Hospice of Montezumapatient Care Policies and Procedures

Hospice of MontezumaPatient Care Policies and Procedures

Policy Title / Policy #
Abbreviations / PC.A10
Abuse, Neglect and Exploitation / PC.A15a
Abuse, and/or Molestation – Sexual / PC.A15b
Admission to Hospice Care – Prior Certification of Terminal Illness / PC.A20
Admission to Hospice Care – Criteria for Admission / PC.A25
Admission to Hospice Care – Election of the Medicare Hospice Benefit / PC.A30
Admission to Hospice Care – Eligibility Determination for Medicare / PC.A35
Admission to Hospice Care – Informed Consent / PC.A40
Admission to Hospice Care – Physician’s Orders / PC.A45
Admission to Hospice Care – Process / PC.A50
Admission to Hospice Care – Readmission / PC.A55
Admission to Hospice Care – Referrals / PC.A60
Admission to Hospice Care – Referrals from Acute Care Facilities / PC.A65
Advance Beneficiary Notice / PC.A70
Advance Directives / PC.A75
Assessment – Comprehensive Assessment of the Client / PC.A80
Assessment – Content of the Comprehensive Assessment / PC.A85
Assessment - Initial / PC.A90
Assessment – Patient Outcome Measures / PC.A95
Assessments – Updates to the Comprehensive Assessment / PC.A100
Attending Physicians / PC.A105
Availability 24/7 / PC.A110
Bereavement - Care Planning / PC.B10
Bereavement – Files / PC.B15
Bereavement – Mailings / PC.B20
Bereavement - Risk Assessment / PC.B25
Bereavement – Services / PC.B30
Bereavement - Tracking and Evaluation / PC.B35
Change of Designated Hospice / PC.C10
Clinical Records / PC.C15
Communication Barriers / PC.C20
Community Resources / PC.C25
Complementary Therapies / PC.C30
Continuation of Care – Inability to Pay for Care / PC.C35
Continuity of Care / PC.C40
Coordination of Services / PC.C45
Death of a Hospice Client / PC.D10
Dietary Services / PC.D15
Discharge for Reasons Other Than Death / PC.D20
Documentation Requirements / PC.D25
Durable Medical Equipment / PC.D30
Facility Residents – Hospice Care for / PC.F25
Facility Residents – Hospice Plan of Care / PC.F30
Home Health Aide Services / PC.H10
Home Health Aide Supervision / PC.H15
Home Visit Procedure for Non-Hospice Employees / PC.H20
Hospice Care for Nursing Facility Residents / PC.H25
Infection Control – Bag Technique / PC.I10
Infection Control – Bio-hazardous Waste Management / PC.I15
Infection Control – Cleaning and Decontaminating Spills or Blood / PC.I20
Infection Control – Education / PC.I25
Infection Control – Exposure to Blood and Body Fluids / PC.I30
Infection Control – Occupational Exposure Procedures Classification / PC.I35
Infection Control – Program / PC.I40
Infection Control – Responsibilities / PC.I45
Infection Control - Standard Precautions / PC.I50
Interdisciplinary Team / PC.I55
Interdisciplinary Team Meeting / PC.I60
Laboratory Services / PC.L10
Levels of Care / PC.L15
Levels of Care - Continuous Care / PC.L20
Levels of Care - General Inpatient Care / PC.L25
Levels of Care - Inpatient Respite Care / PC.L30
Medical Director / PC.M10
Medical Supplies / PC.M20
Medications – Administration / PC.M25
Medications - Adverse Drug Reactions / PC.M30
Medications – Do Not Crush Medications / PC.M35
Medications – Errors / PC.M40
Medications – Management / PC.M45
Medications Orders / PC.M50
Medications – Tracking and Disposing of Controlled Drugs
in the Patient's Home / PC.M55
Notification of Non-Coverage / PC.N10
Nursing Services / PC.N15
On-Call Services / PC.O10
Pain and Symptom Management / PC.P10
Patient / Caregiver Education / PC.P15
Patients Without Primary Caregivers / PC.P20
Physical, Occupational, Speech and Other Therapies / PC.P25
Physician Orders / PC.P35
Physician Services / PC.P40
Plan of Care / PC.P45
Plan of Care – Initial / PC.P50
Professional Management / PC.P60
Recertification of Terminal Illness / PC.R10
Revocation of the Medicare Hospice Benefit / PC.R15
Safety - Home Visits / PC.S10
Safety - Patient/Caregiver / PC.S15
Social Work Services / PC.S20
Spiritual Care Services / PC.S25
Standards of Practice / PC.S30
Suicide / PC.S35
Transfer of a Hospice Patient / PC.T10
Traveling Hospice Patients / PC.T15
Volunteers - Assignment / PC.V10
Volunteers - Documentation / PC.V15
Volunteers – Services / PC.V20
Table of Contents List Items that are Grayed Out are Not Included
In Policies and Procedures yet. They are still in the process of being created.
ABBREVIATIONS / Policy Number:
PC.A10
NHPCO Standard(s):
Regulatory Citation / Other:
Adopted: 9/26/2007 Reviewed/Revised: 3/24/2010

