or might reasonably be expected to result in fear or emotional or mental distress to an adult.
Neglect: the failure or omission by one's self, caretaker or another person with a duty to supply or provide goods or services that are reasonably necessary to ensure safety and well-being and to avoid physical or mental harm or illness.
TheKey of Kansas, LLC
________________
Category: Rights, Responsibilities, & Ethics
Subject: Reporting Abuse, Neglect, and Exploitation
Applies: All Staff Page: 2 of 4
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Financial Exploitation: the unlawful or improper use, control or withholding of an adult's property, income, resources or trust funds by any other person or entity in a manner that is not for the profit of or to the advantage of the adult. "Financial exploitation" includes, but is not limited to:
1. The use of deception, intimidation, coercion, extortion or undue influence by a person or entity to obtain or use an adult's property, income, resources or trust funds in a manner for the profit of or to the advantage of such person or entity;
2. The breach of a fiduciary duty, including, but not limited to, the misuse of a power of attorney, trust or a guardianship or conservatorship appointment, as it relates to the property, income, resources or trust funds of the adult; or
3. The obtainment or use of an adult's property, income, resources or trust funds, without lawful authority, by a person or entity who knows or clearly should know that the adult lacks the capacity to consent to the release or use of such adult's property, income, resources or trust funds.
Procedure:
1. Immediate Reporting:
* Any employee who suspects abuse, neglect, or exploitation must report it immediately to their supervisor.
* Employees are encouraged to provide as much detail as possible, including names, dates, times, and descriptions of the suspected incident.
2. Internal Reporting:
* Employees must report the suspected abuse, neglect, or exploitation to their direct supervisor immediately upon suspicion.
* The supervisor will document the report and initiate an internal investigation.
* As a result of reporting and investigation of suspected or alleged abuse, neglect or exploitation of a client, corrective actions will be taken as necessary to prevent future incidents.
TheKey of Kansas, LLC
________________
Category: Rights, Responsibilities, & Ethics
Subject: Reporting Abuse, Neglect, and Exploitation
Applies: All Staff Page: 3 of 4
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3. External Reporting:
* In addition to internal reporting, employees must report suspected abuse, neglect, or exploitation to the Kansas Department of Health and Environment (KDHE) using the following contact information:
* KDHE Abuse, Neglect, and Exploitation Complaint Hotline: 1-800-842-0078.
* The hotline is available 24/7 for reporting.
4. Documentation:
* The supervisor and employee will complete the internal incident report form with all known details.
* The supervisor and employee will ensure that all documentation is accurate, thorough, and submitted to the designated person for record-keeping and further action.
5. Confidentiality:
* All reports and investigations of suspected abuse, neglect, or exploitation will be handled with the utmost confidentiality.
* Information will only be shared with individuals directly involved in the investigation or those who need to know in order to take appropriate action.
6. Protection from Retaliation:
* TheKey of Kansas, LLC prohibits retaliation against any employee who reports suspected abuse, neglect, or exploitation in good faith.
* Any employee who believes they are experiencing retaliation should report it to the Human Resources department or the compliance officer immediately.
Training and Awareness
* All employees will receive training on recognizing and reporting abuse, neglect, and exploitation during their initial orientation and through annual refresher courses.
* Employees will be provided with resources and contacts for reporting and will be reminded of the importance of vigilance and responsibility in safeguarding vulnerable individuals.
TheKey of Kansas, LLC
________________
Category: Rights, Responsibilities, & Ethics
Subject: Reporting Abuse, Neglect, and Exploitation
Applies: All Staff Page: 4 of 4
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Compliance
Failure to comply with this policy may result in disciplinary action, up to and including termination of employment. Compliance with reporting procedures is mandatory and essential to maintaining the safety and well-being of those in our care.
TheKey of Kansas, LLC
________________
Category: Client Information Reviewed/Updated: 6.2024
Subject: Client Records
Applies: All Staff Page: 1 of 3
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Purpose:
* To maintain an accurate record of the services provided by TheKey of Kansas, LLC for each client.
* To outline the requirements and components of a client record.
* To provide a mechanism by which client care information is documented, maintained, protected, utilized, and transferred as appropriate.
