Washington, DC Hospice Policy and Procedure Manual
For Medicare-certified hospices in Washington, DC. The District has adopted no hospice licensing rules, so the manual is written for a hospice that operates on Medicare certification, surveyed by DC Health as the State survey agency, with a Certificate of Need from SHPDA where District law requires one. The manual has 60 policies and 52 forms, written to the federal hospice Conditions of Participation (42 CFR Part 418), the District laws that bind every hospice and, for enrolled hospices, DC Medicaid's hospice rule (29 DCMR §939). 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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Washington, DC · Hospice
60 policies written to the Washington, DC rules, with 52 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
- 52
- 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.
DC-HSP-CMP-01Free sample
Client rights
Complaints and Grievances
Sets out how patients, families and others can complain about hospice care or lack of respect for property, how the Agency logs, acknowledges, investigates and resolves each complaint within its own time frames (no District rule sets hospice complaint time frames), how complaints are protected from reprisal, and where patients can complain outside the Agency, including DC Health, the BFCC-QIO and the long-term care ombudsman.
Read the full policy DC-HSP-ANE-01Free sample SafeguardingRecognizing and Reporting Abuse, Neglect and Exploitation of Adults and Children
Sets out how staff recognize abuse, neglect, self-neglect and exploitation of adults and abuse and neglect of children, who must report under District law, and how reports are made at once to Adult Protective Services (APS) or the Child and Family Services Agency (CFSA), alongside the federal duty to report every alleged violation immediately to the hospice administrator.
Read the full policy DC-HSP-IC-01Free sample Infection controlInfection Prevention and Control Program
Sets the Agency’s infection prevention and control program: who leads it, standard and transmission-based precautions in the home, bag technique and equipment cleaning, the agency-wide surveillance log and how it feeds the QAPI program, education for staff, contractors, patients and families, reporting of the District’s notifiable diseases, outbreaks among patients or staff, home sharps and waste, and the extra standards for an Agency inpatient facility.
Read the full policy
Washington, DC rules
What federal and District rules ask your policies to cover
- Election statement addendum. For elections on or after October 1, 2026, every patient gets the addendum within the first 5 days of the effective date of election, and an update within 3 days of a plan of care change that affects it. 42 CFR §418.24(c) and (d)
- Assessments and plan of care. A registered nurse's initial assessment within 48 hours after the election, a comprehensive assessment within 5 calendar days, and plan of care reviews at least every 15 calendar days. 42 CFR §418.54; §418.56(d)
- Alleged violations. Alleged mistreatment, neglect or abuse is reported to the administrator immediately. Verified violations go to State and local bodies, including the State survey agency, within 5 working days. 42 CFR §418.52(b)(4)
- Adverse events. Adverse events are reported to DC Health's system no later than 60 days after they occur. D.C. Code §7-161(d)
- Background checks. Completed within the 45 days before work starts, looking back 7 years, and repeated every 4 years. DC Health is told within 10 days when someone leaves over criminal, unprofessional or unethical conduct. D.C. Code §44-552; 22-B DCMR §4701
- Death at home. A registered nurse may pronounce an expected death at the patient's residence. The physician in charge of the patient's care completes the medical certification within 48 hours after death, except in deaths the medical examiner must look into. D.C. Code §7-231.12
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:
What authorizes you to operate a hospice in the District? Show me your Certificate of Need and your Medicare certification.DC-HSP-GOV-03Authority to Operate: No District Hospice License, Certificate of Need and Medicare Certification
Show me the election statement addendum and the date you furnished it. Was it within the first 5 days of the effective date?DC-HSP-ELC-01Election of Hospice, Election Statement Addendum and Notice of Election
Which verified violations did you report to the State Agency, and on what dates?DC-HSP-ANE-02Investigation of Alleged Violations and Protection of Patients
Who may pronounce death for your patients in the District, and in what circumstances?DC-HSP-DTH-01Death at Home, Pronouncement of Death and Post-Death Care
Has anyone resigned or been fired for criminal, unprofessional or unethical conduct? Did you tell DC Health within 10 days?DC-HSP-HR-03Criminal Background Checks and Registry Checks
The full pack
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
DC-HSP-CMP-01Free sample
Complaints and Grievances
Sets out how patients, families and others can complain about hospice care or lack of respect for property, how the Agency logs, acknowledges, investigates and resolves each complaint within its own time frames (no District rule sets hospice complaint time frames), how complaints are protected from reprisal, and where patients can complain outside the Agency, including DC Health, the BFCC-QIO and the long-term care ombudsman.
