health.pa.gov Apply for a Hospice Agency License : Pennsylvania Department of Health

Name of the Organization : Pennsylvania Department of Health
Type of Facility : Apply for a Hospice Agency License
State : Pennsylvania
Country : United States of America

Website : http://www.health.pa.gov/facilities/Consumers/Health%20Facilities/Home%20Health%20Services%20amp;%20Hospices/Pages/Hospicelicensure.aspx#.V1_PoeQgsqg
Download Instruction : https://www.statusin.org/uploads/24111-hospice.pdf

Apply for a Hospice Agency License  :

Hospice Agency State Licensure and/or Federal Medicare Certification :
** To apply for the state Hospice Agency License, complete the following five documents –

Related : Pennsylvania Department of Health Apply for a Home Care Agency/Registry License : www.statusin.org/24105.html

Hospice Agency Application Materials:
** Initial Hospice Application
** Civil Rights Survey
** Documentation Required for Initial Hospice License
** Questions for Initial Hospice Agency
** Password Agreement Form for Facility Administrator
** If your application is in accordance with Pa. state licensure rules and regulations, the Division will issue you a license.
** Please keep in mind the length of time for the licensure process depends upon the accuracy of information provided.

Hospice Agency Application for Federal Medicare Certification :
Note :
** State licensure as a Hospice Agency is a requirement for Federal certification.
** Please submit one copy of the CMS Form 417 to the Division of Home Health.
** Please submit one copy of the CMS Form 690 to the Division of Home Health.
** Please submit one copy of the CMS Form 1561 to the Division of Home Health.
** Please submit the CMS Form 855A – Enrollment Application to your Fiscal Intermediary – see Helpful Links on the right.

Documentation Required For Hospice Licensure Approval :
** The following material must be submitted with your license application.
** This documentation will be reviewed by the Division of Home Health for substantial compliance with the federal conditions of participating for a hospice facility
** (Code of Federal Regulations (CFR), Title 42, Part 418 – Hospice Care).
** The Hospice cannot admit or treat any patients until approval is received from the Department of Health.

Please send the following :
Patient Rights :
1. Policy for informed consent
2. Copy of patient rights

Initial and Comprehensive Assessment of the Patient :
1. Policy for initial assessment
2. Policy for completion of the comprehensive assessment.

Interdisciplinary Group, Care Planning and Coordinated Services :
1. List members and interdisciplinary group (including professional background).
2. Policy for IDG
3. If more than one IDG, indicate which is responsible for establishing policies and procedures
4. Policy for establishment of the plan of care
5. Copy of plan of care forms
6. Policy for review of the plan of care

Quality Assessment and Performance Improvement :
1. Policy for QAPI
2. List individuals with titles responsible for operating QAPI

Infection Control :
1. Infection control policy
2. Policy for monitoring staff for compliance with infection control policy and procedure
3. Policy for infection control education for staff

Licensed Professional Services :
1. List of hospice employees
2. Policy and procedure for verifying validity of professional license
3. Policy and procedure for criminal background checks
4. Policy for in-service training and copy of in-service plan

Core Services :
1. List services which are provided by the hospice employee
2. Policy for social services, counseling services, bereavement counseling, dietary counseling and spiritual counseling
3. Resume and job description of Medical Social Worker, Bereavement Counselor, Dietary Counselor, and spiritual counselor
4. Names and copy of job description of physician employees of the Hospice