POLICY STATEMENT: Hospice of Montezuma prohibits the routine use of abbreviations, acronyms and symbols by staff with the exception of those abbreviations, acronyms and symbols on the approved list (which includes those that are on the drop down menu of the computerized clinical documentation program.)

PROCEDURES:

1. Abbreviations and symbols are used in the medical record only when there is a drop down menu of the computerized documentation system available or the abbreviation is listed on the approved abbreviations list (See Addendum PCA10A).

1. All Hospice of Montezuma clinicians receive a listing of dangerous abbreviations that may not be used in clinical documentation (See Addendum PC.A10B).

ADDENDUM PC.A10A

Approved Abbreviations

All abbreviations contained in the Suncoast System, plus the abbreviations listed below with an ^ which are not in Suncoast.

ADLsactivities of daily living

ALFassisted living facility

ambambulate

bilatbilaterally

BSblood sugar

BSDbedside drainage, for a catheter drainage system

BMbowel movement

BMIbody mass index

BUNblood urea nitrogen

CHFcongestive heart failure

CNAcertified nurse’s aide

c/o^complaint of

CPAPcontinuous positive airway pressure

chemochemotherapy

DMEdurable medical equipment

DNRdo not resuscitate

DNRO do not resuscitate order

DPOAdurable power of attorney

dxdiagnosis, diagnostic

dyspdyspnea

endurendurance

EKG^electrocardiogram

egfor example, as an example

ERemergency room

ESASEdmonton Symptom Assessment Scale

freqfrequency

ftfoot, feet (distance)

G tubegastric tube (for feedings)

GFR^glomerular filtration rate

G/Ugenito-urinary

HEENThead, eyes, ears, nose and throat

HHhome health

HHAhome health aide

HCS^Home Care Service

HMhomemaker

HOM^Hospice of Montezuma

hosphospital

Approved Abbreviations Page 2

hxhistory

IADLsindependent activities of daily living

IDDMinsulin dependent diabetes mellitus

indepindependent

IVintra-venous

JVDjugular vein distention

J-tubefeeding tube placed in the jejunum

Kpotassium

Lleft

LMOM^left message on machine

LWliving will

lbpound, as in weight

LOC*level of care

LPNlicensed practical nurse

MDmedical doctor, physician

MPOAmedical power of attorney

MS^morphine sulfate

medmedication, medical

momonth

N/Anot applicable, does not apply

NCnasal cannula

NG tubenaso-gastric tube

NIDDMnon-insulin dependent diabetes mellitus

NPOnothing by mouth

NRBnon-rebreather mask

O2oxygen

O2 satOxygen Saturation

OTOccupational Therapy

occoccasional

Pcgprimary caregiver

PERLpupils equal, reactive to light

PERLApupils equal, reactive to light and accommodation

phys actphysical activity

PN*primary nurse

POApower of attorney

POCplan of care

pt patient

PRNwhen necessary; as needed

P/SPsychoSocial

P/U^pick up (as in a prescription)

