3701-19-06 Governing body; quality assessment and performance improvement.

(A) The overall conduct and operation of the hospice care program, including the quality of care and the provision of services, shall be the full legal responsibility of a clearly defined, organized governing body.

(B) The governing body of a licensed hospice care program may also provide governance for a pediatric respite care program if the programs are dually-licensed and meet all requirements set forth in this rule and chapter.

(C) The governing body shall:

(1) Establish and review policies for the management, operation, and evaluation of the hospice care program, including, but not limited to:

(a) Qualifications of employees and independent contractors; and

(b) Policies and procedures to receive and respond to patient grievances regarding medical treatment, quality of care, the lack of respect for person or property, mistreatment, neglect, verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by any individual furnishing services on behalf of the hospice care program. The policies and procedures developed by the governing body shall, at a minimum, include:

(i) Notification procedures for hospice patients, employees and contracted staff to report alleged violations to the hospice program administration;

(ii) Documentation requirements for reported alleged violations, including time frames for response;

(iii) Reporting procedures for verified violations to the appropriate state licensing authority, local authorities, or both where appropriate; and

(iv) Requirements for timely corrective actions for all verified violations.

(2) Arrange for a physician to serve as medical director for the hospice care program who:

(a) Shall be knowledgeable about the psychological, social, and medical aspects of hospice care as the result of training, experience, and interest;

(b) May also serve as the physician representative on an interdisciplinary team or teams or as an attending physician; and

(c) Shall designate a physician to act in his or her absence.

(3) Appoint a qualified individual to serve as the director of the hospice care program who shall perform the following duties:

(a) Be responsible for the day-to-day management of the program and for assuring compliance with Chapter 3712. of the Revised Code, Chapter 3701-13, and this chapter of the Administrative Code;

(b) Implement the hospice care program's policies and procedures regarding all activities and services provided by the hospice care program;

(c) Designate an individual to act in his or her absence;

(d) Implement the hospice care program's quality assessment and performance improvement program under paragraph (D) of this rule;

(e) Implement the hospice care program's patient grievance program established under paragraph (C)(1) of this rule.

(f) Implement the drug diversion investigation and reporting program required by section 3712.062 of the Revised Code. The hospice director or the director's designee, must:

(i) Receive reports of suspected drug diversion from hospice staff;

(ii) Within twenty four hours of receipt, investigate reports of suspected drug diversion; and

(iii) No later than ten days after receipt of a report of suspected drug diversion or upon conclusion of an investigation, report to the law enforcement agency with jurisdiction over the territory in which the hospice patient's home is located the results of the hospice program's investigation when the investigation substantiates that drug diversion has occurred or when the results of the investigation are inconclusive. Nothing in this rule prohibits a hospice care program from reporting the result of any other drug diversion investigation to law enforcement.

(4) Designate a registered nurse that is a member of an interdisciplinary team to coordinate the overall functioning of the team; and

(5) Ensure that all services provided are consistent with accepted standards of practice for hospice care.

(D) Each hospice care program governing body shall ensure that an ongoing, comprehensive, integrated, self-assessment of the quality and appropriateness of care provided by the program, including inpatient care, home care, and care provided under contracts with other persons or public agencies is conducted. The assessment shall include all services that were indicated and provided to the hospice care patients and their families and the patients' and caregivers' responses or outcomes to those services.

(E) The hospice care program governing body shall ensure the use of the findings of the quality assessment and performance improvement program to correct identified problems and to revise hospice care program policies if necessary.

(F) The hospice care program governing body shall ensure that an evaluation of the hospice care program's quality assessment and performance improvement program is conducted on an annual basis.

Replaces: 3701-19-08, 3701-19-22

Effective: 2/15/2015
Five Year Review (FYR) Dates: 05/01/2019
Promulgated Under: 119.03
Statutory Authority: 3712.03
Rule Amplifies: 3712.01 , 3712.03 , 3712.06
Prior Effective Dates: 12/31/1990, 9/5/97, 10/17/99, 1/1/05, 8/23/09