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Ohio Hospice Policy and Procedure Manual

For Ohio hospice care programs licensed by the Ohio Department of Health (ODH) under ORC Chapter 3712. The manual has 60 policies and 59 forms, written to OAC Chapter 3701-19, Ohio's hospice licensing rules, and the federal hospice Conditions of Participation (42 CFR Part 418), which Ohio Medicaid requires of every Medicaid hospice provider. 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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Ohio · Hospice

60 policies written to the Ohio rules, with 59 forms. Every one is filled in with your agency's details.

  • A plain-English summary first
  • The rule each policy follows
  • Word and PDF downloads, yours to keep
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Policies
60
Forms
59
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.

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3 free sample policies, shown in full for a sample agency.

OH-HSP-CMP-01Free sample Client rights

Patient Grievances and Complaints

Sets how patients, families and others can complain or voice grievances to the Agency about any aspect of care or treatment, without fear of reprisal, and how the Agency acknowledges, investigates, resolves and documents each one within its own time frames, as 42 CFR §418.52(b) and the governing body policies required by OAC 3701-19-06(C)(1)(b) require; how grievances that allege abuse, neglect or misappropriation are handled; and how to reach the Ohio Department of Health and the State Long-Term Care Ombudsman.

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

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 adults, and how to make the immediate report to the county department of job and family services that Ohio's adult protective services law (ORC 5101.60 to 5101.63) requires of hospice staff serving adults aged 60 or older, together with the immediate internal report to the Administrator, the route for residents of nursing homes and residential care facilities, what to do for adults under 60, and the protections for people who report.

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

Infection Prevention and Control Program

Sets out the Agency's infection prevention and control program required by 42 CFR §418.60: standard and transmission-based precautions, hand hygiene and equipment cleaning in the home, surveillance and investigation of infections using the infection surveillance log, reporting of diseases under Ohio's communicable disease rules, the link to the QAPI program, education for staff, contractors, patients and families, and the Ohio requirements for staff screening and for linens and isolation in an inpatient hospice facility.

Read the full policy
Ohio rules

What Ohio's hospice rules ask your policies to cover

  • Certification of terminal illness. An oral certification before admission or within 48 hours after it, followed by written certification. OAC 3701-19-20(G)
  • Plan of care reviews. The interdisciplinary team reviews each patient's plan of care at least every 15 days. OAC 3701-19-11(C)(4); 42 CFR §418.56(d)
  • Aide supervision. A registered nurse makes a supervisory visit at least every two weeks. OAC 3701-19-16(F)
  • Opioid diversion policy. A written policy on preventing the diversion of opioids prescribed to patients at home, given to and discussed with the patient and family, and attested to with each license renewal. ORC 3712.062
  • Suspected drug diversion. The administrator or a designee investigates within 24 hours of a report and, if diversion is substantiated or the result is inconclusive, reports to law enforcement no later than ten days after the report or when the investigation ends. OAC 3701-19-06(C)(3)(f)
  • Background checks. For a direct care applicant, the BCII check is requested within five business days after conditional employment begins, and the job ends if results other than FBI are not received within thirty days. ORC 3712.09; OAC 3701-13-04

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:

Who receives reports of suspected diversion, and how quickly are they investigated and reported to law enforcement? OH-HSP-MED-02Opioid Diversion Prevention and Disposal Policy For this patient, when did you obtain the oral statements certifying terminal illness, and from whom? OH-HSP-ELC-02Certification of Terminal Illness: 48-Hour Oral Certification, Written Certification and Recertification When did you file your last renewal, and did it include the written evidence that you comply with ORC 3712.062? OH-HSP-GOV-03Hospice Care Program License, Renewal and Notices to the Director of Health Show me your applicant log. For this aide, when did she start, when was the BCII request submitted and when did you receive the results? OH-HSP-HR-03Criminal Records Checks and Exclusion Screening When did the Administrator learn of it, what was done to protect the patient that day, and when was the self-report filed with ODH? OH-HSP-ANE-02Investigating Alleged Violations and Self-Reported Incidents to the Ohio Department of Health
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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