Approved Abbreviations Page 3

pstpast

PTphysical therapy or in lab results, ProTime

Pxprognosis

QAquality assurance and improvement

quads*quadrants, typically of the abdomen

Rright

RBrebreather mask

reqrequires, required

ROMrange of motion

RNregistered nurse

r/t^related to

Rx^prescription

S/Ssigns and symptoms

SLPSpeech/Language Therapy

SNskilled nurse

SNFskilled nursing facility

SOBShort of breath

STDsexually transmitted disease

SWsocial worker

SWMH^Southwest Memorial Hospital

TIAtransient ischemic attack

TPNtotal parenteral nutrition; nutrition provided by IV

TPRtemperature, pulse, and respirations

URutilization review

VI^Valley Inn

VGI^Vista Grande Inn

VM^Vista Mesa

VC*volunteer coordinator

volvolunteer

vsvisit

wwith

wcwheel chair

wkweek

WNLwithin normal limits

wtweight

yryear

greater than

less than

*This abbreviation has another common use. Be cautious to use it only as indicated by this document.
ADDENDUM PC.A10B

DO NOT USE ABBREVIATIONS

The abbreviations on this list are allowed only when selected by the EMR.

Do Not Use / Potential Problem / Do This
Apothecary
Symbols
(dram, minim) / Misunderstood or misread (symbol for dram misread for “3” and minim misread as “mL”) / Use the metric system, i.e., gram = ounce.
AS, AD, AU (Latin abbrev. for left, right or both ears) / When poorly written, mistaken for OS, OD, and OU (meaning left, right or both eyes) / Write “left ear” or
“right ear” or “both ears”
c.c. (for cubic centimeter) / Mistaken for U (units) when poorly written. / Write “mL” for milliliters
D/C (discharge, discontinue)
Allowed only when
selected by the EMR / Mistaken to mean “discontinue” whatever medications follow (which typically is a list of discharge meds) / Write “discharge” or “discontinue”
Inderal40 mg / Name letters and dose numbers run together. Misread as Inderal 140mg / Always use space between drug name, dose and unit of measure
H. S. (Latin for “hour of sleep”);
also qhs (for nightly) / Misread as half-strength or “at bedtime”
Can result in dosing error; “qhs” misread as (every hour) / Write “half-strength” or “at bedtime”;
Write “nightly”
IU (for international unit) / Mistaken as IV (intravenous) or 10 (ten) / Write “international unit”
MSO4, MgSO4 / Confused for one another; can mean morphine sulfate or magnesium sulfate / Write “morphine sulfate” or “magnesium sulfate”
OD (for once daily) Also OS, OD, OU (Latin for left, right or both eyes) / Misinterpreted as “right eye.”
Also, when poorly written, mistaken for AS, AD, and AU (meaning left, right or both ears) / Write “daily” or
Write “left eye,”
“right eye,” or “both eyes”
Q.D. (once daily) and
Q.O.D. (every other day) / Mistaken for each other. In Q.D. the period after the Q can be mistaken for an “I.” In Q.O.D. the “O” can be mistaken for “I.” Both result in Q.I.D. (four times a day). / Write “daily” or
Write “every other day”
qn (for nightly) /

Misinterpreted as “qh” every hour

/ Write “nightly”
Q6PM, etc. (for every evening at 6 PM) /

Misread as every six hours

/ Write “nightly”
S.C. or S.Q.
sub q
(subcutaneous) /

Mistaken as SL for sublingual, or “5 every.” Also, the “q” has been mistaken for “every” (e.g. one heparin dose ordered “sub q 2 hours before surgery” misunderstood as every 2 hours before surgery).

/ Use the abbreviation “subQ” or write the word “subcutaneous”
SYMBOLS:
> greater than
< less than
Allowed only when
selected by the EMR /

Mistakenly used opposite of intended

/ Write “greater than” or “less than”
SYMBOLS: The slash mark “/” separating two doses or “per” /

Misunderstood as the number 1 (“25 unit/10 units” read as “110” units.)

/ DO NOT USE A SLASH MARK to separate doses. Write “per”
ss (sliding scale [insulin] or ½ (apothecary) /

Mistaken for “55”

/ Write “sliding scale” or “one half” or use “1/2”
T.I.W.; B.I.W. / Can mean either twice weekly or three times weekly. Also can be mistaken for T.I.D (three times a day). All can result in a wrong dose. / Write “twice weekly” or “three times weekly”
Trailing zero
(X.0 mg)
Lack of leading zero (.X mg) /

Decimal point is missed, resulting in higher figure.

