Michigan Hospice Policy and Procedure Manual
For Michigan hospices licensed by LARA's Bureau of Community and Health Systems. The manual has 59 policies and 55 forms, with every patient form in English and Spanish, written to Michigan's hospice licensing rules (Mich. Admin. Code R 325.45101 to R 325.45385), the hospice sections of the Public Health Code (MCL 333.21401 et seq.) 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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Michigan · Hospice
59 policies written to the Michigan 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
- Policies
- 59
- 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.
MI-HSP-CMP-01Free sample
Client rights
Complaints and Grievances
Sets out the Agency's written complaint procedure as Michigan's licensing rules require: how patients and representatives are told at admission how to complain to the Agency, the Department or both; the staff member who receives complaints; the Michigan time limits to start (3 or 7 business days), complete (15 business days) and send written results (10 business days); records kept for 3 years; and how complainants can go to the Department and other bodies.
Read the full policy MI-HSP-ANE-01Free sample SafeguardingRecognizing and Reporting Abuse, Neglect and Exploitation of Adults
Tells every staff member and volunteer how to recognize abuse, neglect (including self-neglect) and exploitation of an adult and how to report it at once by telephone to Adult Protective Services through MDHHS Centralized Intake, as Michigan law requires of everyone employed by an agency licensed to provide health care, and how the report connects with the Agency's own duty to report and investigate alleged violations.
Read the full policy MI-HSP-IC-01Free sample Infection controlInfection Prevention and Control Program
Sets out the Agency's infection prevention and control program as Michigan requires: the infection preventionist designated in writing and the multidisciplinary team, outbreak investigation authority, the evidence-based written policies on standard precautions, transmission-based precautions and a sanitary environment (including in private homes), active surveillance of patients and staff, communicable disease reporting to the local health department, risk mitigation monitoring, education of staff, patients and families, and how the program feeds the quality program.
Read the full policy
Michigan rules
What Michigan's hospice rules ask your policies to cover
- Physician review. A physician reviews the patient's medical history and initial assessment no more than 15 days before or 2 days after admission. Mich. Admin. Code R 325.45351(3)
- Assessments and plan of care. A registered nurse's initial assessment within 48 hours after the election, a comprehensive assessment within 5 calendar days, and the plan of care revised every 15 days. Mich. Admin. Code R 325.45353
- Controlled substances in the home. A written disposal policy, given with an offer to discuss it within 5 days of admission. At a death, help with disposal is offered within 72 hours, only by an RN or LPN employed by the hospice, with another adult as witness. MCL 333.21418
- Complaints. An investigation starts within 3 business days for a complaint of serious injury, harm, impairment or death, and within 7 for others. It ends within 15 business days, and written results follow within 10 business days. Mich. Admin. Code R 325.45241
- Aides. Besides the federal supervisory visit at least every 14 days, a registered nurse observes each aide giving care on site every year, recorded in the aide's personnel file. Mich. Admin. Code R 325.45365(3); 42 CFR §418.76(h)
- Emergency preparedness. The plan is reviewed, updated and approved every year and exercised at least twice a year, one of which may be a tabletop. Training and testing records are kept at least 4 years. Mich. Admin. Code R 325.45151(3); R 325.45157
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, for this patient, when a physician reviewed the medical history and initial assessment. Was it within 15 days before or 2 days after admission?MI-HSP-MD-01Medical Director, Medical Staff Leadership and Physician Services
Show me the copy of your controlled substance disposal policy that patients receive, and where you recorded giving it within 5 days of admission.MI-HSP-MED-02Controlled Substances in the Home: Management and Disposal Policy
This complaint alleged harm. When did your investigation start?MI-HSP-CMP-01Complaints and Grievances
Show me this aide's personnel file. Where is the annual onsite observation by the registered nurse?MI-HSP-HR-04Personnel Records
Show me your two exercises from last year and the after-action reports.MI-HSP-EP-01Emergency Preparedness Program
The full pack
Browse all 59 policies
Search by title, policy number or rule. Open any policy to see its summary, the rules it follows and what is inside.