OH-HSP-CMP-01Free sample Patient Grievances and Complaints Sets how patients, families and others can complain or voice grievances to the Agency about any aspect of care or treatment, without fear of reprisal, and how the Agency acknowledges, investigates, resolves and documents each one within its own time frames, as 42 CFR §418.52(b) and the governing body policies required by OAC 3701-19-06(C)(1)(b) require; how grievances that allege abuse, neglect or misappropriation are handled; and how to reach the Ohio Department of Health and the State Long-Term Care Ombudsman. OAC 3701-19-06(C)(1)(b) OH-HSP-PR-01 Patient and Family Rights and Responsibilities Sets out the rights and responsibilities of hospice patients and families under 42 CFR §418.52 and the Ohio hospice rules, how and when the Agency gives the notice of rights, who exercises a patient's rights when the patient cannot, the Ohio contacts every patient receives, and how staff protect those rights in daily practice. 42 CFR §418.52 OH-HSP-PR-02 Informed Consent, Scope of Services, Limitations and Charges Sets out how the Agency obtains the signed informed consent Ohio requires before hospice care, what the patient is told about the palliative nature of hospice care, the scope of services, their limitations and the charges, who may consent for a patient, and how the Agency honors refusals and the right to withdraw consent at any time. OAC 3701-19-20(C)-(E) OH-HSP-PR-03 Advance Directives, DNR Orders and Health Care Powers of Attorney Sets out how the Agency informs adult patients about Ohio advance directives (living will declarations and durable powers of attorney for health care), records whether each adult patient has one, honors Ohio do-not-resuscitate orders and DNR identification under the Ohio DNR protocol, handles revocation and transfers, and educates staff and the community. ORC Chapter 2133

Service delivery2

OH-HSP-SAF-01 Staff Safety, Home Safety and Emergencies in the Home Sets out the Agency's safety policies and procedures for staff and volunteers working in patients' homes: the home safety assessment and fall and fire prevention, what to do in a medical or other emergency in the home, personal safety before, during and after visits, workplace violence and leaving an unsafe home, driving, hazardous chemicals, and reporting and recording staff injuries, including the OSHA reporting time limits and Ohio workers' compensation. OAC 3701-19-13(B)(7) OH-HSP-SVC-01 24-Hour Availability, On-Call and After-Hours Response Sets out how the Agency makes care available 24 hours a day, 7 days a week: the on-call system, nursing, physician, pharmacy and equipment availability, telephone triage and the Agency's response time standards, nursing in inpatient facilities, the after-hours call log, teaching families when to call, and testing the system. ORC 3712.06(B)