/ Never write a zero by itself after a decimal point (write X mg) and always use a zero before a decimal point (write 0.X mg)
U or u (for unit) / Mistaken as zero or, if poorly written, as either four or cc. / Write “unit”
x3d (for three days) / Write “for three days” or “q. 72 hours”
ABUSE, NEGLECT AND EXPLOITATION / Policy Number:
PC.A15a
NHPCO Standard(s):
Regulatory Citation / Other: CoP 418.52(b)(4)
Adopted 9/26/2007 Reviewed/Revised:3/24/2010

POLICY STATEMENT: All alleged violations involving mistreatment, neglect by self or others, or verbal, mental, sexual and/or physical abuse, including injuries of unknown source and misappropriation of client property are reported to State and local bodies having jurisdiction within 24 hours of the incident. Suspected cases of abuse, neglect by self or others or exploitation of clients/caregivers, including elderly or disabled adults and children, are thoroughly investigated and reported if warranted.

Definitions

Abuse: The intentional infliction of physical, emotional, or sexual pain or injury.

Neglect: The failure to provide, in a timely manner, adequate food, clothing, shelter, psychological care, physical care, medical care, or supervision for an at-risk adult or child to the degree that a reasonable person in the same situation would provide. This does not include provision of artificial nutrition as described in Article 18 of title 15, C.R.S.

Exploitation: the illegal or improper use of an at-risk adult or a child, their money, or their property for another person’s advantage.

Self-Neglect: an act or failure to act whereby an at-risk adult substantially endangers the adult’s health, safety, welfare, or life by not seeking or obtaining services necessary to meet the adult’s essential human needs. Choice of lifestyle or living arrangements shall not, by itself, be evidence of self-neglect.

PROCEDURES:

During orientation, all new employees receive instruction regarding legal requirements for reporting suspected abuse, neglect by self or others and exploitation. This instruction includes a review of the State’s legal definitions of abuse, neglect and exploitation and mandatory reporting requirements and processes. (Reporting requirements for abuse, neglect, exploitation

co.us/.../OCCURRENCE%20REPORTING%20REQUIREMENTS.ppt)

1.During the admission process and throughout the course of care, Hospice of Montezuma personnel assess the potential / likelihood of abuse, neglect by self or others or exploitation in the client’s environment.

2.Suspicion of abuse, neglect by self or others and/or exploitation of any client, family member or caregiver is documented and brought to the attention of the interdisciplinary team and appropriate manager immediately.

PC.A25a Page 2

3.A call to the appropriate State Agency / Abuse Hotline for further investigation is made by hospice personnel who are members of disciplines required to report such incidents when,

in their professional judgment, such reporting is warranted. The supervisor is apprised of the report immediately after such a report is made.

4.A review of the suspected abuse, neglect by self or others and/or exploitation is conducted with the Executive Director and/or Hospice of Montezuma Medical Director. Every attempt is made to protect the client/family/caregiver.

5.All assessments, interventions, discussions and follow-up with the State Agency are carefully documented and kept confidential.

6.An Incident Report is completed describing the suspected abuse, neglect by self or other, or exploitation.

7.Failure on the part of Hospice of Montezuma personnel to report suspected abuse, neglect by self or others, or exploitation results in disciplinary action and the potential for civil damages.

ABUSE, AND/OR MOLESTATION- SEXUAL / Policy Number:
PC.A15b
NHPCO Standard(s):
Regulatory Citation / Other: CoP 418.52(b)(4)
Adopted 9/26/2007 Reviewed/Revised: 3/24/2010

POLICY: Hospice of Montezuma has a Zero-Tolerance policy for any sexual abuse and/or molestation committed by an employee, volunteer, board member or third party. Upon completion of the investigation, disciplinary action up to and including termination of employment and criminal prosecution may ensue. Hospice of Montezuma prohibits and does not tolerate sexual abuse, and/or molestation in the workplace or in any organization related activity. Hospice of Montezuma provides procedures for employees, volunteers, family members, board members, patients, victims of sexual abuse, or others to report sexual abuse and enforces disciplinary penalties for those who commit such acts.

Definition

Sexual abuse or molestation is inappropriate sexual contact of a criminal nature or interaction for gratification of the adult who is a caregiver and responsible for the patient or child's care. Sexual abuse includes sexual molestation, sexual assault, sexual exploitation, or sexual injury, but does not include sexual harassment. All reported incidents of sexual abuse will be investigated and reported to appropriate law enforcement agencies and regulatory agencies.