All 59 policies
Client rights4
MI-HSP-CMP-01Free sample
Complaints and Grievances
Sets out the Agency's written complaint procedure as Michigan's licensing rules require: how patients and representatives are told at admission how to complain to the Agency, the Department or both; the staff member who receives complaints; the Michigan time limits to start (3 or 7 business days), complete (15 business days) and send written results (10 business days); records kept for 3 years; and how complainants can go to the Department and other bodies.
Mich. Admin. Code R 325.45241
MI-HSP-PR-01
Patient Rights and Responsibilities
Adopts the Agency's written policy on the rights and responsibilities of patients required by MCL 333.20201 and R 325.45231, combined with the patient rights Condition of Participation (42 CFR §418.52). It lists every right the Michigan statute and the federal rule give, the patient responsibilities in MCL 333.20202, how and when the rights are explained (before admission and during the initial assessment visit, verbally and in writing, in a language the patient understands), how the policy is posted and given to staff, who may exercise a patient's rights, and what staff do when a right is not respected.
MCL 333.20201
MI-HSP-PR-02
Informed Consent, Admission Agreement and Medicaid Admission Notices
Sets out how the Agency obtains informed consent to hospice care, what the written admission agreement contains, who may consent for a patient who cannot, what happens when consent is refused or withdrawn, and the Michigan Medicaid admission steps: reviewing the Conditions of Admission with the beneficiary, the signed CHAMPS admission copy, and the written conditions of admission and procedures for obtaining health care that must be given within ten days of the effective date of admission.
Mich. Admin. Code R 325.45129
MI-HSP-PR-03
Advance Directives, Patient Advocates, Do-Not-Resuscitate Orders and MI-POST
Sets out how the Agency gives each adult patient written information about advance directives and Michigan law at the start of hospice care, records whether the patient has a patient advocate designation, an out-of-hospital do-not-resuscitate order or a physician orders for scope of treatment (POST) form, helps patients who want to make one, honors and reviews these documents, handles revocations, and never makes care depend on whether a patient has one.
42 CFR §418.52(a)(2)
Service delivery2
MI-HSP-SAF-01
Staff Safety, Home Safety and Emergency Transportation
Sets out how the Agency keeps patients, families and staff safe: the home safety assessment and fall, fire and oxygen precautions for patients; staff safety before and during visits, including workplace violence, animals, weapons, driving and safe patient handling; the protocol for obtaining emergency transportation and when a qualified professional goes with the patient; transportation related to the terminal illness; and how injuries, illnesses and incidents on duty are reported and recorded.
Mich. Admin. Code R 325.45221(2)
MI-HSP-SVC-01
24-Hour Availability, On-Call and After-Hours Response
Makes sure that nursing, physician services, drugs and biologicals are available to every patient 24 hours a day, 7 days a week, and social work 7 days a week when needed, as the Michigan rules and Medicare require. Sets the on-call system (on-call registered nurse, on-call supervisor, on-call hospice physician and weekend social worker), the Agency's response standards, how calls are handled, logged and handed over, after-hours drugs and equipment, emergencies and emergency transportation (including the Michigan protocol duty and the Medicaid rule that transportation related to the terminal illness is the hospice's responsibility), and backup when scheduled staff cannot come.
Mich. Admin. Code R 325.45353(7)
Hospice care17
MI-HSP-ADM-01
Referral, Eligibility and Admission
Sets out how the Agency receives and screens referrals, the Michigan and federal admission criteria (a terminal prognosis in a physician's opinion, a voluntary request, and a physician's recommendation), the Michigan requirement that a physician review the medical history and initial assessment no more than 15 days before or 2 days after admission, the steps of the admission visit, Medicaid eligibility, health plan authorization and coordination with other Medicaid programs, and what the Agency does when it cannot admit.
