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Georgia Hospice Policy and Procedure Manual

For Georgia hospices licensed by the Department of Community Health's Healthcare Facility Regulation Division. The manual has 60 policies and 55 forms, written to Georgia's hospice rules (Rules 111-8-37) and the federal 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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Georgia · Hospice

60 policies written to the Georgia rules, with 55 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
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Policies
60
Forms
55
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.

GA-HSP-CMP-01Free sample Client rights

Complaints and Grievances

Sets out how patients, families and others make complaints and grievances to the Agency and to the Department: education on the grievance process for every patient, the Department’s contact information and website given at admission and posted, how staff take and log a complaint, the Agency’s acknowledgment and resolution time frames, escalation, outside bodies, and review by the quality management committee.

Read the full policy GA-HSP-ANE-01Free sample Safeguarding

Recognizing and Reporting Abuse, Neglect and Exploitation

Tells every employee, contractor and volunteer how to recognize abuse, neglect and exploitation of a hospice patient and exactly whom to tell under Georgia law: Adult Protective Services and law enforcement for elder persons and disabled adults living in the community; the Department and law enforcement, with a written report within 24 hours, for residents of long-term care facilities; the Division of Family and Children Services for children; the facility administrator for harm by facility staff; the Administrator every time; and the Department within 24 hours or the next business day through the incident report. Gives every patient a written notice of how to report.

Read the full policy GA-HSP-IC-01Free sample Infection control

Infection Prevention and Control Program

Sets the Agency’s infection control program: leadership, the surveillance plan with outcome and process surveillance, the 16 subjects Georgia requires the policies to address and where each is covered, standard and transmission-based precautions, home environment risk assessment, outbreak investigation, reporting of notifiable diseases to the Department of Public Health, education of staff, patients and caregivers, and the annual program evaluation.

Read the full policy
Georgia rules

What Georgia's hospice rules ask your policies to cover

  • Plan of care. An initial plan within 24 hours of admission, a comprehensive assessment within five days, and plan reviews by the team at least every 15 days. Ga. Comp. R. & Regs. 111-8-37-.14 and -.15
  • Verbal orders. Repeated back and verified, recorded as "repeated and verified", with a written copy to the prescriber within 24 hours or by the end of the next business day. Ga. Comp. R. & Regs. 111-8-37-.17(5)
  • Crisis visits. A nurse on site within one hour in a symptom-management crisis, and an after-hours on-call log kept for two years. Ga. Comp. R. & Regs. 111-8-37-.18(1)
  • Aides. A supervisory visit at least every two weeks and 12 hours of continuing education a year. Ga. Comp. R. & Regs. 111-8-37-.18(5)
  • Bereavement. Services for at least one year after a death. Ga. Comp. R. & Regs. 111-8-37-.19
  • Discharge. At least 14 days' notice of an involuntary discharge, except when there is imminent danger. Ga. Comp. R. & Regs. 111-8-37-.14(6)

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:

For this patient, show me the physician referral, the initial assessment, the written consent, the written certification and the initial plan of care made within 24 hours of admission. GA-HSP-ADM-01Referral, Eligibility and Admission Ask an aide: a patient tells you her son takes her pain medicine and her money. Whom do you call, and how fast? GA-HSP-ANE-01Recognizing and Reporting Abuse, Neglect and Exploitation Show me the bereavement assessment and bereavement plan of care for this family. GA-HSP-BRV-01Bereavement Program Show me the RN’s initial competency evaluation of this aide before independent care, and this year’s direct observation. GA-HSP-AIDE-01Personal Care Aides (Hospice Aides) and Homemakers Who are your disaster coordinator and alternate, and how are they reached after hours? GA-HSP-EP-01Emergency Preparedness and Disaster Plan
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

