Florida Hospice Policy and Procedure Manual
For Florida hospices licensed by the Agency for Health Care Administration (AHCA). The manual has 60 policies and 61 forms, with the patient forms in English and Spanish, written to Part IV of Chapter 400, Florida Statutes, Rule 59A-38 of the Florida Administrative Code and, for Medicare-certified hospices, the hospice Conditions of Participation (42 CFR Part 418). 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.
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Florida · Hospice
60 policies written to the Florida rules, with 61 forms. Every one is filled in with your agency's details.
- A plain-English summary first
- The rule each policy follows
- Word and PDF downloads, yours to keep
- Policies
- 60
- Forms
- 61
- Categories
- 14
- Policy Pack · required
- $1,100one-timeIncludes 90 days in the portal with Premium. To keep it open after that, Premium is $109 a month or $1,090 a year.
Read before you buy
3 free sample policies, shown in full for a sample agency.
FL-HSP-CMP-01Free sample
Client rights
Complaints and Grievances
Sets how patients, families and others can complain to the Agency and to outside bodies, how the complaint officer logs, acknowledges, investigates and resolves each complaint within the Agency’s own time frames (Florida sets none), how complaints that allege abuse or a rights violation are escalated, how patients learn about AHCA’s complaint line, the Medicare quality improvement organization and, for facility residents, the long-term care ombudsman, and how complaints feed the QAUR/QAPI program.
Read the full policy FL-HSP-ANE-01Free sample SafeguardingRecognizing and Reporting Abuse, Neglect and Exploitation
Explains how every staff member, contractor and volunteer recognizes abuse, neglect and exploitation of vulnerable adults and abuse, abandonment or neglect of children, reports it immediately to the Florida Abuse Hotline as ss. 415.1034 and 39.201, F.S. require, tells the Administrator immediately, and, for nursing home residents, makes sure the facility administrator is told within 24 hours. It also covers the notice patients receive, immunity, protection from retaliation and penalties for failing to report.
Read the full policy FL-HSP-IC-01Free sample Infection controlInfection Control Program, Universal Precautions and Facial Coverings
Sets the Agency’s infection control program for home, residential and inpatient care: leadership and approval by the medical director and governing body, CDC standard (universal) precautions, hand hygiene, PPE and transmission-based precautions, bag technique, cleaning equipment, biomedical waste under Chapter 64E-16, F.A.C., surveillance and outbreak response, reporting notifiable diseases to the county health department, staff health as an Agency standard, education of staff, patients and families, and the Agency’s facial covering policy under s. 408.824, F.S. and Rule 59A-35.125, F.A.C.
Read the full policy
Florida rules
What Florida's hospice rules ask your policies to cover
- Routine home care visits. The minimum for routine home care is "a weekly telephone contact and a biweekly visit by a registered nurse". Rule 59A-38.005(1)(c), F.A.C.
- Florida's inpatient limit. Inpatient days for all patients in any 12-month period may not exceed 20 percent of total hospice days. This is separate from the Medicare limit. s. 400.609(4), F.S.
- Verbal orders. Signed by the physician within 30 calendar days of the order, and medication orders signed by a Florida-licensed physician. Rule 59A-38.004(3)(a)5., F.A.C.
- Governing body. At least seven members who represent the community and live or work in the service area, meeting at least quarterly. s. 400.610(1), F.S.
- Controlled drugs after a death. A hospice physician, nurse or social worker may assist with disposal in the home at the time of death, with a family member's or caregiver's permission. Staff and volunteers never remove the drugs from the home. s. 400.6096, F.S.
- Advertising. The year of initial licensure appears directly beneath the hospice's name, in type at least 25 percent of the size used for the name. s. 400.602(1)(b), F.S.
Questions a surveyor may ask
Every policy lists questions a surveyor may ask about it, so your staff can practice the answers. A few from this manual:
Show me the notice you give on or before the first day of service with the complaint, abuse and Medicaid fraud numbers.FL-HSP-PR-01Patient and Family Rights and Responsibilities and the First-Day Notice
How do you make sure every routine home care patient gets at least a weekly telephone contact and a registered nurse visit every two weeks?FL-HSP-LOC-01Levels of Care, Routine Home Care Minimum Contacts and the Inpatient Limit
Who may dispose of a patient’s controlled substances after death, and how is it documented?FL-HSP-MED-02Controlled Substances: Drug Control System and Disposal After Death
Show me the dementia training certificates for this aide and this nurse, with the dates they started work.FL-HSP-HR-02Alzheimer’s Disease and Related Disorders Training and HIV/AIDS Education
Show me your comprehensive emergency management plan and proof of submission to, and approval by, the county health department in each county you serve.FL-HSP-EP-01Comprehensive Emergency Management Plan and Emergency Preparedness Program
The full pack
Browse all 60 policies
Search by title, policy number or rule. Open any policy to see its summary, the rules it follows and what is inside.