MCL 333.21417
MI-HSP-ASM-01
Initial and Comprehensive Assessment and Hospice Quality Reporting Data
Sets out the registered nurse's initial assessment within 48 hours after the election of hospice care, the team's comprehensive assessment no later than 5 calendar days after the election, what the comprehensive assessment covers (including the drug profile and the initial bereavement assessment), the referrals it triggers, updates at least every 15 days, the outcome data elements, and the Hospice Quality Reporting Program data the Agency submits to CMS.
Mich. Admin. Code R 325.45353(1)-(2)
MI-HSP-BRV-01
Bereavement Program
Sets out the Agency's bereavement program: offered to the family for no less than one year after the patient's death, designed to meet needs before and after the death, supervised by a professional qualified in grief and loss, built on the initial bereavement assessment and a written bereavement plan of care, and extended to residents and staff of facilities where appropriate.
Mich. Admin. Code R 325.45357
MI-HSP-CNS-01
Spiritual, Dietary and Other Counseling Services
Sets out the counseling the Agency offers the patient and family: spiritual counseling based on an assessment of spiritual needs and the family's own beliefs, with help reaching local clergy; dietary counseling by a qualified individual when the plan of care calls for it; and other counseling that helps the patient and family with the stress of the illness and the dying process.
Mich. Admin. Code R 325.45359
MI-HSP-DC-01
Discharge, Transfer and Discharge for Cause
Sets the Agency's written discharge and transfer policy required by Mich. Admin. Code R 325.45131: the only reasons the Agency may discharge a living patient (a move out of the service area or a transfer, no longer terminally ill, or for cause), discharge planning with care planning, the four federal steps and the Michigan Medicaid rules before a discharge for cause, the written physician discharge order, the notices to the patient (including the Medicare notice of non-coverage and the expedited determination right), the notice of termination within 5 calendar days, the Medicaid discharge in CHAMPS with the signed copy, the discharge summary and referral package sent with the patient, and returning to hospice care later.
42 CFR §418.26
MI-HSP-DTH-01
Death in the Home, Pronouncement of Death, Medical Examiner Notification and Post-Death Care
Sets out what the Agency does when a patient dies: preparing the family beforehand, who may pronounce death in Michigan (a physician or a registered nurse), when the county medical examiner must be told, notifying the physician so the death record can be certified on time, care of the body and the family, the controlled substance disposal offer within 72 hours, removing equipment, the Medicaid discharge in CHAMPS, and starting bereavement care.
MCL 333.1033(3)
MI-HSP-ELC-01
Election of Hospice, Election Statement Addendum and Notice of Election
Sets out how a patient (or representative) elects hospice care with the Agency: the required content of the election statement, how the election is explained and completed, the election statement addendum that the Agency must give in writing for every election beginning on or after October 1, 2026 (within the first 5 days of the effective date) and update within 3 days when the plan of care changes the determinations, the notice of election filed within 5 calendar days, election periods, the waiver of other Medicare benefits, re-election, and the Michigan Medicaid and dual-eligible rules.
42 CFR §418.24
MI-HSP-ELC-02
Certification and Recertification of Terminal Illness and Face-to-Face Encounters
Sets out who certifies and recertifies that a patient is terminally ill, the time frames (certifications no more than 15 calendar days before the effective date of election, recertifications no more than 15 calendar days before the next benefit period, oral certification within 2 calendar days if the written one is not yet obtained), the content of the certification and the physician's own narrative, the face-to-face encounter before the third benefit period and every later one (no more than 30 calendar days before), the current telecommunications rules, the Michigan duty to validate and record the terminal prognosis, and the Michigan Medicaid requirements.
