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ABBREVIATIONS

VIEWS: 60 PAGES: 126

									Hospice of Montezuma                                  Patient Care Policies and Procedures


                                    Policy Title                                                         Policy #
Abbreviations                                                                                           PC.A10

Abuse, Neglect and Exploitation                                                                         PC.A15a

Abuse, and/or Molestation – Sexual                                                                      PC.A15b

Admission to Hospice Care – Prior Certification of Terminal Illness                                     PC.A20

Admission to Hospice Care – Criteria for Admission                                                      PC.A25

Admission to Hospice Care – Election of the Medicare Hospice Benefit                                    PC.A30

Admission to Hospice Care – Eligibility Determination for Medicare                                      PC.A35

Admission to Hospice Care – Informed Consent                                                            PC.A40

Admission to Hospice Care – Physician’s Orders                                                          PC.A45

Admission to Hospice Care – Process                                                                     PC.A50

Admission to Hospice Care – Readmission                                                                 PC.A55

Admission to Hospice Care – Referrals                                                                   PC.A60

Admission to Hospice Care – Referrals from Acute Care Facilities                                        PC.A65

Advance Beneficiary Notice                                                                              PC.A70

Advance Directives                                                                                      PC.A75

Assessment – Comprehensive Assessment of the Client                                                     PC.A80

Assessment – Content of the Comprehensive Assessment                                                    PC.A85

Assessment - Initial                                                                                    PC.A90

Assessment – Patient Outcome Measures                                                                   PC.A95


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Hospice of Montezuma                                  Patient Care Policies and Procedures


                              Policy Title                                                               Policy #
Assessments – Updates to the Comprehensive Assessment                                                   PC.A100

Attending Physicians                                                                                    PC.A105

Availability 24/7                                                                                       PC.A110

Bereavement - Care Planning                                                                             PC.B10

Bereavement – Files                                                                                     PC.B15

Bereavement – Mailings                                                                                  PC.B20

Bereavement - Risk Assessment                                                                           PC.B25

Bereavement – Services                                                                                  PC.B30

Bereavement - Tracking and Evaluation                                                                   PC.B35

Change of Designated Hospice                                                                            PC.C10

Clinical Records                                                                                        PC.C15

Communication Barriers                                                                                  PC.C20

Community Resources                                                                                     PC.C25

Complementary Therapies                                                                                 PC.C30

Continuation of Care – Inability to Pay for Care                                                        PC.C35

Continuity of Care                                                                                      PC.C40

Coordination of Services                                                                                PC.C45

Death of a Hospice Client                                                                               PC.D10

Dietary Services                                                                                        PC.D15


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Hospice of Montezuma                                  Patient Care Policies and Procedures


                              Policy Title                                                               Policy #
Discharge for Reasons Other Than Death                                                                  PC.D20

Documentation Requirements                                                                              PC.D25

Durable Medical Equipment                                                                               PC.D30

Facility Residents – Hospice Care for                                                                   PC.F25

Facility Residents – Hospice Plan of Care                                                               PC.F30

Home Health Aide Services                                                                               PC.H10

Home Health Aide Supervision                                                                            PC.H15

Home Visit Procedure for Non-Hospice Employees                                                          PC.H20

Hospice Care for Nursing Facility Residents                                                             PC.H25

Infection Control – Bag Technique                                                                       PC.I10

Infection Control – Bio-hazardous Waste Management                                                      PC.I15

Infection Control – Cleaning and Decontaminating Spills or Blood                                        PC.I20

Infection Control – Education                                                                           PC.I25

Infection Control – Exposure to Blood and Body Fluids                                                   PC.I30

Infection Control – Occupational Exposure Procedures Classification                                     PC.I35

Infection Control – Program                                                                             PC.I40

Infection Control – Responsibilities                                                                    PC.I45

Infection Control - Standard Precautions                                                                PC.I50




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Hospice of Montezuma                                    Patient Care Policies and Procedures


                                      Policy Title                                                         Policy #
Interdisciplinary Team                                                                                    PC.I55

Interdisciplinary Team Meeting                                                                            PC.I60

Laboratory Services                                                                                       PC.L10

Levels of Care                                                                                            PC.L15

Levels of Care - Continuous Care                                                                          PC.L20

Levels of Care - General Inpatient Care                                                                   PC.L25

Levels of Care - Inpatient Respite Care                                                                   PC.L30

Medical Director                                                                                          PC.M10

Medical Supplies                                                                                          PC.M20

Medications – Administration                                                                              PC.M25

Medications - Adverse Drug Reactions                                                                      PC.M30

Medications – Do Not Crush Medications                                                                    PC.M35

Medications – Errors                                                                                      PC.M40

Medications – Management                                                                                  PC.M45

Medications Orders                                                                                        PC.M50

Medications – Tracking and Disposing of Controlled Drugs                                                  PC.M55
                in the Patient's Home
Notification of Non-Coverage                                                                              PC.N10

Nursing Services                                                                                          PC.N15

On-Call Services                                                                                          PC.O10


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Hospice of Montezuma                                     Patient Care Policies and Procedures


                          Policy Title                                                                      Policy #
Pain and Symptom Management                                                                                PC.P10

Patient / Caregiver Education                                                                              PC.P15

Patients Without Primary Caregivers                                                                        PC.P20

Physical, Occupational, Speech and Other Therapies                                                         PC.P25

Physician Orders                                                                                           PC.P35

Physician Services                                                                                         PC.P40

Plan of Care                                                                                               PC.P45

Plan of Care – Initial                                                                                     PC.P50

Professional Management                                                                                    PC.P60

Recertification of Terminal Illness                                                                        PC.R10

Revocation of the Medicare Hospice Benefit                                                                 PC.R15

Safety - Home Visits                                                                                       PC.S10

Safety - Patient/Caregiver                                                                                 PC.S15

Social Work Services                                                                                       PC.S20

Spiritual Care Services                                                                                    PC.S25

Standards of Practice                                                                                      PC.S30

Suicide                                                                                                    PC.S35

Transfer of a Hospice Patient                                                                              PC.T10

Traveling Hospice Patients                                                                                 PC.T15


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                                     Policy Title                                                         Policy #
Volunteers - Assignment                                                                                  PC.V10

Volunteers - Documentation                                                                               PC.V15

Volunteers – Services                                                                                    PC.V20




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.




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                    ABBREVIATIONS                                                             Policy Number:
                                                                                                      PC.A10
 NHPCO Standard(s):
 Regulatory Citation / Other:
 Adopted: 9/26/2007                                                      Reviewed/Revised: 3/24/2010

POLICY STATEMENT: Hospice of Montezuma prohibits the routine use of abbreviations,
acronyms and symbols by staff with the exception of those abbreviations, acronyms and
symbols on the approved list (which includes those that are on the drop down menu of the
computerized clinical documentation program.)

PROCEDURES:

1. Abbreviations and symbols are used in the medical record only when there is a drop down
   menu of the computerized documentation system available or the abbreviation is listed on
   the approved abbreviations list (See Addendum PCA10A).

2. All Hospice of Montezuma clinicians receive a listing of dangerous abbreviations that may
   not be used in clinical documentation (See Addendum PC.A10B).




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                                     ADDENDUM PC.A10A
                                     Approved Abbreviations

All abbreviations contained in the Suncoast System, plus the abbreviations listed below with
an ^ which are not in Suncoast.

ADLs          activities of daily living
ALF           assisted living facility
amb           ambulate
bilat         bilaterally
BS            blood sugar
BSD           bedside drainage, for a catheter drainage system
BM            bowel movement
BMI           body mass index
BUN           blood urea nitrogen
CHF           congestive heart failure
CNA           certified nurse’s aide
c/o^          complaint of
CPAP          continuous positive airway pressure
chemo         chemotherapy
DME           durable medical equipment
DNR           do not resuscitate
DNRO          do not resuscitate order
DPOA          durable power of attorney
dx            diagnosis, diagnostic
dysp          dyspnea
endur         endurance
EKG^          electrocardiogram
eg            for example, as an example
ER            emergency room
ESAS          Edmonton Symptom Assessment Scale
freq          frequency
ft            foot, feet (distance)
G tube        gastric tube (for feedings)
GFR^          glomerular filtration rate
G/U           genito-urinary
HEENT         head, eyes, ears, nose and throat
HH            home health
HHA           home health aide
HCS^          Home Care Service
HM            homemaker
HOM^          Hospice of Montezuma
hosp          hospital

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                                                                      Approved Abbreviations Page 2

hx         history
IADLs      independent activities of daily living
IDDM       insulin dependent diabetes mellitus
indep      independent
IV         intra-venous
JVD        jugular vein distention
J-tube     feeding tube placed in the jejunum
K          potassium
L          left
LMOM^      left message on machine
LW         living will
lb         pound, as in weight
LOC*       level of care
LPN        licensed practical nurse
MD         medical doctor, physician
MPOA       medical power of attorney
MS^        morphine sulfate
med        medication, medical
mo         month
N/A        not applicable, does not apply
NC         nasal cannula
NG tube    naso-gastric tube
NIDDM      non-insulin dependent diabetes mellitus
NPO        nothing by mouth
NRB        non-rebreather mask
O2         oxygen
O2 sat     Oxygen Saturation
OT         Occupational Therapy
occ        occasional
Pcg        primary caregiver
PERL       pupils equal, reactive to light
PERLA      pupils equal, reactive to light and accommodation
phys act   physical activity
PN*        primary nurse
POA        power of attorney
POC        plan of care
pt         patient
PRN        when necessary; as needed
P/S        PsychoSocial
P/U^       pick up (as in a prescription)



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                                                                       Approved Abbreviations Page 3
pst           past
PT            physical therapy or in lab results, ProTime
Px            prognosis
QA            quality assurance and improvement
quads*        quadrants, typically of the abdomen
R             right
RB            rebreather mask
req           requires, required
ROM           range of motion
RN            registered nurse
r/t^          related to
Rx^           prescription
S/S           signs and symptoms
SLP           Speech/Language Therapy
SN            skilled nurse
SNF           skilled nursing facility
SOB           Short of breath
STD           sexually transmitted disease
SW            social worker
SWMH^         Southwest Memorial Hospital
TIA           transient ischemic attack
TPN           total parenteral nutrition; nutrition provided by IV
TPR           temperature, pulse, and respirations
UR            utilization review
VI^           Valley Inn
VGI^          Vista Grande Inn
VM^           Vista Mesa
VC*           volunteer coordinator
vol           volunteer
vs            visit
w             with
wc            wheel chair
wk            week
WNL           within normal limits
wt            weight
yr            year
>             greater than
<             less than



*This abbreviation has another common use. Be cautious to use it only as indicated by this
document.

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             ADDENDUM PC.A10B
                                             DO NOT USE ABBREVIATIONS
                          The abbreviations on this list are allowed only when selected by the EMR.
Do Not Use                  Potential Problem                    Do This
Apothecary                   Misunderstood or misread       Use the metric system, i.e., gram = ounce.
Symbols                      (symbol for dram misread for
(dram, minim)                “3” and minim misread as “mL”)



AS, AD, AU (Latin            When poorly written, mistaken               Write “left ear” or
abbrev. for left, right      for OS, OD, and OU (meaning                 “right ear” or “both ears”
or both ears)                left, right or both eyes)

c.c. (for cubic              Mistaken for U (units) when                 Write “mL” for milliliters
centimeter)                  poorly written.

D/C (discharge,              Mistaken to mean “discontinue”              Write “discharge” or “discontinue”
discontinue)                 whatever medications follow
Allowed only when            (which typically is a list of
selected by the EMR          discharge meds)

Inderal40 mg                 Name letters and dose numbers               Always use space between drug name, dose and
                             run together. Misread as Inderal            unit of measure
                             140mg

H. S. (Latin for “hour       Misread as half-strength or “at             Write “half-strength” or “at bedtime”;
of sleep”);                  bedtime”                                    Write “nightly”
also qhs (for nightly)       Can result in dosing error; “qhs”
                             misread as (every hour)

IU (for international        Mistaken as IV (intravenous) or             Write “international unit”
unit)                        10 (ten)



MSO4, MgSO4                  Confused for one another; can               Write “morphine sulfate” or “magnesium sulfate”
                             mean morphine sulfate or
                             magnesium sulfate

OD (for once daily)          Misinterpreted as “right eye.”              Write “daily” or
Also OS, OD, OU              Also, when poorly written,                  Write “left eye,”
(Latin for left, right or    mistaken for AS, AD, and AU                 “right eye,” or “both eyes”

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             Hospice of Montezuma                                    Patient Care Policies and Procedures


Do Not Use               Potential Problem                            Do This
both eyes)               (meaning left, right or both ears)

Q.D. (once daily) and    Mistaken for each other. In Q.D.    Write “daily” or
Q.O.D. (every other      the period after the Q can be       Write “every other day”
day)                     mistaken for an “I.” In Q.O.D.
                         the “O” can be mistaken for “I.”
                         Both result in Q.I.D. (four times a
                         day).

qn (for nightly)         Misinterpreted as “qh” every
                                                                            Write “nightly”
                         hour


Q 6PM, etc. (for every   Misread as every six hours
                                                                            Write “nightly”
evening at 6 PM)

S.C. or S.Q.             Mistaken as SL for sublingual, or
                                                                      Use the abbreviation “subQ” or write the word
sub q                    “5 every.” Also, the “q” has been
                                                                      “subcutaneous”
(subcutaneous)           mistaken for “every” (e.g. one
                         heparin dose ordered “sub q 2
                         hours before surgery”
                         misunderstood as every 2 hours
                         before surgery).


SYMBOLS:                 Mistakenly used opposite of
                                                                      Write “greater than” or “less than”
> greater than           intended
< less than

Allowed only when
selected by the EMR

SYMBOLS: The slash       Misunderstood as the number 1
                                                                      DO NOT USE A SLASH MARK to separate
mark “/” separating      (“25 unit/10 units” read as “110”
                                                                      doses. Write “per”
two doses or “per”       units.)


ss (sliding scale        Mistaken for “55”
                                                                      Write “sliding scale” or “one half” or use “1/2”
[insulin] or ½
(apothecary)

T.I.W.; B.I.W.           Can mean either twice weekly or
                                                                      Write “twice weekly” or “three times weekly”
                         three times weekly. Also can be


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Do Not Use             Potential Problem                           Do This
                       mistaken for T.I.D (three times a
                       day). All can result in a wrong
                       dose.

Trailing zero          Decimal point is missed,
                                                                   Never write a zero by itself after a decimal point
(X.0 mg)               resulting in higher figure.
                                                                   (write X mg) and always use a zero before a
Lack of leading zero
                                                                   decimal point (write 0.X mg)
(.X mg)

U or u (for unit)      Mistaken as zero or, if poorly
                                                                   Write “unit”
                       written, as either four or cc.

x3d (for three days)
                                                                   Write “for three days” or “q. 72 hours”




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           ABUSE, NEGLECT AND EXPLOITATION                                                             Policy Number:
                                                                                                              PC.A15a

 NHPCO Standard(s):
 Regulatory Citation / Other: CoP 418.52(b)(4)
 Adopted 9/26/2007                                                              Reviewed/Revised: 3/24/2010


POLICY STATEMENT: All alleged violations involving mistreatment, neglect by self or
others, or verbal, mental, sexual and/or physical abuse, including injuries of unknown source
and misappropriation of client property are reported to State and local bodies having
jurisdiction within 24 hours of the incident. Suspected cases of abuse, neglect by self or others
or exploitation of clients/caregivers, including elderly or disabled adults and children, are
thoroughly investigated and reported if warranted.

Definitions
Abuse: The intentional infliction of physical, emotional, or sexual pain or injury.
Neglect: The failure to provide, in a timely manner, adequate food, clothing, shelter,
psychological care, physical care, medical care, or supervision for an at-risk adult or child to the
degree that a reasonable person in the same situation would provide. This does not include
provision of artificial nutrition as described in Article 18 of title 15, C.R.S.
Exploitation: the illegal or improper use of an at-risk adult or a child, their money, or their
property for another person’s advantage.
Self-Neglect: an act or failure to act whereby an at-risk adult substantially endangers the adult’s
health, safety, welfare, or life by not seeking or obtaining services necessary to meet the adult’s
essential human needs. Choice of lifestyle or living arrangements shall not, by itself, be
evidence of self-neglect.
PROCEDURES:

During orientation, all new employees receive instruction regarding legal requirements for
reporting suspected abuse, neglect by self or others and exploitation. This instruction includes a
review of the State’s legal definitions of abuse, neglect and exploitation and mandatory
reporting requirements and processes. ( Reporting requirements for abuse, neglect, exploitation
    www.cdphe.state.co.us/.../OCCURRENCE%20REPORTING%20REQUIREMENTS.ppt)

1. During the admission process and throughout the course of care, Hospice of Montezuma
   personnel assess the potential / likelihood of abuse, neglect by self or others or exploitation
   in the client’s environment.

2. Suspicion of abuse, neglect by self or others and/or exploitation of any client, family
   member or caregiver is documented and brought to the attention of the interdisciplinary
   team and appropriate manager immediately.


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                                                                          PC.A25a Page 2
3. A call to the appropriate State Agency / Abuse Hotline for further investigation is made by
   hospice personnel who are members of disciplines required to report such incidents when,
   in their professional judgment, such reporting is warranted. The supervisor is apprised of
   the report immediately after such a report is made.

4. A review of the suspected abuse, neglect by self or others and/or exploitation is conducted
   with the Executive Director and/or Hospice of Montezuma Medical Director. Every attempt
   is made to protect the client/family/caregiver.

5. All assessments, interventions, discussions and follow-up with the State Agency are
   carefully documented and kept confidential.

6. An Incident Report is completed describing the suspected abuse, neglect by self or other, or
   exploitation.

7. Failure on the part of Hospice of Montezuma personnel to report suspected abuse, neglect
   by self or others, or exploitation results in disciplinary action and the potential for civil
   damages.




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       ABUSE, AND/OR MOLESTATION- SEXUAL                                                    Policy Number:
                                                                                                   PC.A15b
 NHPCO Standard(s):
 Regulatory Citation / Other: CoP 418.52(b)(4)
 Adopted 9/26/2007                                                      Reviewed/Revised: 3/24/2010

POLICY: Hospice of Montezuma has a Zero-Tolerance policy for any sexual abuse and/or
molestation committed by an employee, volunteer, board member or third party. Upon
completion of the investigation, disciplinary action up to and including termination of
employment and criminal prosecution may ensue. Hospice of Montezuma prohibits and does
not tolerate sexual abuse, and/or molestation in the workplace or in any organization related
activity. Hospice of Montezuma provides procedures for employees, volunteers, family
members, board members, patients, victims of sexual abuse, or others to report sexual abuse
and enforces disciplinary penalties for those who commit such acts.

Definition
Sexual abuse or molestation is inappropriate sexual contact of a criminal nature or interaction
for gratification of the adult who is a caregiver and responsible for the patient or child's care.
Sexual abuse includes sexual molestation, sexual assault, sexual exploitation, or sexual injury,
but does not include sexual harassment. All reported incidents of sexual abuse will be
investigated and reported to appropriate law enforcement agencies and regulatory agencies.
Common physical and behavioral evidence or signs that someone may be experiencing sexual
abuse are listed below. These signs may also be present when no abuse has occurred.

Physical evidence of abuse:
   1. Difficulty in walking
   2. Torn, stained or bloody underwear
   3. Pain or itching in genital area
   4. Bruises or bleeding of the external genitalia
   5. Sexually transmitted diseases

Behavioral signs of sexual abuse:
   1. Reluctance to be left alone with a particular person
   2. Wearing lots of clothing especially in bed
   3. Fear of touch
   4. Nightmares or fear of night
   5. Apprehension when topic of sex is brought up




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                                                                        PC.A15b Page 2
Anti-retaliation

Hospice of Montezuma prohibits retaliation made against any employee, volunteer, board
member or patient who reports a good faith complaint of sexual abuse or who participates in
any related investigation. Making false accusations of sexual abuse in bad faith can have serious
consequences for those who are wrongly accused. Hospice of Montezuma prohibits making
false and/or malicious sexual abuse allegations, as well as deliberately providing false
information during an investigation. Anyone who violates this rule is subject to disciplinary
action, up to and including termination.



PROCEDURE

If you are aware of or suspect sexual abuse is taking place, you must;
     1. Immediately report it to your Director or Patient Care Coordinator or designee.
     2. If the suspected abuse is to an adult, you should report the abuse to your local or state
        Adult Protective Services (APS) Agency at 970-565-3769.
     3. If it is a child who is the victim then you should report the suspected abuse to the
        Department of Social Services at 970-565-3769 and to Emergency Dispatch at 970-565-
        8441, 24 hours a day, 7 days a week. The National Child Abuse Hotline, 1-800-422-4453,
        TDD 1-800-222-4453, has counselors and information available.
     4. Appropriate family members will be notified by the Executive Director or designee of
        alleged instances of sexual abuse.
     5. Hospice of Montezuma will report the alleged sexual abuse incident to their insurance
        agent.

