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Title: Section 794.1 - Governing authority

Effective Date


Section 794.1 Governing authority. The governing authority, as defined in Part 790 of this Title shall: 

(a) be responsible for the management and fiscal operations of the hospice, the provision of all hospice services, and continuous quality assessment and performance improvement; 

(b) ensure compliance with all applicable Federal, State and local laws, rules and regulations; 

(c) provide for coordinated, interdisciplinary inpatient and home care services, 24 hours a day, 7 days a week; 

(d) ensure adequate staff and resources to provide continuity of care based on the needs of the persons served; 

(e) adopt, amend and implement bylaws regarding the responsibilities, functions and activities of the governing body; 

(f) adopt the hospice budgets, control assets and funds, and provide for annual fiscal audits; 

(g) prohibit any employee of the hospice to be reimbursed by any party other than the hospice for service provided as part of the hospice program, or the splitting or sharing of fees between a referral agency/facility or individual and the hospice; 

(h) ensure the prompt submission of all records and reports required by the department; 

(i) ensure compliance with the pertinent provisions regarding the discontinuance of operations of a medical facility, as set forth in section 401.3 of this Chapter, in the event the hospice discontinues operation for any reason; 

(j) negotiate agreements with other patient care facilities/agencies for the referral and acceptance of hospice patients; 

(k) adopt and amend policies and procedures regarding management and operation of the hospice and the provision of patient care services;  

(l) ensure the development and implementation of a patient complaint procedure to include: 

(1) documentation of receipt, investigation and resolution of any complaint, including maintenance of a complaint log indicating the dates of receipt and resolution of all complaints received by the program; 

(2) review of each complaint with a written response to all written complaints and to oral complaints, if requested by the individual making the oral complaint, explaining the complaint investigation findings and the decisions rendered to date by the program within 15 days of receipt of such complaint; and 

(3) an appeals process with review by a member or committee of the governing authority within 30 days of receipt of the appeal. 

(m) ensure the development, implementation and annual review of a written emergency plan which is current and includes hospice emergency contact information, current staff call down list, and community partners contact list and procedures to be followed to assure health care needs of patients continue to be met in emergencies that interfere with the delivery of services, and orientation of all employees to their responsibilities in carrying out such a plan;  

(n) obtain, from the Department’s Health Commerce System (HCS), accounts for each hospice it operates and ensure that sufficient, knowledgeable staff maintain and keep current such accounts. At a minimum, twenty-four hour, seven-day a week contacts for emergency communication and alerts must be designated by each hospice in the HCS Communications Directory. A policy defining the hospice’s HCS coverage consistent with the hospice’s hours of operation shall be created and reviewed by the hospice no less than annually. Maintenance of each hospice’s HCS accounts shall consist of, but not be limited to, the following: 

(1) sufficient designation of the hospice’s HCS coordinator(s) to allow for HCS individual user application; 

(2) designation by the governing authority of the hospice of sufficient staff users of the HCS accounts to ensure rapid response to requests for information by the State and/or local Department of Health; 

(3) adherence to the requirements of the HCS user contract; and  

(4) current and complete updates of the Communications Directory reflecting changes that include, but are not limited to, general information and personnel role changes as soon as they occur, and at a minimum, on a monthly basis. 


VOLUME E (Title 10)