Free Home Health Agency Prelicensure Desk Review Checklist-F-62536 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62536 (Rev. 04/09)

STATE OF WISCONSIN DHS 133, Wis. Admin. Code Page 1 of 2

HOME HEALTH AGENCY PRELICENSURE DESK REVIEW CHECKLIST
(Refer to procedure 3232.)
Name ­ Agency Name ­ Surveyor Date Assigned

Date

KEY:

*

= Policy Required

+

= Additional Information Required

1. Review application for completeness. 2. Review submitted information from application. All information received is reviewed for compliance with Chapter DHS 133, Wis. Admin. Code, within 30 days of receipt at the designated office, unless otherwise directed by supervisor. The following state rules are included in the desk review process.

* + + + + * + * * * * * * * * * * +* * +* * * * + * * + + +

T107 T108 T110 T111 T112 T120 T121 T122 T123 T124 T125 T126 T127 T129 T132 T133 T248 T249 T136 T140 T141 ­ T148 T149 T150 T152 T153 ­ T163 T170 T214 ­ T215 T216 ­ T222 T223

DHS 133.05(1)(a) DHS 133.05(1)(b) DHS 133.05(1)(d) DHS 133.05(1)(e) DHS 133.05(2) DHS 133.06(3)(a) DHS 133.06(3)(b) DHS 133.06(4)(a) DHS 133.06(4)(a)1 DHS 133.06(4)(a)2 DHS 133.06(4)(a)3 DHS 133.06(4)(a)4 DHS 133.06(4)(a)5 DHS 133.06(4)(c) DHS 133.06(4)(d)3 DHS 133.06(4)(e) DHS 133.06(4)(g) DHS 133.06(5)(a) DHS 133.07(2) DHS 133.08(2) DHS 133.08(2)(a) - (j) DHS 133.08(3) DHS 133.09(1) DHS 133.09(2) DHS 133.09(3) DHS 133.13 DHS 133.18(1) and (2) DHS 133.19(1)(a) ­ (f) DHS 133.19(2)

Governance Governance Governance Governance Professional Advisory Board Personnel Policies ­ Training Evaluation Plan Employees Orientation Program Content Employees Orientation Program Employee Orientation Program Employee Orientation Program Employee Orientation Program Employee Orientation Program Employee Orientation Program Disease Surveillance Employee Orientation Program Background Checks and Caregiver Reporting Infection Control and Prevention Established Program Evaluation Method Patient Rights Statement / Policies Patients Rights Statement Complaints Acceptance of Patients Service Agreement Discharge of Patients Emergency Notification Supervisory Visits Services Under Contract Qualifications of Contractors

F-62536 (Rev. 04/09)

Page 2 of 2

+ + * *

T224 T225 ­ T226 T232 T247

DHS 133.20(1) DHS 133.20(2)(a) and (b) DHS 133.21(2) DHS 133.21(7)

Plan of Treatment Plan of Treatment (Content) Medical Records Security Abbreviations

In addition to the required policies and procedures, the surveyor reviews employee job descriptions, a prototype of the aide assignment sheet, plan of care, service agreement, and patient rights statement. The surveyor sends a written request to the applicant detailing the need for submission of additional information, if necessary. Upon surveyor determination that the application meets or does not meet the intent of Chapter DHS 133, the surveyor forwards the desk review packet to the supervisor. The surveyor must make a formal licensure recommendation of approval or denial to the supervisor and the packet must include an Initial Home Health Application Review Chronology form (DQA form F-62655). The supervisor reviews the packet and makes a final recommendation for approval or denial of the licensure application. If the supervisor disagrees with the surveyor's recommendation, the supervisor contacts the surveyor to discuss and then forwards the desk review with the Bureau of Health Service's (BHS) recommendation to the Bureau of Technology, Licensing and Education (BTLE). The BTLE sends follow-up correspondence to the applicant reflecting issuance or denial of the probationary license. If approval of the probationary license is recommended, the BTLE contacts the applicant with the outcome of the desk review. A final determination from BTLE needs to be sent to the applicant within 60 calendar days of Bureau's receipt of the complete application. Date 3. Review job descriptions: · · · · · · 4. 5. 6. 7. 8. 9. Registered Nurse / Licensed Practical Nurse Therapists Social Worker Home Health Aide Personal Care Worker Other

Contact applicant with results and / or request for additional information. Letter to applicant with results and / or request for additional information. Additional information received. Date additional information reviewed. Applicant contacted: Telephone Written Correspondence

Memo to supervisor with recommendations.