GA-HSP-CMP-01Free sample Complaints and Grievances Sets out how patients, families and others make complaints and grievances to the Agency and to the Department: education on the grievance process for every patient, the Department’s contact information and website given at admission and posted, how staff take and log a complaint, the Agency’s acknowledgment and resolution time frames, escalation, outside bodies, and review by the quality management committee. Ga. Comp. R. & Regs. 111-8-37-.10(1)(f)-(g) GA-HSP-PR-01 Patient and Family Rights Sets out the rights Georgia gives every hospice patient and family unit under Rule 111-8-37-.10 and the Medicare patient rights in 42 CFR §418.52, and how the Agency explains them orally and in writing at admission, gives the Department’s complaint contact information with its website address, posts the rights and complaint information, records the patient’s signature, communicates in a way that works for the patient, and protects each right in daily practice. Ga. Comp. R. & Regs. 111-8-37-.10 GA-HSP-PR-02 Informed Consent, Description of Services and Charges Explains how the Agency gives each patient a description of the scope of services, the levels of care and any charges, and obtains written informed consent from the patient or authorized representative before admission, using one combined admission consent and service agreement. It also covers consent for later changes, refusal and withdrawal of consent. Ga. Comp. R. & Regs. 111-8-37-.14(2)(c) GA-HSP-PR-03 Advance Directives, POLST and Do-Not-Resuscitate Orders Sets out how the Agency gives written information on advance directives and Georgia law at the start of care, records whether each patient has an advance directive, a POLST or a do-not-resuscitate order, honors these documents and their revocation, shares them with facilities where patients live, and states plainly what the Agency cannot do. Ga. Comp. R. & Regs. 111-8-37-.10(1)(q) GA-HSP-PR-04 Restraints and Positioning Devices Sets the Georgia rule that patients receive treatment free from restraints unless a physician determines a restraint is necessary for a temporary period to protect the patient from injury, and the steps that must all be completed before and during any restraint: less restrictive measures, specific consent, a time-limited physician order, a plan of care with release at least every two hours, monitoring records and trained staff. Ga. Comp. R. & Regs. 111-8-37-.15(6)

Service delivery2

GA-HSP-SAF-01 Staff Safety, Home Safety and Emergencies in the Home Sets how staff assess and reduce safety risks in patients’ homes, respond to emergencies during a visit, keep themselves safe before, during and after visits, stop or change visits when safety is at risk, report injuries and serious incidents including to OSHA, and handle hazardous chemicals, so that safety concerns are resolved with the patient and family before any thought of discharge. Ga. Comp. R. & Regs. 111-8-37-.16(3) GA-HSP-SVC-01 24-Hour Availability, On-Call Service and Crisis Response Sets out the Agency’s system for nursing services 24 hours a day, seven days a week, with a registered nurse available at all times, on-site nursing within one hour of notification when a patient has a symptom-management crisis, a hospice physician and a pharmacist available at all times, how after-hours calls are answered and triaged, and the on-call log of every after-hours call kept for two years and reviewed by the quality program. Ga. Comp. R. & Regs. 111-8-37-.18(1)

