abbreviations - Hospice Of Montezuma
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Hospice of Montezuma Patient Care Policies and Procedures Policy Title Abbreviations Policy # 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 1 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures Policy Title Assessments – Updates to the Comprehensive Assessment Policy # 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 2 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures Policy Title Discharge for Reasons Other Than Death Policy # 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 3 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures Policy Title Interdisciplinary Team Policy # 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 in the Patient's Home Notification of Non-Coverage PC.M55 Nursing Services PC.N15 On-Call Services PC.O10 4 PC.N10 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures Policy Title Pain and Symptom Management Policy # 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 5 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures Policy Title Volunteers - Assignment Policy # 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. 6 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures ABBREVIATIONS NHPCO Standard(s): Regulatory Citation / Other: Adopted: 9/26/2007 Policy Number: PC.A10 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). 7 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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 ALF amb bilat BS BSD BM BMI BUN CHF CNA c/o^ CPAP chemo DME DNR DNRO DPOA dx dysp endur EKG^ eg ER ESAS freq ft G tube GFR^ G/U HEENT HH HHA HCS^ HM HOM^ hosp 8 activities of daily living assisted living facility ambulate bilaterally blood sugar bedside drainage, for a catheter drainage system bowel movement body mass index blood urea nitrogen congestive heart failure certified nurse’s aide complaint of continuous positive airway pressure chemotherapy durable medical equipment do not resuscitate do not resuscitate order durable power of attorney diagnosis, diagnostic dyspnea endurance electrocardiogram for example, as an example emergency room Edmonton Symptom Assessment Scale frequency foot, feet (distance) gastric tube (for feedings) glomerular filtration rate genito-urinary head, eyes, ears, nose and throat home health home health aide Home Care Service homemaker Hospice of Montezuma hospital p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures Approved Abbreviations Page 2 hx IADLs IDDM indep IV JVD J-tube K L LMOM^ LW lb LOC* LPN MD MPOA MS^ med mo N/A NC NG tube NIDDM NPO NRB O2 O2 sat OT occ Pcg PERL PERLA phys act PN* POA POC pt PRN P/S P/U^ 9 history independent activities of daily living insulin dependent diabetes mellitus independent intra-venous jugular vein distention feeding tube placed in the jejunum potassium left left message on machine living will pound, as in weight level of care licensed practical nurse medical doctor, physician medical power of attorney morphine sulfate medication, medical month not applicable, does not apply nasal cannula naso-gastric tube non-insulin dependent diabetes mellitus nothing by mouth non-rebreather mask oxygen Oxygen Saturation Occupational Therapy occasional primary caregiver pupils equal, reactive to light pupils equal, reactive to light and accommodation physical activity primary nurse power of attorney plan of care patient when necessary; as needed PsychoSocial pick up (as in a prescription) p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures Approved Abbreviations Page 3 pst PT Px QA quads* R RB req ROM RN r/t^ Rx^ S/S SLP SN SNF SOB STD SW SWMH^ TIA TPN TPR UR VI^ VGI^ VM^ VC* vol vs w wc wk WNL wt yr > < past physical therapy or in lab results, ProTime prognosis quality assurance and improvement quadrants, typically of the abdomen right rebreather mask requires, required range of motion registered nurse related to prescription signs and symptoms Speech/Language Therapy skilled nurse skilled nursing facility Short of breath sexually transmitted disease social worker Southwest Memorial Hospital transient ischemic attack total parenteral nutrition; nutrition provided by IV temperature, pulse, and respirations utilization review Valley Inn Vista Grande Inn Vista Mesa volunteer coordinator volunteer visit with wheel chair week within normal limits weight year greater than less than *This abbreviation has another common use. Be cautious to use it only as indicated by this document. 10 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures ADDENDUM PC.A10B DO NOT USE ABBREVIATIONS The abbreviations on this list are allowed only when selected by the EMR. Potential Problem Do This Do Not Use Apothecary Symbols (dram, minim) Misunderstood or misread Use the metric system, i.e., gram = ounce. (symbol for dram misread for “3” and minim misread as “mL”) AS, AD, AU (Latin abbrev. for left, right or both ears) When poorly written, mistaken for OS, OD, and OU (meaning left, right or both eyes) Write “left ear” or “right ear” or “both ears” c.c. (for cubic centimeter) Mistaken for U (units) when poorly written. Write “mL” for milliliters D/C (discharge, discontinue) Allowed only when selected by the EMR Mistaken to mean “discontinue” whatever medications follow (which typically is a list of discharge meds) Write “discharge” or “discontinue” Inderal40 mg Name