North Carolina Hospice Policy and Procedure Manual
For North Carolina hospices licensed by the Division of Health Service Regulation (DHSR) under the Hospice Licensure Act, whether or not they are Medicare-certified. The manual has 60 policies and 58 forms, written to 10A NCAC 13K, the hospice licensing rules, and, for 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.
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North Carolina · Hospice
60 policies written to the North Carolina rules, with 58 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
- 58
- 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.
NC-HSP-CMP-01Free sample
Client rights
Complaints and Grievances
Sets out how the Agency receives, logs, acknowledges, investigates and resolves complaints from patients, families and others: an investigation started within 72 hours of every complaint made by a patient or family, written acknowledgment and resolution within the Agency's own time frames, a written answer, and no reprisal; how patients are told the Agency's business-hours number and the Division's complaint intake numbers; and how complaint records are kept (at least one year by rule, six years by the Agency).
Read the full policy NC-HSP-ANE-01Free sample SafeguardingRecognizing and Reporting Abuse, Neglect and Exploitation of Adults and Children
Tells every staff member and volunteer how to recognize abuse, neglect (including self-neglect) and exploitation of a disabled adult, and abuse or neglect of a child, and how to report it in North Carolina, where there is no statewide hotline: to the director of the department of social services in the county where the person lives or is present, plus local law enforcement immediately when a child is the victim of a violent offense, sexual offense or misdemeanor child abuse, and always to the Administrator at once.
Read the full policy NC-HSP-IC-01Free sample Infection controlInfection Prevention and Control Program
Sets the Agency's written infection control and communicable disease exposure policies, consistent with 10A NCAC 41A and including compliance with 29 CFR 1910 and 1910.1030 (10A NCAC 13K .0401(a)): leadership of the program, standard precautions and other prevention practices, cleaning of equipment, medical waste, assessment of infection risk in the home, a surveillance log reviewed monthly, outbreak investigation, cooperation with the local health department, and infection control education for staff, contractors, patients and caregivers.
Read the full policy
North Carolina rules
What North Carolina's hospice rules ask your policies to cover
- Team meetings and care plans. The interdisciplinary team meets at least every 15 days, and each patient's care plan is updated monthly. 10A NCAC 13K .0701(b)
- Physician orders. Reviewed and signed by the physician at least every 90 days. Changes in drugs and treatments are signed and in the record within 30 days. 10A NCAC 13K .0601(3); 10A NCAC 13K .0801(d)
- Aide supervision. A registered nurse makes a supervisory visit at least every two weeks. 10A NCAC 13K .0501(6)(c)
- Bereavement. Counseling offered for 12 months after the death, with a written bereavement care plan within six weeks that is reviewed at least quarterly. 10A NCAC 13K .0501(8)
- Discharge notice. At least 48 hours' advance notice before services end, except in the cases the rule lists. 10A NCAC 13K .0601(5)
- Volunteers. Patient family volunteers complete at least 12 hours of training. 10A NCAC 13K .0402(a)
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 plan reviews for the last 30 days. Were they no more than 15 calendar days apart?NC-HSP-IDG-02Care Plan: Development, Monthly Update and Review Every 15 Days
Show me the registered nurse supervisory visits for this patient for the last two months.NC-HSP-AIDE-01Nurse Aide (Hospice Aide) and Homemaker Services
Show me this volunteer's training record. Did it total at least 12 hours and cover all 14 topics?NC-HSP-VOL-01Patient Family Volunteer Program
How do you tell patients that they may object to our review of their records? Show me where that notice is in the record.NC-HSP-GOV-04Inspections, Plans of Correction and Department Access to Records
What happens, step by step, when a family calls at 2:00 a.m.?NC-HSP-SVC-0124-Hour Availability, Nursing On-Call and After-Hours Response
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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 rights4
NC-HSP-CMP-01Free sample
Complaints and Grievances
Sets out how the Agency receives, logs, acknowledges, investigates and resolves complaints from patients, families and others: an investigation started within 72 hours of every complaint made by a patient or family, written acknowledgment and resolution within the Agency's own time frames, a written answer, and no reprisal; how patients are told the Agency's business-hours number and the Division's complaint intake numbers; and how complaint records are kept (at least one year by rule, six years by the Agency).