42 CFR §418.52(b)(1)(iii)
DC-HSP-PR-01
Patient and Family Rights and Responsibilities
Sets how the Agency tells every patient and representative, out loud and in writing, about the patient’s rights and responsibilities before care starts, lists those rights, explains who exercises them for a patient who cannot, and tells patients how to raise a concern inside the Agency and with DC Health, the BFCC-QIO, Adult Protective Services and the Long-Term Care Ombudsman.
42 CFR §418.52
DC-HSP-PR-02
Informed Consent, Description of Services and Charges
Sets how the Agency explains, before care starts, what hospice covers, what the Agency will and will not provide, and what the patient may owe; how it obtains informed consent from the patient or, when the patient’s incapacity has been certified under District law, from the right substitute decision-maker; and how it handles refusals of care.
42 CFR §418.52(c)(7)-(8)
DC-HSP-PR-03
Advance Directives, Health-Care Decisions, Surrogates and MOST
Sets how the Agency gives written information on advance directives when hospice care begins, records whether each patient has one, honors durable powers of attorney for health care, Natural Death Act declarations and MOST Forms as District law provides, finds the right decision-maker when a patient cannot decide, and educates staff and the community.
42 CFR §418.52(a)(2)
Service delivery1
Hospice care13
DC-HSP-ADM-01
Referral, Eligibility and Admission
Sets how the Agency receives and screens referrals, checks Medicare, DC Medicaid and other eligibility, obtains the physician recommendation and certification that admission requires, completes the admission visit in the right order, decides fairly when it cannot admit, and handles admissions of DC Medicaid adults, children under 21 and waiver participants.
42 CFR §418.25
DC-HSP-ASM-01
Initial and Comprehensive Assessment and Hospice Outcome Data
Sets how the Agency’s registered nurse completes the initial assessment within 48 hours after the election is complete, how the interdisciplinary group completes the comprehensive assessment no later than 5 calendar days after the election and updates it at least every 15 days, what the assessments must cover, and how the Agency collects the standardized patient data the Hospice Quality Reporting Program requires.
42 CFR §418.54
DC-HSP-DIS-01
Discharge, Transfer and Discharge for Cause
Sets the only reasons the Agency may discharge a patient (move out of the service area or transfer, no longer terminally ill, or for cause after four required steps), the physician discharge order, discharge planning, the Medicare notice of non-coverage and the patient’s right to a fast BFCC-QIO review, the discharge summary and records sent to the attending physician or receiving facility, and the notice of termination filed with Medicare.
42 CFR §418.26
DC-HSP-ELC-01
Election of Hospice, Election Statement Addendum and Notice of Election
Sets how a patient or representative elects hospice care with the Agency: what the election statement must contain, the effective date, the benefits the patient waives, the election statement addendum ("Patient Notification of Hospice Non-Covered Items, Services, and Drugs") that every patient electing on or after October 1, 2026 receives within the first 5 days and whenever it changes, election periods, the Notice of Election, re-election, and the DC Medicaid election rules.
42 CFR §418.24
DC-HSP-ELC-02
Certification and Recertification of Terminal Illness and Face-to-Face Encounters
Sets how the Agency obtains a timely, complete written certification of terminal illness for every benefit period, who may certify, what the certification and narrative must say, how face-to-face encounters are made before the third and later periods (in person while the District is under the hospice enrollment moratorium), and the extra DC Medicaid signature and timing rules.
42 CFR §418.22
DC-HSP-ELC-03
Revocation, Change of Designated Hospice and Change of Attending Physician
Sets how a patient or representative revokes the hospice election, changes to another hospice once in a benefit period, or changes attending physician; what each signed statement must say; that only the patient or representative can revoke; and what the Agency then does for continuity of care, records and Medicare notices.
42 CFR §418.28
DC-HSP-FAC-01
Hospice Care for Residents of Nursing Facilities, ICF/IIDs and Assisted Living Residences
Sets out how the Agency provides hospice care to residents of skilled nursing facilities, nursing facilities and ICF/IIDs under 42 CFR §418.112 (written agreement signed before services, professional management, a joint plan of care, a designated IDG member, information given to the facility, orientation of facility staff, and 24-hour reporting of alleged violations to the facility administrator), the DC Medicaid room and board pass-through, and care coordination with assisted living residences.
