Hospice Policy and Procedure Manual

Don’t reinvent the wheel when developing policies and procedures! MCN’s Hospice Policy and Procedure Manual provides over 400 ready-to-implement policies, procedures and forms. The manual is cross-referenced to Joint Commission and ACHC standards and CMS regulations, allowing you to stay current with the latest requirements! This valuable resource manual provides administrative, operational and patient-centered policies and procedures, saving you time, money and effort in policy development.

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Table of Contents - TJC Standards and CMS RegulationsTable of Contents - ACHC Standards and CMS RegulationsCopyrightDisclaimerApproval/Signature SheetIntroduction
SECTION 03 - HUMAN RESOURCES
3001 - Position Description/Performance Evaluation - Hospice Executive Director/Administrator3002 - Performance Evaluation - Population-Specific/Age-Related Competency - Hospice Executive Director/Administrator3003 - Annual Competency Clinical Skills Assessment - Hospice Executive Director/Administrator3004 - Position Description/Performance Evaluation - Hospice Medical Director3005 - Performance Evaluation - Population-Specific/Age-Related Competency - Hospice Medical Director3006 - Annual Competency Clinical Skills Assessment - Hospice Medical Director3007 - Position Description/Performance Evaluation - Hospice Nurse Practitioner3008 - Performance Evaluation - Population-Specific/Age-Related Competency - Hospice Nurse Practitioner3009 - Annual Competency Clinical Skills Assessment - Hospice Nurse Practitioner3010 - Position Description/Performance Evaluation - Hospice Clinical Nurse Manager3011 - Performance Evaluation - Population-Specific/Age-Related Competency - Hospice Clinical Nurse Manager3012 - Annual Competency Clinical Skills Assessment - Hospice Clinical Nurse Manager3013 - Position Description/Performance Evaluation - Hospice Registered Nurse3014 - Performance Evaluation - Population-Specific/Age-Related Competency - Hospice Registered Nurse3015 - Annual Competency Clinical Skills Assessment - Hospice Registered Nurse3016 - Position Description/Performance Evaluation - Hospice LPN/LVN3017 - Performance Evaluation - Population-Specific/Age-Related Competency - Hospice LPN/LVN3018 - Annual Competency Clinical Skills Assessment - Hospice LPN/LVN3019 - Position Description/Performance Evaluation - Hospice Licensed Medical Social Worker3020 - Performance Evaluation - Population-Specific/Age-Related Competency - Hospice Licensed Medical Social Worker3021 - Annual Competency Clinical Skills Assessment - Hospice Licensed Medical Social Worker3022 - Position Description/Performance Evaluation - Hospice Bereavement Counselor/Chaplain3023 - Performance Evaluation - Population-Specific/Age-Related Competency - Hospice Bereavement Counselor/Chaplain3024 - Annual Competency Skills Assessment - Hospice Bereavement Counselor/Chaplain3025 - Position Description/Performance Evaluation - Hospice Aide3026 - Performance Evaluation - Population-Specific/Age-Related Competency - Hospice Aide3027 - Annual Competency Clinical Skills Assessment - Hospice Aide3028 - Hospice Aide Training3029 - Hospice Aide Inservice Training3030 - Hospice Aide Assignments and Duties3031 - Hospice Aides - Supervision of3032 - Hospice Aide - Annual On-Site Assessment3033 - Annual Competency - Joint Commission National Patient Safety Goals - Home Health/Hospice3034 - Volunteer Services3035 - The Role of the Hospice Volunteer3036 - Management of Students3037 - Equal Opportunity Employment3038 - Employment of the Disabled3039 - Applications for Employment3040 - Employment of Foreign Applicants3041 - Employment of Relatives3042 - Classification of Employees3043 - Staff Qualifications and Competency3044 - Licensure, Certification and Registration Verification and Control Systems3045 - Background Screening3046 - Pre-Employment Physical Examination3047 - Orientation Program3048 - Performance Evaluations3049 - Employee Education Programs3050 - Continuing Education/Inservice Attendance Record Form3051 - Termination of Employment3052 - Disciplinary Action3053 - Disciplinary Action Form3054 - Exit Interviews3055 - Exit Interview Form - Sample3056 - Attendance and Tardiness3057 - Change in Personal Information3058 - Dress Code3059 - Employee Photo Identification Badge3060 - Employee Assistance Program3061 - Employee Requests for Time Off3062 - Garnishment of Wages3063 - Harassment, Sexual (Either Sex)3064 - Holiday Policy3065 - Payroll Distribution/Time Verification3066 - Personnel Files - Contents and Originations3067 - Procurement of Employees3068 - Personnel Requisition Form - Sample3069 - Re-Employment3070 - Sick Leave Policy3071 - Staff Access to Emotional Support3072 - Vacation Policy3073 - Workers' Compensation