42 CFR §418.22
MI-HSP-ELC-03
Revocation, Change of Designated Hospice and Change of Attending Physician
Sets out how a patient revokes the hospice election, changes the designated hospice once in a benefit period, or changes the attending physician; the written statements each requires; the notice of termination or revocation filed within 5 calendar days; the Michigan Medicaid steps in CHAMPS, including transfers to another hospice with no lapse in services; offering controlled substance disposal help to a patient who revokes; and the rule that staff never encourage a revocation.
42 CFR §418.28
MI-HSP-FAC-01
Hospice Care for Residents of Nursing Facilities, ICF/IID, Adult Foster Care Homes and Homes for the Aged
Sets out how the Agency cares for patients who live in a nursing facility, an intermediate care facility for individuals with intellectual disabilities, an adult foster care home, a home for the aged, an assisted living residence or a boarding home: the written agreement signed before care starts, who does what, one coordinated plan of care, the designated team member, the information the facility must have, orientation of facility staff, abuse reporting within 24 hours to the facility administrator, medications, and the Michigan Medicaid rules for room and board, bed holds, PASARR and the patient-pay amount.
42 CFR §418.112
MI-HSP-FAC-02
Short-Term Inpatient Care Arrangements
Sets out how the Agency makes short-term inpatient care available for pain control, symptom management and respite: the kinds of facilities that may be used, the written agreement each one must have, what the Agency sends and receives, training of the facility's staff, the five-day respite limit, the Medicare 20 percent inpatient day limit, Michigan Medicaid rules for hospital care, and the separate license needed if the Agency provides inpatient care itself.
42 CFR §418.108
MI-HSP-FAC-03
Hospice Residence Operations
Applies only if the Agency holds a Michigan hospice residence license. Sets out the licensing conditions, the 51 percent home care test, the duties of a residence that gives care at the home care level, the registered nurse staffing ratios for each shift, family accommodations and visiting at any hour, unannounced state inspections, the physical plant rules, and the federal standards for a hospice that provides inpatient care directly.
MCL 333.21413(2)-(3)
MI-HSP-IDG-01
Interdisciplinary Care Team
Sets out the membership of the Agency's interdisciplinary care team (at a minimum a doctor of medicine or osteopathy, a registered nurse, a social worker and a pastoral or other counselor under Michigan rules), how teams and the registered nurse coordinator are designated, how often the team meets so that every plan of care is reviewed at least every 15 days, what the meeting record shows, and how the team supervises care between meetings.
42 CFR §418.56(a)
MI-HSP-IDG-02
Plan of Care, Review Every 15 Days and Patient and Caregiver Education
Sets out how the team establishes a written, individualized plan of care before care is provided, who takes part, what the plan must contain under Michigan rules and 42 CFR §418.56(c), how it is reviewed and revised at least every 15 days or sooner as needs change, how care follows the plan, how the team decides whether the patient or in-home caregiver can safely give drugs, and how the patient and caregivers are taught and show they can use drugs, supplies and equipment safely.
Mich. Admin. Code R 325.45353(3)-(5)
MI-HSP-IDG-03
Coordination of Care, Physician Orders and Verbal Orders
Sets out the Agency's system of communication and integration among all disciplines and with outside providers, who may order treatment, how standing, written, verbal and telephone orders are received, read back, recorded and signed (with the ordering practitioner's signature within the Agency's time frame of 14 days), coordination when a patient moves between settings or is hospitalized, the Medicaid monthly service log, and joint plans of care with other Medicaid programs.
Mich. Admin. Code R 325.45199
MI-HSP-LOC-01
Levels of Care: Routine Home Care, Continuous Home Care, Respite and General Inpatient Care
Sets out the four levels of hospice care that Michigan law and Medicare recognize (routine home care, continuous home care, inpatient respite care and general inpatient care): when each is used, who orders it, where it is given, how it is documented and reviewed, the 8-hour minimum for continuous home care, the 5-consecutive-day limit for respite, the Medicare 20 percent inpatient limit, the service intensity add-on in the last 7 days of life, the Michigan Medicaid rules on hospital care related to the terminal illness, and the rule that a level of care is chosen only by the patient's clinical need.
