{"pack":"la-hospice","path":"/policies/louisiana/hospice/","name":"Louisiana Hospice Policy and Procedure Manual","state":"Louisiana","service":"Hospice","license":"Louisiana hospice license","count":60,"forms":68,"categories":[{"name":"Client rights","count":5},{"name":"Service delivery","count":3},{"name":"Hospice care","count":17},{"name":"Clinical tasks","count":7},{"name":"Safeguarding","count":2},{"name":"Infection control","count":2},{"name":"Emergency preparedness","count":1},{"name":"Records","count":1},{"name":"Privacy","count":3},{"name":"Human resources","count":7},{"name":"Governance","count":7},{"name":"Quality","count":1},{"name":"Business","count":2},{"name":"Ethics","count":2}],"policies":[{"ref":"LA-HSP-CMP-01","path":"/policies/louisiana/hospice/complaints-and-grievances/","title":"Complaints and Grievances","category":"Client rights","citation":"LAC 48:I §8231.A.9","summary":"Sets out how patients and families are told how to complain, how staff receive and report complaints the same day, the Agency’s acknowledgment, investigation and response time frames, protection from retaliation, how the Louisiana Department of Health receives and investigates complaints (including the 120-day outdated report rule), other outside contacts, and how complaints feed quality improvement.","sample":true},{"ref":"LA-HSP-FAC-04","path":"/policies/louisiana/hospice/visitation-in-the-inpatient-hospice-during-a-declared-public-health/","title":"Visitation in the Inpatient Hospice During a Declared Public Health Emergency","category":"Client rights","citation":"LAC 48:I §8259","summary":"For a licensed inpatient hospice only: the written clergy and family visitation policy and procedure Louisiana requires during a declared public health emergency, covering who may visit and the order of priority of immediate family members, screening to at least CDC methods, when a visit may be refused, PPE, reasonable time, place and manner restrictions set with medical advice, the right to hand-holding and hugging, free copies, posting on the website homepage within 24 hours, and submission to the Health Standards Section.","sample":false},{"ref":"LA-HSP-PR-01","path":"/policies/louisiana/hospice/patient-rights-and-responsibilities/","title":"Patient Rights and Responsibilities","category":"Client rights","citation":"LAC 48:I §8231","summary":"States the ten patient rights and four patient responsibilities of LAC 48:I §8231 word for word, the federal hospice rights, and the rights Act 480 of 2026 gives hospice patients in facilities; sets out how the notice is explained and signed before care starts, the contacts every patient receives, and how staff protect the rights and respond to concerns.","sample":false},{"ref":"LA-HSP-PR-02","path":"/policies/louisiana/hospice/informed-consent-description-of-services-and-charges/","title":"Informed Consent, Description of Services and Charges","category":"Client rights","citation":"LAC 48:I §8231.B","summary":"Sets out who may give informed consent to hospice care under R.S. 40:1159.4 and the Louisiana Medicaid rules, what the admitting nurse explains before consent (services, scope, risks, charges and cost-sharing), how written consent and the release of information are obtained and kept, and how refusal and withdrawal of consent are handled.","sample":false},{"ref":"LA-HSP-PR-03","path":"/policies/louisiana/hospice/advance-directives-lapost-and-do-not-resuscitate-orders/","title":"Advance Directives, LaPOST and Do-Not-Resuscitate Orders","category":"Client rights","citation":"LAC 48:I §8235.D.2.g","summary":"Sets out how the Agency gives every patient written information on advance directives and LaPOST at the start of care, records whether a directive exists, helps patients who wish to make one, honors DNR orders and LaPOST forms across settings, handles review, voiding and revocation under LAC 48:I Chapter 2, and educates staff and the community.","sample":false},{"ref":"LA-HSP-SAF-01","path":"/policies/louisiana/hospice/safety-program-accidents-hazards-home-safety-and-smoking-materials/","title":"Safety Program: Accidents, Hazards, Home Safety and Smoking Materials","category":"Service delivery","citation":"LAC 48:I §8235.D.3","summary":"Sets out the Agency’s safety program under LAC 48:I §8235.D.3: a safe environment where the Agency knows or has reason to know a setting might be dangerous; reporting, monitoring and follow-up of all accidents, injuries and safety hazards; the home safety assessment; the policy on smoking materials in all care settings; insurance and workers’ compensation; realistic workloads and travel time; and the OSHA injury and illness recording and reporting duties (29 CFR Part 1904).","sample":false},{"ref":"LA-HSP-SAF-02","path":"/policies/louisiana/hospice/workplace-violence-prevention/","title":"Workplace Violence Prevention","category":"Service delivery","citation":"R.S. 40:2199.15","summary":"The Agency’s workplace violence prevention plan under R.S. 40:2199.11 et seq.: the sign required at its premises, education, prevention, response and debriefing resources, annual interactive training for direct-care staff, the system for responding to and investigating incidents, the annual assessment of risk factors, the written safety and security plan, orientation of all employees, reporting of incidents (within 24 hours where there is injury, a weapon or an urgent threat), no retaliation, and field safety for home visits.","sample":false},{"ref":"LA-HSP-SVC-01","path":"/policies/louisiana/hospice/24-hour-availability-on-call-nursing-and-timely-services/","title":"24-Hour Availability, On-Call Nursing and Timely Services","category":"Service delivery","citation":"LAC 48:I §8235.B","summary":"Sets out the posted business hours Louisiana requires (at least 8 hours a day, 5 days a week between 7 a.m. and 6 p.m.), the distinct telephone and answering service rules, 24-hour