(a)  The governing body or its designee shall establish and implement at a minimum, a description of written policies governing all aspects of the hospice program.  Such policies shall be available for inspection by the Department and shall include at a minimum:

(1)           provision for offering of the full scope of hospice services in the agency's defined service area;

(2)           admission and discharge policies;

(3)           patient's rights policies, including the right to have an advance directive;

(4)           personnel policies and records;

(5)           orientation, patient family volunteer training, and inservice education policies;

(6)           communicable disease exposure and infection control policies;

(7)           care planning and updates policies;

(8)           medical record content and handling of orders for drug treatment administration;

(9)           annual evaluation of the agency;

(10)         storage, preventive maintenance, and infection control of supplies and equipment;

(11)         handling of complaints about services; and

(12)         emergency preparedness and disaster planning.

(b)  The governing body shall designate an individual to serve as agency director.

(c)  There shall be written policies that specify the authority and responsibilities of the director.  In the event this position becomes vacant, the Department shall be notified in writing within five working days of the vacancy along with the name of the replacement if available.  Agency policies shall define the order of authority in the absence of the administrator.

(d)  The agency shall have the ultimate responsibility for the services provided under its license; however, it may make arrangements with contractors and others to provide services in accordance with Rule .0505 of this Subchapter.

(e)  A hospice agency shall have written policies which identify the specific geographic areas in which the agency provides its services.

(f)  If an agency plans to permanently expand its geographic service area beyond that currently on file with the Department without opening an additional site, the Department shall be notified in writing 30 days in advance.  The agency must offer its full scope of hospice services in its entire geographic service area.


History Note:        Authority G.S. 131E‑202;

Eff. November 1, 1984;

Amended Eff. February 1, 1996.