The applicant or licensee must develop and implement a plan of operation which includes:

(1) A description of the organizational structure;

(2) Personnel job descriptions according to WAC 246-335-625(2);

(3) Responsibilities of contractors and volunteers;

(4) Services to be provided;

(5) The days and hours of agency operation; and

(6) Criteria for management and supervision of hospice services throughout all approved service areas, which include:

(a) How the initial assessment and development of the plan of care will be completed per WAC 246-335-640;

(b) How supervision of personnel and volunteers and monitoring of services provided by contractors will occur which meet the requirements of WAC 246-335-645;

(c) How performance evaluations for personnel and volunteers and evaluation of services provided by contractors will be conducted per WAC 246-335-625 (15) and (16); and

(d) How the quality improvement program required in WAC 246-335-655 will be applied throughout all approved service areas.

(7) A process to inform patients of alternative services prior to ceasing operation or when the licensee is unable to meet the patient's needs;

(8) A plan for preserving records, including the process to preserve or dispose of records prior to ceasing operation according to WAC 246-335-650 (7) and (8); and

(9) Time frames for filing documents in the patient records;

(10) Emergency preparedness that addresses service delivery when natural disasters, man-made incidents, or public health emergencies occur that prevent normal agency operation. Include, at minimum: Risk assessment and emergency planning, communication plan, coordination of service delivery with emergency personnel to meet emergent needs of patients, and staff training;

(11) Availability of a bereavement program for up to one year after a patient's death;

(12) Availability of social services, spiritual counseling, volunteer services, and respite care;

(13) Assuring direct care personnel, contractors and volunteers have training specific to the needs of the terminally ill patients and their families;

(14) The applicant or licensee must identify an administrator. The administrator is appointed by and reports to the agency owner or governing body, is a hospice employee, and possesses education and experience required by the agency's policies or the hospice's governing body. The administrator is responsible to:

(a) Oversee the day-to-day operation and fiscal affairs of the agency;

(b) Implement the provisions of this section;

(c) Designate in writing an alternate to act in the administrator's absence;

(d) Provide management and supervision of services throughout all approved service areas according to subsection (6) of this section;

(e) Arrange for necessary services;

(f) Keep contracts current and consistent with WAC 246-335-625(4);

(g) Serve as a liaison between the licensee, personnel, contractors and volunteers;

(h) Ensure personnel, contractors and volunteers are currently credentialed by the state of Washington, when appropriate, according to applicable practice acts and consistent with WAC 246-335-625(5);

(i) Ensure personnel, contractors and volunteers comply with the licensee's policies and procedures;

(j) Implement a quality improvement process consistent with WAC 246-335-655;

(k) Manage recordkeeping according to WAC 246-335-650;

(l) Ensure supplies and equipment necessary to patient care are available, maintained, and in working order;

(m) Ensure the accuracy of public information materials; and

(n) Ensure current written policies and procedures are accessible to personnel, contractors, and volunteers during hours of operation.

(15) The applicant or licensee must identify a medical director who is responsible to:

(a) Advise the licensee on policies and procedures;

(b) Serve as liaison with a patient's authorizing practitioner;

(c) Provide patient care and family support;

(d) Approve modifications in individual plans of care; and

(e) Participate in interdisciplinary team conferences as required by WAC 246-335-640, hospice plan of care.

(16) The licensee must continue to update its plan of operation to reflect current practice, services provided by the agency, and state and local laws.