Compassion with Excellence

POLICIES, PROCEDURES & PROTOCOLS - MANUAL

Policies and Procedures Regarding: General Employee Conduct

 1.      Agape Home Care (AHC) Staff may not act in anyway which conflicts with the interests of AHC and its business practices (whether alone or as an agent, employee or representative of another).  AHC Staff shall not use private and/or confidential information about AHC (its business practices, systems, documents, forms, training maerials, Clientele or personnel) for personal gain or for the use of another individual or organization.  AHC Staff must notify AHC Administrative personnel if they become an agent, employee or representative for any individual (including themselves) or organization operating in direct competition with AHC.

2.      AHC Staff are to remain professional in their conversation at all times while representing AHC.  AHC Staff are prohibited from initiating personal discussions with AHC Clientele, their associates or representatives from third-party organizations while on duty, such as: personal legal and financial matters, religion and politics, personal or family hardships (past or present).  AHC Staff must not engage in vulgar, inflammatory or defamatory conversation while on duty, such as: crude or vulgar humor; sexual discourse; religious, racial or gender bigotry.

3.      AHC Staff shall conduct themselves professionally at all times while representing AHC (courteous, respectful, gracious and patient). AHC Staff must never argue, disrespect or act in a confrontational, dishonoring or threatening manner toward AHC Clientele, their associates, co-workers or representatives from third-party organizations under any circumstances. 

4.      AHC Staff must not be under the influence of alcohol, marijuana or any other intoxicants while representing AHC.  If an employee is under the influence of an intoxicant while on duty, or if the use of such substance becomes questionable, AHC reserves the right to require AHC Staff to submit to a random alcohol/drug test at any time.  If the use of alcohol or other intoxicant is proven through testing, the employee will be terminated. Refusal to submit to a random drug test will result in termination.  If an employee wishes to dispute the results of a positive test, they must immediately submit to a third-party, professional testing source of AHC Management’s choosing and at the employee’s cost.  Should the results of third-party, professional testing reveal a negative reading, the cost for the test will be fully reimbursed to the employee from AHC.

5.      AHC Staff are required to notify AHC Management immediately should they suffer any injury while working their scheduled shift with a written explanation of the events that occurred being submitted to the Administrative Office within 24 hours.

6.      AHC Staff are required to direct any complaints or criticisms they may have against AHC Administrative Staff, co-workers, AHC Clientele and/or their associates or representatives from third-party organizations directly to AHC Management.  If an employee’s concerns are not satisfactorily addressed after meeting with AHC Management, they are to direct their concerns to the AHC Executive Director.  AHC Staff should never voice such complaints or criticisms to anyone outside of AHC unless required to do so by law.

7.      AHC Staff are required to make a report to AHC Management of any co-worker(s) who are violating company policies, who are not giving proper care to AHC Clientele or who are not performing their scheduled shift duties as directed. 

Policies and Procedures Regarding: Client and Staff Relations

1.      AHC Staff may not solicit nor accept solicitation to work privately for AHC Clientele or their associates (family, friends or Responsible Party) in like capacity to services performed by AHC for a minimum of one year following termination of employment with AHC.

2.      AHC Staff shall not request nor accept any money, property, loans or gifts from AHC Clientele or their associates (family members, friends, or Responsible Party).  If a Client or their associate offers a gift of any kind, AHC Staff shall notify AHC Management and receive written permission, including an itemized list of items being gifted, before any gifts can be accepted by AHC Staff.

3.      AHC Staff must honor Client’s legal rights to privacy and confidentiality. AHC Staff shall not disclose or share any personal health information (PHI) regarding AHC Clientele (past or present) with anyone (including other AHC Staff who are not directly involved in the Client’s care team) unless the sharing of such information is authorized by the Client in writing or required for the purposes of the performance of assigned duties and responsibilities.  Failure to follow this policy is a violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and punishable by law. If there is any question regarding what constitutes private or confidential information, direct such questions to the AHC Management for clarification before disclosing or sharing ANY AHC Clientele information with anyone.