* To safeguard the integrity of information maintained in service and billing records.
Policy:
A client record will be maintained for each client receiving services. The client record will contain sufficient information to identify the client, describe client problems and needs, accurately document service provided and results in detail, and facilitate continuity of services among organization and contract personnel. All entries to the client record will be legible (either written or typed), clear, complete, objective, appropriately authenticated and dated (month, day, year). All staff will be trained on the appropriate documentation protocols.
Procedure:
1. A client record will be initiated and maintained for each client receiving services.
2. Each client’s record includes at least the following:
1. Date of service enrollment
2. Written fee agreement.
1. Charges fees for personal support services, a written agreement dated and signed by the client or the client’s legal representative (conservator, guardian, or legal custodian) or person paying for services prior to the provision of services. The written agreement shall include at least the following information:
1. The fee or fees to be paid by the client
2. The services covered by such fees
3. Any additional charges for services not covered by the basic service fee
TheKey of Kansas, LLC
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Category: Client Information
Subject: Client Records
Applies: All Staff Page: 2 of 3
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3. Written acknowledgement that the client or client’s legal representative (conservator, parent, guardian, or legal custodian) has been informed of the client’s rights;
4. A written plan of care;
5. Consent for services by the client or client’s legal representative (conservator, parent, guardian, or legal custodian), surrogate decision maker or attorney-in-fact under a durable power of attorney for health care, when applicable;
6. If applicable, address, phone number or email address to reach the client’s legal representative (conservator, parent, guardian, or legal custodian) or surrogate decision maker or attorney-in-fact under a durable power of attorney for health care;
7. Documentation of party responsible for payment of services;
8. The name of the client’s physician, nurse practitioner, clinical nurse specialist, or physician assistant;
9. Physician orders for drugs, diet, treatment, and activity;
10. Signed and dated admission notes;
11. Documentation of supportive care services provided, the date and time the provider of supportive care services checked in and out, and a confirmation that supportive care services were provided;
12. Documentation of medical problems, illnesses and treatments, accidents, seizures, adverse incidents, and follow-up, while the client receives services.
13. A copy of progress notes;
14. The date of each on-site visit for supervision required by K.A.R. 28-51-117;
15. Client’s primary language and communication needs;
16. Allergies or sensitivities;
17. Relevant diet or dietary restrictions if any;
18. Record and findings of client assessment;
19. Safety measures to protect the client from harm or injury;
20. Evaluation of the home, if applicable; and
21. Client Transfer, Referral, or Discharge summary if applicable
TheKey of Kansas, LLC
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Category: Client Information
Subject: Client Records
Applies: All Staff Page: 3 of 3
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3. A service delivery note will be written for each shift made to a client who is receiving services.
4. Entries into the client record will be made by organization personnel who have a written agreement with the organization.
5. Service delivery notes shall be written at the time of service and shall include the following:
1. The first initial of the given name, full surname, and initials or licensing credentials of organization personnel.
2. What service or task was provided to the client;
3. The date the service was provided, including the month, day, and year;
4. The signature and title of organization personnel providing the service to the client; and
5. The client’s response to care, as applicable
6. Only on organization approved forms or electronic platform, as applicable
6. If the organization is utilizing a computer to authenticate documentation, staff and contracted personnel will sign a computer confidentiality statement, verifying that others will not be allowed to use their computer password. Each staff and contracted individual is responsible for the security of his/her computer password.
TheKey of Kansas, LLC
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Category: Client Information Reviewed/Updated: 6.2024
Subject: Client Record Use, Removal, and Release of Information
Applies: All Staff Page: 1 of 3
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Policy:
TheKey of Kansas, LLC ensures that client records are managed in a manner that maintains confidentiality, security, and compliance with state regulations and applicable federal laws. This policy outlines the procedures for the use, removal, and release of client information.
Procedure:
Use of Client Records
1. Authorized Use
* Client records shall only be used by authorized personnel for purposes directly related to service provision, including:
* Service planning and delivery
* Case management
* Quality assurance and improvement
* Billing and financial management
2. Confidentiality
* All employees must maintain the confidentiality of client records. Unauthorized access, use, or disclosure of client information is strictly prohibited and subject to disciplinary action.