Hospice care17

OH-HSP-ADM-01 Referral, Eligibility, Admission and Veterans Benefits Notice Sets out how the Agency receives referrals, decides whether a person is eligible for hospice care under Ohio and federal rules, completes the admission visit in the required order, gives the Ohio veterans benefits notice, meets the Ohio Medicaid conditions that must be in place before care, and responds when it cannot admit. OAC 3701-19-20(A) OH-HSP-ASM-01 Initial and Comprehensive Assessment and Hospice Quality Reporting Sets out the registered nurse's initial assessment within 48 hours after election, the IDG comprehensive assessment within 5 calendar days, its required content (including the Ohio assessment of opioid diversion risk, spiritual needs, nutrition and the family's bereavement needs), updates at least every 15 days, outcome data, and the Medicare hospice quality reporting program. 42 CFR §418.54 OH-HSP-BRV-01 Bereavement Program Sets out the Agency's organized bereavement program: the designated qualified professional who supervises it, the bereavement assessment before and after death, the written bereavement plan of care stating the services, their frequency and who provides them, services for up to one year after the patient's death, help for residents and staff of facilities, and the response when a bereaved person is at risk of harm. OAC 3701-19-18(D) OH-HSP-CNS-01 Spiritual and Dietary Counseling Sets out how the Agency makes counseling available to patients and families while the patient is enrolled: assessing spiritual needs in line with the patient's and family's religious preferences, providing spiritual counseling and arranging clergy visits, and providing dietary counseling planned and given by or under the supervision of a dietitian or, when the Agency cannot obtain one, a nurse. OAC 3701-19-18(A)-(C) OH-HSP-DC-01 Discharge, Transfer and Discharge for Cause Sets out when the Agency may discharge a patient alive (moving away, transfer, no longer terminally ill, or for cause after the required steps), the physician discharge order, discharge planning, the Medicare advance notice of termination, the Ohio Medicaid written statement of reasons and portal entry, discharge summaries, notices to Medicare, and the reasons for which the Agency never discharges. 42 CFR §418.26 OH-HSP-DTH-01 Death at Home, Pronouncement of Death and Post-Death Care Sets out what staff do when a patient's death is near or has occurred: preparing the family for an expected death, the death visit, determination and pronouncement of death by a registered nurse under ORC 4723.36 (effective March 20, 2025), notifying the attending practitioner within 24 hours, deaths that must be reported to the coroner under ORC 313.12, the death certificate, care of the body, the written request to relinquish opioids, equipment, records, and support for the family and staff. ORC 4723.36 OH-HSP-ELC-01 Election of Hospice, Election Statement Addendum and Notice of Election Sets out how a patient elects hospice care under Medicare and Ohio Medicaid: the required content of the election statement, the election statement addendum that applies to elections on or after October 1, 2026, the Medicare notice of election, the Ohio Medicaid election steps and portal upload, benefit periods, the services waived by election, and re-election. 42 CFR §418.24 OH-HSP-ELC-02 Certification of Terminal Illness: 48-Hour Oral Certification, Written Certification and Recertification Sets out how the Agency obtains certification of terminal illness: the Ohio requirement for an oral statement prior to or within 48 hours after admission and written confirmation after admission, the Medicare written and oral certification time frames, who may certify, the content and narrative, face-to-face encounters before the third benefit period, recertification, and the Ohio Medicaid portal entries. OAC 3701-19-20(G) OH-HSP-ELC-03 Withdrawal of Consent, Revocation, Change of Designated Hospice and Change of Attending Physician Sets out how the Agency honors a patient's withdrawal of consent and revocation of the hospice election, a change of designated hospice once in each benefit period and a change of attending physician, with the signed statements, notices, Ohio Medicaid portal entries and hearing rights each requires, and the rule that staff never pressure a patient to revoke. 