All 60 policies
Client rights5
FL-HSP-CMP-01Free sample
Complaints and Grievances
Sets how patients, families and others can complain to the Agency and to outside bodies, how the complaint officer logs, acknowledges, investigates and resolves each complaint within the Agency’s own time frames (Florida sets none), how complaints that allege abuse or a rights violation are escalated, how patients learn about AHCA’s complaint line, the Medicare quality improvement organization and, for facility residents, the long-term care ombudsman, and how complaints feed the QAUR/QAPI program.
42 CFR §418.52(b)(1)(iii)
FL-HSP-PR-01
Patient and Family Rights and Responsibilities and the First-Day Notice
Gives every patient and family the rights and responsibilities information Florida and Medicare require before care begins: the Florida Patient’s Bill of Rights and Responsibilities summary (s. 381.026, F.S., given under s. 400.6095(3), F.S.), the hospice patient rights in 42 CFR §418.52, and, on or before the first day of service, the statutory notice of the right to report complaints, abuse, neglect or exploitation, and Medicaid fraud (s. 408.810(5), F.S.), explained aloud and in writing, with a signed acknowledgment.
s. 400.6095(3), F.S.
FL-HSP-PR-02
Informed Consent, Admission Agreement and Experimental Drugs
Sets how the Agency obtains the patient’s expressed request and informed consent before admission (s. 400.6095(2), F.S.), who may consent for a patient who lacks capacity under Chapter 765, F.S., what the admission agreement explains about services, coverage, cost-sharing and charges, how refusals and withdrawals of consent are handled, and the written consent and safeguards required before any experimental drug is given (Rule 59A-38.004(3)(a)5.d., F.A.C.).
s. 400.6095(2), F.S.
FL-HSP-PR-03
Advance Directives and Do Not Resuscitate Orders
Implements Rule 59A-38.015, F.A.C. and 42 CFR §418.52(a)(2): at admission the Agency asks about advance directives, gives Form SCHS-4-2006 (or a substantially similar document) and written information on its resuscitation policies and the Florida Do Not Resuscitate Order (DH Form 1896), files any advance directive in the interdisciplinary record, never conditions admission or care on whether one exists, honors valid DNROs under s. 400.6095(8), F.S., and resolves conflicts under Chapter 765, F.S.
Rule 59A-38.015, F.A.C.
FL-HSP-PR-04
Nondiscrimination, Language Access and Respect for Values and Beliefs
Makes hospice services available to all terminally ill persons and their families without regard to age, gender, national origin, sexual orientation, disability, diagnosis, cost of therapy, ability to pay, or life circumstances (s. 400.6095(1), F.S.), respects and never imposes value or belief systems, and meets federal civil rights duties for language assistance, effective communication with people with disabilities, and nondiscrimination notices under Title VI, Section 504 and Section 1557 (45 CFR Parts 84 and 92).
s. 400.6095(1), F.S.
Service delivery2
FL-HSP-SAF-01
Staff Safety, Home Safety and Emergencies in the Home
Sets how the Agency keeps staff and patients safe in homes and on the road: home safety assessments (falls, fire, oxygen, electrical, firearms, pets, infestation), what to do in a medical emergency during a visit, staff safety before, during and after visits including check-in and the right to leave an unsafe home, workplace violence prevention, hazardous chemicals, reporting staff injuries to the workers’ compensation carrier within 7 days and serious injuries to OSHA, and incident reports for patient injuries.
29 U.S.C. §654(a)(1)
FL-HSP-SVC-01
24-Hour Availability, On-Call Service and Response to Requests for Care
Makes hospice services available 24 hours a day, 7 days a week (s. 400.609, F.S.): direct communication with a member of the hospice care team at all hours; staffing to receive and respond to requests and provide interdisciplinary services around the clock; documentation of every communication and request with its disposition (Rule 59A-38.005(3), F.A.C.); medications, laboratory services and a hospice physician available at all hours; and the Agency’s own call-back and visit standards, which Florida does not set.
Rule 59A-38.005(3), F.A.C.