Hospice care18

GA-HSP-ADM-01 Referral, Eligibility and Admission Sets the Agency’s written admission criteria and the steps from referral to admission for home hospice care: a physician referral based on a personal evaluation, an initial assessment, informed consent, written certification, residence in the service area, a designated primary caregiver or a detailed plan where there is none, an initial plan of care within 24 hours, and no exclusion for inability to pay. It points to the criteria for inpatient, residential and palliative care admissions. Ga. Comp. R. & Regs. 111-8-37-.14(1)-(2) GA-HSP-ADM-02 Palliative Care for Persons With Advanced and Progressive Disease Applies only if the Agency offers palliative care to persons with advanced and progressive disease, a Georgia hospice service that is not the Medicare hospice benefit. It sets the Georgia admission criteria, the change-of-scope application to the Department before the service starts, how care is planned and reviewed, how patients move to hospice care if they become terminally ill, and the rights that apply. Ga. Comp. R. & Regs. 111-8-37-.14(5) GA-HSP-ASM-01 Initial and Comprehensive Assessment and Hospice Outcome Data Sets the time frames and content for the initial assessment, the comprehensive assessment (no later than five days after admission under Georgia rules and 5 calendar days after election under Medicare), the referrals the comprehensive assessment must trigger, updates at least every 15 days, reassessment when the patient’s condition changes, outcome data elements measured the same way for all patients, and the standardized patient assessment data reported to CMS. Ga. Comp. R. & Regs. 111-8-37-.15(3) GA-HSP-BRV-01 Bereavement Program Sets the Agency’s organized bereavement program: who supervises it, the bereavement assessment before death, the bereavement plan of care, services offered for at least one year after the death, support for facility staff, how risk of harm is handled and how bereavement services are documented. Ga. Comp. R. & Regs. 111-8-37-.19(a) GA-HSP-CNS-01 Spiritual, Dietary and Other Counseling Sets how the Agency offers spiritual counseling without imposing any belief, tells patients and families that clergy are available, who may serve as clergy or other counselor, how short-term professional counseling is made available, and how dietary and nutritional services are provided or supervised by a licensed dietitian, as Georgia requires. Ga. Comp. R. & Regs. 111-8-37-.19 GA-HSP-DC-01 Discharge, Involuntary Discharge and Transfer Sets the Georgia limits on discharge (only at the patient’s free request or as an involuntary discharge under the rules), the duty to make every effort to resolve safety issues first and document them, at least 14 days’ notice of an involuntary discharge except in imminent danger or immediate peril, notice to the Department at the time the patient is told, no discharge for inability to pay or during a coordinated hospital admission, and help with continued care; and the Medicare discharge reasons, physician discharge order, discharge planning, discharge summary, notice of termination within 5 calendar days and the advance notice of non-coverage. Ga. Comp. R. & Regs. 111-8-37-.14(6) GA-HSP-DTH-01 Death in the Home, Pronouncement of Death and Post-Death Care Sets how the Agency prepares families for an expected death, responds when a death is reported, who may determine and pronounce death in Georgia without an attending physician and on which form, when the coroner or medical examiner must be told, who certifies the cause of death, notifications, care of the body, controlled substance disposal, reports to the Department and support for families and staff. Ga. Comp. R. & Regs. 111-8-37-.18(4) GA-HSP-ELC-01 Election of the Hospice Benefit, Election Statement Addendum and Notice of Election Sets out how a Medicare patient (or representative) elects the hospice benefit: the eight required parts of the election statement, the election statement addendum "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" required for elections beginning on or after October 1, 2026, and its 5-day and 3-day time frames, the Notice of Election filed within 5 calendar days, election periods, the waiver of other Medicare benefits and re-election. 42 CFR §418.24 GA-HSP-ELC-02 Certification and Recertification of Terminal Illness and Face-to-Face Encounters Sets out the Georgia requirements for a physician referral, a written certification of a life expectancy of six months or less, and the six-monthly face-to-face assessment or life-expectancy scale with written certification, and the Medicare requirements for certification and recertification in each benefit period: timing, the 2-day oral certification, the 15-day windows, the narrative and attestation, who signs, and face-to-face encounters before the third and each later benefit period, including the telehealth limits. 