Removal of Client Records
1. Physical Records
* Client records shall not be removed from agency premises without written authorization from a supervisor. When records are removed, they must be transported in a secure manner.
2. Electronic Records
* Access to electronic records outside of agency premises is allowed only through secure, encrypted connections. Unauthorized downloading or copying of electronic records is prohibited.
TheKey of Kansas, LLC
________________
Category: Client Information
Subject: Client Record Use, Removal, and Release of Information
Applies: All Staff Page: 2 of 3
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Release of Information
1. Authorization
* The release of client information requires a signed authorization form from the client or their legal representative, except in cases where disclosure is mandated by law.
2. Required Information for Release of Information
* The authorization form must include:
* Client’s name and identification details
* Description of the information to be released
* Purpose of the release
* Expiration date of the authorization
* Signature of the client or legal representative
* Date of the signature
3. Exceptions
* Information may be released without client consent in the following circumstances:
* To comply with a court order or subpoena
* To report abuse, neglect, or exploitation as required by law
* In emergency situations to protect the health and safety of the client or others
4. Documentation
* All releases of information must be documented in the client’s record, including the date, recipient, and purpose of the disclosure.
Security Measures
1. Physical Security
* Client records must be stored in locked cabinets or rooms accessible only to authorized personnel.
2. Electronic Security
* Electronic records are protected with passwords, encryption, and regular backups. Access will be restricted based on role and necessity.
TheKey of Kansas, LLC
________________
Category: Client Information
Subject: Client Record Use, Removal, and Release of Information
Applies: All Staff Page: 3 of 3
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Training
* All employees will receive training on this policy during onboarding and annual refresher training. Training will cover confidentiality, proper handling of records, and procedures for releasing information.
Violations
* Violations of this policy may result in disciplinary action, up to and including termination of employment. Legal consequences may also apply depending on the nature of the violation.
TheKey of Kansas, LLC
________________
Category: Client Information Reviewed/Updated: 6.2024
Subject: Safeguard and Retrieval of Client Records
Applies: All Staff Page: 1 of 4
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Purpose:
To establish a procedure for the protection of client record information from loss or unauthorized use.
Policy:
TheKey of Kansas, LLC will safeguard the client record against loss, destruction, tampering or unauthorized use through the development of processes, policies, and procedures. Portions of the record left in the client’s place of service are the responsibility of the client or the client’s responsible party/family.
TheKey of Kansas, LLC shall ensure the confidentiality of clients’ information, including the following:
1. TheKey of Kansas, LLC supportive services workers shall comply with applicable confidentiality laws and regulations.
2. The client shall not be required to make public statements which acknowledge gratitude to the licensee or for TheKey of Kansas, LLC services.
3. Identifiable photographs of clients shall not be used without the written and signed consent of the individual or the individual’s legal guardian and/or conservator.
Procedure:
1. Authorized personnel will be assigned passwords and/or access codes and complete a signed statement that no one else will be allowed to use his/her computer key. Signed staff security statements and pass code identification files are secured and maintained in the Administrator or designee’s office. Information accessible via remote terminals is filtered through these passwords and security checks creating an audit trail to identify individual users when necessary.
2. Electronic client records will be accessible only as appropriate to its users. Personnel will only have access to information on those clients to which they are actively providing care and services.
3. Personnel accessing client records electronically will do so on organization issued devices.
TheKey of Kansas, LLC
________________
Category: Client Information
Subject: Safeguard and Retrieval of Client Records
Applies: All Staff Page: 2 of 4
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4. Access to client records for individuals from outside the organization, such as surveyors, reviewers, or consultants will be approved by the Administrator on a per-occurrence basis providing they have appropriate identification.
5. All client records will be maintained electronically in WellSky. Only authorized personnel will have access to records.
6. Client information and documents such as the plan of care or data being retrieved from records for performance improvement will not be left on desks at night.
