HIGH PEAKS HOSPICE & PALLIATIVE CARE, INC.
CLINICAL POLICIES AND PROCEDURES 
ALPHABETICAL INDEX
As of May 23, 2017

 

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 (Revised 1/19/2012, Updated 08/14)

Absence of Executive Director and Management Staff CP-201 (Rev 05/19/15)

     Form: Coverage During Absence (Rev 04/16)

Admission Criteria CP-202 (Rev 12/01/16)

     Form - Admission and Care Consent (Rev 03/17)

     Form - Intake Worksheet R08/14

    Form - Live-alone Consent Form Addendum Rev11/11

 Admission Guidelines – High Tech Procedures CP-203 (Rev 12/01/16)

 Advance Directives CP-204 (Rev 03/21/17) (Also See "Do Not Resuscitate, CP221")

      Form -  Health Care Proxy DOH1430 (Rev07/12)
      Form -  Hospice Care Agreement NO Health Care Proxy (R04/17)

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

     Information: Patient Self-Determination Information (Rev 01/17)

 Adverse Events CP230 (Rev 05/25/16) replaces "Incident Reporting"

   Form-  Incident Report - Patient (Rev 11/15)

   Form - Incident Report for Visitors/Equipment/Property (Rev 05/16)

CADD Pump CP-284 (Upd 07/01/2008)

Care of Peripherally Inserted Central Catheters (PICC) CP-281 (Revised 08/26/2014)

Certification of Hospice Eligibility CP-205 (Rev 05/19/15)
      FormGENERAL DECLINE IN CLINICAL STATUS Baseline Guidelines (Rev 10/15)

     FormGuidelines for ALS (Rev 10/15)

     Form - Guidelines for Alzheimer's Disease & Related Disorders (Rev 10/15)

     Form - Guidelines for Cancer (Rev 10/15)  

     Form - Guidelines for Heart  Disease (Rev 10/15)

     Form - Guidelines for HIV Disease (Rev 10/15)

     Form - Guidelines for Liver Disease (Rev 10/15)

     Form -  Guidelines for Pulmonary Disease (Rev 10/15)

     Form - Guidelines for Renal Disease (Rev 10/15)

     Form -  Guidelines for Stroke & Coma (Rev 10/15)

Change of Designated Hospice Provider CP-206  (Rev 05/19/15)

     Form - Change of Hospice Provider Statement (R01/15)

Clinical Records CP-207 (Revised 08/26/2014)

      FormChart Check Sheet (Rev 05/15)

      FormStaff Signature Sheet Blank (Rev 01/17)

      FormClinical Record Audit Review Notice (Rev 1/11)

     Form - Clinical Record Table of Contents Rev08/14

    FormClinical Record Table of Contents (for Blank Master Chart) (N0410)

    FormClinical Records Abbreviation List (Rev 1/27/11) 

Code of Ethical BehaviorCP-208 (Rev 03/26/14)

     Form - Our Missions Statement 2009

Complaints and Grievances CP-210 (Rev 03/26/14, Upd10/15)

     FormComplaint and Grievance Summary (Rev 03/16)

Confidentiality of HIV Related Information CP-211 (Rev03/26/14)

     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 (Upd 10/15)

Confidentiality of Information CP-212  (Rev 05/19/15)
     FormConfidentiality Agreement (U11/12)

Continuous Care CP-274  (Rev 03/26/14) 

      Form: Continuous Care Hospice Nursing Responsibilities (Upd 04/15)

     FormContinuous Care- Medication Record (Upd 04/15)

     Form - Continuous Care - Narcotic & Syringe Count (Upd 04/15)

     Form - Continuous Care- Orders Received From RN (Upd 04/15)

     Form - Continuous Care- Schedule (Upd 04/15)

Contracts with Nursing Facilities CP-213 (Rev 03/26/14)

Controlled Medication Safe Storage and Disposal CP 220 (Upd 09/02/15) 

     Form:  Controlled Substance Disposition Record (Rev 05/15)

Core Services CP-214 (Rev 03/26/14)

CPR Certification CP-216 (Rev 03/26/14)

Criteria for Further Assessment CP-217 (Rev 03/26/14)

Deactivation of the Implantable Cardioverter Defibrillator (ICD) CP-285 (New 05/28/08)