42 CFR §418.302
MI-HSP-PAIN-01
Pain and Symptom Management and Care of the Actively Dying Patient
Sets out how the Agency assesses, treats and reassesses pain and other distressing symptoms for every patient, the symptom management guidelines nurses and physicians use, safe opioid practice in the home, how a pain or symptom crisis is handled at any hour, and how the team cares for a patient who is actively dying and supports the family through the last days and hours.
MCL 333.20201(2)(o)
Clinical tasks8
MI-HSP-AIDE-01
Hospice Aide and Homemaker Services
Sets out who may work as a hospice aide or homemaker for the Agency, the 75-hour training program and RN competency evaluation, at least 12 hours of in-service training every 12 months, RN assignment and written care instructions, what aides may and may not do, RN supervisory visits at least every 14 days, the annual onsite RN observation of each aide that Michigan requires to be documented in the aide's personnel file, and coordination with Medicaid Home Help.
Mich. Admin. Code R 325.45365
MI-HSP-DME-01
Medical Supplies, Appliances and Durable Medical Equipment
Sets out how the Agency provides the medical supplies, appliances and durable medical equipment in each plan of care while the patient is in its care, uses only qualified suppliers, makes sure equipment is safe and maintained as the manufacturer recommends, teaches patients and caregivers until they can show safe use, keeps oxygen safe, and removes equipment after discharge or death.
Mich. Admin. Code R 325.45215(1)
MI-HSP-LAB-01
Laboratory Services and Waived Testing
Sets out how the Agency provides laboratory services when medically necessary, directly or through contract, in compliance with CLIA: when the Agency needs a CLIA certificate of waiver (for example for fingerstick blood glucose tests by staff), the waived tests staff may perform and how, renewal and change notices, the exception for helping a patient use an FDA-approved self-test device, use of certified reference laboratories, specimen handling, results, and cleaning of shared devices.
Mich. Admin. Code R 325.45211
MI-HSP-MED-01
Drugs and Biologicals: Ordering, Pharmacy Services, Drug Control and Safe Use in the Home
Sets out how the Agency provides the drugs and biologicals in each plan of care while the patient is in its care: licensed pharmacy services available at all hours, drug profile review, who may order drugs and take verbal orders, how drugs reach the home, how the care team decides whether the patient or caregiver can safely give them, teaching with return demonstration, labeling, the drug control rules staff follow, and how errors and reactions are handled.
Mich. Admin. Code R 325.45215
MI-HSP-MED-02
Controlled Substances in the Home: Management and Disposal Policy
This is the Agency's written controlled substance disposal policy under MCL 333.21418 and R 325.45367(1). It sets out how controlled substances are kept safe in the home, the copy and offer to discuss given within 5 days of admission, the offer to help with disposal when a drug is no longer needed, when the patient revokes and at the time of death (within 72 hours), who may help (an RN or LPN employed by the Agency), witnessing by another competent adult, disposal only in the patient's private home, and what is recorded.
MCL 333.21418
MI-HSP-NUR-01
Nursing Services and the Director of Nursing
Sets out how the Agency provides nursing services: the director of nursing who directs them and the registered nurse delegate, the registered nurse case manager named for each patient, the initial assessment within 48 hours after election, plan of care updates every 15 days or sooner, nursing available 24 hours a day, 7 days a week, what registered nurses and licensed practical nurses may and may not do, when nurses may be contracted, and the pain and symptom resource materials every nurse must be able to reach.
Mich. Admin. Code R 325.45353
MI-HSP-SW-01
Social Work Services
Sets out how the Agency provides social work to every patient and family: licensed Michigan social workers who meet the Medicare qualifications, employed directly by the Agency, working under the direction of a physician, completing the psychosocial assessment within the comprehensive assessment, available 7 days a week when reasonable and necessary, helping the patient and family adjust to death, and coordinating with Medicaid Home Help and MI Choice.