Hospice care17
FL-HSP-ADM-01
Requests for Services, Eligibility and Admission
Sets how the Agency receives, records and answers every request for hospice services, including whether the patient can pay (Rule 59A-38.004(3)(a)11., F.A.C.); the eligibility criteria under Florida’s one-year definition of terminally ill and the six-month Medicare and Medicaid test; the admission decision by the medical director with the attending physician; the admission visit; and the identification of a primary caregiver or an alternative plan of care, with no refusal or discharge for inability to pay.
s. 400.6095(2)-(4), F.S.
FL-HSP-ASM-01
Initial and Comprehensive Assessment and Hospice Outcome Data
Sets the Florida admission assessment of the patient’s physical, social, psychological, spiritual and financial needs and the ongoing assessment of patient and family needs (s. 400.6095(4), (6), F.S.); the initial assessment by a registered nurse within 48 hours after the election and the comprehensive assessment by the hospice care team within 5 calendar days (42 CFR §418.54(a)-(b)), with the required content including the drug profile and the initial bereavement assessment; updates at least every 15 days; and the standardized outcome data and national quality measures Florida adopts (Rule 59A-38.004(4)-(5), F.A.C.).
42 CFR §418.54
FL-HSP-BRV-01
Bereavement Program
Sets the Agency’s bereavement program: at least one year of counseling and services for the family after the patient’s death under professional supervision, the initial bereavement assessment at admission, the bereavement plan of care, educational and spiritual materials and individual and group support, services for facility residents and staff, risk screening and referral, and closing.
Rule 59A-38.013, F.A.C.
FL-HSP-CNS-01
Spiritual Counseling and Dietary Counseling
Sets how the Agency provides spiritual counseling (qualifications of the clergy-person or pastoral counselor, spiritual assessment, respect for every belief system, links with the patient’s own clergy) and dietary and nutritional counseling (available to every patient and family as needed, licensed dietitian consultation and favorite foods in residential and inpatient settings).
Rule 59A-38.010, F.A.C.
FL-HSP-DC-01
Discharge, Transfer and Discharge Planning
Sets when and how the Agency discharges a living patient or transfers care: the Medicare discharge reasons (moving out of the service area or transferring, no longer terminally ill, or for cause after the required steps); the written discharge order from the medical director, physician designee or a physician member of the interdisciplinary group, with the attending physician consulted (42 CFR §418.26(b), effective October 1, 2026); discharge planning; the Notice of Medicare Non-Coverage and the right to a fast appeal; the Notice of Termination/Revocation; the Florida comprehensive discharge summary for the receiving provider (s. 400.6095(7), F.S.); and the rule that no patient is discharged for inability to pay.
s. 400.6095(7), F.S.
FL-HSP-DTH-01
Death of a Patient, Death Certificates and Reporting to the Medical Examiner
Sets what Agency staff do when a patient dies: preparing the family for an expected death, the nurse’s death visit and determination of death, when the death must be reported to the medical examiner, notifications, the death certificate and the medical certification of cause of death, care of the body and the family, disposal of controlled substances in the home, and records.
s. 400.6095(9), F.S.
FL-HSP-ELC-01
Election of Hospice, Election Statement Addendum and Notice of Election
Explains how a Medicare or Medicaid patient elects hospice care with the Agency: the content of the election statement (42 CFR §418.24(b)); the mandatory election statement addendum titled "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" for every election beginning on or after October 1, 2026, given within the first 5 days of the effective date and updated within 3 days of plan of care changes (§418.24(c)-(d)); filing the Notice of Election within 5 calendar days (§418.24(e)); benefit periods; and how the election relates to Florida admission consent.
42 CFR §418.24
FL-HSP-ELC-02
Certification and Recertification of Terminal Illness and Face-to-Face Encounters
Sets how the Agency obtains written certification and recertification of terminal illness for each benefit period (42 CFR §418.22): who may certify, when, and what the certification must contain, including the physician’s own narrative; face-to-face encounters before the third benefit period and every later one; when telehealth may and may not be used for those encounters through December 31, 2027; and the Florida duty of the medical director to validate the prognosis.
42 CFR §418.22
FL-HSP-ELC-03
Revocation, Transfer to Another Hospice and Change of Attending Physician
Explains how a patient or representative revokes the hospice election (42 CFR §418.28), changes the designated hospice once in each election period (§418.30), or changes the attending physician (§418.24(i)); the Notice of Termination/Revocation within 5 calendar days; the Florida duty to arrange continuing care and complete a comprehensive discharge summary for the receiving provider (s. 400.6095(7), F.S.); and the rule that staff never ask or pressure a patient to revoke.