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

     Form - Funeral Director Information R0609

Determining Medicare Eligibility CP-218 (Revised 08/26/2014)

      Form -Attending Physician Change Notice for Hospice Benefit (New 08/14)

     Form - Election of Medicare Hospice Benefit (Rev 04/17/15)

Discharge from Hospice Services  CP 219  (Rev 03/21/17)
     Form - Acknowledgement of Discharge (Rev 10/16)

    Form - Discharge Summary (Rev 10/16)

   Form - Notice of Medicare Non Coverage  NOMNC Live Discharge CMS10123 (Rev 02/17)

                  CMS 10123 Instructions Upd 0217
     Form - Detailed Explaination Notice of Medicare Non Coverage NOMNC DENC CMS 10124 (Rev 02/17)
                 CMS 10124 Instructions Upd0217 

  Do Not Resuscitate CP-221 (Upd 07/01/2008)

     Form - Do Not Resuscitate NYS (DNR) DOH3474 04/09
                 Brochure:  Do Not Resuscitate DOH
     Form -Waiver of DNR (Rev 07/16)

Electronic Signatures CP-250 (Rev 03/21/17)

Emergency Preparedness CP-280 (Rev 03/21/17)

Emergency Room CP-282 (Rev 03/26/14)

Ethical Issues: Consultation & Resolution CP-225 (Rev 03/26/14)

Evaluating Proposed Treatment of Expanded Hospice Therapy  CP-226 (Rev 12/01/16)

Functional Status Assessment  CP-227 (Rev 03/26/14)

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

     Form -Hospice Aide Activity Sheet (Rev 12/16)
     Form  -Hospice Aide Extended Service Checklist (Rev 12/16)
     Form - Hospice Aide Orientation/Supervision Summary (Rev 12/16)
     Form - Hospice Aide Orientation to Hospice Care (Rev 12/16)

     Form - Hospice Aide Plan of Care (Rev 12/16)
     FormHospice Aide Request Fax (Rev 12/16)
     Form- Hospice Aide Tracking Sheet (Rev 12/16)
     Form - HA Contract Monitoring Audit Tool

Hospice Approved Medications  CP-222 (Rev 03/21/17)

      Exhibit A - List of Hospice Approved Medications (Hospiscript Rev 2012)

Infection Control: Bloodborne Pathogens - Exposure Control Plan (ECP) CP-289 (New 11/17/15)

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

Infection Control: Hand Hygiene CP228 (Revised 11/17/15)

Infection Control: Influenza Vaccination CP288 (New 11/17/15)

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

     Form: Report of Emergency Involving Patient Treatment - Staff Unable to Use PPE (Upd 6/15)

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

Infection Control: Standard and Transmission Based Precautions CP270 (Rev 11/17/15)

     Form: Post Exposure Followup Checklist (Upd 06/15)

    Form: Post Exposure Needlestick/Sharps (Upd 06/15)

    Form: Post Exposure Splash (Upd 06/15)

    Form: Sharps Injury Record (Upd 06/15)

Infection Control: Surveillance CP293 (New 11/17/15)

  Form - Infection Control Monthly Tracking Sheet (Rev 02/15)
  Form  - Infection Control Surveillance Report (Rev 04/16

Infection Control: Tuberculosis CP292 (New 11/17/15)

    Form: Annual Review of Positive TB Test (Rev 08/16)

 Initial and Comprehensive Assessment of Patient CP233 (Rev 03/21/177) 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 (Rev 03/26/14)
     Form - Guidelines and Protocols for Symptom Control Hospital Admissions (Rev 01/17)

    Form - Information for Patients/Families During Hospitalization (Rev 01/17)

    Form - Inpatient Admission Checklist (Rev 05/15)
     Form Inpatient Admission Worksheet (Rev 05/15)

Interdisciplinary Team (IDT) CP-286 (Rev 05/23/17)

     Form - IDT Sign-in Sheet (Rev01/15)

     Form - Interdisciplinary Team Meeting (IDT) (Rev07/16)

Life Sustaining Treatment: Decisions to Give, Withhold, or Terminate Treatment CP-235 (Rev 05/23/2017)

Medical Management of the Hospice Patient  CP-236 (Rev 05/15)

     Form: Fax-Non-Urgent Physician Notification (Rev 03/17)
     Form - Medical Director Consultation (Rev 05/15)

Medication Administration  CP-238 (Rev 03/21/17)