42 CFR §418.28 OH-HSP-FAC-01 Hospice Care for Residents of Nursing Facilities, ICF/IID and Residential Care Facilities Sets how the Agency provides hospice care to residents of nursing facilities (SNF/NF), intermediate care facilities for individuals with intellectual disabilities (ICF/IID) and residential care facilities: the written agreement signed before services begin with the content 42 CFR §418.112(c) and OAC 5160-56-04(H) require, the Agency's professional management of the resident's hospice care, the shared plan of care, coordination and the information given to the facility, orientation of facility staff, reporting of alleged violations to the facility administrator within 24 hours, and Ohio Medicaid room and board payment. 42 CFR §418.112 OH-HSP-FAC-02 Short-Term Inpatient Care Arrangements Sets how the Agency provides or arranges short-term inpatient care for pain control, symptom management and respite: the settings Ohio (OAC 3701-19-22) and federal rules (42 CFR §418.108) allow, the written agreement each contracted inpatient facility must have, the staffing and comfort standards the facility must meet, the seven-consecutive-day Ohio limit on respite stays, the Agency's continued management of the patient during the stay, and the Medicare 20 percent inpatient day limitation. OAC 3701-19-22 OH-HSP-FAC-03 Inpatient Hospice Facility Operations and Non-Hospice Palliative Care Patients Applies only if the Agency operates its own inpatient hospice facility. Sets the Ohio building, fire, room, meal and pharmaceutical standards of OAC 3701-19-08 and the federal standards of 42 CFR §418.110 (applying the stricter where they differ, such as no more than two patients per room), restraint and seclusion and death reporting, controlled drug storage, and, where the Agency chooses to admit non-hospice palliative care patients under ORC 3712.10, every requirement of OAC 3701-19-22.1, including informed consent, the 51 percent attestation, plan of care review at least every three days, record retention and notice to ODH. OAC 3701-19-08 OH-HSP-IDG-01 Interdisciplinary Team and Registered Nurse Coordinator Sets out the membership of the Agency's interdisciplinary team or teams (Ohio adds a volunteer to the federal core), the registered nurse the Administrator designates to coordinate each team and that nurse's duties, the team that sets policies when there is more than one team, the functions Ohio assigns to the team, and how the team meets and communicates. OAC 3701-19-11(A)-(C) OH-HSP-IDG-02 Interdisciplinary Plan of Care, 15-Day Review and Attending Physician Copies Sets out how the IDT establishes each patient's and family's interdisciplinary plan of care with the attending physician, patient and caregiver, what the plan must contain under Ohio and federal rules (including services, persons authorized to give drugs, opioid items and the bereavement plan), the review at least every 15 days, the copy sent to the attending physician with the date recorded, and caregiver education. OAC 3701-19-11(C)-(E) OH-HSP-IDG-03 Coordination of Care, Physician Orders and Verbal Orders Sets out the Agency's system of communication and integration across disciplines, settings and outside providers, who may sign medical orders and order drugs, how nurses receive, record and authenticate verbal orders (with the Agency's own signature time frame), care transitions, and coordination with non-hospice providers under Ohio Medicaid. OAC 3701-19-17(C) OH-HSP-LOC-01 Levels of Care and Short-Term Inpatient Care Sets out the four levels of hospice care (routine home care, continuous home care, inpatient respite care and general inpatient care), when each is used, where short-term inpatient care may be provided under Ohio and federal rules, the Ohio limit on respite stays and the Medicare five-day respite payment rule, the standards inpatient facilities must meet, and the limits the Agency monitors. OAC 3701-19-22 OH-HSP-PAIN-01 Pain and Symptom Management and Care of the Actively Dying Patient Sets out how the Agency provides effective palliation and management of the terminal illness and related conditions: assessing pain and other symptoms with standard tools, planning and treating them, reassessing after each intervention, responding to symptom crises day and night, using short-term inpatient care when symptoms cannot be managed at home, caring for the actively dying patient and family, and the safeguards for palliative sedation. OAC 3701-19-17(B)

