Missouri Hospice Policy and Procedure Manual
For Missouri hospices certified by the Department of Health and Senior Services (DHSS), which issues a hospice certificate rather than a license. The manual has 59 policies and 62 forms, written to Missouri's hospice rules (19 CSR 30-35) and, for Medicare-certified hospices, 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.
Live now
Missouri · Hospice
59 policies written to the Missouri rules, with 62 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
- 62
- 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.
MO-HSP-CMP-01Free sample
Client rights
Complaints and Grievances
Sets out how patients, families and anyone else can complain or voice a grievance about the Agency's care or services, how staff receive and pass on every complaint, the Agency's own time frames for acknowledging, investigating and answering, how patients are told about the Missouri home health and hospice toll-free hotline, how complaints made to the Department are handled, and how complaints feed into quality improvement. Missouri sets no time frame for a hospice's own grievance process, so the Agency uses the time frames its governing body has set.
Read the full policy MO-HSP-ANE-01Free sample SafeguardingRecognizing and Reporting Abuse, Neglect and Exploitation of Adults
Explains how Agency staff, contractors and volunteers recognize abuse, neglect, bullying and financial exploitation of adults, including self-neglect and harm in nursing facilities and other long-term care facilities, and how they report it. Under Missouri law nurses, physicians, social workers, ministers, pharmacists, therapists, other health practitioners and anyone with responsibility for the care of an eligible adult must immediately report reasonable cause to suspect abuse or neglect to the Department of Health and Senior Services; the Agency requires every staff member and volunteer to do so, and also to tell the Administrator.
Read the full policy MO-HSP-IC-01Free sample Infection controlInfection Prevention and Control Program
Sets out the Agency's infection control program under 19 CSR 30-35.010(1)(I): the person responsible for implementing, maintaining and documenting it, surveillance, identification, prevention, control and investigation of infections and communicable diseases, standard precautions and transmission-based precautions in the home, bag technique, periodic review and update of infection control policies, education of staff, patients and caregivers, monitoring for compliance, and reporting of communicable diseases to the local health authority or the Department under 19 CSR 20-20.020.
Read the full policy
Missouri rules
What Missouri's hospice rules ask your policies to cover
- Patient rights. A bill of rights submitted to DHSS for approval, which tells patients about the state home health and hospice hotline, and written notice of a change in what the patient must pay within 30 days of the hospice learning of it. RSMo 197.264.1; 19 CSR 30-35.010(1)(F)
- Emergent visits. Access to services 24 hours a day, a plan for prompt telephone response, and, when clinically indicated, an emergent visit within 90 minutes from the time the need is identified. 19 CSR 30-35.010(1)(H)
- Assessments and plan of care. A registered nurse visit within 48 hours of election, social work and spiritual assessments within five days of admission, a plan of care within seven days of admission, and IDG review at least every two weeks. 19 CSR 30-35.010(2)(D) and (G)
- Volunteers. Volunteer hours equal at least 5 percent of paid employee and contract staff patient care hours. In Missouri this is a state rule for every certified hospice. 19 CSR 30-35.010(2)(J)1
- Bereavement. An encounter other than the funeral within two months of the death to assess risk, a plan for one year, and another encounter within six months. 19 CSR 30-35.010(2)(G)5
- Emergency preparedness. Emergency preparedness policies reviewed and updated at least once a year, and the emergency plan tested by exercises every year. 19 CSR 30-35.010(1)(J)2
Questions a surveyor may ask
Every policy lists questions a surveyor may ask about it, so your staff can practice the answers. A few from this manual:
Show me the Department's approval of your bill of rights. Is the version you hand out the version that was approved?MO-HSP-PR-01Patient Bill of Rights and Responsibilities
Show me the after-hours log for last weekend. Were emergent visits made within 90 minutes from the time the need was identified?MO-HSP-SVC-0124-Hour Access, Telephone Response and Emergent Visits
Are any oral orders unsigned more than 30 days after they were given?MO-HSP-IDG-03Authorized Prescriber Orders, Verbal Orders and Standing Orders
Show me your last medication incidents. Were the prescriber, the registered nurse coordinator and the pharmacist told?MO-HSP-MED-01Medication Management: Orders, Medication List, Administration and Medication Incidents
Show me how you calculate your volunteer hours as a percentage of paid patient care hours, and the result for the last twelve months.MO-HSP-VOL-01Volunteer 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
MO-HSP-CMP-01Free sample
Complaints and Grievances
Sets out how patients, families and anyone else can complain or voice a grievance about the Agency's care or services, how staff receive and pass on every complaint, the Agency's own time frames for acknowledging, investigating and answering, how patients are told about the Missouri home health and hospice toll-free hotline, how complaints made to the Department are handled, and how complaints feed into quality improvement. Missouri sets no time frame for a hospice's own grievance process, so the Agency uses the time frames its governing body has set.