42 CFR §418.28
FL-HSP-FAC-01
Hospice Care for Residents of Nursing Homes, Assisted Living Facilities and Adult Family-Care Homes
Sets how the Agency cares for patients who live in nursing homes, assisted living facilities, adult family-care homes and other licensed facilities: the Agency stays responsible for coordinating and ensuring hospice care (s. 400.609(3), F.S.), signs a written agreement with each facility (with the nine Medicare terms for nursing facilities and ICFs/IID), builds one plan of care with the facility that shows who does what, names a coordinating team member, gives the facility the information 42 CFR §418.112(e) lists, orients facility staff, and reports alleged violations by others to the facility administrator within 24 hours.
s. 400.609(3), F.S.
FL-HSP-FAC-02
Inpatient Care Arrangements and Contracted Inpatient Beds
Sets how the Agency arranges short-term inpatient care for pain control, symptom management and respite in contracted hospital and nursing facility beds: the Florida rules that inpatient care stays under the Agency’s direct administration, is homelike with no more than double occupancy, and keeps continuity of caregivers; the s. 400.6085, F.S. contract terms; the ban on placing a patient in a facility under a moratorium or with a revoked or conditional license; the Medicare written agreement terms in 42 CFR §418.108(c); visitation; and the Florida and Medicare 20 percent inpatient limits.
s. 400.609(4), F.S.
FL-HSP-FAC-03
Hospice Residential Units and Freestanding Inpatient Facilities
Applies only if the Agency operates a hospice residential unit or a freestanding hospice inpatient facility. It sets the Florida construction and certificate of need rules, the residential unit standards in Rule 59A-38.016, F.A.C. (a principal advocate for each resident; at least two staff at all times, one a licensed nurse; 1:4 over 24 hours and never below 1:6 for units over eight patients), pharmacist and dietitian services, the In-Person Visitation law (s. 408.823, F.S.: essential caregiver at least 2 hours daily, end-of-life visits, policies on the website within 24 hours and given to AHCA), and, if Medicare-certified, the inpatient facility standards in 42 CFR §418.110.
Rule 59A-38.016, F.A.C.
FL-HSP-IDG-01
Hospice Care Team and Coordinated Care Program
Establishes the Agency’s hospice care team (the Medicare interdisciplinary group) with at least a Florida-licensed physician, a nurse, a social worker and a pastoral or other counselor (s. 400.6105(3), F.S.; 42 CFR §418.56(a)); the full-time registered nurse who coordinates each plan of care (s. 400.6105(2), F.S.); the written plan for cooperative planning, decision-making and documentation required by Rule 59A-38.005(2)-(3), F.A.C.; team meetings; the medical director’s part in care conferences; and how the team shares information across disciplines, settings and outside providers (42 CFR §418.56(e)).
s. 400.6105(3), F.S.
FL-HSP-IDG-02
Plan of Care, Plan of Care Review and Patient and Family Teaching
Sets the content of each patient’s written plan of care under s. 400.6095(5), F.S. (primary caregiver or alternative plan; diagnosis, prognosis and preferences; needs and the services to meet them; teaching plans; the coordinating nurse; and how care continues in an emergency) and 42 CFR §418.56(c); its preparation with the patient and the attending physician and its medical validation by the medical director; review at least every 15 calendar days; family access; and patient and family teaching toward comfort and self-sufficiency at home.
s. 400.6095(5)-(6), F.S.
FL-HSP-IDG-03
Physician Orders, Verbal Orders and Coordination With Attending Physicians
Sets how medication and treatment orders are written, taken and signed under Rule 59A-38.004(3)(a)5., F.A.C.: medication orders dated and signed by a Florida-licensed physician with the drug, dosage, frequency and route; verbal orders taken only by a licensed health professional, recorded in the record and signed by the physician within the Agency’s time frame and never later than 30 calendar days after the order; how the Agency works with attending physicians, nurse practitioners and physician assistants; and how orders are coordinated across settings (42 CFR §418.56(e); §418.106(b)).
Rule 59A-38.004(3)(a)5., F.A.C.
FL-HSP-LOC-01
Levels of Care, Routine Home Care Minimum Contacts and the Inpatient Limit
Defines the four levels of hospice care (routine home care, continuous home care, inpatient respite care and general inpatient care, 42 CFR §418.302(b)); sets the Florida minimum for routine home care of a weekly telephone contact and a biweekly registered nurse visit (Rule 59A-38.005(1)(c), F.A.C.); applies Florida’s rule that inpatient care is a short-term adjunct used only for pain control, symptom management or respite and that inpatient days for all patients in any 12-month period may not exceed 20 percent of all hospice days (s. 400.609(4), F.S.); tracks the separate Medicare 20 percent inpatient limit; and sets how each level is ordered, documented and reviewed.
