DMEPOS Operational Policy and Procedure Manual
Table of Contents Chapter 1 Policy 1-01 - Patient Rights Attachment 1-01-01 - Patient Bill of Rights Attachment 1-01-02 - Customer Orientation Form Policy 1-02 - Staff Comprehensio n of Rights and Responsibilities Policy 1-03 - Patient Participation and Consent for Services Attachment 1-03-01 - Organization Objectives Attachment 1-03-02 - Equipment and Services Policy 1-04 - Refusal of Care and Service Attachment 1-04-01 - Release of Liability Attachment 1-04-02 - Visit Refusal Report Policy 1-05 - Resolution of Conflicts Policy 1-06 - Ethical Guidelines Attachment 1-06-01 - Code of Ethics Policy 1-07 - Conflicts of Interest Attachment 1-07-01 - Conflict of Interest Notification Policy 1-08 - Resolution of Ethical Issues Attachment 1-08-01 - Ethical Resolution Checklist Policy 1-09 - Patient Complaints and Compliments Attachment 1-09-01 - Patient Communication Form Policy 1-10 - Confidentiality, Communication, and Informed Consent Attachment 1-10-01 - Employee Confidentiality Agreement Attachment 1-10-02 - Authorization for Release of Information, Assignment of Benefits and Deductible/Co-Pay Responsibility Attachment 1-10-03 - Consent to Record Policy 1-11 - Respect of Patient Confidentiality, Privacy, Security, and Property Policy 1-12 - Care Coordination Attachment 1-12-01 - Patient Communication Log Policy 1-13 - Patient Responsibility Attachment 1-13-01 - Responsibilities of the Patients Attachment 1-13-02 - Equipment Purchase Certification Chapter 2 Policy 2-01 - Initial Assessment Attachment 2-01-01 - Plan of Care/Initial Assessment: General Equipment Attachment 2-01-05 - Plan of Care/Initial Assessment: Continuation Policy 2-02 - Reassessments and Follow Up Policy 2-03 - Assessment Qualifications Policy 2-04 - Patient Abuse, Neglect, and Exploitation Policy 2-05 - Plan of Care/Service/Treatment Policy 2-06 - Orders for Services Policy 2-07 - Care Standards Policy 2-08 - Patient Education Attachment 2-08-01 - Medicare Supplier Standards Attachment 2-08-02 - Delivery Invoice Attachment 2-08-03 - Patient Education Sheets - English Policy 2-09 - Education Review Policy 2-10 - Patient Safety Education Policy 2-11 - Patient/Family Medication Education Policy 2-12 - Referral, Transfer, and Discharge Attachment 2-12-01 - Transfer/Discharge/Referral Notification Policy 2-13 - Admission/Refusal of a Patient Policy 2-14 - Appropriate and Timely Care Policy 2-15 - Initial Respiratory Assessment Policy 2-16 - Clinical Respiratory Assessment Attachment 2-16-01 - Respiratory Assessment Form Policy 2-17 - Plan of Treatment or Care Chapter 3 Policy 3-01 - Governing Body Authority and Responsibility Attachment 3-01-01 - Organizational Chart Attachment 3-01-02 - Mission Statement Policy 3-02 - Organizational Plan Policy 3-03 - Patient Perception of Care Attachment 3-03-01 - Perception of Care Policy 3-04 - Contract Services Attachment 3-04-01 - Contract Standards Attachment 3-04-02 - Attachment 1: Payment Rates Attachment 3-04-03 - Sample Contract: Individual Attachment 3-04-04 - Sample Contract: Entity Policy 3-05 - Operating Budget Policy 3-06 - Administrative Responsibility/Competency/Backup Policy 3-07 - Process Implementation and Review Attachment 3-07-01 - Process/Policy Action for Non-Compliant Status Attachment 3-07-02 - Acknowledgement of Review of Policies Chapter 4 Policy 4-01 - Safety Program Policy 4-02 - Cleaning and Disinfecting Policy 4-03 - Identifying Risks & Safety Hazards