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Pennsylvania Hospice Policy and Procedure Manual

For Pennsylvania hospices licensed by the Department of Health under the Health Care Facilities Act. Pennsylvania has no hospice chapter in its regulations, so the Department uses the federal hospice Conditions of Participation (42 CFR Part 418) as its licensing standards, whether or not a hospice is Medicare-certified. The manual has 60 policies and 47 forms, written to those standards and the general licensing rules in 28 Pa. Code Chapter 51. 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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Pennsylvania · Hospice

60 policies written to the Pennsylvania rules, with 47 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
47
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.

PA-HSP-CMP-01Free sample Client rights

Complaints and Grievances

Explains how patients, families and others can complain to the Agency or outside it, how the Agency receives, records, investigates and answers complaints within its own time frames, how complaints that allege abuse or other serious matters are escalated and reported, and how complaints feed the quality program, without reprisal against anyone who complains.

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

Recognizing and Reporting Abuse, Neglect and Exploitation of Adults

Every employee and the Administrator must report suspected abuse of any patient. This policy explains what to look for, who reports, the immediate oral report to the Area Agency on Aging protective services unit, the extra reports to law enforcement and the Department of Aging for sexual abuse, serious injury and suspicious death, the separate Adult Protective Services reports for adults 18 to 59 with a disability, the written reports within 48 hours, the report to the Administrator, and the protections for people who report.

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

Infection Prevention and Control Program

Sets out the Agency's infection prevention and control program: standard and transmission-based precautions, staff health and the Pennsylvania work restrictions, surveillance and the patient infection log, reporting of reportable diseases and outbreaks to the Department of Health, infection control education, staff and patient immunizations, and the safe handling of sharps and regulated medical waste.

Read the full policy
Pennsylvania rules

What Pennsylvania's hospice standards ask your policies to cover

  • Assessment and plan of care. A comprehensive assessment within 5 calendar days after the election, and plan of care reviews by the interdisciplinary group at least every 15 calendar days. 42 CFR §§418.54 and 418.56
  • Aides. A registered nurse supervisory visit at least every 14 days, an on-site observation every year and 12 hours of in-service training a year. 42 CFR §418.76
  • Serious events. The Department of Health is told immediately and in writing of serious noncompliance and of any event that could seriously compromise quality assurance or patient safety. 28 Pa. Code §51.3
  • Abuse of adults. An immediate oral report to the Area Agency on Aging protective services unit and a written report within 48 hours. Sexual abuse, serious injury and suspicious deaths also go to law enforcement and the Department of Aging. 35 P.S. §10225.701
  • Child abuse. Staff are mandated reporters for any child they meet at work: an immediate report to ChildLine, with a written report within 48 hours if the first report was by phone. 23 Pa.C.S. §§6311 and 6313
  • Photo ID badges. Every employee who gives direct care in a patient's home wears a photo identification badge with the contents the law sets. 35 P.S. §448.809b

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 comprehensive assessment. Was it completed by the IDG with the attending physician within 5 calendar days after the election? PA-HSP-ASM-01Initial and Comprehensive Assessment and Hospice Quality Reporting Data When was the last RN supervisory visit for this patient's aide services? And the one before? PA-HSP-AIDE-01Hospice Aide and Homemaker Services Call your after-hours number now. Who answers, and how quickly does a nurse call back? PA-HSP-SVC-0124-Hour Availability, On-Call and After-Hours Response An aide sees bruises on a patient's arms and the patient says her son grabbed her. What does the aide do, and in what order? PA-HSP-ANE-01Recognizing and Reporting Abuse, Neglect and Exploitation of Adults What events do you report to the Department of Health, and how quickly? PA-HSP-GOV-04Reporting Serious Events and Noncompliance to the 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