7. The parts of the client record that may be copied for use by staff include:
1. The plan of care
2. Recent notes (no more than one week of client reports)
8. Parts of the record being transported to and from a client’s place of service will be protected during transport.
1. Records will be transported in a covered, preferably waterproof bag.
2. Once placed in a vehicle, the information will be in an inconspicuous location, such as the trunk or floor of the back seat, face down
3. The vehicle will be locked at all times
4. Records removed from the office will be returned to the office during the same business day. Exceptions will be pre-approved by the supervisor
9. Selected documents may be kept in the client’s place of service in a home client record.
1. Elements of the client record necessary to provide continuity of care while the case is active, including the plan of care, service delivery notes, etc.
2. Home client record documents will be delivered to the office on a weekly basis
3. All home client record documents and supplies will be picked up by the organization personnel and returned to the office when services end
10. Original client records will be removed from the office only with the approval of the Administrator.
TheKey of Kansas, LLC
________________
Category: Client Information
Subject: Safeguard and Retrieval of Client Records
Applies: All Staff Page: 3 of 4
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11. Security of information will be ensured for electronic and manual systems and includes issues such as:
1. Disaster recovery plan and continuity of business:
1. Plans for scheduled and unscheduled interruptions
2. Contingency procedures for operations interruptions
3. Plans for minimal interruptions due to scheduled downtime
4. An emergency service plan
5. A backup system plan, either computerized or manual
6. How data retrieval will be addressed, including retrieval from storage and information presently in the system, retrieval of data in the event of system interruption and backup of data
2. Theft
3. Vandalism
4. Fire and flood recovery
12. Any confirmed, suspected, or potential violation of security or confidentiality will be reported to the Administrator. Violations will be considered a serious incident requiring immediate investigation and response. Violations or security will be reported and monitored through the Organization’s performance improvement plan.
13. A thorough analysis will be conducted, assessing the need to process improvements, or increasing security or confidentiality measures.
14. As a result of this review, action will be taken as necessary to improve care. The Supervisor/Client Success Manager, or designee will identify issues with documentation and based on the review, if the issue:
1. If applicable to an individual, the individual will be counseled.
2. If applicable to the organization as a whole, refer the issue to the Governing Body for review.
15. Any areas demonstrating a pattern or trend will be analyzed by the performance improvement committee or designee for development of recommendations and actions.
16. Staff will receive training on alternative procedures to follow when electronic information systems are unavailable.
TheKey of Kansas, LLC
________________
Category: Client Information
Subject: Safeguard and Retrieval of Client Records
Applies: All Staff Page: 4 of 4
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17. Clients have the right to access their service records and are informed of the process for requesting access at the time of admission.
18. The client’s, or guardian’s written consent shall be required for release of information not required by law.
19. Records will be retained in a retrievable form for at least five years after the date of the last discharge of the client.
20. When Organization Name meets the definition of a Covered Entity, as that term is defined in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and implementing regulations and/or similar state law applies to Organization Name, breach notification requirements as outlined in the Health Information Technology for Economic and Clinical Health (HITECH) Act and/or relevant state law will be followed. See for HIPAA notification requirements: http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/index.html
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TheKey of Kansas, LLC
________________
Category: Client Information Reviewed/Updated: 6.2024
Subject: Retention of Records
Applies: All Staff Page: 1 of 2
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Purpose:
To comply with applicable laws and regulations regarding the retention of records.
Policy:
The client record, whether paper or electronic, will be retained in a retrievable form for at least five years after the date of the last discharge of the client.
Procedure:
1. Active electronic records shall be available through the organization’s secure digital or electronic records platform.
2. When a client services are terminated:
1. The client record will be reviewed for completeness
2. The client record will be closed within thirty (30) days of the client’s discharge from the organization
3. The client record will remain the property of the organization.
4. The organization will keep client records involved in litigation until the case is concluded or seven (7) years, whichever is longer.
5. In the event the organization ceases operation, client records, administrative records, and financial files (including all electronic information) will be stored at the organization's offices or other designated location.
Administrative, Financial and Personnel Records
1. Applicable local, state, and federal regulations regarding record retention will be reviewed on an ongoing basis.
2. Financial records will be kept according to applicable statutes and IRS regulations regarding time frame requirements.
3. A review of administrative, financial and personnel records produced by TheKey of Kansas, LLC will be completed to determine which records meet criteria for inclusion in local, state, and federal regulations. A directory of organization-specific reports and their respective retention times may be maintained by TheKey of Kansas, LLC.