  • AHC Staff must not discuss or disclose any details pertaining to their Client’s personal information (name, date of birth, social security number, address, phone number, financial situation), their physical or mental status (diagnosis) or any details pertaining to the care their Client is receiving with anyone outside of: the Client’s Responsible Party, authorized friends and family members, attending physician (including office personnel) and medical healthcare agencies (social workers, nurses, CNA/HHA), Client’s pharmacy and AHC direct care team - and only on a need to know bases. AHC Staff must take precautions to avoid being overheard by unauthorized parties when discussing Client PHI and ensure any written PHI is protected from unauthorized access and viewing.

  • When answering Client’s phone or residence, Staff must only acknowledge Client’s last name unless directed otherwise. Take a detailed message if Client is unavailable or unable to communicate, and direct caller/visitor to contact AHC Management if they require immediate information.

  • AHC Staff must discard (shred) any printed information and/or delete any electronically transmitted details pertaining to their Client’s PHI on their personal devises. Electronic transmission of Client PHI is only permitted via secured and encrypted sources.

  • AHC Staff must report any observed or reasonably suspected HIPAA violation to AHC Management as soon as is practical; depending on the offence, AHC Staff who mishandle Client PHI may: receive a written reprimand, lose bonuses, be demoted, be suspended without pay or be terminated.

  • AHC Staff who need to list a work number for emergency purposes may give out the AHC's urgent message number, and AHC Management will relay any messages to the employee.

  • AHC Staff must not have any visitation from friends, family or pets while working on the premises of a Client’s home.  If an employee requires something while on duty, they must consult with AHC Management before making arrangements to have anything delivered to a Client’s home.

4.      AHC Staff must not engage in any activity that infringes upon the privacy and independence of AHC Clientele unless such activity is required to ensure the Client’s safety and wellbeing as per assigned duties and responsibilities.  Unless directed to do so by the Client, the following actions are considered inappropriate and intrusive:

  • AHC Staff must not look through a Client’s personal property (entering closed bedrooms or closets, garage or storage areas, files and paperwork, cupboards, dressers and chests).

  • AHC Staff must not re-arrange the Client’s furniture or personal property unless requested.

  • AHC Staff must not dictate television or radio programming nor download or purchase pay-per-view programing. 

  • AHC Staff must not answer a Client’s telephone or door except by the Client’s direction or at the direction of their responsible party as part of their duties & responsibilities.

  • AHC Staff must not engage themselves in personal, medical or professional visitations (financial or legal) that the Client receives unless such involvement is necessary to receive updated information required for the Client’s care.

5.      AHC Staff are prohibited from using AHC Clientele’s resources and equipment for their own personal use (food and beverages, medications or vitamins, stationary supplies, internet, phone, appliances, laundry facilities, etc.) except as required for the performance of their assigned duties and responsibilities (employee’s personal food storage and preparation is acceptable). Some exceptions may apply with certain AHC Clientele, and if AHC Staff believes such special circumstances may apply, they must confirm with AHC Management before partaking.

6.      AHC Staff shall not remove any property from AHC Clientele’s home for any reason (burrow from or store on behalf) without advanced authorization from the AHC Management except where such action is required for the performance of their assigned duties and responsibilities. Likewise, ACH Staff shall not store any belongings at AHC Clientele’s residence.

7.      AHC Staff shall not conduct personal business while on-duty (except upon advanced authorization).  Personal business would include: work unrelated to AHC, school studies, crafting and hobby projects, phone calls unrelated to AHC, social media, internet surfing, gaming and etcetera.

8.      AHC Staff shall bring their own food for meal breaks while on duty unless otherwise instructed by AHC Management.  AHC Staff shall not drink or eat a Client’s food unless it is offered by the Client themselves. If food is being offered on a regular basis, consult with AHC Management for authorization (each assignment is a unique situation).

9.      AHC Staff are prohibited from giving their personal contact information to AHC Clientele or their associates (family members, friends or Responsible Party) without advanced authorization from the AHC Management.  AHC Staff shall not request personal contact information from AHC Clientele or their associates.

10.  For the protection of AHC Clientele privacy, AHC Staff shall not visit or call upon AHC Clientele or their associates (family members, friends or Responsible Party) outside of their regularly scheduled shifts without receiving advance approval from AHC Management.

11.  AHC Staff shall not make any purchases nor negotiate or sign any lease or contract on behalf of AHC Clientele without advanced authorization from the AHC Management except where such action is expressly required as a part of regular performance of the employee’s duties and responsibilities.