Mich. Admin. Code R 325.45363
MI-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 written agreement, by therapists licensed in Michigan who meet the Medicare qualifications, for symptom control and to help the patient keep daily living and basic functional skills, on a physician's order in the plan of care.
Mich. Admin. Code R 325.45345(1)(g)
Safeguarding3
MI-HSP-ANE-01Free sample
Recognizing and Reporting Abuse, Neglect and Exploitation of Adults
Tells every staff member and volunteer how to recognize abuse, neglect (including self-neglect) and exploitation of an adult and how to report it at once by telephone to Adult Protective Services through MDHHS Centralized Intake, as Michigan law requires of everyone employed by an agency licensed to provide health care, and how the report connects with the Agency's own duty to report and investigate alleged violations.
MCL 400.11a
MI-HSP-ANE-02
Investigation of Alleged Violations and Reporting Verified Violations to the State Survey Agency
Sets out how the Agency handles any allegation of mistreatment, neglect, verbal, mental, sexual or physical abuse, injury of unknown source, or misappropriation of patient property involving anyone furnishing services on its behalf: immediate report to the Administrator, immediate protection of the patient and investigation, corrective action, and reporting of verified violations to the State survey agency and other bodies with jurisdiction within 5 working days.
42 CFR §418.52(b)(4)
MI-HSP-ANE-03
Recognizing and Reporting Suspected Child Abuse and Neglect
Explains how Agency staff recognize suspected child abuse and neglect, both of children who are hospice patients and of children living in or visiting a patient's home, and how the professionals Michigan names as mandated reporters make an immediate report to MDHHS Centralized Intake by telephone or online and file the written report within 72 hours, with the Agency's support.
MCL 722.623
Infection control2
MI-HSP-IC-01Free sample
Infection Prevention and Control Program
Sets out the Agency's infection prevention and control program as Michigan requires: the infection preventionist designated in writing and the multidisciplinary team, outbreak investigation authority, the evidence-based written policies on standard precautions, transmission-based precautions and a sanitary environment (including in private homes), active surveillance of patients and staff, communicable disease reporting to the local health department, risk mitigation monitoring, education of staff, patients and families, and how the program feeds the quality program.
Mich. Admin. Code R 325.45133
MI-HSP-IC-02
Bloodborne Pathogens Exposure Control Plan
This is the Agency's written exposure control plan under MIOSHA Occupational Health Standard Part 554, Bloodborne Infectious Diseases. It sets out which jobs have exposure (category A), universal precautions, safer sharps and other engineering controls, work practices, PPE at no cost, sharps and regulated waste, hepatitis B vaccination within 10 working days of initial assignment, what to do after an exposure and the confidential medical evaluation that follows, training at assignment and every year, the sharps injury log, record retention, and the annual review of the plan.
Mich. Admin. Code R 325.70001 to R 325.70018
Emergency preparedness1
Records1
Privacy3
MI-HSP-PRV-01
HIPAA Privacy and Michigan Confidentiality Laws
Explains how the Agency protects patients' health information under the HIPAA Privacy Rule and the Michigan confidentiality laws: who may see it, when it may be shared with or without the patient's permission, how families are kept informed, the Notice of Privacy Practices, patients' privacy rights, business associates, and how privacy complaints and violations are handled.
45 CFR Part 164, Subpart E
MI-HSP-PRV-02
HIPAA Security
Sets out the administrative, physical and technical safeguards the Agency uses to protect electronic patient information under the HIPAA Security Rule and the Michigan records rules: the security risk analysis, the Security Official, access control, devices used in the field, passwords and authentication, encryption, audit logs, backups and contingency plans, disposal of devices and media, and how security incidents are reported.