10A NCAC 13K .0604(c)
NC-HSP-PR-01
Patient Rights and Responsibilities
Gives every patient written notice of his or her rights and responsibilities before care starts, applies the 15 rights of G.S. 131E-144.3 to hospice patients as 10A NCAC 13K .0604(a) requires, adds the federal hospice rights of 42 CFR §418.52, gives the business-hours and Division complaint numbers, and keeps proof of delivery in the record.
10A NCAC 13K .0604(a)
NC-HSP-PR-02
Informed Consent, Service Information and Charges
Requires a written informed consent signed by the patient before hospice services begin (or by the guardian, health care agent or primary caregiver when the patient cannot sign), written information about services and how to reach on-call staff, and a written statement of services and charges, and sets out the admission packet and the patient's continuing right to accept or refuse services.
10A NCAC 13K .0601(4)
NC-HSP-PR-03
Advance Directives, Portable DNR Orders and MOST
Protects the patient's right to have an advance directive, gives written information on the Agency's policy and on North Carolina law (living will, health care power of attorney, portable DNR order, MOST, advance instruction for mental health treatment) when hospice care begins, records in a prominent place whether the patient has one, never conditions care on it, and explains how staff honor a portable DNR order or MOST in the home.
10A NCAC 13K .0301(a)(3)
Service delivery2
NC-HSP-SAF-01
Staff Safety, Home Safety and Emergencies in the Home
Sets how the Agency keeps patients and staff safe in the home: a home safety assessment at admission and when things change, what staff do in a medical emergency during a visit, safety before, during and after visits including lone-worker check-in, workplace violence prevention, safe patient handling, hazardous chemicals, travel in bad weather, and reporting of staff injuries. Safety is a required training topic for all direct care staff (10A NCAC 13K .0402(b)(12)).
10A NCAC 13K .0402(b)(12)
NC-HSP-SVC-01
24-Hour Availability, Nursing On-Call and After-Hours Response
Makes hospice care available 24 hours a day, seven days a week, with nursing services by or under the supervision of a registered nurse at all hours, a physician on call, an after-hours number answered by a person, Agency response standards for call-backs and visits, an on-call log, and nursing on-call schedules kept for one year for the Division.
G.S. 131E-203(c)
Hospice care18
NC-HSP-ADM-01
Acceptance of Patients, Referral and Admission
Sets the Agency's written acceptance policy under 10A NCAC 13K .0601: IDT involvement in acceptance and the designation of a primary caregiver, an initial assessment before acceptance, the attending physician's determination and agreement, signed informed consent, written service and on-call information and the 48-hour notice before termination; and adds the federal admission rules (physician recommendation under 42 CFR §418.25) and NC Medicaid coordination before admission.
10A NCAC 13K .0601
NC-HSP-ADM-02
Hospice Care for Children and Concurrent Care
Explains how the Agency serves children and young adults, including concurrent care for NC Medicaid beneficiaries under 21 (who keep coverage of treatment aimed at cure while receiving hospice care), consent by parents and guardians, coordination with treating specialists and other programs, pediatric competence, child abuse reporting and the longer record retention for minors.
NC Medicaid Clinical Coverage Policy 3D, section 5.11
NC-HSP-ASM-01
Initial, Comprehensive and Updated Assessments and Hospice Outcome Data
Sets the assessments every patient receives: the North Carolina assessment before acceptance, the registered nurse's initial assessment within 48 hours after the election, the IDT's comprehensive assessment within 5 calendar days (with the spiritual assessment and survivor risk factors 10A NCAC 13K requires at admission), updates at least every 15 days, and the standardized HOPE data the Agency collects for the Hospice Quality Reporting Program.