PA-HSP-CMP-01Free sample Complaints and Grievances Explains how patients, families and others can complain to the Agency or outside it, how the Agency receives, records, investigates and answers complaints within its own time frames, how complaints that allege abuse or other serious matters are escalated and reported, and how complaints feed the quality program, without reprisal against anyone who complains. 42 CFR §418.52(b)(1)(iii) PA-HSP-PR-01 Patient Rights and Responsibilities Sets out the rights of every hospice patient of the Agency, how and when the Agency gives the spoken and written notice of rights and responsibilities and obtains the signed acknowledgment, who exercises the rights of a patient who cannot, the written information Medical Assistance recipients must receive before admission, the patient's responsibilities, and how staff protect the rights in daily practice. 42 CFR §418.52 PA-HSP-PR-02 Informed Consent, Service Agreement and Pre-Admission Disclosures Explains how the Agency obtains informed consent to hospice care, who may consent for a patient who lacks capacity under Pennsylvania law (guardian, health care agent or health care representative in the statutory order), what the Hospice Service Agreement and Consent contains, and what the Agency tells patients before care begins about covered services, limitations, cost-sharing and, for Medical Assistance recipients, the written pre-admission information. 42 CFR §418.52(c) PA-HSP-PR-03 Advance Directives, Out-of-Hospital DNR Orders and POLST Sets out how the Agency gives written information on advance directives and Pennsylvania law, asks about and records living wills, health care powers of attorney and out-of-hospital do-not-resuscitate orders, honors them or helps transfer the patient where it cannot, handles revocations and countermands, treats POLST forms as physician orders, and educates staff and the community. 20 Pa.C.S. Ch. 54

Service delivery2

PA-HSP-SAF-01 Staff Safety and Emergencies in the Home Sets out how the Agency keeps patients and staff safe in the home: the home safety assessment, what staff do in each kind of emergency during a visit, how staff stay safe on visits and on the road, how threats and violence are handled, when visits may be changed or a patient discharged for cause, and how staff injuries and hazardous chemicals are managed. 29 U.S.C. §654(a)(1) PA-HSP-SVC-01 24-Hour Availability, On-Call and After-Hours Response Explains how the Agency makes nursing services, physician services and drugs and biologicals routinely available 24 hours a day, 7 days a week, and other services around the clock when reasonable and necessary: how patients are taught to reach the Agency, how the on-call system works and the Agency's response standards, how after-hours drugs, supplies and equipment are obtained, what to do in emergencies, and how backup is arranged when scheduled staff are unavailable. 42 CFR §418.100(c)(2)

