HIGH PEAKS HOSPICE 
CLINICAL POLICIES AND PROCEDURES 
ALPHABETICAL INDEX
As of May 8, 2018

Updated with New Logo as of 09/01/18

 These policies are listed in alphabetical order regardless of policy number; revision date is indicated after the title. Forms are listed under the policy to which they pertain. 

24 Hour Availability of Services CP-200 (Updated 09/01/18)

Absence of Management Staff CP-201 (Updated 09/01/18)

     Form: Coverage During Absence (Rev 07/18)

Admission Criteria CP-202 (Updated 09/01/18)

     Form - Admission and Care Consent (Rev 06/18)

    FormAdmission Packet Table of Contents (New 07/18)

    Form - Live-Alone Consent Addendum Rev 07/18

    Form - Names and Phone Number (Rev 07/18)

 Admission Guidelines – High Tech Procedures CP-203 (Updated 09/01/18)

 Advance Directives CP-204 (Updated 09/01/18) (Also See "Do Not Resuscitate, CP221")

      Form -  Health Care Proxy DOH1430 (Rev07/12)
      Form -  Hospice Care Agreement NO Health Care Proxy (Rev 07/18)

     Brochure: Planning Your Health Care in Advance (NYSOAG)2016 (27 Pages)

     Information: Patient Self-Determination Information (Rev 07/18)

 Adverse Events CP230 (Upd 09/01/18)  For Medication Incidents see "Medication Errors CP239"

   Form-  Incident Report - Patient (Rev 07/18)

   Form - Incident Report for Visitors/Equipment/Property (Rev 07/18)

CADD Pump CP-284 (Upd 09/01/18)

     Form - CADD Pump Tracking Sheet (Rev 07/18)

Care of Peripherally Inserted Central Catheters (PICC) CP-281 (Upd 09/01/18)

Certification of Hospice Eligibility CP-205 (Updated 09/01/18)
      Form - Guidelines for GENERAL DECLINE IN CLINICAL STATUS Baseline (Rev 07/18)

     FormGuidelines for ALS (Rev 07/18)

     Form - Guidelines for Alzheimer's Disease & Related Disorders (Rev 07/18)

     Form - Guidelines for Cancer (Rev 07/18)  

     Form - Guidelines for Heart  Disease (Rev 07/18)

     Form - Guidelines for HIV Disease (Rev 07/18)

     Form - Guidelines for Liver Disease (Rev 07/18)

     Form -  Guidelines for Pulmonary Disease (Rev 07/18)

     Form - Guidelines for Renal Disease (Rev 07/18)

     Form -  Guidelines for Stroke & Coma (Rev 07/18)

Change of Designated Hospice Provider CP-206  (Upd 09/01/18)

     FormChange of Hospice Provider Statement (Rev 07/18)

Clinical Records CP-207 (Upd 09/01/18

    Attachment: Abbreviations List  for Clinical Records (Upd 09/10/18)

     FormChart Check Sheet (Rev 03/18)

     Form - Clinical Record Table of Contents Rev 07/18

     Form - Staff Signature Sheet Blank (Rev 07/18)

Code of Ethical BehaviorCP-208 (Updated 09/01/18)

     Form - Our Missions Statement 2009

Complaints and Grievances CP-210 (Updated 09/01/18)

     FormComplaint and Grievance Summary (Rev 07/18)

Confidentiality of HIV Related Information CP-211 (Updated 09/01/18)

     Form - Authorization for Release of Health Information and Confidential HIV Related Information (DOH2557, R2/11) go to NYS DOH Website for this form
     Form - Redisclosure of HIV Information (Rev 07/18)

Confidentiality of Information CP-212  (Updated 09/01/18)
     FormConfidentiality Agreement (Rev 07/18)

Continuous Care CP-274  (Updated 09/01/18)

      Form: Continuous Care Hospice Nursing Responsibilities (Rev 07/18)

     FormContinuous Care- Medication Record (Rev 07/18)

     Form - Continuous Care - Narcotic & Syringe Count (Rev 07/18)

     Form - Continuous Care- Orders Received From RN (Rev 07/18)

     Form - Continuous Care- Schedule (Rev 07/18)

Contracts with Skilled Nursing Facilities CP-213 (Updated 09/01/18)

Controlled Medication Safe Use, Storage and Disposal CP 220 (Updated 09/02/15) 

 Form - Controlled Substance Delivery Record (Rev 07/18)    

 Form -  Controlled Substance Disposition Record (Rev 07/18)

Core Services CP-214 (Updated 09/01/18) 

CPR Certification CP-216 (Updated 09/01/18)

Criteria for Further Assessment CP-217 (Updated 09/01/18)

Deactivation of the Implantable Cardioverter Defibrillator (ICD) CP-285 (Updated 09/01/18)

     Form - Consent for "ICD" Deactivation (Rev 07/18)

Death Attendance PC.D30 (Revised 07/31/12)

     Form - Funeral Director Information (Rev 07/18)

Determining Medicare Eligibility CP-218 (Updated 09/01/18)

      Form -Attending Physician Change Notice for Hospice Benefit (Rev 07/18)