TheKey of Kansas, LLC
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Category: Client Information
Subject: Retention of Records
Applies: All Staff Page: 2 of 2
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4. Records may be retained as a part of the organization’s computer back-up system so long as they are easily retrievable.
5. Records will be stored securely with access by authorized personnel only.
6. The organization will keep personnel records involved in litigation until the case is concluded or seven (7) years, whichever is longer.
7. Governing Body meeting minutes will be retained for a minimum of five (5) years.
8. All medical records for personnel and staff shall be maintained for at least the duration of employment, plus thirty (30) years.
Destruction of Records
1. In the absence of an Investigation, Litigation, Cost Report or Legal Hold, records may be destroyed upon the termination of the applicable mandatory retention period.
2. The appropriate method of destruction depends on the record’s physical form or medium or subject matter or content.
3. Records that include Protected Health Information (PHI) or client-specific identifiers will be destroyed or disposed of so that the personal data cannot practically be read or reconstructed.
4. Electronic records will be destroyed or erased.
5. Absent any special instructions or unique circumstances, records generally will be destroyed at the end of their retention period; retaining any record past its mandatory retention period should be on an exceptions-only basis after weighing the potential usefulness of the record against cost or space limitations.
Destruction of Records (Unintentional)
1. Records destroyed unintentionally due to fire, natural disaster or human error will be recovered by means appropriate to the medium that they were stored.
2. Electronic records will be recovered by accessing the back-up system.
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TheKey of Kansas, LLC
________________
Category: Client Information Reviewed/Updated: 6.2024
Subject: Data Collection and Verification Of Service Delivery
Applies: All Staff Page: 1 of 1
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Purpose:
* To implement and maintain systems to collect data related to client care.
* To implement and maintain systems to allow for caregivers to report the duration of care provided.
* To implement and maintain systems to allow for caregivers to report the type of service provided on each assignment.
Policy:
TheKey of Kansas, LLC will maintain systems to allow for the accurate and timely collection of data to substantiate the quantity and type of service provided.
Procedure:
* Caregivers will be required to clock in and out for each shift and report services provided using TheKey caregiver app or telephony.
* TheKey caregiver app and/or the telephony system will provide details about each date service was provided, time service started and ended, and a summary of services provided each shift.
* Clients, or responsible parties, must review invoices each week to acknowledge the designated service was provided.
* Client service records will allow the caregiver to designate the specific type of care provided.
* The Supervisor, or designee, will review all weekly service records.
TheKey of Kansas, LLC
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Category: Client Information Reviewed/Updated: 6.2024
Subject: Admission Notes
Applies: All Staff Page: 1 of 2
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Policy:
Admission notes must be completed for every new client at the time of their admission to the agency’s services. These notes are crucial for developing an individualized care plan and must be maintained as part of the client’s permanent record.
Procedure:
1. Pre-Admission
* Initial Contact: The agency will collect preliminary information from the prospective client or their representative, including personal details, primary concerns, and service needs.
* Eligibility Verification: The agency will confirm that the client meets the eligibility criteria for non-medical supportive care services as per Kansas regulations.
2. Admission Assessment
* Scheduling: The agency will arrange a home visit or in-agency appointment for a comprehensive assessment within 5 business days of initial contact.
* Assessment Team: A designated qualified staff member (e.g., client success manager) will conduct the assessment.
* Documentation: The agency’s standardized assessment form will be used to gather information on:
* Personal details (name, date of birth, address, contact information)
* Emergency contacts
* Medical history (non-diagnostic, general health information)
* Current medications
* Daily living activities and support needs
* Psychosocial status
* Environmental assessment (safety and accessibility of the home)
* Client’s preferences and goals
3. Admission Note Completion
* Timeliness: The admission note will be completed within 48 hours of the assessment visit.
TheKey of Kansas, LLC
________________
Category: Client Information
Subject: Admission Notes
Applies: All Staff Page: 2 of 2
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* Content: The assessment team will ensure the admission note includes:
* Date and time of assessment
* Name and title of the staff member conducting the assessment
* Comprehensive summary of the assessment findings
* Identified care needs and recommended services
* Initial care plan outline
* Client Consent: The agency will obtain written consent from the client or their legal representative for the proposed services and care plan.