Clinical tasks8

OH-HSP-AIDE-01 Home Health Aide and Hospice Aide Services, Training and Supervisory Visits Sets out who may give home care services as a home health aide or hospice aide for the Agency, the selection factors and nine training topics Ohio requires, the federal 75-hour training, competency evaluation and 12-hour in-service rules, the RN's written care instructions, the RN supervisory visit at least every two weeks under OAC 3701-19-16(F) and every 14 days under 42 CFR §418.76(h), the annual observation of each aide, and homemaker services. OAC 3701-19-16 OH-HSP-DME-01 Medical Supplies, Appliances and Durable Medical Equipment Sets out how the Agency arranges the medical supplies, appliances and durable medical equipment patients need for the palliation and management of the terminal illness, uses only suppliers that meet 42 CFR §424.57 and, as applicable, ORC Chapter 4752, keeps equipment safe and maintained, teaches patients and families to use it, and handles oxygen safety and equipment removal. OAC 3701-19-21(A) OH-HSP-LAB-01 Laboratory Services and Waived Testing Sets how the Agency handles laboratory testing: when staff only assist a patient to self-test with an FDA-approved device (not laboratory testing), when the Agency itself performs waived tests and must hold a CLIA certificate of waiver and follow the manufacturer's instructions, how specimens are collected and sent only to CLIA-certified reference laboratories, and how results are documented and acted on. Ohio's hospice rules contain no separate laboratory requirement. 42 CFR §418.116(b) OH-HSP-MED-01 Drugs and Biologicals: Ordering, Administration and Safe Use Sets out how the Agency arranges the drugs and biologicals needed for the palliation and management of each patient's terminal illness and related conditions and keeps them available at all times; who may order drugs and take verbal drug orders; who may administer drugs under OAC 3701-19-21(B) and how they are named in the plan of care; drug profile review; labeling, storage and safe use; and the extra pharmacy rules for an inpatient hospice facility the Agency operates. OAC 3701-19-21(A)-(C) OH-HSP-MED-02 Opioid Diversion Prevention and Disposal Policy This is the Agency's written policy on preventing the diversion of controlled substances containing opioids prescribed to its patients at home, required by ORC 3712.062(A) and attested to with each license renewal. It covers giving and discussing the policy before care, the diversion risk assessment, accurate counts and monitoring, investigating and reporting suspected diversion, the written request to relinquish opioids after death or when no longer needed, witnessed and documented disposal in one of the three ways the law allows, and reporting opioids that are not relinquished to local law enforcement. ORC 3712.062 OH-HSP-NUR-01 Nursing Services and Registered Nurse Supervision Sets out how the Agency provides nursing care by or under the supervision of a registered nurse, names the registered nurse responsible for supervision and oversight of all nursing services, specifies the patient care responsibilities of each type of nursing staff, and makes nursing available 24 hours a day, 7 days a week in the home and in every inpatient facility the Agency uses, as OAC 3701-19-14 and 42 CFR §418.64(b) require. OAC 3701-19-14 OH-HSP-SW-01 Medical Social Services Sets out how the Agency makes medical social services available to each patient and family as needed, by a social worker licensed in Ohio and qualified under 42 CFR §418.114(b)(3), under the direction of a physician; how the psychosocial assessment is done and reviewed with the interdisciplinary team; and the Agency's own time frames for providing social work services, which OAC 3701-19-15(C) requires the Agency to set. OAC 3701-19-15 OH-HSP-THR-01 Physical Therapy, Occupational Therapy and Speech-Language Services Sets out how the Agency provides or arranges physical therapy, occupational therapy and speech-language therapy adequate in frequency to meet patients' needs, the Ohio licensure and criminal records check requirements for therapists, how therapy is ordered, planned and documented within the hospice plan of care, and what happens if therapy is not available in the area served. OAC 3701-19-19

Safeguarding3

OH-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 adults, and how to make the immediate report to the county department of job and family services that Ohio's adult protective services law (ORC 5101.60 to 5101.63) requires of hospice staff serving adults aged 60 or older, together with the immediate internal report to the Administrator, the route for residents of nursing homes and residential care facilities, what to do for adults under 60, and the protections for people who report. ORC 5101.63 OH-HSP-ANE-02 Investigating Alleged Violations and Self-Reported Incidents to the Ohio Department of Health Sets how the Agency receives, investigates and acts on every alleged violation involving mistreatment, neglect, verbal, mental, sexual or physical abuse, injuries of unknown source or misappropriation of patient property by anyone furnishing services on its behalf: immediate report to the Administrator, immediate investigation and protective action, corrective action, and the Ohio Department of Health Hospice Self-Reported Incident Form filed within five working days of becoming aware of the allegation, as 42 CFR §418.52(b)(4) and OAC 3701-19-06(C)(1)(b) require. 42 CFR §418.52(b)(4) OH-HSP-ANE-03 Recognizing and Reporting Child Abuse and Neglect Tells every staff member and volunteer how to recognize child abuse and neglect and how to make the immediate report Ohio law requires, under ORC 2151.421, to the public children services agency or a peace officer in the county where the child lives or where the abuse or neglect happened, for pediatric patients, for children living in or visiting patients' homes, and for people under 21 with a developmental disability or physical impairment. ORC 2151.421