42 CFR §418.54
NC-HSP-BRV-01
Bereavement Program
Sets up the Agency's organized bereavement program under its Bereavement Coordinator: survivor risk assessment during admission and during the illness, a written bereavement care plan within six weeks after the death that says who receives services and what services, review of that plan at least quarterly, bereavement counseling offered for 12 months after the death, and justified and documented discharge before 12 months.
10A NCAC 13K .0501(8)
NC-HSP-CNS-01
Spiritual Counseling, Dietary Counseling and Other Counseling
Requires the Agency to designate a clergy member to coordinate spiritual care, offer spiritual counseling to every patient and family without imposing any belief, complete a spiritual assessment during admission and work with the family's own clergy or spiritual caregiver; to offer nutritional assessment and dietary counseling by a licensed dietitian/nutritionist or licensed nutritionist when ordered; and to make other counseling available to ease the stress of the terminal illness and dying.
10A NCAC 13K .0501(3)
NC-HSP-DC-01
Discharge, Termination of Services and Transfer
Sets when the Agency may discharge a living patient (move out of the service area or transfer, no longer terminally ill, or for cause after the required steps), the written physician discharge order, the North Carolina 48-hour advance notice, the Medicare non-coverage notice and appeal rights, discharge planning, notices to Medicare and NC Medicaid, and the discharge summary sent to the receiving facility or attending physician.
10A NCAC 13K .0601(5)
NC-HSP-DTH-01
Patient Death: Plan for Death, Pronouncement and Report of Death
Sets the Agency's written plan to be followed in case of patient death, in every setting: collection of the data needed for the death certificate, recording the time of death, determination and pronouncement of death, notice to the attending physician who signs the death certificate, notice to next of kin or legal guardian, authorization and release of the body to the funeral home, notice to the medical examiner when the law requires it, and notice to the Division of any death resulting from an injury, accident or other possible unnatural causes.
10A NCAC 13K .1108
NC-HSP-ELC-01
Election of Hospice Care, Election Statement Addendum and Notice of Election
Sets how a Medicare or NC Medicaid patient elects hospice care: who may sign, the required content of the election statement, the mandatory election statement addendum ("Patient Notification of Hospice Non-Covered Items, Services, and Drugs") for elections on or after October 1, 2026, the waiver of other benefits, benefit periods, the 5-day notice of election and the NC Medicaid six-day upload of the election statement.
42 CFR §418.24
NC-HSP-ELC-02
Certification and Recertification of Terminal Illness and Face-to-Face Encounters
Sets how the Agency obtains written (and when needed oral) certification of terminal illness for every benefit period, who may certify, the physician narrative and signatures, the face-to-face encounter before the third and each later benefit period (including the limits on telehealth encounters), and the NC Medicaid prior approval with clinical review for third and later periods.
42 CFR §418.22
NC-HSP-ELC-03
Revocation, Change of Designated Hospice and Change of Attending Physician
Sets how a patient may revoke the hospice election, re-elect later, change the designated hospice once in each election period, or change the attending physician, using signed statements with the content federal rules require, the notices to Medicare and NC Medicaid that follow, and the rule that the Agency never asks or pressures a patient to revoke.
42 CFR §418.28
NC-HSP-FAC-01
Hospice Care for Residents of Nursing Facilities, ICF/IID and Adult Care Homes
Sets out how the Agency cares for patients who live in a nursing facility, ICF/IID or adult care home: a written agreement signed before care starts with every provision 42 CFR §418.112(c) and NC Medicaid Policy 3D require, a single coordinated plan of care that says which provider does what and that only the Agency may change, a designated IDT member for each resident, the information the facility must be given, orientation of facility staff, reports of alleged violations to the facility administrator within 24 hours, and the NC Medicaid level of care, room and board and patient monthly liability steps.
42 CFR §418.112
NC-HSP-FAC-02
Inpatient Care Arrangements for Symptom Management and Respite
Sets out how the Agency arranges short-term inpatient care for pain and symptom management and for respite when it does not provide that care in its own facility: only in a licensed hospital, nursing facility or hospice inpatient facility that meets the federal standards, under a written agreement signed by both providers with every provision North Carolina and 42 CFR §418.108(c) require, with the monthly updated plan of care sent to the facility, hospice professional management throughout the stay, the discharge summary kept in the hospice record, and the Medicare five-day respite and 20 percent inpatient limits monitored.