     Form - Election of Medicare Hospice Benefit (Rev 07/18)

Discharge from Hospice Services  CP 219  (Updated 09/01/18)
     Form - Acknowledgement of Discharge (Rev 07/18)

    Form - Discharge Summary (Rev 07/18)

   Form - Notice of Medicare Non Coverage  NOMNC Live Discharge CMS10123 (Rev 07/18)

                  CMS 10123 Instructions Upd 0217
    Form - Detailed Explaination Notice of Medicare Non Coverage NOMNC DENC CMS 10124 (Rev 07/18)
                 CMS 10124 Instructions Upd0217 

  Do Not Resuscitate CP-221 (Updated 09/01/18)

     Form - Do Not Resuscitate NYS (DNR) DOH3474 04/09
                 Brochure:  Do Not Resuscitate DOH
     Form - Waiver of DNR (Rev 07/18)

Electronic Signatures CP-250 (Updated 09/01/18)

Emergency Preparedness CP-280 (Updated 09/01/18)

Emergency Room CP-282 (Updated 09/01/18)

Ethical Issues: Consultation & Resolution CP-225 (Updated 09/01/18)

Evaluating Proposed Treatment of Expanded Hospice Therapy  CP-226 (Updated 09/01/18)

Functional Assessment  CP-227 (Updated 09/01/18)

Hospice Aide Services CP-229 (Rev 12/01/16)

     Form - Hospice Aide Activity Sheet (Rev 07/18)
     Form  - Hospice Aide Extended Service Checklist (Rev 07/18)
     Form - Hospice Aide Orientation/Supervision Summary (Rev 07/18)
     Form - Hospice Aide Orientation to Hospice Care (Rev 07/18)

     Form - Hospice Aide Plan of Care (Rev 07/18)
     FormHospice Aide Request Fax (Rev 07/18)
     Form - Hospice Aide Tracking Sheet (Rev 07/18)

 Hospice Approved Medications  CP-222 (Updated 09/01/18)

Infection Control: Bloodborne Pathogens - Exposure Control Plan (ECP) CP-289 (Updated 09/01/18)

Infection Control: Education CP290 (New 11/17/15)

Infection Control: Hand Hygiene CP228 (Updated 09/01/18)

Infection Control: Influenza Vaccination CP288 (Updated 09/01/18)

 Form:  Flu Vaccine Patient Release (Rev 07/18)

Infection Control: Personal Protective Equipment CP291 (New 11/17/15)

     Form: Report of Emergency Involving Patient Treatment - Staff Unable to Use PPE (Rev 07/18)

Infection Control Program CP-231 (Rev11/17/15)

Infection Control: Standard and Transmission Based Precautions CP270 (Updated 09/01/18)

     Form: Post Exposure Followup Checklist (Rev 07/18)

    Form: Post Exposure Needlestick/Sharps (Rev 07/18)

    Form: Post Exposure Splash (Rev 07/18)

    Form: Sharps Injury Record (Rev 07/18)

Infection Control: Surveillance CP293 (Updated 09/01/18)

  Form - Infection Control Monthly Tracking Sheet (Rev 07/18)
  Form  - Infection Control Surveillance Report (Rev 07/18)

Infection Control: Tuberculosis CP292 (Updated 09/01/18)

    Form: Annual Review of Positive TB Test (Rev 07/18)

 Initial and Comprehensive Assessment of Patient CP233 (Rev 03/21/17) Was "Initial Assessment and Admission Note" (Upd 07/01/2008)

     FormPrecauctions to Avoid Fire Hazards with Oxygen Use (Oxygen Safety) (Rev 07/16)

Inpatient Care CP-276 (Updated 09/01/18)

     Form - Fax Cover - Facility Records Request (Rev 07/18)
     Form - Guidelines and Protocols for Symptom Control Hospital Admissions (Rev 07/18)

     Form - Information for Patients/Families During Hospitalization (Rev 07/18)

     Form - Inpatient Admission Checklist (Rev 07/18)
     FormInpatient Admission Worksheet (Rev 07/18)

     Form - Inpatient Facility Physician Orders (Rev 07/18)

 Interdisciplinary Team (IDT) CP-286 (Updated 09/01/18)

      Form - IDT Meeting (Rev 07/18)

     Form - IDT Progress Notes (Rev 07/18)

    Form - IDT Sign-in Sheet (Rev 07/18) 

 Life Sustaining Treatment: Decisions to Give, Withhold, or Terminate Treatment CP-235 (Updated 09/01/18)

 Medical Management of the Hospice Patient  CP-236 (Updated 09/01/18)

     Form: Fax Cover-Non-Urgent Physician Notification (Rev 07/18)

     Form: Fax Cover-Physician's Certification (Rev 07/18)

     Form: Fax Cover-Physician's Change of Orders (Rev 07/18)

     Form: Fax Cover-Physician's Orders (Rev 07/18)
     Form - Medical Director Consultation (Rev 07/18)

     Form - Physician's Change of Orders (Rev 07/18)

     Form - Physician's Standing Orders 2Pages (Rev 07/18) 