     Form - Home Medication Schedule (Rev 04/17)
     Form - Hospiscript Fax Cover Sheet (Essex)
     Form - Hospiscript Fax Cover Sheet (Tri Lakes)
     Form- Hospiscript Fax Cover Sheet (Warren)

Medication Errors CP-239 (Rev 03/21/17)
     Form - Medication Incident Report (Rev 05/16)

Medication Reactions CP-240 (Rev 03/26/14)

Movement of Patients Between Sites within HPHPC CP-269 (Rev 05/25/16) replaced "Transfer of Patients Between Sites within HPHPC

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

Nursing Care CP-242 (Rev 05/23/2017)
     Form - Documentation Guidelines (Rev 1/10)
     Form - Home Visit Performance Appraisal (Rev 05/17)

    Form -  Precautions to Avoid Fire Hazards with Oxygen Use (Rev 05/17)

Nursing Home Care CP-277 (Upd 07/01/2008)

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

 

     Form: Nutritional Consult (Rev 05/15)

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 (Rev05/17)    

                 Instructions: ABN of Non Coverage CMS-R-131

    Form - Financial Assistance Eligibility (Rev 04/16)

    Form -  Nursing Home Room & Board Authorization (Rev 01/17)
    Form-  Patient Commercial Insurance Coverage Summary (R09/13)

    Form - Temporary Relocation Agreement (Rev04/12)

Patient/Family Bill of Rights CP-246 (Rev 05/25/16)

       FormPatient/Family Bill of Rights (Rev 10/16)

Patient/Family Informed Consent CP-248  (Rev 05/23/2017)

      Chart - Informed Consent Flowsheet by Arent Fox

       Information -  Informed Consent Policy by Arent Fox

Patient/Family Plan of Care CP-247 (Rev 05/23/2017)

        Form - 48 Hour Care Plan Review (Rev 05/17)

Patient Readmission CP-278 (Rev 03/26/14)

Patient Reassessment CP-243 (Rev 05/23/2017)

Patient Responsibilities CP-249 (Rev 05/23/2017)
      Form - Your Responsibility as a Patient (Rev 11/11)

Physician Billing for Consultation Services CP-251 (Upd 07/01/08)

Professional Management CP-253 (Rev 03/26/14)

Professional Nursing Practice CP-254 (Rev 03/26/14)

Recertification of Hospice Eligibility CP-255  (Upd 01/01/2011)
    Form- Narrative for Face to Face Visit R08/13

    Form- Assessment Worksheet for Face to Face Visit  5 Pages (N08/13)

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

     Form: Referral/Informational for Hospice Care (Rev 08/16)

Respite Care CP-256  (Rev 03/26/14)

     Form: Respite Care Admission Physician Information (Rev 01/17)

    FormGuidelines and Protocol for Respite Care (Upd 06/15)

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

      Form: Revocation of Medicare Hospice Benefit (Rev 05/17)

Scope of Service  CP-259 (Rev 05/23/2017)
     Information- Hospice Care Services (Rev 05/17)

Scope of Service – Bereavement CP-260 (Rev 03/26/14)
     Form - Bereavement Follow-Up Adult (Upd 02/12)
     Form - Bereavement Follow-Up Child (Upd 02/12)
     Form - Bereavement Referral Form - Adult (Upd 02/12)
     Form - Bereavement Referral Form - Child (Upd 02/12)

Scope of Service – Nursing Practice CP-261 (Rev 05/23/2017)  

Scope of Service – Social Work CP-262 (Upd 07/01/2008)

Scope of Service - Spiritual Care CP263 (Rev 03/21/17) was "Scope of Service - Pastoral Care"

Suicide and Suicide Risk Assessment CP-264 (Rev 05/29/14)

Supplies and Equipment CP-265 (Rev 03/26/14)

     Form : DME Tracking Record Upd 06/15

Suspected Abuse and/or Neglect CP-266 (Upd 07/01/2008)
      FormReport of Suspected Child Abuse  (NYS OCFSForm 09/16) Fill in form on NYS OCFS website

Theft of Controlled Substances CP-283 (Revised 08/26/2014)

Therapy Services CP-267 (Rev 03/26/14)

Transfer of Patiens to Different Hospice CP-279 (Rev 05/23/2017)
     Form - Patient Transfer (R04/12) 

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