Louisiana Hospice Policy and Procedure Manual
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.
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Louisiana · Hospice
60 policies written to the Louisiana rules, with 68 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
- 68
- 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.
LA-HSP-CMP-01Free sample
Client rights
Complaints and Grievances
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from retaliation, how the Louisiana Department of Health receives and investigates complaints (including the 120-day outdated report rule), other outside contacts, and how complaints feed quality improvement.
Read the full policy LA-HSP-ANE-01Free sample SafeguardingRecognizing and Reporting Abuse, Neglect and Exploitation
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.
Read the full policy LA-HSP-IC-01Free sample Infection controlInfection Prevention and Control Program
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.
Read the full policy
Louisiana rules
What Louisiana's hospice rules ask your policies to cover
- Assessment visit. 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. LAC 48:I.8219.C.1
- Plan of care. 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. LAC 48:I.8221.B
- Nurses and aides. 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. LAC 48:I.8217.O.2; LAC 48:I.8217.G
- Volunteers. Volunteer services equal at least 5 percent of the hospice's total hours of service, with a volunteer coordinator who is an employee. LAC 48:I.8217.Q.5; LAC 48:I.8217.R
- Bereavement. Services for at least one year after the death. LAC 48:I.8201
- Emergency preparedness. 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. LAC 48:I.8216; LAC 48:I.8235.D.1.f
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:
How do you make sure a continuous home care patient is reviewed every 7 days?LA-HSP-IDG-01Interdisciplinary Team and IDT Conferences
Walk me through what your nurse does with the patient’s morphine after the patient dies.LA-HSP-MED-02Controlled Substances in the Home and Disposal at Death
Who must report abuse or neglect under Louisiana law, and within what time?LA-HSP-ANE-01Recognizing and Reporting Abuse, Neglect and Exploitation
How do you calculate the 5 percent volunteer level, and what was it last quarter?LA-HSP-VOL-01Volunteer Program and Volunteer Coordinator
When did you last have an interruption in services, and when did you notify the Health Standards Section?LA-HSP-EP-01Emergency Preparedness and the Louisiana At-Risk Registry
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
LA-HSP-CMP-01Free sample
Complaints and Grievances
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.
LAC 48:I §8231.A.9
LA-HSP-FAC-04
Visitation in the Inpatient Hospice During a Declared Public Health Emergency
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.
LAC 48:I §8259
LA-HSP-PR-01
Patient Rights and Responsibilities
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.
LAC 48:I §8231
LA-HSP-PR-02
Informed Consent, Description of Services and Charges
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.
LAC 48:I §8231.B
LA-HSP-PR-03
Advance Directives, LaPOST and Do-Not-Resuscitate Orders
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.
LAC 48:I §8235.D.2.g
Service delivery3
LA-HSP-SAF-01
Safety Program: Accidents, Hazards, Home Safety and Smoking Materials
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).
LAC 48:I §8235.D.3
LA-HSP-SAF-02
Workplace Violence Prevention
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.
R.S. 40:2199.15
LA-HSP-SVC-01
24-Hour Availability, On-Call Nursing and Timely Services
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.
LAC 48:I §8235.B
Hospice care17
LA-HSP-ADM-01
Referral, Admission Criteria and Admission Procedure
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.
LAC 48:I §8219.B, C
LA-HSP-ASM-01
Initial and Comprehensive Assessment and Quality Reporting Data
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.
LAC 48:I §8219.C.1
LA-HSP-BRV-01
Bereavement Program
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.
LAC 48:I §8201 (Bereavement Services)
LA-HSP-CNS-01
Spiritual, Dietary and Other Counseling
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.
LAC 48:I §8217.C, D
LA-HSP-DC-01
Discharge, Non-Compliance and Transfer
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.
LAC 48:I §8229
LA-HSP-DTH-01
Death of a Patient, Pronouncement and Post-Mortem Care
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.
LAC 48:I §8221.C.17
LA-HSP-ELC-01
Election of Hospice, Election Statement Addendum and Notice of Election
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.
LAC 48:I §8219.A
LA-HSP-ELC-02
Certification and Recertification of Terminal Illness and Face-to-Face Encounters
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.
LAC 48:I §8219.B.2
LA-HSP-ELC-03
Revocation, Transfer to Another Hospice and Change of Attending Practitioner
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.
LAC 48:I §8229.C, E
LA-HSP-FAC-01
Hospice Care in Nursing Facilities, Assisted Living and Other Residential Settings
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.
R.S. 40:2009.26
LA-HSP-FAC-02
Short-Term Inpatient Care and Respite Arrangements
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.
LAC 48:I §8221.C.7
LA-HSP-FAC-03
Licensed Inpatient Hospice Facility Operations
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.
LAC 48:I §8247
LA-HSP-IDG-01
Interdisciplinary Team and IDT Conferences
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.
LAC 48:I §8201 (Interdisciplinary Team)
LA-HSP-IDG-02
Plan of Care: Initial Plan, Reviews and Practitioner Orders
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).