Attachment 4-03-01 - Safety Hazard Report (Organization) Attachment 4-03-02 - Safety Hazard Report (Patient) Policy 4-04 - Incidents Attachment 4-04-01 - Incident Report Policy 4-05 - Sentinel/Adverse Events Policy 4-06 - Equipment Incidents Attachment 4-06-01 - Equipment Incident Report Attachment 4-06-02 - Equipment Incident Tag Policy 4-07 - Emergency Preparedness Attachment 4-07-01 - Hazard Vulnerability Analysis Policy 4-08 - Equipment Tracking, Hazards, Recalls, and Returns Attachment 4-08-01 - Medical Device Registration Attachment 4-08-02 - Daily Vehicle Log Policy 4-09 - Routine and Preventive Maintenance Attachment 4-09-01 - Preventive Maintenance/Repair Log Attachment 4-09-02 - Equipment Status Stickers Attachment 4-09-03 - Vehicle Maintenance Schedule Policy 4-10 - Safe, Operable Equipment Attachment 4-10-01 - Warehouse Layout Sample Attachment 4-10-02 - General Equipment Log Attachment 4-10-03 - Equipment Tracing Number Control Log (Page 1) Attachment 4-10-04 – Equipment Tracking Log (Page 2) Attachment 4-10-05 – Preventive Maintenance WorkSheet (Page 3) Policy 4-11 - Response Procedures Attachment 4-11-01 - On-Call Log Policy 4-12 - Emergency Maintenance and Replacement Policy 4-13 - Staff Safety and Security Policy 4-14 - Care/Service at the Organization's Site Policy 4-15 - OSHA Compliance Attachment 4-15-01 - General Health and Safety Activities Checklist Attachment 4-15-02 - Facility Safety Checklist Attachment 4-15-03 - Fire Protection Checklist Attachment 4-15-04 - Personal Protection Checklist Attachment 4-15-05 - Accident Reporting and Record Keeping Checklist Attachment 4-15-06 - Medical Services and First Aid Checklist Attachment 4-15-07 - Hand and Portable Power-Operated Tool Checklist Attachment 4-15-08 - Hoists and Forklifts Checklist Attachment 4-15-09 - Flammable and Combustible Material Checklist Attachment 4-15-10 - Hazardous Materials, Waste, Disposal, and Exposure Checklist Attachment 4-15-11 - Electrical Safety Checklist Attachment 4-15-12 - Material Handling Checklist Attachment 4-15-13 - Compressors and Compressed Air Checklist Attachment 4-15-14 - Compressed Gases Checklist Attachment 4-15-15 - Personal Protective Equipment Checklist Policy 4-17 - FDA Compliance Attachment 4-17-01 - Batch Production Log Chapter 5 Policy 5-01 - Personnel Policies/Procedures Policy 5-02 - Employee Qualifications Policy 5-03 - Personnel Selection Attachment 5-03-01 - Receipt of Job Description Attachment 5-03-02 - Job Descriptions Policy 5-04 - Supervision Policy 5-05 - Staff Orientation Attachment 5-05-01 - New Employee Orientation Checklist Attachment 5-05-02 - Competency Checklist Page 1 Attachment 5-05-03 - Competency Checklist Page 2 Attachment 5-05-04 - Competency Checklist Page 3 Attachment 5-05-05 - Competency Checklist Page 4 Policy 5-06 - Staff Education Attachment 5-06-01 - Six Steps to Safe Lifting Attachment 5-06-02 - Fire Safety Attachment 5-06-03 - Basic Home Safety Attachment 5-06-04 - Equipment Operation Attachment 5-06-05 - Training Outline: Occupational Exposure to Tuberculosis Attachment 5-06-06 - Training Outline: Hepatitis B Attachment 5-06-07 - Training Outline: Severe Acute Respiratory Syndrome Attachment 5-06-08 - Inservice Training Log Attachment 5-06-09 - Inservice Training New Product or Process Attachment 5-06-10 - Mandatory Annual Inservice Training Attachment 5-06-11 - Procedural Checklist: Deliveries Attachment 5-06-20 - Procedural Checklists: Enteral Nutrition Pumps Policy 