Investigation and Follow-up

   1. Hospice of Montezuma takes all allegations of sexual abuse seriously and will promptly
      investigate whether sexual abuse has taken place.
   2. Hospice of Montezuma will use an outside third party (Mountain States Employment
      Council, 303-223-5469) to conduct an investigation.
   3. Hospice of Montezuma will cooperate fully with any investigation conducted by law
      enforcement or other regulatory agencies. It is Hospice of Montezuma's objective to
      conduct a fair and impartial investigation.
   4. Hospice of Montezuma provides notice that they have the option of placing the accused
      on an unpaid leave of absence or on a reassignment to non-patient contact.
   5. Hospice of Montezuma will make every reasonable effort to keep the matters involved
      in the allegation as confidential as possible while still allowing for a prompt and
      thorough investigation.




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                             HOSPICE OF MONTEZUMA
            Acknowledgment of Receipt and Understanding of Sexual Abuse Policy

I acknowledge that I have received and read the sexual abuse policy and/or have had it
explained to me. I understand that Hospice of Montezuma will not tolerate any employee,
volunteer, board member or third party who commits sexual abuse. Disciplinary actions will be
taken against those who are found to have committed sexual abuse. I understand that Hospice
of Montezuma has the option of placing anyone accused of sexual abuse on unpaid leave of
absence or on a reassignment to non-patient contact duties.

I understand that it is my responsibility to abide by all rules contained in the policy. I also
understand how to report incidents of sexual abuse as set forth in the abuse policy, and that
retaliation against any employee/volunteer exercising his or her rights under the policy is
prohibited.




____________________________                                   ________________________
Employee/Volunteer                                             Employee/Volunteer’s
Printed Name                                                   Signature




Date:_________________________




This policy is to be signed annually by all employees, volunteers, and Board Members.




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       ADMISSION TO HOSPICE OF MONTEZUMA                                                                 Policy Number:
     PRIOR CERTIFICATION OF TERMINAL ILLNESS                                                                     PC.A20
 NHPCO Standard(s):
 Regulatory Citation / Other: 42 CFR 418.22; CoP 418.102(a)
 Adopted 9/26/2007                                                                  Reviewed/Revised: 3/24/2010



POLICY STATEMENT: The Hospice of Montezuma Medical Director and the patient's
attending physician (if the patient has one) sign a written statement prior to the patient’s
admission to Hospice of Montezuma, certifying that the patient's prognosis is 6 months or less
if the terminal illness follows its normal course.

PROCEDURES:

1. The Certification of Terminal Illness form specifies that the patient’s prognosis is for a life
    expectancy of six months or less if the terminal illness runs its normal course.

2. The certification of the patient’s terminal illness is based on the physician’s clinical
    judgment regarding the normal course of the patient’s illness.

3. Clinical information (which may be provided verbally initially, but must also be obtained in
    writing prior to billing for care) and other documentation that supports the patient’s
    medical prognosis and the physician’s certification of terminal illness is included in the
    patient’s clinical record and documented as part of Hospice of Montezuma’s eligibility
    assessment.

4. If the Hospice of Montezuma Medical Director and the patient’s attending physician are not
    available to sign the Certification of Terminal Illness form the day of admission, a verbal
    certification is obtained from both physicians within two days and is documented in the
    patient’s clinical record. Signatures must be obtained before billing for care begins.

5. The signed Certification of Terminal Illness form is available in the patient’s clinical record
    prior to submitting claims for payment.

6. The Hospice of Montezuma Medical Director must consider the following information
    when making his/her certification decision based on review of the patient’s medical records:
          a. diagnosis of the terminal condition of the patent;
          b. other health conditions, whether related or unrelated to the terminal condition;
             and
          c. current clinically relevant information supporting all diagnoses.




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    ADMISSION TO HOSPICE OF MONTEZUMA, INC.                                                             Policy Number:
                 CRITERIA FOR ADMISSION                                                                         PC.A25
 NHPCO Standard(s): PFC 2.1; IA 1.2; OE 2.1; CLR 2.2
 Regulatory Citation / Other:
 Adopted 9/26/2007                                                                  Reviewed/Revised: 3/24/2010



POLICY STATEMENT: Patients who meet the admission criteria are admitted to Hospice of
Montezuma without regard to ancestry, religion, gender, age, physical or mental disabilities,
sexual orientation or ability to pay.

PROCEDURES:

1. During the referral process, Hospice of Montezuma staff determine the patient’s eligibility
   for hospice care based on the following criteria:
            a. verbal or written certification by the patient’s attending physician (if there is
                one) and Hospice of Montezuma’s Medical Director that the patient has a
                prognosis of 6 months or less if the disease follows its normal course;
            b. medical records from physicians, hospitals, and/or other health care providers
                supporting the prognosis;
            c. the patient resides in the geographic area served by Hospice of Montezuma,
                specifically the counties of Dolores, La Plata, San Juan, San Miguel, and
                Montezuma, CO;
            d. patient care in areas outside of the named counties will be coordinated upon
                notification of the need;
            e. the patient understands and accepts the palliative nature of Hospice of
                Montezuma care and no longer seeks aggressive treatment;
            f. there is a capable primary caregiver living in the home or, if no caregiver is
                available, the patient agrees to assist Hospice of Montezuma in developing a
                plan of care to meet his or her future needs;
            g. Hospice of Montezuma has adequate resources and staffing to meet the needs
                of the patient; and
            h. the patient and/or caregiver wish to receive Hospice of Montezuma services.

2. If it is determined that the patient does not meet the criteria for admission, reasons for non-
   acceptance are documented in the EMR and communicated to the referrer and
   patient/caregiver as appropriate.

3. Efforts are made to refer non-accepted patients to appropriate community resources or other
   health care providers.

4. A plan for follow up contact with non-accepted patients is developed and recorded in the
   EMR.

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                                                                       PC.A25, Page 2
5. Hospice of Montezuma collects data regarding the appropriateness and timeliness of
   admissions that is utilized in Hospice of Montezuma’s Quality Assessment and
   Performance Improvement (QAPI) program.




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       ADMISSION TO HOSPICE OF MONTEZUMA, INC                                                          Policy Number:
       ELECTION OF THE MEDICARE HOSPICE BENEFIT                                                                PC.A30
                                                                                                            Page 1 of 2
 NHPCO Standard(s):
 Regulatory Citation / Other: 42 CFR 418.24
 Adopted: 9/26/2007                                                               Reviewed/Revised: 3/24/2010



POLICY STATEMENT: Medicare beneficiaries are required to sign an election statement
regarding their intent to receive services from Hospice of Montezuma

PROCEDURES:

1. During the admission process, the patient or his or her legal representative signs Hospice of
   Montezuma’s election form. The election form:
         a. identifies Hospice of Montezuma as the hospice that will provide care to the
            individual;
         b. states that the individual or representative acknowledges that he or she has been
            given a full understanding of Hospice of Montezuma care;
         c. states that the individual or representative acknowledges that he or she
            understands that certain Medicare services are waived by the election; and
         d. includes the effective date of the election and the signature of the individual or
            representative.

2. When a Medicare beneficiary elects the Hospice of Montezuma benefit, he or she waives the
   right to the following services for the duration of the Hospice of Montezuma election:
           a. Hospice care provided by a hospice other than Hospice of Montezuma;
           b. any Medicare services related to the terminal condition for which Hospice of
               Montezuma care was elected except:
                     i. services provided (either directly or under arrangement) by Hospice of
                        Montezuma.;
                    ii. services provided by another hospice under arrangements made by
                        Hospice of Montezuma or
                   iii. services provided by the patient’s independent attending physician if that
                        physician is not an employee of Hospice of Montezuma. or receiving
                        compensation from Hospice of Montezuma. for those services.

3. The patient’s election to receive Hospice of Montezuma care continues through the initial
   election period of 90 days and subsequent election periods without a break as long as the
   patient remains in the care of Hospice of Montezuma and does not revoke
   or is not discharged.


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                                                                                    PC.A30 Page 2

4. An individual may designate an effective date for the election period that begins with the
   first day of Hospice of Montezuma care or any subsequent day of Hospice of Montezuma
   care, but an individual may not designate an effective date that is earlier than the date that
   the election form is signed.

5. The patient is not required to sign additional election statements unless he or she has
   revoked the Medicare benefit or been discharged from Hospice of Montezuma.

6. When the beneficiary either revokes the Hospice of Montezuma benefit or is discharged
   from Hospice of Montezuma, and later meets the conditions of the Hospice of Montezuma
   benefit, he or she must complete a new notice of election.

7. If a patient is incapacitated and/or unable to sign the election form, the patient’s legal
   representative may sign the form. If the patient’s representative is not available, the election
   form may be faxed or sent to him or her by overnight mail for signature. “Verbal elections”
   are not accepted and the election becomes effective on the date the form is signed.




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 ADMISSION TO HOSPICE OF MONTEZUMA, INC.                                                      Policy Number:
  ELIGIBILITY DETERMINATION FOR MEDICARE                                                              PC.A35
                                                                                                   Page 1 of 2
 NHPCO Standard(s): PFC 2.1; IA 1.2; IA 1.3; CLR 2.2
 Regulatory Citation / Other: 42 CFR 418.20
 Adopted 9/26/2007                                                       Reviewed/Revised: 3/24/2010

POLICY STATEMENT: Patients must meet eligibility requirements to be admitted to Hospice
of Montezuma for Medicare-covered services.

PROCEDURES:
1. To be eligible to elect the Hospice Medicare benefit, the patient must:
          a. be entitled to Medicare Part A; and
          b. be certified by the Hospice of Montezuma Medical Director and attending
               physician (if there is one) as being terminally ill (having a prognosis of six
               months or less if the illness follows its normal course).

2. Hospice of Montezuma admits a patient only on the recommendation of the Hospice of
   Montezuma Medical Director in consultation with, or with input from, the patient’s
   attending physician (if there is one).

3. Hospice of Montezuma adopts and implements Local Coverage Determinations (LCD’s),
   formerly Local Medical Review Policies (LMRP’s), provided by its fiscal intermediary.

4. Prior to admission, all patients are assessed for Hospice of Montezuma appropriateness and
   eligibility using the LCD guidelines. Patients who meet the LCD guidelines are eligible for
   admission.

5. Failure to meet the LCD guidelines does not disqualify a patient for admission to Hospice of
   Montezuma. Patients who do not fully meet the LCD guidelines are discussed with the
   Hospice of Montezuma Medical Director in order to determine hospice appropriateness and
   eligibility. Additional documentation is needed to support Hospice of Montezuma
   eligibility if the patient does not meet the LCD guidelines.

6. Hospice of Montezuma staff may use the following assessment tools to measure and
   document functional status:
        a. Edmonton Symptom Assessment;
        b. *Reisberg Functional Assessment Staging (FAST); and/or
        c. *Karnofsky Performance Scale (KPS).




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                                                                                                   PC.A35 Page 2

7. Complete and timely documentation of the specific clinical factors that qualify a patient for
   the Medicare hospice benefit is provided in the patient's clinical record.

8. Documentation regarding the patient’s eligibility for the Medicare hospice benefit is
   maintained, appropriately organized in legible form, and available for audit and review.

9. The final determination of Hospice of Montezuma eligibility is the responsibility of the
   Hospice of Montezuma Medical Director.

10. The patient’s clinical record contains complete documentation to support the certification
    made by the Hospice of Montezuma Medical Director and attending physician.

11. Hospice of Montezuma periodically evaluates its eligibility requirements and limitations
    with the goal to increase access to hospice care in the community.

12. Hospice of Montezuma employs oversight mechanisms to ensure that the terminal illness of
    a Medicare beneficiary is verified and accurately documented.




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  ADMISSION TO HOSPICE OF MONTEZUMA, INC.                           Policy Number:
                INFORMED CONSENT                                              PC.A40
 NHPCO Standard(s): EBR 1.1; EBR 1.2; EBR 4.2; CES 21.3
 Regulatory Citation / Other: 42 CFR 418.62; CoP 418.52(b)(2)
 Adopted 9/26/2007                                       Reviewed/Revised: 3/24/2010

POLICY STATEMENT: Informed consent for Hospice of Montezuma care is obtained from the
patient or designated representative and documented in the clinical record.

PROCEDURES:

1. Prior to admission, all patients (or their legal representatives) are given a complete
   description of the palliative nature of hospice care and the services provided by Hospice of
   Montezuma.

2. All patients and/or their legal representatives are required to acknowledge that they have
   been given a complete understanding of the services to be provided by Hospice of
   Montezuma and of the Medicare hospice benefit if applicable.

3. Patients and/or their legal representatives are informed of the eligibility requirements for
   Hospice of Montezuma services and that the goal of hospice care is directed toward relief of
   symptoms rather than the cure of the underlying disease.

4. A signed consent form is obtained from each patient or their legal representative and is
   included in the patient’s clinical record.

5. Care is not provided unless and until a signed consent form is received.

6. If a patient has been adjudged incompetent, the person appointed pursuant to State law to
   act on the patient’s behalf signs the informed consent form.

7. Regular clinical record audits ensure that consent form has been signed and received from
   every patient prior to the start of care.




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  ADMISSION TO HOSPICE OF MONTEZUMA, INC.                 Policy Number:
                 PHYSICIAN’S ORDERS                                PC.A45
 NHPCO Standard(s): CES 21.3; WE 13.2; WE 13.3
 Regulatory Citation / Other: CoP 418.54(a)
 Adopted: 9/26/2007                            Reviewed/Revised: 3/24/2010

POLICY STATEMENT: Patients admitted to Hospice of Montezuma have a physician’s order
for care.

PROCEDURES:

1. Hospice of Montezuma obtains orders from a physician according to law, regulation and
   professional standards of practice before providing care.

2. Verbal orders are put in writing and signed and dated with the date of receipt by the person
   accepting the order.

3. Verbal orders are only accepted by personnel authorized to do so by applicable State or
   Federal laws and regulations.

4. The Patient Care Coordinator or designee is responsible for confirming the admission orders
   with the patient’s attending physician (if there is one) or the Hospice of Montezuma Medical
   Director.

5. The admission orders are sent to the physician’s office for signature and upon receipt by
   Hospice of Montezuma, placed in the patient’s clinical record.

6. Hospice of Montezuma verifies the licensure of physicians, nurse practitioners and other
   authorized individuals who provide orders or prescriptions for patients. See Addendum
   PC.A45 for procedure.

7. The Patient Care Coordinator or designee makes an initial assessment visit within forty–
   eight (48) hours after Hospice of Montezuma receives a physician’s admission order for
   care.




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                                       Hospice of Montezuma

               Addendum PC.A45: Procedure for Verifying Licensure

  1. Access the Colorado Division of Registrations homepage at:
            http://www.dora.state.co.us/registrations/index.htm

  2. On the left side of the screen, under the Registration Online Services menu, click
      on “Verify a Colorado Licensee.”
  3. A new page opens. Under the heading “Online License Verification”, click the
      link to ALISON.
  4. You will be asked to choose a method of accessing the secure site.
  5. On the secure website, leave the search criteria at “Search all Boards” and click
      on “Go To Search Form.”
  6. Enter the name of the person whose license you wish to verify.
  7. Click on “Begin Search.”You will either receive verification or a statement that
      the person you searched for was not located.
  8. Physicians working with the IHS do not appear in the registry above.

Accessing NPI Number

  1. Access the National Plan & Provider Enumeration System (NPPES) at:
         https://nppes.cms.hhs.gov/NPPES
  2. Click on Search the “NPI Registry”
  3. Go to Search the NPI Registry and either
         Search for an Individual Provider or
         Search for an Organizational Provider
  4. Enter the last name. Click on Search.
  5. Print results for our records

Accessing UPIN Number

  1. Access the NEBO Systems eCare Online ECare UPIN Lookup at:
         http://upin.ecare.com
  2. Enter last name and first name. Click on “Process Request”
  3. Print results for our records




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       ADMISSION TO HOSPICE OF MONTEZUMA                                                    Policy Number:
                    PROCESS                                                                         PC.A50
                                                                                                 Page 1 of 2
 NHPCO Standard(s): PFC 2.1; IA 1.2; CLR 2.2
 Adopted 9/26/2007                                                     Reviewed/Revised: 3/24/2010

POLICY STATEMENT: Admission to Hospice of Montezuma may occur 24 hours per day,
seven days per week. Prior to initiation of the admission process:
       1. the patient must be determined hospice eligible
       2. the attending physician/Hospice of Montezuma Medical Director must have
          completed the Certification of Terminal Illness form or have given verbal certification.
       3. the attending physician/Hospice of Montezuma Medical Director must have written
          care orders.

PROCEDURES:

1. The patient is eligible for Hospice of Montezuma care when admission criteria including the
   Certification of Terminal Illness are met and, the Patient Care Coordinator or designee
   completes the admission of the patient to Hospice of Montezuma.

2. The Hospice of Montezuma Patient Care Coordinator or designee gives report to the
   patient’s attending physician or designee and obtains and documents verbal orders for the
   care and treatment of the patient.

3. The Hospice of Montezuma Patient Care Coordinator or designee notifies the Hospice of
   Montezuma Medical Director or designee of the admission and completes the required
   documentation.

4. The Patient Care Coordinator, designee, or On Call Nurse performs the admission using the
   Admission Checklist as a guide. Whenever possible, a social worker participates in the
   admission process. Those disciplines whose role includes care plan development may assist
   with an admission. An Initial Plan of Care is developed during the admission process and a
   copy is provided to the patient/caregiver.

5. The patient will be offered a Do Not Resuscitate order at admission if there is not one in
   their records.

6. The admitting nurse registers the patient with the equipment vendor, pharmacy, and others
   as needed.

7. Care may be provided by a Home Health Aid and other disciplines when the admission
   process has been completed and the collaborative care plan has been developed.

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                                                                                            PC.A50 Page 2

8. The Patient Care Coordinator, or designee, assigns an RN Case Manager (primary nurse) to
   review, implement and coordinate the patient’s plan of care.

9. The admitting nurse notifies appropriate interdisciplinary team members and the On-Call
   Nurse of the admission and communicates pertinent patient/caregiver information.

10. The admitting nurse develops and documents the patient’s initial plan of care in
    consultation with any or all of the following: the family, other members of the
    interdisciplinary team, the Hospice of Montezuma Medical Director and the patient’s
    attending physician (if there is one).

11. Admission documentation is to be completed within forty-eight (48) hours




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       ADMISSION TO HOSPICE OF MONTEZUMA                                                       Policy Number:
                  READMISSION                                                                          PC.A55
 NHPCO Standard(s):
 Regulatory Citation / Other:
 Adopted 9/26/2007                                                    Reviewed/Revised: 3/24/2010

POLICY STATEMENT: Hospice of Montezuma will readmit any patient who meets the
Hospice of Montezuma admission criteria.

PROCEDURES:

1. When a patient is readmitted, patient information and medical records since the previous
   admission are obtained and documented.

2. A new Face Sheet is completed and the patient is reassigned his or her original medical
   record number.

3. If the referral to readmit the patient is made by someone other than the patient’s attending
   physician, the attending physician is contacted to confirm appropriateness of the admission
   and the physician’s continued involvement with the patient.

4. If it was less than thirty (30) days since the patient revoked, was discharged or transferred
   from Hospice of Montezuma, an abbreviated admission process will be completed
   including, at a minimum:
           a. new admission orders from the patient’s attending physician;
           b. a nursing reassessment;
           c. a reassessment by the Social Worker completed within 48 hours of the admission;
           d. signed Medicare election and informed consent forms; and
           e. updated information regarding advance directives.

5. The Hospice of Montezuma Medical Director will be notified and asked to recertify the
   patient.

6. If it was longer than 30 days since the patient left the care of Hospice of Montezuma, a
   complete admission is performed.

7. When possible and appropriate, staff assignments include team members who provided
   care to the patient/caregiver during the previous admission.

8. Readmission documentation is to be completed within forty-eight (48) hours



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       ADMISSION TO HOSPICE OF MONTEZUMA                                                       Policy Number:
                   REFERRALS                                                                           PC.A60
                                                                                                    Page 1 of 2
 NHPCO Standard(s): PFC 2.1; CES 1.1
 Regulatory Citation / Other:
 Adopted 9/26/2007                                                    Reviewed/Revised: 3/24/2010

POLICY STATEMENT: Hospice of Montezuma accepts referrals of clients for hospice care 24
hours a day, 7 days a week from any interested party (family, friends, clergy, health agencies or
facilities, etc.) Contact will be made by phone or in person within 24 hours of the referral.

PROCEDURES:

1. During scheduled working hours of 8:00am to 5:00pm, Monday through Friday, referrals
   are taken by the Patient Care Coordinator or designee, who completes the Referral/Intake
   Form and/or enters the referral into Suncoast.

2. Outside of scheduled working hours, referrals are taken by the On-Call Nurse, who
   completes the Referral/Intake Form and notifies the referral source that a Hospice of
   Montezuma representative will return their call the same day or next day. The On-Call
   Nurse responds to urgent referrals for admission.

3. When someone other than the attending physician makes a referral, the Patient Care
   Coordinator, designee, or the On-Call Nurse contacts the client’s attending physician and
   Hospice of Montezuma Medical Director to confirm the client’s eligibility for hospice care,
   and to obtain medical records and orders to admit the client for Hospice of Montezuma
   services.

