Coordination and Continuity of Care: The hospice shall adhere to the following

Coordination and Continuity of Care: The hospice shall adhere to the following additional principles and responsibilities: 1. An assessment of the patient/family needs and desire for hospice services and a hospice program’s specific admission, transfer, and discharge criteria determine any changes in services; 2. Nursing services, physician services, and drugs and biologicals are routinely available to hospice patients on a 24 hour basis, seven days a week; 3. All other covered services are available on a 24 hour basis to the extent necessary to meet the needs of individuals for care that is reasonable and necessary for the palliation and management of terminal illness and related conditions; 4. Case-management is provided and an accurate and complete documented record of services and activities describing care of patient/family is maintained; 5. Collaboration with other providers to ensure coordination of services; 6. Maintenance of professional management responsibility and coordination of the patient/family care regardless of the setting; 7. Maintenance of contracts/agreements for the provision of services not directly provided by the hospice, including but not limited to: a. Radiation therapy; b. Infusion therapy; c. Inpatient care; d. Consulting physician. 8. Provision or access to emergency medical care; 9. When home care is no longer possible, assistance to the patient in transferring to an appropriate setting where hospice care can be delivered; 10. When the patient is admitted to a setting where hospice care cannot be delivered, hospice adheres to standards, policies and procedures on transfer and discharge and facilitates the patient’s transfer to another care provider; 11. Maintenance of appropriately qualified IDT health care professionals and volunteers to meet patients need; 12. Maintenance and documentation of a volunteer staff to provide administrative or direct patient care. The hospice must document a continuing level of volunteer activity 13. Coordination of the IDT, as well as of volunteers, by a qualified health care professional, to assure continuous assessment, continuity of care and implementation of the POC; 14. Supervision and professional consultation by qualified personnel, available to staff and volunteers during all hours of service; 15. Hospice care provided in accordance with accepted professional standards and accepted code of ethics; 16. The facility must proceed in accordance with written policy at the time of death of the patient.