Common physical and behavioral evidence or signs that someone may be experiencing sexual abuse are listed below. These signs may also be present when no abuse has occurred.

Physical evidence of abuse:

1. Difficulty in walking
2. Torn, stained or bloody underwear
3. Pain or itching in genital area
4. Bruises or bleeding of the external genitalia
5. Sexually transmitted diseases

Behavioral signs of sexual abuse:

1. Reluctance to be left alone with a particular person
2. Wearing lots of clothing especially in bed
3. Fear of touch
4. Nightmares or fear of night
5. Apprehension when topic of sex is brought up

PC.A15b Page 2

Anti-retaliation

Hospice of Montezuma prohibits retaliation made against any employee, volunteer, board member or patient who reports a good faith complaint of sexual abuse or who participates in any related investigation. Making false accusations of sexual abuse in bad faith can have serious consequences for those who are wrongly accused. Hospice of Montezuma prohibits making false and/or malicious sexual abuse allegations, as well as deliberately providing false information during an investigation. Anyone who violates this rule is subject to disciplinary action, up to and including termination.

PROCEDURE

If you are aware of or suspect sexual abuse is taking place, you must;

1. Immediately report it to your Director or Patient Care Coordinator or designee.
2. If the suspected abuse is to an adult, you should report the abuse to your local or state Adult Protective Services (APS) Agency at 970-565-3769.
3. If it is a child who is the victim then you should report the suspected abuse to the Department of Social Services at 970-565-3769 and to Emergency Dispatch at 970-565-8441, 24 hours a day, 7 days a week. The National Child Abuse Hotline, 1-800-422-4453, TDD 1-800-222-4453, has counselors and information available.
4. Appropriate family members will be notified by the Executive Director or designee of alleged instances of sexual abuse.
5. Hospice of Montezuma will report the alleged sexual abuse incident to their insurance agent.

Investigation and Follow-up

1. Hospice of Montezuma takes all allegations of sexual abuse seriously and will promptly investigate whether sexual abuse has taken place.
2. Hospice of Montezuma will use an outside third party (Mountain States Employment Council, 303-223-5469) to conduct an investigation.
3. Hospice of Montezuma will cooperate fully with any investigation conducted by law enforcement or other regulatory agencies. It is Hospice of Montezuma's objective to conduct a fair and impartial investigation.
4. Hospice of Montezuma provides notice that they have the option of placing the accused on an unpaid leave of absence or on a reassignment to non-patient contact.
5. Hospice of Montezuma will make every reasonable effort to keep the matters involved in the allegation as confidential as possible while still allowing for a prompt and thorough investigation.

HOSPICE OF MONTEZUMA

Acknowledgment of Receipt and Understanding of Sexual Abuse Policy

I acknowledge that I have received and read the sexual abuse policy and/or have had it explained to me. I understand that Hospice of Montezuma will not tolerate any employee, volunteer, board member or third party who commits sexual abuse. Disciplinary actions will be taken against those who are found to have committed sexual abuse. I understand that Hospice of Montezuma has the option of placing anyone accused of sexual abuse on unpaid leave of absence or on a reassignment to non-patient contact duties.

I understand that it is my responsibility to abide by all rules contained in the policy. I also understand how to report incidents of sexual abuse as set forth in the abuse policy, and that retaliation against any employee/volunteer exercising his or her rights under the policy is prohibited.

______

Employee/Volunteer Employee/Volunteer’s

Printed NameSignature

Date:______

This policy is to be signed annually by all employees, volunteers, and Board Members.

ADMISSION TO HOSPICE OF MONTEZUMA
PRIOR CERTIFICATION OF TERMINAL ILLNESS / Policy Number:
PC.A20
NHPCO Standard(s):
Regulatory Citation / Other: 42 CFR 418.22; CoP 418.102(a)
Adopted 9/26/2007 Reviewed/Revised: 3/24/2010

POLICY STATEMENT: The Hospice of Montezuma Medical Director and the patient's attending physician (if the patient has one)sign a written statement prior to the patient’s admission to Hospice of Montezuma, certifying that the patient's prognosis is 6 months or less if the terminal illness follows its normal course.