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
Universal Citation: WY Code of Rules 10-5
Current through September 21, 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.
Disclaimer: These regulations may not be the most recent version. Wyoming may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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