4. If the attending physician or Hospice of Montezuma Medical Director denies approval of
   the referral to Hospice of Montezuma, the Patient Care Coordinator or designee or On-Call
   Nurse notifies the referral source of the attending physician’s/ Hospice of Montezuma
   Medical Director’s response. The referral is cancelled in Suncoast, with documentation as to
   why the client was not admitted.

5. When the referral is initiated or approved by the attending physician/ Hospice of
   Montezuma Medical Director/ and orders have been obtained, the Patient Care Coordinator
   or designee:
          a. contacts the client/caregiver to schedule an appointment to visit within twenty-
              four (24) hours unless the client/caregiver requests otherwise.
          b. notifies the Social Worker of the date, time, and the location of the initial
              appointment.
          c. provides a copy of the Referral/Intake Form to the SW.

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                                                                                    PC.A60 Page 2

           d. notifies the referral source of the Hospice of Montezuma intervention(s).

6. For an afterhours referral/intake, the On-Call Nurse notifies the Patient Care Coordinator or
   designee and provides information from the Referral/Intake Form. The On-Call Nurse
   contacts the client/caregiver to schedule the admission visit.

7. If the client is appropriate for admission, the Patient Care Coordinator or designee visits the
   client/caregiver at the agreed upon date, time, and location. The admitting nurse provides
   information on the hospice philosophy of care and the scope of services offered by Hospice
   of Montezuma, and admits the client if they choose hospice care.

8. All referrals who are not admitted are, with their permission, contacted every 2-4 weeks to
   provide support and offer services if appropriate at that time.

9. A copy of the referral will be provided to the business manager who will begin the
   authorization process. It is the responsibility of the business manager to coordinate with
   private insurances regarding pre-authorizations and payments or verifying grant funds.
   When the business manager is not available, the admitting nurse or Executive Director will
   begin the authorization process.




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     ADMISSION TO HOSPICE OF MONTEZUMA                                                          Policy Number:
     REFERRALS FROM ACUTE CARE FACILITIES                                                                PC.65
 NHPCO Standard(s):
 Regulatory Citation / Other:
 Approved: 9/26/2007                                                      Reviewed/Revised: 3/24/2010

POLICY STATEMENT: Hospice of Montezuma responds to referrals from acute care facilities
of those clients with a life-threatening illness who meet admission criteria.

PROCEDURES:

1. Referrals from acute care facilities must be accompanied by a physician’s order.

2. The Patient Care Coordinator or designee reviews the client’s hospital chart to determine
   the client’s eligibility for Hospice of Montezuma services.

3. The Patient Care Coordinator, designee, or Social Worker meets with the client/caregiver to
   explain the services provided by Hospice of Montezuma and any care limitations.

4. If the client is eligible for Hospice of Montezuma care, and the client and family desire
   services, the Hospice of Montezuma Patient Care Coordinator, designee, or Social Worker:
       a. completes a pre-admission assessment.
       b. documents the visit and outcome on the hospital chart according to hospital policy.

5. The Hospice of Montezuma Patient Care Coordinator, designee, or Social Worker continues
   to visit the client and contacts the hospital nurse, discharge planner, and/or attending
   physician during regular business hours to inquire about the condition of the client and any
   noted changes.

6. Prior to the client's discharge from the hospital, the Hospice of Montezuma Client Care
   Coordinator or designee:
      a. checks the insurance coverage and obtains pre-authorization if necessary
      b. confirms all needed equipment and services, documents this information on the face
         sheet, and orders equipment through the appropriate vendor.
      c. obtains orders for medications as needed.
      d. confirms a meeting time with the client at his or her place of residence for admission
         after discharge from the hospital.




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            ADVANCE BENEFICIARY NOTICE                                                          Policy Number:
                                                                                                        PC.A70
                                                                                                     Page 1 of 2
 NHPCO Standard(s):
 Regulatory Citation / Other: CoP 418.52(e)
 Adopted 9/26/2007                                                     Reviewed/Revised: 3/24/2010

POLICY STATEMENT: Hospice of Montezuma provides Medicare beneficiaries (or their
representatives) with an Advance Beneficiary Notice (ABN) when it is likely that Medicare will
not pay for a particular item or service.

PROCEDURES:

1. The ABN form (CMS R-131-G) is completed accurately and cites the particular items or
   services for which payment will be or is likely to be denied and the expected reasons for the
   denial.

2. The most likely instances for issuing an ABN to a Hospice of Montezuma patient include:
         a. when the beneficiary no longer meets Medicare’s definition of terminally ill and
              the patient is thus no longer eligible for the Medicare Hospice of Montezuma
              benefit but the patient wants service to continue.
         b. the patient requests remaining at a level of care that is higher (for instance, the
              general inpatient level of care) than what is reasonable or medically necessary to
              manage the patient’s terminal illness.
         c. items and services that are billed separately from the Hospice of Montezuma
              payment (for example, physician services) that are not reasonable or medically
              necessary.

3. The ABN form is given to Medicare beneficiaries by the Primary Nurse or the Social Worker
   far enough in advance of furnishing items or services that are not likely to be covered so that
   the beneficiary may make an informed decision regarding whether or not to assume the
   responsibility for financial liability if necessary.

4. The Social Worker or Primary Nurse fully explains the ABN to the beneficiary or his or her
   legal representative to ensure comprehension.

5. The Medicare beneficiary’s signature (or that of his or her legal representative) is obtained
   on two copies of the form. One copy of the form is left with the Medicare beneficiary
   (patient) and the second copy is returned to Hospice of Montezuma.




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                                                                                   PC.A70 Page 2

6. The ABN form is not given during emergencies or when the patient is under duress, and is
   only provided when there is a specific, identifiable reason to believe that Medicare will not
   pay for the items or services.




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                               Hospice of Montezuma, Inc.
                               Advance Beneficiary Notice (ABN)

Patient’s Name:_________________________                       Medicare # (HICN):___________

Advance Beneficiary Notice note: You need to make a choice about receiving these health care
items or services. We expect that Medicare will not pay for the item(s) or service(s) that are
described below. Medicare does not pay for all of your health care costs. Medicare only pays for
covered items and services when Medicare rules are met. The fact that Medicare may not pay
for a particular item or service does not mean that you should not receive it. There may be a
good reason your doctor recommended it. Right now, in your case, Medicare probably will not
pay for:



Because:



The purpose of this form is to help you make an informed choice about whether or not you
want to receive these items or services, knowing that you might have to pay for them yourself.
Before you make a decision about your options, you should read this entire notice carefully.
• Ask us to explain, if you don’t understand why Medicare probably won’t pay.
• Ask us how much these items or services will cost you.

(Estimated Cost: $_________________),in case you have to pay for them yourself or through
other insurance.

PLEASE CHOOSE ONE OPTION. CHECK ONE BOX. SIGN & DATE YOUR CHOICE.
��Option 1. YES. I want to receive these items or services. I understand that Medicare will not
decide whether to pay unless I receive these items or services. Please submit my claim to
Medicare. I understand that you may bill me for items or services and that I may have to pay
the bill while Medicare is making its decision. If Medicare does pay, you will refund to me any
payments I made to you that are due to me. If Medicare denies payment, I agree to be
personally and fully responsible for payment. That is, I will pay personally, either out of pocket
or through any other insurance that I have. I understand I can appeal Medicare’s decision.

��Option 2. NO. I have decided not to receive these items or services. I will not receive these
items or services. I understand that you will not be able to submit a claim to Medicare and that I
will not be able to appeal your opinion that Medicare won’t pay.

______________________________________                         ______________
Signature of patient or legal representative                   Date




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NOTE: Your health information will be kept confidential. Any information that we collect
about you on this form will be kept confidential in our offices. If a claim is submitted to
Medicare, your health information on this form may be shared with Medicare. Your health
information which Medicare sees will be kept confidential by Medicare.
OMB Approval No. 0938-0566 Form No. CMS-R-131-G (June 2002)




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                  ADVANCE DIRECTIVES                                                           Policy Number:
                                                                                                       PC.A75
NHPCO Standard(s): EBR 1.3; EBR 1.4; EBR 1.5
Regulatory Citation / Other: 42 CFR 498.102; CoP 418.52(a)(2)
Adopted 9/26/2007                                     Reviewed/Revised: 3/24/2010

POLICY STATEMENT: Hospice of Montezuma complies with all State and Federal laws
regarding advance directives and informs and distributes written information to the patient on
his or her right to formulate advance directives. The provision of hospice care is not
conditioned upon whether or not the individual has executed an advance directive.

PROCEDURES:

1. During the admission interview, and prior to receiving care, the Hospice of Montezuma
   Patient Care Coordinator or designee, or Social Worker asks whether the patient has
   executed an advance directive. If not, Hospice of Montezuma provides written information
   and instruction on advance directives to the patient. If the patient is unable to understand
   this information, it is given to the patient’s legal health care representative or proxy. The
   written information given to the patient and or legal representative includes:
            a. Hospice of Montezuma’s policies on the implementation of the patient’s
               advance directives including any limitations;
            b. a description of the patient’s rights under State law, including the patient’s right
               to formulate an advance directive and the right to accept or refuse medical or
               surgical treatment, including do not resuscitate (DNR) orders.

2. In the administrative section of the patient's clinical record, the Hospice of Montezuma
   Patient Care Coordinator or designee or Social Worker documents that the patient has
   received written information related to advance directives and whether the patient has or has
   not executed an advance directive.

3. If available, a copy of any advance directive is placed in the patient's clinical record and the
   patient’s wishes, including his or her DNR status, are communicated to members of the
   interdisciplinary team to be included in care planning for the patient.

4. If the opportunity to formulate an advance directive is declined at the time of admission, the
   patient may execute one at a later date by notifying a staff member who then notifies the
   Social Worker. The Social Worker provides the patient with appropriate forms and ensures
   that they are properly completed.




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                                                                                              PC.A75



5. DNR orders are signed by the patient’s physician with a copy placed in the patient’s clinical
   record, the On-Call book and on the patient’s refrigerator. The original is retained by the
   patient.

6. Education is provided to Hospice of Montezuma staff and the community regarding advance
   directives, advance care planning and patient rights in regard to advance directives.




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            ASSESSMENT – COMPREHENSIVE                                                           Policy Number:
             ASSESSMENT OF THE PATIENT                                                                   PC.A80
  NHPCO Standard(s): PFC 2.2; CES 1; WE 11.3
  Regulatory Citation / Other: CoP 418.54
  Adopted 9/26/2007                                                    Reviewed/Revised: 3/24/2010

 POLICY STATEMENT: Following admission and the development of the initial plan of care,
 the Hospice of Montezuma interdisciplinary team conducts and documents a patient-specific
 comprehensive assessment that identifies the patient’s need for hospice care, including medical,
 nursing, psychosocial, emotional and spiritual care.

 PROCEDURES:

1. The Hospice of Montezuma Patient Care Coordinator or designee makes an initial assessment
   visit to the patient/caregiver within twenty-four (24) hours after Hospice of Montezuma
   receives a physician’s admission order for care, in order to determine the patient’s immediate
   care and support needs.

2. The comprehensive assessment of the patient is completed by members of the
   interdisciplinary team in consultation with the patient’s attending physician no later than five
   (5) calendar days after the patient elects the Hospice of Montezuma benefit.

3. The Patient Care Coordinator or designee coordinates the comprehensive assessment process
   and ensures that the patient’s physical, emotional, psychosocial, spiritual, and bereavement
   needs are assessed.

4. Each member of the interdisciplinary team provides input into the comprehensive assessment
   within the scope of his/her practice.

5. Discipline-specific assessment tools obtain accurate and timely information that guide
   decisions for the development of the patient’s plan of care. These tools are available in the
   computerized documentation system.

6. The patient’s comprehensive assessment is updated at a minimum every 14 days and before
   the patient is recertified into a new benefit period.

7. The Hospice of Montezuma’s assessment and reassessment tools contain data elements that
   allow for the measurement of outcomes.

8. The interdisciplinary team treats and attempts to prevent symptoms of the patient’s disease
   and/or co-morbidity factors based on findings in the comprehensive assessment and
   reassessments.

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             ASSESSMENT – CONTENT OF THE                           Policy Number: PC.A85
              COMPREHENSIVE ASSESSMENT                                           Page 1 of 2
  NHPCO Standard(s): PFC 8; PFC 9.1; PFC 11; PFC 11.3; PFC 12; PFC 14.1; PFC 14.2; CES
  1.2; CES 1.3; CES 1.4; CES 2.1; CES 3. CES 3.2; CES 7; CS 7.1; CES 7.3
  Regulatory Citation / Other: CoP 418.54(c)
  Adopted: 9/26/2007                                           Reviewed/Revised: 3/24/2010

 POLICY STATEMENT: The comprehensive assessment identifies the physical, psychosocial,
 emotional and spiritual needs of the patient related to the terminal illness that must be
 addressed in order to promote the patient’s well-being, comfort, and dignity throughout the
 dying process.

 PROCEDURES:

1. The comprehensive assessment of the patient consists of the following discipline-specific
   assessment tools:
           a. the nursing assessment (RN); nursing care may not be provided until the initial
               nursing assessment is completed by the RN
           b. the psychosocial assessment (SW);
           c. the spiritual care assessment (RN, SW or Clergy); and
           d. the volunteer assessment (RN, SW, or Volunteer Coordinator )

2. Each assessment tool is designed to obtain information related to the patient’s history, current
   status, problems, and needs and contain data elements for the collection of information
   related to patient outcomes.

3. The nursing assessment tool assesses the patient’s:
            a. medical history;
            b. nature and conditions causing admission;
            c. physical condition;
            d. complications and risk factors that affect care planning;
            e. nutritional status;
            f. pain and other symptoms;
            g. safety;
            h. communication barriers;
            i. caregiver competency and availability;
            j. current prescriptions and over-the counter drug profile including allergies,
               ineffective drug therapies, unwanted drug side and toxic effects and drug
               interactions;
            k. the need for referrals and further evaluation by members of the interdisciplinary
               team and other health professionals; and


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                                                                                                PC:.A85 page 2
             l.   preliminary psychosocial, spiritual and bereavement needs

4. The psychosocial assessment tool assesses the patient/caregiver’s;
           a. emotional status,
           b. social history,
           c. financial and legal needs,
           d. funeral planning,
           e. available support systems,
           f. need for volunteer services,
           g. potential bereavement risk factors,
           h. preferred styles of communicating,
           i. advance directives and
           j. need for spiritual care services.



5. The spiritual assessment tool assesses the patient/caregiver’s spiritual needs related to end-of-
   life issues;
              a. reconciliation, if indicated;
              b. requests for visits from clergy,
              c. prayer,
              d. spiritual concerns such as the meaning of life and death, after-life and funeral
                 planning.

6. The interdisciplinary team uses information obtained from the comprehensive assessment
   tools to develop an effective plan of care with interventions that address the identified needs
   of the patient/caregiver.




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                  ASSESSMENT - INITIAL                                                         Policy Number:
                                                                                                       PC.A90
 NHPCO Standard(s): PFC 2.2
 Regulatory Citation / Other: CoP 418.54(a)
 Adopted: 9/26/2007                                                   Reviewed/Revised: 3/24/2010

POLICY STATEMENT: An initial assessment to determine the patient’s immediate care and
support needs is conducted by the Hospice of Montezuma Patient Care Coordinator or designee
within twenty-four (24) hours of receiving a physician’s order for the patient’s Hospice of
Montezuma care.

PROCEDURES:

1. Hospice of Montezuma’s staff immediately informs the Patient Care Coordinator or
   designee when physician orders for a patient have been received.

2. The Patient Care Coordinator or designee attempts to conduct an initial assessment of the
   patient’s immediate needs within 24 hours of receipt of the order. A complete nursing
   assessment must be documented by a RN prior to the provision of any nursing care.

3. If an initial assessment is not made within 24 hours of receipt of the order, documentation in
   the patient’s clinical record provides an explanation of the reason why.

4. Acceptable reasons for not conducting the initial assessment visit within 24 hours may
   include:
          a. orders by the physician to conduct the initial assessment at another time;
          b. a request from the patient/caregiver for a later visit time; and/or
          c. the patient/caregiver not available at time of the scheduled visit.

5. The Hospice of Montezuma Patient Care Coordinator or designee completes the initial
   assessment tool and ensures that orders for treatment and services are obtained to meet the
   immediate support needs of the patient.




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 ASSESSMENT – UPDATES TO THE COMPREHENSIVE                 Policy Number:
                       ASSESSMENT                                  PC.A100
 NHPCO Standard(s):
 Regulatory Citation / Other: CoP 418.54(d)
 Adopted: 9/26/2007                         Reviewed/Revised: 3/24/2010

POLICY STATEMENT: The Hospice of Montezuma’s interdisciplinary team updates the
comprehensive assessment and reassesses the patient’s response to care on a regular basis.

PROCEDURES:

1. A patient’s progress toward desired outcomes is reassessed as often as required by the
   patient’s condition but no less frequently than every 14 days.

2. The patient’s response to care is also reassessed at the time of recertification into a new
   benefit period in order to determine the patient’s continued eligibility for Hospice of
   Montezuma care.

3. Information from the updated comprehensive assessment is reviewed by the
   interdisciplinary team at Interdisciplinary team (IDT) meetings and is used to revise the
   patient’s plan of care as needed.

4. Documentation of the interdisciplinary team’s care planning meetings reflects the ongoing
   reassessment of the patient/caregiver’s status and needs.




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                ATTENDING PHYSICIANS                                                              Policy Number:
                                                                                                         PC.A105
 NHPCO Standard(s): WE 13; WE 13.1; WE 13.4; WE 13.5; WE 13.6
 Regulatory Citation / Other: CMS Program Memorandum A-03-053 on Nurse
 Practitioners
 Adopted 9/26/2007                                  Reviewed/Revised: 3/24/2010

POLICY STATEMENT: The patient’s attending physician provides initial and ongoing
management of the medical component of the patient’s care.

PROCEDURES:

1. At the time of admission to Hospice of Montezuma, the patient or his/her representative
   designates an attending physician who will have the most significant role in the
   determination and delivery of the patient’s medical care. The call physician designated by
   the attending physician is deemed the attending physician for after hours care.

2. The attending physician must be a doctor of medicine or osteopathy licensed to practice in
   the State of Colorado.

3. The attending physician may be a nurse practitioner* who is a registered nurse as permitted
   by Colorado laws and regulations to perform the duties of an attending physician.

4. The patient may designate the Hospice of Montezuma’s Medical Director as his/her
   attending physician if the patient does not have a primary care physician at the time of
   admission to Hospice of Montezuma.

5. Hospice of Montezuma communicates expectations and responsibilities to attending
   physicians, including but not limited to:
          a. management of the patient’s medical care;
          b. participation in the establishment, development and review of the patient’s plan
              of care;
          c. providing verbal and signed orders within time frames required by laws and
              regulations;
          d. availability to Hospice of Montezuma staff and the patient/caregiver;
          e. sharing information as needed to facilitate the continuity of care;
          f. consultation with Hospice of Montezuma’s Medical Director or physician
              designee(s) as needed; and
          g. signing the initial certification of terminal illness form that certifies that the
              patient has a prognosis of six months or less if the illness follows its normal
              course. (Nurse Practitioners acting as the attending physician are not allowed to
              perform this function.).

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                    AVAILABILITY 24/7                                   Policy Number:
                                                                               PC.A110
 NHPCO Standard(s): PFC 1; PFC 1.1; PFC 1.2; PFC 1.3; PFC 16.1; CES 4.6; CES 20.3
 Regulatory Citation / Other: CFR 42 418.50(b)(1)(2)
 Adopted 9/26/2007                                    Reviewed/Revised: 3/24/2010

POLICY STATEMENT: Care and services provided by Hospice of Montezuma are available 24
hours a day, 7 days a week, as needed to meet the needs of patients and their caregivers.

PROCEDURE:

1. Hospice of Montezuma assures that there is adequate staffing to meet the needs of its
   patients.

2. On-call services are provided to patients and their caregivers after business hours and on
   weekends and holidays for telephone consultation and visits as needed.

3. The Hospice of Montezuma Medical Director or designee provides 24-hour coverage for
   patient medical needs that arise.

4. Hospice of Montezuma maintains contracts with medical equipment companies to assure
   that medical equipment (including emergency maintenance, replacement or backup) and
   supplies are available to all patients 24/7 and in a timely fashion. A medical supply
   inventory is maintained at the office and may be accessed on an as needed basis.

5. Contractual agreements are maintained with pharmacies/ hospitals in the Hospice of
   Montezuma’s service area to assure that medications are readily available.

6. Contracts with acute care facilities throughout the Hospice of Montezuma’s service area are
   maintained to provide general inpatient and inpatient respite care when necessary.

7. Other Hospice of Montezuma services, including social work services, spiritual care, and
   bereavement support, are available on an on-call basis as needed outside of normal business
   hours.

8. Interdisciplinary team members are available to attend patient deaths twenty-four (24)
   hours a day, seven (7) days a week.