Rule 59A-38.005(1)(c), F.A.C.
FL-HSP-PAIN-01
Symptom Control Protocols, Pain Management and Care of the Actively Dying Patient
Sets how the Agency controls pain and other symptoms: the medical director’s written symptom control protocols, assessment and reassessment, treatment under the plan of care, the Agency’s response standards for symptom crises, opioid safety, continuous home care and inpatient care for symptoms that cannot be managed at home, care of the actively dying patient and family, palliative sedation safeguards, and how the Agency evaluates and studies its symptom control methods.
Rule 59A-38.008(2)(b)9., F.A.C.
Clinical tasks8
FL-HSP-AIDE-01
Home Health Aides (Hospice Aides) and Homemakers
Sets who may work as a home health aide (hospice aide) or homemaker for the Agency, the training and competency evaluation every aide must pass under 42 CFR §418.76, 12 hours of in-service each year, written care instructions from a registered nurse, what aides do and never do, registered nurse supervisory visits at least every 14 days and a yearly on-site observation of each aide, and homemaker qualifications and supervision.
42 CFR §418.76
FL-HSP-DME-01
Medical Supplies and Durable Medical Equipment
Sets how the Agency provides medical supplies and durable medical equipment related to the terminal illness: ordering through the plan of care, licensed and accredited suppliers, maintenance under the manufacturer’s recommendations, teaching the patient and family to use equipment safely, oxygen and electrical safety, equipment for emergencies and power outages, problems and recalls, and removal after discharge or death.
42 CFR §418.106(f)
FL-HSP-LAB-01
Laboratory, Radiology and Waived Testing
Sets how the Agency makes clinical laboratory and radiology services available 24 hours a day, 7 days a week through written agreements or its own services (Rule 59A-38.004(3)(b), F.A.C.), how nurses perform only CLIA-waived tests under a certificate of waiver following the manufacturer’s instructions, how specimens are collected, labeled and sent to CLIA-certified reference laboratories, and how patients are helped to use their own FDA-approved home test devices.
Rule 59A-38.004(3)(b), F.A.C.
FL-HSP-MED-01
Drugs and Biologicals: Orders, Pharmaceutical Services and 24-Hour Availability
Sets how the Agency provides drugs and biologicals related to the terminal illness: medication orders signed by a Florida physician, the drug profile review, the Florida pharmacist who directs pharmaceutical services in residential and inpatient settings, procedures that make medications available 24 hours a day, 7 days a week, who may give medications, self-administration by the patient and family, labeling and storage, and reporting of medication errors and adverse reactions.
Rule 59A-38.004(3)(a)5.-8., F.A.C.
FL-HSP-MED-02
Controlled Substances: Drug Control System and Disposal After Death
Sets the Agency’s drug control system for controlled substances in the home: the written policy given to and discussed with the patient and family when a controlled drug is first ordered, safe storage and counts, disposal of unused controlled substances in the home (for example leftover morphine or other opioids) at the time of death with family or caregiver permission by a trained hospice physician or nurse (with a social worker assisting if needed), the rule that staff and volunteers never remove drugs from the home, documentation, suspected diversion, and controlled drugs in the Agency’s own facility.
s. 400.6096, F.S.
FL-HSP-NUR-01
Nursing Services, Supervising Registered Nurse and Coordinating Nurse
Sets how the Agency provides nursing directly as a core service: the supervising registered nurse who monitors all nursing and aide services, the full-time registered nurse who coordinates each patient’s plan of care, the Florida routine home care minimum of a weekly telephone contact and a registered nurse visit every two weeks, licensed practical nurse practice, contracted nurses, staffing, documentation and evaluation of nursing care.
Rule 59A-38.009, F.A.C.
FL-HSP-SW-01
Social Work and Therapeutic Counseling
Sets the qualifications of the Agency’s social workers and who may give therapeutic counseling in Florida, the psychosocial and financial assessment, the services social workers provide (caregiver planning, community resources, advance care planning support, facility placement, financial and legal referrals, crisis counseling), physician direction for Medicare, visit frequency and documentation.
Rule 59A-38.011, F.A.C.
FL-HSP-THR-01
Therapy and Additional Hospice Services
Sets how the Agency provides or arranges physical therapy, occupational therapy, speech-language pathology, massage therapy, infusion therapy, day care, homemaker and chore services, funeral services and other additional services that patients and families need, who may provide them, and how they are ordered, delivered and documented.
s. 400.609(1)(b), F.S.