42 CFR §418.22 GA-HSP-ELC-03 Revocation, Change of Designated Hospice and Change of Attending Physician Protects the patient’s right to leave hospice at any time and states the Georgia ban on requiring or demanding that a patient request discharge or sign a request as a condition of admission or continued care. It sets out the Medicare revocation statement and its effects, the notice of termination/revocation within 5 calendar days, change of designated hospice once per election period, and change of attending physician. 42 CFR §418.28 GA-HSP-FAC-01 Hospice Care for Residents of Nursing Homes, Personal Care Homes and Assisted Living Communities Sets out how the Agency provides hospice care to residents of nursing homes, intermediate care homes, personal care homes, assisted living communities and other hospices’ inpatient units: the Georgia written communication that makes clear the Agency takes full responsibility for professional management of hospice care, who does what, named communication contacts, advance directives and POLST, the Medicare written agreement for nursing facilities, a shared plan of care, information given to the facility, orientation of facility staff, reporting alleged violations, and the strict conditions under which an assisted living community’s certified medication aide may give liquid morphine. Ga. Comp. R. & Regs. 111-8-37-.16(4) GA-HSP-FAC-02 Short-Term Inpatient and Respite Care Arrangements Sets out how the Agency makes short-term inpatient care for pain control and symptom management, and inpatient respite care, available when it does not provide them itself: the contract with a licensed hospital, skilled nursing facility or inpatient hospice, the admission criteria, transport, the Medicare agreement contents and setting standards, the family’s right to be present, no discharge during a coordinated admission, records from the inpatient facility, and the 20 percent inpatient day limit. Ga. Comp. R. & Regs. 111-8-37-.16(5)-(6) GA-HSP-FAC-03 Hospice Care Facilities: Residential and Inpatient Units Applies only if the Agency operates a residential or inpatient hospice care facility. Sets out the Georgia approval needed before opening one, admission criteria, unit size and location limits, the building, rooms and environment, policies for post-mortem care, pronouncement of death and smoking, 24-hour staffing with a registered nurse, meals and dietitian review, missing patients, the facility disaster plan and annual rehearsal, and, if Medicare-certified, the federal inpatient unit standards including restraint and seclusion and death reporting. Ga. Comp. R. & Regs. 111-8-37-.24 GA-HSP-IDG-01 Hospice Care Team (Interdisciplinary Group) Sets out how the Agency designates a hospice care team (the interdisciplinary group) for each patient, its required members under Georgia rules (physician, registered nurse, social worker, clergy or other counselor, and volunteers) and Medicare, the RN coordinator, how the team meets as a group to review each plan of care at intervals of no more than 15 days, and how meetings are recorded. Ga. Comp. R. & Regs. 111-8-37-.15(1)-(2) GA-HSP-IDG-02 Plan of Care, Plan of Care Review and Caregiver Education Sets out how the hospice care team establishes a written plan of care before providing care, with an initial plan within 24 hours of admission, with the input of the patient, family, facility caregivers and representative; what the plan must contain; review as a group at intervals of no more than 15 days with the attending physician’s opportunity to approve (or the medical director’s written approval); and education of the patient and primary caregiver at each home visit. Ga. Comp. R. & Regs. 111-8-37-.15(4)-(5) GA-HSP-IDG-03 Coordination of Care, Care Transitions and Physician Orders Sets out the Agency’s system for coordinating care among disciplines, settings and outside providers; how transitions across care sites (for example hospital to home hospice) are handled so that communication supports continuity of care; that patients stay on hospice during coordinated hospital admissions; and how physician orders, including verbal orders, are received, read back as "repeated and verified", sent in writing to the prescriber within 24 hours or by the end of the next business day, and signed. Ga. Comp. R. & Regs. 111-8-37-.17(5) GA-HSP-LOC-01 Levels of Care: Routine Home Care, Continuous Home Care, Respite and General Inpatient Care Defines the four levels of hospice care (routine home care, continuous home care, inpatient respite care and general inpatient care), the Georgia criteria for admission to acute inpatient care and respite care, the Medicare rules for periods of crisis, the 8-hour minimum for continuous home care, the 5-consecutive-day respite limit, the 20 percent inpatient cap, where inpatient care may be given, and how the hospice care team orders, documents and reviews each level. 42 CFR §418.302 GA-HSP-PAIN-01 Pain and Symptom Management and Care of the Actively Dying Patient Sets the Agency’s written protocols for assessing, planning, treating and reassessing pain and other symptoms, responding to a symptom-management crisis within one hour, moving to a higher level of care when symptoms cannot be managed at home, caring for the actively dying patient and family, and the safeguards for palliative sedation. 42 CFR §418.52(c)(1)