12.  AHC Staff shall not solicit any products or services to AHC Clientele, nor shall they offer to purchase any items belonging to AHC Clientele (from the Client, their family members, friends or Responsible Party) without advance approval from AHC Management.

13.  AHC Staff are prohibited from bringing large bags (handbags, backpacks, duffle bags or other carry items) or excessive personal affects (anything beyond what is necessary for the performance of their duties) into the homes of AHC Clientele.  If such items are necessary to maintain with you, consult with AHC Management prior to bringing them into AHC Clientele’s residence. 

14.  AHC Staff are prohibited from smoking in the homes of AHC Clientele.  Smoking should be avoided entirely while working, but if this is not possible, consult with AHC Management to inquire whether a Client will permit smoking breaks (do not ask the Client directly).  Unless approval is granted in advance by AHC Management, smoking breaks are prohibited during a scheduled shift.

Policies and Procedures Regarding: Client Care

1.      AHC Staff are required to be on time and ready to work when scheduled.  If an employee anticipates that they will be late for their scheduled shift, they are to immediately contact AHC Management so that the Client and/or their co-worker can be notified of the delay. 

2.      AHC Staff are required to work their entire scheduled shift until it is completed and/or their relief has arrived unless expressly directed otherwise by AHC Management.  If a non-dependent Client requests that AHC Staff leaves before their scheduled shift is completed, then they may leave; however, they must immediately notify AHC Management of the situation. 

3.      AHC Staff are never to leave a dependent Client unattended under any circumstance (those who are physically or cognitively impaired and require care for their safety and well-being).  Contact AHC Management immediately if there is any question about a Client’s care dependence level, safety or well-being before leaving an assignment. If a relief worker fails to report at their scheduled time, or if a dependent Client requests that an employee leave before their scheduled shift is completed, the employee is to notify AHC Management immediately for instructions.

4.      AHC Staff are expected to perform only those duties they are trained for; have been assigned and/or approved by AHC Management and that are detailed in their job duties and responsibilities.  If an employee is unsure of how to perform a certain procedure or a request is made to perform a task outside regularly assigned duties and responsibilities, the employee is to ask AHC Management for clarification and/or approval to perform the task.

5.      AHC Staff are expected to follow and perform all regularly assigned duties and responsibilities (Client care plans, shift duties and chore lists) that are set up by AHC Management during their scheduled shift.  This would also include following proper charting procedures in the Client logbook.

6.      AHC Staff are expected to follow the directions of AHC Clientele, their responsible party and medical professionals who are responsible for overseeing the medical care needs of AHC Clientele.  AHC Staff must notify AHC Management immediately of any/all changes that are introduced into the care plan of their Client.  AHC Management must approve any changes made to a Client’s care plan before such changes are put into effect and incorporated into a Client’s regularly assigned duties and responsibilities. 

7.      AHC Staff are never to take it upon themselves to diagnose and/or treat AHC Clientele, nor are AHC Staff to alter a Client’s care plan that has been set up by AHC Management and/or prescribed by medical professionals who are responsible for overseeing the medical needs of the Client.  AHC Staff must never introduce diet changes, vitamins, herbs or any other alternate forms of treatment to AHC Clientele without advanced authorization from AHC Management.

8.      AHC Staff must never allow any personal activity to distract them from their assigned duties and responsibilities.  AHC Staff must remain awake, alert and attentive to the Client’s needs at all times while on duty.  For some overnight shifts where AHC Clientele sleep through the night and do not require constant observation, AHC Staff may be permitted to doze during such periods providing that approval is given in advance by AHC Management and the AHC Staff can remain responsive should the AHC Clientele require care (intercom and/or call bell in place).

9.      AHC Staff must not take breaks during their scheduled shifts until all their duties have been completed, AHC Clientele’s needs are met (and they are safe) and they have notified AHC Clientele that they are taking a scheduled break (and for how long).  When AHC Staff is taking an “on-duty” break, they must remain attentive to the Client’s needs and be accessible to them if needed.

