Hospice Administrative Policy & Procedure Manual Index

Hospice Administrative Policy & Procedure Manual











Abuse | Neglect Assessment and Reporting
Administrative Control
Annual Agency Evaluation
Approval of Policy and Procedure
Authorization in Absence of Administrator

Budget Policy | Committee

Communication – Agency
Conflict of Interest
Conflict of Interest Form
Contractual Agreements
Corporate Compliance
Corporate Responsibility and Confidentiality Statement
Customer Complaint and Grievance Process

Description of Services
Disclosure of Information

Emergency Plan | Acuity
Ethical Issues

Financial Management
Financial Management: Billing and Collections
Fire Plan

Governing Body
Guidelines – For Determining Appropriateness for Admission Under the Medicare Benefit

Hospice Memorial Fund
Hospice Philosophy of Care

Incident Reports
Intermediary Requests: ADR/Denials

Line of Authority

On Call Responsibilities
Organizational Chart

Payment Options
Professional Advisory Board

Research Activities

Safety Program
Staffing | Productivity

Verification of Physician License

Patient Rights

Advanced Beneficiary Notice
Advance Directive

Communications with Non-English Speaking or Sensory Impaired Patients

Election of Benefits Medicare | Medicaid

Hospice Request for Amendment of Medical or Billing Record

Informed Consent

Nondiscrimination Policy
Notice of Medicare Non-Coverage
Notification of Patient Rights, Responsibilities and Advance Directives

Patient Authorization to Use and Disclose Patient Information
Patient Bill of Rights
Patient Bill of Rights and Responsibilities
Patient/Client Confidentiality
Patient Rights

Right to Request Confidential Communications

HIPAA Privacy

Accounting of Disclosures

Delivery of Notice of Privacy Practices
Disclosure of Protected Health Information (PHI) to Another Covered Entity
Disclosures to Personal Representatives

Electronic and Telephonic Communications
Electronic Patient Data Privacy
Electronic Protected Health Information

HIPAA Policy on De-Identification of PHI
Hospice Privacy Notice

Request for Access to Health Information
Request for an Accounting of Disclosures
Right to Accounting
Right to Inspect and Copy Protected Health Information
Right to Request Amendment of Protected Health Information

Safeguarding Protected Health Information (PHI)

Verification of Individual Requesting Personal Health Information (PHI)

Medical Supervision

Acceptance of Physician Orders

Medical Supervision

Tracking of Physician Orders

Coordination of Care

Abbreviations – Acceptable
Abbreviations – Medication Do Not Use
Acceptance of Patients
Admission Criteria
Assessment Guidelines
Assessment, Initial Patient
Assessment- Patient Reassessment

Bereavement Services

Care of the Dying Patient
CLIA Lab Testing
Continuity of Care
Continuity of Care – Nursing Home
Continuous Care under the Medicare Hospice Benefit
Coordination of Services – Medical Director
Coordination of Services – Medical Social Worker (MSW)
Coordination of Services – Occupational Therapy (OT)
Coordination of Services – Physical Therapy (PT)
Coordination of Services – Skilled Nursing
Coordination of Services – Speech Therapy (ST)
Coordination of Services – Spiritual Care
Coordination of Services – Volunteer Coordinator
Coordination of Services – Volunteers

Do Not Resuscitate

Emergency Care of Patient
Emergency Care of Patient – CPR

Glucometer Quality Control Testing

Home Health Aide – Competency
Home Health Aide – Coordination of Services
Home Health Aide – Supervisory Visits
Home Medical Equipment

Interdisciplinary Conferences
Interdisciplinary Team Services

Lab Services – Procedures
Lab Services –Staff Requirements
Lab Specimen- Transporting of

Medication – Administration
Medication – Administration of Blood Products
Medication – Adverse Drug Reactions
Medication – Approved for Administration
Medication – Control Drug Disposal
Medication – Delivery
Medication – Discontinued
Medication – Errors
Medication – Guidelines for Possession of Drugs
Medication Regimen Review

Nutritional Assessment

On-Call System

Patient Discharge – Revocation
Patient Family Education
Plan of Care
Primary Care Person

Referral Process
Restraints and Seclusion

Transfer from Inpatient Facility
Transfer to Another Hospice
Transfer to Inpatient Facility

Clinical Records

Authorization – Authentication of Entries, Clinical Record

Clinical Record – Central Clinical Record
Clinical Record – Keeping of
Confidentiality of, Clinical Records
Contents of, Clinical Records

Electronic Signature

Submission of Patient Documentation

Infection Control

Bag Technique – Equipment & Supplies

Communicable Disease Reporting

Disposal of Sharps

Exposure Control Plan

Hazardous Materials and Waste

Infection Control

Patient Infection Surveillance Report Form
Personal Protective Equipment

Standard Precautions

Tuberculosis Control Plan
TB Symptom Screen

Performance Improvement

Clinical Record Review
Confidentiality – Performance Improvement
Customer Satisfaction
Customer Satisfaction Survey Hospice Family
Customer Satisfaction Survey Hospice Patients

Medical Device Act Reporting

Performance Improvement Plan

Human Resources

Cell Phone Use

Employee Health
Employee Personal Files
Employment Process
Exit Interview

Grievance Process – Employee

HR Audit

Inservice Programs
Introductory Period

Performance Evaluations

Hospice Administrative Policy & Procedure Manual