Hospice of Montezuma Administrative Policies and Procedures
TABLE OF CONTENTS page 1 of 4
Policy Title / Policy # /Access to Hospice Care / AD.A10
Administrator / AD.A15
Annual Evaluation / AD.A20
Anti-kickback Statute / AD.A25
Community Education and Outreach / AD.C10
Complaint Resolution / AD.C15
Compliance with Regulations / AD.C20
Conflict of Interest / AD.C25
Corporate Compliance – Auditing and Monitoring / AD.C30
Corporate Compliance – Compliance Education and Training / AD.C35
Corporate Compliance – Compliance Officer and Committee / AD.C40
Corporate Compliance – Compliance Program / AD.C45
Corporate Compliance – Disciplinary Action / AD.C50
Corporate Compliance – Non-Hiring or Retention of Sanctioned Individuals / AD.C55
Corporate Compliance – Reporting Mechanism / AD.C60
Corporate Compliance – Response and Corrective Action / AD.C65
Corporate Compliance – Standards of Conduct / AD.C70
Diversity / AD.D10
Emergency / Disaster Management / AD.E10
Ethical Billing Practices / AD.E15
Ethical Issues and Ethics Committee / AD.E20
Fiscal and Fiduciary Responsibility / AD.F10
Governing Body / AD.G10
HIPAA Privacy - Authorizations / AD.HP10
HIPAA Privacy – Fundraising and Protected Health Information (PHI) / AD.HP15
HIPAA Privacy – Marketing and Protected Health Information / AD.HP20
HIPAA Privacy – Minimum Necessary Disclosures of PHI / AD.HP25
HIPAA Privacy – Minimum Necessary Requests of PHI / AD.HP30
HIPAA Privacy – Minimum Necessary Uses of PHI / AD.HP35
HIPAA Privacy – Notice of Privacy Practices / AD.HP40
HIPAA Privacy – Patient Privacy Rights / AD.HP45
HIPAA Privacy – Protected Health Information of Deceased Patients / AD.HP50
HIPAA Privacy – Requests for Access to Protected Health Information / AD.HP55
HIPAA Privacy – Requests for an Accounting of Disclosures of PHI / AD.HP60
HIPAA Privacy – Requests for an Amendment to Protected Health Info. / AD.HP65
HIPAA Privacy – Requests for Confidential Communications / AD.HP70
HIPAA Privacy – Requests for Restrictions on Use and Disclosure / AD.HP75
HIPAA Privacy and Security – Business Associates / AD.HPS10
HIPAA Privacy and Security – Privacy and Security Awareness & Training / AD.HPS15
HIPAA Privacy and Security – Privacy and Security Official / AD.HPS20
HIPAA Privacy and Security – Sanctions for Privacy and/or Security Violations / AD.HPS25
HIPAA Security – Contingency Plan / AD.HS10
HIPAA Security – Device and Media Controls / AD.HS15
HIPAA Security – Facility Access Controls / AD.HS20
HIPAA Security – Information Access Management / AD.HS25
HIPAA Security – Information System Activity Review / AD.HS30
HIPAA Security – Password Management / AD.HS35
HIPAA Security – Person or Entity Authentication / AD.HS40
HIPAA Security – Protection from Malicious Software / AD.HS45
HIPAA Security – Risk Analysis / AD.HS50
HIPAA Security – Risk Management / AD.HS55
HIPAA Security – Security Evaluations / AD.HS60
HIPAA Security – Security Incidents / AD.HS65
HIPAA Security – Technical Access Control / AD.HS70
HIPAA Security – Transmission Security / AD.HS75
HIPAA Security – Workforce Security / AD.HS80
HIPAA Security – Workstation Use and Security / AD.HS85
Incident Reporting / AD.I10
Information Management - Program / AD.I15
Marketing Materials / AD.M10
Mission and Vision Statements / AD.M15
Organization and Administration of Services / AD.O10
Patient / Caregiver Satisfaction / AD.P10
Patient Rights and Responsibilities / AD.P15
Policies and Procedures / AD.P20
Quality Assessment / Performance Improvement (QAPI) - Benchmarking / AD.Q10
Quality Assessment / Performance Improvement (QAPI) – Activities & Projects / AD.Q15
Quality Assessment / Performance Improvement (QAPI) - Program / AD.Q20
Quality Assessment / Performance Improvement (QAPI) – Program Data / AD.Q25
Research / AD.R10
Retention of Records / AD.R15
Scope of Services / AD.S10
Strategic Planning / AD.S15
Written Agreements / AD.W10
Table of Contents List Items that are “Grayed Out” are Not Included
In Policies and Procedures yet. They are still in the process of being created or approved.
ACCESS TO HOSPICE CARE / Policy Number: AD.A10
NHPCO Standard(s): IA 1; IA 1.3; IA 1.4
Regulatory Citation(s):
Approved 06/16/2010 Reviewed/Revised: 03/30/2011
POLICY STATEMENT: Hospice of Montezuma is committed to increasing access to hospice care for eligible patients and their caregivers.