10.  AHC Staff shall notify AHC Management of any illness, injury or otherwise concerning event (mental or emotional distress) that AHC Clientele suffers during their shift and/or if AHC Clientele is removed from their home for any reason (hospitalization, etc.).  This is to be done immediately with a full explanation of the events that occurred.

11.  AHC Staff who have concerns about a Client’s wellbeing due to the treatment or services (or lack thereof) provided by a third-party agency or agent representing the Client’s personal or professional interests (including family members, friends or Responsible Party) should immediately direct such concerns to AHC Management.

12.  AHC Staff shall be observant and notify AHC Management immediately whenever an inappropriate or unusual visitation is made to a Client’s home.  For example, if a visitor (family member, friend or Responsible Party) were to begin removing items unexpectedly from the Client’s home or a visitor makes the Client feel threatened, agitated or noticeably uncomfortable.

13.  AHC Staff are mandated reporters and must immediately report to AHC Management and proper authorities any suspicion of elder or dependent adult abuse of any AHC Clientele.  This would include: sexual, physical, emotional or fiduciary abuse; neglect and/or abandonment; intimidation and/or harassment; theft of property or misappropriation of funds; denial of or forced use of medications; punishment or physical restraint or any other action taken against a Client which puts their health, safely, well-being or personal property at risk.

14.  AHC Staff must never transport a Client in a vehicle without prior consent from AHC Management.  A copy of the employee’s current Driver’s License, DMV printout, current registration and auto insurance must be on file before an employee is to transport a Client in their own personal vehicle.

15. AHC Staff are to observe the following protocols when handling Client’s finances: 1) never handle Client’s finances unless specifically directed by AHC Management; 2) retain any/all deposit slips, receipts and petty cash in their pre-assigned location; 3) never to utilize Client’s funds for personal purchases under any circumstances; 4) Client’s Responsible Party or AHC Management will collect all deposit slips, receipts and petty cash for accounting and documentation. 5) immediate notify AHC Management of any discrepancies or questionable activity observed with Client’s deposit slips, receipts, supplies or petty cash on hand.

16. AHC Staff are to observe the following protocols when handling Client’s medications: 1) never handle Client’s medications unless specifically directed by AHC Management; 2) count out bottled narcotic and psychotropic medications in the presence of the pharmacist/clinician upon taking possession of them (check blister pack for any open or empty compartments) to ensure an accurate accounting (do not take possession of medications if the count differs from that listed on the prescription bottle/order); 3) count out all narcotic and psychotropic medications upon delivery to the Client to ensure an accurate accounting (have Client observe and acknowledge count in designated logbook); 4) document all medications given to Clients in the designated logbook (distinguishing between general medications and PRN pain/narcotics); 5) Client’s Responsible Party, third-party medical professionals or AHC Management will review medications and logbooks to ensure all medications are accounted for and are being taken as prescribed; 6) immediate notify AHC Management of any discrepancy observed in Participant’s medications on hand and the documentation recorded in the logbook.

Policies and Procedures Regarding: Logbooks

AHC Staff scheduled to work in a Client’s home where a log book is used as part of the Client’s care routine must make log entries daily in accordance with these log rules:

1.      Log books contain confidential and protected information regarding the Client’s personal health information (PHI).  Log books must be maintained closed and secured from unauthorized viewing and access by anyone who is not directly involved in the Client’s care team. Failure to follow this policy is a violation of the Health Insurance Portability and Accountability Act (HIPAA) and punishable by law.

2.      AHC Management will retrieve log book information or make arrangements to have it delivered to the Administrative Office. AHC Staff are not to discard or remove the log books or any of the entries contained therein from the premises of a Client unless instructed to do so by AHC Management. Logbooks are scheduled for periodic inspections by AHC Management.

3.      Depending on AHC Clientele’s needs, the following information may be included in logbook entries: times and dosages of medications given/taken; physical care delivered; voiding details (urine and feces); meals served (quantity and percentage consumed); positioning, exercises and range of motion details (duration and services performed); shift duties and chores that were completed; documentation of the Client’s physical, emotional and mental status during the shift; unusual and/or noteworthy occurrences observed during the shift. 

4.      AHC Staff’s Daily Logbook entries must be truthful and accurate. contain the following information at the beginning and ending of their shifts: employee's full name, date/time shift began and date/time shift ended.  This information must coincide with the employee's time sheets. 