* Signature: The staff member conducting the assessment must sign and date the admission note.
4. Review and Approval
* Supervisor Review: The completed admission note and initial care plan must be reviewed and approved by a supervisor.
5. Record Keeping
* Admission notes must be entered into WellSky promptly.
* Confidentiality: The agency will maintain strict confidentiality of all client information in accordance with HIPAA regulations and state laws.
6. Training
* Staff Training: The agency will provide initial and ongoing training to all relevant staff on the admission process, documentation standards, and confidentiality requirements.
TheKey of Kansas, LLC
________________
Category: Client Information Reviewed/Updated: 6.2024
Subject: Progress Notes
Applies: All Staff Page: 1 of 1
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Policy:
TheKey of Kansas, LLC has established a standardized procedure for documenting progress notes for clients receiving non-medical supportive care services. This ensures compliance with Kansas state regulations, continuity of care, and quality assurance.
Procedure:
1. Documentation Requirement:
* Progress notes must be completed for every client interaction.
* Notes will be written clearly, concisely, and objectively.
2. Timeliness:
* Progress notes should be documented immediately following the service delivery, but no later than the end of the working day.
* In cases of emergency or significant events, notes should be documented as soon as possible.
3. Content:
* Date and time of service.
* Description of services provided.
* Observations of the client's condition and environment.
* Client’s response to the services provided.
* Any changes in the client's condition or needs.
* Signature and designation of the person documenting the note.
4. Storage and Accessibility:
* Progress notes will be stored in the client’s file in a secure and organized manner.
* Only authorized personnel will have access to progress notes as needed for continuity of care and audits.
5. Confidentiality:
* All progress notes are confidential and will only be shared with individuals directly involved in the client's care or as legally required.
TheKey of Kansas, LLC
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Category: Client Information Reviewed/Updated: 6.2024
Subject: Client Transfer, Referral, and Discharge Criteria and Process
Applies: All Staff Page: 1 of 3
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Purpose:
To delineate the processes by which services are reduced or clients are transferred, referred
or discharged.
Policy:
The client will participate in developing the plan of care. The client or organization may initiate a reduction in services, a transfer, referral, or discharge.
Discharge or Reduction of Services Criteria
1. Services will be terminated when the client meets one or more of the following
discharge criteria:
1. A change in the client’s status requires services other than those provided by
the organization
2. The service plan goals have been attained or are no longer attainable and/or there is no longer a payer for services
3. The client refuses or discontinues services
4. The client refuses to pay for further services
5. Situation at the site of services is no longer safe for the client and/or organization personnel
6. The client moves away from the geographic area served by the organization
7. The organization is discontinuing a service or all services
8. The client expires
Transfer or Referral Criteria
1. A client will not be arbitrarily transferred or referred. A client may be transferred or referred for the following reasons which will be documented in the client record:
1. A client requests a transfer or referral to another provider
2. Medical reasons, necessitating care beyond the scope of the organization
3. It is no longer a safe environment for the client and/or organization personnel.
4. A change in the client’s medical or care program that the organization
cannot accommodate under the scope of service or state licensure.
TheKey of Kansas, LLC
________________
Category: Client Information
Subject: Client Transfer, Referral, and Discharge Criteria and Process
Applies: All Staff Page: 2 of 3
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Procedure:
Discharge or Reduction of Services
1. The organization will verbally notify the client of the need to terminate or reduce services prior to the last scheduled shift.
2. For clients requiring continuing care not available through TheKey of Kansas, LLC, assistance will be given to clients in order to transfer to another organization or facility that can better meet the client’s ongoing needs.
1. Arrangements for such services will be coordinated by the organization
3. If the organization is making the decision to reduce or terminate services, the supervisor or Administrator will be responsible for the decision. The decision will be documented in the client record, citing the circumstances and notification of the client.
4. The Client Success Manager, or designee will be responsible for documenting the termination.
5. Prior notice, unless documented in the service agreement, is not necessary when services are discontinued by the client. However, actions will be documented in the client record.