letters and dose numbers run together. Misread as Inderal 140mg Always use space between drug name, dose and unit of measure H. S. (Latin for “hour of sleep”); also qhs (for nightly) Misread as half-strength or “at bedtime” Can result in dosing error; “qhs” misread as (every hour) Write “half-strength” or “at bedtime”; Write “nightly” IU (for international unit) Mistaken as IV (intravenous) or 10 (ten) Write “international unit” MSO4, MgSO4 Confused for one another; can mean morphine sulfate or magnesium sulfate Write “morphine sulfate” or “magnesium sulfate” OD (for once daily) Also OS, OD, OU (Latin for left, right or Misinterpreted as “right eye.” Also, when poorly written, mistaken for AS, AD, and AU Write “daily” or Write “left eye,” “right eye,” or “both eyes” 11 p:policies/official policies/approved patient care combined policies (also in agency information) 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 Q.O.D. (every other day) Mistaken for each other. In Q.D. Write “daily” or the period after the Q can be Write “every other 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 hour Q 6PM, etc. (for every evening at 6 PM) Misread as every six hours S.C. or S.Q. sub q (subcutaneous) Mistaken as SL for sublingual, or “5 every.” Also, the “q” has been mistaken for “every” (e.g. one heparin dose ordered “sub q 2 hours before surgery” misunderstood as every 2 hours before surgery). SYMBOLS: > greater than < less than Mistakenly used opposite of intended Write “greater than” or “less than” SYMBOLS: The slash mark “/” separating two doses or “per” Misunderstood as the number 1 (“25 unit/10 units” read as “110” units.) DO NOT USE A SLASH MARK to separate doses. Write “per” ss (sliding scale [insulin] or ½ (apothecary) Mistaken for “55” T.I.W.; B.I.W. Can mean either twice weekly or three times weekly. Also can be Write “nightly” Write “nightly” Use the abbreviation “subQ” or write the word “subcutaneous” Allowed only when selected by the EMR 12 Write “sliding scale” or “one half” or use “1/2” Write “twice weekly” or “three times weekly” p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Do Not Use Patient Care Policies and Procedures Potential Problem Do This mistaken for T.I.D (three times a day). All can result in a wrong dose. Trailing zero (X.0 mg) Lack of leading zero (.X mg) Decimal point is missed, resulting in higher figure. U or u (for unit) Mistaken as zero or, if poorly written, as either four or cc. x3d (for three days) 13 Never write a zero by itself after a decimal point (write X mg) and always use a zero before a decimal point (write 0.X mg) Write “unit” Write “for three days” or “q. 72 hours” p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 14 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 15 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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 16 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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 970-5658441, 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. 17 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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 Printed Name ________________________ Employee/Volunteer’s Signature Date:_________________________ This policy is to be signed annually by all employees, volunteers, and Board Members. 18 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures ADMISSION TO HOSPICE OF MONTEZUMA PRIOR CERTIFICATION OF TERMINAL ILLNESS NHPCO Standard(s): Regulatory Citation / Other: 42 CFR 418.22; CoP 418.102(a) Adopted 9/26/2007 Policy Number: PC.A20 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. 19 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures ADMISSION TO HOSPICE OF MONTEZUMA, INC. CRITERIA FOR ADMISSION NHPCO Standard(s): PFC 2.1; IA 1.2; OE 2.1; CLR 2.2 Regulatory Citation / Other: Adopted 9/26/2007 Policy Number: PC.A25 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 nonacceptance 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. 20 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 21 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures ADMISSION TO HOSPICE OF MONTEZUMA, INC ELECTION OF THE MEDICARE HOSPICE BENEFIT NHPCO Standard(s): Regulatory Citation / Other: 42 CFR 418.24 Adopted: 9/26/2007 Policy Number: PC.A30 Page 1 of 2 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. 22 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 23 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures ADMISSION TO HOSPICE OF MONTEZUMA, INC. ELIGIBILITY DETERMINATION FOR MEDICARE 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 Policy Number: PC.A35 Page 1 of 2 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). 24 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 25 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 26 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 27 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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 28 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures ADMISSION TO HOSPICE OF MONTEZUMA PROCESS NHPCO Standard(s): PFC 2.1; IA 1.2; CLR 2.2 Adopted 9/26/2007 Policy Number: PC.A50 Page 1 of 2 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. 