SECTION 04 - INFECTION PREVENTION AND CONTROL
4001 - Infection Prevention and Control Plan - Hospice4002 - Reporting Patient Infections4003 - Nationally Notifiable Infectious Diseases4004 - Employee Reporting and Work Restrictions Due to Exposure to Communicable Diseases4005 - Standard Precautions4006 - Hand Hygiene - CDC Guidelines4007 - Soap for Handwashing4008 - Transmission-Based Precautions (Isolation Precautions)4009 - N-95 Respirators4010 - Required Personal Protective Equipment Form4011 - Infectious Waste Management Plan4012 - Management of Multidrug-Resistant Organisms in Non-Hospital Healthcare Settings4013 - Increased Number of Potentially Infectious Patients4014 - Nursing Bag Techniques4015 - Hospice Aide Bag Technique4016 - Sterile Technique4017 - Precautions for Invasive Procedures4018 - AIDS/HIV Positive Guidelines4019 - Exposure to HIV4020 - Pandemic Risk Assessment Tool for Home Care Organizations4021 - CDC - Home Healthcare Services Pandemic Influenza Planning Checklist4022 - Hospice Plan and Response to a Potential or Actual Influenza Pandemic Outbreak4023 - Care of Influenza Pandemic Patients in the Home4024 - Patient and Family Education Handout - Precautions During a Flu Pandemic4025 - 4025 - Housekeeping Checklist4026 - TB Risk Assessment Worksheet4027 - Guidelines for Prevention of Tuberculosis Transmission in the Home4028 - Tuberculosis Training Program Outlines4029 - Tuberculosis Screening Program4030 - Baseline and Follow-up Testing for M. Tuberculosis Infection4031 - Health Questionnaire for Positive Tuberculosis Skin Test Reactions4032 - Exposure Control Plan4033 - Sharps Injury Protection Plan4034 - Sharps Injury Log Form4035 - Record Keeping4036 - Employee Health4037 - Employee Illnesses4038 - Workplace Injury, Illness or Fatality Reporting4039 - Employee Health - Immunizations4040 - Influenza Vaccination Program for Healthcare Staff4041 - Hepatitis B Vaccine Program4042 - Hepatitis B Vaccine Declination Form4043 - Informed Consent for Hepatitis B Vaccine Form4044 - Latex Allergy Prevention and Management in Healthcare Workers
SECTION 06 - LEADERSHIP
6001 - Governing Body - Hospital-Based6002 - Professional Advisory Committee and Annual Evaluation6003 - Lines of Authority/Use of Organizational Chart6004 - Organizational Planning6005 - Operational Policy Decisions6006 - Appointment of Executive Director/Administrator6007 - Designation of Individual in Absence of Executive Director/Administrator6008 - Staff Recruitment, Retention and Education6009 - Mission/Philosophy Statement6010 - Communication Process - Staff, Patients and Community6011 - Internal Communication6012 - Code of Conduct - Sample6013 - Culture of Safety and Quality6014 - Examples of Survey Tools to Survey a Culture of Safety and Quality6015 - Survey Assessment Tools6016 - Disruptive and Inappropriate Behavior6017 - Incident Reporting Staff Questionnaire Form6018 - Standards of Conduct/Ethical Behavior6019 - Departmental Staff Meetings6020 - Community Outreach Programs Form6021 - Licensure6022 - Corporate Compliance Plan6023 - Nondiscrimination Policy6024 - Contingency Plan If Organization Closes6025 - Certificate of Insurance6026 - Annual Operating Budget - Freestanding Hospice6027 - Physician Services - Medical Director6028 - Physician Responsibility in Managing Hospice Patients6029 - Responsibilities/Supervision of Clinical Services6030 - Coordination of Care, Treatment and Services with Contracts/Agreements6031 - Development of Policies and Procedures6032 - Hospice Policy Review and Revision Flow Sheet6033 - Space, Equipment and Resources6034 - Conflict of Interest6035 - Contract Services6036 - Referral Disclosure6037 - Financial Incentives/Clinical Decision Making6038 - Ethical Issues6039 - Code of Ethics6040 - Marketing Practices6041 - Billing Practices6042 - Staff Rights and Ethical Dilemmas in Patient Care6043 - Scope of Services6044 - Uniform Quality of Care, Treatment and Services6045 - Oversight of Contractual Agreements6046 - Staff Responsibilities in Improving Hospice Performance6047 - Patient Safety Plan6048 - Sentinel Event6049 - Conducting Root Cause Analysis6050 - Donated Funds