19 CSR 30-35.010(1)(F)3.B
MO-HSP-PR-01
Patient Bill of Rights and Responsibilities
Sets out the Agency's bill of rights, which Missouri law requires the hospice to submit to the Department for approval and to apply equally to all patients; the ten rights in 19 CSR 30-35.010(1)(F)3, including written notice of payment changes within 30 days and access to the Missouri home health and hospice toll-free hotline; how the rights are given and explained before care starts; who may exercise them for the patient; how staff protect them every day; and the responsibilities the Agency asks of patients and families.
RSMo §197.264.1
MO-HSP-PR-02
Consent for Hospice Care and Admission Disclosures
Sets out the Missouri requirement that every patient who wishes to receive hospice care signs a consent form naming the Agency, acknowledging the palliative nature of hospice care and listing the care and services that may be provided; who may sign; the admission disclosures given in the same visit; how consent is kept separate from the Medicare and MO HealthNet election statement; and how refusals, withdrawals and changes are handled.
19 CSR 30-35.010(1)(C)
MO-HSP-PR-03
Advance Directives, Outside-the-Hospital DNR Orders and Health Care Decision-Makers
Explains how the Agency meets state and federal advance directive law: the written information given at the start of care, with a summary of Missouri law on declarations (living wills), durable powers of attorney for health care and outside the hospital do-not-resuscitate (OHDNR) orders; documenting in a prominent place whether the patient has an advance directive; never conditioning care on having one; honoring directives, revocations and OHDNR orders; conscience objections; and staff and community education.
19 CSR 30-35.010(1)(E)4
Service delivery2
MO-HSP-DC-01
Discharge, Transfer and Discontinuance of Hospice Care
Names the specific circumstances in which the Agency discharges a patient (death, a move out of the service area, transfer to another hospice, no longer terminally ill, discharge for cause, and discontinuance by the patient), and sets out ongoing discharge planning, the steps required before a discharge for cause, the physician discharge order, Missouri's requirements to notify the patient or legal representative immediately with the effective date, to assess continuing care needs and refer, to notify the attending physician in every instance, and to send the receiving provider the medication profile, advance directive, problems needing follow-up and current plan of care, and the Medicare notices, notice of termination and discharge summary.
19 CSR 30-35.010(1)(D)
MO-HSP-SVC-01
24-Hour Access, Telephone Response and Emergent Visits
Sets out how the Agency gives access to all services, medications, equipment and supplies during business hours, after hours and in emergencies: 24-hour nursing coverage for telephone consultation and visits, the Agency's plan for prompt telephone response, unscheduled non-emergent visits as agreed with the patient or caregiver, Missouri's requirement that emergent visits be made within 90 minutes from the time the need is identified when clinically indicated, 24-hour medication services for emergencies, other services around the clock, emergencies and 911, and the on-call log.
19 CSR 30-35.010(1)(H)
Hospice care17
MO-HSP-ADM-01
Referral, Admission Criteria and Palliative Treatment Policy
Sets out the Agency's written admission criteria and its policy on palliative treatments such as chemotherapy and radiation, as 19 CSR 30-35.010(1)(B) requires; how referrals are received and answered; the medical director's review of patient appropriateness; the federal rule that a hospice admits a patient only on the recommendation of the medical director, physician designee or IDG physician; the admission visit; concurrent care for MO HealthNet participants under 21; and what happens when the Agency does not admit.
19 CSR 30-35.010(1)(B)
MO-HSP-ASM-01
Initial and Comprehensive Assessments, Including Social Work and Spiritual Assessments
Sets out the assessments every patient and family receive and their Missouri and federal time frames: the registered nurse initial assessment visit within 48 hours of election, the social services assessment visit and the documented spiritual assessment within five days of admission or sooner if indicated, the comprehensive assessment by the IDG no later than five calendar days after election, and updates at least every 15 days; the content of each; the spiritual counselor's role when a patient declines visits; the initial bereavement assessment; and the standardized data the Agency collects for outcome measurement and quality reporting.