Hospice care17

PA-HSP-ADM-01 Referral, Eligibility and Admission Sets out how the Agency receives and responds to referrals, screens eligibility for Medicare, Medical Assistance and other payers, obtains the physician recommendation for admission that 42 CFR §418.25 requires, conducts the admission visit, handles patients it cannot admit, and admits children, nursing facility residents and patients near the edge of the service area. 42 CFR §418.25 PA-HSP-ASM-01 Initial and Comprehensive Assessment and Hospice Quality Reporting Data Sets out who completes the initial assessment and the comprehensive assessment and by when, what the comprehensive assessment must identify and consider (including the drug profile review and the initial bereavement assessment), how and how often it is updated, when patients are reassessed between updates, and how outcome data and the standardized patient assessment items for the Hospice Quality Reporting Program are collected and submitted. 42 CFR §418.54 PA-HSP-BRV-01 Bereavement Program Sets out the Agency's organized bereavement program: who supervises it, how bereavement needs are assessed before and after the death, how each bereavement plan of care is written, and how services are offered to the family and others for up to 1 year after the patient's death. 42 CFR §418.64(d)(1) PA-HSP-CNS-01 Spiritual and Dietary Counseling Sets out how the Agency makes counseling available to patients and families, and how spiritual counseling and dietary counseling are assessed, offered and provided in a way that respects each family's beliefs and wishes. 42 CFR §418.64(d) PA-HSP-DC-01 Discharge, Transfer and Discharge for Cause Sets out the only reasons the Agency may discharge a patient alive, the steps it must take before a discharge for cause, discharge planning when a patient is no longer terminally ill, the physician discharge order, the Medicare notice of non-coverage and expedited determination process, the notice of termination to the Medicare contractor, notices to Medical Assistance, and the discharge summary and records sent to the attending physician or receiving provider. 42 CFR §418.26 PA-HSP-DTH-01 Death at Home, Pronouncement of Death and Post-Death Care Sets out how the Agency prepares families for an expected death at home, how a registered nurse under section 507 or a trained licensed practical nurse under section 508 of the Vital Statistics Law pronounces death and releases the body, the LPN training and competency program Act 137 of 2024 requires, which deaths go to the coroner, who is notified, and how post-death care is given. 35 P.S. §450.507 PA-HSP-ELC-01 Election of Hospice, Election Statement Addendum and Notice of Election Explains who may elect hospice, what the election statement must contain, how the effective date is set, how and when the Agency gives the election statement addendum "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" for elections beginning on or after October 1, 2026, how the addendum is updated, how the Notice of Election is filed, and the additional Pennsylvania Medical Assistance election statement and County Assistance Office notice. 42 CFR §418.24 PA-HSP-ELC-02 Certification and Recertification of Terminal Illness and Face-to-Face Encounters Sets out who certifies and recertifies terminal illness, the federal timing rules and the separate Pennsylvania Medical Assistance timing rules, what each certification must contain including the physician's own narrative, how oral certifications are recorded, how face-to-face encounters are scheduled and attested before the third benefit period and each later one, when they may be done by telehealth, and what happens when a physician does not recertify. 42 CFR §418.22 PA-HSP-ELC-03 Revocation, Change of Designated Hospice and Change of Attending Physician Explains how a patient or representative revokes the hospice election, changes the designated hospice once in a period, or changes the attending physician; what each statement must contain under Medicare and Pennsylvania Medical Assistance rules; the effect of each change; the notices the Agency files; the records sent to the attending physician or receiving provider; and the rule that the Agency never revokes, or encourages revocation, on a patient's behalf. 42 CFR §418.28 PA-HSP-FAC-01 Hospice Care for Residents of a Nursing Facility or ICF/IID Sets out how the Agency cares for patients who live in a skilled nursing facility, nursing facility or ICF/IID: the written agreement signed before any service, professional management of the hospice care, one shared plan of care, a designated interdisciplinary group member for coordination, the information packet given to the facility, orientation of facility staff, the 24-hour report of alleged violations to the facility administrator, and the Medical Assistance room and board rules. 42 CFR §418.112 PA-HSP-FAC-02 Short-Term Inpatient Care Arrangements Sets out how the Agency makes short-term inpatient care available for pain control, symptom management and respite: the settings that qualify, the written agreement each facility must sign, telling Medical Assistance recipients before admission which facilities the Agency uses, the steps for every inpatient stay, training and verification, and the Medicare inpatient day limit. 42 CFR §418.108 PA-HSP-FAC-03 Hospice Inpatient Unit Operations Applies only if the Agency operates its own hospice inpatient unit. Sets out the Department of Health approvals needed before building, adding beds or occupying space, and the federal inpatient standards: staffing and 24-hour nursing, physical environment, Life Safety Code and Health Care Facilities Code, patient areas and rooms, infection control, linen and meals, restraint and seclusion, death reporting, drugs, staff identification and emergency preparedness. 42 CFR §418.110 PA-HSP-IDG-01 Interdisciplinary Group Sets out how the Agency designates its interdisciplinary group or groups, who must be on each group and what qualifications they need, how a registered nurse is designated to coordinate each patient's care, how often and how the group meets, how volunteers and the attending physician take part, and how the group as a whole supervises care. 42 CFR §418.56(a) PA-HSP-IDG-02 Plan of Care, Plan of Care Review and Caregiver Education Sets out how the interdisciplinary group, with the attending physician, patient, representative and primary caregiver, establishes an individualized written plan of care before care is provided, what it must contain, how it is reviewed and revised at least every 15 calendar days, how the patient's involvement and agreement are documented, and how patients and caregivers are taught to carry out their part of the care. 42 CFR §418.56(b)-(d) PA-HSP-IDG-03 Coordination of Services and Physician Orders Sets out the Agency's system for communication and integration among its disciplines, contractors, volunteers and the facilities where patients live, and with non-hospice providers, and how orders are given, received, recorded and authenticated, including who may order drugs, who may take verbal orders, the Pennsylvania conditions for licensed practical nurses accepting oral orders, and the Agency's time frame for the practitioner to sign verbal orders. 42 CFR §418.56(e) PA-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), the clinical criteria and documentation for each, where inpatient care may be given, the Medicare and Pennsylvania Medical Assistance limits on respite and inpatient days, and how the IDG and a hospice physician decide and review each change in level of care. 42 CFR §418.302 PA-HSP-PAIN-01 Pain and Symptom Management and Care of the Actively Dying Patient Sets out how the Agency assesses, plans for, treats and reassesses pain and other distressing symptoms, how symptom crises are escalated to continuous home care or general inpatient care, and how the team cares for a patient who is actively dying and supports the family at the bedside. 42 CFR §418.52(c)(1)

