Our Policies

Policy:

Heavenly Inspired Home Care maintains comprehensive procedures to ensure the safety and well-being of participants and staff during emergencies. All employees must follow established emergency response protocols consistent with Wisconsin DHS and OSHA standards.

Policy Explanation and Compliance Guidelines:

1. Emergency Contacts: Staff must have immediate access to emergency phone numbers, including 911, poison control, and the Administrator’s contact information.

2. Fire Safety: Staff must be trained in fire prevention, extinguisher use, and evacuation procedures. Fire drills will be conducted at least twice per year.

3. Medical Emergencies: In the event of a medical emergency, staff must call 911, provide first aid as trained, and notify the Administrator immediately.

4. Severe Weather: During storms or tornado warnings, staff should follow designated shelter-in-place procedures to ensure participant safety.

5. Utility Outages: Staff must report any loss of power, water, or heat immediately and take measures to maintain a safe environment until restored.

6. Evacuation Procedures: Evacuation routes must be posted and practiced. Participants requiring mobility assistance will have individualized plans documented.

7. Incident Reporting: All emergency events must be documented on an incident report form within 24 hours and submitted to the Administrator.

8. Training: Staff will receive initial and annual training in emergency preparedness, fire safety, and first aid/CPR.

9. Post-Emergency Review: The Administrator will review each emergency event to evaluate response effectiveness and update safety procedures as necessary.

Compliance: This policy meets Wisconsin DHS requirements and OSHA emergency preparedness standards. Non-compliance may result in disciplinary action or retraining.

Policy:

Heavenly Inspired Home Care is committed to protecting the confidentiality, integrity, and security of all Protected Health Information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable Wisconsin privacy laws.

Policy Explanation and Compliance Guidelines:

1. Definition: Protected Health Information (PHI) includes any information related to a participant’s health status, treatment, or payment that can identify the individual.

2. Access Control: Only authorized staff may access or disclose PHI necessary for providing services or fulfilling administrative duties.

3. Confidential Communication: PHI may not be discussed in public areas or shared with unauthorized persons. Verbal and written communication must remain private.

4. Documentation and Storage: All records containing PHI must be stored in secure locations or password-protected systems. Paper documents must be kept in locked cabinets.

5. Release of Information: PHI may be released only with a signed authorization from the participant or as required by law (e.g., APS, DHS, or law enforcement).

6. Electronic Security: Electronic records must be encrypted, and staff must log out of devices when not in use.

7. Breach Reporting: Any suspected or actual breach of PHI must be reported immediately to the Administrator, who will follow HIPAA breach notification procedures.

8. Training: All staff receive HIPAA and confidentiality training upon hire and annually thereafter.

9. Sanctions: Unauthorized disclosure of PHI will result in disciplinary action, up to and including termination.

Compliance: This policy ensures compliance with HIPAA (45 CFR Parts 160–164) and Wisconsin privacy regulations. Violations may result in disciplinary action and civil penalties.

Policy:

Heavenly Inspired Home Care ensures the safe management, storage, and assistance of participant medications in accordance with Wisconsin DHS 105 regulations and IRIS standards. All staff must follow this policy to maintain participant safety and compliance with state and federal guidelines.

Policy Explanation and Compliance Guidelines:

1. Definitions: Medication assistance includes helping participants take their prescribed medications as directed, without interpreting or altering prescriptions.

2. Self-Administration: Participants who are able to self-administer medications may do so independently, with caregivers providing reminders or opening containers as needed.

3. Medication Administration: Only qualified and trained staff may administer medications under written physician orders, following all DHS requirements.

4. Storage: Medications must be stored in their original labeled containers in a locked cabinet or drawer accessible only to authorized staff.

5. Documentation: All medications administered or assisted with must be documented immediately on the Medication Administration Record (MAR), including date, time, dose, and staff initials.

6. Medication Errors: Any medication error or omission must be reported to the Administrator immediately and documented on an incident report.

7. Disposal: Expired or discontinued medications must be disposed of properly, following DHS and pharmacy guidelines, with documentation maintained.

8. Training: All staff assisting with medications must complete medication administration training and competency evaluations annually.

9. Participant Rights: Participants have the right to refuse medications, and refusals must be documented and reported to the Administrator or nurse consultant.

Compliance: Failure to adhere to this policy may result in disciplinary action and retraining. This policy complies with Wisconsin DHS 105, IRIS provider standards, and pharmacy regulations.