29 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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 30 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures ADMISSION TO HOSPICE OF MONTEZUMA READMISSION NHPCO Standard(s): Regulatory Citation / Other: Adopted 9/26/2007 Policy Number: PC.A55 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 31 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures ADMISSION TO HOSPICE OF MONTEZUMA REFERRALS NHPCO Standard(s): PFC 2.1; CES 1.1 Regulatory Citation / Other: Adopted 9/26/2007 Policy Number: PC.A60 Page 1 of 2 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 twentyfour (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. 32 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 33 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures ADMISSION TO HOSPICE OF MONTEZUMA REFERRALS FROM ACUTE CARE FACILITIES NHPCO Standard(s): Regulatory Citation / Other: Approved: 9/26/2007 Policy Number: PC.65 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. 34 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures ADVANCE BENEFICIARY NOTICE NHPCO Standard(s): Regulatory Citation / Other: CoP 418.52(e) Adopted 9/26/2007 Policy Number: PC.A70 Page 1 of 2 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. 35 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 36 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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 37 ______________ Date p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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) 38 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 39 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 40 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures ASSESSMENT – COMPREHENSIVE ASSESSMENT OF THE PATIENT NHPCO Standard(s): PFC 2.2; CES 1; WE 11.3 Regulatory Citation / Other: CoP 418.54 Adopted 9/26/2007 Policy Number: PC.A80 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. 41 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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 42 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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-oflife 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. 43 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures ASSESSMENT - INITIAL NHPCO Standard(s): PFC 2.2 Regulatory Citation / Other: CoP 418.54(a) Adopted: 9/26/2007 Policy Number: PC.A90 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. 44 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 45 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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.). 46 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 47 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 48 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures BEREAVEMENT – FILES NHPCO Standard(s): PFC 17.1; PFC 19.2 Regulatory Citation / Other: Adopted: 2/24/2010 Policy Number: PC.B15 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. 49 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures BEREAVEMENT – MAILINGS NHPCO Standard(s): PFC 17.1; PFC 17.4 Regulatory Citation / Other: Adopted: 2/24/2010 Policy Number: PC.B20 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. 50 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 51 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 52 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 53 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures BEREAVEMENT – TRACKING AND EVALUATION NHPCO Standard(s): PFC 17.1 Regulatory Citation / Other: 42 CFR 418.88(a) Adopted: 2/24/2010 Policy Number: PC.B35 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. 54 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures CHANGE OF DESIGNATED HOSPICE NHPCO Standard(s): CES 9; CES 9.1; CES 9.4 Regulatory Citation / Other: 42 CFR 418.30 Adopted 9/26/2007 Policy Number: PC.C10 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. 55 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 56 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 57 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures COMMUNICATION BARRIERS NHPCO Standard(s): PFC 11.3 Regulatory Citation / Other: Adopted 9/26/2007 Policy Number: PC.C20 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. 3. 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. For visually impaired patients: a. 58 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. p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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 5658411). 59 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures COMMUNITY RESOURCES NHPCO Standard(s): Regulatory Citation / Other: Adopted 9/26/2007 Policy Number: PC.C25 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. 60 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. b. c. d. e. f. g. h. acupuncture; aromatherapy; comfort touch expressive therapy; reflexology; hypnosis; Reiki; and 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. 61 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 62 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 63 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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 64 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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 ï‚· 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. ï‚· A determination of death must be made in accordance with accepted medical standards (Uniform Determination of Death Act). ï‚· 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. ï‚· 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. ï‚· 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. 