42 CFR §418.112
DC-HSP-FAC-02
Short-Term Inpatient Care and Respite Arrangements
Sets out how the Agency makes short-term inpatient care available for pain control, symptom management and respite in participating Medicare or Medicaid facilities, the written agreements it must have with those facilities under 42 CFR §418.108(c), the training and verification it remains responsible for, the five-consecutive-day respite limit, and how it tracks the 20 percent inpatient limit for Medicare and DC Medicaid patients.
42 CFR §418.108
DC-HSP-FAC-03
Hospice Inpatient Unit Operations
Applies only if the Agency provides inpatient care directly in its own facility. Sets out the federal standards for staffing, 24-hour nursing (with an RN providing direct care on each shift when a patient is receiving general inpatient care), the physical environment, fire and building safety, patient areas and rooms, infection control, meals, pharmacy services, controlled drugs, restraint and seclusion, and reporting deaths associated with restraint or seclusion to CMS by the close of business the next business day.
42 CFR §418.110
DC-HSP-IDG-01
Interdisciplinary Group
Sets who makes up the Agency’s interdisciplinary group (with the licensed clinical social worker DC Medicaid requires), how each patient gets a designated registered nurse coordinator, which group sets day-to-day policies if there is more than one, how the group meets and reviews every patient at least every 15 calendar days, and how it supervises all care.
42 CFR §418.56(a)
DC-HSP-IDG-02
Plan of Care, Plan of Care Review and Caregiver Education
Sets how the interdisciplinary group, with the attending physician, the patient or representative and the primary caregiver, establishes each patient’s 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 care follows it, and how the Agency teaches patients and caregivers the care they give.
42 CFR §418.56(b)-(d)
DC-HSP-IDG-03
Coordination of Services, Physician Orders and Waiver Coordination
Sets the Agency’s system of communication and integration among its disciplines, contractors and settings, and with other providers who treat unrelated conditions; how drug and treatment orders, including verbal and electronic orders, are received, recorded and signed; and how hospice care is coordinated with DC Medicaid personal care aide services and with EPD and IDD waiver case managers.
42 CFR §418.56(e)
DC-HSP-LOC-01
Levels of Care: Routine Home Care, Continuous Home Care, Respite and General Inpatient Care
Defines the four levels of hospice care (routine home care, continuous home care, inpatient respite care and general inpatient care), sets the clinical criteria, orders, settings and documentation for each, the limits on respite and inpatient days, and the extra DC Medicaid rules, so that every patient gets the level of care his or her needs call for, and only that level is billed.
42 CFR §418.302
Clinical tasks13
DC-HSP-AIDE-01
Hospice Aide and Homemaker Services
Sets who may work as a hospice aide or homemaker for the Agency (the federal training and competency routes plus the District certification the Health Occupations Revision Act requires of nursing assistive personnel), how aide training, competency evaluation and 12 hours of yearly in-service are provided and recorded, how a registered nurse assigns aides and writes their care instructions, what aides may and may not do, and how aides are supervised: an RN on-site visit at least every 14 days, follow-up when a concern is noted, and an annual on-site observation of each aide.
42 CFR §418.76
DC-HSP-BRV-01
Bereavement Program
Sets the Agency’s organized bereavement program under a qualified bereavement coordinator: the initial bereavement assessment before death, the bereavement plan of care, the services offered to the family and others for up to one year after the death, support for residents and staff of nursing facilities and ICF/IIDs, how risk of harm is handled, and how bereavement services are closed and recorded.
42 CFR §418.64(d)(1)
DC-HSP-CNS-01
Spiritual and Dietary Counseling
Sets how the Agency makes counseling available to patients and families: the spiritual assessment and spiritual counseling given in keeping with the family’s beliefs and acceptance, help bringing in the family’s own clergy, dietary counseling by dietitians, nurses and other qualified people when the plan of care calls for it, and other counseling for caregiver training and adjustment to the approaching death.
42 CFR §418.64(d)(2)-(3)
DC-HSP-DME-01
Medical Supplies and Durable Medical Equipment
Sets how the Agency provides medical supplies and durable medical equipment for the palliation and management of the terminal illness: ordering and delivery, contracting only with suppliers that meet the Medicare DMEPOS standards, following manufacturer maintenance recommendations, teaching the patient and family with return demonstration, oxygen and home safety, patients in facilities, equipment problems and recalls, and removal after discharge or death.
