Hospice Standards of Practice

The Michigan Home Care recommends to it’s membership the following Standards of Practice as a basis of development for each agency’s individualized standards of care.

The Michigan Home Care recommends to its membership the following Guidelines for Implementation of Standards of Practice as a basis of development for each agency’s individualized guidelines.

Standard I

Hospice services are provided in accordance with professionally recognized standards.

Guidelines:

1. The agency has a process to insure that a person’s qualifications are consistent with his/her job responsibilities and applicable laws/regulations.
2. Competency to perform job responsibilities is assessed, demonstrated, and maintained per policies of the agency and applicable laws/regulations.
3. The agency assures adequate number and mix of appropriately trained staff to meet the needs of the client.

Standard II

The initial assessment is completed by the appropriate personnel.

Guidelines

1. The appropriately licensed professional completes the initial assessment on all clinical care clients.
2. The initial assessment visit of the client/family may include but is not limited to the following:
   1. Data collection related to the client’s physical, psychosocial, spiritual status and environmental conditions, as appropriate to the service provided
   2. An explanation of services
   3. Disclosure of financial responsibility
   4. Development of a service plan of care
   5. Client/advocates authorization for care, treatment, services
   6. Obtaining physician’s orders as necessary
   7. Arranging support services as necessary
3. The assessment information is recorded in a timely, efficient and retrievable manner according to agency policy.
4. The need for and frequency of reassessment/re-evaluation is determined in accordance with agency policies, applicable laws/regulations and client status.
5. Services are delivered in a timely manner in accordance with agency policy. Factors influencing the assignment of responsibilities include:
   1. Skill level required
   2. Availability of personnel
   3. Client/family requests
   4. Third party payor coverage
   5. Physician’s orders
   6. Applicable laws/regulations
6. On-call coordinator services are available to meet the needs of the client.

Standard III

Assessment data collection is systematic, documented and communicated within the agency policies and applicable laws/regulations.

Guidelines

1. Data collection may include:
   1. Assessment of the client/family physical, psychosocial, and spiritual status
   2. Assessment of the client’s environment of care
   3. Assessment of the client’s goals of care and immediate needs
   4. The client’s medical history, physician orders, medical treatment plan, when appropriate
   5. Assessment of the client/family support systems, community resources
   6. Assessment of family dynamics
   7. Assessment of social, cultural, ethnic and spiritual beliefs/practices affecting health
   8. Assessment of learning needs/barriers that may affect services
   9. Assessment of abuse, neglect and exploitation of the client
2. The hospice agency maintains a record keeping system that provides for:
   1. Systematic, complete, and retrievable collection of data
   2. Frequent updating of records
   3. Confidentiality of the records

Standard IV

Plans of service are developed for all clients/families based on agency policy, services provided, applicable laws/regulations, and place of service.

Guidelines

1. All assessment data are interpreted and analyzed in collaboration with the client, family and caregivers prior to formulating a plan of service.
2. The plan of service includes goals/expected outcomes that are individualized to the patient/family and appropriate to the service delivery.
   1. To achieve the goals and expected outcomes the professional will:
      • Provide appropriate professional intervention
      • Coordinate available community resources
      • Provide instructions for safety
      • Initiate or develop a support system as needed
      • Encourage client/family participation in determination of goals
      • Educate the client/family toward goals and expected outcomes
   2. Expected outcomes for services provided may include:
      • An improved level of well-being
      • Optimal independence
      • Comfort
3. Plans for service include interventions to achieve the identified goals and expected outcomes.
   1. Interventions are developed based on expected client outcomes. They may provide one or more of the following:
      • Comfort
      • Restoration
      • Health promotion/maintenance
      • Prevention of complications
      • Education
      • Safety
   2. Interventions are:
      • Specific/individualized
      • Consistent with the plan of care
      • Consistent with the defined standards of practice
      • In accordance with the client/family physiological, psychosocial and spiritual needs
      • Inclusive of teaching and education
   3. Interventions and the client’s response to the interventions are recorded according to agency policy
   4. The agency maintains a policy/procedure manual for clinical practices
   5. The agency maintains an internal review to ensure that clinical practices follow the established policies/procedures
4. The client/family progress toward goal achievement is evaluated as appropriate to the service provided.
   1. Plans toward goal achievement are dependent on evaluation of mutually agreed upon outcomes
   2. Baseline and ongoing data are reviewed and interpreted to measure progress toward goals
   3. Active participation of client, family, or caregiver is encouraged to revise priorities, goals, and interventions
   4. Revisions to the plan of service are documented per agency policy

Standard V

Continuity of care is assured.

Guidelines

1. The plan of service includes the utilization of available and appropriate resources. They may include any or all of the following:
   1. Core Hospice services
   2. Additional Hospice services
   3. Client education materials
   4. Community resources
   5. Other medical providers
2. The client/family/significant other are provided with information needed to make decisions and choices about:
   1. Promoting, maintaining and restoring wellness
   2. Seeking and utilizing appropriate health care personnel
   3. Maintaining and using health care resources
3. During transition from one agency to another, the professional provides adequate information to assure coordination of services.
4. There is documentation in the client record of coordination among referral sources and contracted services.

Standard VI

An emergency plan is established for the client.

Guidelines

1. An emergency plan related to the care or service provided is established by all agencies.
2. The emergency plan may include, but is not limited to the following:
   1. Emergency contact’s names and phone numbers
   2. Basic home safety precautions
   3. Changes in medical condition to report to physician and/or home care organization.
3. The emergency plan is reviewed with the client, family, and care givers.
4. The emergency plan is understood by staff providing services.

Standard VII

Continuing educational growth of staff is encouraged.

Guidelines

1. The hospice organization provides resources to all staff for participation in continuing education activities.
2. Continuing education is based on identified needs.

Standard VIII

The agency collects data to monitor its performance, per agency policy and applicable laws/regulations.

Guidelines

1. Data is systematically gathered and analyzed on an on-going basis.
2. Data collected is based on the risk/safety of the client/care provider.
3. Undesired patterns are identified and changes made to ensure safety.
4. Re-evaluation of impact of change is monitored.

Standard IV

The agency follows ethical practice in the delivery of services.

Guidelines

1. The agency develops policies that address:
   1. Patient rights/responsibilities
   2. Patient/family decisions regarding care/treatment.
   3. Informed consent
   4. Right to refuse care/services
   5. Advanced directives
   6. Resolution of complaints
2. The agency reviews its policies to promote access to care.