Transfer or Referral
1. Clients will be given immediate notice and assistance in selecting other services appropriate to their needs.
2. If a client is referred to another organization, service or individual, the client will be informed of any financial benefit to the referring organization.
3. The Client Success Manager, or designee will serve as a liaison in the transfer process unless refused by the client or client representative.
4. The Client Success Manager, or designee will verbally confirm the transfer arrangements with the receiving provider.
5. The receiving provider will be provided with relevant written or verbal information within seventy-two (72) hours of transfer. Communication with the receiving facility will be documented in the client record.
TheKey of Kansas, LLC
________________
Category: Client Information
Subject: Client Transfer, Referral, and Discharge Criteria and Process
Applies: All Staff Page: 3 of 3
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Transfer Documentation
1. Documentation in the client record includes, but is not limited to the following as applicable to care and services provided:
1. Date of transfer
2. Identifying information and emergency contact information for the client
3. Destination of the client
4. Date and name of person/organization receiving report
5. Client’s healthcare provider’s name and phone number
6. Significant health history
7. Transfer orders and instructions
8. Summary of services provided by the organization and ongoing needs that cannot be met
9. Status of client at the time of transfer
Discharge Documentation
1. Documentation in the client record includes, but is not limited to the following as applicable to care and services provided:
1. Date of discharge
2. Client identifying information
3. Client’s healthcare provider’s name and phone number
4. Reason for discharge
5. Summary of care/services provided by the organization
6. Status of the client at the time of discharge
2. Any instructions given to the client/responsible party/family
3. The client record will be reviewed by the supervisor and completed within thirty (30) days of discharge. The client record will then be removed from the active files.
TheKey of Kansas, LLC
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Category: Client Services Reviewed/Updated: 6.2024
Subject: Supervision of Services
Applies: All Staff Page: 1 of 2
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Policy:
TheKey of Kansas, LLC ensures high-quality supportive care services are provided to clients through regular supervision of supportive care workers by the manager. The policy outlines the procedures for on-site visits, client satisfaction assessments, and documentation requirements.
Procedure:
1. On-Site Visits by Manager
* Frequency: The manager shall conduct an on-site visit to each client every three months.
* Purpose: The purpose of the visit is to supervise the supportive care worker, ensuring they adhere to the plan of care and to address any issues or concerns.
* Process:
* The agency will schedule the visit at a mutually convenient time for the client and supportive care worker.
* During the visit, the manager will observe the supportive care worker while they perform their duties.
* The manager will provide feedback, support, and guidance to the supportive care worker as needed.
2. Assessment of Client Satisfaction and Adherence to Plan of Care
* Client Satisfaction:
* The manager will assess client satisfaction during the on-site visit through direct conversation and a standardized questionnaire.
* Questions will cover various aspects of the services provided, including reliability, professionalism, and the client’s overall satisfaction.
* Adherence to Plan of Care:
* The manager will review the supportive care worker’s adherence to the plan of care by checking documentation and observing care activities.
TheKey of Kansas, LLC
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Category: Client Services
Subject: Supervision of Services
Applies: All Staff Page: 2 of 2
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* Any deviations from the plan of care will be addressed, and corrective actions will be documented and implemented.
3. Documentation in Client Records
* On-Site Visit Documentation:
* The date of each on-site visit for supervision will be recorded in the client’s record.
* The record will include the manager’s observations, feedback provided to the supportive care worker, client satisfaction assessment results, and any identified issues or actions taken.
* Compliance:
* Documentation must ensure accuracy, completeness, and confidentiality.
* Review and Maintenance:
* Client records will be reviewed regularly to ensure ongoing compliance with supervision policies and regulations.
* Records will be maintained securely and accessible only to authorized personnel.
Responsibilities
* Manager:
* Schedule and conduct on-site visits every three months.
* Assess client satisfaction and supportive care worker adherence to the plan of care.
* Provide supervision, feedback, and guidance to supportive care workers.
* Document all on-site visits and assessments accurately in client records.
* Supportive Care Worker:
* Cooperate with the manager during on-site visits.
* Follow the plan of care and implement feedback provided by the manager.
* Maintain high standards of care and professionalism.