Infection control2

OH-HSP-IC-01Free sample Infection Prevention and Control Program Sets out the Agency's infection prevention and control program required by 42 CFR §418.60: standard and transmission-based precautions, hand hygiene and equipment cleaning in the home, surveillance and investigation of infections using the infection surveillance log, reporting of diseases under Ohio's communicable disease rules, the link to the QAPI program, education for staff, contractors, patients and families, and the Ohio requirements for staff screening and for linens and isolation in an inpatient hospice facility. 42 CFR §418.60 OH-HSP-IC-02 Bloodborne Pathogens Exposure Control Plan This is the Agency's written exposure control plan under the OSHA bloodborne pathogens standard, 29 CFR §1910.1030: which jobs have occupational exposure, the engineering and work practice controls and PPE used, housekeeping and waste, hepatitis B vaccination within 10 working days of initial assignment, what to do after an exposure incident, training at initial assignment and at least annually, recordkeeping, and the yearly review of the plan, documented as OAC 3701-19-09(B)(4)(d) requires. 29 CFR §1910.1030

Emergency preparedness1

OH-HSP-EP-01 Emergency Preparedness Program Sets the Agency's emergency preparedness program under 42 CFR §418.113, which Ohio Medicaid also requires of every Medicaid hospice: the all-hazards risk assessment and emergency plan (reviewed and updated at least every two years), delegations of authority and succession, an emergency plan and priority level for every patient, the required policies and procedures (follow-up with staff and patients, informing officials, records, staffing, arrangements with other providers), the extra duties of an Agency inpatient facility, the communication plan, training, and the exercises the rule requires each year. 42 CFR §418.113

Records1

OH-HSP-REC-01 Central Clinical Record, Retention and Electronic Signatures Sets how the Agency keeps one central clinical record for each patient and family under ORC 3712.06(G) and OAC 3701-19-23: what every record contains, how entries are made, dated and signed (including electronic signatures that meet ORC 3701.75), how records are stored and protected, who may see them, what is sent on transfer or discharge, and how long records are kept when Ohio's hospice rules set no retention period. OAC 3701-19-23

Privacy3

OH-HSP-PRV-01 HIPAA Privacy and Ohio Confidentiality Laws Sets the Agency's rules for protecting the privacy of patients' and families' health information under the HIPAA Privacy Rule (45 CFR Part 164 Subpart E) and the Ohio laws that add to it: the privacy official, the Notice of Privacy Practices, when information may be used or shared, minimum necessary, authorizations, the extra Ohio protections for HIV test information and for Medicaid recipients' information, patients' rights of access, amendment and accounting, safeguards in homes and facilities, complaints and sanctions. 45 CFR Part 164 Subpart E OH-HSP-PRV-02 HIPAA Security Sets the administrative, physical and technical safeguards the Agency uses to protect electronic protected health information under the HIPAA Security Rule (45 CFR Part 164 Subpart C): the security official, risk analysis and risk management, workforce access, mobile devices used in patients' homes, email and texting, facility and device controls, audit logs, security incidents, the contingency plan, vendors and documentation, together with the Ohio electronic signature requirements of ORC 3701.75 and OAC 3701-19-23(E). 45 CFR Part 164 Subpart C OH-HSP-PRV-03 Breach Notification Sets how the Agency finds, assesses and reports breaches of unsecured protected health information under the HIPAA Breach Notification Rule (45 CFR §§164.400 to 164.414): reporting a possible breach at once, the four-factor risk assessment, notice to patients without unreasonable delay and no later than 60 calendar days after discovery, notice to the media and to the Secretary of Health and Human Services, law enforcement delay, business associate breaches, and why the Ohio data breach law, ORC 1349.19, does not apply to the Agency as a HIPAA covered entity. 45 CFR §164.400-414

