130 CMR 458.421
Written Policies and Procedures
(A) Written Policies and Procedures. The medical respite provider must have and adhere to
written policies and procedures that include:
(1) a statement of its philosophy and objectives and of the geographic area served;
(2) an intake policy, including eligible referring acute care hospitals and screening
individuals for eligibility;
(3) admission procedures;
(4) service delivery procedures, including, but not limited to, development of members’
individualized care plans, case assignment, case review, and discharge planning;
(5) a referral policy, including procedures for ensuring coordinated member care;
(6) recordkeeping policies, including what information must be included in each record, and
procedures to ensure confidentiality;
(7) personnel and management policies, including policies for hiring, training, evaluation,
supervision, and termination protocol for all staff;
(8) conflict of interest policies;
(9) managing safety in the medical respite setting, including policies on weapon use and
substance use;
(10) managing planned and unplanned medical and non-medical leaves of absence;
(11) managing urgent and emergent clinical issues;
(12) discharge procedures, including when there are leaves of absence and when the
member’s medical respite service period is ending; and
(13) a written procedure for managing, reporting, responding to incidents, including member
falls and proactive approaches to prevent future related incidents.