42 CFR §418.106(f)
DC-HSP-DTH-01
Death at Home, Pronouncement of Death and Post-Death Care
Sets what the Agency does when a patient dies: preparing the family for an expected death at home, who may pronounce death under District vital records law (a registered nurse for an expected death at the residence, never a licensed practical nurse), deaths the Office of the Chief Medical Examiner must be told about, release of the body to the funeral director, the physician’s medical certification, notifications, care of the body, controlled drug disposal, and the record of the pronouncement.
D.C. Code §7-231.12
DC-HSP-LAB-01
Laboratory Services and Waived Testing
Sets out when Agency staff may perform laboratory tests: only waived tests under a CLIA certificate of waiver (42 CFR Part 493), only after the Administrator has confirmed with DC Health whether a District clinical laboratory license is also needed (D.C. Code §44-202), and with specimens referred only to laboratories CLIA-certified for the tests; and how results are acted on.
42 CFR §418.116(b)
DC-HSP-MED-01
Drugs and Biologicals: Ordering, Drug Profile Review, Labeling and Safe Use
Sets which drugs and biologicals the Agency provides, how the drug profile is reviewed at the comprehensive assessment and at each update, who may order drugs and how verbal orders are handled, how drugs are obtained from pharmacies and delivered, how the IDG decides whether the patient and family can safely give drugs at home, labeling, safe storage, the extra duties that apply only if the Agency runs its own inpatient facility, and how medication errors and adverse reactions are handled.
42 CFR §418.106
DC-HSP-MED-02
Controlled Substances in the Home: Management and Disposal
Sets the Agency’s written procedures for managing and disposing of controlled drugs in the patient’s home: what staff give and explain to the patient, representative and family when a controlled drug is first ordered, how controlled drugs are kept safe at home, when hospice employees may dispose of them under 21 U.S.C. §822(g)(5) (after death, when expired, or by a registered hospice physician when the plan of care changes), how disposal is done and recorded, what happens when a family declines, patients in facilities, and suspected loss or diversion.
42 CFR §418.106(e)(2)
DC-HSP-NUR-01
Nursing Services and Nursing Practice
Sets how the Agency provides nursing care by or under the supervision of a registered nurse: who directs nursing, the RN who coordinates each patient’s care, what registered nurses, licensed practical nurses and nurse practitioners may do under District law, how nursing visits, teaching and procedures are carried out, how nursing is available around the clock, when nursing may be contracted, and how nurse licenses are kept current.
42 CFR §418.64(b)
DC-HSP-PAIN-01
Pain and Symptom Management and Care of the Actively Dying Patient
Sets how the Agency meets each patient’s right to effective pain management and symptom control: assessing pain and other symptoms with standard tools, planning interventions in the plan of care, treating and reassessing, escalating a symptom crisis through the on-call system to continuous home care or general inpatient care, palliative sedation as a last resort, and caring for the actively dying patient and the family.
42 CFR §418.52(c)(1)
DC-HSP-SAF-01
Staff Safety, Home Safety and Emergencies in the Home
Sets how the Agency keeps patients and staff safe in the home: the home safety assessment at admission, what staff do in an emergency during a visit, how staff plan and make visits safely, how threats and violence are prevented, reported and followed up (including screening an assault as a possible DC serious reportable event), how visits are changed for safety without abandoning the patient and only within the federal rules for discharge for cause, and how staff injuries are reported.
42 CFR §418.26(a)(3)
DC-HSP-SW-01
Medical Social Services
Sets how the Agency provides medical social services by a qualified, District-licensed social worker under the direction of a physician, based on the psychosocial assessment and the patient’s and family’s needs and acceptance; who is qualified (and the licensed clinical social worker rule for DC Medicaid patients); how marriage and family therapists and mental health counselors fit on the team without replacing medical social services; and what the social worker assesses, provides, documents and reports.
42 CFR §418.64(c)
DC-HSP-THR-01
Physical Therapy, Occupational Therapy and Speech-Language Pathology
Sets how the Agency makes physical therapy, occupational therapy and speech-language pathology available to patients for symptom control and to keep daily activities and basic functional skills, who may provide them under District licensure, how therapy is ordered in the plan of care and delivered, how therapists teach families and recommend equipment, and how arranged therapy is managed.