registered nurse, medication and supply availability, on-call RN triage (never an LPN as primary on-call), Agency response standards, the on-call log and handover, and how families are taught to call.","sample":false},{"ref":"LA-HSP-ADM-01","path":"/policies/louisiana/hospice/referral-admission-criteria-and-admission-procedure/","title":"Referral, Admission Criteria and Admission Procedure","category":"Hospice care","citation":"LAC 48:I §8219.B, C","summary":"Sets out the Agency’s written admission criteria under LAC 48:I §8219.B, how referrals are received only from physicians or their authorized representatives, the attending physician’s order, the registered nurse assessment visit within 48 hours of referral (and of election for Medicare), the admission documents of §8219.C.2, and the Medicaid, PACE, waiver and pediatric rules that apply at admission.","sample":false},{"ref":"LA-HSP-ASM-01","path":"/policies/louisiana/hospice/initial-and-comprehensive-assessment-and-quality-reporting-data/","title":"Initial and Comprehensive Assessment and Quality Reporting Data","category":"Hospice care","citation":"LAC 48:I §8219.C.1","summary":"Sets out the registered nurse assessment within 48 hours of referral (Louisiana) and of election (Medicare), the IDT comprehensive assessment within 5 calendar days with its required content (drug profile, psychosocial, spiritual, bereavement), reassessment at least every 14 days, the referrals an assessment must trigger, and outcome and HOPE quality data.","sample":false},{"ref":"LA-HSP-BRV-01","path":"/policies/louisiana/hospice/bereavement-program/","title":"Bereavement Program","category":"Hospice care","citation":"LAC 48:I §8201 (Bereavement Services)","summary":"Sets out the Agency’s organized bereavement program: services under the supervision of a qualified professional for at least one year following the death of the patient (Louisiana is stricter than the federal “up to 1 year”), the initial bereavement assessment, the bereavement plan of care, the bereavement counselor’s qualifications and duties under LAC 48:I §8217.B, referrals for family members outside the service area, support for staff, and residents of facilities.","sample":false},{"ref":"LA-HSP-CNS-01","path":"/policies/louisiana/hospice/spiritual-dietary-and-other-counseling/","title":"Spiritual, Dietary and Other Counseling","category":"Hospice care","citation":"LAC 48:I §8217.C, D","summary":"Sets out how the Agency provides spiritual counseling, dietary counseling and any other counseling the patient and family need: the qualifications and duties of the spiritual counselor and dietary counselor under LAC 48:I §8217.C and D, the availability of clergy, liaison with community clergy, employment or contract for dietary counseling as §8201 permits, documentation and continuing education.","sample":false},{"ref":"LA-HSP-DC-01","path":"/policies/louisiana/hospice/discharge-non-compliance-and-transfer/","title":"Discharge, Non-Compliance and Transfer","category":"Hospice care","citation":"LAC 48:I §8229","summary":"Limits live discharge to the reasons in LAC 48:I §8229.B, 42 CFR §418.26 and the Medicaid manual, sets out the steps before a discharge for safety or cause, counseling (not discharge) for non-compliance, the written physician discharge order required since August 3, 2026, notice to the patient and the CMS notice of non-coverage, the discharge summary, and the Medicare and Medicaid filings within five calendar days.","sample":false},{"ref":"LA-HSP-DTH-01","path":"/policies/louisiana/hospice/death-of-a-patient-pronouncement-and-post-mortem-care/","title":"Death of a Patient, Pronouncement and Post-Mortem Care","category":"Hospice care","citation":"LAC 48:I §8221.C.17","summary":"The Agency’s written policy to follow at the time of a patient’s death (LAC 48:I §8221.C.17) and its post-mortem care procedures (§8235.D.1.i): preparing the family, the death visit, who pronounces death in Louisiana (a physician under R.S. 9:111(A), or the coroner, who may rely on a registered nurse’s or LPN’s firsthand observation at the scene under R.S. 9:111(B) as amended by Act 367 of 2026), when the coroner must be notified (R.S. 13:5712), controlled substance disposal, post-mortem care, release to the funeral home, and records.","sample":false},{"ref":"LA-HSP-ELC-01","path":"/policies/louisiana/hospice/election-of-hospice-election-statement-addendum-and-notice-of-election/","title":"Election of Hospice, Election Statement Addendum and Notice of Election","category":"Hospice care","citation":"LAC 48:I §8219.A","summary":"Sets out the content and signing of the hospice election statement and attending practitioner designation, the election statement addendum that is mandatory for elections on or after October 1, 2026 (within the first 5 days, updates within 3 days), the Medicare Notice of Election within 5 calendar days, and the Louisiana Medicaid NOE, CTI and prior authorization steps.","sample":false},{"ref":"LA-HSP-ELC-02","path":"/policies/louisiana/hospice/certification-and-recertification-of-terminal-illness-and-face-to-face/","title":"Certification and Recertification of Terminal Illness and Face-to-Face Encounters","category":"Hospice care","citation":"LAC 48:I §8219.B.2","summary":"Sets out who signs the certification of terminal illness in Louisiana (never an APRN), the Medicare and Louisiana Medicaid time frames for initial and later certifications, the narrative and attestation content, the face-to-face encounter before the third and later periods, the 2026 telehealth limits during the nationwide enrollment moratorium, and what happens when a physician will not recertify.","sample":false},{"ref":"LA-HSP-ELC-03","path":"/policies/louisiana/hospice/revocation-transfer-to-another-hospice-and-change-of-attending/","title":"Revocation, Transfer to Another Hospice and Change of Attending Practitioner","category":"Hospice