19 CSR 30-35.010(2)(G)1.C
MO-HSP-BRV-01
Bereavement Program
Sets out the Agency's organized bereavement program under Missouri's hospice rule: supervision by Drew Sample, a qualified professional with training or experience related to death, dying and bereavement; the bereavement assessment that begins before the death; an encounter (other than funeral attendance or visitation) within two months after the death to assess the risk of each bereaved person; a bereavement plan of care that extends for one year following the death appropriate to the level of risk; at least one additional encounter within six months after the death; services by risk level; facility residents and staff; and records.
19 CSR 30-35.010(2)(G)5
MO-HSP-CNS-01
Spiritual Care, Dietary Counseling and Other Counseling Services
Sets out spiritual care (available to all patients and families; a documented spiritual assessment within five days of admission or sooner if indicated, covering religious affiliation and spiritual concerns; a spiritual counselor visit offered to every patient; what happens when visits are declined), the Missouri qualifications and 90-day training for spiritual counselors, dietary counseling planned by a qualified dietary counselor, additional counseling services, and the Department waiver for areas without dietitians or nutritionists.
19 CSR 30-35.010(2)(G)4
MO-HSP-DTH-01
Death in the Home, Pronouncement and Post-Death Care
Sets out what the Agency does when a patient dies: preparing the family before death, the death visit, how death is determined and recorded under Missouri's legal standard for death (RSMo §194.005), the conditions before an Agency nurse pronounces death, notice to the attending physician, the coroner or medical examiner contact for deaths outside a licensed health care facility and the hospice's written notice within twenty-four hours of the death (RSMo §§58.451 and 58.720), the medical certification within seventy-two hours and the death certificate within five days (RSMo §193.145), unexpected deaths, care of the body, medications after death, and support for the family and staff.
RSMo §193.145
MO-HSP-ELC-01
Election of Hospice, Election Statement Addendum and Notice of Election
Sets out how a patient elects the hospice benefit with the Agency: who may elect, the content of the election statement under Medicare (42 CFR §418.24(b)) and MO HealthNet (13 CSR 70-50.010(3)(B)), the effective date, the election statement addendum that every Medicare patient must receive for elections on or after October 1, 2026 and its update within three days of a plan of care change, the notice of election filed within five calendar days, election periods, the waiver of other benefits, and re-election.
42 CFR §418.24
MO-HSP-ELC-02
Certification and Recertification of Terminal Illness and Face-to-Face Encounters
Sets out how the Agency obtains certification and recertification that each patient is terminally ill: who certifies for the initial and later benefit periods, the two-day and 15-day timing rules, the content of the certification and the physician's own narrative, the face-to-face encounter before the third and each later benefit period (including the telehealth rules through December 31, 2027), oral certification, the MO HealthNet certification rule, and what happens when a physician will not recertify.
42 CFR §418.22
MO-HSP-ELC-03
Revocation, Change of Designated Hospice and Change of Attending Physician
Sets out how a patient or legal representative may end hospice care at any time by revoking the election, change the designated hospice once in each benefit period, or change the attending physician; the signed statements each requires under Medicare and MO HealthNet; effective dates; the notice of termination or revocation filed within five calendar days; the information sent to the attending physician and to a new hospice; and the Agency's rule that staff never pressure a patient to revoke.
42 CFR §418.28
MO-HSP-FAC-01
Hospice Care for Residents of Nursing Facilities and Other Residential Settings
Sets out how the Agency cares for patients who live in nursing facilities and other residential settings: written agreements only with appropriately licensed facilities, a coordinated single plan of care that shows who does what, a hospice registered nurse designated to coordinate with each facility, hospice services at the same level as in a private home, education of facility staff on the four topics Missouri requires (documented even when the facility declines), communication and notification duties, abuse reporting for facility residents, and MO HealthNet room and board payments.
19 CSR 30-35.010(2)(L)
MO-HSP-FAC-02
Short-Term Inpatient and Respite Care Arrangements
Sets out where the Agency arranges general inpatient care and inpatient respite care, what every inpatient agreement contains, how the plan of care goes with the patient and is updated on inpatient admission as Missouri requires, how the Agency keeps professional management of the patient during the stay, the respite limits that Medicare (no more than five consecutive days at a time) and MO HealthNet (five days per calendar month) place on payment, and how the Agency keeps inpatient days within the 20 percent limit.
