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Title: Section 794.9 Records and reports

Effective Date


Section 794.9 Records and reports. (a) The governing authority shall ensure that: 

(1) the following records are retained on file at the principal office of the hospice within its approved geographic service area and available to the Department upon request: 

(i) the certificate of incorporation, if applicable; 

(ii) the certificate of approval; 

(iii) all current contracts, leases and other agreements entered into by the hospice; 

(iv) current operating policies and procedures; and 

(v) a current patient/family roster; 

(2) copies of the documents under subparagraphs (1)(iv) and (v) of this subdivision are retained on file at each suboffice of the hospice, if applicable; 

(3) the following reports and records are retained by the hospice and available to the department upon request: 

(i) minutes of the meetings of the hospice governing authority and the quality assurance committee which shall be retained for three years from the date of the meeting; 

(ii) the reports of hospice surveys and inspections by outside agencies with statements attached thereto specifying the steps taken to correct any deficiencies or to carry out the recommendations contained therein which shall be retained for five years from the date of such survey or inspection; 

(iii) records of all financial transactions which shall be retained eight years from the date of the transaction; 

(iv) personnel records, which shall be retained six years from the date of employee termination or resignation;  

(v) records of complaints and appeals, which shall be retained three years from resolution; and 

(vi) records of tracking, receipt and resolution of accident and incidents. 

(b) The hospice shall furnish annually to the department a copy of: 

(1) the current annual report submitted to its governing body; and  

(2) other such data, records and reports as may be required by the department. 


VOLUME E (Title 10)