Administrative Code

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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 391. Regulations for the Licensure of Hospice
7/13/2020

12VAC5-391-190. Written Policies and Procedures.

A. The hospice program shall implement written policies and procedures approved by the governing body.

B. All policies and procedures shall be reviewed at least annually, with recommended changes submitted to the governing body for approval, as necessary.

C. Administrative and operational policies and procedures shall include:

1. Administrative records;

2. Admission and discharge criteria;

3. Informed consent;

4. Advance directives, including Durable Do Not Resuscitate Orders;

5. Patient rights;

6. Pain assessment and management;

7. Medical supplies and appliances including drugs and biologicals, disposal of controlled drugs when no longer needed by patients, and handling of medications procured from a pharmacy of the patient's choice;

8. Contract services;

9. Transfer of patients to an inpatient facility including arrangements for an ambulance and the patient escort, when appropriate, to the facility by a professional staff member of the hospice program;

10. Medical social services;

11. Quality improvement;

12. Communicable and reportable diseases;

13. Post-mortem activities;

14. Mandated reporting of abuse, neglect, and exploitation pursuant to § 63.2-1606 of the Code of Virginia;

15. Medical records, including confidentiality;

16. Record retention, including termination of services;

17. Supervision and delivery of services;

18. Interdisciplinary group duties and responsibilities;

19. Bereavement and spiritual services;

20. Volunteer services;

21. Infection control;

22. Special services;

23. Emergency preparedness;

24. Handling consumer complaints; and

25. Approved variances.

D. Financial policies and procedures shall include:

1. Admission agreements;

2. Data collection and verification of services delivered;

3. Methods of billing for services by the hospice program and contractors;

4. Patient notification of changes in fees and charges;

5. Refund policy and correction of billing errors; and

6. Collection of delinquent patient accounts.

E. Personnel policies and procedures shall include a:

1. Written job description specifying responsibility, qualifications, and authority for each job classification;

2. Process for obtaining a criminal background check;

3. Process for maintaining an accurate, complete, and current personnel record for each employee;

4. Process for verifying current professional credentials and training of employees, or independent contractors;

5. Process for annually evaluating employee performance and competency;

6. Process for verifying that contractors and their employees meet the personnel qualifications of the hospice program; and

7. Process for reporting licensed and certified medical personnel for violations of the licensing or certification to the appropriate board within the Department of Health Professions.

F. Admission and discharge policies and procedures shall include:

1. Criteria for accepting patients;

2. The process for assessing a patient and maintaining a plan of care;

3. Criteria for determining discharge from hospice and referral to other agencies or community services; and

4. Process for notifying patients of intent to discharge or refer, including:

a. Oral and written notice and explanation of the reason for discharge or referral;

b. The name, address, telephone number, and contact name at the referral hospice program; and

c. Documentation in the medical record of the referral or notice.

G. Policies shall be made available for review, upon request, to patients and their designated representatives.

H. Policies and procedures shall be readily available for staff use at all times.

I. The hospice program shall establish policies and procedures for the disposal of drugs dispensed as part of the hospice plan of care to include:

1. Disposal shall be performed by a licensed nurse, physician assistant, or physician employed by or under contract with the hospice program;

2. Disposal shall be witnessed by a patient's family member or another employee of the hospice program who is licensed by a health regulatory board within the Department of Health Professions;

3. Disposal shall be documented in the patient's medical record; and

4. Disposal shall comply with all state and federal requirements for the safe disposal of drugs.

Statutory Authority

§§ 32.1-12 and 32.1-162.5 of the Code of Virginia.

Historical Notes

Derived from Volume 21, Issue 23, eff. November 1, 2005; amended, Virginia Register Volume 35, Issue 04, eff. November 14, 2018.

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