SECTION 07 - MEDICATION MANAGEMENT
7001 - Hospice Medication Oversight7002 - Pharmacy Services7003 - Medication Management - Patient Information7004 - High Alert Medication Management7005 - Look-Alike, Sound-Alike Medication Management7006 - Selection of Medications7007 - Medications for Dispensing/Administration in the Patient's Home7008 - Safe Storage of Medications in the Patient's Home7009 - Home Use and Disposal of Controlled Substance7010 - Controlled Drug Distribution - Inpatient7011 - Controlled Drug Management on Patient Care Units7012 - Controlled Drug Disposal in the Home7013 - Emergency Medications and Supplies7014 - Patient's Own Medication (Usage)7015 - Medications Acquired from Outside Sources by an LIP7016 - Prescribing/Ordering - General Practices7017 - Verbal and Written Orders - General7018 - Telephone, Verbal and Written Orders for Medication7019 - Standing Orders7020 - Automatic Stop Orders7021 - Titrating Medications7022 - Tapering of Medications7023 - Range Orders for Medications7024 - Patients' Use of Herbals and "Natural" Remedies7025 - Influenza and Pneumococcal Vaccine Standing Orders7026 - Use of Vaccine Information Statements (VISs)7027 - Discharge Prescriptions (Inpatient Hospice)7028 - Investigational Drugs7029 - Investigational Drug Information Record Form7030 - Pharmacist Order Verification (Inpatient Hospice)7031 - Medication Preparation7032 - Labeling Standards7033 - Night Medication Locker7034 - Pharmacy Night Log Form7035 - Contracted Pharmacy and On-Call Pharmacist7036 - Medication Recall7037 - Medication Patient Information and Reconciliation7038 - Medication Patient Information and Reconciliation Form7039 - Identification of Medication for Administration7040 - Administration and Documentation of Medications7041 - Use of Multiple Dose Vials (MDVs)7042 - Patient Self-Administration of Medication7043 - Safe/Effective Use of Medications7044 - Intravenous Administration of Medications/Solutions7045 - Medications Approved for Intravenous Administration7046 - Crushing Medications7047 - Medication Monitoring7048 - Anaphylaxis Protocol7049 - Medication Errors7050 - Medication Inadvertent Incident Report7051 - Medication Inadvertent Incident Report Form7052 - Adverse Drug Reaction Reporting7053 - Adverse Drug Reaction Reporting Form (Internal)7054 - Medication Management Program
SECTION 09 – PROVISION OF CARE, TREATMENT AND SERVICES
Patient Care, Treatment and Services
9101 - Patient Identification for Clinical Care and Treatment9102 - Plan of Care9103 - Interdisciplinary Group (IDG) Assessment and Plan of Care9104 - Interdisciplinary Group (IDG) Coordination of Care9105 - Interdisciplinary Group (IDG) Meeting9106 - Standards of Care and Practice9107 - Hospice Nursing Care9108 - Hospice Aide Services9109 - Internal Referral Process9110 - Communication of Patient Information9111 - Identification, Prevention and Treatment of Secondary Symptoms9112 - Psychosocial Services9113 - Spiritual Care Services9114 - Hospice Spiritual Concerns9115 - Suicide9116 - Critical Results of Tests and Diagnostic Procedures - Reporting of9117 - Invasive Procedure Site Identification (Outside of the OR)9118 - Invasive/Surgical Procedure Verification/Time Out Checklist9119 - "Hand-Off" Communication9120 - Obtaining Blood by Venipuncture9121 - Short-Term Inpatient Services9122 - Admission for General Inpatient Services9123 - Admission for Respite Care9124 - Resumption of Care9125 - Verification of Physician Orders and Licensure9126 - Physician Communication9127 - Monitoring Patient's Response - Reporting to Physician9128 - Medical Consultation9129 - Blood Storage for Home Transfusions9130 - Blood/Blood Components - Transfusion9131 - Blood/Blood Components - Transfusion Reactions9132 - Patient Notification of Changes in Care, Treatment and Services9133 - Access to Emergency Department, Pharmacy, Imaging Services/Radiology, Clinical Laboratory9134 - Responsibilities of Continuous Care Staff9135 - Continuous Care Service9136 - Documenting Guidelines for Continuous Care9137 - Nutritional Care Planning9138 - Nutritional Services (Hospital-Based)9139 - Diet Orders - Inpatient9140 - On-Call Services9141 - Care of the Dying Patient9142 - Death at Home
SECTION 12 - WAIVED TESTING