Clinical tasks8

PA-HSP-AIDE-01 Hospice Aide and Homemaker Services Sets out who may work as a hospice aide or homemaker for the Agency, the aide training, competency evaluation and 12-hour in-service requirements, how aides are assigned and given written care instructions, the registered nurse supervisory visit at least every 14 days and the annual on-site observation, and how homemaker and Medical Assistance personal care services are coordinated. 42 CFR §418.76 PA-HSP-DME-01 Medical Supplies and Durable Medical Equipment Sets out how the Agency provides medical supplies, appliances and durable medical equipment related to the terminal illness, how it chooses suppliers, how equipment is kept safe and maintained, how patients and families are taught to use it, and the Agency's oxygen safety practice. 42 CFR §418.106(f) PA-HSP-LAB-01 Laboratory Services and Waived Testing Sets out when the Agency may perform laboratory tests, the federal CLIA certificate of waiver it needs if staff perform any waived test, the Pennsylvania clinical laboratory permit question the Administrator must settle with the Department of Health before testing starts, how waived tests are performed and recorded, how specimens go to certified reference laboratories, and how staff help patients with their own home test devices. 42 CFR §418.116(b) PA-HSP-MED-01 Drugs and Biologicals: Ordering, Drug Profile Review, Labeling and Safe Use Sets out how the Agency provides drugs and biologicals related to the terminal illness and related conditions, how the interdisciplinary group reviews each patient's drug profile, who may order drugs under federal and Pennsylvania rules, how oral orders are handled, and how drugs are obtained, labeled, given and stored safely in the home. 42 CFR §418.106 PA-HSP-MED-02 Controlled Substances in the Home: Management and Disposal Sets out how the Agency manages controlled drugs in patients' homes: what the patient and family are given and told when a controlled drug is first ordered, how the drugs are kept safe, the governing body's decision on disposal by Agency staff under federal law, when and how disposal is done and recorded, and what happens if loss or diversion is suspected. 42 CFR §418.106(e)(2) PA-HSP-NUR-01 Nursing Services and Nursing Practice Sets out how the Agency provides nursing services by or under the supervision of a registered nurse, what registered nurses, licensed practical nurses and certified registered nurse practitioners may do under the Pennsylvania Board of Nursing rules, how intravenous therapy and other procedures are controlled, when nursing may be contracted, and how the Agency makes sure every nurse practices within the Professional Nursing Law and the Practical Nurse Law. 42 CFR §418.64(b) PA-HSP-SW-01 Medical Social Services Sets out who may provide medical social services for the Agency, how the social worker assesses the psychosocial needs of the patient and family, what the social worker provides under the direction of a physician, how social work is supervised and documented, and how Pennsylvania social work licensure applies. 42 CFR §418.64(c) PA-HSP-THR-01 Physical Therapy, Occupational Therapy and Speech-Language Pathology Sets out how the Agency makes physical therapy, occupational therapy and speech-language pathology available to hospice patients, who may provide them, when they are used, and how therapy is ordered, planned, delivered and documented. 42 CFR §418.72