care","citation":"LAC 48:I §8229.C, E","summary":"Protects the patient’s sole right to revoke hospice care, with the Louisiana signed statement giving the reason, no back-dating and no verbal revocations; sets out the transfer statement and once-per-period change of hospice, the change of attending practitioner, and the Medicare and Louisiana Medicaid notices due within five calendar days.","sample":false},{"ref":"LA-HSP-FAC-01","path":"/policies/louisiana/hospice/hospice-care-in-nursing-facilities-assisted-living-and-other/","title":"Hospice Care in Nursing Facilities, Assisted Living and Other Residential Settings","category":"Hospice care","citation":"R.S. 40:2009.26","summary":"Sets out how the Agency serves patients living in nursing facilities, assisted living and other residential settings: facility licensure and the written agreement, the rights and the patient-specific care plan Louisiana required from 2026 (R.S. 40:2009.26), coordination and the information facilities receive, the food and fluid log, transfers with a new care plan within 24 hours, visitation, reporting alleged violations to the facility administrator within 24 hours, orientation of facility staff, and nonprofit end-of-life homes.","sample":false},{"ref":"LA-HSP-FAC-02","path":"/policies/louisiana/hospice/short-term-inpatient-care-and-respite-arrangements/","title":"Short-Term Inpatient Care and Respite Arrangements","category":"Hospice care","citation":"LAC 48:I §8221.C.7","summary":"Sets out how the Agency makes short-term general inpatient and respite care available: the settings allowed, the facility standards checked, the Louisiana and federal terms every inpatient agreement must contain, how a stay is arranged and managed (with the plan of care reviewed every 7 days), what the facility returns at discharge, the federal respite and 20 percent inpatient limits, and the Agency’s own inpatient facility.","sample":false},{"ref":"LA-HSP-FAC-03","path":"/policies/louisiana/hospice/licensed-inpatient-hospice-facility-operations/","title":"Licensed Inpatient Hospice Facility Operations","category":"Hospice care","citation":"LAC 48:I §8247","summary":"For an Agency with an inpatient hospice facility sublicense only: licensure, OPH and OSFM approvals, renewals and changes; care and a named advocate for each patient; 24-hour nursing with a registered nurse on every shift and at least one nurse to eight patients; room standards; water temperature logs and linen; isolation and tuberculosis rules; nutrition and food temperatures; pharmacy rules including 30-day order signing, 2-hour administration, quarterly monitoring and the STAT cabinet; restraint and seclusion; and visiting.","sample":false},{"ref":"LA-HSP-IDG-01","path":"/policies/louisiana/hospice/interdisciplinary-team-and-idt-conferences/","title":"Interdisciplinary Team and IDT Conferences","category":"Hospice care","citation":"LAC 48:I §8201 (Interdisciplinary Team)","summary":"Sets out the required IDT members (physician, RN, LMSW social worker, spiritual counselor, volunteer services representative and bereavement counselor), designation of teams and of the policy team, weekly IDT conferences so every patient is reviewed at least every 14 days (7 days for general inpatient and continuous home care), the conference record, and supervision during all hours of service.","sample":false},{"ref":"LA-HSP-IDG-02","path":"/policies/louisiana/hospice/plan-of-care-initial-plan-reviews-and-practitioner-orders/","title":"Plan of Care: Initial Plan, Reviews and Practitioner Orders","category":"Hospice care","citation":"LAC 48:I §8221.A, B","summary":"Sets out the initial plan of care on the day of the assessment with IDT input within two days, the content Louisiana and Medicare require, review at least every 14 days for home care and every 7 days for general inpatient and continuous home care, documented attending practitioner participation, and orders signed within the Agency’s time frame and never later than 14 days (30 days with documented attempts).","sample":false},{"ref":"LA-HSP-IDG-03","path":"/policies/louisiana/hospice/coordination-of-care-continuity-and-case-management/","title":"Coordination of Care, Continuity and Case Management","category":"Hospice care","citation":"LAC 48:I §8221.C","summary":"Sets out how the Agency meets each principle of LAC 48:I §8221.C: an RN case manager for every patient, communication among disciplines, who may take verbal orders, professional management of contracted services, coordination with Medicaid and other providers, emergency care and hospital admissions, transfers, the Act 480 duties for patients in facilities, and professional boundaries.","sample":false},{"ref":"LA-HSP-LOC-01","path":"/policies/louisiana/hospice/levels-of-care-routine-continuous-home-care-respite-and-general/","title":"Levels of Care: Routine, Continuous Home Care, Respite and General Inpatient","category":"Hospice care","citation":"LAC 48:I §8201 (Continuous Home Care; Respite Care; Acute/General Inpatient Care)","summary":"Sets out the four levels of hospice care and when each is used: continuous home care only in a period of crisis, at least 8 hours a day and more than half nursing, after a registered nurse assessment; respite for not more than five consecutive days; short-term general inpatient care for symptoms that cannot be managed elsewhere; with 7-day plan of care reviews and the Medicare and Medicaid 20 percent inpatient limit.","sample":false},{"ref":"LA-HSP-PAIN-01","path":"/policies/louisiana/hospice/pain-and-symptom-management-and-care-of-the-actively-dying-patient/","title":"Pain and Symptom Management and Care of the Actively Dying Patient","category":"Hospice care","citation":"LAC 48:I §8219.C.1","summary":"Sets out how the Agency assesses and manages pain and other symptoms, from the registered nurse assessment with emphasis on pain and symptom control (LAC 48:I §8219.C.1) through the plan of care interventions, reassessment after treatment (Agency clinical standards), uncontrolled symptoms and periods of crisis, opioid safety, the patient’s right to accept or refuse treatment, and care of the actively dying patient and family.","sample":false},{"ref":"LA-HSP-AIDE-01","path":"/policies/louisiana/hospice/hospice-aide-and-homemaker-services-competency-and-supervision/","title":"Hospice Aide and Homemaker Services, Competency and Supervision","category":"Clinical tasks","citation":"LAC 48:I §8217.G","summary":"Sets out who may work as a hospice aide or homemaker under LAC 48:I §8217.G (and 42 CFR §418.76 if Medicare-certified), the registered nurse competency evaluation before patient care, the written care instructions, what aides may and may not do (no medications, no sterile or invasive procedures), clinical notes each visit, registered nurse supervisory visits at least every 14 days, the annual aide-present visit and annual performance review.","sample":false},{"ref":"LA-HSP-DME-01","path":"/policies/louisiana/hospice/medical-supplies-equipment-and-equipment-safety/","title":"Medical Supplies, Equipment and Equipment Safety","category":"Clinical tasks","citation":"LAC 48:I §8235.D.3.b.ii-iii","summary":"Sets out how the Agency provides the medical supplies, appliances and durable medical equipment in each plan of care, makes equipment and supplies for immediate needs available 24 hours a day, educates patients, families, caregivers, staff and volunteers on safe use, keeps evidence that equipment maintenance and safety requirements are met (LAC 48:I §8235.D.3.b.ii-iii), uses only accredited DMEPOS suppliers if Medicare-certified (42 CFR §418.106(f)), and manages oxygen safety.","sample":false},{"ref":"LA-HSP-MED-01","path":"/policies/louisiana/hospice/pharmaceutical-services-drug-profile-and-medication-safety/","title":"Pharmaceutical Services, Drug Profile and Medication Safety","category":"Clinical tasks","citation":"LAC 48:I §8223","summary":"Sets out how the Agency meets each patient’s pharmaceutical needs under LAC 48:I §8223: drugs and biologicals for palliation provided 24 hours a day, 7 days a week through the pharmacies in its written agreements, the drug profile and its review, orders and verbal orders, who may give medications (never aides), teaching the patient and family, procedures to prevent medication errors, labeling and storage, and, if Medicare-certified, 42 CFR §418.106.","sample":false},{"ref":"LA-HSP-MED-02","path":"/policies/louisiana/hospice/controlled-substances-in-the-home-and-disposal-at-death/","title":"Controlled Substances in the Home and Disposal at Death","category":"Clinical tasks","citation":"R.S. 40:2191","summary":"Sets out the Agency’s written procedure under R.S. 40:2191 for the safe disposal of a deceased patient’s unused controlled substances by a hospice nurse at the time of death (witnessed record of each drug and quantity, immediate disposal at the site of care or immediate mail-back to an authorized collector, method recorded, no removal from the home), the copy of the policy given to each patient and representative at enrollment, the federal duty to give and discuss the policy when controlled drugs are first ordered, and safe use and storage of controlled substances in the home.","sample":false},{"ref":"LA-HSP-NUR-01","path":"/policies/louisiana/hospice/nursing-services-director-of-nurses-and-rn-case-management/","title":"Nursing Services, Director of Nurses and RN Case Management","category":"Clinical tasks","citation":"LAC 48:I §8217.O","summary":"Sets out how the Agency provides nursing services as a core service: the registered nurse designated to coordinate each patient’s plan of care, the registered nurse’s qualifications and duties under LAC 48:I §8217.O (reassessment at least every 14 days, notes within one week, aide supervision every 14 days), the limits on licensed practical nurses under §8217.H, the annual on-site LPN supervisory visit, nursing during continuous home care, and the federal nursing standard for a Medicare-certified hospice.","sample":false},{"ref":"LA-HSP-SW-01","path":"/policies/louisiana/hospice/medical-social-services/","title":"Medical Social Services","category":"Clinical tasks","citation":"LAC 48:I §8217.J","summary":"Sets out how the Agency provides medical social services as a core service: the Louisiana requirement that the social worker hold a current LMSW license and a master’s degree from a CSWE-accredited school of social work (stricter than the federal rule), the social worker’s duties under LAC 48:I §8217.J, notes within one week of the visit, the written summary when services end, and two hours of continuing education each year.","sample":false},{"ref":"LA-HSP-THR-01","path":"/policies/louisiana/hospice/physical-therapy-occupational-therapy-and-speech-language-pathology/","title":"Physical Therapy, Occupational Therapy and Speech-Language Pathology","category":"Clinical tasks","citation":"LAC 48:I §8217.K-N, P","summary":"Sets out how the Agency makes physical therapy, occupational therapy and speech-language pathology available directly or under arrangement, the qualifications Louisiana requires of each therapist and assistant (LAC 48:I §8217.K to N and P), how therapists supervise assistants (OT and OTA joint visits at least every two weeks or every four to six sessions; PT reassessment at least every sixth visit and monthly, and weekly conference with each PTA), notes within one week, and discharge summaries.","sample":false},{"ref":"LA-HSP-ANE-01","path":"/policies/louisiana/hospice/recognizing-and-reporting-abuse-neglect-and-exploitation/","title":"Recognizing and Reporting Abuse, Neglect and Exploitation","category":"Safeguarding","citation":"R.S. 40:2009.20","summary":"Explains how staff recognize abuse, neglect, exploitation and misappropriation, who must report under Louisiana law, where