PROCEDURES:
1. Hospice of Montezuma provides care and services to patients and families who meet hospice admission criteria regardless of race, color, national origin, ancestry, age, sexual orientation, religious creed, disability, diagnosis, or ability to pay.
2. Hospice provides information to the community and to referral resources regarding hospice services, eligibility for hospice care and how services may be obtained.
3. When appropriate, community outreach efforts and education regarding hospice are provided, including participation in community events where information is distributed to underserved populations.
4. Admission criteria and eligibility limitations are periodically evaluated to identify potential impediments to access.
ADMINISTRATOR / Policy Number: AD.A15page 1 of 2
NHPCO Standard(s): SA 3.2; SA 7; SA 7.1; SA 7.2; SA 7.3; SA 7.4
Regulatory Citation(s): 42 CFR 418.52 CoP 418.100(b)
Approved: 05/28/2008 Reviewed/Revised: 3/29/2011
POLICY STATEMENT: The Board of Directors appoints a qualified individual with appropriate education and experience to serve as the Executive Director of Hospice of Montezuma who assumes responsibility for the day to day administration of the hospice program.
PROCEDURES:
1. The Board of Directors conducts a search to find the most qualified, experienced and competent individual to serve as the Executive Director of the hospice program.
2. The education, experience and references of potential candidates are verified.
3. When interviews with the finalists are complete, the Board of Directors votes for the candidate most suitable to assume the position of Executive Director.
4. The Executive Director is the chief administrator of the hospice program, is employed by the hospice, reports to the Board of Directors and fulfills the responsibilities outlined in the job description for this position, including but not limited to:
a. implementing financial policies and practices;
b. implementing, monitoring and reporting on the hospice’s services;
c. assuring the quality of patient care;
d. resolving problems;
e. assuring the implementation of the QAPI program and safety activities; and
f. assuring open and timely communication.
5. In the absence of the Executive Director, the authority and responsibility for the daily operations of the hospice program are delegated to the Executive Assistant and/or the Quality Assurance, Utilization and Compliance Officer.
6. The Board of Directors evaluates the performance of the Executive Director annually and reviews the documented evaluation with him or her.
ADMINISTRATOR(continued) / Policy Number: AD.A15
page 2 of 2
NHPCO Standard(s): SA 3.2; SA 7; SA 7.1; SA 7.2; SA 7.3; SA 7.4
Regulatory Citation(s): 42 CFR 418.52 CoP 418.100(b)
Approved: 05/28/2008 Reviewed/Revised: 3/29/2011
7. The Executive Director, with the Board of Directors, ensures that all care, treatment and services provided by the hospice are in accordance with Federal, State and local laws and regulations and consistent with accepted standards of practice.
ANNUAL EVALUATION / Policy Number: AD.A20Page 1 of 2
NHPCO Standard(s): IA 2.2; SA 8.2
Regulatory Citation(s):
Approved: 05/28/2008 Reviewed/Revised: 03/29/2011
POLICY STATEMENT: A systematic review of all clinical, financial and operational aspects of Hospice of Montezuma is conducted annually to evaluate the hospice’s performance in relation to its vision, mission and goals.
PROCEDURES:
1. Quarterly, the Executive Director solicits a report and data from each department related to clinical, financial and operational achievement of goals. This data is provided to the Board of Directors at their regular monthly meetings.
2. Components of the hospice program that are evaluated annually may include but not be limited to:
a. policies and procedures;
b. organizational structure and system;
c. achievement of goals;
d. patient outcomes;
e. programs, services and products provided;
f. patient care data;
g. human resources;
h. safety practices;
i. risk management;
j. financial resources and billing practices;
k. compliance with regulations;
l. information systems;
m. quality assessment and performance improvement program; and
n. corporate compliance program.
ANNUAL EVALUATION(continued) / Policy Number: AD.A20
Page 2 of 2
NHPCO Standard(s): IA 2.2; SA 8.2
Regulatory Citation(s):
Approved: 05/28/2008 Reviewed/Revised: 03/29/2011
3. Data collection may include, but is not limited to:
a. clinical data;
b. quality assessment and performance improvement data;
c. risk management data;
d. human resources data; and
e. financial data
4. Based on the reports and data received, the Executive Director develops an Annual Report that summarizes areas of strength and weakness and identifies priorities for performance improvement.
5. The Annual Report is presented to and acted upon by the Board of Directors at the April meeting each year.
6. A copy of the Annual Report is retained as an administrative record and provides a basis for future planning and performance improvement activities.
ANTI-KICKBACK STATUTE / Policy Number: AD.A25NHPCO Standard(s):
Regulatory Citation(s): 42 U.S.C. §1320a-7b
Approved: 5/28/2008 Reviewed/Revised: 03/29/2011
POLICY STATEMENT: Hospice of Montezuma complies with Federal and State anti-kickback statutes and other applicable laws.