10A NCAC 13K .0501(5)
NC-HSP-FAC-03
Hospice Residential Care Facilities and Hospice Inpatient Units
Applies only if the Agency operates a licensed hospice residential care facility or hospice inpatient facility or unit. Sets out the North Carolina rules for those facilities (administration, staffing with at least two staff on duty at all times, pharmacy with monthly drug storage inspection and drug regimen review, dietary with no more than 14 hours between evening meal and breakfast, visitation at any hour, monthly infection control monitoring, linens, fire and disaster plans with yearly training and quarterly fire drills on each shift, 72 hours of generator fuel, and the physical plant), the North Carolina visitation law and notice, and, if the Agency is Medicare-certified, the federal inpatient standards including restraint and seclusion.
10A NCAC 13K .1101
NC-HSP-IDG-01
Interdisciplinary Team, Patient and Family Care Coordinator and Team Meetings
Sets the membership of the Agency's interdisciplinary team under North Carolina law (physician licensed in North Carolina, nurse, social worker, clergy member and trained hospice volunteer) and the federal interdisciplinary group, the Patient and Family Care Coordinator for each patient, and IDT meetings at least every 15 days for care plan review and staff support, with minutes and record entries.
10A NCAC 13K .0701(b)
NC-HSP-IDG-02
Care Plan: Development, Monthly Update and Review Every 15 Days
Requires a written care plan for each patient and family, established by the IDT under the attending physician's orders and based on the medical, psychosocial and spiritual assessment, with the North Carolina content (diagnosis and prognosis, problems and goals, types and frequency of services, responsible disciplines) and the federal content; reviewed at every IDT meeting and at least every 15 calendar days, and fully updated at least monthly.
10A NCAC 13K .0701(a)
NC-HSP-IDG-03
Physician Orders, Coordination of Services and Care Transitions
Sets how the Agency receives, records and has signed physician orders (written, faxed and verbal), the North Carolina rules that orders are reviewed and signed at least every 90 days and that changes in drugs and treatments are signed within 30 days, how the IDT coordinates services with contracted and outside providers (including NC Medicaid coordination with home care, CAP and personal care services), and how continuity is kept when the patient moves between settings.
10A NCAC 13K .0601(3)
NC-HSP-LOC-01
Levels of Care: Routine Home Care, Continuous Home Care, Respite and General Inpatient Care
Describes the four levels of hospice care (routine home care, continuous home care during brief periods of crisis, inpatient respite care and general inpatient care for symptoms that cannot be managed elsewhere), who decides the level, the physician order and documentation each level needs, the settings and limits that apply, and how the Agency keeps care continuous when the level changes.
42 CFR §418.302
NC-HSP-PAIN-01
Pain and Symptom Management and Care of the Imminently Dying Patient
Sets how the Agency assesses, plans, treats and reassesses pain and other symptoms, responds to a symptom crisis, and cares for the patient and family when death is near, so that each patient's drug regimen gives optimal symptom control (10A NCAC 13K .0801(e)) and, if the Agency is Medicare-certified, each patient receives effective pain management and symptom control (42 CFR §418.52(c)(1)).
10A NCAC 13K .0801(e)
Clinical tasks8
NC-HSP-AIDE-01
Nurse Aide (Hospice Aide) and Homemaker Services
Sets who may work as a nurse aide (hospice aide) or homemaker, how competency is evaluated and recorded before any task is assigned, the 12 hours of in-service each 12 months, the written assignment prepared by the registered nurse, what aides do and report, the North Carolina supervisory visit at least every two weeks and the federal visit no less than every 14 days, the annual observed visit, homemaker supervision, and coordination with NC Medicaid personal care services, including Form DMA-3165 within five days of hospice admission.