65 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 66 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 67 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 68 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures DISCHARGE FOR REASONS OTHER THAN DEATH 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) Policy Number: PC.D20 Page 1 of 2 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. 69 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures PC.D20 Page 2 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. 70 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures DOCUMENTATION REQUIREMENTS NHPCO Standard(s): PFC 7.3; CES 21.3; WE 11.4 Regulatory Citation / Other: Policy Number: PC.D25 Page 1 of 2 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. 71 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 72 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 73 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures HOSPICE CARE FOR FACILITY RESIDENTS NHPCO Standard(s): NF PFC 1 Regulatory Citation / Other: Proposed CoP 418.112 Policy Number: PC.F25 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. 74 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures HOSPICE CARE FOR FACILITY RESIDENTS – HOSPICE PLAN OF CARE NHPCO Standard(s): NF PFC 1.1; PFC 2.2 Regulatory Citation / Other: CoP 418.112(f) Policy Number: PC.F30 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. 75 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures HOME HEALTH AIDE SERVICES NHPCO Standard(s): WE 19; WE 19.1; WE 19.2; WE 19.3 Regulatory Citation / Other: 42 CFR 418.94; CoP 418.76 Policy Number: PC.H10 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. 76 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures HOME HEALTH AIDE SUPERVISION NHPCO Standard(s): WE 20; WE 20.1; WE 20.2 Regulatory Citation / Other: 42 CFR 418.94(a); Cop 418.76(h) Policy Number: PC.H15 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. 77 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures INFECTION CONTROL – BAG TECHNIQUE NHPCO Standard(s): CES 13.1 Regulatory Citation / Other: Policy Number: PC.I10 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. 78 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures INFECTION CONTROL – BIOHAZARDOUS WASTE MANAGEMENT NHPCO Standard(s): CES 12; CES 12.1 Regulatory Citation / Other: CoP 418.60 Policy Number: PC.I15 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 “biohazardous.” 3. Hospice of Montezuma ensures appropriate collection and removal of all biohazardous materials from the hospice’s property. 79 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures INFECTION CONTROL – CLEANING AND DECONTAMINATING SPILLS OR BLOOD NHPCO Standard(s): CES 12; CES 12.1 Regulatory Citation / Other: Proposed CoP 418.60 Policy Number: PC.I20 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. 80 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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; 81 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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 82 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures INFECTION CONTROL – EXPOSURE TO BLOOD AND BODY FLUIDS NHPCO Standard(s): Regulatory Citation / Other: 29 CFR 1910.1030; CoP 418.60 Policy Number: PC.I30 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. 83 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 84 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures Hospice of Montezuma, Inc. OCCUPATIONAL EXPOSURE PROCEDURE CLASSIFICATION CATEGORIES 85 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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: ï‚· Bladder irrigation ï‚· Cleaning of blood/body fluids spill ï‚· Catheter care ï‚· Catheterization ï‚· ChemStick/AccuCheck (blood sugar testing) ï‚· Collecting blood specimen ï‚· Collecting sputum specimen ï‚· Collecting stool/urine specimen ï‚· Colostomy/ileostomy care (including irrigation) ï‚· Cultures, obtaining ï‚· Diabetic urine testing ï‚· Disposal of contaminated articles (including trash) ï‚· Dressing change, IV ï‚· Dressing changes, wound ï‚· Enema-giving and/or suppository insertion ï‚· Fecal impaction, removal of ï‚· Incontinent care ï‚· IV, administering (including insertion of) ï‚· Laundry/linen, handling of soiled ï‚· NG tube (including insertion, removal, feeding, giving meds via, & dressing change) ï‚· Nasal/oral/tracheal suctioning ï‚· Oral hygiene ï‚· Output, measuring of ï‚· Rectal/oral temperature, measuring of ï‚· Perineal care ï‚· Post mortem care ï‚· Topical medication, application of ï‚· Tracheotomy care ï‚· Vaginal douching ï‚· Cleaning, body fluids spill and/or splash ï‚· Cleaning, toilets (including bedside commodes) 86 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma ï‚· ï‚· ï‚· ï‚· Patient Care Policies and Procedures 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 Category Gloves I Yes, utilitytype I Yes, utilitytype Cleaning, rooms (including patient rooms) I Yes, utilitytype Dishes & utensils, handling soiled I Yes, utilitytype Feeding syringes, handling soiled I Yes, utilitytype I Yes, utilitytype PROCEDURE