5.      AHC Staff shall make a final entry in the Daily Log section of AHC Clientele’s logbook at the conclusion of their shift titled “Pass Notes” for oncoming AHC Staff and third-party to review, including the following information: AHC Client’s current physical, mental and emotional status, any  changes to their Plan of Care or Shift Duties, upcoming visits or appointments.

6.      AHC Staff shall review previous log entries at the beginning of their shift, especially “Pass Notes” from the employee being relieved, to review the current status of AHC Clientele since the last shift worked and to check for any changes to their Plan of Care or Shift Duties, upcoming visits or appointments.

7.      AHC Staff must keep log entries brief but specific, including only information pertinent and necessary to assist co-workers and third-party representatives to care for the Client’s physical, mental and emotional needs as described and directed in the AHC Client’s Plan of Care.

8.      The logbook is the primary tool for Client care documentation and correspondence between AHC Staff, Client’s responsible Party and medical professionals overseeing the Client’s care.  Log entries must remain neat, legible, respectful and professional.   

9.      Instructions given by medical professionals overseeing the Client’s care needs must be documented in the daily log.  Immediately notify AHC Management of any changes to the Client’s care regime.

10.  Logbook documentation provides a written record of duties performed, care provided for the Client and their response to that care.  In addition, documentation provides information regarding the effect of care delivered.  If it isn't written down, there is no evidence that services and/or care was delivered.

11.  Logbooks are not the format for voicing complaints or concerns of a confidential matter concerning AHC Staff, Clients, their family members, friends, Responsible Party or other agencies involved in the Client’s care. Any such confidential complaints or concerns must be discussed with AHC Management in person and NOT written in the logbook.

12.  AHC Staff are to contact AHC Management when log book supplies are running low and need to be replaced (before they run out). 

Policies and Procedures Regarding: Employee Dress Code

1.      AHC Staff shall wear their name badge at all times while on duty. Lost or damaged badges are to be reported to Administrative Office Personnel for replacement.  AHC Staff are never to allow anyone to use their badge, and Staff are to return their badge & lanyard to the Administrative Office upon termination of employment.

2.      AHC Staff are not required to wear a uniform or scrubs (at this time; however, this policy is subject to change). AHC Staff are to use their best discretion when choosing articles of clothing for work that are clean (free of stains and holes), modest (miniskirts, shorts above the thigh, low cut blouses, tank tops, uncovered leggings are prohibited), comfortable yet un-encumbering (sweat pants and work out clothing are prohibited) and professional (concert, political, religious, sexual, alcohol, drugs or cannabis promotional prints are prohibited) with securely fitted shoes (clogs, slippers, open/loose sandals and heals are prohibited). 

3.      AHC Staff shall arrive to their assignments neatly dressed, clean and well groomed. AHC Staff must refrain from using strong perfumes or colognes to avoid agitating AHC Clientele repertory issues.

Policies and Procedures Regarding: Scheduling, Time Sheets & Pay Periods

1.      AHC Staff may only work the schedules and hours they are assigned and must notify AHC Management of any requested schedule changes before consulting with Clients and/or other AHC Staff personally.  No schedule changes are permitted outside of the approval of AHC Management.

2.      AHC Staff must submit a written request for time off (text message or email is acceptable) one week in advance to the Administrative Office.  During major holidays, AHC Staff must submit their request at least two weeks in advance.  AHC Staff should not assume time off has been granted unless AHC Management has provided authorization.

3.      AHC Staff who are sick and unable to report for duty must give at least 2-hours notice (more if possible) directly to AHC Management to confirm that their AHC Client’s shift will be covered.  Call-offs due to illness must be verified by a doctor’s note to qualify as an excused absence. Three unexcused absences within a quarter-year will adversely impact employment status.

4.      AHC Staff who receive a doctor’s order for extended sick leave must submit a copy of the order to the AHC personnel director; otherwise, the absence will be considered un-excused.  

5.      AHC Staff who fail to report to their regularly scheduled shifts (no call, no show), except when properly following procedures for calling off, will be subject to termination. Excessive absences (excused or otherwise) will adversely impact employment status.

