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ADMIISTRATIVE/GENERAL ADMIN: 02.1.1

PAGE: 1
Annual Agency Evaluation OF: 2

REVISED: 01/24
EFFECTIVE: 01/2024 REVIEWED: 01/24

PURPOSE:

To analyze the effectiveness of the organization’s administrative practices, policies and procedures including staff,
financial and program administration policies.

POLICY:

• Annually agency will conduct an annual evaluation to assess the extent to which the programs of this agency
are appropriate for the community served, adequate in extent of services/products offered, effective in
delivery of service or product and efficient in operation.

• The annual evaluation shall include objective and documented analysis of the HHA's compliance with any
federal and state regulations, accreditation guidelines and/or compliance with any applicable payer
requirements.

PROCEDURE:
The annual evaluation will be based on the following criteria, including, but not limited to:

• Organization and administration, including bylaws, policies, advisory committees, personnel policies,
contracts, etc.
• Statistical/fiscal information, including billing and fiscal policies, contracts, payroll records, denials, non-admits,
SAMPLE
budget etc.
• Professional services, including client/patient care service policies, in-service education, coordination, case
conferences, operations, client/patient clinical records, care/service provided under contractual arrangements,
etc.
• Performance improvement activities, including summary information from recent clinical record
reviews, results of performance improvement, ongoing monitoring/ measuring, actions, etc.

Data Collection
Data will be accumulated and collected during the year by means of internal recordkeeping and QA&I Reports.

• Company statistics and fiscal
• Data collected from client/patient/physician/other referral source satisfaction surveys
• Policies and procedures for operations and client/patient care
• Summary information from QA&I reports and compliance issues
• Employee statistical reports including numbers of personnel by discipline
• Client information including:
• New/returning clients
• Diagnosis/reason for referral
• Services/products provided including those provided under contractual arrangements
• Discharge from service and reason for discharge
• Financial information
• Other pertinent information as needed