LAC 48:I §8221.A, B
LA-HSP-IDG-03
Coordination of Care, Continuity and Case Management
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.
LAC 48:I §8221.C
LA-HSP-LOC-01
Levels of Care: Routine, Continuous Home Care, Respite and General Inpatient
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.
LAC 48:I §8201 (Continuous Home Care; Respite Care; Acute/General Inpatient Care)
LA-HSP-PAIN-01
Pain and Symptom Management and Care of the Actively Dying Patient
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.
LAC 48:I §8219.C.1
Clinical tasks7
LA-HSP-AIDE-01
Hospice Aide and Homemaker Services, Competency and Supervision
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.
LAC 48:I §8217.G
LA-HSP-DME-01
Medical Supplies, Equipment and Equipment Safety
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.
LAC 48:I §8235.D.3.b.ii-iii
LA-HSP-MED-01
Pharmaceutical Services, Drug Profile and Medication Safety
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.
LAC 48:I §8223
LA-HSP-MED-02
Controlled Substances in the Home and Disposal at Death
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.
R.S. 40:2191
LA-HSP-NUR-01
Nursing Services, Director of Nurses and RN Case Management
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.
LAC 48:I §8217.O
LA-HSP-SW-01
Medical Social Services
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.
LAC 48:I §8217.J
LA-HSP-THR-01
Physical Therapy, Occupational Therapy and Speech-Language Pathology
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.
LAC 48:I §8217.K-N, P
Safeguarding2
LA-HSP-ANE-01Free sample
Recognizing and Reporting Abuse, Neglect and Exploitation
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.
R.S. 40:2009.20
LA-HSP-ANE-02
Investigation of Alleged Violations and Protection of Patients
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.
42 CFR §418.52(b)(4)
Infection control2
LA-HSP-IC-01Free sample
Infection Prevention and Control Program
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.
42 CFR §418.60
LA-HSP-IC-02
Bloodborne Pathogens Exposure Control and Hazardous Waste
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).
29 CFR §1910.1030
Emergency preparedness1
Records1
Privacy3
LA-HSP-PRV-01
HIPAA Privacy and Louisiana Confidentiality Laws
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.
45 CFR Part 164, Subpart E
LA-HSP-PRV-02
HIPAA Security and Electronic Records
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.
45 CFR Part 164, Subpart C
LA-HSP-PRV-03
Breach Notification
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.
45 CFR Part 164, Subpart D
Human resources7
LA-HSP-HR-01
Orientation, In-Service Training and Continuing Education
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.
LAC 48:I §8217.E.2.e.iv-vii
LA-HSP-HR-02
Personnel Qualifications, License Verification and Job Descriptions
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.
LAC 48:I §8217
LA-HSP-HR-03
Criminal History Checks, Registry Checks and Exclusion Screening
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.
R.S. 40:1203.2
LA-HSP-HR-04
Personnel Records and Annual Performance Evaluations
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.
LAC 48:I §8217.E.2.e.vi
LA-HSP-HR-05
Employee Health Program and Health Screening
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.
LAC 48:I §8217.E.2.d
LA-HSP-HR-06
State Certified Hospice Attendants
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.
R.S. 40:2192
LA-HSP-VOL-01
Volunteer Program and Volunteer Coordinator
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.
LAC 48:I §8217.Q, R
Governance7
LA-HSP-GOV-01
Governing Body, Administrator and Key Designations
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.
LAC 48:I §8217.F
LA-HSP-GOV-02
Organizational Chart, Premises, Business Hours, Geographic Area and Branch Offices
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.
LAC 48:I §8235.A, B
LA-HSP-GOV-03
Administrator and Director of Nurses: Qualifications, Duties and Alternates
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.
LAC 48:I §8217.A, E
LA-HSP-GOV-04
Licensure, Facility Need Review, Surveys and Notices of Change
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.
LAC 48:I §8203
LA-HSP-GOV-05
Cessation of Business, License Inactivation After a Disaster and Records After Closure
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.
LAC 48:I §8243
LA-HSP-GOV-06
Hospice Program, Scope of Services and Policy Manual
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.
LAC 48:I §8235.C
LA-HSP-MD-01
Medical Director, Physician Designee and Physician Services
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.
LAC 48:I §8217.I
Quality1
Business2
LA-HSP-CON-01
Contracted Services, Arrangements, Laboratory and Radiology
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.
LAC 48:I §8237
LA-HSP-FIN-01
Patients With No or Limited Payor Source, Charges and Billing Integrity
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.
LAC 48:I §8235.D.1.e
Ethics2
LA-HSP-ETH-01
Compliance, Marketing, Referrals and Prohibited Solicitation
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.
LAC 48:I §8235.D.1
LA-HSP-ETH-02
Prohibited Use of Social Media
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.
LAC 48:I §8235.C.3
Questions
Questions about this manual
Is this the right manual for my license?
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.
Who may pronounce death for a hospice patient at home?
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.
What are the election deadlines for Louisiana Medicaid patients?
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)).
What do the 60 policies cover?
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).
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