Clinical tasks8

GA-HSP-AIDE-01 Personal Care Aides (Hospice Aides) and Homemakers Sets who may work as a personal care aide (hospice aide) in Georgia, the 75-hour training program the Agency may run, the RN competency evaluation before independent care and every year, 12 hours of continuing education a year, written care instructions, RN supervisory visits at least every two weeks (every 14 days for Medicare), what aides may and may not do, and how homemakers are qualified and supervised. Ga. Comp. R. & Regs. 111-8-37-.18(5) GA-HSP-DME-01 Medical Supplies and Durable Medical Equipment Sets how the Agency makes medical supplies and equipment available for the palliation and management of the terminal illness, how it chooses and contracts with suppliers, maintenance and safety, teaching patients and caregivers, oxygen safety, recalls and equipment failure, and removal after discharge or death. Ga. Comp. R. & Regs. 111-8-37-.22 GA-HSP-LAB-01 Laboratory Services and Waived Testing Sets out when hospice staff may do laboratory tests: helping a patient use his or her own FDA-approved home test, performing waived tests such as fingerstick blood glucose under the Agency’s CLIA Certificate of Waiver, and collecting specimens for a CLIA-certified reference laboratory. Covers the certificate Georgia law requires, following manufacturer instructions, competency, quality checks, safe handling, transport and disposal of specimens, results and records. 42 CFR Part 493 GA-HSP-MED-01 Pharmaceutical Services, Drug Orders and Medication Administration Sets how the Agency procures, stores, labels, orders, administers and accounts for drugs and biologicals; the licensed pharmacist who approves the Agency’s medication procedures and is available 24 hours a day; who may order drugs and receive verbal orders; the Georgia rule that only licensed nurses or physicians administer medications for the hospice; the drug profile review; self-administration by patients and families; and how medication errors are handled. Ga. Comp. R. & Regs. 111-8-37-.21 GA-HSP-MED-02 Controlled Substances in the Home: Management and Disposal Sets the Agency’s written policy for the management and disposal of controlled drugs in the patient’s home: giving and discussing this policy when controlled drugs are first ordered, safe storage and counts, when Agency staff may dispose of a patient’s controlled substances under federal law, how disposal is done, witnessed and recorded, facility residents, and suspected loss or diversion. 42 CFR §418.106(e)(2) GA-HSP-NUR-01 Nursing Services and Director of Nursing Sets how the Agency makes nursing available 24 hours a day with a registered nurse always available, how the director of nursing organizes, staffs, supervises and evaluates nursing and personal care services, the role of the RN case manager, when contracted nurses may be used, how nurses work within their Georgia license, and the duty to give medications and treatments only as ordered. Ga. Comp. R. & Regs. 111-8-37-.18(1)-(3) GA-HSP-SW-01 Medical Social Services Sets who may provide medical social services, the social worker’s place on every hospice care team, the psychosocial evaluation in the comprehensive assessment, the services social workers provide, physician direction, visit frequency and documentation. 42 CFR §418.64(c) GA-HSP-THR-01 Physical Therapy, Occupational Therapy and Speech-Language Pathology Sets how the Agency makes physical therapy, occupational therapy and speech-language pathology available to every patient, who may provide them, how therapy is ordered, planned and documented for symptom control and daily function, and how therapists recommend equipment and teach caregivers. Ga. Comp. R. & Regs. 111-8-37-.19(d)

