Current through Register Vol. XLI, No. 45, November 8, 2024
Section 64-54-4 - Organization and Management4.1. A hospice shall have a governing body that determines, implements and monitors policies governing the hospice's total operation in accordance with established bylaws. 4.1.a. If a hospice is operated by a hospital, nursing home or other type of organization, there shall be an identifiable separate administration which serves the function of the governing body for a hospice program, although a separate ownership or board of directors is not required.4.1.b. The governing body shall meet at least annually to review the hospice's total operation including at a minimum: 4.1.b.2. Provision and coordination of inpatient care and in home care;4.1.b.3. The quality assessment and performance improvement committee's reports and actions; and4.1.b.4. Any other reviews necessary to determine adequate care, treatment, health, safety, welfare and comfort of hospice patients .4.1.c. Annual reviews shall be documented by signed meeting minutes kept at the hospice.4.2. The governing body shall designate a person who is responsible for the day to day operation of the hospice. 4.2.a. The person designated shall be qualified by education or training as specified in a job description developed by the governing body.4.2.b. The person designated shall be responsible for the overall supervision of all staff working on behalf of the hospice.4.2.c. The person designated shall be responsible for the overall development of staff qualifications and shall develop and approve job descriptions for each job classification.4.2.d. Each job description shall designate by job title who is responsible for supervision for all licensed and unlicensed staff providing services to the hospice.4.3. The governing body shall develop and maintain a current organizational chart which clearly delineates the lines of authority and supervision of all staff.4.4. The hospice shall develop and implement written policies and procedures consistent with this rule. 4.4.a. Policies and procedures shall accurately reflect a description of the hospice's goals, methods by which these goals are sought, and mechanisms by which the hospice care services are delivered.4.4.b. The interdisciplinary team shall review the clinical policies and procedures annually and shall document the review by a dated signature.4.4.c. The interdisciplinary team shall revise the clinical policies and procedures as needed.4.5. The hospice shall maintain clinical records and business records pertaining to the patient according to hospice policy.4.5.a. The hospice shall establish policies and procedures specifying who may use the records, under what conditions the records may be removed from the hospice and under what conditions the information from the records may be released.4.5.b. A hospice that discontinues operation shall inform the Director, in writing, where the clinical and business records are stored and how the records may be accessed.4.5.c. The hospice shall take measures to ensure the safety of the clinical and business records.4.5.d. The patient or his or her legal representative has the right to examine the patient's clinical record at reasonable times and shall, upon written request, be provided with a copy or a summary of the clinical record within a reasonable time. A hospice shall comply with other provisions of W. Va. Code § 16-29-14.6. The patient or his or her legal representative may voice complaints regarding the care or lack of care and services provided by the hospice. 4.6.a. The person designated by the governing body for the day to day operation of the hospice shall be responsible for the complaint process.4.6.b. The hospice shall designate a person or persons who shall be responsible for reviewing and investigating allegations.4.6.c. The hospice shall communicate the results of the investigation to the patient or his or her legal representative as soon as possible but no later than 30 days after the receipt of the complaint.4.6.d. The hospice shall maintain documentation of the investigation until the next re-certification survey.4.7. The hospice shall have a legally binding contract for any services provided by contract at the hospice. 4.7.a. The contract shall state the services to be provided.4.7.b. The contract shall state how the hospice will be responsible for the supervision of services.