10A NCAC 13K .0501(6)
NC-HSP-DME-01
Home Medical Equipment and Supplies
Requires the Agency to arrange the supplies, equipment and prosthetic devices each patient needs at home (for example dressings, catheters and oxygen), and sets the policies 10A NCAC 13K .0504(b) requires: set-up, delivery, electrical safety and environment; cleaning, storage, maintenance and repair to the manufacturer's guidelines; transportation, tracking and recall; emergency back-up for equipment or power failure; and written patient instruction for each item, documented by staff.
10A NCAC 13K .0504
NC-HSP-LAB-01
Laboratory, Radiology and Waived Testing
Sets out how the Agency arranges laboratory, radiology and pathology services: only on a physician's or practitioner's order that fits the plan of care, through licensed providers under written agreement (and, for its own inpatient facility, under a qualified physician's direction), and how any test staff perform themselves, such as a fingerstick blood glucose, is done only under a CLIA certificate of waiver or other CLIA certificate, following the manufacturer's instructions.
10A NCAC 13K .1203
NC-HSP-MED-01
Drugs and Treatments: Orders, Administration and Drug Regimen Review
Sets the Agency's written policies for the administration of drugs and treatments (10A NCAC 13K .0801(a)): signed original orders, faxed and verbal orders, signature of changes within the Agency's time frame and never later than 30 days, monitoring of each patient's drug regimen for optimal symptom control by the professionals North Carolina names, who gives medications at home and in facilities, documentation by the licensed nurse of all medications given, and, if the Agency is Medicare-certified, the drug profile, ordering, dispensing, administration and labeling rules of 42 CFR §418.106.
10A NCAC 13K .0801
NC-HSP-MED-02
Controlled Substances, Medications in the Home and Disposal
Sets the Agency's policies for the procurement, storage, administration and disposal of drugs and biologicals (10A NCAC 13K .0802(f)): medications in the home are the patient's and family's property and are stored safely, staff encourage disposal of unused or discontinued medications and document every witnessed or reported disposal, the written controlled drug policy is given to and discussed with the patient and family when a controlled drug is first ordered, and trained hospice nurses dispose of controlled substances in the home only in the cases federal law allows.
10A NCAC 13K .0802(f)
NC-HSP-NUR-01
Nursing Services: Registered Nurse and Licensed Practical Nurse Duties
Makes hospice nursing available 24 hours a day, by or under the supervision of a registered nurse, under the North Carolina Nursing Practice Act and the care plan; sets the minimum registered nurse and licensed practical nurse duties of 10A NCAC 13K .0501(1); requires current North Carolina licensure, competency before assignment, and retention of nursing on-call schedules for one year; and, if the Agency is Medicare-certified, sets the federal core-services rule for nursing.
10A NCAC 13K .0501(1)
NC-HSP-SW-01
Social Work Services
Requires social work services for every patient and family: a psychosocial assessment with goals in the care plan, ongoing counseling on death and dying, and help using community resources (10A NCAC 13K .0501(2)); sets social worker qualifications and, if the Agency is Medicare-certified, the federal rule that medical social services are given by a qualified social worker under the direction of a physician.
10A NCAC 13K .0501(2)
NC-HSP-THR-01
Therapy Services and Other Physician-Ordered Services
Requires the Agency to offer physical therapy, occupational therapy, nutritional assessment and dietary counseling and other services ordered by the physician in accordance with the plan of care, directly or by arrangement; makes speech-language pathology available; sets therapist qualifications; and sets how therapy is ordered, planned, delivered and documented to control symptoms and help the patient keep daily activities and basic functional skills.
10A NCAC 13K .0501(7)
Safeguarding2
NC-HSP-ANE-01Free sample
Recognizing and Reporting Abuse, Neglect and Exploitation of Adults and Children
Tells every staff member and volunteer how to recognize abuse, neglect (including self-neglect) and exploitation of a disabled adult, and abuse or neglect of a child, and how to report it in North Carolina, where there is no statewide hotline: to the director of the department of social services in the county where the person lives or is present, plus local law enforcement immediately when a child is the victim of a violent offense, sexual offense or misdemeanor child abuse, and always to the Administrator at once.