Safeguarding2

GA-HSP-ANE-01Free sample Recognizing and Reporting Abuse, Neglect and Exploitation Tells every employee, contractor and volunteer how to recognize abuse, neglect and exploitation of a hospice patient and exactly whom to tell under Georgia law: Adult Protective Services and law enforcement for elder persons and disabled adults living in the community; the Department and law enforcement, with a written report within 24 hours, for residents of long-term care facilities; the Division of Family and Children Services for children; the facility administrator for harm by facility staff; the Administrator every time; and the Department within 24 hours or the next business day through the incident report. Gives every patient a written notice of how to report. O.C.G.A. §30-5-4 GA-HSP-ANE-02 Investigation of Alleged Violations and Protection of Patients Sets out how the Agency investigates alleged abuse, neglect, exploitation, mistreatment, injuries of unknown source and misappropriation of patient property: starting immediately, protecting patients at once, interviewing and gathering evidence, cooperating with Adult Protective Services, law enforcement and the Department, completing the Georgia 45-day written report, reporting verified violations within 5 working days, and taking corrective action without retaliation. 42 CFR §418.52(b)(4)

Infection control2

GA-HSP-IC-01Free sample Infection Prevention and Control Program Sets the Agency’s infection control program: leadership, the surveillance plan with outcome and process surveillance, the 16 subjects Georgia requires the policies to address and where each is covered, standard and transmission-based precautions, home environment risk assessment, outbreak investigation, reporting of notifiable diseases to the Department of Public Health, education of staff, patients and caregivers, and the annual program evaluation. Ga. Comp. R. & Regs. 111-8-37-.12 GA-HSP-IC-02 Bloodborne Pathogens Exposure Control Plan The Agency’s written Exposure Control Plan under the OSHA Bloodborne Pathogens Standard: which jobs have occupational exposure, engineering and work practice controls, personal protective equipment, housekeeping and waste, hepatitis B vaccination and declination, what to do after an exposure incident, labels, training, the sharps injury log and record retention. 29 CFR §1910.1030

Emergency preparedness1

GA-HSP-EP-01 Emergency Preparedness and Disaster Plan Sets out the Agency’s disaster preparedness plan and emergency preparedness program: the all-hazards risk assessment, the Georgia minimum situations (severe weather and natural disasters, utility interruptions, evacuation), the disaster coordinator and alternate, patient priority levels and each patient’s emergency plan, staffing and supplies, communication with patients, families, staff and emergency management agencies, reports to the Department, the emergency documentation system, training, exercises and the annual review. 42 CFR §418.113

Records1

GA-HSP-REC-01 Medical Records and Retention Sets out how the Agency keeps one complete, accurate and secure medical record for every hospice patient: what the record contains, how entries are signed and dated on the day of service and filed within seven days, how errors are corrected, how records are stored, produced for the Department and released under Georgia and federal law, what is sent when a patient is transferred, revokes or is discharged, and how long records are kept. Ga. Comp. R. & Regs. 111-8-37-.23

Privacy3

GA-HSP-PRV-01 HIPAA Privacy and Georgia Confidentiality Laws Explains how staff protect the health information of hospice patients and their families: who may see it, when it may be shared with family, facilities, other providers and authorities, what patients may ask for under HIPAA, and how the Agency applies the HIPAA Privacy Rule together with the Georgia patient right to confidentiality, Georgia’s health records law and its special protection for AIDS confidential information. 45 CFR Part 164 Subpart E GA-HSP-PRV-02 HIPAA Security Explains how the Agency keeps electronic patient information safe: the risk analysis, who has access, passwords and locked devices, the phones and tablets staff carry, backups and the emergency medical documentation system, business associate agreements, and what staff do when a device is lost or something looks wrong. 45 CFR Part 164 Subpart C GA-HSP-PRV-03 Breach Notification Explains what happens when patient information is lost, stolen, sent to the wrong person or seen by someone who should not see it: staff report it the same day, the Privacy Official assesses it, and the Agency notifies every affected individual, the U.S. Department of Health and Human Services and, for large breaches, the media, within the HIPAA time limits. It also explains how the Georgia breach statute relates to a private hospice. 45 CFR Part 164 Subpart D