 Medical Marihuana for Hospice Patient CP295 (Upd 09/01/18)

 Medication Administration  CP-238 (Updated 09/01/18)

     Form - Flu Vaccine Patient Release (Rev 07/18)     

     Form - Home Medication Schedule (Rev 07/18)

 Medication Errors CP-239 (Updated 09/01/18)

     Form - Medication Incident Report (Rev 07/18)

Medication Reactions CP-240 (Updated 09/01/18)

Movement of Patients Between Sites within Service Area CP-269 (Updated 09/01/18)

Nursing Bag Technique CP-241 (Rev 03/26/14)

Nursing Care CP-242 (updated 09/01/18)
     Form - Documentation Guidelines (Rev 07/18)

    Form - Home Visit Performance Appraisal (Rev 07/18)

    Form -  Precautions to Avoid Fire Hazards with Oxygen Use (Rev 07/18)

 Nursing Home Care CP277 is now under "SKilled Nursing Facility Care"

 Nutritional Counseling CP-244 (Rev 03/26/14)

      Form: Nutritional Consult (Rev 07/18)

On-Call Services CP245 (Rev 8/15/2016)

     Form:  On Call Log (Rev 08/16)

Patient Billing for Hospice Services CP-237 (Upd 01/01/11)

     Form - Advance Beneficiary Notice of NonCoverage (ABN) CMS-R-131 (Rev 07/18)    

                 Instructions: ABN of Non Coverage CMS-R-131   

     Form - Financial Assistance Eligibility (Rev 07/18)

    Form -  Nursing Home Room & Board Authorization (Rev 07/18)
    Form-  Patient Commercial Insurance Coverage Summary (Rev 07/18)

    Form - Temporary Relocation Agreement (Rev 08/18)

Patient/Family Bill of Rights CP-246 (Updated 09/01/18)

       FormPatient/Family Bill of Rights (Rev 07/18)

Patient/Family Informed Consent CP-248  (Updated 09/01/18)

      Chart - Informed Consent Flowsheet by Arent Fox

       Information -  Informed Consent Policy by Arent Fox

Patient/Family Plan of Care CP-247 (Updated 09/01/18)

Patient Readmission CP-278 (Updated 09/01/18)

Patient Reassessment CP-243 (Updated 09/01/18)

Patient Responsibilities CP-249 (Updated 09/01/18)
      FormYour Responsibility as a Patient (Rev 07/18)

Physician Billing for Consultation Services CP-251 (Updated 09/01/18)

Professional Management CP-253 (Updated 09/01/18)

Professional Nursing Practice CP-254 (Updated 09/01/18)

Recertification of Hospice Eligibility CP-255  (Updated 09/01/18)
    Form- Face-to-Face Visit Narrative (Rev 07/18)

    Form- Assessment Worksheet for Face to Face Visit  5 Pages (Rev 07/18)

Referral to Hospice Care CP294 (New 12/01/16)

     Form: Referral/Informational for Hospice Care (Rev 07/18)

Respite Care CP-256  (Rev 03/26/14)

     Form: Respite Care Admission Physician Information (Rev 07/18)

    FormGuidelines and Protocol for Respite Care (Rev 07/18)

 Revocation of the Medicare Hospice Benefit CP258 (Rev 05/23/2017 )

      Form: Revocation of Medicare Hospice Benefit (Rev 07/18)

Scope of Services  CP-259 (Updated 09/01/18)
     Information- Hospice Care Services (Rev 07/18)

Scope of Services – Bereavement CP-260 (Rev 03/26/14)
      Form - Bereavement Contact Sheet Rev 07/18

     Form - Bereavement Follow-Up Adult (Rev 07/18)
     Form - Bereavement Follow-Up Child (Rev 07/18)

     Form - Bereavement Note Rev 07/18
     Form - Bereavement Referral Form - Adult (Rev 07/18)
     Form - Bereavement Referral Form - Child (Rev 07/18)

Scope of Services – Nursing Practice CP-261 (Updated 09/01/18)  

Scope of Services – Social Work CP-262 (Updated 09/01/18)

Scope of Services - Spiritual Care CP263 (Updated 09/01/18)

Skilled Nursing Facility Care CP277 (Updated 09/01/18) was "Nursing Home Care"

     Form - Fax Cover - Billing Department  Facility (Rev 07/18)

Suicide and Suicide Risk Assessment CP-264 (Updated 09/01/18)

Supplies and Equipment CP-265 (Updated 09/01/18)

     Form : DME Tracking Record (Rev 07/18)

Suspected Abuse and/or Neglect CP-266 (Updated 09/01/18)
      FormReport of Suspected Child Abuse  (NYS OCFSForm 09/16) Fill in form on NYS OCFS website

Theft of Controlled Substances CP-283 (Updated 09/01/18)

Therapy Services CP-267 (Updated 09/01/18)

Transfer of Patient to Different Hospice Provider CP-279 (Updated 09/01/18)
     FormPatient Transfer (Rev 07/18) 

Use of Cleaning Agents CP-271  Rev 03/16/14)