(a) Governing Body. The hospice program shall have a governing body which has the legal authority and responsibility to operate the hospice program. The governing body shall: - (i) Obtain employee dishonesty coverage through a general liability insurance policy, fidelity bond, or surety bond. This coverage is for patient protection due to dishonesty, integrity, or fidelity on behalf of an employee. The coverage shall be no less than five thousand dollars ($5,000).
- (ii) Provide verification of a central registry check on all employees hired at the time of or after the filing of these rules. The individual agencies or corporations are responsible for obtaining central registry verifications. Central Registry information can be obtained by contacting the Department of Family Services at307-777-5894 (this number may be subject to change).
- (iii) Insure that all staff successfully complete, at a minimum, a full fingerprint-based National Criminal Background Check before unsupervised direct patient contact. If there are any flags on the background check and the facility employs the individual, the facility must document in the individual's personnel file that prior to hire the flagged issue was thoroughly investigated and it was determined the individual is appropriate to provide services to vulnerable adults.
- (iv) Adopt, revise, and approve personnel policies, including:
- (A) Frequency of evaluations; and
- (B) Insuring confidentiality of central registry information and criminal background checks.
- (v) Prepare an organizational chart that reflects the administrative control and lines of authority for the delegation of responsibility from management down to the patient level.
- (vi) Ensure that all services provided are consistent with accepted standards of practice.
- (vii) Ensure adequate numbers of qualified staff to provide quality hospice care and volunteer services, and, if offered, non-hospice respite care.
- (viii) Develop and implement policies and procedures for services offered which shall be reviewed annually by the medical director and either the governing body or appropriate administrative representative.
- (ix) Develop an effective, ongoing, agency-wide written quality improvement program which ensures and evaluates quality of care to all patients in accordance with W.S. § 35-2-910.
- (x) Develop a written grievance procedure.
- (A) The grievance procedure shall establish a system of reviewing complaints and allegations of patients' rights violations to include, but not be limited to:
- (I) Patient method to voice grievance;
- (II) The Hospice Program's written response to patient grievances;
- (III) List of agencies, with addresses and telephone numbers, for patients to contact if grievances are not addressed satisfactorily; and
- (IV) Written reports on all grievances and resolutions shall be provided to the State Survey Agency, within ten (10) days after the grievance is filed.
- (xi) Refer Complaint Investigations.
- (A) Patient complaints and problems shall be referred in writing to the Long Term Care Ombudsman.
- (B) The office of the Ombudsman shall complete all complaint investigations within an appropriate time frame depending upon the nature of the allegations.
- (C) Written reports of an investigation and the status of resolutions completed by the hospice shall be provided by the Long Term Care Ombudsman to the State Survey Agency within thirty (30) days after the completion of an investigation.
- (I) Exception: Complaints or problems reported directly to the State Survey Agency or referred by the Long Term Care Ombudsman to the State Survey Agency shall be investigated by the State Survey Agency.
- (xii) Maintain employee Personnel records. There shall be one (1) person designated responsible for maintaining confidentiality of personnel records.
- (xiii) Develop policies and procedures with regard to Employee Health. The hospice program shall at a minimum:
- (A) Include a policy listing communicable diseases that put the patient population at risk. In addition, the hospice shall report communicable diseases or conditions as required by W.S. § 35-4-107 through W.S. § 35-4-108 and;
- (B) Document that the employee is free of communicable diseases that could be a risk to the client population.
- (xiv) Adopt Advanced Directives. The hospice program shall adopt policies which assure that information on advanced directives is provided to all patients. If the patient's advanced directives are known, they shall be followed by the hospice program.
- (xv) Make specific notifications:
- (A) Prior to admission, all prospective patients shall be notified if the hospice program is not Medicare/Medicaid certified.
- (B) Each hospice program will notify its prospective patients, or the responsible party, of the services it provides and the charges for those services.
- (C) The responsible party shall be notified of the service charges and any change in charges.
048-10 Wyo. Code R. § 10-5