Human resources6

GA-HSP-HR-01 Orientation, Annual Training and Competency Sets the orientation every person providing services must receive before working, the annual training and education program for staff and volunteers who give hands-on care, yearly skills competency assessments, and how training is recorded. Ga. Comp. R. & Regs. 111-8-37-.13(2), (4) GA-HSP-HR-02 Personnel Qualifications, License Verification and CPR Certification Sets the qualifications for each discipline under Georgia law and, if Medicare-certified, 42 CFR §418.114; how licenses and certifications are verified at hire and kept current; the Georgia CPR or basic cardiac life support requirement for hands-on caregivers; and credential checks for staffing agency workers. 42 CFR §418.114 GA-HSP-HR-03 Criminal Background Checks and Registry Checks Implements the Georgia long-term care background check program for hospices: registry checks and license queries first, then a fingerprint-based state and national criminal background check through the Department, the 30-day supervised grace period and when it cannot be used, the employment prohibitions, the required notice on application forms, appeals, record keeping, and the Medicare criminal background check standard for staff the state program does not cover. Ga. Comp. R. & Regs. 111-8-12 GA-HSP-HR-04 Personnel Files Lists what must be in the human resource file of every staff member, independent contractor and volunteer who delivers services under a plan of care, where the files are kept, who may see them, and how they are audited and retained. Ga. Comp. R. & Regs. 111-8-37-.13(6) GA-HSP-HR-05 Staff and Volunteer Health Screening and Work Restrictions Sets the initial and annual health screening required in Georgia for the administrator and for staff and volunteers with direct patient or family contact, including tuberculosis surveillance and immunizations, who performs it, and when staff with potentially infectious conditions must not work. Ga. Comp. R. & Regs. 111-8-37-.13(5) GA-HSP-VOL-01 Volunteer Program Establishes the Agency’s volunteer program as Georgia requires: a designated coordinator of volunteer services, written policies on recruitment and retention, screening, orientation, scope of function, supervision, infection control, training, documentation and patient rights and abuse reporting; volunteers serving without compensation; and, if Medicare-certified, the 5 percent level of activity and cost savings records. Ga. Comp. R. & Regs. 111-8-37-.20

Governance7

GA-HSP-GOV-01 Governing Body and Administrator Sets out what the governing body of the Agency must do itself, what it delegates to the Administrator and the medical director, who acts when the Administrator is absent, how the governing body monitors quality, budget and compliance with the license, and how leadership stays reachable. Ga. Comp. R. & Regs. 111-8-37-.07 GA-HSP-GOV-02 Organizational Structure, Service Area and Multiple Locations Requires a current written organizational structure with clear lines of authority, defines the Agency’s service area by county, and sets the conditions and supervision for any additional hospice location or hospice care facility, including the Georgia single-license criteria and Medicare approval. Ga. Comp. R. & Regs. 111-8-37-.04(14) GA-HSP-GOV-03 Administrator and Director of Nursing: Qualifications and Designation Sets the Georgia qualifications for the hospice administrator and the director of nursing, the Agency’s standards for the people who act for them, the checks completed before anyone takes up these posts, and how designations are documented. Ga. Comp. R. & Regs. 111-8-37-.08(2) GA-HSP-GOV-04 Licensure, Inspections, Plans of Correction and Reporting Changes Explains how the Agency keeps its Georgia hospice license valid: what changes need a new application at least 30 days in advance, how the license is displayed, how Department inspections and plans of correction are handled, annual licensure fees, waivers and variances, certificate of need status, and Medicare enrollment changes. Ga. Comp. R. & Regs. 111-8-37-.04 GA-HSP-GOV-05 Agency Closure, Temporary Inactive Status and Records After Closure Sets the written contingency plan for permanent closure or temporary closure of the Agency: notice to the Department, referral sources, patients and families; safe transfer of every patient; return of the license; temporary inactive status; and keeping and retrieving medical records after closure. Ga. Comp. R. & Regs. 111-8-37-.04(12)-(13) GA-HSP-GOV-06 Hospice Program, Description of Services and Policy Index Defines the Agency’s hospice program: the services it provides and how they are available around the clock, where care is given, the Georgia requirement that most care days are delivered at home, the written description of services given to patients and families, and an index mapping each Georgia and federal written-policy requirement to the policy in this manual. Ga. Comp. R. & Regs. 111-8-37-.07(5)(b), (d) GA-HSP-MD-01 Medical Director and Physician Services Sets the Georgia qualifications for the medical director, the written appointment of the medical director and of the physician who acts in the medical director’s absence, the medical director’s duties under Georgia and Medicare rules, 24-hour physician on-call coverage, and how hospice physicians work with each patient’s attending physician. Ga. Comp. R. & Regs. 111-8-37-.17