Safeguarding3

PA-HSP-ANE-01Free sample Recognizing and Reporting Abuse, Neglect and Exploitation of Adults Every employee and the Administrator must report suspected abuse of any patient. This policy explains what to look for, who reports, the immediate oral report to the Area Agency on Aging protective services unit, the extra reports to law enforcement and the Department of Aging for sexual abuse, serious injury and suspicious death, the separate Adult Protective Services reports for adults 18 to 59 with a disability, the written reports within 48 hours, the report to the Administrator, and the protections for people who report. 35 P.S. §10225.701 PA-HSP-ANE-02 Investigation, Plans of Supervision and Reporting Verified Violations Sets out what the Agency does after an allegation of mistreatment, neglect, abuse, injury of unknown source or misappropriation: immediate protection of patients, suspension or a plan of supervision for an accused employee approved by protective services and the Department of Health, the Agency's own investigation, cooperation with protective services and police, corrective action, and the report of verified violations to the Department of Health within 5 working days. 42 CFR §418.52(b)(4) PA-HSP-ANE-03 Recognizing and Reporting Suspected Child Abuse Agency staff are mandated reporters of suspected child abuse under the Child Protective Services Law. This policy explains who must report, when, the immediate report to ChildLine, the written report within 48 hours, the duty to tell the person in charge, what child abuse means, and the protections and penalties. It covers any child staff come into contact with at work, not only pediatric patients. 23 Pa.C.S. §6311

Infection control2

PA-HSP-IC-01Free sample Infection Prevention and Control Program Sets out the Agency's infection prevention and control program: standard and transmission-based precautions, staff health and the Pennsylvania work restrictions, surveillance and the patient infection log, reporting of reportable diseases and outbreaks to the Department of Health, infection control education, staff and patient immunizations, and the safe handling of sharps and regulated medical waste. 42 CFR §418.60 PA-HSP-IC-02 Bloodborne Pathogens Exposure Control Plan The Agency's written Exposure Control Plan under the OSHA Bloodborne Pathogens standard: which jobs and tasks carry exposure, how exposure is prevented, the hepatitis B vaccination program, what happens after an exposure, training, and the medical, training and sharps injury records the Agency keeps. 29 CFR §1910.1030

Emergency preparedness1

PA-HSP-EP-01 Emergency Preparedness Program Sets out the Agency's emergency preparedness program: the all-hazards risk assessment, the emergency plan, emergency policies and procedures, patient emergency priority levels and individual emergency plans, the communication plan, training and exercises, and the notices to the Department of Health when a disaster or loss of utilities disrupts services. 42 CFR §418.113

Records1

PA-HSP-REC-01 Clinical Records, Retention and Access Sets out what goes into every patient's clinical record, how entries are made, signed and corrected, how records are stored, protected and produced for the Department of Health, what is sent when a patient is transferred, revokes or is discharged, and how long records are kept. Pennsylvania has no hospice record rule of its own, so the federal clinical record condition applies as a licensure standard, with the Medical Assistance record standards added for MA recipients. 42 CFR §418.104

Privacy3

PA-HSP-PRV-01 HIPAA Privacy and Pennsylvania Confidentiality Laws Sets out how the Agency protects patient and family information under the HIPAA Privacy Rule and the stricter Pennsylvania laws on HIV-related information, mental health treatment records and drug and alcohol records: who may see or receive information, the patient's privacy rights and the time limits for answering requests, and what staff do in homes, facilities and on the telephone. 45 CFR Part 164 Subpart E PA-HSP-PRV-02 HIPAA Security Sets out how the Agency protects electronic patient information on the record system, phones, tablets and laptops that staff carry into homes and facilities: the security official, risk analysis, the security measures register, device and password rules, incident response, backups and downtime, business associates, and disposal. 45 CFR Part 164 Subpart C PA-HSP-PRV-03 Breach Notification Sets out what the Agency does when patient or staff information may have been lost, seen or sent to the wrong person: same-day reporting, containment, the HIPAA risk assessment, the federal notices to individuals, HHS and the media, and the Pennsylvania breach law duties, including the Attorney General and consumer reporting agency notices and free credit monitoring. 45 CFR §§164.400-164.414