6.      AHC Staff are to give a minimum notice of two weeks, in writing, when terminating their employment with AHC (some exceptions may apply upon advance approval from AHC Management). Failure to give proper notice will be reflected in their personnel record and included in any reference requests.

7.      AHC pay periods consist of two workweeks, beginning Monday morning at 12:00 AM, and running through the second Sunday evening at 11:59 PM (14 total days per pay period). Timesheets are due on Monday, immediately following the final day of the pay period. Timesheets can be hand delivered to the Administrative Office during business hours, dropped in the mail slot, sent by fax or email.

8.      Workdays run between 12:00 AM to 11:59 PM (24-hours). AHC Staff must not record more hours in their "Daily Hours" box than are actually worked on any given day. A shift from 4 PM to 8 AM would show as 4 PM to 12:00 AM on one day (8 hours), and 12:00 AM to 8 AM on the following day (8 hours).

9.      AHC Staff are to accurately record their arrival and departure times on their timesheets to the nearest quarter-hour. Split-shifts (more than one entry in the daily "Time In" and "Time Out" boxes) are recorded with a slash between the times in the appropriate boxes.

10.  AHC Staff are to record hours worked for each AHC Client on separate time sheets (AHC Staff serving three Clients would submit three timesheets). Time sheets must include their Client’s full names.

11.  AHC Staff are to have their Client(s) initial each daily hours worked and sign their timesheets at the conclusion of the pay period before submitting them for processing to verify AHC Staff’s hours worked (some exceptions may apply for Clients who are unable to follow this protocol).

12.  AHC Staff’s time sheets must be filled out completely and legibly. Additional time sheets can be obtained online (AHC Resources Page), picked up at the Administrative Office during regular office hours or arrangements made to have them mailed.

13.  Payday is every other Friday following the end of the pay period. AHC Staff receiving direct deposits should have their paychecks post in their bank account by Thursday evening. Hardcopy checks will be available for pick up at the Administrative Office during regular office hours. Paychecks that are not picked up by 5 PM on Friday will be mailed unless other arrangements are made in advance. 

14.  AHC Staff are to carefully review their paystubs when receiving them before cashing/depositing their paycheck. AHC Staff are to contact AHC Bookkeeper to resolve any payroll issues. An employee's intentions will be called into question if they fail to notify AHC Management of a payroll error that is in the employee's favor (overpayment, advances given that were not taken out). Payroll errors and paycheck corrections will be processed the following business day from when any error was brought to AHC Bookkeeper’s attention.

15.  AHC Staff who have a change of address or withholding status are to schedule an appointment with AHC Bookkeeper to fill out a new W4 form.

Policies and Procedures Regarding: Administrative Office 

1.      AHC Administrative Office is located at 321 West Wabash Avenue, Eureka, CA, 95501 (office door faces Wabash Street). Office hours are from 9 AM to 5 PM, Monday through Friday (except for major holidays). The office phone number is (707) 445-1212.  When calling outside of regular business hours (or if voice mail picks up during regular business hours), AHC Staff are to leave non-urgent messages on the answering service, and calls will be returned during regular business hours. Urgent messages requiring immediate attention should be directed to AHC's urgent line, (707) 498-2000.

2.      AHC Management is available 24 hours a day, 7 days a week by calling the urgent message line. This number is to be used for urgent matters only.  AHC Staff are expected to use their best judgment in determining what constitutes an urgent call and what can wait until the following business day.

  • Examples of non-urgent calls: timesheet requests; payroll related matters (draw requests, paycheck questions, check corrections); time-off and schedule change requests that are days in advance; personnel record inquiries/replies; arranging office appointments with Administrative Staff; any/all inquiries that can wait until the following business day

  • Example of urgent calls: suspected abuse of AHC Clientele; injury to self or AHC Clientele; calling off from work assignments scheduled that day; relief staff failing to show up; critical and immediate questions pertaining to AHC Clientele’s Plan of Care or assigned duties; AHC Clientele experiencing unusual health concerns or distress; immediate safety concerns in the work environment; AHC Clientele requesting AHC Staff to leave before their schedule shift is completed, especially dependent persons

3.      AHC Staff are discouraged from making unscheduled visits to the Administrative Office to meet with Administrative Personnel. Unscheduled visits are disruptive and may interfere with other prearranged appointments. Mondays and Fridays of payroll weeks are open for unscheduled, drop-in visits for turning in timesheets, getting more timesheets & picking up paychecks during regular office hours.