G.S. 108A-102
NC-HSP-ANE-02
Allegations Against Staff: Health Care Personnel Registry Reports, Investigation and Protection
Sets out what happens when anyone furnishing services for the Agency is accused of abusing or neglecting a patient, taking a patient's or the Agency's property or drugs, or committing fraud, or when a patient has an injury of unknown source: immediate report to the Administrator, immediate protection of patients, a report to Health Care Personnel Investigations within 24 hours for unlicensed staff, an investigation with results to the Division within five working days, reports to licensing boards for licensed staff, and, for a Medicare-certified hospice, reports of verified violations within 5 working days.
10A NCAC 13O .0102
Infection control2
NC-HSP-IC-01Free sample
Infection Prevention and Control Program
Sets the Agency's written infection control and communicable disease exposure policies, consistent with 10A NCAC 41A and including compliance with 29 CFR 1910 and 1910.1030 (10A NCAC 13K .0401(a)): leadership of the program, standard precautions and other prevention practices, cleaning of equipment, medical waste, assessment of infection risk in the home, a surveillance log reviewed monthly, outbreak investigation, cooperation with the local health department, and infection control education for staff, contractors, patients and caregivers.
10A NCAC 13K .0401(a)
NC-HSP-IC-02
Bloodborne Pathogens Exposure Control Plan
The Agency's written exposure control plan under 29 CFR §1910.1030, which 10A NCAC 13K .0401(a) incorporates: exposure determination, universal precautions, engineering and work practice controls, PPE at no cost, housekeeping and regulated waste, hepatitis B vaccination within 10 working days of initial assignment with the mandatory declination statement, post-exposure evaluation and follow-up, labels, training at initial assignment and at least annually, records, the sharps injury log, and review of the plan at least annually.
29 CFR §1910.1030
Emergency preparedness1
Records1
Privacy3
NC-HSP-PRV-01
HIPAA Privacy and North Carolina Confidentiality Laws
Names the Privacy Official, sets out how the Agency gives the Notice of Privacy Practices and gets the acknowledgment, when staff may share health information with family, physicians, facilities and others, how patients and personal representatives use their HIPAA rights (access within 30 days, amendment and accounting within 60 days), and how North Carolina's own confidentiality rules (the patient rights statute, the right to object to state review, and the security of original records) fit in.
45 CFR §164.530
NC-HSP-PRV-02
HIPAA Security
Sets out how the Agency protects electronic health information under the HIPAA Security Rule: a named Security Official, a written risk analysis and risk management plan, role-based EHR access with unique logins, rules for laptops, tablets and phones used in patients' homes, encryption, audit-log review, security incident response, backup and disaster recovery tied to the emergency plan, and six-year retention of security documentation.
45 CFR §164.308
NC-HSP-PRV-03
Breach Notification
Sets out what staff do the moment health or personal information may have gone to the wrong person: report at once, contain, assess the four HIPAA risk factors, and, for a breach, notify each patient (or the next of kin of a patient who has died) without unreasonable delay and within 60 calendar days, the media and HHS as the size of the breach requires, and, under the North Carolina Identity Theft Protection Act, the Consumer Protection Division of the Attorney General's Office and, above 1,000 persons, the consumer reporting agencies.
45 CFR §164.404
Human resources6
NC-HSP-HR-01
Orientation, Hospice Training and In-Service Education
Requires orientation in the hospice philosophy and the employee's own duties, North Carolina's 14 required training topics for everyone who gives direct patient and family care, at least eight hours of hospice training for staff and 12 hours for volunteers, annual in-service education (at least 12 hours in each 12-month period for nurse aides), extra training for hospice caregivers in residential facilities, and attendance records.
10A NCAC 13K .0402
NC-HSP-HR-02
Job Descriptions, Qualifications, License Verification and Competency
Requires a job description with qualifications and responsibilities for every position (including direct-care volunteers), sets the qualifications for each discipline under North Carolina and federal rules, verifies licenses and registry listings at hire and before they expire, defines how competency is verified, and requires performance evaluations at least annually.