Quality2

GA-HSP-QA-01 Quality Management, Utilization and Peer Review (QAPI) Sets out the Agency’s quality management, utilization and peer review program: the interdisciplinary committee and the person the governing body appoints to lead it, the written criteria and the ten systematic reviews Georgia requires, how adverse events and incidents are reported on Form GA-HSP-QA-01-A, performance improvement projects, hospice quality reporting to CMS, the annual evaluation for the medical staff and governing body, and confidentiality. Ga. Comp. R. & Regs. 111-8-37-.09 GA-HSP-QA-02 Reports to the Department of Community Health and Internal Investigations Sets out the reports the Agency must make to the Georgia Department of Community Health under Ga. Comp. R. & Regs. 111-8-37-.06: patient incidents (unexpected deaths, rape, assault, abuse, neglect or exploitation, and facility patients missing more than eight hours) within 24 hours or the next business day through the peer review committee; the 45-day internal investigation report; pending involuntary discharges; and disasters and interruptions of vital services, with their 45-day evaluation. Ga. Comp. R. & Regs. 111-8-37-.06

Business2

GA-HSP-CON-01 Contracted Services and Professional Management Responsibility Sets the rules for any service the Agency obtains by contract or arrangement: the Agency keeps professional management responsibility; which core services may be contracted and when; required contract terms, including staffing agency credential verification and background checks; and how contracts are approved, monitored and kept. 42 CFR §418.100(e) GA-HSP-FIN-01 Care Regardless of Ability to Pay, Billing Integrity and Notices to Medicare Makes sure no terminally ill patient is refused, reduced or discharged because of inability to pay, that patients receive a description of services, levels of care and charges, and that billing is accurate and timely, including the Medicare notice of election and notice of termination or revocation within 5 calendar days, inpatient and aggregate caps, and record retention for claims. Ga. Comp. R. & Regs. 111-8-37-.07(5)(i)

Ethics1

GA-HSP-ETH-01 Compliance Program, Marketing and Prohibited Inducements Sets the Agency’s compliance program: the Georgia ban on staff and their families steering patients into naming them in wills, trusts or insurance, taking out insurance on patients, or giving or lending things of value; factual, non-coercive advertising; fraud and abuse laws; referral and marketing integrity; and how concerns are reported and investigated without retaliation. Ga. Comp. R. & Regs. 111-8-37-.07(4)
Questions

Questions about this manual

Who may pronounce death?

A registered nurse, nurse practitioner or physician assistant employed by the hospice may pronounce death on the Department-approved form (Rule 111-8-37-.18(4); O.C.G.A. §31-7-176.1). Since 2024, a registered nurse may not certify the cause of death (O.C.G.A. §31-10-15(c)).

Does the state inspect a Medicare-certified hospice?

A federally certified hospice is exempt from routine state licensure inspections, but the Department still investigates complaints (Rule 111-8-37-.05(2)).

What must we report to the Department?

Incidents within 24 hours or by the next business day, the internal investigation report within 45 days, an involuntary discharge when the patient is told, and disasters or utility disruptions (Rule 111-8-37-.06).

What do the 60 policies cover?

Client rights (5), service delivery (2), hospice care (18), clinical tasks (8), safeguarding (2), infection control (2), emergency preparedness (1), records (1), privacy (3), human resources (6), governance (7), quality (2), business (2) and ethics (1).

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