42 CFR §418.108
MO-HSP-FAC-03
Hospice-Operated Inpatient Facility
Applies only while the Agency operates its own inpatient hospice facility that is not otherwise licensed. Sets out the Missouri facility rule (19 CSR 30-35.020): 24-hour staffing of at least one qualified staff member for every ten patients per shift per patient unit and never fewer than two staff, disaster plan rehearsal and quarterly fire drills, meals, patient areas and visitors, infection control and infectious waste, pharmacy and medication rules, and construction, including the emergency amendment in effect from August 20, 2026 to February 15, 2027 that replaces plan approval with notice to the Department. Adds the federal standards that apply if the Agency is Medicare-certified.
19 CSR 30-35.020
MO-HSP-IDG-01
Interdisciplinary Group and IDG Meetings
Sets out the Agency's interdisciplinary groups: the four core members who must be employees of the hospice (physician, who may be contracted, registered nurse, social worker and spiritual counselor), their responsibilities, the designated IDG for each branch and for day-to-day policy, the Missouri minimum of an IDG meeting at least every 15 calendar days and the Agency's schedule that reviews every patient at least every 14 days to meet the two-week plan of care review, the medical director's routine attendance, the meeting record, and communication between meetings.
19 CSR 30-35.010(2)(F)
MO-HSP-IDG-02
Plan of Care, Two-Week Review and Caregiver Education
Sets out how the IDG, with the attending physician, establishes a written plan of care for every patient within seven days of admission (with an initial plan before care starts), what the plan contains under Missouri and federal rules, how the patient and caregiver take part, Missouri's requirement that the IDG review and update the plan at least every two weeks (stricter than the federal 15 days), how changes are made and communicated in advance, and how patients and primary caregivers are educated and trained for their part of the care.
19 CSR 30-35.010(2)(D)
MO-HSP-IDG-03
Authorized Prescriber Orders, Verbal Orders and Standing Orders
Sets out Missouri's rules for authorized prescriber orders: medications, treatments and procedures only with an order; written orders dated and signed when written; oral orders received only by persons authorized within their scope of practice, immediately written down, signed by the receiver, and signed and dated by the prescriber within 30 days (the Agency's own time frame, which may be shorter, is 14 days); the content of medication orders; and standing orders, which must be specific, individualized, signed and in the record, reviewed by the medical director at least annually, with an Agency time frame for notifying the prescriber when a standing order is used.
19 CSR 30-35.010(2)(E)
MO-HSP-LOC-01
Levels of Care: Routine, Continuous Home Care, Respite and General Inpatient
Defines the four levels of hospice care (routine home care, continuous home care, inpatient respite care and general inpatient care) that every Missouri plan of care must state, the clinical criteria, orders and documentation for each, where inpatient care may be given, the Medicare limits (continuous home care of at least 8 hours in a day, respite of no more than five consecutive days, 20 percent inpatient days) and the MO HealthNet limits (at least eight hours of continuous care in 24 hours, respite limited to five days per calendar month, 20 percent inpatient days from November 1 to October 31), and how a change in level of care is decided, explained to the patient and recorded.
42 CFR §418.302
MO-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 for every patient: a pain and symptom assessment at every clinical visit with tools suited to the patient, interventions in the plan of care, the medical director's consultation with attending physicians on pain and symptom control, time frames for follow-up when a symptom is not controlled, opioid safety, emergent visits within 90 minutes when clinically indicated, when to consider continuous home care or general inpatient care, and care of the actively dying patient and family. Missouri's hospice rule sets no pain scale or visit frequency, so those are Agency standards.
19 CSR 30-35.010(2)(G)2.A
MO-HSP-SW-01
Medical Social Services
Sets out how the Agency provides medical social services through direct employees under Missouri's hospice rule: recognized standards of practice, staffing that meets each patient's and family's medical social service needs, the social worker's responsibility for assessment, planning and provision, the social services assessment visit within five days of admission or sooner if indicated, Missouri social worker qualifications (narrower than the federal ones), MSW supervision of a BSW, and the services social workers provide.
19 CSR 30-35.010(2)(G)3
Clinical tasks8
MO-HSP-AIDE-01
Hospice Aide and Homemaker Services
Sets out who may work as a hospice aide in Missouri (a person who meets 42 CFR 418.76 as incorporated by 19 CSR 30-35.010 as last amended August 6, 2009), training and competency evaluation, the 24-month lapse rule, twelve hours of in-service training in every twelve months, the registered nurse's written aide assignment and care instructions, RN supervisory visits at least every two weeks, the annual on-site observation of each aide, aides permanently assigned to a hospice facility, homemaker services assigned and coordinated by an IDG member, and coordination with Medicaid personal care.