Policies and Procedures Regarding: PACE Participant Protocols

In addition to Agape Home Care Policies, Procedures and Protocols detailed in this manual, the following directives are to be observed for all PACE Participants:

1.      GENERAL PROTOCOLS - PACE has specific protocols for everything related to PACE Participants and its program (guidelines imposed by the State of California), and AHC staff are to observe these protocols at all times.  AHC Staff are not to contact PACE Staff or PACE offices directly unless requested to do so by AHC Management or otherwise described herein.  Any questions or concerns related to PACE Participant’s health care, medications, diet, equipment, assigned duties, scheduling, transportation, appointments, etc. shall be initiated by the PACE Participant directly on their own behalf OR be directed to AHC Management unless otherwise directed.  AHC Management will contact the appropriate PACE representative to resolve any issues related to PACE Participants.

2.      DUTIES PROTOCOLS - AHC Staff are only to provide services expressly requested, authorized and approved by PACE for PACE Participants.  This would include transportation services (errands & shopping trips) and duties performed on site (ADL’s & household chores).  PACE Participant duties are stated in writing (Plan of Care) and posted on site at Participant’s home, generally in the Participant’s logbook and/or online.  Neither PACE Participants, nor AHC Staff are permitted to modify PACE approved duties or schedules, and advanced approval from AHC Management must be given before any changes can be implemented to posted written directives (and only upon approve from PACE).

3.      MEDICATION PROTOCOLS (ADMINISTRATION) - AHC Staff are to observe the following protocols when administering Participant medications: 1) administer medications only as prescribed and documented; 2) administer medications from medication dispenser (module or blister pack) only on posted dates and days (do not exchange days or dates - unless directed to do so); 3) document medications given (or declined) in logbook.  AHC Staff are to immediately notify AHC Management when/if a Participant’s medications are found to be missed, declined, missing, miss-taken or mislabeled (dates out of synch on module or blister pack) to receive directives.

4.      MEDICATION PROTOCOLS (REFILLS) - AHC Staff are to observe the following protocols when ordering refills for medications and medical related supplies and equipment for Participants: 1) whenever possible, the Participant should place their own supplies orders by calling PACE directly – Ronnie Sayres, (707) 443-9747 @ EX 3260; 2) orders are to be submitted before medications and/or supplies run out (allow 48 hours for refill); 3) AHC Staff may place supply orders for Participants who are unable or require assistance doing so (following previous protocols).

5.      MEDICATION PROTOCOLS (DISPOSAL) - AHC Staff are to observe the following protocols when Participant medications are discontinued: 1) whenever possible, the Participant should dispose of their own discontinued medications, especially pain medications and other controlled substances. If a Participant wants assistance with this, they should contact PACE directly – Ronnie Sayres, (707) 443-9747 @ EX 3260; 2) For Participants who are unable to dispose of their discontinued medications, especially pain medications and other controlled substances, AHC Staff should contact Agape Management for directives.

6.      TRANSPORTATION PROTOCOLS (AUTHORIZED ACTIVITIES, LOCATIONS & DAYS) - AHC Staff are only permitted to transport PACE Participants to PACE authorized activities, locations and days (frequency).  Unless approval is granted in advance, shopping and errands are limited to once weekly (groceries, household supplies, banking, bill paying). Weekly shopping should be done at a location nearest to the Participant’s residence (in the same town, if possible) and in the most efficient manner possible when traveling to more than one location.  Bulk shopping trips to Costco and WINCO (or outside city limits) are to be planned monthly.  Unless approval is granted in advance, PACE does not cover transportation costs for Participant’s pleasure or social outings (including pet care).  Agape staff are to only claim mileage reimbursement when using their personal vehicles for Participant transportation; recording mileage from the Participant’s residence, to the various locations and returning to the Participant’s residence; detailing on their time sheet the names of each location and why each visit was made.