Infection Control “Preventing Spread of Infection” Hand Hygiene

In-Service Training Guide

F-880 – Infection Control

Review Regulation(s):

§483.80 – Infection Control 

The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a)(2)(vi) – Hand Hygiene

The hand hygiene procedures to be followed by staff involved in direct resident contact.

Review Intent of Regulation:

One intent of this regulation is to ensure that the facility:

Develops and implements an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible and reviews and updates the IPCP annually and as necessary. This would include revision of the IPCP as national standards change.

Review Definitions:

“Hand hygiene” is a general term that applies to hand washing, antiseptic hand wash, and alcohol-based hand rub.

“Hand washing” is the vigorous, brief rubbing together of all surfaces of hands with plain (i.e., nonantimicrobial) soap and water, followed by rinsing under a stream of water.

Review Excerpt from Interpretive Guidance:

The facility must develop and implement written policies and procedures for the provision of infection prevention and control. The facility administration and medical director should ensure that current standards of practice based on recognized guidelines are incorporated in the resident care policies and procedures. These IPCP policies and procedures must include, at a minimum:

How to use standard precautions and how and when to use transmission-based precautions (i.e., contact precautions, droplet precautions, airborne isolation precautions). The areas described below are part of standard and transmission-based precautions.  For example: 

Hand hygiene (HH) (e.g., hand washing and/or ABHR): consistent with accepted standards of practice such as the use of ABHR instead of soap and water in all clinical situations except when hands are visibly soiled (e.g., blood, body fluids), or after caring for a resident with known or suspected Clostridium (C.) difficile or norovirus infection during an outbreak, or if infection rates of C. difficile infection (CDI) are high; in these circumstances, soap and water should be used.

NOTE: 

According to the CDC, strict adherence to glove use is the most effective means of preventing hand contamination with C. difficile spores as spores are not killed by ABHR and may be difficult to remove even with thorough hand washing. For further information on appropriate hand hygiene practices see the following CDC website: http://www.cdc.gov/handhygiene/providers/index.html.

CDC recommends using ABHR with 60-95% alcohol in healthcare settings. For further information, see the following CDC website: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html.

Hand Hygiene 

Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene (even if gloves are used): 

When coming on duty; 

When hands are visibly soiled (hand washing with soap and water); 

Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice);

Before and after performing any invasive procedure (e.g., fingerstick blood sampling); 

Before and after entering isolation precaution settings; 

Before and after eating or handling food (hand washing with soap and water); 

Before and after assisting a resident with meals; 

Before and after assisting a resident with personal care (e.g., oral care, bathing); 

Before and after handling peripheral vascular catheters and other invasive devices; 

Before and after inserting indwelling catheters; 

Before and after changing a dressing; 

Upon and after coming in contact with a resident’s intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident); 

After personal use of the toilet (hand washing with soap and water); 

Before and after assisting a resident with toileting; 

After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, and C. difficile (hand washing with soap and water); 

After blowing or wiping nose; 

After contact with a resident’s mucous membranes and body fluids or excretions; 

After handling soiled or used linens, dressings, bedpans, catheters and urinals; 

After handling soiled equipment or utensils; 

After performing your personal hygiene (hand washing with soap and water); 

After removing gloves or aprons; and 

After completing duty. 

Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections.  It is necessary for staff to have access to proper hand hygiene facilities with available soap (regular or anti-microbial), warm water, and disposable towels and/or heat/air drying methods.  Alcohol based hand rubs (ABHR) cannot be used in place of proper hand washing techniques in a food service setting.  Recommended techniques for washing hands with soap and water include wetting hands first with clean, running warm water, applying the amount of product recommended by the manufacturer to hands, and rubbing hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers; then rinsing hands with water and drying thoroughly with a disposable towel; and turning off the faucet on the hand sink with the disposable paper towel. 

Except for situations where hand washing is specifically required, antimicrobial agents such as ABHR with 60-95% alcohol are also appropriate for cleaning hands and can be used for direct resident care.  Recommended techniques for performing hand hygiene with an ABHR include applying product to the palm of one hand and rubbing hands together, covering all surfaces of hands and fingers, until the hands are dry.  In addition, gloves or the use of baby wipes are not a substitute for hand hygiene.

Facility Policy and Practice

Review:

Facility’s Hand Hygiene – Policy.

Facility’s Hand Hygiene – Validation Checklist.

Record of Training

Complete Record of In-service Training and Attendance Form.  Be sure all participants sign-in.