19 CSR 30-35.010(2)(G)7
MO-HSP-DME-01
Medical Supplies and Equipment
Sets out how the Agency coordinates medical supplies and equipment for the palliation and management of the terminal illness and related conditions, educates patients, families, employees and volunteers on safe use, inspects and maintains all hospice-owned patient care equipment at least once a year and in line with manufacturer specifications, cleans, stores, tracks and distributes hospice-owned equipment, stores supplies cleanly, and uses only qualified equipment suppliers.
19 CSR 30-35.010(2)(I)
MO-HSP-LAB-01
Laboratory Services and Waived Testing
Sets out when the Agency needs a Clinical Laboratory Improvement Amendments (CLIA) certificate, how it holds and renews a certificate of waiver for simple tests such as fingerstick blood glucose, how staff perform waived tests by following the manufacturer's instructions, how specimens are sent only to CLIA-certified reference laboratories, and how patients are helped to test themselves. The Missouri hospice rule has no laboratory section; the federal CLIA rules apply to any laboratory testing the Agency's staff perform.
42 CFR §418.116(b)
MO-HSP-MED-01
Medication Management: Orders, Medication List, Administration and Medication Incidents
Sets out the Agency's policies and procedures for the safe and effective use of medications under 19 CSR 30-35.010(2)(H): a medication list for every patient, complete orders (name, dose, frequency, route, with a maximum and a reason for variable doses), timely provision and 24-hour emergency medication services, review and teaching, current reference material, who may administer, the nurse's documented evaluation of patient and family administration, and reporting every medication incident to the prescriber, the registered nurse coordinator and the pharmacist (Sky Sample).
19 CSR 30-35.010(2)(H)
MO-HSP-MED-02
Controlled Substances in the Home: Delivery Records, Misuse and Disposal
Sets out how the Agency manages controlled substances in the patient's home: the written policy given to and discussed with the patient and family when a controlled substance is first ordered, the delivery record (date, patient, medication name and strength, quantity on the container and two signatures) when staff deliver, safe storage and counts, identifying and documenting misuse and notifying the prescriber, the Missouri rule that staff never remove medications from the residence, and on-site disposal by trained hospice nurses after death or expiry under the federal SUPPORT Act provision, with information to families on disposal when medications are no longer needed.
19 CSR 30-35.010(2)(H)12
MO-HSP-NUR-01
Nursing Services, Registered Nurse Coordinator and LPN Supervision
Sets out how the Agency provides nursing services through direct employees under Missouri's hospice rule: recognized standards of practice, staffing that meets every patient's nursing needs, a registered nurse initial assessment visit within 48 hours of election, the registered nurse's responsibility for ongoing assessment and planning, RN supervision of licensed practical nurses (available at least by phone and an on-site supervisory visit at least monthly), 24-hour nursing coverage, the role of the registered nurse coordinator and case manager, and when contracted nurses may be used.
19 CSR 30-35.010(2)(G)1
MO-HSP-SAF-01
Safety Plan: Accidents, Injuries, Safety Concerns and Staff Safety in the Home
Sets out the Agency's safety plan under 19 CSR 30-35.010(1)(J)1: policies and procedures for reporting, monitoring and following up on all accidents, injuries and safety concerns, documentation of monitoring activity and follow-up actions, and the hazardous waste system (Policy MO-HSP-IC-02). It covers the home safety assessment and teaching for patients and families (falls, fire and oxygen, medications, firearms, equipment), staff safety in the home and on the road, workplace violence, the Missouri workers' compensation report within thirty days after knowledge of a staff injury, and OSHA injury recording and reporting.
19 CSR 30-35.010(1)(J)1
MO-HSP-THR-01
Physical Therapy, Occupational Therapy and Speech-Language Pathology
Sets out how the Agency offers physical therapy, occupational therapy and speech-language pathology consistent with accepted standards of practice, directly or through a contracted provider; who may provide them under Missouri's definitions; supervision of physical therapy and occupational therapy assistants (therapist available at least by phone and a supervisory visit to the patient's residence at least every thirty days); and the Department waiver for areas of the state with no licensed therapists, which must be resubmitted annually.
