State of Maryland Dept. of Health and Mental Hygiene

Residential Services Agency (RSA)

Service Group One, Skilled Nursing with Aides

Prior to completion of the licensure process, which will include an on-site survey of your agency, the following items will be required:

Written policies and procedures including but not limited to the following:

A policy stating the scope of services to be provided by the agency

A policy which outlines how the agency will perform a skill assessment for all licensed and certified staff

A statement which outlines the patient admission criteria

Emergency procedures

Administration of drugs

A policy which outlines billing procedures, notification of patient payment liability and the maintenance of billing records

A policy for the provision of personal care services by a certified home health aide

A policy for skilled care services including the process of evaluation of patients’ needs prior to their acceptance into the agency’s program and periodic re-evaluation

A policy which outlines the process for clinical management of the patients’ care

Infection control procedures

A policy defining the training and re-training of patients and patient representatives

A written process for equipment maintenance

A policy outlining the process for coordination of care, including delineation of services provided by the agency, and communication and coordination between nurses, aides, and patients

A written complaint process to inform patients of the agency’s responsibilities, a mechanism for filing both verbal and written complaints with the agency, an internal investigation process, and maintenance of a complaint file by source, category, and disposition. The policy must include patients/representatives that filing a complaint will not adversely impact on care and services they are receiving from the agency. The complaint process must provide a mechanism for forwarding to OHCQ any complaint received by the agency but not investigated by the agency. Finally, the written information must also provide the name, address and complaint hotline number for the Office of Health Care Quality, and ensure the patient or patient representative has a choice of alleging a complaint to either OHCQ or the agency.

In addition to having the policies and procedures in a written format, the agency administrator must have a working knowledge of the policies and be able to discuss them with the surveyor.

Qualified staff. The agency must have documented evidence of staff qualifications including job descriptions which delineates the responsibilities for each level of staff, orientation/training, professional reference checks, skills demonstration of all licensed and certified staff, evidence of face to face job interviews, health requirements, appropriate licenses and certificates, and background checks.

An organizational chart which includes the position titles and identifies the individual filling the role.

A written quality improvement plan which outlines the quality indicators to be used, identification of the individuals responsible to perform the quality improvement activities, the frequency of quality improvement activities and meetings and the process for compiling, reviewing and using the data to improve care.

Clinical record management policies and procedures including, submission of clinical information, filing of data in the clinical record, retention of the information and protection of the clinical information from loss or misuse.

Once you have developed the above written information, notify OHCQ in writing that the above items are in place and available for review. Upon receipt of the notification and patient availability, a temporary three (3) month license will be issued.

An on-site survey will be conducted by the OHCQ nurse surveyor. Prior to the initial licensure survey, you will be required to admit three to five patients. These patients CANNOT be admitted until the above reference policies are in place. Once the patients have been admitted, again notify OHCQ so that the survey can be scheduled. Click here to order the complete policies and procedures required for licensure.