Human resources6

PA-HSP-HR-01 Orientation, Competency and In-Service Training Explains how every person who works for the Agency, including contracted staff and volunteers, is oriented to the hospice philosophy and to their own job, how the Agency assesses and documents each person's competence before and during their work, and how it plans and records in-service training, including the training Pennsylvania requires before a licensed practical nurse may pronounce death. 42 CFR §418.100(g) PA-HSP-HR-02 Personnel Qualifications and License Verification Sets the qualifications every professional and aide must hold, how the Agency verifies Pennsylvania licenses (including multistate nursing privileges under the Nurse Licensure Compact) before work starts and at every renewal, and what happens if a license lapses or a person works outside their scope. 42 CFR §418.114(a)-(c) PA-HSP-HR-03 Criminal History Background Checks and Exclusion Screening Explains the Pennsylvania criminal history checks the Older Adults Protective Services Act requires before and during employment (State Police report, and FBI fingerprint check through the Department of Aging for applicants who have not lived in Pennsylvania for two years), the strict rules for provisional hiring while results are pending, how the Agency decides whether a person with a conviction may work, and federal exclusion screening. 35 P.S. §10225.502 PA-HSP-HR-04 Personnel Records Lists what the Agency keeps in each personnel record for employees, volunteers and contracted staff, how criminal history information is kept confidential, where records are kept, who may see them, and how long they are kept. 42 CFR §418.100(g)(3) PA-HSP-HR-05 Staff Identification Badges Pennsylvania requires every employee of a licensed health care facility who gives direct care in a patient's home to wear a photo identification badge with set contents, and requires the Agency to have written procedures for the two allowed exceptions. This policy sets out the badge, the exceptions and how badges are issued and recovered. 35 P.S. §448.809b PA-HSP-VOL-01 Volunteer Program Sets out how the Agency recruits, screens, trains, supervises and records the work of its volunteers, how it documents the cost savings they achieve, and how it makes sure volunteer hours reach at least 5 percent of the patient care hours of its paid staff, as Pennsylvania's hospice licensure standard requires. 42 CFR §418.78

Governance8

PA-HSP-GOV-01 Governing Body, Administrator and Key Designations Sets out how the governing body of the Agency holds legal responsibility for the hospice, appoints and oversees the Administrator, and designates in writing the people every Pennsylvania hospice must name: the medical director and physician designee, the QAPI lead, the bereavement supervisor, the volunteer supervisor and the emergency preparedness lead. It also covers the Agency's own back-up roles and how Department of Health surveyors are received. 42 CFR §418.100(b) PA-HSP-GOV-02 Organizational Structure, Multiple Locations and Lines of Authority Describes how the Agency keeps a written organizational structure that shows who answers to whom down to the patient's bedside, how any additional location is approved, licensed and supervised as part of the one hospice, and what must happen before the Agency opens or closes a location or a service. 42 CFR §418.100(f) PA-HSP-GOV-03 State Licensure, Medicare Certification and Notices to the Department of Health Explains how the Agency keeps its Pennsylvania hospice license in force, renews it every year, posts it, responds to deficiencies with a plan of correction, and makes every advance or after-the-fact notice the Department of Health, Medicare and Medical Assistance require, with a single log so nothing is missed. 35 P.S. §448.806 PA-HSP-GOV-04 Reporting Serious Events and Noncompliance to the Department of Health Pennsylvania requires every licensed health care facility, including a hospice, to notify the Department of Health immediately and in writing when it learns of serious noncompliance or of an event that could seriously compromise quality assurance or patient safety. This policy lists those events, says who sends the notice and what it contains, and links it to abuse reporting and the QAPI program. 28 Pa. Code §51.3(e)-(h) PA-HSP-GOV-05 Closure, Suspension of Services and Change of Ownership Sets out what the Agency does if it plans to close, stop a service, suspend admissions or change ownership: the notices to the Department of Health, Medicare and Medical Assistance, the safe transfer of every patient, and the storage and access arrangements for records after closure. 28 Pa. Code §51.3(c) PA-HSP-GOV-06 Hospice Program, Scope of Services and Policy Index Defines what the Agency's hospice program is under Pennsylvania law, the services it provides directly and under arrangement, where care is given, and the round-the-clock availability rules. It also serves as the index that maps each Medicare Hospice Condition of Participation, which Pennsylvania uses as its licensure standard, to the Agency policy that carries it out. 42 CFR §418.100(a), (c) PA-HSP-GOV-07 Civil Rights, Nondiscrimination and Language Access Pennsylvania requires every licensed health care facility to have a written nondiscriminatory policy for patients and staff, to sign a civil rights compliance statement, to publicize its nondiscriminatory practices in the community at least every three years, and to send the Department a copy whenever the policy changes. This policy is that policy, with the Agency's language access and disability access practices. 28 Pa. Code §51.12 PA-HSP-MD-01 Medical Director and Physician Services Sets out how the Agency designates its medical director and the physician designee who covers when the medical director is unavailable, what the medical director is responsible for, how hospice physicians work with each patient's attending physician, how physician services are available around the clock, and when a physician must be reported to a Pennsylvania licensing board. 42 CFR §418.102