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           BEREAVEMENT – CARE PLANNING                                                          Policy Number:
                                                                                                        PC.B10
 NHPCO Standard(s): PFC 17.1; PFC 19; PFC 19.1; PFC 19.3; PFC 19.4
 Regulatory Citation / Other: 42 CFR 418.88(a); CoPs 418.54(c)(3)(i) and 418.64(d)(1)
 Adopted: 2/24/2010                                  Reviewed/Revised: 8/6/2010

POLICY STATEMENT: Bereavement needs, interventions, goals and outcomes are developed
and documented for designated family members and caregivers in the bereavement plan of
care.

PROCEDURES:

1. At the time of the patient’s admission to hospice, the interdisciplinary team identifies family
   members, caregivers, or significant others who are at risk for a complicated grief reaction. A
   bereavement risk assessment is completed for each caregiver/significant other and updated
   during interdisciplinary team meetings.

2. The team monitors the evolving bereavement needs of the patient and identified persons
   while the patient is active on the program while the patient is on service.

3. The Bereavement Coordinator is notified of all deaths and initiates the bereavement
   discussion and care planning at the first interdisciplinary team meeting following the
   patient’s death. At this time, the bereavement plan of care is developed. The Social Worker
   for the patient/family (if the family accepted Social Work visits) is responsible for fulfilling
   the bereavement plan of care with the exception of mailings. Bereavement patients who do
   not need individual sessions may be referred to the Bereavement Coordinator for ongoing
   services.

4. The bereavement plan of care reflects the assessed needs of the bereaved and notes the kind
   of bereavement services to be provided and the frequency of delivery.

5. The Bereavement Coordinator ensures that the bereavement plan of care is followed for
   thirteen (13) months following the patient’s death, appropriate to the level of need assessed.

6. Bereavement services listed in a patient’s bereavement plan of care may include, but are not
   limited to: bereavement visits and counseling, mailings and/or telephone contact.

7. Support groups, community education, and/or additional bereavement services are
   provided on an as needed basis.

8. A Memorial Service is offered annually.


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                  BEREAVEMENT – FILES                                                          Policy Number:
                                                                                                       PC.B15
 NHPCO Standard(s): PFC 17.1; PFC 19.2
 Regulatory Citation / Other:
 Adopted: 2/24/2010                                               Reviewed/Revised: 8/6/2010

POLICY STATEMENT: A bereavement file is developed for each patient admitted to the
hospice program.

PROCEDURES:

1. A condolence card and a bereavement file is initiated for each patient by the Office Manager
   the first working day after the death.

2. The bereavement file is maintained by the Social Worker (if the patient/family accepted
   social work) or the Bereavement Coordinator for thirteen months after the patient’s death.

3. The electronic bereavement file contains or provides access to:
     a. a copy of the patient’s Psychosocial Assessment;
     b. the bereavement risk assessment(s) and care plan(s) for the person(s) for
        whom the hospice will provide bereavement services; and
     c. bereavement notes documenting all services to and contact with the
        bereaved person(s).

4. The Bereavement Coordinator or assigned Social Worker updates information in the file as
   needed.

5. The Bereavement Coordinator retains and maintains the paper bereavement files in a secure
   and locked filing cabinet for thirteen months following the patient’s death.

6. At the completion of bereavement services, the contents of the paper file are merged with
   the patient’s clinical record.




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               BEREAVEMENT – MAILINGS                                                          Policy Number:
                                                                                                       PC.B20
 NHPCO Standard(s): PFC 17.1; PFC 17.4
 Regulatory Citation / Other:
 Adopted: 2/24/2010                                                     Reviewed/Revised: 8/6/2010

POLICY STATEMENT: Bereavement mailings are sent to identified family members,
caregivers and significant others of deceased hospice patients. These mailings are sent at
regular intervals: condolence card signed by IDT team within 10 days of the death; letter
introducing bereavement services and scheduled open bereavement groups at two weeks;
bereavement information letters at three months, six months, nine months and thirteen months.
The mailings include standardized bereavement literature appropriate to the needs of the
bereaved person and may include a personalized note.

PROCEDURES:

1. Within ten days of the patient’s death, the Office Manager sends a sympathy card that is
   signed by members of the hospice interdisciplinary team as appropriate.

2. An initial letter explaining Hospice of Montezuma’s bereavement services is sent two weeks
   after the patient’s death.

3. The second bereavement mailing is sent three months after the patient’s death. A schedule
   of current bereavement groups is included.

4. The third bereavement mailing is sent six months after the patient’s death. This mailing
   includes a schedule restating bereavement groups offered and a Bereavement Update Form
   with a stamped envelope addressed to Hospice of Montezuma.

5. The fourth bereavement mailing is sent nine months after the patient’s death.

6. The final bereavement contact is a phone call thirteen months after the patient’s death and
   includes an explanation regarding the ending of formal bereavement services provided by
   Hospice of Montezuma. The Bereavement Evaluation Form is mailed following this phone
   call. If the bereavement client is not reached by phone, a letter explaining the end of
   bereavement services is sent and the Bereavement Evaluation Form is enclosed.

7. When Memorial Services are offered, an invitation is sent to the family members, caregivers
   and/or significant others of patients who have died within the previous thirteen months.




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          BEREAVEMENT – RISK ASSESSMENT                               Policy Number:
                                                                              PC.B25
 NHPCO Standard(s): PFC 17.1; PFC 18; PFC 18.1; PFC 18.2; PFC 18.3; PFC 19.4
 Regulatory Citation / Other:
 Adopted: 2/24/2010                                 Reviewed/Revised: 8/6/2010

POLICY STATEMENT: Hospice patients and significant family members and caregivers are
assessed for grief and bereavement needs.

PROCEDURES:

1. During the comprehensive assessment of the patient, information is obtained related to
   anticipated bereavement needs of the patient’s family, caregivers and significant others.

2. Throughout the course of the patient’s care, members of the interdisciplinary team reassess,
   document and address the anticipatory mourning needs of the patient’s family, caregivers
   and significant others.

3. Bereavement risk factors and needs of family members, caregivers, and significant others
   are identified and documented by the Social Worker or, if the family refused Social Work,
   by the Bereavement Coordinator in collaboration with other team members.

4. Each person designated to receive bereavement services is categorized according to level of
   risk for complicated grief reactions and receives appropriate interventions according to
   identified need.

5. The three levels of bereavement risk are determined as follows:
          a. High risk
          b. Moderate risk
          c. Low risk

6. The interventions associated with the three levels of risk are as follows:
          a. Low risk – condolence call within 72 hours of the death, condolence card within
              10 days after the death, a phone call within four (4) weeks of the patient’s death,
              invitations to bereavement support groups and memorial services, and mailings
              at 3, 6, 9, and 13 months following the patient’s death.
          b. Moderate risk – includes all of the above and a phone call within two (2) weeks
              of patient’s death as well as continued assessment of need for additional services.
          c. High risk – includes all of the above and a scheduled visit offered within two (2)
              weeks of the patient’s death, plus additional information regarding community
              resources, bereavement literature and, if necessary, referral to appropriate
              professional assistance.

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7. If the needs of the bereaved are beyond the scope of the service provided by the hospice,
   referrals are made to appropriate community resources or practitioners.




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                 BEREAVEMENT – SERVICES                                      Policy Number:
                                                                                      PC.B30
  NHPCO Standard(s): PFC 2.7; PFC 17; PFC 17.1; PFC 17.2. PFC 17.3; PFC 17.4; PFC 19.3;
  PFC 20; PFC 20.1; PFC 20.2; IA 3; IA 3.1; IA 3.2; IA 3.3; IA 3.4
  Regulatory Citation / Other: CoP 418.64(d)(1)
  Adopted: 2/24/2010                                               Reviewed/Revised: 8/6/2010

 POLICY STATEMENT: Hospice of Montezuma has an organized program for the provision of
 bereavement services available to the hospice patient’s family members, caregivers and
 significant others and to the community at large.

 PROCEDURES:

1. Hospice of Montezuma’s bereavement program is under the supervision of the Bereavement
   Coordinator who is a qualified professional with experience in grief and loss counseling.

2. Hospice of Montezuma provides bereavement services to the family, caregivers and/or
   significant others of deceased hospice patients for thirteen months following the patient’s
   death.

3. The bereavement services provided are based on the assessed needs of the deceased’s
   survivors and are in accordance with a bereavement plan of care formulated after the
   patient’s death.

4. Bereavement services provided include, but are not limited to:
           a. letters and supportive information provided at two weeks, and three, six, nine
              and thirteen months after the patient’s death;
           b. support groups;
           c. memorial services;
           d. bereavement visits and/or phone calls

5. Bereavement services are also provided to members of the community and may include
   support groups, community education, crisis counseling, and working with schools or
   businesses impacted by loss.




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   BEREAVEMENT – TRACKING AND EVALUATION                                                       Policy Number:
                                                                                                       PC.B35
 NHPCO Standard(s): PFC 17.1
 Regulatory Citation / Other: 42 CFR 418.88(a)
 Adopted: 2/24/2010                                                   Reviewed/Revised: 8/6/2010

POLICY STATEMENT: Hospice of Montezuma monitors the patient’s family, caregiver and /
or significant others receiving bereavement care for thirteen months following the death of the
patient

PROCEDURES:

1. A bereavement file is initiated at the time of the patient’s death that contains documentation
   related to all bereavement services, intervention and support provided to the patient’s
   family, caregiver and/or significant other(s).

2. The Bereavement Coordinator or assigned Social Worker documents the dates when each of
   the follow-up services, as specified in the bereaved person's plan of care, has been
   completed.

3. At least two attempts are made to reach the family member / caregiver / significant other of
   the deceased patient within the designated time as determined by the bereavement plan of
   care. If no one can be reached, a “No Answer” letter is sent informing the bereaved that
   attempts have been made to be in contact.

4. Family members, caregivers and significant others of the hospice’s patients have the right to
   refuse bereavement services and support at any time.

5. To ensure that the bereavement program meets the individual bereavement needs of the
   persons served, the schedule of services may vary somewhat from the initial bereavement
   plan of care. Any deviations are documented.

6. The evaluation of the hospice’s bereavement services is conducted twice: in the Family
   Evaluation of Hospice Care sent three months after the death, and at the end of bereavement
   services.

7. Data obtained from returned bereavement surveys/questionnaires is used to improve the
   bereavement services offered by Hospice of Montezuma.




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       CHANGE OF DESIGNATED HOSPICE                                                             Policy Number:
                                                                                                        PC.C10
 NHPCO Standard(s): CES 9; CES 9.1; CES 9.4
 Regulatory Citation / Other: 42 CFR 418.30
 Adopted 9/26/2007                                          Reviewed/Revised: 8/6/2010

POLICY STATEMENT: A patient may change, once in each election period, the designation of
the particular hospice from which he or she elects to receive hospice care. The change of the
designated hospice is not considered a revocation of the election of the Medicare Hospice
benefit.

PROCEDURES:

1. When a hospice patient wishes to change the designation of hospice programs, the patient
   must file, with both Hospice of Montezuma and with the newly designated hospice, a
   signed statement that includes the following information:
       a. the name of the hospice from which the individual has received care;
       b. the name of the hospice from which he or she plans to receive care; and
       c. the date the change is to be effective.

2. Hospice of Montezuma follows its discharge and transfer policies and procedures when a
   patient chooses to transfer to another hospice program, ensuring the necessary medical
   records accompany the patient.

3. Hospice of Montezuma follows its admissions policies and procedures when a patient
   chooses to transfer from another hospice program to Hospice of Montezuma, including
   obtaining copies of all pertinent medical records.




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                CLINICAL RECORDS                                        Policy Number:
                                                                                PC.C15
                                                                             Page 1 of 2
 NHPCO Standard(s): CES 21; CES 21.1;CES 21.2; CES 21.3; CES 21.4; CES 21.5; CES 21.6;
 CES 21.8
 Regulatory Citation / Other: 42 CFR 418.74; CoP 418.104
 Adopted 9/26/2007                               Reviewed/Revised: 8/6/2010

POLICY STATEMENT: A clinical record is established and maintained for every patient
receiving care and services from Hospice of Montezuma. The record is complete, promptly and
accurately documented, readily accessible, and systematically organized to facilitate retrieval.

PROCEDURES:

1. Entries are made in the clinical record for all services provided (both those services
   provided directly and through contracted providers) in a standardized format and are
   signed by the person providing the services.

2. Each patient’s clinical record includes, at a minimum, the following:
      a. identification data;
      b. referral information and pertinent medical history;
      c. the plan of care, initial assessment, comprehensive assessment and updated
          comprehensive assessments, clinical notes and progress notes;
      d. signed informed consent, physician orders, authorization and election forms;
      e. documentation of the patient’s responses to medications, symptom management,
          treatments and services;
      f. outcome measure data elements;
      g. physician certification and recertification statements; and
      h. copies of advance directives (if applicable).

3. Access to patient clinical records is restricted to members of the interdisciplinary team, the
   patient, and employees who require such access to perform their jobs effectively.

4. A patient’s entire clinical record may only be used or disclosed in accordance with the
   Hospice of Montezuma’s policies and procedures related to uses and disclosures of
   protected health information.

5. Hospice of Montezuma has a zero tolerance policy for falsification of clinical records.




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                                                                                    PC.C15 Page 2



6. The clinical record contains a discharge summary and clinical records of discharged patients
   are completed within 2 weeks of the patient’s discharge from Hospice of Montezuma care.

7. The patient’s clinical record is entered into the computerized documentation system by all
   providers of care. Forms requiring patient signatures and certain other forms are not
   available in the computerized record and are completed by hand. In these instances a hard
   copy is placed in the patient’s physical chart and a reference note is entered in the
   computerized record stating completion of such a form.

8. When an error is made in the written clinical record, it may only be corrected by drawing a
   single thin line through the error with the initials of the individual making the correction.
   White-out liquid or tape, erasure, or obliteration of the error by multiple cross-outs and/or
   write-overs is not allowed.

9. When an error is made in the computerized clinical record, it may only be corrected by
   completing a Systems Trouble Report which is available on the network P drive.

10. Clinical records are safeguarded against loss or destruction. Computer drives containing
    patient data are backed up daily and the backup is taken off site.

11. Clinical records are retained and protected in compliance with the Federal regulations for
    the privacy and security of protected health information.




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                 COMMUNICATION BARRIERS                                                           Policy Number:
                                                                                                          PC.C20
 NHPCO Standard(s): PFC 11.3
 Regulatory Citation / Other:
 Adopted 9/26/2007                                                        Reviewed/Revised 8/6/2010

POLICY STATEMENT: Hospice of Montezuma ensures that all patients/caregivers receive
information in a language and in a manner that is understandable to them.

PROCEDURES:

1.    Questions regarding the patient’s ability to communicate are asked during the
      referral/intake process.

2.    If a patient has a language or sensory impediment that hampers meaningful
      communication, efforts are made to ensure the patient’s communication needs can be met
      during the admission process.

3.    For patients/caregivers with limited English proficiency

      a.   If the patient does not speak English, attempts are made to secure an interpreter from
           amongst the patient’s family or friends.

      b.   The Patient Care Coordinator or designee maintains a list of staff and volunteers who
           have proficiency in other languages who may serve as interpreters.

      c.   Admission and other written materials are read aloud to patients by the translator and
           the opportunity is provided to ask questions before signing forms.
      d.
      e.   Hospice of Montezuma maintains access to the AT&T Language Line. The Patient Care
           Coordinator maintains the information required to access the AT&T Language Line
           when necessary to meet the communication needs of the patient.

3.    For visually impaired patients:

      a.    The Hospice of Montezuma nurse reads aloud all documents normally provided to the
            patient during admission and documents that the patient/caregiver has understood
            what was read.




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                                                                                                          PC.C20 Page 2

4.    For hearing impaired patients:

      a. The Hospice of Montezuma nurse determines if writing, lip reading or signing is the
          most effective means of communication with the patient.

      b. If sign language is the most effective means of communication, Hospice of Montezuma
          contacts resources in the community that provide signing services (SW BOCS at 565-
          8411).




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                COMMUNITY RESOURCES                                                            Policy Number:
                                                                                                       PC.C25
 NHPCO Standard(s):
 Regulatory Citation / Other:
 Adopted 9/26/2007                                                    Reviewed/Revised: 11/18/10

POLICY STATEMENT: The Social Worker assists the patient and his or her caregivers in
obtaining available community resources to help meet their needs.

PROCEDURES:

1. The Social Worker assesses the needs of the patient and his or her caregiver(s) on an
   ongoing basis.

2. Based on the assessment, the Social Worker facilitates referrals to community resources as
   needed and desired by the patient or caregiver(s).

3. The Social Worker maintains an updated listing of community resources that may
   potentially be needed by patients and their caregivers.

4. With the consent of the patient or caregiver(s), the Social Worker provides the referral
   source with appropriate information regarding the needs which precipitated the referral.

5. The Social Worker follows up with the patient/caregiver to ensure their needs were met by
   the community resource.

6. The Social Worker documents all referrals and all outcomes in the patients’ computerized
   clinical records.




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              COMPLEMENTARY THERAPIES                                                           Policy Number:
                                                                                                        PC.C30
 NHPCO Standard(s): CES 6.3; WE 16; WE16.1; WE16.2
 Regulatory Citation / Other:
 Adopted 9/26/2007                                Reviewed/Revised: 11/18/10

POLICY STATEMENT: Complementary therapies are offered when appropriate for symptom
management and/or as an adjunct to promote quality of life.

PROCEDURES:

1. Complementary therapies that may be provided include, but are not limited to:
       a.   acupuncture;
       b.   aromatherapy;
       c.   comfort touch
       d.   expressive therapy;
       e.   reflexology;
       f.   hypnosis;
       g.   Reiki; and
       h.   massage.

2. Complementary therapies are provided by qualified Hospice of Montezuma employees,
   volunteers, or contracted providers under the supervision and professional management of
   the interdisciplinary team.

3. The provision of complementary therapies is included in the patient’s plan of care and
   based on assessed need.

4. A physician’s order for complementary therapies is obtained when required.




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                INABILITY TO PAY FOR CARE                                                        Policy Number:
                                                                                                         PC.C35
 NHPCO Standard(s):
 Regulatory Citation / Other: 42 CFR 418.60; CoP 418.100(d)
 Adopted 9/26/2007                                     Reviewed/Revised: 11/18/10

POLICY STATEMENT: Hospice of Montezuma does not discontinue or diminish care
provided to a Medicare beneficiary, or any patient, because of the individual’s inability to pay
for that care.

PROCEDURES:

1.    Medicare beneficiaries who are eligible for the Medicare hospice benefit receive
      comprehensive interdisciplinary care and services related to their terminal illness.

2.    Care and services provided are in accordance with the patient’s plan of care and are based
      on the patient’s identified needs for the palliation and management of symptoms related to
      the terminal illness.



3.    Patients who are not beneficiaries of Medicare or Medicaid, or who are underinsured or
      uninsured, receive care through the Indigent Care Program at Hospice of Montezuma.
      Their care is equal in every respect to the care provided to patients with a pay source.




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                    CONTINUITY OF CARE                                                            Policy Number:
                                                                                                          PC.C40
 NHPCO Standard(s): CES 8; CES 9; CES 9.2; CES 9.3; CES 21.5
 Regulatory Citation / Other: 42 CFR 418.56(a); CoP 418.56(e)(4)
 Adopted 9/26/2007                                      Reviewed/Revised: 11/18/10

POLICY STATEMENT: Hospice of Montezuma assures the continuity of care for the
patient/caregiver(s) in the home, outpatient and inpatient settings.

PROCEDURES:

1.    All disciplines providing services to the patient/caregiver follow established
      communication mechanisms to ensure that services continue without interruption
      whenever there are changes to the patient’s level of care or care setting.

2.    The Hospice of Montezuma’s transfer, revocation and discharge policies and procedures
      are followed to assure continuity of care and well coordinated transitions for
      patient/caregivers and other service providers.

3.    Education regarding the Hospice of Montezuma philosophy of care and the patient’s
      hospice plan of care is provided to other providers as needed when there is a change in the
      patient’s care setting.

4.    The clinical records of patients transferring to a different level of care or care setting
      contain detailed information that promotes continuity of care.




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             COORDINATION OF SERVICES                                                          Policy Number:
                                                                                                       PC.C45
 NHPCO Standard(s): PFC 2; PFC 2.4; PFC 2.5; CES 8.2; WE 5.3; WE 16
 Regulatory Citation / Other: Cop 418.56(e)
 Adopted 9/26/2007                                  Reviewed/Revised: 11/18/10

POLICY STATEMENT: The interdisciplinary team maintains responsibility for directing,
coordinating and supervising the care and services provided to Hospice of Montezuma’s
patients and their caregivers.


PROCEDURES:

1. The Patient Care Coordinator or designee assumes overall responsibility for the
   coordination of the care and services provided by the interdisciplinary team.

2. The RN Case Manager (primary nurse) coordinates the patient’s plan of care and facilitates
   communication with the attending physician, contracted facilities, vendors, and other
   members of the interdisciplinary team.

3. The interdisciplinary team meets every week to provide care planning for the Hospice of
   Montezuma’s patients/caregivers. Each patient/caregiver is discussed, at a minimum,
   every15 days.