42 CFR §418.72
Safeguarding2
DC-HSP-ANE-01Free sample
Recognizing and Reporting Abuse, Neglect and Exploitation of Adults and Children
Sets out how staff recognize abuse, neglect, self-neglect and exploitation of adults and abuse and neglect of children, who must report under District law, and how reports are made at once to Adult Protective Services (APS) or the Child and Family Services Agency (CFSA), alongside the federal duty to report every alleged violation immediately to the hospice administrator.
D.C. Code §7-1903
DC-HSP-ANE-02
Investigation of Alleged Violations and Protection of Patients
Sets out how the Agency immediately investigates every alleged violation involving anyone furnishing services on its behalf, protects the patient while the allegation is verified, takes corrective action, reports verified violations to the State Agency and other bodies with jurisdiction within 5 working days of becoming aware of the violation, and makes the related facility, DC Health and adverse event reports.
42 CFR §418.52(b)(4)
Infection control2
DC-HSP-IC-01Free sample
Infection Prevention and Control Program
Sets the Agency’s infection prevention and control program: who leads it, standard and transmission-based precautions in the home, bag technique and equipment cleaning, the agency-wide surveillance log and how it feeds the QAPI program, education for staff, contractors, patients and families, reporting of the District’s notifiable diseases, outbreaks among patients or staff, home sharps and waste, and the extra standards for an Agency inpatient facility.
42 CFR §418.60
DC-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 occupational exposure, universal precautions, engineering and work practice controls including safer sharps, PPE at no cost, housekeeping and regulated waste, hepatitis B vaccination, what happens after an exposure incident (immediate confidential evaluation and the healthcare professional’s written opinion within 15 days), labels and training, and the records the standard requires, with yearly review.
29 CFR §1910.1030
Emergency preparedness1
Records1
Privacy3
DC-HSP-PRV-01
HIPAA Privacy and District Confidentiality Laws
Sets out how the Agency protects patients’ health information under the HIPAA Privacy Rule and the District’s stricter laws, including the privacy official, the Notice of Privacy Practices and its acknowledgment, when information may be shared with family and others, the Mental Health Information Act, patients’ privacy rights, business associates, complaints, sanctions and documentation.
45 CFR §164.500 et seq.
DC-HSP-PRV-02
HIPAA Security
Sets out how the Agency protects electronic patient information under the HIPAA Security Rule: the security official, risk analysis and risk management, workforce access, training, incident response, contingency planning, physical and device safeguards for staff who work in patients’ homes, technical controls, business associates and documentation.
45 CFR Part 164, Subpart C
DC-HSP-PRV-03
Breach Notification
Sets out how the Agency recognizes, assesses and reports a breach of patient information: notice to each patient without unreasonable delay and no later than 60 calendar days after discovery, notice to HHS and, for more than 500 District residents, the media under HIPAA, and the District’s added duties under D.C. Code §28-3852, including written notice to the DC Attorney General when 50 or more District residents are affected.
45 CFR §164.400-414
Human resources6
DC-HSP-HR-01
Orientation, In-Service Training and Competency
Sets the hospice philosophy orientation for everyone with patient and family contact, job-specific orientation for each employee, how the Agency assesses the competence of everyone who furnishes care (including volunteers), and the in-service training plan, including the federal minimums for hospice aides, bloodborne pathogens, emergency preparedness, privacy and civil rights, and the District topics every staff member must know.
42 CFR §418.100(g)
DC-HSP-HR-02
Personnel Qualifications, License Verification and Exclusion Screening
Sets the qualifications each discipline must meet under 42 CFR §418.114 and District licensure law, how the Agency verifies licenses and credentials before work starts and keeps them current, how it screens every person against federal exclusion lists, and what happens when a credential lapses.
42 CFR §418.114
DC-HSP-HR-03
Criminal Background Checks and Registry Checks
Sets the District criminal background check required before anyone with direct patient access starts work (fingerprints or live scan in the District, an MPD and FBI check verified by DC Health, sex offender and Nurse Aide Abuse Registry checks and a sworn statement, all within the 45 days before work starts), the offenses that bar employment, repeat checks every four years, the 10-day notice to DC Health, contracted staff and volunteers, and how criminal records are kept confidential and destroyed.