and when to report (the Department or law enforcement within 24 hours for direct caregivers, Adult or Elderly Protective Services for adults, the DCFS hotline immediately for children, and the Administrator immediately), what a report contains, how to keep the patient safe, protections and penalties for reporters, and what patients are told.","sample":true},{"ref":"LA-HSP-ANE-02","path":"/policies/louisiana/hospice/investigation-of-alleged-violations-and-protection-of-patients/","title":"Investigation of Alleged Violations and Protection of Patients","category":"Safeguarding","citation":"42 CFR §418.52(b)(4)","summary":"Sets out what the Agency does once an allegation of abuse, neglect, exploitation, mistreatment, an injury of unknown source or misappropriation is made: immediate protection of the patient and removal of the person suspected from patient contact, a prompt and fair investigation led by the director of nurses, corrective action, reporting verified violations to the Health Standards Section within 5 working days, the Direct Service Worker Registry process, facility cases, confidentiality and learning from allegations.","sample":false},{"ref":"LA-HSP-IC-01","path":"/policies/louisiana/hospice/infection-prevention-and-control-program/","title":"Infection Prevention and Control Program","category":"Infection control","citation":"42 CFR §418.60","summary":"Sets out the Agency’s infection prevention and control program, written to 42 CFR §418.60 because Chapter 82 has no separate infection control section: standard and transmission-based precautions in the home, equipment cleaning, surveillance with the patient infection log, the program’s place in quality improvement, education for staff, contractors, patients and families, reporting of reportable diseases to the Office of Public Health within the time frames LAC 51:II.105 sets by class, and the extra isolation rules for an inpatient facility.","sample":true},{"ref":"LA-HSP-IC-02","path":"/policies/louisiana/hospice/bloodborne-pathogens-exposure-control-and-hazardous-waste/","title":"Bloodborne Pathogens Exposure Control and Hazardous Waste","category":"Infection control","citation":"29 CFR §1910.1030","summary":"The Agency’s bloodborne pathogens exposure control plan under 29 CFR §1910.1030 (exposure determination, annual review, safer sharps, personal protective equipment, hepatitis B vaccine within 10 working days of initial assignment, post-exposure evaluation, training at assignment and annually, records for 3 years and 30 years, sharps injury log), and its safe and sanitary system for identifying, handling and disposing of hazardous wastes (LAC 48:I §8235.D.3.b.v; Louisiana Sanitary Code, Part XXVII).","sample":false},{"ref":"LA-HSP-EP-01","path":"/policies/louisiana/hospice/emergency-preparedness-and-the-louisiana-at-risk-registry/","title":"Emergency Preparedness and the Louisiana At-Risk Registry","category":"Emergency preparedness","citation":"LAC 48:I §8216","summary":"Sets out the Agency’s emergency preparedness program under LAC 48:I §8216 and, if Medicare-certified, 42 CFR §418.113: the yearly all-hazards risk assessment and governing body approval, the seven required plan elements, each patient’s emergency plan and priority level, updating the Louisiana at-risk registry for patients who meet the four criteria, what to do when an emergency is forecast or happens, notice to the Health Standards Section by the next stated business day, recovery, training, exercises and the inpatient facility plan.","sample":false},{"ref":"LA-HSP-REC-01","path":"/policies/louisiana/hospice/clinical-records-retention-and-access/","title":"Clinical Records, Retention and Access","category":"Records","citation":"LAC 48:I §8233","summary":"Sets out what every patient’s clinical record must contain, the time by which each discipline’s notes must be in the record under Chapter 82, how entries are signed and corrected, where records are kept and who may use them, how patients and families get access and copies within Louisiana and HIPAA time limits, how information is released, and how long records are kept and then destroyed.","sample":false},{"ref":"LA-HSP-PRV-01","path":"/policies/louisiana/hospice/hipaa-privacy-and-louisiana-confidentiality-laws/","title":"HIPAA Privacy and Louisiana Confidentiality Laws","category":"Privacy","citation":"45 CFR Part 164, Subpart E","summary":"Sets out how the Agency protects the privacy of patient information under the HIPAA Privacy Rule and Louisiana’s hospice rules and confidentiality laws: the Privacy Official, the Notice of Privacy Practices, when information may be used and shared, Louisiana’s added protections for HIV results and abuse reports, everyday privacy practices, business associates, patients’ privacy rights and time limits, and sanctions.","sample":false},{"ref":"LA-HSP-PRV-02","path":"/policies/louisiana/hospice/hipaa-security-and-electronic-records/","title":"HIPAA Security and Electronic Records","category":"Privacy","citation":"45 CFR Part 164, Subpart C","summary":"Sets out how the Agency protects electronic patient information under the HIPAA Security Rule and Louisiana’s rule that electronic clinical records be password protected: the Security Official, annual risk analysis, workforce access, passwords and encrypted devices, secure email and messaging, physical and technical safeguards, backups and downtime procedures, security incidents and vendors.","sample":false},{"ref":"LA-HSP-PRV-03","path":"/policies/louisiana/hospice/breach-notification/","title":"Breach Notification","category":"Privacy","citation":"45 CFR Part 164, Subpart D","summary":"Sets out how the Agency handles a lost, stolen or misdirected record or any other possible breach: same-day reporting, investigation, the HIPAA four-factor risk assessment, the separate Louisiana test for computerized personal information, the notices to