45 CFR Part 164, Subpart C
MI-HSP-PRV-03
Breach Notification
Explains how the Agency investigates a possible breach of patient information, decides whether notification is required under the HIPAA Breach Notification Rule, and notifies patients, the U.S. Department of Health and Human Services and, for large breaches, the media within the federal time limits, and how this relates to the Michigan Identity Theft Protection Act.
45 CFR Part 164, Subpart D
Human resources7
MI-HSP-HR-01
Orientation, Competency and In-Service Training
Sets out the orientation every employee, contracted worker and volunteer receives before giving care, the Michigan-required infection control and emergency preparedness training at hire and every year, how the Agency assesses competence, the yearly in-service program, and how training is recorded.
42 CFR §418.100(g)
MI-HSP-HR-02
Personnel Qualifications, License Verification and Job Descriptions
Lists the qualifications for each hospice position, how the Agency verifies Michigan licenses and credentials before hire and keeps them current, the use of job descriptions, and the rule that no one works with an expired or restricted license.
42 CFR §418.114
MI-HSP-HR-03
Criminal History Checks (Michigan Workforce Background Check) and Exclusion Screening
Sets out how the Agency obtains fingerprint-based criminal history checks and registry checks through the Michigan Workforce Background Check before anyone with regular direct access to patients starts work, the narrow conditions for conditional employment while results are pending, who may not be employed and for how long, the written agreement to report arraignments and convictions, how criminal history information is protected, appeals, and monthly exclusion screening.
MCL 333.20173a
MI-HSP-HR-04
Personnel Records
Lists what each employee's personnel record must contain under Michigan rules (license number, credentials and education, start date and position, baseline communicable disease screening, separation date) and what else the Agency keeps (training, competency, the annual aide observation, background check papers in a separate file, health and exposure records), and how the records are secured and retained.
Mich. Admin. Code R 325.45183
MI-HSP-HR-05
Employee Health: Communicable Disease and Tuberculosis Screening, Immunizations and Work Restrictions
Sets out the Michigan-required employee health program: screening every employee on hire for communicable disease including tuberculosis under the CDC 2005 guideline and its 2019 update, evaluating immunization status against the adopted vaccination recommendations, when staff are screened again, and when infectious staff are kept from patient care.
Mich. Admin. Code R 325.45139
MI-HSP-HR-06
Credentialing, Clinical Privileges and Reporting Disciplinary Action to the Department
Sets out how the Agency credentials physicians, nurse practitioners and other medical and allied health professionals and grants clinical privileges, how it re-credentials them, and how it reports disciplinary actions against any licensed or registered health professional to the Department within 30 days as MCL 333.20175(10) requires.
Mich. Admin. Code R 325.45185
MI-HSP-VOL-01
Volunteer Program
Sets out how the Agency recruits, screens, orients, trains, assigns, supervises and keeps volunteers; gives each volunteer the health and safety information Michigan requires; makes sure volunteer services follow the written plan of care; and documents volunteer hours, the 5 percent level of activity and the cost savings Medicare requires.
Mich. Admin. Code R 325.45361
Governance7
MI-HSP-GOV-01
Governing Body, Administrator and Key Designations
Sets out what the governing body of the Agency does itself, the appointments it makes in writing (Administrator, Alternate Administrator, medical director and leader of the medical staff, director of nursing, quality lead and the other named roles Michigan and Medicare require), what the Administrator is responsible for, how leadership is reachable, and how the governing body meets at least once a year and keeps a written record.
Mich. Admin. Code R 325.45123
MI-HSP-GOV-02
Organizational Structure, Lines of Authority, Delegation and Multiple Locations
Describes the Agency's organizational structure and lines of authority, how the administrator, medical staff leader and director of nursing roles are delegated in writing when needed, how any additional location is approved and supervised, and why a hospice residence or other inpatient facility needs its own Michigan license.