4. All members of the interdisciplinary team participate in care planning and document
   problems, interventions, goals, observations, and outcomes based on the assessed and
   reassessed needs of the patient/caregiver.

5. All members of the interdisciplinary team, volunteers, and contracted personnel have access
   to the patient’s plan of care and are expected to provide care in accordance with it.

6. Continuity of care is facilitated by established formal and informal communication
   mechanisms between all disciplines providing care (whether directly or under contract).
   These communication mechanisms include, but are not limited to:
      a. interdisciplinary team meetings;
      b. ad hoc case conferences when needed;
      c. family meetings as appropriate;
      d. discharge and/or transfer summaries as needed;
      e. telephone communications and voice mail; and
      f. report from and to on-call staff




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             DEATH OF A HOSPICE PATIENT                                                        Policy Number:
                                                                                                       PC.D10
                                                                                                    Page 1 of 3
 NHPCO Standard(s): PFC 16; PFC 16.1; PFC 16.2; PFC 16.3; PFC 16.4
 Regulatory Citation / Other:
 Adopted 9/26/2007                                  Reviewed/Revised: 11/18/10

POLICY STATEMENT: Members of the Hospice of Montezuma’s interdisciplinary team are
available to attend patient deaths 24 hours a day, 7 days a week. The Hospice of Montezuma
nurses are sworn in as Assistant Deputy Coroners in Montezuma County and this allows them
to do death pronouncement. In addition, professional nurses may pronounce death and release
the body of the deceased as specified in Colorado Nurse Practice Act
     Professional nurses licensed under the act of May 22, 1951 (P.L. 317, No. 69) known as
       the “The Professional Nursing Law,” as amended, who are involved in direct care of a
       patient shall have the authority to pronounce death as determined under the act of
       December 17, 1982 (P.L. 1401, No. 323) known as the “Uniform Determination of Death
       Act,” in the case of death from natural causes of a patient who is under the care of a
       physician when the physician is unable to be present within a reasonable period of time
       to certify the cause of death. For this policy “who are involved in direct care” means
       patients under the direct care of a professional nurse employed by Hospice of
       Montezuma.
     A determination of death must be made in accordance with accepted medical standards
       (Uniform Determination of Death Act).
     Professional nurses shall have the authority to release the body of the deceased to a
       funeral director after notice has been given to the attending physician, and to a family
       member.
     If circumstances surrounding the nature of death are not anticipated and require a
       coroner’s investigation, the professional nurse shall notify the county coroner, and the
       release to the funeral home shall be the responsibility of the coroner.
     The pronouncement of death by professional nurses shall be in accordance with the
       Uniform Determination Act, which in no way authorizes a nurse to determine the cause
       of death. The responsibility for determining the cause of death remains with the
       physician or coroner.



PROCEDURES:

For an expected death at home:

1. The patient and family are prepared as to the signs and symptoms of approaching death as
   well as having a written protocol to follow.


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                                                                   Policy Number: PC.D10 p.2



2. The RN Case Manager or designee visits the home of a patient when notified that the
   patient death is imminent or has occurred. The Social Worker, Chaplain, or Bereavement
   Coordinator may accompany the RN Case Manager as appropriate.

3. The RN Case Manager assesses the patient for the absence of an apical pulse and
   respirations The Hospice of Montezuma staff attending the death respects the cultural,
   religious and spiritual traditions of the patient’s family/caregivers and provides support as
   needed and appropriate. The offer is made to bathe the body.

4. The patient’s death is pronounced, documented and communicated in accordance with
   State laws and regulations.

5. The Hospice of Montezuma staff member(s) may notify the selected funeral home of the
   patient's death. If funeral arrangements have not been made, assistance is provided.

6. The Hospice of Montezuma nurse clamps and removes all tubing that enters the body,
   empties all drainage bags, and turns off IV pumps and oxygen.

7. The body is placed in as natural a position as is possible and is handled with respect and
   dignity.

8. The patient's prescribed medications are disposed of with a family member or other witness
   present. The Prescription Medication Disposition Sheet is completed.

9. The patient’s attending physician is notified of the date and time of death. A message is left
   with the physician's answering service for deaths occurring after normal business hours.

10. The RN case manager or nurse attending the death will complete the Final Checklist form.

11. The Hospice of Montezuma nurse and/or other Hospice of Montezuma staff remain at the
   residence until the body has been removed and the bereaved are coping effectively. The
   offer will be made to strip the bed. DME from Hospice will be removed by the Hospice staff
   who attends the death unless the family requests another arrangement.

12. The Hospice of Montezuma office notifies all appropriate parties of the patient's death.
   After hours or on weekends and holidays, the On Call RN notifies all team members
   involved in the patient’s care.




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                                                                Policy Number: PC.D10 p.3

 13. The RN Case Manager notifies the equipment company of the need to pick-up equipment
      (DME) from the home. If death occurs after hours, the equipment company is notified the
      next morning.

 14. The primary hospice caregivers should attend the memorial services for the patient if
      possible.

 For death in the hospital, nursing home or assisted living;

 1. The institution’s staff will notify the RN Case Manager, Patient Care Coordinator or On-call
      nurse at the time of death.

 2. The nurse will speak with the patient’s family and make a visit unless the family refuses.

3.    The nurse will notify other team members as for any other death.

 4. The hospice nurse and bereavement counselor will provide support for the family members.

 5. The nurse attending the death will complete the Final Checklist form.

 6. The primary hospice caregivers should attend the memorial services for the patient if
      possible.




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                    DIETARY SERVICES                                                            Policy Number:
                                                                                                        PC.D15
 NHPCO Standard(s): CES 3.2
 Regulatory Citation / Other: 42 CFR 418.88(b); CoP 418.64((d)(2)
 Adopted 9/26/2007                                     Reviewed/Revised: 11/18/10

POLICY STATEMENT: The nutritional status of the patient is assessed during the
comprehensive assessment and reassessments.

PROCEDURES:

1. The changing dietary needs of the patient are evaluated and documented regularly by the
   interdisciplinary team as appropriate.

2. Members of the interdisciplinary team educate the patient/caregiver regarding the
   nutritional needs of patients at the end of life.

3. When the interdisciplinary team or attending physician identifies special nutritional needs,
   the RN Case Manager or designee contacts a qualified individual to provide nutritional
   counseling.

4. When additional nutritional counseling is identified as a need in the patient’s plan of care,
   the designated nutritional counselor:
       a. assesses the patient's nutritional problems and counsels the patient/caregiver as
          needed;
       b. provides the patient/caregiver with written guidelines, menus, recipes, samples of
          supplements when appropriate, and printed educational materials; and
       c. documents the diet/nutritional problems, suggestions and information provided to
          the patient/caregiver in the patient's clinical record.




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       DISCHARGE FOR REASONS OTHER THAN                                                       Policy Number:
                    DEATH                                                                             PC.D20
                                                                                                   Page 1 of 2
 NHPCO Standard(s): CES 9; CES 9.1; CES 9.4; CES 21.7; IA 1.2
 Regulatory Citation / Other: 42 CFR 418.26; CoP 418.104(e)                    Reviewed/Revised 12/23/10


POLICY STATEMENT: Hospice of Montezuma follows a consistent plan for
discontinuance of services and supports the patient/caregiver with referrals and
planning for continued care as appropriate.

PROCEDURES:

1. Hospice services may be discontinued:
     a. if the patient moves outside the geographical area serviced by Hospice of
         Montezuma or transfers to another hospice;
     b. if the patient no longer meets the eligibility requirements for hospice care;
     c. if the patient desires curative care or aggressive treatment that is inconsistent
         with Hospice of Montezuma philosophy and/or the patient’s plan of care;
     d. if the patient chooses to receive treatment from an inpatient facility with
         which Hospice of Montezuma does not have and/or cannot obtain a written
         agreement;
     e. if the patient no longer desires hospice services; and/or
     f. for cause, if Hospice of Montezuma determines that the patient’s (or other
         persons in the patient’s home) behavior is disruptive, abusive, or
         uncooperative to the extent that the delivery of care to the patient or the
         ability of Hospice of Montezuma to operate effectively is impaired.

2. Before the patient can be discharged for cause, Hospice of Montezuma:
      a. advises the patient that a discharge for cause is being considered;
      b. makes a serious effort to resolve the problem(s) caused by the patient’s
          behavior or the situation;
      c. ensures that the decision to discharge the patient is not related to the
          patient’s use of necessary hospice services; and
      d. documents in the patient’s clinical record the problem(s) and the efforts made
          to resolve the situation.




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3. When a patient is discharged from hospice (and is not transferring to another
   hospice), he or she is no longer covered under the Medicare hospice benefit, resumes
   Medicare coverage of the benefits waived by the election of hospice care and may, at
   any time, elect to receive hospice care again in the future if he or she meets the
   eligibility requirements.

4. Prior to discharge, Hospice of Montezuma obtains a written physician’s discharge
   order from Hospice of Montezuma Medical Director and consults with the patient’s
   attending physician (if there is one), documenting his or her review of the discharge
   decision in the discharge note.

5. If the interdisciplinary team determines that the patient no longer meets Hospice of
   Montezuma’s eligibility requirements, discharge planning occurs as follows:
       a. the RN Case Manager consults with the patient’s attending physician
           regarding the need for other health care services and obtains appropriate
           discharge and referral orders;
       b. the RN Case Manager or Social Worker arranges for these services at the
           request of the patient/caregiver after acquiring physician approval;
       c. the patient and his or her caregivers are included in the discharge planning
           process and members of the interdisciplinary team provide appropriate
           education and support as needed; and
       d. notification of the discharge date is provided to the patient and to the
           patient’s attending physician as soon as it is determined.

6. When the patient is discharged from hospice because eligibility criteria are no longer
   met, Hospice of Montezuma provides a copy of the clinical record and Hospice of
   Montezuma discharge summary to the patient’s attending physician. This discharge
   summary is filed in the clinical record and includes:
      a. a summary of the patient’s stay including treatments, symptoms and pain
         management;
      b. the patient’s current plan of care;
      c. the patient’s latest physician orders; and
      d. any other documentation that will assist in post-discharge continuity of care.




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        DOCUMENTATION REQUIREMENTS                                                          Policy Number:
                                                                                                    PC.D25
                                                                                                 Page 1 of 2
 NHPCO Standard(s): PFC 7.3; CES 21.3; WE 11.4
 Regulatory Citation / Other:                                                Reviewed/Revised: 12/23/10


POLICY STATEMENT: Members of the interdisciplinary team document the
interventions provided to the patient/caregiver, their response to care, services
provided and the goals or outcomes achieved.

PROCEDURES:

1. Documentation is completed by all hospice staff and volunteers whenever:
     a. patient/caregiver visits occur;
     b. patient/caregiver phone conversations related to the patient’s condition or
        care occur;
     c. community resource contact related to a patient/family/caregiver is initiated;
        and/or
     d. physician or healthcare provider contact is made on behalf of the patient.

2. All documentation is completed in black ink or in the electronic medical record.

3. Documentation must be legible, grammatically correct, accurate, and completed
   within one working day. Medication changes must be documented the same day
   they occur.

4. When an error is made in the clinical record, it may only be corrected by the
   individual who made the error. Errors are corrected by submitting a written request
   to the Security Officer or Executive Director stating the reason for the request to
   unsign the document. The original of this form is filed in the patient’s paper record.
   Corrections to paper forms are made by drawing a single thin line through the error
   and initialing the error. White-out liquid or tape, erasure, or obliteration of the error
   by multiple cross-outs and/or write-overs or electronic deletion is not allowed.
   Electronic documents are unsigned only in those cases in which the erroneous
   documentation could be dangerous to the patient. All non-dangerous errors are
   corrected through a documentation addendum.

5. Only agency-authorized abbreviations may be used.


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                                                                                  PC.D25 Page 2



6. The last name of the patient, followed by the complete first name, not just initial, is
   noted on every page of documentation.

7. The patient’s clinical record number is noted on every page of documentation.




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       DURABLE MEDICAL EQUIPMENT (DME)                                                       Policy Number:
                                                                                                     PC.D30

 NHPCO Standard(s): PFC 11.1; CES 20; CES 20.1; CES 20.2; CES 20.3; CES 20.4; CES 20.5
 Regulatory Citation / Other: Proposed CoP 418.106(c)          Reviewed/Revised: 12/23/10


POLICY STATEMENT: Hospice of Montezuma provides for the safe and effective use
of medical equipment including delivery, setup, maintenance and training of staff,
patients, family members and other caregivers.

PROCEDURES:

1. Hospice of Montezuma maintains contracts with vendors for the provision of safe
   and effective DME for Hospice of Montezuma’s patients. Certain types of DME may
   be provided directly by Hospice of Montezuma.

2. The DME provider is responsible for the selection, delivery, setup, maintenance and
   pickup of all DME provided to Hospice of Montezuma’s patients by the vendor.

3. The DME provider assures that emergency maintenance, replacement and backup of
   DME is available 24 hours a day, seven days a week.

4. DME must be approved by Hospice of Montezuma interdisciplinary team, ordered
   by the patient’s attending physician, and included in the patient’s plan of care.

5. The RN Case Manager requests the ordered DME from the DME provider and
   informs the patient/caregiver of its expected delivery time and ensures that the
   patient/caregiver receive adequate instruction and information related to the
   equipment used by the patient.

6. All equipment hazards, defects and recalls are appropriately addressed and
   reported as required by the Safe Medical Devices Act. Any employee who
   experiences, witnesses, or receives a report of the failure of a medical device
   completes a Hospice of Montezuma Incident Report and submits it to his or her
   supervisor within 24 hours of the event or discovery of the event.

7. Hospice of Montezuma complies with manufacturer’s instructions, and State laws
   regarding the use of DME.


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       HOSPICE CARE FOR FACILITY RESIDENTS                                                    Policy Number:
                                                                                                      PC.F25
 NHPCO Standard(s): NF PFC 1
 Regulatory Citation / Other: Proposed CoP 418.112                            Reviewed/Revised: 12/23/10


POLICY STATEMENT: Hospice of Montezuma ensures that all care and services
routinely offered to hospice patients is available to individuals eligible for hospice care
who reside in nursing or assisted living facilities.

PROCEDURES:

1. Hospice of Montezuma provides services to patients who reside in facilities when a
   written agreement that specifies the responsibilities of Hospice of Montezuma and
   the facility has been signed and is in effect.

2. Hospice of Montezuma does not offer or provide gifts, free services, or other
   incentives to patients, relatives of patients, or physicians of the facility for the
   purpose of inducing referrals of facility residents.

3. Hospice of Montezuma does not engage in the referral-inducing practice of “patient
   charting”.

4. Hospice of Montezuma assumes full responsibility for the professional management
   of the facility patient’s hospice care and routinely provides all core services
   including nursing, medical social services and counseling.

5. Hospice of Montezuma Medical Director provides overall coordination of the
   medical care of the facility patient in collaboration with the patient’s attending
   physician and the facility’s Medical Director.

6. Hospice of Montezuma may use the facility’s nursing personnel to assist in the
   administration of prescribed therapies included in the patient’s plan of care only to
   the extent that Hospice of Montezuma would routinely utilize the services of a
   hospice patient’s family in implementing the plan of care.

7. Hospice staff provides orientation and training to facility staff as needed and
   bereavement care to identified facility staff when appropriate.



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   HOSPICE CARE FOR FACILITY RESIDENTS –                                                      Policy Number:
           HOSPICE PLAN OF CARE                                                                       PC.F30
 NHPCO Standard(s): NF PFC 1.1; PFC 2.2
 Regulatory Citation / Other: CoP 418.112(f)                                 Reviewed/Revised: 12.23.10


POLICY STATEMENT: A written plan of care is established and maintained for each
facility patient and is developed and coordinated with the Hospice of Montezuma
interdisciplinary team in consultation with facility representatives and the patient’s
attending physician.

PROCEDURES:

1. The Primary Nurse assigned to the facility patient is responsible for coordinating
   and implementing the patient’s plan of care in collaboration with members of
   Hospice of Montezuma interdisciplinary team and with representatives from the
   facility.

2. All care provided to the facility patient must be in accordance with the written plan
   of care that includes the patient’s current medical, physical, social, emotional and
   spiritual needs.

3. The plan of care for the facility patient identifies the care and services that are
   needed and specifically identifies which provider is responsible for performing the
   respective functions that have been agreed upon and included in the plan of care.

4. The plan of care reflects the participation of Hospice of Montezuma, the facility and
   the patient and his/her family to the extent possible.

5. In conjunction with a representative from the facility, the plan of care is reviewed, at
   a minimum, every fourteen days.

6. Any changes to the plan of care are discussed among all caregivers and must be
   approved by Hospice of Montezuma before implementation.




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           HOME HEALTH AIDE SERVICES                                                          Policy Number:
                                                                                                      PC.H10
 NHPCO Standard(s): WE 19; WE 19.1; WE 19.2; WE 19.3
 Regulatory Citation / Other: 42 CFR 418.94; CoP 418.76                       Reviewed/Revised: 12.23.10


POLICY STATEMENT: Home health aide services are provided under the supervision
of a registered nurse by individuals who have current Certified Nurse Aide certification
and who have successfully completed a competency evaluation program as required by
regulations.

PROCEDURES:
1. Hospice of Montezuma ensures that there are enough home health aides employed
   by Hospice of Montezuma to meet the needs of its patients. If necessary, Hospice of
   Montezuma contracts with other entities to provide home health aides and ensures
   that the overall quality of services provided and the qualifications of the contract
   aides meet regulatory requirements.

2. Home health aide services are assigned based on the Primary Nurse’s
   comprehensive assessment and reassessment of the patient’s personal care needs
   and ability to perform activities of daily living.

3. The Primary Nurse develops a written home health aide plan of care that provides
   instructions to the home health aide of the care to be provided.

4. The home health aides’ services are ordered by the attending physician, included in
   the patient’s plan of care and are consistent with the home health aides’ training.

5. Duties of the home health aide included in the home health aide plan of care might
   include, but not be limited to:
         a. hands on personal care;
         b. performing simple procedures as an extension of nursing services;
         c. assistance with ambulation and exercises; and

6. The home health aide is required to report changes in the patient’s medical, nursing,
   rehabilitative and social needs to the Primary Nurse.

7. The home health aide complies with Hospice of Montezuma’s documentation
   requirements and completes documentation within one work day.
8. Home health aides receive twenty hours of in-service training every twelve months.

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         HOME HEALTH AIDE SUPERVISION                                                          Policy Number:
                                                                                                       PC.H15
 NHPCO Standard(s): WE 20; WE 20.1; WE 20.2
 Regulatory Citation / Other: 42 CFR 418.94(a); Cop 418.76(h)                  Reviewed/Revised: 12/23/10

POLICY STATEMENT: When a patient is receiving home health aide services, a
registered nurse makes a visit to the patient’s home every two weeks to evaluate and
supervise the aide’s services. One supervisory visit every four weeks is made while the
home health aid is actively providing care to the patient.


PROCEDURES:

1. Hospice of Montezuma RN s supervise home health aides that are employed by
   Hospice of Montezuma and those that work for Hospice of Montezuma under
   contract.

2. Hospice of Montezuma RNs document the supervision of the home health aides’
   services in the patient’s clinical record.

3. During the supervisory visits, Hospice of Montezuma RNs assesses the aide’s
   performance with regard to:
     a. following the patient’s plan of care;
     b. creating a successful interpersonal relationship with the patient/caregiver;
     c. demonstrating competency with assigned tasks;
     d. complying with infection control policies and procedures; and
     e. reporting changes in the patient’s condition.

3. If the performance of the home health aide is unsatisfactory, Hospice of Montezuma
   RNs take immediate corrective action.




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       INFECTION CONTROL – BAG TECHNIQUE                                                    Policy Number:
                                                                                                    PC.I10
 NHPCO Standard(s): CES 13.1
 Regulatory Citation / Other:                                               Reviewed/Revised: 12/23/10


POLICY STATEMENT: Hospice nurses and hospice aides are required to maintain
their bags containing equipment and supplies in a clean environment at all times.

PROCEDURES:

1. The bag is transported in a clean container in the employee’s car.

2. Upon arrival at the patient’s home, the bag is placed on a clean surface utilizing
   newspaper, paper towels, and/or a liner as a barrier. Alternatively, the bag may be
   hung on a doorknob if no liner is available.

3. Hand washing supplies are retrieved from the bag if needed and hands are washed
   before removing other items from the bag.

4. Clean and dirty items are kept separate within the bag.

5. All items that might be used with other patients (for example, stethoscopes) are
   cleaned with the appropriate disinfectant after each use and before being returned to
   the bag.

6. The newspaper, paper towel, and/or liner are disposed of upon completion of the
   visit.

7. All nurses and hospice aides are required to have a home care bag. Other
   disciplines may utilize home care bags as needed.




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    INFECTION CONTROL – BIOHAZARDOUS                                                          Policy Number:
              WASTE MANAGEMENT                                                                        PC.I15
 NHPCO Standard(s): CES 12; CES 12.1
 Regulatory Citation / Other: CoP 418.60                                  Reviewed/Revised: 12/23/10

POLICY STATEMENT: Bio-hazardous waste is segregated, handled, labeled and
stored in accordance with local, State and Federal regulations.