individuals, HHS, the media and the Louisiana Attorney General with their time limits, law enforcement delay, and records.","sample":false},{"ref":"LA-HSP-HR-01","path":"/policies/louisiana/hospice/orientation-in-service-training-and-continuing-education/","title":"Orientation, In-Service Training and Continuing Education","category":"Human resources","citation":"LAC 48:I §8217.E.2.e.iv-vii","summary":"Sets out the orientation every staff member receives, the Louisiana orientation and initial training topics for hospice aides and homemakers, how competency is assessed, the 12 hours of annual in-service for aides (two on end-of-life care, six every six months), the continuing education hours Chapter 82 requires for each discipline, and the annual training every staff member completes.","sample":false},{"ref":"LA-HSP-HR-02","path":"/policies/louisiana/hospice/personnel-qualifications-license-verification-and-job-descriptions/","title":"Personnel Qualifications, License Verification and Job Descriptions","category":"Human resources","citation":"LAC 48:I §8217","summary":"Lists the Louisiana qualifications for every hospice discipline, how licenses and certifications are verified before employment and every year, which positions must be filled by Agency employees, how staff who work for more than one agency must coordinate, and how job descriptions are kept.","sample":false},{"ref":"LA-HSP-HR-03","path":"/policies/louisiana/hospice/criminal-history-checks-registry-checks-and-exclusion-screening/","title":"Criminal History Checks, Registry Checks and Exclusion Screening","category":"Human resources","citation":"R.S. 40:1203.2","summary":"Sets out how the Agency obtains Louisiana State Police criminal history and security checks before offering work to nonlicensed staff (as amended by Act 802 of 2026), when a person may start work while a check is pending, who may not be hired, and how the Agency checks the Direct Service Worker Registry, the Louisiana Certified Nurse Aide Registry, the adverse actions list and the federal exclusion list before hire and every month.","sample":false},{"ref":"LA-HSP-HR-04","path":"/policies/louisiana/hospice/personnel-records-and-annual-performance-evaluations/","title":"Personnel Records and Annual Performance Evaluations","category":"Human resources","citation":"LAC 48:I §8217.E.2.e.vi","summary":"Lists what goes into each personnel record (including the items Chapter 82 says must be kept there, such as aide in-service records, supervisory visits, LPN competency and the medical director’s CME), how annual performance evaluations are done, where records are kept, who may see them, and how long they are kept.","sample":false},{"ref":"LA-HSP-HR-05","path":"/policies/louisiana/hospice/employee-health-program-and-health-screening/","title":"Employee Health Program and Health Screening","category":"Human resources","citation":"LAC 48:I §8217.E.2.d","summary":"Describes the employee health program the director of nurses supervises: health screening and tuberculosis screening before patient contact, offers of hepatitis B and other vaccines, annual screening and education, work restrictions for illness, confidentiality of health information, and work injuries.","sample":false},{"ref":"LA-HSP-HR-06","path":"/policies/louisiana/hospice/state-certified-hospice-attendants/","title":"State Certified Hospice Attendants","category":"Human resources","citation":"R.S. 40:2192","summary":"Louisiana allows a licensed hospice to employ a state certified hospice attendant: a former inmate who completed hospice training in a Louisiana state prison and holds a state certification. This policy sets out the Agency’s full disclosure policy, the notice to the Health Standards Section before hiring and on any change of employment status, the disclosure to staff, patients and families, supervision, and the attendant’s in-service and continuing education.","sample":false},{"ref":"LA-HSP-VOL-01","path":"/policies/louisiana/hospice/volunteer-program-and-volunteer-coordinator/","title":"Volunteer Program and Volunteer Coordinator","category":"Human resources","citation":"LAC 48:I §8217.Q, R","summary":"Sets out how the Agency recruits, screens, trains and supervises volunteers, the 16 training topics Louisiana requires, quarterly in-service, the duties of the volunteer coordinator, and how the Agency measures and documents that volunteer services equal at least 5 percent of its total hours of service.","sample":false},{"ref":"LA-HSP-GOV-01","path":"/policies/louisiana/hospice/governing-body-administrator-and-key-designations/","title":"Governing Body, Administrator and Key Designations","category":"Governance","citation":"LAC 48:I §8217.F","summary":"Sets out what the governing body of the Agency must do itself under Louisiana’s hospice licensing rules, the written designations it makes (Administrator, Alternate Administrator, director of nurses, medical director and others), what the Administrator is responsible for, how leadership stays reachable during operating hours and surveys, and how the governing body keeps minutes and receives reports.","sample":false},{"ref":"LA-HSP-GOV-02","path":"/policies/louisiana/hospice/organizational-chart-premises-business-hours-geographic-area-and/","title":"Organizational Chart, Premises, Business Hours, Geographic Area and Branch Offices","category":"Governance","citation":"LAC 48:I §8235.A, B","summary":"Describes the Agency’s organizational chart, the rules for its office premises and telephone, its posted business days and hours, the geographic area it serves (parishes within a 50-mile radius) and the conditions for opening and keeping a branch office.","sample":false},{"ref":"LA-HSP-GOV-03","path":"/policies/louisiana/hospice/administrator-and-director-of-nurses-qualifications-duties-and/","title":"Administrator and Director of Nurses: Qualifications, Duties and