D.C. Code §44-552
DC-HSP-HR-04
Personnel Records
Lists what goes into each personnel record, how records for contracted staff are kept, who may see personnel records, and how long each kind of record is kept, from criminal background check records (destroyed one year after employment ends) to occupational exposure medical records (employment plus 30 years).
42 CFR §418.100(g)(3)
DC-HSP-HR-05
Staff and Volunteer Health Screening, Immunizations and Work Restrictions
Sets the health screening the Agency requires before staff and volunteers have patient contact (Agency standards following CDC guidance, because the District has no hospice health screening rule), the hepatitis B vaccination that OSHA requires the Agency to make available within 10 working days of initial assignment, other vaccinations offered, when sick staff must stay away from patients, and how health information is kept confidential.
42 CFR §418.60
DC-HSP-VOL-01
Volunteer Program
Sets how the Agency recruits, screens, orients, trains, assesses, supervises and keeps volunteers in defined administrative and direct patient care roles, and how it records volunteer hours, services and cost savings so it can show that volunteer services equal at least 5 percent of the total patient care hours of all paid hospice employees and contract staff.
42 CFR §418.78
Governance8
DC-HSP-GOV-01
Governing Body, Administrator and Key Designations
Names the governing body as the body legally responsible for the Agency, sets how the Administrator is appointed and what the Administrator does, lists every role the Conditions of Participation and privacy and civil rights rules require a hospice to designate, and explains how leadership is covered during absences, surveys and changes of key personnel. The District does not license hospices, so this policy follows 42 CFR §418.100(b).
42 CFR §418.100(b)
DC-HSP-GOV-02
Organizational Structure, Service Area and Multiple Locations
Requires a written organizational chart that traces every line of authority to the location that holds the Medicare certification number, defines the Agency’s service area, and sets the steps before the Agency opens another location or starts or stops a service, including the CMS hospice enrollment moratorium and the District’s Certificate of Need law.
42 CFR §418.100(f)
DC-HSP-GOV-03
Authority to Operate: No District Hospice License, Certificate of Need and Medicare Certification
States plainly that the District of Columbia does not issue a hospice license, and sets out what does authorize the Agency to operate: a Certificate of Need from SHPDA where D.C. Code §44-406 requires one, Medicare certification under 42 CFR Part 418 with surveys by the State Agency, accurate Medicare enrollment, and DC Medicaid enrollment if the Agency takes DC Medicaid. Includes the survey, plan of correction and informal dispute resolution steps and one log for every filing.
D.C. Code §44-406
DC-HSP-GOV-04
Reporting Adverse Events and Required Notices to DC Health, SHPDA and CMS
Sets out how the Agency reports adverse events to DC Health within 60 days under D.C. Code §7-161 through the Serious Adverse Event Reporting System launched September 1, 2026, and lists in one table every other report or notice the Agency owes DC Health, SHPDA, DHCF and CMS, with the time frame and the policy that governs it.
D.C. Code §7-161(d)
DC-HSP-GOV-05
Closure, Suspension of Services, Change of Ownership and Records After Closure
Sets the steps when the Agency plans to close, stop a service, suspend admissions, change ownership or change its name: SHPDA notice at least 90 days before a closure and its approval, CMS notice and public notice at least 15 days before a provider agreement ends, help for every patient to move safely to another hospice, the Certificate of Need and Medicare rules on changes of ownership (including the 36-month rule and the moratorium), and how clinical records are kept and found after closure.
D.C. Code §44-406(c)
DC-HSP-GOV-06
Hospice Program, Scope of Services and Policy Index
Describes the Agency’s hospice program: the services it provides and how (directly or under arrangement), its 24-hour availability, where care is given, the four levels of care, the rule that care continues regardless of ability to pay, and an index of every policy in this manual.
42 CFR §418.100(a), (c)
DC-HSP-GOV-07
Civil Rights, Nondiscrimination and Language Access
Sets the Agency’s nondiscrimination policy under Section 1557 of the Affordable Care Act and the DC Human Rights Act, the Section 1557 Coordinator, the required notices and taglines, language assistance, effective communication for people with disabilities, reasonable modifications, the civil rights grievance procedure and staff training.
45 CFR Part 92
DC-HSP-MD-01
Medical Director and Physician Services
Sets who may be the Agency’s medical director and physician designee, what the medical director does (certification review, admission and discharge decisions, supervision of all hospice physicians, responsibility for the medical component of care), how a hospice physician is available around the clock, how the Agency works with each patient’s attending physician, and who may furnish pre-election evaluation and counseling.