Policy:

Each resident’s medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident’s progress through complete, accurate, and timely documentation.

Policy Explanation and Compliance Guidelines:

Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident’s medical record in accordance with state law and facility policy.

Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Documentation may be performed manually or as per the facility’s specific electronic medical record software program.

Principles of documentation include, but are not limited to:

Documentation shall be factual, objective, and resident centered.

False information shall not be documented.

Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided.

Subjective information shall be recorded only as relevant, such as the resident’s verbalizations, in quotation marks.

Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident’s care and/or responses to care.

Documentation shall be timely and in chronological order.

Write legibly in black ink or follow the facility’s specific electronic medical record software for inputting information.

Record date and time of entry.

Sign each entry with name and credentials of the person making the entry.  

Only standardized terminology, acronyms, and symbols may be used.

Avoid generalizations and vague phrases or expressions.

Only document conclusions that can be supported by data and avoid bias, labels, and value judgments.

When documentation occurs after the fact, outside acceptable time limits, the entry shall be clearly indicated as “late entry”.

Corrections to a medical record shall be made to clarify inaccurate information.

Only the individual who made the original entry shall correct the entry.

The original content shall remain legible, with a notation that the entry has been corrected.

The date and time of the new entry shall be recorded, and annotated as a correction or addendum.

Contradictory information may be clarified by a new entry in the medical record.

Date and time the entry.

Provide sufficient details to support that the current information is accurate.

Sign each entry with name and credentials.

References:

Centers for Medicare & Medicaid Services, Department of Health and Human Services. State Operations Manual (SOM): Appendix PP Guidance to Surveyors for Long Term Care Facilities. (February 2023)  F842: Resident Records – Identifiable Information.

Policy:

Heavenly Inspired Home Care mandates the use of the state-approved Electronic Visit Verification (EVV) system for all Medicaid personal care and supportive home care services. Accurate EVV documentation ensures compliance with ForwardHealth and federal requirements.

Policy Explanation and Compliance Guidelines:

1. Clock-In/Clock-Out Requirements: Caregivers must clock in at the beginning and clock out at the end of each visit using the approved EVV system.

2. GPS Verification: EVV must record location data verifying the service took place at the authorized address. Location services must remain enabled.

3. Accuracy and Accountability: Caregivers are responsible for ensuring the accuracy of all EVV entries. Errors must be reported immediately for correction.

4. Monitoring and Audits: Supervisors review EVV data weekly for accuracy and compliance. Discrepancies trigger retraining or disciplinary action.

5. Fraud Prevention: Falsifying EVV data or using another employee’s credentials will result in investigation and possible termination.

6. Training: All employees receive EVV training prior to service provision and ongoing support for system updates.

Compliance: Failure to comply may result in disciplinary action or termination. This policy aligns with Wisconsin Medicaid EVV requirements and IRIS provider standards.

Policy:

Heavenly Inspired Home Care maintains a zero-tolerance policy for abuse, neglect, or exploitation of participants. All employees are mandatory reporters under Wisconsin law (Wis. Stat. §46.90, §48.981) and must take immediate action when such concerns are identified.

Policy Explanation and Compliance Guidelines:

1. Definitions: Abuse includes physical, emotional, or sexual harm. Neglect involves failure to provide necessary care or supervision. Exploitation refers to misuse of a participant’s funds or property.

2. Mandatory Reporting: All staff are required to report suspected abuse, neglect, or exploitation immediately to Wisconsin Adult Protective Services (APS) and the participant’s IRIS Consultant Agency.

3. Internal Notification: The Administrator must be informed of all reports made to APS or the IRIS Consultant Agency within the same working day.

4. Procedure: Staff must ensure participant safety, document the concern objectively, and submit a written report to the Administrator. The Administrator ensures required external reporting is completed.

5. Protection Against Retaliation: Employees who report in good faith are protected from retaliation under Wisconsin law.

6. Investigation: The Administrator cooperates with APS, IRIS Consultant Agencies, or law enforcement during investigations and implements corrective actions as needed.

7. Training: All staff receive initial and annual training on identifying, preventing, and reporting abuse, neglect, and exploitation.

8. Confidentiality: All reports and investigations are handled confidentially to protect the participant’s privacy.

Compliance: Failure to comply with this policy or to report suspected abuse, neglect, or exploitation may result in termination and referral to regulatory authorities. This policy complies with Wisconsin Statutes §46.90 and §48.981, DHS regulations, and IRIS Provider Standards.