19 CSR 30-35.010(2)(G)6.B
Safeguarding2
MO-HSP-ANE-01Free sample
Recognizing and Reporting Abuse, Neglect and Exploitation of Adults
Explains how Agency staff, contractors and volunteers recognize abuse, neglect, bullying and financial exploitation of adults, including self-neglect and harm in nursing facilities and other long-term care facilities, and how they report it. Under Missouri law nurses, physicians, social workers, ministers, pharmacists, therapists, other health practitioners and anyone with responsibility for the care of an eligible adult must immediately report reasonable cause to suspect abuse or neglect to the Department of Health and Senior Services; the Agency requires every staff member and volunteer to do so, and also to tell the Administrator.
RSMo §192.2405
MO-HSP-ANE-02
Recognizing and Reporting Suspected Child Abuse or Neglect
Explains how Agency staff, contractors and volunteers recognize and report suspected abuse or neglect of a child (anyone under 18), whether the child is a patient, a family member in a patient's home, or a child in the bereavement program. Missouri law requires nurses, physicians, social workers, ministers, other health practitioners and others to immediately report to the Children's Division, says that no internal investigation may be started until the report has been made, makes the duty personal, and requires the employer to give staff immediate access to a telephone and time to report.
RSMo §210.115
Infection control2
MO-HSP-IC-01Free sample
Infection Prevention and Control Program
Sets out the Agency's infection control program under 19 CSR 30-35.010(1)(I): the person responsible for implementing, maintaining and documenting it, surveillance, identification, prevention, control and investigation of infections and communicable diseases, standard precautions and transmission-based precautions in the home, bag technique, periodic review and update of infection control policies, education of staff, patients and caregivers, monitoring for compliance, and reporting of communicable diseases to the local health authority or the Department under 19 CSR 20-20.020.
19 CSR 30-35.010(1)(I)
MO-HSP-IC-02
Bloodborne Pathogens Exposure Control and Hazardous Waste
Sets out the Agency's written exposure control plan under the OSHA bloodborne pathogens standard (29 CFR §1910.1030): exposure determination, engineering and work practice controls including safer sharps devices, PPE at no cost, hepatitis B vaccination within ten working days of initial assignment, post-exposure evaluation and follow-up made immediately available, the healthcare professional's written opinion within fifteen days, training at assignment and at least annually, the sharps injury log and record retention, and the annual review of the plan. It also sets out the safe and sanitary system for identifying, handling and disposing of hazardous wastes that Missouri's hospice rule requires, including sharps packaging under the Missouri infectious waste rule.
29 CFR §1910.1030
Emergency preparedness1
Records1
Privacy3
MO-HSP-PRV-01
HIPAA Privacy and Missouri Confidentiality Requirements
Explains how the Agency protects patients' health information under the HIPAA Privacy Rule and Missouri law: the patient's Missouri right to confidentiality of the clinical record and to be told the disclosure policy, the privacy official, when staff may and may not share information (including with family members, nursing facilities, the Department and the abuse hotline), Missouri's stricter rule for HIV information, patients' privacy rights and time frames, everyday privacy in homes and facilities, business associates, complaints and sanctions.
45 CFR Part 164, Subpart E
MO-HSP-PRV-02
HIPAA Security
Sets out how the Agency protects electronic patient information under the HIPAA Security Rule: the security official, the yearly risk analysis and risk management plan, administrative, physical and technical safeguards, rules for phones, tablets and laptops used in homes and facilities, security incidents, backups and the contingency plan that keeps records available in an emergency, business associates, device disposal and documentation. It also meets the Missouri duty to safeguard the clinical record against loss, destruction and unauthorized use.
45 CFR Part 164, Subpart C
MO-HSP-PRV-03
Breach Notification
Sets out what the Agency does when patient information may have been lost, stolen, sent to the wrong person or seen by someone who should not see it: immediate containment, the four-factor HIPAA risk assessment, notices to patients, the media and the U.S. Department of Health and Human Services within the federal time limits, and the Missouri breach notice law (RSMo §407.1500), which also covers employees' and others' personal information and requires notice to the Missouri Attorney General and the consumer reporting agencies when more than 1,000 Missouri residents are notified at one time.
45 CFR §§164.400-164.414
Human resources6
MO-HSP-HR-01
Orientation, Dementia-Specific Training and In-Service Education
Sets out the orientation every direct employee, contract employee and volunteer must receive under 19 CSR 30-35.010(2)(M), the Alzheimer's disease and dementia-specific training Missouri requires at orientation and every year, the 12 hours of yearly in-service for hospice aides, the other required annual training, competency checks, and how training is documented.