Human resources6

OH-HSP-HR-01 Orientation, In-Service Training and Competency Sets out the orientation every staff member, contractor and volunteer receives before working with patients, the job-specific orientation, how the Agency assesses competence before and during practice, the annual in-service program, and the training records that Ohio and federal rules require. OAC 3701-19-09(E) OH-HSP-HR-02 Personnel Qualifications, Job Descriptions and Performance Evaluation Sets the qualifications for each position, the written job description every staff member, volunteer and contractor receives, how licenses, certifications and registry status are verified at hire and kept current, and how and when performance is evaluated. OAC 3701-19-09(A)-(B) OH-HSP-HR-03 Criminal Records Checks and Exclusion Screening Sets out the Ohio criminal records check every applicant for a direct care position must have under ORC 3712.09 and OAC Chapter 3701-13: the notice at application, fingerprints, BCII and FBI checks, conditional employment with the five-business-day request and the thirty-day limit, disqualifying offenses, personal character standards, confidentiality and the applicant log, plus federal exclusion screening and the Agency's re-check standard. ORC 3712.09 OH-HSP-HR-04 Personnel Records Lists what the Agency keeps in each personnel record for employees, volunteers and contracted staff, how criminal records check reports and health information are kept confidential and separate, who may see personnel records, and how long each kind of record is kept. OAC 3701-13-07 OH-HSP-HR-05 Employee Health, Communicable Disease Screening and Work Restrictions Sets the Agency's employee health policies required by OAC 3701-19-09(B)(4): health screening before and during work, tuberculosis control, vaccinations, the rules for when ill or infected staff and volunteers must not give direct patient care, return to work, and the documentation of compliance with OSHA, CDC and Ohio Department of Health requirements. OAC 3701-19-09(B)(4) OH-HSP-VOL-01 Volunteer Program Sets out how the Agency recruits, screens, orients, trains, supervises and keeps volunteers; the roles volunteers may and may not fill; the volunteer place on every interdisciplinary team; and the records of volunteer hours and cost savings, including the federal level of activity of at least five percent of paid patient care hours. OAC 3701-19-13

Governance8

OH-HSP-GOV-01 Governing Body, Administrator and Key Designations Sets out what the governing body of the Agency must do itself under OAC 3701-19-06, what it delegates to the Administrator and the medical director, who acts when either is absent, which written designations must always be in place, and how the governing body oversees quality, grievances, drug diversion investigations and the budget. OAC 3701-19-06 OH-HSP-GOV-02 Organizational Structure, Multiple Locations and Out-of-State Programs Describes how the Agency is organized, how authority runs from the governing body to every location and team, the Ohio conditions for serving patients from more than one location under one license, what an out-of-state hospice must keep in Ohio, and how new locations are approved before they serve patients. OAC 3701-19-03(F) OH-HSP-GOV-03 Hospice Care Program License, Renewal and Notices to the Director of Health Explains the Ohio hospice care program license: who needs one, what the application and renewal must contain, the fees, when the license must be renewed, what changes must be reported to the director of health and by when, how to relocate the licensed location, and the parallel notices to Medicare and Ohio Medicaid. ORC 3712.04 OH-HSP-GOV-04 Inspections, Plans of Correction, Variances and Waivers Sets out how the Agency prepares for and handles ODH licensure, complaint and follow-up inspections, what access surveyors must have, how a plan of correction is written and filed within ten calendar days when ODH requires one, and how the Agency asks ODH for a variance, a waiver or a therapy waiver. OAC 3701-19-05 OH-HSP-GOV-05 Ceasing Operation and Continuity of Care Sets out what the Agency must do if it decides to stop operating: written notice to the director of health and to every patient or family at least 60 days before closing, a continuity of care plan, a written discharge plan in each record, written approval of each transfer and release of records, and safe keeping of records after closure. OAC 3701-19-07(D)(3)-(4) OH-HSP-GOV-06 Hospice Care Program, Scope of Services and Policy Index Describes the hospice care program the Agency is licensed to provide: the ten services Ohio law requires, the duties of every licensed program under ORC 3712.06, which services the Agency gives directly and which under contract, how the interdisciplinary team establishes care policies, and the index of every policy in this manual. ORC 3712.06 OH-HSP-GOV-07 Nondiscrimination, Civil Rights and Language Access States the Agency's nondiscrimination policy for patients and staff under Ohio's hospice rules and federal civil rights law, and sets out how the Agency provides free language assistance, qualified interpreters, auxiliary aids and reasonable modifications, gives the required notices, and handles discrimination grievances. OAC 3701-19-20(B) OH-HSP-MD-01 Medical Director and Physician Services Sets out how the Agency arranges for a medical director and a physician designee, their qualifications, the duties OAC 3701-19-10 and 42 CFR §418.102 give them, round-the-clock physician coverage, the role of attending physicians, physician assistants and advanced practice registered nurses, and who may sign medical orders and certify terminal illness. OAC 3701-19-10