42 CFR §418.100(f)
MI-HSP-GOV-03
State License, Renewal, Surveys and Medicare Certification
Explains the Michigan hospice license (who needs one and the use of the word "hospice"), how the license is posted and renewed before August 1 each year, which changes need Department approval first, how licensure surveys and complaint investigations work (including unannounced visits and the accreditation survey waiver), how the Agency answers findings, and how it keeps its Medicare certification and enrollment current.
MCL 333.21411
MI-HSP-GOV-04
Hospice Program, Scope of Services and Policy Management
Describes the Agency's hospice program (planned and continuous care under a physician's direction), the nine services Michigan requires a hospice to make available and how each is provided, where care is given, how policies are written, approved, reviewed (at least every 3 years, and every 24 months for bereavement, social work, counseling and volunteer policies) and recorded, and gives the index of this manual.
Mich. Admin. Code R 325.45345
MI-HSP-GOV-05
Closure of the Hospice, Change of Ownership and Records Custody
Sets out what the Agency does if it plans to close: written notice to the Department at least 30 days before the closure date, a closure plan the Department must approve before any closure activity, safe transfer of every patient with a referral package, custody of medical records, notice to Medicare and the public, and what a change of ownership requires.
Mich. Admin. Code R 325.45169
MI-HSP-GOV-06
Civil Rights, Nondiscrimination and Communication Access
Commits the Agency to admit, care for and employ people without discrimination, as Michigan's hospice law, Michigan's patient rights statute and federal civil rights laws require; and sets out how the Agency communicates with patients who do not speak English or who have hearing, vision, speech or cognitive impairments, and how it safeguards glasses, dentures and hearing aids.
MCL 333.21413(1)(c)
MI-HSP-MD-01
Medical Director, Medical Staff Leadership and Physician Services
Sets out how the Agency designates its medical director (who is also the leader of the medical staff under Michigan rules) and the physician designee, what they are responsible for, the Michigan requirement that a physician review each patient's medical history and initial assessment no more than 15 days before or 2 days after admission and validate the terminal prognosis, how a physician is designated for each patient, how physician services are available 24 hours a day, and how hospice physicians work with attending physicians.
Mich. Admin. Code R 325.45351
Quality1
Business2
MI-HSP-CON-01
Contracted Services and Professional Management Responsibility
Sets out which services the Agency must provide with its own employees, when it may contract, the terms every Michigan hospice contract must contain (including signature by the administrator, care according to the hospice plan of care and a ban on fee sharing with referral sources), and how the Agency keeps responsibility for and monitors contracted services.
Mich. Admin. Code R 325.45349
MI-HSP-FIN-01
Billing, Medicaid and Medicare Admission Records, and Care Regardless of Ability to Pay
Sets out how the Agency verifies coverage, completes Medicaid admissions and discharges in CHAMPS, files Medicare notices of election and termination on time, bills accurately for the level of care actually provided, handles Medicaid nursing facility room and board and the patient-pay amount (with a receipt every time), never bills a Medicaid beneficiary for coinsurance or room and board, and never stops or reduces care because a patient cannot pay.
42 CFR §418.100(d)
Ethics1
Questions
Questions about this manual
Is this the right manual for my license?
It is for hospices licensed in Michigan. Medicare-certified home health agencies need the Michigan home health manual, and agencies that give only non-medical care need the Michigan home care manual.
Our old policies cite R 325.13101. Are those rules still in force?
No. The hospice rules in force before February 21, 2020 (R 325.13101 et seq.) were rescinded. The rules in force are R 325.45101 to R 325.45385, so time frames taken from the old rules no longer apply.
How often must we review our policies?
All policies at least every 3 years, with the review dates on record (R 325.45123(2)). The hospice administrator reviews the bereavement, social work, counseling and volunteer policies at least every 24 months (R 325.45347(2)).
What do the 59 policies cover?
Client rights (4), service delivery (2), hospice care (17), clinical tasks (8), safeguarding (3), infection control (2), emergency preparedness (1), records (1), privacy (3), human resources (7), governance (7), quality (1), business (2) and ethics (1).
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