Safeguarding2
FL-HSP-ANE-01Free sample
Recognizing and Reporting Abuse, Neglect and Exploitation
Explains how every staff member, contractor and volunteer recognizes abuse, neglect and exploitation of vulnerable adults and abuse, abandonment or neglect of children, reports it immediately to the Florida Abuse Hotline as ss. 415.1034 and 39.201, F.S. require, tells the Administrator immediately, and, for nursing home residents, makes sure the facility administrator is told within 24 hours. It also covers the notice patients receive, immunity, protection from retaliation and penalties for failing to report.
s. 415.1034, F.S.
FL-HSP-ANE-02
Investigating Alleged Violations and Protecting Patients
Sets how the Administrator immediately investigates every alleged violation involving anyone furnishing services on behalf of the Agency, protects patients while it is checked (including removing the accused person from patient contact), takes corrective action, and reports verified violations to AHCA and other bodies with jurisdiction within 5 working days of becoming aware of them, while the Florida Abuse Hotline report goes ahead without delay.
42 CFR §418.52(b)(4)
Infection control2
FL-HSP-IC-01Free sample
Infection Control Program, Universal Precautions and Facial Coverings
Sets the Agency’s infection control program for home, residential and inpatient care: leadership and approval by the medical director and governing body, CDC standard (universal) precautions, hand hygiene, PPE and transmission-based precautions, bag technique, cleaning equipment, biomedical waste under Chapter 64E-16, F.A.C., surveillance and outbreak response, reporting notifiable diseases to the county health department, staff health as an Agency standard, education of staff, patients and families, and the Agency’s facial covering policy under s. 408.824, F.S. and Rule 59A-35.125, F.A.C.
Rule 59A-38.004(3)(c), F.A.C.
FL-HSP-IC-02
Bloodborne Pathogens Exposure Control Plan
The Agency’s written exposure control plan under the OSHA bloodborne pathogens standard: exposure determination, engineering and work practice controls including safer sharps, personal protective equipment, housekeeping, laundry and waste, hepatitis B vaccination at no cost within 10 working days of initial assignment with the mandatory declination, post-exposure evaluation and follow-up, source testing under Florida law, labels, training at assignment and yearly, the sharps injury log, recordkeeping and the yearly plan review.
29 CFR §1910.1030
Emergency preparedness2
FL-HSP-EP-01
Comprehensive Emergency Management Plan and Emergency Preparedness Program
Sets how the Agency prepares, submits, reviews and carries out its comprehensive emergency management plan (CEMP) in the DOEA Form H-001 format: the safety liaison, electronic submission to the county health department in each county served, the s. 408.821, F.S. 30-day deadlines and annual submission, the governing body’s annual review, continuing care for patients who go to special needs shelters, and, if the Agency is Medicare-certified, the all-hazards program, communication plan, training and exercises in 42 CFR §418.113.
Rule 59A-38.018, F.A.C.
FL-HSP-EP-02
Patient Emergency Planning, Special Needs Registry and Shelter Care
Sets what the Agency does for each patient and caregiver before, during and after an emergency: telling every patient at admission about the Agency’s plan and the county special needs registry, documenting whether the patient will evacuate and who will give care, collecting and submitting registration information, giving registration information every year, keeping the medication, supply and equipment list for each special-needs patient, confirming each patient’s plan when a threat is imminent, staffing patients in special needs shelters, and telling patients when services will be interrupted and restored.
Rule 59A-38.018(7)-(15), F.A.C.
Records1
Privacy3
FL-HSP-PRV-01
HIPAA Privacy and Florida Confidentiality Laws
Explains how the Agency protects patient information under the HIPAA Privacy Rule and the stricter Florida rules: the hospice record release limits in s. 400.611, F.S., the HIV test result rules in s. 381.004, F.S., and 42 CFR Part 2 for substance use disorder records received from treatment programs. It covers the Notice of Privacy Practices, the patient’s HIPAA rights, minimum necessary, family involvement, business associates, privacy complaints and sanctions.
45 CFR Part 164 Subpart E
FL-HSP-PRV-02
HIPAA Security and Electronic Health Records
Sets how the Agency protects electronic patient information under the HIPAA Security Rule and Florida law: the security official, annual risk analysis, access controls, encryption of laptops, tablets and phones, secure messaging, audit logs, backups and downtime procedures, business associate safeguards, the Florida rule that offsite and cloud storage stay in the continental United States, its territories or Canada (s. 408.051(3), F.S.) with the affidavit at each license application, and safe disposal.
