The applicant or licensee must develop and operationalize policies and procedures that describe:

(1) Admission, transfer, discharge, and referral processes:

(a) In order to minimize the possibility of patient abandonment, patients must be given at least a forty-eight hour written or verbal notice prior to discharge that will be documented in the patient record;

(b) Forty-eight hour notice is not required if hospice agency worker safety, significant patient noncompliance, or patient's failure to pay for services rendered are the reason(s) for the discharge;

(c) A Hospice agency discharging a patient that is concerned about their ongoing care and safety may submit a self-report to appropriate state agencies which identifies the reasons for discharge and the steps taken to mitigate safety concerns;

(2) Specific hospice services, including palliative care and any nonmedical services, available to meet patient, or family needs as identified in plans of care;

(3) Initial patient assessment completed by a registered nurse within seven calendar days of receiving and accepting a physician or practitioner referral for hospice services. Longer time frames are permitted when one or more of the following is documented:

(a) Longer time frame for completing the initial patient assessment is requested by physician or practitioner;

(b) Longer time frame for completing the initial patient assessment is requested by the patient, designated family member, or legal representative; or

(c) Initial patient assessment was delayed due to agency having challenges contacting the patient, designated family member, or legal representative.

(4) Agency personnel, contractor, and volunteer roles and responsibilities related to medication self-administration with assistance and medication administration;

(5) Coordination of care, including:

(a) Coordination among services being provided by a licensee having an additional home health or home care service category; and

(b) Coordination with other agencies when care being provided impacts patient health.

(6) Actions to address patient or family communication needs;

(7) Utilization of telehealth or telemedicine for patient consultation or to acquire patient vitals and other health data in accordance to state and federal laws;

(8) Management of patient medications and treatments in accordance with appropriate practice acts;

(9) Utilization of restraints and/or seclusion following an individualized patient assessment process;

(10) Emergency care of the patient;

(11) Actions to be taken upon death of a patient;

(12) Providing back-up care to the patient when services cannot be provided as scheduled. Back-up care which requires assistance with patient ADLs or patient health services must be provided by staff with minimum health care credentialing. Noncredentialed staff may provide back-up care only when assisting a patient with IADLs or in emergency situations;

(13) Actions to be taken when the patient has a signed advanced directive;

(14) Actions to be taken when the patient has a signed POLST form. Any section of the POLST form not completed implies full treatment for that section. Also include: In the event of a patient medical emergency and agency staff are present, provide emergency medical personnel with a patient's signed POLST form; and

(15) Nurse delegation according to the following:

(a) Delegation is only permitted for patients requiring specific nursing tasks that do not require clinical judgment.

(b) Hospice agencies coordinating patient care with a separate home care agency must ensure that a formal delegation contract has been established between the two agencies in order for the hospice nurse to delegate to the home care agency workers.