Alternates","category":"Governance","citation":"LAC 48:I §8217.A, E","summary":"Sets the Louisiana qualifications, duties, availability and continuing education of the Administrator and the director of nurses, how each one’s alternate is designated, and what happens when either position changes.","sample":false},{"ref":"LA-HSP-GOV-04","path":"/policies/louisiana/hospice/licensure-facility-need-review-surveys-and-notices-of-change/","title":"Licensure, Facility Need Review, Surveys and Notices of Change","category":"Governance","citation":"LAC 48:I §8203","summary":"Explains how the Agency keeps its Louisiana hospice license: Facility Need Review, display of the license, annual renewal, provisional licenses, surveys and complaint investigations, statements of deficiencies and plans of correction, reconsideration and appeal, the written notices of change the Department must receive within five working days, and change of ownership.","sample":false},{"ref":"LA-HSP-GOV-05","path":"/policies/louisiana/hospice/cessation-of-business-license-inactivation-after-a-disaster-and/","title":"Cessation of Business, License Inactivation After a Disaster and Records After Closure","category":"Governance","citation":"LAC 48:I §8243","summary":"Sets out what the Agency must do if it decides to close: 30 days’ written notice to the Health Standards Section, every attending practitioner and every patient, an orderly discharge and transition of patients, a Department-approved plan and custodian for clinical records, a newspaper notice at least 15 days before closure, and return of the license. It also covers temporary inactivation of the license after a declared or non-declared disaster.","sample":false},{"ref":"LA-HSP-GOV-06","path":"/policies/louisiana/hospice/hospice-program-scope-of-services-and-policy-manual/","title":"Hospice Program, Scope of Services and Policy Manual","category":"Governance","citation":"LAC 48:I §8235.C","summary":"Describes the Agency’s hospice program and the full scope of services it offers (core services by its own employees, non-core services directly or under arrangement, the four levels of care and the settings where care is given), and how the policy manual is written, approved, reviewed every year and kept current. It ends with the index of all policies.","sample":false},{"ref":"LA-HSP-MD-01","path":"/policies/louisiana/hospice/medical-director-physician-designee-and-physician-services/","title":"Medical Director, Physician Designee and Physician Services","category":"Governance","citation":"LAC 48:I §8217.I","summary":"Sets out the Louisiana qualifications and responsibilities of the medical director and physician designee, the limits on advanced practice registered nurses, physician availability around the clock, the medical director’s role with attending practitioners and the interdisciplinary team, the record of active participation, and the two hours of end-of-life continuing medical education required each year.","sample":false},{"ref":"LA-HSP-QA-01","path":"/policies/louisiana/hospice/quality-assessment-and-performance-improvement/","title":"Quality Assessment and Performance Improvement","category":"Quality","citation":"LAC 48:I §8239","summary":"Sets up the Agency’s quality assessment and performance improvement program under LAC 48:I §8239 and, if Medicare-certified, 42 CFR §418.58: governing body leadership and the named QAPI lead, the committee, the required contents of the written plan, the data Chapter 82 requires, standing indicators for Louisiana time frames, incident and adverse event reporting, improvement projects, corrective action, resource use, quality reporting, and the annual plan review.","sample":false},{"ref":"LA-HSP-CON-01","path":"/policies/louisiana/hospice/contracted-services-arrangements-laboratory-and-radiology/","title":"Contracted Services, Arrangements, Laboratory and Radiology","category":"Business","citation":"LAC 48:I §8237","summary":"Sets out what the Agency may and may not contract out, the nine items every Louisiana contract must contain, the Agency’s continuing responsibility for contract personnel, annual documented review of contracts, and how laboratory and radiology services are obtained.","sample":false},{"ref":"LA-HSP-FIN-01","path":"/policies/louisiana/hospice/patients-with-no-or-limited-payor-source-charges-and-billing-integrity/","title":"Patients With No or Limited Payor Source, Charges and Billing Integrity","category":"Business","citation":"LAC 48:I §8235.D.1.e","summary":"Sets out the Agency’s policy for patients with no or limited payor source (required by Louisiana), how patients are told about charges in advance, continuation of care regardless of ability to pay, the Medicare notices and caps, the Louisiana Medicaid hospice filing deadlines, and billing accuracy.","sample":false},{"ref":"LA-HSP-ETH-01","path":"/policies/louisiana/hospice/compliance-marketing-referrals-and-prohibited-solicitation/","title":"Compliance, Marketing, Referrals and Prohibited Solicitation","category":"Ethics","citation":"LAC 48:I §8235.D.1","summary":"Sets out the Agency’s duties to the community under Louisiana’s hospice rules: accepting orders only from physicians, factual advertising, no door-to-door solicitation, never harassing or coercing anyone to choose or change hospice, never admitting a patient who is not terminally ill, plus professional boundaries, gifts, relationships with referral sources, federal fraud and abuse laws and the Agency’s compliance program.","sample":false},{"ref":"LA-HSP-ETH-02","path":"/policies/louisiana/hospice/prohibited-use-of-social-media/","title":"Prohibited Use of Social Media","category":"Ethics","citation":"LAC 48:I §8235.C.3","summary":"Louisiana requires every hospice to state its prohibited use of social media and to train all staff, contracted or employed, on it. This policy lists what staff may never post or share, how the Agency’s own accounts