45 CFR Part 164 Subpart C
FL-HSP-PRV-03
Breach Notification
Sets how the Agency finds, assesses and reports a breach of patient information: the HIPAA four-factor risk assessment, notice to patients without unreasonable delay and no later than 60 days after discovery, notice to HHS and the media, and the Florida Information Protection Act (s. 501.171, F.S.), which requires notice to the Florida Department of Legal Affairs within 30 days when 500 or more Floridians are affected and notice to consumer reporting agencies when more than 1,000 are notified.
45 CFR §§164.400-164.414
Human resources6
FL-HSP-HR-01
Orientation, Hospice Training Program and Competency
Sets the Agency’s written plan for orientation and training of all staff and volunteers before they deliver services, the hospice training program that Florida requires the supervising nurse, social worker and clergy-person or pastoral counselor to complete, ongoing in-service training, and how the Agency assesses and documents the competence of everyone who furnishes care.
Rule 59A-38.004(3)(a)3., F.A.C.
FL-HSP-HR-02
Alzheimer’s Disease and Related Disorders Training and HIV/AIDS Education
Sets the Florida dementia (Alzheimer’s disease and related disorders) training every hospice employee needs: written information at the start of employment, at least 1 hour within 3 months for staff with direct contact, and 3 more hours within 9 months for direct care staff, using training approved by the Department of Elder Affairs, with certificates in personnel files; and the one-time HIV/AIDS educational course required for hospice employees.
s. 400.6045(1), F.S.
FL-HSP-HR-03
Personnel Qualifications, Job Descriptions and Staffing Plan
Sets the personnel policies the Florida hospice rules require: written job descriptions with qualifications for every paid and volunteer position, the qualifications for each discipline under Florida rules and 42 CFR §418.114, license verification, the full-time registered nurse who coordinates plans of care, and the staffing pattern and staffing plan the Administrator must keep for home, residential and inpatient care.
Rule 59A-38.004(3)(a)2., F.A.C.
FL-HSP-HR-04
Level 2 Background Screening
Sets how the Agency carries out Florida Level 2 background screening (FDLE and FBI fingerprints through AHCA’s Care Provider Background Screening Clearinghouse) for owners, the Administrator, the financial officer, employees, contractors and volunteers; the rule that no one has contact with a patient until screening is complete; the attestation on AHCA Form 3100-0008; exemptions; five-year rescreening; arrests while employed; and federal exclusion checks.
s. 408.809, F.S.
FL-HSP-HR-05
Personnel Files and Employment Records
Sets what the Agency keeps in each personnel and contractor file (screening results and attestation, dementia certificates, HIV/AIDS course record, licenses, orientation and competency records, employment eligibility verification), keeps employee medical records separate, and sets access, confidentiality and retention.
Rule 59A-35.090(3)(c), F.A.C.
FL-HSP-VOL-01
Volunteer Program
Sets up the volunteer program Florida and Medicare require: a coordinator of volunteer services, recruitment and retention, screening, orientation and training before service, defined roles under a designated employee, supervision, and records of each volunteer’s hours and tasks so that volunteer time equals at least 5 percent of paid staff hours, with the cost savings documented.
s. 400.6105(4), F.S.
Governance7
FL-HSP-GOV-01
Governing Body, Bylaws and Annual Plans
Sets how the governing body of the hospice is made up (at least seven people who represent the community served and live or work in the service area), the written bylaws and their annual signed review, the documents the governing body must adopt in writing, its quarterly meetings, the annual plan (including uncompensated care), the annual budget and audited financial statement, and its oversight of quality.
s. 400.610(1), F.S.
FL-HSP-GOV-02
Administrator and Key Designations
Sets the Administrator’s job description, qualifications, approval by the governing body, background screening before appointment and the 21-day report to AHCA when the Administrator changes, and records every other person the Florida hospice rules, the Medicare Conditions of Participation and HIPAA require the Agency to designate, with how each designation is made and kept current.
Rule 59A-38.004(2), F.A.C.
FL-HSP-GOV-03
Licensure, Certificate of Need, Inspections and Plans of Correction
Covers the Florida hospice license and the certificate of need it depends on: what the license shows and where it is displayed, renewal 60 to 120 days before expiry, the 60-day notice for a change of name or address and other license amendments, the 21-day report of other changes, conditions on the certificate of need, the deadlines to start home and inpatient care, and how the Agency handles unannounced AHCA inspections, deficiencies, plans of correction and inspection reports.
s. 400.602, F.S.
FL-HSP-GOV-04
Required Reports to the Agency for Health Care Administration
Lists every report the hospice must send to AHCA and other authorities on a schedule or when something happens, including the annual demographic and provision of care data due March 31, the semi-annual utilization reports due July 20 and January 20, the annual certificate of need condition report, 21-day change reports and emergency plan submissions, and sets how the Agency diaries, files and proves each report.
