Section 325.13109. Development of policies and procedures for home or inpatient care and services program provided by a hospice and its hospice residence, if applicable.

(1) Written  policies   and  procedures  shall   be  developed  to coordinate a program for home or inpatient care and services provided by a hospice and its hospice residence, if applicable. The written policies and procedures shall include all of the following:

(a)  Philosophy and objectives.

(b)   Patient?family unit rights and responsibilities.

(c)   Medical direction.

(d)  Admissions, transfers, and discharges of the patient?family unit.

(e)   Types of services provided and  the  coordination   of  those  services, including inpatient care and follow?up.

(f)  ) Quality assurance programs.

(g)   Determining the number and types of staff and volunteers needed.

(h)   Position descriptions for each  category  of  employed,  volunteer,  or contracted personnel.

(i)     Orientation  and  staff  development to all  personnel,  including volunteers.

(j)   Functions of interdisciplinary care team.

(k)   Medical services.

(l) Nursing services.
(m) Nutrition services.
(n) Pharmaceutical services.
(o) Bereavement services.
(p) Social work services.
(q) Volunteer services.
(r) Informed consent.
(s)  Availability  of   a  staff  member,  24   hours  a  day,   7  days	a	week,	to	a

patient?family unit.

(t) A hospice patient?family unit record relating to all of the following:

(i)   Documentation by staff of services rendered to patient?family units.

(ii)   Confidentiality of medical information.

(iii)      Release of information or the provision of copies of the information to patient?family units or authorized persons upon written consent of the patient or guardian.

(iv)      Transfer  of  medical  information  to  another  hospice   program  or inpatient

unit.

(v)     Records  retention  for  a  period of not less than 5  years  following  death  or

discharge or, in the case of a minor, 3 years after the  individual  comes of age under state law, whichever is longer.

(vi)    Notification to the department regarding storage of records if the hospice ceases to operate.

(2)   All policies and procedures shall be reviewed and shall be revised, if necessary, annually.

(3)   All policies and procedures shall be immediately available for on?site inspection by the department.

History: 1984 AACS; 2003 AACS.