Governing body and management

1. A hospice program must have a clearly defined, organized governing body that must assume full legal responsibility for the overall conduct and operation of the hospice program including quality of care and services. 2. The governing body shall adopt bylaws which include at least the following: a. The purpose of the hospice program. b. The powers and duties of the officers and committees of the governing body. c. The qualifications, methods of selection, and terms of office of members and chairman of committees. d. A mechanism for approval of the appointment to the medical staff, if applicable. e. Specifications of the frequency of governing body meetings and attendance requirements. f. A provision for the taking of sufficient minutes of its meetings to record the business conducted and for making them available to all members. 3. There must be an organizational chart, description of services offered, and channels of authority for responsibility for care provided to patients and their families. 4. There must be policies and procedures for each department or service offered, which must be reviewed annually by the governing body, or appropriate administrative representative. a. Policies and procedures must be dated and signed to indicate the time of the most recent review. b. All pen and pencil changes of policies and procedures must be dated with the date the change or revision was made and initialed by the department head. 5. When the hospice has services, including inpatient care, provided for under arrangement, there must be a current written agreement which must be signed and dated by the administrator of the hospice program, and the duly authorized official of the agency providing the service or resource. The agreement must clearly delineate the responsibilities of the parties involved and must include no less than the following: a. Identification of services to be provided. b. A stipulation that services provided are consistent with the hospice service plan of care. c. The manner in which the contracted services are coordinated, supervised, and evaluated. d. A statement that the hospice program retains the responsibility for planning and coordinating services and care on behalf of the patient and family. e. Procedures for submitting clinical and progress notes when applicable. f. Assurance that personnel and services contracted for meet the requirements specified herein pertaining to personnel and services, including licensure, personnel qualifications, and attendance at care conferences. g. Reimbursement mechanism, charges, and terms for the renewal or termination of the agreement. 6. The governing body shall approve an annual operating budget and capital expenditure plan. 7. The governing body or its appropriate administrative representative shall appoint a member of the hospice program team who is responsible for providing for coordination and administration of hospice program service plan for patients and families. The person appointed shall: a. Develop, implement, and annually evaluate the policies and procedures for the total hospice program operation. b. Provide a formal budget that reflects the organization of the hospice program. c. Provide a designation, in writing, of a qualified individual to act in the administrator's absence. d. Act as a liaison between the governing body, medical staff, and other hospice program staff. e. Implement personnel policies and practice with orientation of all new employees, maintenance of complete personnel records for each employee, verification of applicable current licensure or registration of personnel, performance evaluation based on a job description, and current health requirements. f. Provide an ongoing program of training including orientation and continuing education for all employees. Records of inservice training must be maintained which list the content of and attendance at staff development programs.