42 CFR §418.102
Quality2
DC-HSP-QA-01
Quality Assessment and Performance Improvement and the Quality Management Committee
Sets out the Agency’s hospice-wide, data-driven quality assessment and performance improvement (QAPI) program under 42 CFR §418.58: governing body responsibilities, the QAPI lead, the multidisciplinary Quality Management Committee, the indicators measured, performance improvement projects, quality reporting to CMS, the annual evaluation, and, if the Agency is enrolled in DC Medicaid, the quality management and peer review program submitted to DHCF by June 30 each year.
42 CFR §418.58
DC-HSP-QA-02
Incident Reporting, Internal Investigation and Learning From Adverse Events
Sets out how staff report incidents inside the Agency, how each incident is triaged, screened for external reporting and investigated, and how the causes are analyzed and turned into preventive actions with feedback and learning across the Agency, as 42 CFR §418.58 requires.
42 CFR §418.58(a)(2), (c)(2)
Business2
DC-HSP-CON-01
Contracted Services and Professional Management Responsibility
Sets when the Agency may use contracts or arrangements for services, what every written agreement must contain (including the three federal requirements that arranged services be authorized by the hospice, furnished safely by qualified personnel and delivered under the plan of care), and how the Agency keeps administrative and financial management and oversight of every arranged service.
42 CFR §418.100(e)
DC-HSP-FIN-01
Billing, Notices to Medicare and DC Medicaid, Prior Authorization and Continuation of Care
Sets the billing steps that protect patients and the Agency: the Notice of Election within 5 calendar days, notices of termination or revocation within 5 calendar days, no claim before written certification, the inpatient day and aggregate cap limits, quality reporting, what patients may owe, DC Medicaid prior authorization for each election period and the other DC Medicaid payment rules, care regardless of ability to pay, and correction of errors.
42 CFR §418.24(e)
Ethics2
DC-HSP-ETH-01
Compliance Program, Referral Integrity and Fraud Prevention
Sets the Agency’s compliance program: rules on referrals, gifts and marketing so that no one is paid or rewarded for referring patients, hospice eligibility integrity, the federal and District false claims laws and whistleblower protections, how staff report concerns without retaliation, and how the Agency investigates problems and reports and returns overpayments within 60 days of identifying them.
42 U.S.C. §1320a-7b(b)
DC-HSP-ETH-02
Medical Aid in Dying Under the District’s Death with Dignity Act
Records the position the governing body has adopted under the District’s Death with Dignity Act: hospice care continues for every patient whatever the patient decides, Agency staff do not take part in providing a covered medication in the course of their Agency duties, and staff respond to questions and requests with information, referral, records and full hospice support. Explains what federal funding law allows and what the Act protects and forbids.
D.C. Code §7-661.10
Questions
Questions about this manual
Is this the right manual for my hospice?
It is for Medicare-certified hospices in Washington, DC. Agencies licensed by DC Health as a home care agency need the Washington, DC home health manual, and home support agencies need the Washington, DC home care manual.
Does the District license hospices?
The District has adopted no hospice licensing rules. D.C. Code §44-501(a)(7) leaves hospices out of the home care agency license, and 22-B DCMR has no hospice chapter. The manual is written for a hospice that operates on Medicare certification and, where D.C. Code §44-406 requires one, a Certificate of Need.
Does it cover the Death with Dignity Act?
Yes. Policy DC-HSP-ETH-02 covers the Act (D.C. Code §7-661.01 et seq.). As written, hospice care continues whatever the patient decides, staff answer questions with information and referral, and staff do not take part in providing a covered medication in the course of their work. That position is the hospice's own choice, and your governing body can change it.
Do the policies cover DC Medicaid?
Yes, for enrolled hospices. DC Medicaid's hospice rule adds prior authorization for each election period and a coordinated plan of care with an EPD or IDD waiver case manager within 5 days of the first day of hospice care (29 DCMR §939.25, §939.18(a)).
What do the 60 policies cover?
Client rights (4), service delivery (1), hospice care (13), clinical tasks (13), safeguarding (2), infection control (2), emergency preparedness (1), records (1), privacy (3), human resources (6), governance (8), quality (2), business (2) and ethics (2).
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