PROCEDURES:

1. Bio-hazardous waste is defined as any solid or liquid waste which may present a
   threat of infection to humans, including, but not limited to:
          a. blood and blood products – Items contaminated with blood or other
              potentially infectious materials (i.e., semen, vaginal secretions,
              cerebrospinal fluid, synovial fluid, pleural fluid, etc.) that are capable of
              releasing the substance in a liquid or semi-liquid state if compressed;
          b. contaminated sharps; and
          c. pathological or microbiological waste containing blood, body fluids or
              other potentially infectious materials;

2. Bio-hazardous waste is identified and segregated at the point of origin as follows:
         a. discarded sharps are placed in an approved container directly at the site of
            origin and segregated from all other waste;
         b. sharps containers are:
                Leak-proof                      Rigid
                One-way                  Puncture resistant
                Red in color             Labeled "Bio-hazardous Waste"
         c. prior to disposal, and when they are ¾ full, containers are sealed with a
            self-closing device and taped to prevent spilling; and
         d. bio-hazardous waste other than sharps and liquids are placed in red bags
            that are at least 3ml thick and stored in a receptacle labeled “bio-
            hazardous.”

3.        Hospice of Montezuma ensures appropriate collection and removal of all bio-
          hazardous materials from the hospice’s property.


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   INFECTION CONTROL – CLEANING AND                                                        Policy Number:
   DECONTAMINATING SPILLS OR BLOOD                                                                 PC.I20
NHPCO Standard(s): CES 12; CES 12.1
Regulatory Citation / Other: Proposed CoP 418.60                       Reviewed/Revised: 12/23/10

POLICY STATEMENT: All spills of blood or body fluids are removed and the affected
area is decontaminated as soon as possible.

PROCEDURES:

1. Surfaces and equipment contaminated with spills or body fluids are cleaned as
   soon as possible.

2. Gloves are worn when cleaning up blood or body fluid spills.

3. Spills and/or splashes of blood or body fluids are absorbed with paper towels, not a
   sponge or cloth.

4. Surfaces are washed with detergent and water, then with a freshly-made solution of
   household bleach (one part bleach to 10 parts water; 2 Tbsp bleach in 10 oz. of
   water) or with a chemical germicide that is an approved "disinfectant" and
   “tuberculocidal” when used at recommended dilutions to decontaminate blood or
   body fluid spills.

5. Paper towels and gloves are discarded and hands are thoroughly washed.




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         INFECTION CONTROL - EDUCATION                                                       Policy Number:
                                                                                                     PC.I25
                                                                                                  Page 1 of 2
  NHPCO Standard(s): CES 13.1
  Regulatory Citation / Other: OSHA 29 CFR 1910.1030(g)(2)(i); CoP 418.60(c)
  Reviewed/Revised 12/23/10

 POLICY STATEMENT: All employees who have occupational exposure to bloodborne
 pathogens receive initial and annual training.

 PROCEDURES:

1. All employees who have occupational exposure to bloodborne pathogens receive
   training on the epidemiology, symptoms, and transmission of bloodborne pathogen
   diseases. In addition, the training program covers, at a minimum, the following
   elements:
            a. a copy and explanation of the OSHA bloodborne pathogen standard;
            b. an explanation of Hospice of Montezuma’s infection control policies and
                procedures that detail Hospice of Montezuma’s exposure control plan;
            c. an explanation of methods to recognize tasks and other activities that may
                involve exposure to blood, including what constitutes an exposure
                incident;
            d. an explanation of the use and limitations of engineering controls, work
                practices, and personal protective equipment;
            e. an explanation of the types, uses, location, removal, handling,
                decontamination, and disposal of personal protective equipment;
            f. an explanation of the basis for selection of personal protective equipment;
            g. information on the hepatitis B vaccine, including information on its
                efficacy, safety, method of administration, the benefits of being
                vaccinated, and that the vaccine is offered free of charge;
            h. information on the appropriate actions to take and persons to contact in
                an emergency involving blood;
            i. an explanation of the procedure to follow if an exposure incident occurs,
                including the method of reporting the incident and the medical follow-up
                that is made available;
            j. information on the post-exposure evaluation and follow-up that Hospice
                of Montezuma provides for the employee following an exposure incident;



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                                                                                              PC.I25 p. 2



           k. an explanation of the signs and labels and/or color coding for
              biohazardous materials used at this hospice;
           l. an opportunity for interactive questions and answers with the person
              responsible for infection control at Hospice of Montezuma.

2. Training records are documented for each employee upon completion of training.

3. Training records are kept for at least three years with the employee’s personnel record
   and include:
           a. the dates of the training sessions;
           b. the contents or a summary of the training sessions;
           c. the names and qualifications of persons conducting the training; and
               the names and job titles of all persons attending the training sessions




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  INFECTION CONTROL – EXPOSURE TO BLOOD                                                       Policy Number:
             AND BODY FLUIDS                                                                          PC.I30
 NHPCO Standard(s):
 Regulatory Citation / Other: 29 CFR 1910.1030; CoP 418.60             Reviewed/Revised: 12/23/10


POLICY STATEMENT: Any employee who sustains an exposure to blood or body
fluids will adhere to specific procedures for treatment and reporting.

PROCEDURES:

1. Infectious body fluids are defined as any of the following:
       a. Blood/blood products
       b. Semen/vaginal secretions
       c. Amniotic fluid
       d. Cerebrospinal fluid
       e. Pleural fluid
       f. Peritoneal fluid
       g. Pericardial fluid
       h. Synovial fluid
       i. Concentrated virus
       j. Any body fluid, including urine or stool, visibly contaminated with blood
       k. Fluid from any open or closed wound

2. An employee who is exposed to any of the above obtains immediate treatment to the
   exposure site as follows:
     a. For percutaneous injury (i.e., needlestick/sharp object):
            i.       Briefly induce bleeding from the wound; and
            ii.      Wash wound for 10 minutes with soap and water or a disinfectant
                     with known activity against HIV (10% iodine solution or foam
                     care).
     b. For mucous membrane exposure:
            i.       Irrigate copiously with tap water, sterile saline or sterile water for
                     10-15 minutes.

3. An employee who is exposed to blood/body fluids contacts his/her supervisor
   immediately after initiating the emergency treatment outlined above.

4. All exposures are documented on an incident report and follow-up care, including
   but not limited to testing and treatment, is initiated immediately.

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    INFECTION CONTROL – OCCUPATIONAL                             Policy Number:
   EXPOSURE PROCEDURES CLASSIFICATION                                     PC.I35
 NHPCO Standard(s):
 Regulatory Citation / Other: OSHA 29 CFR 1910.1030(c)(2)(i)(A)(B)(C); CoP 418.60

POLICY STATEMENT: All patient care procedures performed by hospice employees,
including volunteers, are classified as Category I, II, or III depending on their potential
for occupational exposure.

PROCEDURES:

1. The Patient Care Coordinator identifies, evaluates, and classifies each patient care
   procedure performed by hospice staff to:
         a. identify parts of the body that might be contaminated;
         b. determine the probability of the employee being exposed to contaminated
             body fluids as a result of performing the procedure;
         c. identify the personal protective equipment that should be used while
             performing the procedure; and
         d. identify the work practices that are necessary to perform the procedure
             safely.

2. Once the above characteristics have been determined, an exposure risk category of I,
   II or III is assigned to the procedures.

3. Once the patient care procedure is classified, the proper procedures are initiated.

4. Classification categories are reviewed yearly by the Patent Care Coordinator to
   determine if and when a task should be re-classified to a higher or lower risk
   category.

5. Inquiries concerning this classification system should be directed to the Patent Care
   Coordinator.




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                         Hospice of Montezuma, Inc.

   OCCUPATIONAL EXPOSURE PROCEDURE CLASSIFICATION
                    CATEGORIES




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                            CATEGORY I PROCEDURES

All job-related tasks that involve an inherent potential for mucous membrane or skin
contact with blood, body fluids, tissues, or have a potential for spills or splashes. Use of
the appropriate personal protective equipment is required for every employee who
performs Category I procedures.

Category 1 procedures include:
 Bladder irrigation
 Cleaning of blood/body fluids spill
 Catheter care
 Catheterization
 ChemStick/AccuCheck (blood sugar testing)
 Collecting blood specimen
 Collecting sputum specimen
 Collecting stool/urine specimen
 Colostomy/ileostomy care (including irrigation)
 Cultures, obtaining
 Diabetic urine testing
 Disposal of contaminated articles (including trash)
 Dressing change, IV
 Dressing changes, wound
 Enema-giving and/or suppository insertion
 Fecal impaction, removal of
 Incontinent care
 IV, administering (including insertion of)
 Laundry/linen, handling of soiled
 NG tube (including insertion, removal, feeding, giving meds via, & dressing change)
 Nasal/oral/tracheal suctioning
 Oral hygiene
 Output, measuring of
 Rectal/oral temperature, measuring of
 Perineal care
 Post mortem care
 Topical medication, application of
 Tracheotomy care
 Vaginal douching
 Cleaning, body fluids spill and/or splash
 Cleaning, toilets (including bedside commodes)


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    Cleaning, rooms (including patient rooms)
    Dishes and utensils, handling soiled
    Feeding syringes, handling soiled
    Laundry/linen, handling soiled (including sorting & pre-soaking)


                              Procedure Precautions/Category I
                                                 Face Mask/                                                              Staff
                                                                    Gown/         Potential          Duration of
                      Category     Gloves          Shield/                                                              Member
PROCEDURE                                                           Apron        Contaminate         Precautions
                                                   Goggles                                                               Code*
                                                     No,              No,
  Cleaning, body                     Yes,
                                                    unless          unless        Blood/body           During             N/F
fluids spill and/or      I          utility-
                                                  splashing         soiling          fluids           procedure          S/C/V
      splash                         type
                                                    likely           likely

Cleaning, toilets                                                     No,
                                     Yes,       No,
   (including                                                       unless        Blood/body           During             N/F
                         I          utility-        unless
     bedside                                                        soiling          fluids           procedure          S/C/V
                                     type         splashing
  commodes)                                                          likely
                                                    likely
                                                     No,              No,
 Cleaning, rooms                     Yes,
                                                    unless          unless        Blood/body           During             N/F
(including patient       I          utility-
                                                  splashing         soiling          fluids           procedure          S/C/V
      rooms)                         type
                                                    likely           likely
                                                     No,              No,
                                     Yes,
Dishes & utensils,                                  unless          unless        Blood/body           During             N/F
                         I          utility-
 handling soiled                                  splashing         soiling          fluids           procedure          S/C/V
                                     type
                                                    likely           likely
                                                     No,              No,
                                     Yes,
Feeding syringes,                                   unless          unless        Blood/body           During             N/F
                         I          utility-
 handling soiled                                  splashing         soiling          fluids           procedure          S/C/V
                                     type
                                                    likely           likely
  Laundry/linen,
                                                     No,              No,
  handling soiled                    Yes,
                                                    unless          unless        Blood/body           During             N/F
(including sorting       I          utility-
                                                  splashing         soiling          fluids           procedure          S/C/V
   & pre-soaking                     type
                                                    likely           likely

*Staff Member Code
N = Nursing staff (RN, LPN, HHA, Homemaker)
S = Social work staff
C = Chaplains
B = Bereavement staff
V = Volunteers
P = Physicians
O = Office & clerical staff
F = Family members/caregivers/visitors
A = All of the above




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                                          CATEGORY II
The normal work routine involves no exposure to blood, body fluids, or tissues, but
exposure or potential exposure may occur. Personnel performing Category II
procedures need not wear personal protective equipment but they should be prepared
to utilize it on short notice.

Category II procedures include:

    Bedside/table/over-bed table, cleaning
    Compress, applying (cold / warm)
    Dressing/undressing the patient
    Ear or ear care
    Eye drops/ointments, administration
    Oral medications, administration
    Vital signs, measuring
    Cleaning baseboards, bathrooms or furniture
    Cleaning laundry equipment
    Cleaning wheelchairs & other medical equipment
    Floor care
    Maintenance procedures
    Washing windows
    Accidents & incidents
    Ace bandage, application and/or removal of
    Back rub
    Bath (including bed bath & skin care)
    Bed-making (occupied)
    Bed-making (unoccupied)
    Bedpan/urinal/bedside commode/kidney basin, patient assistance with (including
     emptying & cleaning)
    Feeding (including syringe feeding)
    Hair care
    Injections
    Intake, measuring of
    Nebulizer/IPPB treatments
    Nursing/physical assessments
    Nose drops, instillation of
    Oxygen administration of
    Protective devices/restraints (including application & removal of)


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       Range of motion
       Shaving
       Transfer of patient, assisting with
       Turning/repositioning patient, assisting with
       Weighing the patient



                                    Procedure Precautions/Category II
                                                    Face Mask/                                                               Staff
                                                                       Gown/           Potential          Duration of
                   Category       Gloves              Shield/                                                               Member
PROCEDURE                                                              Apron          Contaminate         Precautions
                                                      Goggles                                                                Code*
                                                        No,               No,
  Accidents &                                          unless           unless         Blood/body           During             N/F
                      II            Yes
   incidents                                         splashing          soiling           fluids           procedure          S/C/V
                                                       likely            likely
 Ace bandage,                    No, unless             No,               No,
  application                   contact with           unless           unless         Blood/body           During
                      II                                                                                                       N/F
and/or removal                     blood/            splashing          soiling           fluids           procedure
      of                      body fluid likely        likely            likely
                                                        No,               No,
                                 No, unless
                                contact with           unless           unless         Blood/body           During             N/F
    Back rub          II
                                   blood/            splashing          soiling           fluids           procedure          S/C/V
                              body fluid likely
                                                       likely            likely
                                                        No,               No,
Bath (including
                                                       unless           unless         Blood/body           During
bed bath & skin       II            Yes                                                                                        N/F
                                                     splashing          soiling           fluids           procedure
     care)
                                                       likely            likely
                                                        No,               No,
  Bed-making                                           unless           unless         Blood/body           During
                      II            No                                                                                         N/F
   (occupied)                                        splashing          soiling           fluids           procedure
                                                       likely            likely
                                                        No,               No,
  Bed-making                                           unless           unless                              During
                      II            No                                                     N/A                                 N/F
 (unoccupied)                                        splashing          soiling                            procedure
                                                       likely            likely
Bedpan/urinal/be
       dside
commode/kidney                                          No,               No,          Urine/feces/
  basin, patient                                       unless           unless          vomitus;            During             N/F
                      II            Yes
 assistance with                                     splashing          soiling        blood/body          procedure          S/C/V
    (including                                         likely            likely           fluids
   emptying &
     cleaning)
Bedside/table/ov
        er-                         Yes,                                               Blood/body           During            N/F/H
                      II                                 No               No
    bed table,                  utility-type                                              fluids           procedure          S/C/V
     cleaning
     Cleaning                       Yes,                                               Blood/body           During
                      II                                 No               No                                                  N/F/H
   baseboards                   utility-type                                              fluids           procedure

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                                                    Face Mask/                                                               Staff
                                                                       Gown/           Potential          Duration of
                   Category       Gloves              Shield/                                                               Member
PROCEDURE                                                              Apron          Contaminate         Precautions
                                                      Goggles                                                                Code*
                                                        No,               No,
    Cleaning                        Yes,               unless           unless         Blood/body           During
                      II                                                                                                      N/F/H
   bathrooms                    utility-type         splashing          soiling           fluids           procedure
                                                       likely            likely
     Cleaning                       Yes,                                               Blood/body           During
                      II                                 No               No                                                  N/F/H
     furniture                  utility-type                                              fluids           procedure
Cleaning laundry                    Yes,                                               Blood/body           During
                      II                                 No               No                                                  N/F/H
    equipment                   utility-type                                              fluids           procedure
     Cleaning
   wheelchairs                      Yes,                                               Blood/body           During
                      II                                 No               No                                                  N/F/H
& other medical                 utility-type                                              fluids           procedure
    equipment
    Compress,
     applying                    No, unless
  (cold / warm)                 contact with                                           Blood/body           During
                      II                                 No               No                                                   N/F
                                   blood/                                                 fluids           procedure
                              body fluid likely

                                 No, unless
Dressing/undress
                                contact with                                           Blood/body           During
       ing            II                                 No               No                                                   N/F
                                   blood/                                                 fluids           procedure
   the patient
                              body fluid likely
                                 No, unless
                                                                                       Secretions/
                                contact with                                                                During
    Ear care          II                                 No               No             blood/                                N/F
                                   blood/                                                                  procedure
                                                                                       body fluids
                              body fluid likely
                                 No, unless
                                                                                       Secretions/
                                contact with                                                                During
    Eye care          II                                 No               No             blood/                                N/F
                                   blood/                                                                  procedure
                                                                                       body fluids
                              body fluid likely
      Eye                                                                              Secretions/
                                                                                                            During
drops/ointments,      II            Yes                  No               No             blood/                                N/F
                                                                                                           procedure
 administration                                                                        body fluids
                                                        No,               No,
                                                                                         Saliva/
                                                       unless           unless                              During             N/F
    Feeding           II            No                                                 secretions/
                                                     splashing          soiling                            procedure          S/C/V
                                                                                        exudate
                                                       likely            likely
  Feeding - by                                                                         Secretions,          During
                      II            Yes                  No               No                                                       N
    syringe                                                                             exudates           procedure
                                     Yes,                                              Blood/body           During
   Floor care         II                                 No               No                                                   N/F
                                 utility-type                                             fluids           procedure
                                 No, unless             No,               No,
                                contact with           unless           unless         Blood/body           During             N/F
   Hair care          II
                                    blood/           splashing          soiling           fluids           procedure          S/C/V
                              body fluid likely        likely            likely
                                                        No,               No,
                                                       unless           unless         Blood/body           During
   Injections         II            Yes                                                                                        N/F
                                                     splashing          soiling           fluids           procedure
                                                       likely            likely


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                                                      Face Mask/                                                               Staff
                                                                         Gown/           Potential          Duration of
                     Category       Gloves               Shield/                                                              Member
PROCEDURE                                                                Apron          Contaminate         Precautions
                                                        Goggles                                                                Code*
                                                      No, unless
                                   No, unless
                                                        required
                                  contact with                                                                During
  Maintenance                                               for                          Blood/body
                        II         bio-hazard                               No                               procedure           N/F
  Procedures                                           protection                           fluids
                                    material
                                                      from flying
                                      likely
                                                         debris
                                                           No,              No,
                                                         unless           unless         Blood/body           During             N/F
    Nail care           II            Yes
                                                       splashing          soiling           fluids           procedure          S/C/V
                                                          likely           likely
                                                           No,              No,
Nursing/physical                                         unless           unless         Blood/body           During
                        II            No                                                                                         N/F
  assessments                                          splashing          soiling           fluids           procedure
                                                          likely           likely
                                                           No,              No,
  Nose drops,                                            unless           unless            Nasal             During
                        II            Yes                                                                                        N/F
 installation of                                       splashing          soiling         secretions         procedure
                                                          likely           likely
                                   No, unless                                              Saliva/
Oral medications,                 contact with                                           secretions/          During
                        II                                 No               No                                                   N/F
 administration                      blood/                                              blood/body          procedure
                                body fluid likely                                           fluids
                                                          No,
                                                                            No,
                                                         unless
   Oxygen,                                                                unless            Nasal             During
                        II            No               splashing                                                                 N/F
administration of                                                         soiling         secretions         procedure
                                                         likely
                                                                           likely

    Protective
                                   No, unless             No,               No,
devices/restraints
                                  contact with           unless           unless         Blood/body           During
    (including          II                                                                                                       N/F
                                     blood/            splashing          soiling           fluids           procedure
  application &
                                body fluid likely        likely            likely
   removal of)

                                   No, unless             No,               No,
                                  contact with           unless           unless         Blood/body           During
Range of motion         II                                                                                                       N/F
                                     blood/            splashing          soiling           fluids           procedure
                                body fluid likely        likely            likely

                                                          No,               No,
  Respiratory                                            unless           unless       Saliva/secretio        During
                        II            Yes                                                                                        N/F
  treatments                                           splashing          soiling            ns              procedure
                                                         likely            likely
                                                          No,               No,
                                                         unless           unless         Blood/body           During
    Shaving             II            Yes                                                                                        N/F
                                                       splashing          soiling           fluids           procedure
                                                         likely            likely
  Transfer of                      No, unless             No,               No,
                                                                                         Blood/body           During
    patient,            II        contact with           unless           unless                                                 N/F
                                                                                            fluids           procedure
 assisting with                      blood/            splashing          soiling


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                                                     Face Mask/                                                               Staff
                                                                        Gown/           Potential          Duration of
                    Category       Gloves              Shield/                                                               Member
PROCEDURE                                                               Apron          Contaminate         Precautions
                                                       Goggles                                                                Code*
                               body fluid likely        likely            likely
                                                         No,               No,
Turning/repositio
                                                        unless           unless         Blood/body           During
  ning patient,        II            No                                                                                         N/F
                                                      splashing          soiling           fluids           procedure
 assisting with
                                                        likely            likely
                                  No, unless
   Vital signs,                  contact with                                           Blood/body           During
                       II                                 No               No                                                   N/F
   measuring                         blood/                                                fluids           procedure
                               body fluid likely
    Washing                           Yes,                                              Blood/body           During
                       II                                 No               No                                                   N/F
    windows                       utility-type                                             fluids           procedure
                                  No, unless             No,               No,
 Weighing the                    contact with           unless           unless         Blood/body           During
                       II                                                                                                       N/F
   patient                           blood/           splashing          soiling           fluids           procedure
                               body fluid likely        likely            likely

    *Staff Member Code
    N = Nursing staff (RN, LPN, HHA, Homemaker)
    S = Social work staff
    C = Chaplains
    B = Bereavement staff
    V = Volunteers
    P = Physicians
    O = Office & clerical staff
    F = Family members/caregivers/visitors
    A = All of the above




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                                         CATEGORY III

Category III procedures – The normal work routine involves no exposure to blood,
body fluids, or tissues. Persons who perform these duties are not called to perform or
assist in emergency medical care or first aid, or to be potentially exposed in some other
way. Activities that involve handling of implements or utensils, use of public or shared
bathroom facilities or telephones, and personal contacts such as handshaking are
Category III procedures. These procedures do not involve any exposure to blood and
body fluids. No protective equipment or precautionary measures are needed.