10A NCAC 13K .0401(d)
NC-HSP-HR-03
Criminal Background Checks, Health Care Personnel Registry and Exclusion Screening
Requires a Health Care Personnel Registry check before hiring any unlicensed staff with direct access, with each access noted; Nurse Aide Registry listing for nurse aides; a criminal background check on everyone with direct patient contact or access to patient records (North Carolina has no hospice-specific statute, so the federal standard and the Agency's own standard apply); and federal exclusion screening before hire and monthly.
G.S. 131E-256(d2)
NC-HSP-HR-04
Personnel Records
Lists the nine items North Carolina requires in every personnel record for paid staff and direct-care volunteers, keeps confidential health information separate, makes records available to surveyors on the premises, and keeps them at least one year after employment or service ends (six years as the Agency's standard), with longer periods for OSHA and immigration records.
10A NCAC 13K .0401(e)
NC-HSP-HR-05
Tuberculosis Screening, Hepatitis B and Staff Health
Requires a baseline tuberculosis test for every hands-on care team member before patient contact, proof of non-infectious status before a positive reactor goes into a patient's home, annual symptom verification for anyone previously positive, annual screening records, further testing by CDC guidelines for staff at risk, hepatitis B vaccination or declination, and rules on working while ill.
10A NCAC 13K .0401(b)
NC-HSP-VOL-01
Patient Family Volunteer Program
Sets up the patient family volunteer program North Carolina requires as part of every hospice team: a Coordinator of Patient Family Volunteers, screening, job descriptions and personnel records, at least 12 hours of training on the 14 required topics, assignment and supervision, volunteer notes in the patient record, and (if Medicare-certified) volunteer hours of at least 5 percent of paid patient care hours with documented cost savings.
10A NCAC 13K .0402(a)
Governance8
NC-HSP-GOV-01
Governing Body, Administrator and Order of Authority
Sets out what the governing body does itself, the written appointments it makes, the Administrator's written authority and duties, the order of authority when the Administrator is absent, the five-working-day notice to the Division when the Administrator position falls vacant, and the reports the governing body receives.
10A NCAC 13K .0301
NC-HSP-GOV-02
Organizational Structure, Geographic Service Area and Multiple Premises
Defines the Agency's organizational structure and lines of authority, the counties it serves, the 30-day advance notice to the Division before a permanent expansion of the service area, and how multiple licensed premises share staff and records under one administration.
10A NCAC 13K .0301(e)
NC-HSP-GOV-03
Hospice License, Certificate of Need and Medicare Certification
Explains when a hospice license is required, how the license is renewed, posted and kept current, the certificate of need, the written notices the Agency must send the Division (ownership or name change at least 30 days before, director vacancy within five working days, service area expansion 30 days ahead), provisional licenses and revocation, and how Medicare certification and NC Medicaid enrollment are kept current.
G.S. 131E-203
NC-HSP-GOV-04
Inspections, Plans of Correction and Department Access to Records
Sets out how staff receive Division surveyors, give them immediate access, arrange home visits with patient permission, tell every patient in writing of the right to object to state review of his or her records, keep any signed objection at the front of the record, and file a plan of correction within 10 working days.
10A NCAC 13K .0208
NC-HSP-GOV-05
Closure, Change of Ownership and Records After Closure
Sets out what the Agency does before a change of ownership (30 days' written notice to the Division, a new license) and if it closes or stops serving patients: advance notice and safe transfer of every patient, discharge summaries, notices to Medicare and NC Medicaid, continued bereavement support, and written notice to the Division of where patient records will be stored for the full retention period.
10A NCAC 13K .0902(f)
NC-HSP-GOV-06
Hospice Program, Scope of Services and Policy Index
Describes the hospice program the Agency offers, how each required service is provided (directly or under a written agreement), the 24-hour availability rule, the written information every patient receives, and an index that maps each policy subject North Carolina requires to the policy in this manual that covers it.
