Page 88 - Business Development Orientation Binder

Applies to: VNSNY Certified Home Health Agency
Service: VNSNY Certified Home Health Agency
Procedure Section: Provider Service Administration
Number: CP.164
Page 4 of 5

d. The clinical record must reflect identification of the problems encountered,
communication with team and the physician responsible for the plan of care;
and a plan to resolve the issues and results of the plan implementation.

3. Provide the patient and representative (if any), with contact information for other
agencies or providers who may be able to provide care and coordinate with
community agencies to ensure continuity of care.

4. If the agency believes there will continue to be a substantial risk to the patient's
health and safety subsequent to discharge, a referral shall be made to the
appropriate local Protective Services for Adults program or other official agency,
as appropriate, at the time the discharge determination is made.
5. Cases discharged for cause must be reviewed with VP/ designee and
Compliance Specialist. At discharge Branch Director or designee will enter “Do
Not Readmit” status in the patient records for the case to be evaluated prior to
readmission.

6. If Medicaid is the payer and patient and MD do not concur with discharge,
contact See: Medicaid Recipients: Denial of Services and Discharge based on
Health and Safety

See Protocol for discharge /termination

E. Patient moves to another borough
1. Services will not be terminated if patient moves to another address that is
serviced by VNSNY.
2. Patient will be transferred to another VNSNY branch/ team.
3. Exceptions include: Cases transferred to Nassau and Suffolk County are
classified as “Moved” with a reason code of “Other CHHA” and Discharge
OASIS Type 9 is completed

F. Transfer to a facility
1. When the patient is transferred and admitted to inpatient facility for stay of 24
hours or longer, clinician or CFM manager writes and CFM approves Hospital
Hold order. See CP 121 PROCEDURE TRANSFER TO INPATIENT FACILITY-
HOSPITAL HOLD

Responsibility: Quality Management Services-Homecare
Procedure date:
Revised: 6/2015, 12/2016, 12/2017, 12/2018
Approval: Senior Vice President Patient Care Service