19 CSR 30-35.010(2)(M)
MO-HSP-HR-02
Personnel Qualifications, License Verification and Competency
Lists the qualifications Missouri's hospice rule sets for each discipline (including the social worker, spiritual counselor, dietary counselor and hospice aide definitions), how licenses and credentials are verified before hire and kept current, the aide 24-month lapse rule, scope of practice, and competency.
19 CSR 30-35.010(1)(A)
MO-HSP-HR-03
Criminal Background Checks, Employee Disqualification List and Family Care Safety Registry
Sets out the background screening Missouri requires before any person hired by the hospice has contact with patients (Missouri State Highway Patrol criminal record check, nationwide fingerprint check when needed, and Employee Disqualification List inquiry), the applicant's disclosures, Family Care Safety Registry registration within 15 days, who cannot be employed, the good cause waiver, exclusion screening, and record keeping.
RSMo §192.2495
MO-HSP-HR-04
Personnel Records and Performance Evaluation
Lists what goes into every personnel file (and the restricted screening and medical files kept separately), how files are kept confidential and how long, the annual performance evaluation, the annual performance review Missouri requires for aides permanently assigned to a hospice facility, and how files are audited.
19 CSR 30-35.010(2)(M)1.D
MO-HSP-HR-05
Employee Health Screening, Communicable Disease Work Restrictions and Hepatitis B
Sets the Agency's health screening for employees and patient care volunteers (Missouri has no hospice rule on staff health exams or TB testing, so these are Agency standards built on CDC guidance), the hepatitis B vaccination OSHA requires, other immunization offers, work restrictions for staff with communicable illness, and confidentiality of employee health records.
19 CSR 30-35.010(1)(I)
MO-HSP-VOL-01
Volunteer Program
Sets out how the Agency recruits, screens, orients, trains, supervises and records the work of volunteers, the Missouri requirement that volunteer administrative and direct patient care hours equal at least five percent of the total patient care hours of paid employees and contract staff, how that level is measured, and, if the Agency is Medicare-certified, the cost savings record.
19 CSR 30-35.010(2)(J)
Governance8
MO-HSP-GOV-01
Governing Body, Administrator and Written Designations
Sets out what the governing body of the Agency must do itself, the written designations Missouri requires (Administrator with the date of designation, the person who acts in the Administrator's absence, the registered nurse coordinator), the other key appointments, what the Administrator does, how leadership stays reachable for surveyors, and the reports the governing body receives.
19 CSR 30-35.010(2)(A)-(B)
MO-HSP-GOV-02
Organizational Structure, Branch Offices and Multiple Locations
Sets out how the Agency is organized, how lines of authority run from the governing body to every staff member, how the service area is defined under one Missouri hospice certificate, and what must be in place before a branch office or other location serves patients, including Department approval, the 100-mile limit and the branch IDG.
19 CSR 30-35.010(1)(K)
MO-HSP-GOV-03
Administrator and Registered Nurse Coordinator: Qualifications and Duties
States the qualifications for the Administrator (including the qualifications Missouri requires for administrators appointed after July 1, 2023), the Alternate Administrator, the registered nurse coordinator and the nurse who acts for the coordinator, how those qualifications are checked before appointment, and what each person does.
19 CSR 30-35.010(1)(A)16
MO-HSP-GOV-04
State Certification, Renewal, Surveys and Plans of Correction
Explains the Missouri hospice certificate: when it is required, the temporary operating permit, posting, annual renewal and the fee scale, statistical reports, how the Agency handles Department surveys and complaint investigations, the statement of deficiencies and plan of correction time frames, and the Department's enforcement powers.
RSMo §197.252
MO-HSP-GOV-05
Change of Ownership or Management, Closure and Records After Closure
Sets out what the Agency does before any change in ownership or management (including the 30-day Missouri application deadlines and the Department's change of ownership package), how changes of key managers are handled with the Department, and how the Agency protects patients and records if it closes or stops serving an area.
RSMo §197.256.1
MO-HSP-GOV-06
Hospice Program, Scope of Services and Policy Index
Describes the Agency's hospice program as Missouri defines it, lists every service the Agency provides and whether it is given by direct employees or under contract, sets the 24-hour availability standard, describes how services are explained to patients and families, and indexes the policy manual the Department reviews for certification.