Category III procedures include:

    Administrative tasks, all departments
    Beverages, serving
    Charting and record-keeping tasks
    Cleaning office areas
    Kitchen, routine cleaning procedure
    Medications, delivery of
    Medications, destroying
    Medication orders
    Storage of medications
    Storing clean equipment




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         INFECTION CONTROL - PROGRAM                                                         Policy Number:
                                                                                                     PC.I40
 NHPCO Standard(s): CES 13; CES 13.1; CES 14; CES 14.1; CES 15; CES 15.1
 Regulatory Citation / Other: Proposed CoP 418.60


POLICY STATEMENT: Hospice of Montezuma maintains and documents an effective,
organization-wide infection control program that includes active monitoring,
surveillance, identification, prevention and control of known or suspected infections
among Hospice of Montezuma’s patients and employees.

PROCEDURES:

1. Hospice of Montezuma’s infection control program includes, but is not limited to the
   following components:

           a. education and training for staff, volunteers, and patients/caregivers on the
              principles of infection identification, prevention and control;
           b. education for staff and volunteers on the use of standard precautions;
           c. designation of the Patient Care Coordinator as the focal point of
              accountability for the infection control program in collaboration with
              Hospice of Montezuma’s QAPI committee;
           d. collection and analysis of surveillance data related to infections among
              staff, volunteers and hospice patients;
           e. a written blood borne pathogen exposure control plan; and
           f. a written plan for dealing with epidemics as a component of Hospice of
              Montezuma’s emergency/disaster management plan.

2. As an integral component of Hospice of Montezuma’s quality assessment and
   performance improvement program, infection control data is collected and analyzed
   to determine trends and areas in need of improvement to minimize the risk of
   infections. Data collected may include, but not be limited to:

           a. identification of targeted infections;
           b. identification of unusual/undesirable trends and factors contributing to
              those trends;
           c. monitoring staff compliance with infection control policies and
              procedures; and
           d. reportable employee or patient illnesses and infections.


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                                                                                                      PC.I40 p.2



3. A summary of all infection control activities performed as well as results of
   aggregated surveillance data analysis is provided by the QAPI Committee and
   included in reports to Hospice of Montezuma’s leaders.
4. Hospice of Montezuma’s written infection control plan and its infection control
   practices are monitored, reviewed, evaluated and updated on an annual basis and as
   needed.




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    INFECTION CONTROL – RESPONSIBILITIES                                                      Policy Number:
                                                                                                      PC.I45
                                                                                                   Page 1 of 2
 NHPCO Standard(s):
 Regulatory Citation / Other: Proposed CoP 418.60


POLICY STATEMENT: Implementation and maintenance of the infection control
program is the responsibility of the Patient Care Coordinator.

PROCEDURES:

1. The Patient Care Coordinator:

       a. Implements written policies and procedures for the prevention and control of
          infectious, contagious or communicable diseases.

       b. Disseminates current information on health practices to all employees.

       c. Reviews and observes techniques used in the maintenance of equipment.

       d. Implements written policies and procedures for the care of patients who have
          contagious, infectious or communicable diseases.

       e. Ensures that employees and volunteers with infectious or communicable
          diseases are not assigned to direct patient care.

       f. Ensures that infection control training programs and in-services are provided
          to employees on a timely basis.

       g. Evaluates each task performed by employees and volunteers to determine its
          exposure risk category.

       h. Monitors the health status of all employees and volunteers, ensuring that all
          personnel receive appropriate testing prior to and during employment as
          outlined in the personnel policies and in accordance with State and Federal
          regulations.

       i. Reviews procedures to ensure that all personnel and caregivers are following
          established guidelines and precautions and revises these when necessary.

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                                                                                            PC.I45, p.2

      j.   Reviews all written infection control policies, techniques and procedures
           annually for revisions and/or updates.

      k. Provides as appropriate, written accounts of unusual occurrences involving
         infection control.

      l. Other duties as required, or that may become necessary, to ensure that the
         prevention and control of communicable disease can be provided at all times.

      m. Collaborates with the Volunteer Coordinator to educate all volunteers to
         ensure safe work practices.
      n. Reports all reportable diseases to State and local agencies as required by law.
      o. Completes infection control reports and calculates infection rates. Report
         findings as appropriate on a regular basis.




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        INFECTION CONTROL – STANDARD                                                         Policy Number:
                PRECAUTIONS                                                                          PC.I50
                                                                                                  Page 1 of 3
 NHPCO Standard(s): CES 14.2
 Regulatory Citation / Other: OSHA 29 CFR 1910.1030; Proposed CoP 418.60
 Approved:                                                                     Reviewed/revised:


POLICY STATEMENT: Hospice staff use standard precautions in the care of all
hospice patients, regardless of diagnosis or presumed infection status.

PROCEDURES:

1. Standard precautions apply to 1) blood; 2) all body fluids, secretions and excretions
   (except sweat) regardless of whether or not they contain visible blood; 3) non-intact
   skin; and 4) mucous membranes.

2. The use of the following standard precautions are required of all staff performing
   Category 1 procedures:

Hand Washing

   a. Wash hands after touching blood, body fluids, secretions, excretions, and
      contaminated items, whether or not gloves are worn;
   b. Wash hands immediately after gloves are removed, between patient contacts,
      and when otherwise indicated to avoid transfer of microorganisms to other
      patients or environments;
   c. Wash hands between tasks and procedures on the same patient to prevent cross-
      contamination of different body sites;
   d. Use a plain (non-antimicrobial) soap for routine hand washing before and after
      every patient visit;
   e. Use an antimicrobial agent or a waterless antiseptic agent for specific
      circumstances (e.g., control of outbreaks or hyperendemic infections).
Gloves

   a. Wear gloves (clean, non-sterile gloves are adequate) when touching blood, body
      fluids, secretions, excretions, and contaminated items;
   b. Put on clean gloves just before touching mucous membranes and non-intact skin;
   c. Change gloves between tasks and procedures on the same patient after contact
      with material that may contain a high concentration of microorganisms; and

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                                                                                                         PC.I50 p. 2

   d. Remove gloves promptly after use, before touching non-contaminated items and
      environmental surfaces, and before going to another patient, and wash hands
      immediately to avoid transfer of microorganisms to other patients or
      environments.



Mask, Eye Protection, Face Shield

   a. Wear a mask and eye protection or a face shield to protect mucous membranes of
      the eyes, nose, and mouth during procedures and patient-care activities that are
      likely to generate splashes or sprays of blood, body fluids, secretions, and
      excretions.

Gown

   a. Wear a gown (a clean, non-sterile gown is adequate) to protect skin and to
      prevent soiling of clothing during procedures and patient-care activities that are
      likely to generate splashes or sprays of blood, body fluids, secretions, or
      excretions;
   b. Select a gown that is appropriate for the activity and amount of fluid likely to be
      encountered; and
   c. Remove a soiled gown as promptly as possible and wash hands to avoid transfer
      of microorganisms to other patients or environments.

Patient-Care Equipment

   a. Handle used patient-care equipment soiled with blood, body fluids, secretions,
      and excretions in a manner that prevents skin and mucous membrane exposures,
      contamination of clothing, and transfer of microorganisms to other patients and
      environments;
   b. Ensure that reusable equipment is not used for the care of another patient until it
      has been cleaned and reprocessed appropriately; and
   c. Ensure that single-use items are discarded properly.




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                                                                                                       PC.I50 p. 3
Linen

   a. Handle, transport, and process used linen soiled with blood, body fluids,
      secretions, and excretions in a manner that prevents skin and mucous membrane
      exposures and contamination of clothing, and that avoids transfer of
      microorganisms to other patients and environments.

Occupational Health and Bloodborne Pathogens

   a. Handle used patient-care equipment soiled with blood, body fluids, secretions,
      and excretions in a manner that prevents skin and mucous membrane exposures,
      contamination of clothing, and transfer of microorganisms to other patients and
      environments;
   b. Take care to prevent injuries when using needles, scalpels, and other sharp
      instruments or devices; when handling sharp instruments after procedures;
      when cleaning used instruments; and when disposing of used needles;
   c. Never recap used needles, or otherwise manipulate them using both hands,
      or use any other technique that involves directing the point of a needle toward
      any part of the body; rather, use either a one-handed "scoop" technique or a
      mechanical device designed for holding the needle sheath;
   d. Do not remove used needles from disposable syringes by hand, and do not bend,
      break, or otherwise manipulate used needles by hand;
   e. Place used disposable syringes and needles, scalpel blades, and other sharp items
      in appropriate puncture-resistant containers, which are located as close as
      practical to the area in which the items were used, and place reusable syringes
      and needles in a puncture-resistant container for transport to the reprocessing
      area; and
   f. Use mouthpieces, resuscitation bags, or other ventilation devices as an
      alternative to mouth-to-mouth resuscitation methods in areas where the need for
      resuscitation is predictable.




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              INTERDISICPLINARY TEAM                                                          Policy Number:
                                                                                                      PC.I55
                                                                                                   Page 1 of 2
 NHPCO Standard(s): PFC 5; PFC 5.1; PFC 6; PFC 7; PFC 7.1; PFC 7.2; PFC 7.3; PFC 10.2; PFC 12.3;
 PFC 13; PFC 13.1; PFC 13.2; PFC 13.4; WE 11; WE 11.1; WE 13.6; WE 16
 Regulatory Citation / Other: 42 CFR 418.68; Proposed CoP 418.56(a)


POLICY STATEMENT: Hospice of Montezuma designates an interdisciplinary team
composed of qualified individuals who assess, plan, provide and evaluate the care and
services provided to hospice patients/caregivers.

PROCEDURES:

1. The interdisciplinary team at Hospice of Montezuma includes, at a minimum, the
   following individuals:
       a. a doctor of medicine or osteopathy
       b. a registered nurse
       c. a social worker or counselor

2. In addition, the team may include:
       a. the patient’s attending physician;
       b. trained volunteers under the supervision of the Volunteer Coordinator;
       c. home health aides;
       d. bereavement counselors;
       e. spiritual counselors and/or members of the clergy; and
       f. others with appropriate clinical and educational experience who meet specific
          needs of Hospice of Montezuma’s patients as identified in the plan of care.

3. The interdisciplinary team is responsible for:
      a. establishing, implementing, reviewing and revising the patient’s plan of care;
      b. providing or coordinating care and services in accordance with the patient’s
          plan of care ;
      c. documenting all care and services provided in a timely manner in accordance
          with Hospice of Montezuma’s documentation requirements;




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                                                                                   PC.I55 Page 2



        d. promoting the patient’s acceptance of his/her own strengths and unique
           qualities;
        e. communicating with the patient’s attending physician on a regular basis;
        f. recognizing and addressing the patient/caregiver’s feelings of loss, despair,
           loneliness, unresolved guilt, fear and anger;
        g. promoting opportunities for the patient/caregiver’s personal growth
           including identifying areas for reconciliation, facilitating expressions of love,
           concern, regret and forgiveness, and supporting a sense of meaning; and

        h. recommending policies governing the day-to-day provision of hospice care
           and services.

4. A registered nurse member of the interdisciplinary team is designated as the
   Primary Nurse for each patient/caregiver. The Primary Nurse is responsible for
   coordinating the care and services provided by the interdisciplinary team, ensuring
   continuous assessment of patient/caregiver needs, and implementing the
   interdisciplinary plan of care.




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        INTERDISCIPLINARY TEAM MEETING                                                       Policy Number:
                                                                                                     PC.I60
 NHPCO Standard(s): WE 11.5
 Regulatory Citation / Other: 42 CFR 418.68
 Approved:
 Reviewed/revised:

POLICY STATEMENT: The members of the interdisciplinary team meet in person weekly to
plan and coordinate the care and services provided to Hospice of Montezuma’s patients and
their caregivers.

PROCEDURES:

1. The interdisciplinary team reviews each patient’s plan of care every two weeks, or more
   frequently if needed, in order to continually monitor the care and services provided to the
   patient and his or her continued eligibility for hospice care.

2. During the interdisciplinary team meeting the patient’s plan of care is reviewed and
   updated and changes are communicated to the patient’s attending physician with requests
   for new orders when needed.

3. The interdisciplinary team meeting follows a consistent agenda to ensure that all patients
   are reviewed and that appropriate care planning occurs. The agenda follows includes the
   following items:
              A. Care plan review for all patients whose last care plan review was more than
                  10 days ago is conducted on alternating weeks.
              B. Care plan review for patients whose condition necessitates team consultation
                  for a Problem, Issue, or Opportunity on a week other than their scheduled
                  review or who are due for recertification within the following two weeks.
              C. Care plan review for patients admitted since the last Interdisciplinary Team
                  meeting.
              D. Care plan review for discharged patients and review of deaths.
              E. Bereavement Care Plan development for caregivers/friends of patients who
                  have died since the last Interdisciplinary Team Meeting.

4. The review of existing patients is guided by the appropriate LCD guidelines to monitor the
   patient’s status and continued eligibility for hospice care.

The focus of the interdisciplinary team meeting is on reviewing the patient’s plan of care and
revising it as needed, based on comprehensive assessment information.



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                LABORATORY SERVICES                                                           Policy Number:
                                                                                                      PC.L10
 NHPCO Standard(s): CES 5; CES 5.1; CES 5.2; CES 5.3; CES 5.4
 Regulatory Citation / Other: 42 CFR 418.92(b)(1)(2); CoP 418.116(c)
 Approved:                                                           Reviewed/rev ised:


POLICY STATEMENT: Diagnostic services are provided that are ordered by the
physician, identified in the patient’s plan of care and are necessary for the management
of the patient’s symptoms.


PROCEDURES:

1. Hospice of Montezuma contracts with laboratories that meet regulatory
   requirements.

2. Lab specimens obtained in the patient’s home are taken only to laboratories with
   which Hospice of Montezuma has a contract.

3. Hospice nurses may only collect specimens ordered by the patient’s attending
   physician for delivery to the contracted laboratory.

4. For self-administered tests, Hospice of Montezuma nurses educate and assist the
   patient/caregiver administering the test with an appliance approved by the FDA.
   The patient/caregiver is asked to provide a return demonstration and education
   continues until competency with the skill is achieved.

5. Hospice of Montezuma complies with applicable State laws and regulations and
   obtains a CLIA certificate of waiver for any waived testing performed by qualified
   hospice staff.




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                     LEVELS OF CARE                                                           Policy Number:
                                                                                                      PC.L15
 NHPCO Standard(s): PFC 2.3; CES 21.5
 Regulatory Citation / Other:
 Approved:                                                                    Reviewed/revised :

POLICY STATEMENT: Hospice of Montezuma offers the four levels of care, as
provided for by the Medicare hospice benefit, to meet the needs of patients/caregivers.
The levels of care include routine home care, continuous care, inpatient respite care and
general inpatient care.

PROCEDURES:

1.    Routine home care is the most frequently provided level of care provided in the
      patient’s residence that may be a skilled nursing facility or another setting
      considered the patient’s home.

2.    Continuous care is provided during a period of crisis to achieve palliation or
      management of acute medical symptoms in order to maintain the patient at home.
      Continuous care is provided on a short term basis when the patient needs more
      intensive care that is predominantly nursing for at least 8 hours within a 24 hour
      period that begins and ends at midnight.

3.    Inpatient respite care is provided in a contracted facility when necessary to provide
      respite for family members or others caring for the patient. This level of care is
      limited to no more than five consecutive days for each respite stay.

4.    The general inpatient level of care is provided in a contracted facility when a
      patient’s need for pain or acute or chronic symptom management cannot be
      managed in other settings.

5.    Hospice of Montezuma utilizes all levels of care and has criteria for determining
      appropriate levels of care for each patient based on his or her evolving needs.

6.    Documentation in the clinical record supports the level of care received by each
      patient and clearly reflects the need for any changes in the patient’s level of care.




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                                                                                    PC.L15, p.2


7.    When a patient’s condition changes and requires a change in level of care, the
      Primary Nurse or On-Call Nurse notifies the attending physician to receive an
      order for change in level of care and revises the patient’s plan of care accordingly.

8.    Members of the interdisciplinary team providing care to the patient are advised of
      any changes to the patient’s level of care and detailed information is provided in
      the clinical record to ensure continuity of care.




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        LEVELS OF CARE – CONTINUOUS CARE                                                       Policy Number:
                                                                                                       PC.L20
                                                                                                    Page 1 of 2
 NHPCO Standard(s): PFC 2.3
 Regulatory Citation / Other: 42 CFR 418.204(a); 42 CFR 418.302(b)(2)
 Approved:                                                           Reviewed/revi sed:


POLICY STATEMENT: Continuous is provided to hospice patients during periods of
medical crisis and only as necessary to maintain the patient at home.

PROCEDURES:

1. The Primary Nurse or designee assesses the patient to determine whether he/she
   requires a level of care change to achieve palliation and/or management of acute
   symptoms in order to remain at home.

2. The Primary Nurse confirms the assessed need for a level of care change to
   continuous care with the Clinical Care Coordinator and the patient’s attending
   physician.

3. The patient’s plan of care is revised to reflect the crisis precipitating the need for a
   change in level of care and a physician’s order is obtained and documented in the
   clinical record.

4. The Clinical Care Coordinator assigns available hospice registered nurses, licensed
   practical nurses and home health aides to respond to the continuous care needs of
   the patient. Only nurses who are hospice employees are routinely assigned to
   provide continuous care unless there is a period of peak patient workloads or
   unusual circumstances during which contracted nursing personnel may be used.

5. The provision of continuous care requires detailed documentation that clearly
   supports the need for this level of care and includes a Continuous Care Log divided
   into 15 minute increments that details the date services were provided, the time in
   and out of different disciplines providing care, names and titles of hospice personnel
   and a summary of the care provided.




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                                                                                 PC.L20 page 2



6. The Continuous Care Log becomes a part of the patient’s clinical record after
   continuous care is discontinued and is used to substantiate the care provided and
   the need for the provision of continuous care.

7. Computation of clinical care hours for billing purposes is based on the following
   statutory and regulatory requirements:
          a. a minimum of 8 hours of care that is predominantly nursing, is provided
             during a 24-hour day that begins and ends at midnight;
          b. the care provided need not be continuous (for example, 4 hours may be
             provided in the morning and another 4 hours provided in the evening
             of the same day) as long as there is an aggregate need for 8 hours of
             predominantly nursing care;
          c. the computation of continuous care hours reflects the total number of
             direct care hours provided by nursing personnel and home health aides.
             If home health aide hours exceed nursing hours, the day is billed as
             routine home care; and
          d. continuous care hours do not include time spent documenting care,
             making phone calls to the physician, supervising aides, hours provided by
             social workers, volunteers, chaplains or other disciplines, etc – only direct
             patient care provided by hospice nurses and home health aides qualifies
             for continuous care computation of hours.




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                  MEDICAL DIRECTOR                                                          Policy Number:
                                                                                                    PC.M10
 NHPCO Standard(s): WE 12; WE 12.1; WE 12.2
 Regulatory Citation / Other: 42 CFR 418.54 and 418.86; Proposed CoP 418.102
 Approved: 2/25/2009                                            Reviewed/revised:

POLICY STATEMENT: Hospice of Montezuma designates an individual who is a
doctor of medicine or osteopathy to serve as Hospice of Montezuma’s Medical Director.
Hospice of Montezuma Medical Director assumes the overall responsibility for the
medical component of the patient care program.

PROCEDURES:

1. Hospice of Montezuma Medical Director may be an employee or work under
   contract with Hospice of Montezuma program.

2. When the Medical Director is not available, a physician designated by the Medical
   Director assumes the same responsibilities and obligations as the Medical Director.