Quality2

PA-HSP-QA-01 Quality Assessment and Performance Improvement Sets out the Agency's quality assessment and performance improvement (QAPI) program, led by the designated quality lead: what is measured, how adverse events and incidents are reported and analyzed, how performance improvement projects are chosen and documented, the governing body's annual evaluation, and the Medicare Hospice Quality Reporting Program. 42 CFR §418.58 PA-HSP-QA-02 Professional Misconduct Reporting and Practitioner Oversight Sets out when and how the Agency reports a physician to the State Board of Medicine or State Board of Osteopathic Medicine under the Health Care Facilities Act, how it notifies the Department of Health of unlicensed practice, how it keeps every professional's license current, and how concerns about any licensed professional are reviewed and reported. 35 P.S. §448.806a

Business2

PA-HSP-CON-01 Contracted Services and Professional Management Responsibility Sets out when the Agency may use contractors or arrangements for hospice services, what every written agreement must contain, and how the Agency keeps administrative and financial management and oversight of contracted staff and services so that patients receive the same quality of care as from its own staff. 42 CFR §418.100(e) PA-HSP-FIN-01 Billing, Notices to Medicare and Medical Assistance, and Continuation of Care Sets out how the Agency keeps its finances sound, files the Medicare notices of election and termination on time, sends the County Assistance Office the notices Pennsylvania Medical Assistance requires, bills accurately for each level of care, never cuts care because a patient cannot pay, and returns overpayments. 42 CFR §418.24(e)

Ethics1

PA-HSP-ETH-01 Compliance Program, Referral Integrity and Fraud Prevention Sets out the Agency's compliance program and the rules every employee, contractor and volunteer follows on referrals, gifts, marketing, eligibility, billing and conflicts of interest, under the federal fraud and abuse laws and the Pennsylvania Medical Assistance provider rules, and how anyone can raise a concern without retaliation. 42 U.S.C. §1320a-7b(b)
Questions

Questions about this manual

Is this the right manual for my license?

It is for hospices licensed by the Department of Health. Home health care agencies licensed under 28 Pa. Code Chapter 601 need the Pennsylvania home health manual, and home care agencies licensed under Chapter 611 need the Pennsylvania home care manual.

Do the federal hospice rules apply if we are not Medicare-certified?

For licensing, yes. Until Pennsylvania adopts hospice regulations, the law lets the Department license hospices under interim guidelines (35 P.S. §448.806(g)(2)), and the Department uses 42 CFR Part 418, Subparts C, D and E, as those guidelines. Only payment items, such as the notice of election, claims and the cap, are Medicare-only.

Can our nurses pronounce death?

A registered nurse may pronounce death under section 507 of the Vital Statistics Law of 1953 (35 P.S. §450.507). Since Act 137 of 2024, a licensed practical nurse may also pronounce under the conditions in section 508, after the training and yearly competency assessment it requires. Policy PA-HSP-DTH-01 records which of your nurses are authorized.

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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