19 CSR 30-35.010(1)(E)
MO-HSP-GOV-07
Civil Rights, Nondiscrimination and Language Access
Commits the Agency to serve everyone without discrimination, sets out the Section 1557 duties that apply to a hospice receiving federal funds (coordinator, written procedures, notices, taglines, training and grievances), and explains how staff get interpreters, auxiliary aids and reasonable modifications so every patient and family can understand and take part in their care.
45 CFR Part 92
MO-HSP-MD-01
Medical Director and Physician Services
Sets out the medical director's qualifications under Missouri's rule (a doctor of medicine or osteopathy licensed in Missouri or a bordering state, as a direct or contract employee), the six services the medical director or designee must provide, the annual review of standing orders, physician coverage when the medical director is unavailable, the attending physician's role and who may serve as attending physician in Missouri, and the contract terms for a contracted medical director.
19 CSR 30-35.010(2)(G)2
Quality2
MO-HSP-QA-01
Quality Assessment and Performance Improvement
Sets out the Agency's written quality assessment and performance improvement (QAPI) plan: its goals and objectives, the person responsible for the program, the designated group that reviews it, what is measured in every service (including contracted services), how problems are resolved and corrective actions documented and checked for effect, how adverse events are tracked, how performance improvement projects are run, and how the governing body reviews and approves the plan at least once a year as 19 CSR 30-35.010(2)(N) requires.
19 CSR 30-35.010(2)(N)
MO-HSP-QA-02
Incident Reporting, Investigation of Alleged Violations and Reports to the Department
Sets out how staff report incidents, accidents and alleged violations (mistreatment, neglect, verbal, mental, sexual or physical abuse, injuries of unknown source and misappropriation of patient property), how the Administrator investigates at once and protects the patient while the investigation runs, what corrective action follows, and which reports go outside the Agency and when. Missouri sets no time frame for a hospice to self-report incidents to the Department; reports of suspected abuse and neglect go to the Department at once under Policy MO-HSP-ANE-01, and verified violations are reported within five working days.
42 CFR §418.52(b)(4)
Business2
MO-HSP-CON-01
Contracted Services and Professional Management Responsibility
Sets out which hospice services Missouri requires the Agency to give through its own direct employees and which may be contracted, the five things every Missouri contract for services must contain, the extra federal and Agency contract terms, the checks made before signing, how the Agency keeps professional management responsibility for contracted care, and how contracts are monitored.
19 CSR 30-35.010(2)(C)
MO-HSP-FIN-01
Billing Integrity, Payment Liability Notices and MO HealthNet Requirements
Sets out how the Agency tells patients in writing what they may have to pay and about any change within 30 days, records the determination of financial responsibility, continues care regardless of ability to pay, files Medicare notices on time, meets the MO HealthNet hospice program rules (participation, levels of care, room and board, inpatient limit, documentation and six-year retention), and keeps billing accurate.
19 CSR 30-35.010(1)(F)3.I
Ethics1
Questions
Questions about this manual
Is this the right manual for my hospice?
It is for hospices certified by DHSS, whether or not they are Medicare-certified, including a hospice that runs its own inpatient facility (19 CSR 30-35.020). Home health agencies need the Missouri home health manual, and in-home services providers need the Missouri home care manual.
Does Missouri adopt the federal hospice rules?
Not as a whole. The Missouri rule takes in only the federal hospice aide standard (42 CFR §418.76). The manual writes other federal duties as applying if your hospice is Medicare-certified. MO HealthNet hospice participation requires Medicare certification (13 CSR 70-50.010).
Where is Missouri stricter than Medicare?
The IDG reviews the plan of care at least every two weeks (federal: 15 days), emergency preparedness policies are reviewed and updated every year (federal: every two years), and the 5 percent volunteer level is a state rule for every certified hospice (19 CSR 30-35.010). Each policy follows the stricter rule.
Does Missouri EVV apply to hospice?
No. Hospice is exempt from Missouri's electronic visit verification rule (13 CSR 70-3.320(2)(C)).
What do the 59 policies cover?
Client rights (4), service delivery (2), hospice care (17), clinical tasks (8), safeguarding (2), infection control (2), emergency preparedness (1), records (1), privacy (3), human resources (6), governance (8), quality (2), business (2) and ethics (1).
See Cura Core with your agency's name on it.
Choose your state and type of agency, buy your Policy Pack online and get your sign-in by email. Already a customer? Sign in to your portal.