Cleaning, body fluids spill and/or splash Cleaning, toilets (including bedside commodes) Laundry/linen, handling soiled (including sorting & pre-soaking Face Mask/ Shield/ Goggles No, unless splashing likely No, unless splashing likely No, unless splashing likely No, unless splashing likely No, unless splashing likely No, unless splashing likely Gown/ Apron Potential Contaminate Duration of Precautions Staff Member Code* No, unless soiling likely Blood/body fluids During procedure N/F S/C/V No, unless soiling likely Blood/body fluids During procedure N/F S/C/V Blood/body fluids During procedure N/F S/C/V Blood/body fluids During procedure N/F S/C/V Blood/body fluids During procedure N/F S/C/V Blood/body fluids During procedure N/F S/C/V No, unless soiling likely No, unless soiling likely No, unless soiling likely No, unless soiling 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 87 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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: ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· 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) 88 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma ï‚· ï‚· ï‚· ï‚· ï‚· Patient Care Policies and Procedures Range of motion Shaving Transfer of patient, assisting with Turning/repositioning patient, assisting with Weighing the patient Procedure Precautions/Category II PROCEDURE Accidents & incidents Ace bandage, application and/or removal of Back rub Category Gloves II Yes II No, unless contact with blood/ body fluid likely II No, unless contact with blood/ body fluid likely Bath (including bed bath & skin care) II Yes Bed-making (occupied) II No Bed-making (unoccupied) II No Bedpan/urinal/be dside commode/kidney basin, patient assistance with (including emptying & cleaning) Bedside/table/ov erbed table, cleaning Cleaning baseboards 89 Face Mask/ Shield/ Goggles No, unless splashing likely No, unless splashing likely No, Gown/ Apron No, unless soiling likely No, unless soiling likely No, Potential Contaminate Duration of Precautions Staff Member Code* Blood/body fluids During procedure N/F S/C/V Blood/body fluids During procedure N/F Blood/body fluids During procedure N/F S/C/V Blood/body fluids During procedure N/F Blood/body fluids During procedure N/F N/A During procedure N/F unless splashing likely unless soiling likely No, unless splashing likely No, unless splashing likely No, unless splashing likely No, unless soiling likely No, unless soiling likely No, unless soiling likely No, unless soiling likely Urine/feces/ vomitus; blood/body fluids During procedure N/F S/C/V II Yes No, unless splashing likely II Yes, utility-type No No Blood/body fluids During procedure N/F/H S/C/V II Yes, utility-type No No Blood/body fluids During procedure N/F/H p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma PROCEDURE Cleaning bathrooms Cleaning furniture Cleaning laundry equipment Cleaning wheelchairs & other medical equipment Compress, applying (cold / warm) Patient Care Policies and Procedures Category Gloves II Yes, utility-type II II Yes, utility-type Yes, utility-type Face Mask/ Shield/ Goggles No, unless splashing likely Gown/ Apron Potential Contaminate Duration of Precautions Staff Member Code* No, unless soiling likely Blood/body fluids During procedure N/F/H Blood/body fluids Blood/body fluids During procedure During procedure No No No No N/F/H II Yes, utility-type No No Blood/body fluids During procedure N/F/H II No, unless contact with blood/ body fluid likely No No Blood/body fluids During procedure N/F No No Blood/body fluids During procedure N/F No No Secretions/ blood/ body fluids During procedure N/F No No Secretions/ blood/ body fluids During procedure N/F Yes No No Secretions/ blood/ body fluids During procedure N/F No, unless soiling likely Saliva/ secretions/ exudate During procedure N/F S/C/V Secretions, exudates Blood/body fluids During procedure During procedure Blood/body fluids During procedure N/F S/C/V Blood/body fluids During procedure N/F Dressing/undress ing the patient II Ear care II Eye care II Eye drops/ointments, administration II No, unless contact with blood/ body fluid likely No, unless contact with blood/ body fluid likely No, unless contact with blood/ body fluid likely Feeding II No No, unless splashing likely Feeding - by syringe II Yes No No Floor care II No No No, unless splashing likely No, unless splashing likely No, unless soiling likely No, unless soiling likely Hair care II Injections II 90 N/F/H Yes, utility-type No, unless contact with blood/ body fluid likely Yes N N/F p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma PROCEDURE Maintenance Procedures Patient Care Policies and Procedures Category Gloves II No, unless contact with bio-hazard material likely Nail care II Yes Nursing/physical assessments II No Nose drops, installation of II Yes II No, unless contact with blood/ body fluid likely Oral medications, administration Oxygen, administration of Protective devices/restraints (including application & removal of) Range of motion No No, unless splashing likely Gown/ Apron Potential Contaminate No Blood/body fluids Duration of Precautions Staff Member Code* During procedure N/F Blood/body fluids During procedure N/F S/C/V Blood/body fluids During procedure N/F Nasal secretions During procedure N/F No Saliva/ secretions/ blood/body fluids During procedure N/F