10A NCAC 13K .0301(a)
NC-HSP-GOV-07
Annual Budget, Statistical Records and Data Reports
Requires an annual budget available for inspection, monthly statistical records (staff and volunteer hours, referrals, admissions, discharges, diagnoses, home or inpatient location) kept at least five years, separate hospice records when the hospice is part of a larger organization, and the data needed for the license renewal and any annual data report the Department asks for.
10A NCAC 13K .0303
NC-HSP-MD-01
Medical Director, Physician Designee and Attending Physicians
Requires a Medical Director licensed in North Carolina who directs the medical aspects of the patient care program, a physician designee who acts in the Medical Director's absence, 24-hour physician availability, and sets out the duties of hospice physicians and attending physicians, including the North Carolina rule that physician orders are reviewed and signed at least every 90 days.
10A NCAC 13K .0102(17)
Quality2
NC-HSP-QA-01
Annual Agency Evaluation and Quality Assessment and Performance Improvement
Sets out the comprehensive evaluation of the whole hospice program that North Carolina requires at least once a year (all policies and procedures and a medical record review, with the evaluators' names and qualifications, criteria, methods and actions documented), and the ongoing, data-driven quality assessment and performance improvement (QAPI) program, adverse event tracking, performance improvement projects and Hospice Quality Reporting Program data (HOPE and Hospice CAHPS) required of a Medicare-certified hospice.
10A NCAC 13K .1001
NC-HSP-QA-02
Incidents, Adverse Events and Reports to the Division
Sets out what staff do when something goes wrong: make the patient safe, report to a supervisor at once and on Form NC-HSP-QA-02-A by the end of the shift, and make every outside report on time (a death from injury, accident or other possible unnatural causes to the Department; allegations against unlicensed staff to the Health Care Personnel Registry within 24 hours; abuse and neglect to the county department of social services; suspected crimes against residents of long-term care facilities within 2 or 24 hours). It then sets out investigation, analysis and learning through the QAPI program.
10A NCAC 13K .1108(7)
Business2
NC-HSP-CON-01
Services Arranged with Other Agencies and Individuals
Requires a written agreement signed by both parties before any arranged service starts, with the nine contents North Carolina specifies; keeps the Agency professionally and financially responsible for every arranged service; requires contract providers to document on the day of care and send records at least every two weeks; and requires an annual review of every agreement.
10A NCAC 13K .0505
NC-HSP-FIN-01
Billing Integrity, Notices to Medicare and NC Medicaid, and Care Regardless of Ability to Pay
Sets out the Medicare notice of election and notice of termination deadlines (5 calendar days), the NC Medicaid prior approval and election statement upload in NCTracks within six calendar days, prior approval for later benefit periods, reporting discharges and revocations to NC Medicaid, billing only what is documented, the inpatient and aggregate caps, and the rule that care is not reduced or stopped because a Medicare or Medicaid beneficiary cannot pay.
42 CFR §418.24(e)
Ethics1
Questions
Questions about this manual
Is this the right manual for my license?
It is for hospices licensed under 10A NCAC 13K, Medicare-certified or not. A home care agency needs the North Carolina home care manual, and a Medicare-certified home health agency needs the North Carolina home health manual.
We are not Medicare-certified. Does the manual still fit?
Yes. 10A NCAC 13K binds every licensed hospice, and each federal requirement is written as applying if the hospice is Medicare-certified. NC Medicaid enrolls only hospices that are both licensed and Medicare-certified (Clinical Coverage Policy 3D).
Can patients object to the state reviewing their records?
Yes. North Carolina gives hospice patients the right to object to the Department reviewing their records (G.S. 131E-207(a)(2); 10A NCAC 13K .0901(a)). The manual includes the written notice given at admission, and any signed objection is kept at the front of the record.
What do the 60 policies cover?
Client rights (4), service delivery (2), hospice care (18), clinical tasks (8), safeguarding (2), infection control (2), emergency preparedness (1), records (1), privacy (3), human resources (6), governance (8), quality (2), business (2) and ethics (1).
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