5-07 - Staff Competency and Performance Evaluation Attachment 5-07-01 - Performance Review Attachment 5-07-03 - Delivery Procedures Competency Test Attachment 5-07-04 - Equipment Cleaning Competency Test Policy 5-08 - Determining and Assessing Learning Needs Attachment 5-08-01 - Competency Report Policy 5-09 - Clinical Procedures Chapter 6 Policy 6-01 - Information Management Planning Attachment 6-01-01 - Information Management Assessment Attachment 6-01-02 - Information Management Improvement Plan Policy 6-02 - Record Confidentiality, Security, and Integrity Policy 6-03 - Record Keeping Authorization/Authentication Attachment 6-03-01 - Signature Sheet Attachment 6-03-02 - Computer Key/Password Authorization Policy 6-04 - Documentation Standardization Attachment 6-04-01 - Approved Medical Abbreviations Attachment 6-04-02 - Unacceptable Medical Abbreviations, Symbols, and Dose Designations Policy 6-05 - Record Review Attachment 6-05-01 - Record Review Form Policy 6-06 - Patient Documentation Policy 6-07 - Record Retention Chapter 7 Policy 7-01 - Infection Control Program Policy 7-02 - Occupational Exposure - Prone Task List Attachment 7-02-01 - Occupational Exposure Risk and Protection Chart Policy 7-03 - Hepatitis B Vaccination Attachment 7-03-01 - Hepatitis B Declination Policy 7-04 - Infection Control - Universal Precautions Policy 7-05 - Equipment Management - Universal Precautions Policy 7-06 - Communicable Disease Protection/Exposure Policy 7-07 - Health Record Policy 7-08 - TB Identification/Prevention Protocols Policy 7-09 – Infection, Identification, Monitoring, And Tracking Attachment 7-09-01 – Infection Control Monitoring Log (Part 1) Attachment 7-09-02 – Infection Control Monitoring Log (Part 2) Chapter 8 Policy 8-01 - Performance Improvement Plan Attachment 8-01-01 - Performance Improvement Team Members Attachment 8-01-02 - Performance Team Responsibilities Attachment 8-01-03 - Staff Responsibilities Attachment 8-01-04 - Performance Team Rules Attachment 8-01-05 - Meeting Minutes Attachment 8-01-06 - Performance Improvement Annual Education Schedule Attachment 8-01-07 - Summary Tool for Scope of Service Attachment 8-01-08 - Performance Management System Diagram Policy 8-02 - Designing Performance Improvement Processes Attachment 8-02-01 - Design Worksheet Policy 8-03 - Measurement (Data Collection) Attachment 8-03-01 - On-Going Monitoring Attachment 8-03-02 - Annual Staff Competency Assessment Attachment 8-03-03 - Methods of Data Collection Attachment 8-03-04 - Sample Check Sheets Attachment 8-03-05 - Governing Body Competency Report Policy 8-04 - Aggregation and Analysis Attachment 8-04-01 - Instructions for Completing the Assessment of Data Form Attachment 8-04-02 - Assessment of Data Worksheet Policy 8-05 - Performance Improvement Attachment 8-05-01 - Improvement Worksheet Attachment 8-05-02 - Record of Improvement Policy 8-06 - Outcomes Measurement – Benchmarking Our DMEPOS accreditation policy and procedure manual is a comprehensive and user-friendly guide designed to help Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers navigate the accreditation process with ease and confidence. This manual provides detailed policies and procedures, along with step-by-step instructions, templates, and checklists to ensure compliance with accreditation standards. It is an essential resource for DMEPOS suppliers seeking to achieve and maintain accreditation, demonstrating their commitment to quality and patient safety.