PROCEDURES:
1. Hospice of Montezuma does not offer or provide gifts, free services, or other incentives to patients, relatives of patients, physicians, nursing facilities, hospitals, contractors or other potential referral sources for the purpose of inducing referrals in violation of the anti-kickback statute or similar Federal or State statute or regulations.
2. All contracts and arrangements with actual or potential referral sources are reviewed for compliance with all applicable statutes and regulations.
3. Claims are not submitted for patients who were referred to the hospice through contractual or financial arrangements that were designed to induce patient referrals.
4. Hospice of Montezuma does not unlawfully influence the referral of nursing home patients by:
a. providing payments to the nursing home for "room and board" that exceed what the nursing home would have received from Medicaid if the patient had not been enrolled in hospice;
b. paying above fair market value for “additional” non-core services that Medicaid does not consider included in its room and board payments to the nursing home;
c. providing hospice staff or other staff at its expense to perform duties that otherwise would be performed by the nursing home; and
d. providing free or below market value care to nursing home patients receiving the Medicare Skilled Nursing Facility (SNF) benefit with the expectation that the patient would receive services from the hospice once the SNF benefit was exhausted.
COMMUNITY EDUCATION AND OUTREACH / Policy Number: AD.C10NHPCO Standard(s): IA 1.1; IA 1.5; IA 3; IA 3.1; IA 3.2; IA 3.3; IA 3.4; IA 4.1; IA 4.2
Regulatory Citation(s):
Approved: 06/16/2010 Reviewed/Revised: 03/29/2011
POLICY STATEMENT: Hospice of Montezuma provides education regarding hospice and palliative care to community groups and referral sources with the goal of increasing awareness of and access to hospice care.
PROCEDURES:
1. Hospice of Montezuma participates in community health assessments to ensure the hospice is identifying and responding to the end-of-life care needs of the communities it serves.
2. Hospice employees and volunteers are encouraged to participate in community activities and events and/or to serve on national, regional or state boards and committees.
3. Speakers are provided upon request from community groups or referral sources to provide information and targeted education on topics that may include, but not be limited to:
a. advance care planning / advance directives;
b. hospice philosophy of care / Hospice 101;
c. grief and loss;
d. admission criteria and scope of services;
e. spiritual concerns of the dying;
f. pain and symptom management;
g. caregiver support and education; and
h. cultural attitudes towards death and bereavement
4. Community education that has been provided and the identification of needs in the community are documented and reported to the Board of Directors for inclusion in the hospice’s strategic planning process.
COMPLAINT RESOLUTION / Policy Number: AD.C15page 1 of 2
NHPCO Standard(s): EBR 3; EBR 3.1; EBR.3.2; EBR 3.3; EBR 3.4
Regulatory Citation(s): CoP 418.52(b)(4)
Approved 5/28/2008 Reviewed/Revised: 3/29/2011
POLICY STATEMENT: Hospice of Montezuma has a complaint resolution process that is implemented whenever a complaint is received.
PROCEDURES:
1. Hospice patients/caregivers are informed of their right to lodge complaints without fear of discrimination, reprisal or interruption of care, treatment and services.
2. The hospice’s admission materials include a description of the complaint resolution process and the contact information for the hospice and the state hotline (including hours of operation) that may be used to lodge a complaint.
3. Complaints/concerns brought to the direct attention of any hospice employee or volunteer are addressed immediately whenever possible and brought to the attention of the QAPI Coordinator.
4. All complaints are documented in a complaint log by the Office Manager no more than 5 (five) business days from the date the complaint was first received.
5. A documented investigation is conducted by appropriate personnel of all written or verbal complaints received by the hospice.
6. To resolve complaints, a minimum of 3 (three) attempts are made to contact the person filing the complaint by telephone. If telephone contact is unsuccessful, a certified letter is sent. Each contact, attempted contact, or action taken to resolve the issue is documented with the original complaint.
7. Complaints or concerns expressed on a written survey are reviewed initially by the Executive Director. Follow-up is initiated as soon as possible to resolve complaints or concerns.
8. Corrective action is implemented, as appropriate, in response to substantiated complaints.
COMPLAINT RESOLUTION (cont.) / Policy Number: AD.C15page 2 of 2
9. Complaints are tracked and regularly reviewed to identify patterns or trends and performance
improvement opportunities.
10. Hospice employees and volunteers receive training regarding the hospice’s complaint resolution
process.
NHPCO Standard(s): CLR 1; CLR 2; CLR 2.1; CLR 2.3; WE 4.4
Regulatory Citation(s): 42 CFR 418.50(a); CoP 418.116
Approved: 05/28/2008 Reviewed/Revised: 03/29/2011
POLICY STATEMENT: Hospice of Montezuma operates and furnishes services in compliance with all applicable Federal, State and local laws and regulations related to hospice care and the health and safety of patients, and is licensed by the State of Colorado.