Quality2

OH-HSP-QA-01 Quality Assessment and Performance Improvement Sets up the Agency's quality assessment and performance improvement (QAPI) program: the ongoing, comprehensive, integrated self-assessment of all care, including inpatient and contracted care, that OAC 3701-19-06(D) to (G) requires, built to the federal standard in 42 CFR §418.58 (data-driven indicators, adverse event tracking, performance improvement projects and governing body responsibilities), with the Hospice Quality Reporting Program submissions that Medicare and Ohio Medicaid payment depend on and the annual evaluation of the program. OAC 3701-19-06(D)-(G) OH-HSP-QA-02 Investigating and Reporting Suspected Drug Diversion Sets the Agency's drug diversion investigation and reporting program required by ORC 3712.062 and OAC 3701-19-06(C)(3)(f): every staff member reports any sign of suspected diversion at once; the Administrator or the Administrator's designee investigates within twenty-four hours of receiving the report; and, when the investigation substantiates diversion or is inconclusive, reports the results to the law enforcement agency with jurisdiction over the patient's home no later than ten days after receipt of the report or upon conclusion of the investigation. It also covers protecting the patient's comfort, related reports to ODH and others, and use of the results in QAPI. OAC 3701-19-06(C)(3)(f)

Business2

OH-HSP-CON-01 Contracted Services and Professional Management Responsibility Sets out when the Agency may have another person or agency provide part of its hospice care program, what every written contract must contain under OAC 3701-19-12 and ORC 3712.06, the extra terms for hospitals, nursing homes and home health agencies, how the Agency keeps professional management of contracted care, and the limits on contracting core services. OAC 3701-19-12 OH-HSP-FIN-01 Billing, Care Regardless of Ability to Pay and Ohio Medicaid Hospice Reporting Sets out how the Agency charges and bills for hospice care: care is never discontinued or reduced because a patient cannot pay; charges are disclosed; Medicare notices of election and termination are filed within five calendar days; Ohio Medicaid hospice enrollment data are entered in the ODM provider web portal before any claim; and claims, room and board, coinsurance, the cap and quality reporting are handled correctly. ORC 3712.06(F)

Ethics1

OH-HSP-ETH-01 Compliance Program, Ethics and Referral Integrity Sets the Agency's compliance program and code of conduct: respect for patients and their property, honest eligibility decisions and billing, no kickbacks or inducements to referral sources or patients, conflicts of interest, gifts, truthful marketing, how staff report concerns without retaliation, and how overpayments are returned. OAC 3701-19-09(C)
Questions

Questions about this manual

Is this the right manual for my license?

It is for hospice care programs licensed by ODH under ORC Chapter 3712. It covers adult hospice care, not the pediatric respite care rules. Home health agencies need the Ohio home health manual, and nonmedical agencies need the Ohio home care manual.

May our nurses pronounce death?

Yes, within limits. A registered nurse providing or supervising care through a licensed hospice care program may pronounce death when breathing and circulation are not artificially sustained (ORC 4723.36). The nurse completes no part of the death certificate and tells the attending practitioner within 24 hours.

How long can a respite stay last?

Ohio allows inpatient respite on an occasional basis for no more than seven consecutive days (OAC 3701-19-22(E)(2)). Medicare pays for no more than five consecutive days at a time (42 CFR §418.204(b)(2)).

What do the 60 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 (6), governance (8), quality (2), business (2) and ethics (1).

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