3. Specific responsibilities of the Medical Director, as outlined in the Medical Director
   job description, include, but are not limited to:
          a. reviewing clinical information to assess and certify the patient’s initial
              eligibility for hospice care;
          b. reviewing clinical information and consultation with members of the
              interdisciplinary team and the patient’s attending physician (if there is
              one) regarding the patient’s continued eligibility and appropriateness for
              recertification into subsequent benefit periods;
          c. reviewing, coordinating and overseeing the management of the medical
              care for Hospice of Montezuma’s patients;
          d. consulting with the patient’s attending physician (if there is one) as
              needed and appropriate;
          e. serving as a medical resources for members of the interdisciplinary team;
          f. attending and participating in interdisciplinary team meetings;
          g. making home visits to hospice patients as needed;
          h. serving as a liaison to other physicians in the community; and
          i. participating in Hospice of Montezuma’s quality assessment and
              performance improvement program.




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                   MEDICAL SUPPLIES                                                           Policy Number:
                                                                                                      PC.M20
 NHPCO Standard(s):
 Regulatory Citation / Other: 42 CFR 418.96; Proposed CoP 418.106
 Approved:                                                 Reviewed/revised:


POLICY STATEMENT: Hospice of Montezuma provides the medical supplies
necessary for the palliation and management of the patient’s terminal illness and
related conditions. Access to medical supplies is available twenty-four (24) hours a day.

PROCEDURES:

1. Patient care staff may obtain all medical supplies needed for patient care during
   normal working hours at Hospice of Montezuma office.

2. If additional supplies are needed, the staff in need first communicate with other staff
   on duty to inquire if they have the needed supplies available.

3. If additional supplies cannot be obtained from another staff member, the staff in
   need notifies a supervisor who orders or obtains the needed item(s).

4. Staff is required to anticipate patient’s medical supply needs and request
   appropriate amounts in order to avoid running out of supplies.

5. The on-call staff has access to Hospice of Montezuma office, and the medical supply
   closet, after hours.




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           MEDICATIONS – ADMINISTRATION                                                     Policy Number:
                                                                                                    PC.M25
 NHPCO Standard(s): CES 4.4
 Regulatory Citation / Other: 418.96(a); Proposed CoP 418.106(a)
 Approved: 2/25/2009                                                                      Reviewed/revised:

POLICY STATEMENT: All drugs are administered in accordance with accepted
standards of hospice and palliative care practice and the patient’s plan of care.

PROCEDURES:

1.    Drugs may only be administered by a licensed nurse or physician, the patient if able
      and others only in accordance with State laws and regulations and as specified in
      the patient’s plan of care.

2.    All hospice nurses may administer medications by oral, rectal, transdermal, topical,
      sublingual, buccal, subcutaneous, or intramuscular route when following physician
      orders. Hospice registered nurses and IV certified LPNs may also administer
      medications by the intravenous route when following physician orders.

3.    When a hospice nurse administers any medication to a patient, the name of the
      medication, strength, dose, amount, route, date and time of administration is
      documented in the nurse’s visit note.

4.    The Primary Nurse assesses the patient/caregiver’s ability to safely administer
      medications during the initial assessment and whenever there is a significant
      change in the caregiver’s mental or physical condition.

5.    The Primary Nurse or designee provides instruction to the patient/caregiver on the
      proper administration of medications. Instruction includes, but is not limited to:
           a. the potential side effects of medications included in the patient’s plan of
               care;
           b. emergency responses to adverse reactions;
           c. how to safely store medications;
           d. the proper disposal of used syringes or patches;
           e. when to administer medications included in the plan of care;
           f. documenting self-administration of medication (if appropriate); and
           g. when to call Hospice of Montezuma if any difficulties or questions arise
               regarding self-administration of medication


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                                                                                             PC.M25 Page 25



6.    The Primary Nurse or designee documents all instruction given regarding the safe
      administration of medication and includes the response of the patient/caregiver to
      the instruction as appropriate.




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  MEDICATIONS – ADVERSE DRUG REACTIONS                                                     Policy Number:
                                                                                                   PC.M30
                                                                                                Page 1 of 2
NHPCO Standard(s): CES 4.4; CES 4.8
Regulatory Citation / Other:
Approved: 2/25/2009                                                                   Reviewed/revised:


POLICY STATEMENT: Hospice of Montezuma provides an immediate and
coordinated response to adverse drug reactions.

DEFINITION

An adverse drug reaction is any noxious, unintended, undesirable or unexpected
response to a drug that was prescribed and administered correctly.

PROCEDURES:

1. Signs and symptoms of an adverse drug reaction may include, but are not limited to:
       a. Dermatologic – skin rash, exfoliative dermatitis, photosensitivity
       b. Pulmonary - edema, respiratory depression, fibrosis, pleural effusion
       c. Hepatic - hepatic necrosis, hepatitis
       d. Renal – renal failure, nephritis
       e. Hematologic - aplastic anemia, bone marrow suppression, leucocytosis
       f. Neurological – seizures, tardive dyskinesia
       g. Cardiac – arrythmias, CHF
       h. Otic – hearing loss, tinnitus
       i. Ocular – corneal deposits, retinal damage, diplopia, myopia, conjunctival
          pigmentation
       j. Hypersensitivity – anaphylaxis
       k. Gastrointestinal – ulceration, prolonged vomiting, diarrhea, colitis,
          pancreatitis
2. Hospice of Montezuma RN must report any adverse reaction that results in the
   following:
       a. a change and/or discontinuation or modification of the drug therapy;
       b. systemic treatment;
       c. hospital admission;
       d. disability or cognitive impairment; and/or
       e. death


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                                                                                                       PC.M30 p. 2

3. To report an adverse drug reaction, the Primary Nurse or designee:
      a. notifies the patient’s attending physician and the pharmacist of the drug
         causing the reaction, the dosage, route of administration, and reaction;
      b. requests instructions from the attending physician or Hospice of Montezuma
         Medical Director regarding interventions;
      c. documents the date and time of the reaction, the patient’s symptoms and vital
         signs and physician instructions; and
      d. makes arrangements for transportation to the hospital if necessary.

4. Documentation related to the adverse drug reaction includes completing an Incident
   Report and noting:
      a. name of the medication;
      b. dose and route prescribed and administered;
      c. signs and symptoms of the adverse effect;
      d. the nature of discovery of the event;
      e. physician notification and orders; and
      f. patient outcome.

5. The Clinical Director, in consultation with Hospice of Montezuma Medical Director
   and the patient’s attending physician determine the necessity of reporting the
   incident to any external agencies as required by State and Federal laws and
   regulations.

6. Data is collected related to adverse drug reactions and reviewed by Hospice of
   Montezuma’s QAPI Committee on a quarterly basis.




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   MEDICATIONS – DO NOT CRUSH MEDICATIONS                                                       Policy Number:
                                                                                                        PC.M35
                                                                                                     Page 1 of 2
 NHPCO Standard(s): CES 4.4; CES 4.8
 Regulatory Citation / Other:
 Approved: 2/25/2009
 Reviewed/revised:

POLICY STATEMENT: Hospice of Montezuma nurse instructs patients and caregivers
regarding medications that may not be crushed.

PROCEDURES:

1. Hospice patients with swallowing difficulties or who, for others reasons, wish to crush
   medications, are given instructions regarding medications that may not be crushed.

2. The Primary Nurse reviews the patient’s medication profile and informs the
   patient/caregiver regarding prescribed medications that may not be administered in crushed
   form.

3. A partial list of common medications that may not be crushed includes:

        a. Enteric-coated: Bisacodyl (Dulcolax®), enteric-coated aspirin (Ecotrin®),
           lansoprazole (Prevacid®), omeprazole (Prilosec®), pancrelipase (Pancrease®),
           divalproex sodium (Depakote®), many erythromycin products

        b. Extended-release: Diltiazem controlled-dissolution (Cardizem CD®),
           fexofenadine/pseudoephedrine (Allegra-D®), mesalamine (Asacol®, Pentasa®),
           verapamil sustained-release (Calan SR®, Isoptin SR®), oxybutynin extended-release
           (Ditropan XL®), propranolol long-acting (Inderal LA®), tamsulosin (Flomax®),
           divalproex sodium extended-release (Depakote ER®), many theophylline products

        c. Bitter taste: Cefuroxime (Ceftin®), ciprofloxacin (Cipro®), docusate (Colace®),
           ibuprofen (Motrin®)

        d. Irritant: Alendronate (Fosamax®), atomoxetine (Strattera®), diflunisal (Dolobid®),
           isotretinoin (Accutane®), piroxicam (Feldene®), risedronate (Actonel®), valproic acid
           (Depakene®)

        e. Safety: Finasteride (Proscar®), mycophenolate (Cellcept®), other cancer
           chemotherapy agents


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                                                                           Policy Number: PC.M35 Page 2

        f. Anesthetizes local mucosa: Benzonatate (Tessalon Perles®)

        g. Fragility: Mirtazapine (Remeron SolTab®), olanzapine (Zyprexa Zydis®)

        h. Ability to stain teeth: Amoxicillin/clavulanate (Augmentin®), linezolid (Zyvox®),
           iron products

4. For a comprehensive, updated list of medications that may not be crushed, the online
   resource at: www.ismp.org/Tools/DoNotCrush.pdf is consulted on an as needed basis. The
   list is printed from this website quarterly by the person updating the on-call book to enable
   immediate access by the on-call nurse.




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               MEDICATION – ERRORS                                                          Policy Number:
                                                                                                    PC.M40
 NHPCO Standard(s): CES 4.4; CES 4.8
 Regulatory Citation / Other:
 Approved 2/25/09


POLICY STATEMENT: All medication errors are documented on an Incident Report
and reported immediately to the patient’s attending physician.


PROCEDURES:

1. Medication errors include, but are not limited to:
        a. Wrong medication administered
        b. Wrong medication dispensed
        c. Wrong dose
        d. Administered at the wrong time
        e. Wrong route
        f. Omission or missed dose
        g. Extra dose

2. The patient’s response to the medication error is evaluated to determine potential
   negative effects and reported to the physician. Hospice of Montezuma nurse will
   initiate an emergency response if necessary and as instructed by the physician.

3. Documentation of the medication error indicates who made the error: patient,
   family, caregiver, hospice staff, facility staff, contracted personnel or other.

4. An Incident Report detailing the medication error is completed by Hospice of
   Montezuma nurse as soon as feasible following the discovery of the error and
   submitted to the Clinical Director.

5. The Clinical Director reviews and completes the Incident Report, including
   documentation of corrective actions taken to prevent future medication errors.

6. Data is collected related to medication errors and reviewed by Hospice of
   Montezuma’s QAPI Committee on a quarterly basis.




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             MEDICATION – MANAGEMENT                                    Policy Number:
                                                                                PC.M45
 NHPCO Standard(s): CES 2.5; CES 4; CES 4.1; CES 4.2; CES 4.3; CES 4.4; CES 4.6; CES
 4.7; CES 4.8; CES 4.10; CES 18; CES 18.2
 Regulatory Citation / Other:
 Approved: 2/25/2009                                             Reviewed/revised:

POLICY STATEMENT: The pharmaceutical needs of Hospice of Montezuma’s patients are
met, consistent with applicable State and Federal laws and accepted standards of practice.

PROCEDURES:

1. Hospice of Montezuma contracts with licensed pharmacies to provide pharmacy services
   for Hospice of Montezuma’s patients and act as consultants to Hospice of Montezuma
   interdisciplinary team.

2. Medications are provided on a timely basis and are available 24 hours a day and seven days
   a week as needed.

3. All medications must be ordered by a licensed physician.

4. A Medication Profile is maintained for every patient and includes a listing of the current
   medication orders for each patient and specifies whether the medication is or is not related
   to the patient’s terminal illness.

5. Hospice of Montezuma monitors the medications dispensed to and used by the patient.

6. Medication is only administered by persons who have authority to do so under State laws
   and regulations.

7. The Primary Nurse provides instruction to the patient/caregiver regarding the safe
   administration of medications including potential side effects and expected responses, and
   evaluates the patient/caregiver’s ability to safely administer medications.

8. Medication errors and adverse drug reactions receive immediate response and are
   documented and reviewed to ensure corrective action is taken to prevent future
   occurrences.

9. Medications are dispensed in sufficient quantities to meet the needs of the patient and to
   minimize the potential for waste. Medications that are no longer needed are disposed of in
   accordance with accepted standards of practice.



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                                                                                             PC.M45 Page 2

10. The Primary Nurse provides instruction to the patient/caregiver regarding the proper
    storage, handling and preparation of medications included in the patient’s plan of care and
    documents the teaching provided.




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               MEDICATION – ORDERS                                                           Policy Number:
                                                                                                     PC.M50
 NHPCO Standard(s): CES 4.4
 Regulatory Citation / Other:
 Approved:                                                          Reviewed/revised:


POLICY STATEMENT: Medications may only be administered that have been ordered
by the patient’s physician or designee.

PROCEDURES:

1. Both telephone and written orders for medications are documented in the patient’s
   clinical record and include:
       a. date of the order
       b. name of medication
       c. dose
       d. route
       e. frequency
       f. purpose (if PRN and/or antibiotic)

2. Telephone orders for medications may only be accepted by a hospice nurse.

3. Orders for medications are documented in the patient’s current medication profile
   the same day the order is received.

4. The Primary Nurse or designee contacts the pharmacy to fulfill the order.

5. No change may be made to the medication dosage or route without a physician’s
   order.

6. A physician’s order is needed to discontinue medications.

7. A copy of telephone orders is sent to the ordering physician for return with
   signature and included in the patient’s clinical record.




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   MEDICATION – TRACKING AND DISPOSING OF                                                      Policy Number:
   CONTROLLED DRUGS IN THE PATIENT’S HOME                                                              PC.M55
                                                                                                    Page 1 of 2
 NHPCO Standard(s): CES 4.4
 Regulatory Citation / Other: 42 CFR 418.96(b); Proposed CoP 418.106(b)
 Approved: 2/25/2009                                              Reviewed/revised:

POLICY STATEMENT: Hospice of Montezuma and the patient/caregiver share in the
responsibility for tracking, collecting and disposing of controlled substances that are maintained
in the patient’s home.

PROCEDURES:

Education

1. Hospice of Montezuma interdisciplinary team provides education to the patient/caregiver
   regarding the proper use and disposal of controlled substances.

2. Patient/caregiver education regarding controlled substances may be in the form of written
   information provided during the initial assessment and/or discussion with the
   patient/caregiver regarding specific medications prescribed for the patient.

3. All education/information provided to the patient/caregiver related to controlled substances
   is documented in the patient’s clinical record.

Tracking

1. The Primary Nurse or designee documents on the Medication Profile the date, medication
   name and strength, administration frequency and quantity dispensed of all controlled drugs
   ordered for and received by the patient. A lock box will be provided to any family upon
   request, when there is a history of drug diversion or addiction by persons who have patient
   contact, or if extra safety measures are deemed appropriate.

2. The Primary Nurse or designee conducts a weekly count of the amount or quantity of
   medication remaining and notes any discrepancies between amount of medication
   administered to the patient and the amount of medication remaining.

3. The Primary Nurse or designee identifies and documents any misuse of controlled
   substances and notifies the patient’s attending physician, the pharmacist and the Patient
   Care Coordinator for further intervention.




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                                                                                                    PC.M55 Page 2

4. An Incident Report is completed for suspected or actual diversion of controlled substances
   and the interdisciplinary team, in consultation with Hospice of Montezuma Medical
   Director, the patient’s attending physician and the pharmacist determine the appropriate
   course of action, including reporting the diversion to appropriate authorities.

Disposal

1. Controlled drugs no longer needed by the patient are disposed of in compliance with State
   and Federal regulations and disposal instructions and activities are documented.

2. A hospice nurse, accompanied by a witness, is responsible for disposing of the patient’s
   drugs when the patient no longer needs them. The nurse wears a mask and gloves during
   the procedure. Medications are destroyed by: 1)crushing tablets, 2)putting crushed tablets
   and liquids in an empty plastic drink bottle with the label removed, 3)adding vinegar and
   shaking to dissolve fragments, 4) adding cat litter and shaking to absorb the liquid, 4)sealing
   the bottle with duct tape, and 5) placing the sealed bottle in the outside trash receptacle.
   Patches are opened, cut into small pieces, and added to the crushed tablets, then proceeding
   with steps 3 through 5.

3. At the time of destruction, the following information is documented in the patient’s clinical
   record:
           a. name and dose of the medication;
           b. amount or quantity of the medication destroyed;
           c. date of destruction and signature of the nurse and witness.

4. In the event the patient/caregiver refuses to allow medication to be destroyed, the refusal is
   documented in the patient’s clinical record with the name and strength of the medication
   and the amount remaining. Included with the documentation is the patient/caregiver’s
   signature attesting to the refusal, and the date the patient’s attending physician and the
   coroner were notified of the refusal.




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            VOLUNTEERS - ASSIGNMENT                                                           Policy Number:
                                                                                                      PC. V10
 NHPCO Standard(s): WE 9.1
 Regulatory Citation / Other:
 Approved: 9/5/2008


POLICY STATEMENT: Hospice volunteers are assigned in a timely and appropriate
manner.

PROCEDURES:
1. A hospice team member provides the patient with information regarding the
   services provided by volunteers. This information may be provided verbally or in
   writing.

2. If the patient is interested in having a volunteer, the team member notifies
   the Volunteer Coordinator.

3. Alternatively, the Volunteer Coordinator may initiate contact with the patient if,
   based on information gathered at the interdisciplinary team meeting, it appears
   likely the patient or caregivers could benefit from volunteer services. This is done in
   consultation with other members of the interdisciplinary team.

4. Volunteer assignments are made within four (4) working days after notification of
   the request.

5. The Volunteer Coordinator describes the patient situation to an appropriate
   volunteer. The volunteer may either accept or reject the assignment.

6. If the volunteer accepts the assignment, the Volunteer Coordinator provides the
   volunteer with the information needed to make contact with and provide services to
   the patient and his or her caregivers.

7. The volunteer is informed on an ongoing basis of when the patient will be discussed
   at interdisciplinary team meetings and is invited to attend if possible.

8. Upon the death of a patient, the volunteer is notified as soon as possible either by
the On-Call RN (if the death occurs outside of normal business hours) or by the
Volunteer Coordinator.


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         VOLUNTEERS - DOCUMENTATION                                                            Policy Number:
                                                                                                       PC.V15
 NHPCO Standard(s):
 Regulatory Citation / Other:
 Approved: 9/5/2008


POLICY STATEMENT: All volunteers are required to provide timely, accurate and
appropriate documentation of any patient-related contact.


PROCEDURES:

1. Hospice volunteers use the Volunteer Charting - Patient Care form for documentation
   of any and all contact with hospice patients and their caregivers (including visits
   and telephone calls).

2. Volunteers are required to keep a supply of forms available for their use.

3. Upon completion of a patient/caregiver visit (or phone contact), the volunteer
   completes the Volunteer Charting - Patient Care form and brings, mails or faxes the
   completed documentation to the Volunteer Coordinator.

4. All volunteer documentation is submitted within one week of the patient contact for
   incorporation into the patient’s clinical record.

5. The Volunteer Coordinator reads all Volunteer Charting - Patient Care forms.
   Pertinent information is passed on to the primary nurse and the volunteer is
   contacted for further follow up as needed.




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              VOLUNTEERS – SERVICES                                                         Policy Number:
                                                                                                    PC.V20
                                                                                                 Page 1 of 2
 NHPCO Standard(s): WE 9; WE 9.1; WE 18; WE 18.1; WE 18.2
 Regulatory Citation / Other: 418.70; CoP 418.78
 Approved: 9/5/2008


POLICY STATEMENT: The Volunteer Program is designed to meet Federal
regulations for the provision of volunteer services to hospice patients and their
caregivers. The Volunteer Program is monitored on a continuous basis to ensure it is
functioning as intended and meeting the needs of the hospice program and its patients.

PROCEDURES:

1. Volunteers are supervised by the Volunteer Coordinator and are used in prescribed
   roles including, but not limited to:
       a. providing emotional and practical support to patients and families;
       b. providing respite for the patient’s caregiver;
       c. assisting in bereavement education and support services;
       d. assisting with program administration and development; and
       e. assisting with office duties

2. Recruitment efforts are sufficient to ensure that the hospice has enough volunteers
   to meet the needs of patients and families and the requirements of Federal
   regulations.

3. Volunteers are selected regardless of race, color, national origin, ancestry, age, sex,
   religious creed, sexual orientation, or disability.

4. Applicants for volunteer positions are carefully screened and are required to
   complete an application form and interview process.

5. Volunteers are required to complete an orientation and training program prior to
   assignment to patients and caregivers.

6. A personnel file is maintained for each volunteer that contains prescribed contents.




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                                                                                       PC.V20 p. 2

7. Volunteers are assigned to patients and their caregivers based on assessed needs
   and appropriateness.

8. Volunteers report to and are supervised by the Volunteer Coordinator and are
   provided with ongoing support and continuing education.

9. Volunteers are required to document all contact with patients and their caregivers
   and meet the documentation requirements of Hospice of Montezuma.

10. The Volunteer Coordinator maintains records of volunteer activity and records
    levels of volunteer participation and cost savings on a monthly and annual basis.

11. An annual performance evaluation is completed by the Volunteer Coordinator for
    each “active” volunteer.




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