7.      TRANSPORTATION PROTOCOLS (PACE FACILITY - EUREKA) - AHC Staff are to observe the following protocols when transporting Participants to/from PACE (corner of California and Sonoma Streets): 1) PACE DAY CENTER – is accessed through the PACE main building entrance facing California Street; park in the white loading zone directly in front of PACE main entrance; escort Participant up the stairs or ramp into the lobby; office staff will open PACE Day Center doors; escort Participant inside and into the care of PACE staff; 2) PACE CLINIC – is accessed from the alley at the rear of the PACE main building (off Sonoma Street); use parking area nearest the building in the alley; ring bell at alley-facing door and wait for clinic staff to answer; escort Participant inside and into the care of PACE staff; wait in waiting room for Participant’s appointment to conclude unless otherwise directed.

8.      TRANSPORTATION PROTOCOLS (SCHEDULING) – Unless otherwise authorized in advance by PACE and AHC Management, PACE Transportation will transport Participants to any/all scheduled appointments.  Participants cannot authorize AHC staff to provide transportation on their own (check with AHC Management to confirm).  AHC Staff are to observe the following protocols when Participants are unable or unwilling to board PACE transportation as scheduled (Day Program or scheduled appointments): 1) whenever possible, the Participant should notify PACE Transportation directly – Deanna Gordon, (707) 443-9747 @ EX 3250; 2) AHC Staff may notify PACE for Participants who are unable or require assistance doing so (following previous protocols); 3) notify AHC Management of the missed appointment and reason why.

9.      SUPPLIES PROTOCOLS - AHC Staff are to observe the following protocols when ordering refills for incontinent and related supplies for Participants (depends, incontinent pads, moist wipes, non-rinse body/hair wash, etc. – NOTE, PACE is not supplying disposable gloves for Participant care at this time): 1) whenever possible, the Participant should place their own supplies orders by calling PACE directly – Wendy Taylor, (707) 443-9747 @ EX 3263; 2) orders are to be submitted before supplies run out (allow two weeks for delivery); 3) AHC Staff may place supply orders for Participants who are unable or require assistance doing so (following previous protocols); 4) incontinent supplies are not to be utilized for unrelated purposes (household cleaning, pet care, etc).

10.  EQUIPMENT PROTOCOLS - AHC Staff are to observe the following protocols when Participants’ medical equipment is damaged and in need of repair or replacement: 1) whenever possible, the Participant should notify PACE Physical Therapy Department directly – Bart Rankin PT, (707) 443-9747 @ EX 3212; 2) AHC Staff may notify PACE for Participants who are unable or require assistance doing so (following previous protocols); 3) notify AHC Management about the damaged equipment.

11.  INCIDENT REPORTING PROTOCOLS - AHC Management will file an “Incident Report” (using PACE’s proprietary form) to PACE Quality Control for any of the following incidents, either directly observed by Agape staff during the course of their duties or unobserved and reported by others, within one business day of any known incident: 1) suspected abuse of Participants (by others or self-abuse), with suspected abuse form (SOC 341) submitted to Adult Protective Services; 2) slips, falls and/or any injury of Participants, including death; 3) discrepancies observed with Participant finances; 4) discrepancies observed with Participant medications; 5) incidents or interpersonal interactions that negatively impact the health, safety and well-being of Participants; 6) environmental hazards threatening to negatively impact the Participant’s safety or well-being.

12.  COVID-19 PRECAUTIONS & REPORTING PROTOCOLS - AHC staff are required to receive COVID-19 training and pass a quiz to verify appropriate knowledge and skills.  AHC staff are required to self-monitor for symptoms of COVID-19 and report daily to AHC Management whether they are healthy before reporting for duty (symptom free, not been in direct contact with anyone known to have active COVID-19, not been outside the United States or within a known COVID-19 hotspot).  AHC staff are required to report to AHC Manager if they OR any Participant is observed to show COVID-19 symptoms or has been in direct contact with anyone known to have symptoms.  AHC staff are required to wear a facemask at all times while in a PACE Participant’s residence, while transporting Participants in a vehicle or within 6 feet of a Participant outdoors.  AHC staff are required to practice proper hand washing for infection control and sanitize surfaces while serving Participants.  AHC Staff are to be tested for COVID-19 when symptoms are observed or when directly exposed to anyone known to have active COVID-19 or known to have been in direct contact with anyone known to be infected, prior to returning for duty (verified COVID-19 free).