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 which shall perform the following functions:
(A) Establish and review policies for the management, operation, and evaluation of the hospice care program, including, but not limited to:
(1) Qualifications of employees and independent contractors; and
(2) 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:
(a) Notification procedures for hospice patients, employees and contracted staff to report alleged violations to the hospice program administration;
(b) Requirements for the immediate investigation of alleged violations;
(c) Documentation requirements for reported alleged violations, including time frames for response; and
(d) Procedures for the reporting of verified violations to the appropriate state licensing authority and/or local authorities where appropriate; and
(e) Requirements for timely corrective actions for all verified violations.
(B) Arrange for a physician to serve as medical director for the hospice care program.
Interpretive guideline: The physician serving as medical director:
(1) Should be knowledgeable about the psychological, social, and medical aspects of hospice care as the result of training, experience, and interest;
(2) Also may serve as the physician representative on an interdisciplinary team or teams or as an attending physician; and
(3) Shall designate a physician to act in his or her absence.
(C) Appoint a qualified individual to serve as the director of the hospice care program.
Interpretive guideline: The director of the hospice care program shall perform the following duties:
(1) 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;
(2) Implement the hospice care program's policies and procedures regarding all activities and services provided by the hospice care program;
(3) Designate an individual to act in his or her absence;
(4) Implement the hospice care program's quality assessment and performance improvement program under rule 3701-19-22 of the Administrative Code; and
(5) Implement the hospice care program's patient grievance program established under paragraph (A)(2)of this rule.
(D) Ensure that all services provided are consistent with accepted standards of practice for hospice care.
(E) Evaluate the hospice care program's quality assessment and performance improvement program on an annual basis.
R.C. 119.032 review dates: 05/19/2009 and 08/15/2014
Promulgated Under: 119.03
Statutory Authority: 3712.03
Rule Amplifies: 3712.01, 3712.06
Prior Effective Dates: 12/31/1990, 9/5/97, 10/17/99