Conn. Agencies Regs. § 19a-495-6c

Current through December 27, 2024

Section 19a-495-6c - Governing authority

(a) A governing authority shall be established by the licensee for the hospice inpatient facility.

(b) The governing authority shall have the authority and responsibility for the overall management and operation of the hospice inpatient facility and shall adopt bylaws or rules that are periodically reviewed and a notation made of the date of such adoption and review. Such bylaws or rules shall include, but not be limited to:

(1) A mission statement and purpose of the hospice inpatient facility;

(2) Delineation of the powers, duties and voting procedures of the governing authority, its officers and committees;

(3) Qualifications for membership, method of selection and terms of office of members and chairpersons of committees;

(4) A description of the authority delegated to the administrator;

(5) The conflict of interest policy and procedures;

(6) Scope of services offered;

(7) Admission and discharge criteria;

(8) Medical and dental supervision and plans of treatment;

(9) Clinical records;

(10) Personnel qualifications;

(11) Annual review of personnel policies;

(12) Adoption of written policies assuring the protection of patients' rights and patient grievance procedures, a description of which shall be posted conspicuously in the hospice inpatient facility and distributed personally to each patient upon admission; and

(13) Determination of the frequency of meetings of the governing authority.

(c) The bylaws or rules shall be available to all members of the governing authority and the administrator.

(d) The governing authority shall:

(1) Meet as frequently as necessary to fulfill its responsibilities;

(2) Provide a written agenda and minutes for each meeting;

(3) For each meeting, provide minutes that include, but are not limited to, the identity of those members in attendance, reports of the quality assessment and performance improvement program and any patient grievances. Such minutes shall be approved by the governing authority and dated and signed by the secretary; and

(4) Ensure that the agenda and minutes of any of its meetings or any of its committees are available at any time to the commissioner.

(e) Other specific responsibilities of the governing authority shall include, but not be limited to:

(1) Oversight of the management and operation of the hospice inpatient facility;

(2) Oversight of the financial viability and management of the hospice inpatient facility's fiscal affairs;

(3) Adoption and documented annual review of written bylaws and budget;

(4) Services provided by the hospice inpatient facility and the quality of care rendered to patients and their families;

(5) Provision of a safe physical plant equipped and staffed to maintain the hospice inpatient facility and services in accordance with any applicable local and state regulations and any federal regulations that may apply to federal programs in which the hospice inpatient facility participates;

(6) Appointment of a qualified administrator;

(7) Approval of the administrator's appointment of a medical director;

(8) Approval of an organizational chart that establishes clear lines of responsibility and authority in all matters relating to management and maintenance of the facility and patient care;

(9) Annual review and update of the operation and fiscal plan, including anticipated needs, income and expenses;

(10) Establish and maintain the quality assessment and performance improvement program including, but not limited to, the selection and appointment of a quality assessment and performance improvement advisory committee; review of issues, corrective actions and outcomes; and recommendations for improvement;

(11) Policy and program determination and delegation of authority to implement policies and programs. The establishment of such policies shall include, but not be limited to:

(A) Responsibilities of the administrator and the medical director;

(B) Conflict of interest on the part of the governing authority, professional staff and employees;

(C) Services to be provided;

(D) Criteria for the selection, admission and transfer of terminally ill patients and families;

(E) Patient or family consent and involvement in the development of patient centered plan of care;

(F) Developing a support network when the family is not available and the patient needs and wants that support;

(G) Referrals and coordination with community and other health care facilities or agencies that shall include but not be limited to a mechanism for recording, transmitting and receiving information essential to the continuity of patient care. Such information shall include, but not be limited to:

(i) Patient identification data including name, address, age, gender, name of representative, and health insurance coverage;

(ii) Diagnosis and prognosis, medical status of patient, brief description of current illness, medical and nursing plans of care including information such as drugs and biological products, treatments, dietary needs, baseline laboratory data;

(iii) Functional status;

(iv) Special services such as physical therapy, occupational therapy, speech and language therapy, and any other therapy; and

(v) Psychosocial needs.

(H) Professional management responsibilities for contracted services;

(I) Reports of patient's condition and procedures for the transmission of such reports to the patient's physician;

(J) Provisions governing the relationship of the attending physician or the advanced practice registered nurse to the medical director, and the interdisciplinary team; and

(K) Such other matters, as may be relevant to the organization and operation of hospice care.

(12) Ensure that any and all services provided by hospice inpatient facility volunteers and direct service staff are consistent with accepted standards of practice and applicable law;

(13) Maintain an active quality assessment and performance improvement committee and provide any and all services offered in compliance with sections 19a-495-6 a to 19a-495-6m, inclusive of the Regulations of Connecticut State Agencies; and

(14) Compliance with any established hospice inpatient facility policy.

(f) Failure of the administrator to implement the bylaws, rules, policies, or programs adopted by the governing authority shall be grounds for disciplinary action against the licensee under section 19a-494 of the Connecticut General Statutes.

Conn. Agencies Regs. § 19a-495-6c

Effective July 31, 2012