Rule 59A-38.007, F.A.C.
FL-HSP-GOV-05
Closure, Change of Ownership, Merger and Inactive License
Sets what the Agency does if it closes, is sold, merges with another hospice or must stop services for a time after an emergency: notice to AHCA at least 30 days before closing, safe transfer of every patient with a comprehensive discharge summary, family bereavement support, surrender of the license, and keeping or forwarding patient records for six years.
s. 408.810(4), F.S.
FL-HSP-GOV-06
Hospice Program, Scope of Services, Public Notices and Policy Index
Describes the hospice program the Agency runs: the core services it provides directly, the additional services it provides or arranges, the settings of care (home, residential and short-term inpatient), 24-hour availability, the public notices Florida requires (services regardless of ability to pay, the services offered, the geographic area and admission criteria), the program for community resources, and an index showing which policy meets each Florida hospice rule.
s. 400.609, F.S.
FL-HSP-MD-01
Medical Director and Physician Services
Sets the Florida qualifications and written job description of the medical director (a Florida-licensed physician with admission privileges at a hospital serving the service area), the physician designee, the medical director’s ten duties under Rule 59A-38.008, 24-hour physician on-call coverage, physician services policies, and how hospice physicians work with each patient’s attending physician.
Rule 59A-38.008, F.A.C.
Quality1
Business2
FL-HSP-CON-01
Contracted Services and Professional Management Responsibility
Sets which services the Agency may contract for and which it must provide directly, the nine terms Florida requires in every hospice services contract, the rules for contracted inpatient beds (including never placing a patient in a facility under a moratorium or with a revoked or conditional license), the ban on duplicate fees, and how the Agency keeps professional management of and oversight over every contractor.
s. 400.6085, F.S.
FL-HSP-FIN-01
Financial Management, Care Regardless of Ability to Pay and Billing Integrity
Sets the Florida financial policies a hospice must have (annual budget and audited financial statement approved by the governing body, bookkeeping, payroll, procedures for gifts and donations, and a fee schedule), the rule that the Agency never refuses or ends hospice care because a patient cannot pay, the record of requests for services and ability to pay, and billing integrity for Medicare, Florida Medicaid and other payers, including timely notices of election and termination.
Rule 59A-38.004(3)(a)4., F.A.C.
Ethics2
FL-HSP-ETH-01
Compliance Program, Referral Integrity and Fraud Prevention
Sets the Agency’s compliance program: a compliance officer, written standards, training, a way to report concerns without retaliation, monitoring of hospice risk areas (eligibility, length of stay, levels of care, live discharges, marketing), and the rules against kickbacks, patient brokering, false claims, inducements to patients and conflicts of interest, with prompt return of overpayments.
42 U.S.C. §1320a-7b(b)
FL-HSP-MKT-01
Advertising, Marketing and Community Education
Sets the Florida rules for hospice advertising: only a licensed hospice may use the word "hospice" or advertise hospice-like services, every advertisement must state the year of initial licensure directly beneath the hospice’s name in type at least 25 percent of the name’s size, special dementia care claims need a written disclosure, and marketing and community education must be truthful and free of inducements to patients or referral sources.
s. 400.602(1), F.S.
Questions
Questions about this manual
Is this the right manual for my license?
It is for hospices licensed by AHCA, whether or not they are Medicare-certified. Home health agencies need the Florida home health manual, and non-skilled agencies and homemaker and companion registrants need the Florida home care manual.
Does a Florida hospice need a certificate of need?
Yes. AHCA does not issue a hospice license without one (s. 400.606(3), F.S.), and compliance with any conditions on it is reported each year (s. 408.040(1)(d), F.S.). Policy FL-HSP-GOV-03 covers the license and the certificate of need.
What must we send AHCA on a schedule?
Demographic and provision of care data by March 31 each year, and semi-annual utilization reports by July 20 and January 20 (Rule 59A-38.007 and Rule 59C-1.0355(8), F.A.C.). Policy FL-HSP-GOV-04 lists every report.
What dementia training do hospice staff need?
Written information at the start of employment, at least 1 hour of training within 3 months for staff with direct contact, and 3 more hours within 9 months for direct care staff, using training the Department of Elder Affairs approves (s. 400.6045(1), F.S.).
What do the 60 policies cover?
Client rights (5), service delivery (2), hospice care (17), clinical tasks (8), safeguarding (2), infection control (2), emergency preparedness (2), records (1), privacy (3), human resources (6), governance (7), quality (1), business (2) and ethics (2).
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