10.07.21.07

.07 Policies and Procedures.

The hospice care program shall adopt and implement written policies and procedures for:

A. The use of advance directives;

B. Identifying, reviewing, and discussing ethical dilemmas which arise in the care of patients and family;

C. The use of specific treatment modalities in different hospice care settings, that is, palliative chemotherapy or radiation;

D. The administration of medications, including who is qualified to administer medications;

E. The management of treatment-related complications;

F. The use of investigational drugs and implementation of research protocols;

G. The initiation of resuscitation;

H. Attending to remains at the time of death;

I. The disposal of controlled drugs after death;

J. The provision of inpatient hospice care including:

(1) Privacy needs, including space for families to gather;

(2) 24-hour visitation and overnight stays; and

(3) Religious and spiritual worship;

K. Admission, transfer, and discharge, including criteria to be used for each; and

L. Obtaining informed consent.