are run, the required training topics, and what to do if a post breaches a patient’s confidentiality or dignity.","sample":false}],"copy":{"reviewed":"2026-11-08","intro":"For Louisiana hospices licensed by the Louisiana Department of Health (LDH), Health Standards Section, whether or not they are Medicare-certified. The manual has 60 policies and 68 forms, written to LAC 48:I Chapter 82, the hospice licensing rules, and the federal hospice Conditions of Participation (42 CFR Part 418). Policies for an inpatient hospice facility apply only to hospices that hold that sublicense. Each policy opens with a plain-English summary and names the rule it follows, and every one is filled in with your hospice's details. You get Word and PDF files to keep, and your team signs off on their phones.","rulesTitle":"What Louisiana's hospice rules ask your policies to cover","rules":[{"head":"Assessment visit.","text":"A registered nurse makes the assessment visit within 48 hours of referral, unless it is otherwise ordered or the patient or family asks to delay it.","cite":"LAC 48:I.8219.C.1"},{"head":"Plan of care.","text":"Reviews at least every 14 days for home care and every 7 days for general inpatient and continuous home care. Orders are signed within 14 days, or up to 30 days with documented attempts.","cite":"LAC 48:I.8221.B"},{"head":"Nurses and aides.","text":"A registered nurse reassesses each patient and makes a supervisory visit to the residence at least every 14 days, with the aide present at least once a year. Aides complete at least 12 hours of in-service a year, 2 of them on end-of-life care.","cite":"LAC 48:I.8217.O.2; LAC 48:I.8217.G"},{"head":"Volunteers.","text":"Volunteer services equal at least 5 percent of the hospice's total hours of service, with a volunteer coordinator who is an employee.","cite":"LAC 48:I.8217.Q.5; LAC 48:I.8217.R"},{"head":"Bereavement.","text":"Services for at least one year after the death.","cite":"LAC 48:I.8201"},{"head":"Emergency preparedness.","text":"An all-hazards risk assessment and governing body approval of the emergency plan every year, updates to the Louisiana at-risk registry for patients who meet its criteria, and notice to HSS no later than the next stated business day after an emergency interrupts services.","cite":"LAC 48:I.8216; LAC 48:I.8235.D.1.f"}],"asks":[{"ref":"LA-HSP-IDG-01","title":"Interdisciplinary Team and IDT Conferences","category":"Hospice care","q":"How do you make sure a continuous home care patient is reviewed every 7 days?","path":"/policies/louisiana/hospice/interdisciplinary-team-and-idt-conferences/"},{"ref":"LA-HSP-MED-02","title":"Controlled Substances in the Home and Disposal at Death","category":"Clinical tasks","q":"Walk me through what your nurse does with the patient’s morphine after the patient dies.","path":"/policies/louisiana/hospice/controlled-substances-in-the-home-and-disposal-at-death/"},{"ref":"LA-HSP-ANE-01","title":"Recognizing and Reporting Abuse, Neglect and Exploitation","category":"Safeguarding","q":"Who must report abuse or neglect under Louisiana law, and within what time?","path":"/policies/louisiana/hospice/recognizing-and-reporting-abuse-neglect-and-exploitation/"},{"ref":"LA-HSP-VOL-01","title":"Volunteer Program and Volunteer Coordinator","category":"Human resources","q":"How do you calculate the 5 percent volunteer level, and what was it last quarter?","path":"/policies/louisiana/hospice/volunteer-program-and-volunteer-coordinator/"},{"ref":"LA-HSP-EP-01","title":"Emergency Preparedness and the Louisiana At-Risk Registry","category":"Emergency preparedness","q":"When did you last have an interruption in services, and when did you notify the Health Standards Section?","path":"/policies/louisiana/hospice/emergency-preparedness-and-the-louisiana-at-risk-registry/"}],"faq":[{"q":"Is this the right manual for my license?","a":"It is for hospices licensed by LDH, whether or not they are Medicare-certified, including a hospice with an inpatient facility sublicense. Home health agencies need the Louisiana home health manual, and personal care providers with an HCBS license need the Louisiana home care manual."},{"q":"Who may pronounce death for a hospice patient at home?","a":"Under La. R.S. 9:111, a physician pronounces death, or the coroner, who may rely on the firsthand observation of a registered nurse or licensed practical nurse at the scene. The policy has hospice nurses observe and report to the physician or coroner, not pronounce."},{"q":"What are the election deadlines for Louisiana Medicaid patients?","a":"The hospice reports the election to the hospice unit at Gainwell Technologies within 10 calendar days, on BHSF Forms Hospice-NOE and Hospice-CTI (Medicaid Services Manual, Chapter 24, §24.2). For Medicare patients, the notice of election is filed within 5 calendar days after the election takes effect (42 CFR §418.24(e))."},{"q":"What do the 60 policies cover?","a":"Client rights (5), service delivery (3), hospice care (17), clinical tasks (7), safeguarding (2), infection control (2), emergency preparedness (1), records (1), privacy (3), human resources (7), governance (7), quality (1), business (2) and ethics (2)."}]},"guides":[{"path":"/guides/hospice-policies/","h1":"What policies are required for hospice?"},{"path":"/guides/hospice-conditions-of-participation/","h1":"Hospice Conditions of Participation: which policies each one needs"},{"path":"/guides/abuse-neglect-exploitation-reporting/","h1":"Abuse, neglect and exploitation policies: what each state requires"},{"path":"/guides/infection-control-policy/","h1":"What should a home care infection control policy include?"},{"path":"/guides/staff-policy-acknowledgment/","h1":"Staff policy acknowledgment: how read-and-sign works in home care"},{"path":"/guides/how-to-write-policies-and-procedures/","h1":"How to write policies and procedures for a home care agency"}]}