Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0003 - Aging Division › Chapter 10 - PROGRAM ADMINISTRATION OF HOSPICE PROGRAMS › Section 10-5 - Organization and Management

Current through July 13, 2024
(a) Governing Body. The hospice program shall
				have a governing body which has the legal authority and responsibility to
				operate the hospice program. The governing body shall:
(i) Obtain employee dishonesty coverage
				through a general liability insurance policy, fidelity bond, or surety bond.
				This coverage is for patient protection due to dishonesty, integrity, or
				fidelity on behalf of an employee. The coverage shall be no less than five
				thousand dollars ($5,000).
(ii)
				Provide verification of a central registry check on all employees hired at the
				time of or after the filing of these rules. The individual agencies or
				corporations are responsible for obtaining central registry verifications.
				Central Registry information can be obtained by contacting the Department of
				Family Services at307-777-5894 (this number may be subject to
				change).
(iii) Insure that all
				staff successfully complete, at a minimum, a full fingerprint-based National
				Criminal Background Check before unsupervised direct patient contact. If there
				are any flags on the background check and the facility employs the individual,
				the facility must document in the individual's personnel file that prior to
				hire the flagged issue was thoroughly investigated and it was determined the
				individual is appropriate to provide services to vulnerable adults.
(iv) Adopt, revise, and approve personnel
				policies, including:
(A) Frequency of
				evaluations; and
(B) Insuring
				confidentiality of central registry information and criminal background
				checks.
(v) Prepare an
				organizational chart that reflects the administrative control and lines of
				authority for the delegation of responsibility from management down to the
				patient level.
(vi) Ensure that all
				services provided are consistent with accepted standards of practice.
(vii) Ensure adequate numbers of qualified
				staff to provide quality hospice care and volunteer services, and, if offered,
				non-hospice respite care.
(viii)
				Develop and implement policies and procedures for services offered which shall
				be reviewed annually by the medical director and either the governing body or
				appropriate administrative representative.
(ix) Develop an effective, ongoing,
				agency-wide written quality improvement program which ensures and evaluates
				quality of care to all patients in accordance with W.S. §
										
											35-2-910.
(x) Develop a written grievance procedure.
(A) The grievance procedure shall establish a
				system of reviewing complaints and allegations of patients' rights violations
				to include, but not be limited to:
(I)
				Patient method to voice grievance;
(II) The Hospice Program's written response
				to patient grievances;
(III) List
				of agencies, with addresses and telephone numbers, for patients to contact if
				grievances are not addressed satisfactorily; and
(IV) Written reports on all grievances and
				resolutions shall be provided to the State Survey Agency, within ten (10) days
				after the grievance is filed.
(xi) Refer Complaint Investigations.
(A) Patient complaints and problems shall be
				referred in writing to the Long Term Care Ombudsman.
(B) The office of the Ombudsman shall
				complete all complaint investigations within an appropriate time frame
				depending upon the nature of the allegations.
(C) Written reports of an investigation and
				the status of resolutions completed by the hospice shall be provided by the
				Long Term Care Ombudsman to the State Survey Agency within thirty (30) days
				after the completion of an investigation.
(I)
				Exception: Complaints or problems reported directly to the State Survey Agency
				or referred by the Long Term Care Ombudsman to the State Survey Agency shall be
				investigated by the State Survey Agency.
(xii) Maintain employee Personnel records.
				There shall be one (1) person designated responsible for maintaining
				confidentiality of personnel records.
(xiii) Develop policies and procedures with
				regard to Employee Health. The hospice program shall at a minimum:
(A) Include a policy listing communicable
				diseases that put the patient population at risk. In addition, the hospice
				shall report communicable diseases or conditions as required by W.S. §
											
												35-4-107 through W.S. §
											
												35-4-108 and;
(B) Document that the employee is free of
				communicable diseases that could be a risk to the client population.
(xiv) Adopt Advanced Directives.
				The hospice program shall adopt policies which assure that information on
				advanced directives is provided to all patients. If the patient's advanced
				directives are known, they shall be followed by the hospice program.
(xv) Make specific notifications:
(A) Prior to admission, all prospective
				patients shall be notified if the hospice program is not Medicare/Medicaid
				certified.
(B) Each hospice program
				will notify its prospective patients, or the responsible party, of the services
				it provides and the charges for those services.
(C) The responsible party shall be notified
				of the service charges and any change in charges.