No, unless soiling likely Nasal secretions During procedure N/F No, unless soiling likely No, unless soiling likely No, unless soiling likely II No II No, unless contact with blood/ body fluid likely No, unless splashing likely No, unless soiling likely Blood/body fluids During procedure N/F II No, unless contact with blood/ body fluid likely No, unless splashing likely No, unless soiling likely Blood/body fluids During procedure N/F No, unless splashing likely No, unless splashing likely No, unless splashing No, unless soiling likely No, unless soiling likely No, unless soiling Saliva/secretio ns During procedure N/F Blood/body fluids During procedure N/F Blood/body fluids During procedure N/F Respiratory treatments II Yes Shaving II Yes Transfer of patient, assisting with II No, unless contact with blood/ 91 Face Mask/ Shield/ Goggles No, unless required for protection from flying debris No, unless splashing likely No, unless splashing likely No, unless splashing likely p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma PROCEDURE Category Patient Care Policies and Procedures Gloves body fluid likely Turning/repositio ning patient, assisting with II Vital signs, measuring II Washing windows II Weighing the patient II No No, unless contact with blood/ body fluid likely Yes, utility-type No, unless contact with blood/ body fluid likely Face Mask/ Shield/ Goggles likely No, unless splashing likely Gown/ Apron likely No, unless soiling likely Potential Contaminate Duration of Precautions Staff Member Code* Blood/body fluids During procedure N/F No No Blood/body fluids During procedure N/F No No Blood/body fluids During procedure N/F No, unless splashing likely No, unless soiling likely Blood/body fluids During procedure N/F *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 92 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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: ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· ï‚· 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 93 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 94 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 95 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 96 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 97 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures INFECTION CONTROL – STANDARD PRECAUTIONS Policy Number: 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 crosscontamination 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 98 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 99 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 100 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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; 101 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 102 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 103 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 104 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures LEVELS OF CARE NHPCO Standard(s): PFC 2.3; CES 21.5 Regulatory Citation / Other: Approved: Policy Number: PC.L15 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. 105 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 106 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 107 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 108 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 109 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 110 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures MEDICATIONS – ADMINISTRATION NHPCO Standard(s): CES 4.4 Regulatory Citation / Other: 418.96(a); Proposed CoP 418.106(a) Approved: 2/25/2009 Policy Number: PC.M25 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 111 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 112 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures MEDICATIONS – ADVERSE DRUG REACTIONS NHPCO Standard(s): CES 4.4; CES 4.8 Regulatory Citation / Other: Approved: 2/25/2009 Policy Number: PC.M30 Page 1 of 2 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 113 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 114 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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 115 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 116 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 117 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 118 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 119 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures MEDICATION – ORDERS NHPCO Standard(s): CES 4.4 Regulatory Citation / Other: Approved: Policy Number: PC.M50 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. 120 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures MEDICATION – TRACKING AND DISPOSING OF CONTROLLED DRUGS IN THE PATIENT’S HOME Policy Number: 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. 121 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 122 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 123 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 124 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 125 p:policies/official policies/approved patient care combined policies (also in agency information) Hospice of Montezuma Patient Care Policies and Procedures 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. 126 p:policies/official policies/approved patient care combined policies (also in agency information)
