The Salvation Army Agapé Hospice Policy Page
The Salvation Army Agapé Hospice prioritizes the safety and privacy of its clients, donors, employees, and members’ personal information.
We value the trust of those with whom we deal and of the public and recognize that maintaining this trust requires that we protect all personal information you share with us.
Section 1 – Delivery of Care to residents and Families
- 0101 – Admission Process and Assessment
- 0102 – Development Implementation and Evaluation
- 0103 – Allergy Identification
- 0104 -Identification of Caregivers, Service Providers
- 0105 – Clinical Documentation
- 0112 – Transition From Agape Hospice
- 0113a – Inquiries regarding deceased residents
- 0113b – Inquiries Regarding Past-Present Residents from Professional Agencies
- 0116 – Waiver of Responsibility
- 0117 – Resident Passes (Day Passes)
- 0117b – Pass Medication Preparation (including controlled drugs)
- 0118 – Requests for Physician Consults, Implementation of Consultant’s Recommendations
- 0119 – Bereavement Period of Residents Room
- 0120 – Physician Responsible for Resident Care
- 0121 – Respite Admissions At Agape Hospice
- 0122 – Safe Bath and Shower Water Temperatures
- 0124 – Process for Contacting Physicians
- 0142 – Identifiying Residents Prior to Providing Services
- 0145 -Death Care and Transport of Body
- 0146 – Resident’s Belongings
- 0150 – Mechanical Lifts
- 0150 SOP(N) – Mechanical Lifts
- 0155 – Exposure to Blood and Body Fluids
- 0160 – Disposal, Storage, and Cleaning of Wound Care Equipment
- 0163 – Privately Hired Personnel
- 0164 – Unregulated Privately Hired Personnel
- 0165 – Nail Care and Care of Equipment
- 0170 – Assessing Suicide Reviewing Risk
- 0175 – Autopsy Requested by Family
- 0176 – Autopsy required by law
- 0177 – Eye Donation
- 0179 – Medication Reconcilation
- 0180 – Medication Review for Residents
- 0185 – Advance Care Planning
- 0186 – Discharge Against Medical Advice
- 0190 – Pet Visitation
- 0195 – Refused-Declined Admission
- 0196 – Oral Care and Bathing Frequency
- 0197 – Medical Assistance in Dying
- 0198 – Residents Rights and Responsibilities
- 0199 – Pandemic Visitation Policy
Section 2 – Pain and Symptom Management
- 0201 – Revised Ongoing Pain Symptom Assessment
- 0205 – Oxygen Therapy criteria REVISED
- 0207 – Pressure Ulcer Prevention Program
- 0208 – Insertion & Use of Urinary Drainage Catheter
- 0209 – Management of Pressure Ulcers and Wounds
- 0211 – Intravenous Hydration Therapy
- 0213 – Hypodermoclysis Hydration for Symptom Control
- 0214 – Artificial Nutrition
- 0215 – Transfusion of Blood, Blood Products REVISED
- 0216 – Medication Ordering and Administration 1
- 0217 – Self Administration of Medication
- 0218 – Using Medications Brought from Home
- 0220 – Continuous Subcutaneous Infusion
- 0222 – Intramuscular Administration of Medications
- 0223 – Routine Vital Signs
- 0224 Management of febrile states
- 0225 – Alternative,Non-tradition therapies
- 0226 – Restraints
- 0227 – Management of Adverse Effects of Medication
- 0228 – Calculation of Equianalgesic Dosages
- 0229 – Compounded Medications
- 0230 – Transcribing and Checking Doctors Orders
- 0233 – Hypoglycemia Treatment
- 0235 – Blood Glucose Monitoring
- 0240 – Chest Tube Drainage with Pleurx Catheter
- 0243 – Peritoneal Drainage
- 0244 – Biliary Drains
- 0245 – Bladder Irrigation – Manual
- 0246 – Nephrostomy Tubes – Maintenance Dressings
- 0248 – Controlled Drug Management
- 0249 – Safe Handling and Administration of Oral Cytotoxic Drugs/Safe Handling of Human Waste of Residents on Cytotoxic Medications
- 0250 – Anaphylaxis Management
- 0255 – Palliative Sedation
- 0259 – Recieved and Returned Medications
- 0260 – Administration of Naloxone
- 0265 – Methadone Use in a Hospice Setting
- 0270 – Enteral Feeding tubes
- 0271 – Oropharyngeal Suctioning
- 0272 – Tracheostomy Management, Care and Tracheal Suctioning
- 0280 – Partial-Light or Temporary Sedation
- 0281 – STAT medication supply
- 0282 – High-Alert Medication Management
- 0283 Palliative Epidural and Intrathecal Infusion
Section 3 – Psychological, Social and Spiritual Support
- 0302 – Community Clergy and Lay Visitors
- 0303 – Chapel Services
- 0304 – Spirituality Issues – Staff Response to Residents and Families
- 0305 – Proselytizing (Spreading of Religion)
- 0306 – Distribution of Religious Literature
- 0307 – Spiritual Care Responsibilities – On-call Support
- 0309 – Social Work
- 0310 – Referral to Social Work
- 0320 – Benevolent Fund
Section 4 – Loss, Grief and Bereavement Support
Section 7 – Pastoral Care – Administration
Section 8 – Volunteer Services – Administration
Section 9 – Administration
- 0901 – Ownership and Governance
- 0902 – Programs and Services
- 0903 – Strategic Planning
- 0905 – Conflict of Interest
- 0909 – Occupational Health and Safety Methodology
- 0911 – Medication Procurement Storage Control
- 0912 – Complaint Management
- 0913 – Records Retention Storage and Destruction
- 0914 – Reporting Annual Report
- 0915 – Fire, Emergency Preparedness
- 0917 – Building Security and Access to Agape Hospice
- 0919 – Recognizing and Responding to Clinical Adverse
- 0920 Private Resident Status
- 0921 Confidentiality
- 0922 – Ethics for Organizational and Clinical Decision Making
- 0923 – Archives
- 0925 – Gifts of Art and Furniture to the Hospice
- 0926 Personal Gifts to Staff
- 0928 Wish List
- 0930 – Protection for Person in Care
- 0931 Workplace Hazardous Materials Information System (WHMIS)
- 0932 – Alcohol and Substance Use
- 0933 Continuous Quality Assurance Improvement Committee – Term of Reference
- 0934 – Resident’s Cash, Personal Effects
- 0935 – Access to Resident Personal Health Information
- 0936 – Severing of Third Part Information from the Health Record
- 0937 Process for Severing of Third Party Info from the Health Record
- 0938 Applicant’s Request for Correction of Own Personal Information in Health Record
- 0940 – Transitory Records
- 0940 SOP – Transitory Records – Guide to Minimizing
- 0941 – Smoking Policy
- 0946 – Request to Attend Workshops and Seminars by Staff
- 0950 Delegation of Responsibiity
- 0951 – Emergency Care for Staff Family Members and Visitors
- 0960 – Policy Development Framework – Final
- 0965 – Use of Abbreviations in Documentation on Health
- 0966 – Relationship with Contractors Outside Agencies
- 0967 – Audio and Video Recording Devices
Section 10 – Human Resources
- 1001 – Mangerial Processes
- 1002 – Position Descriptions
- 1003 – Payroll, Benefits and Vacation Unionized Employees
- 1004 – Employee Orientation
- 1005 – Reporting Relationship of the Executive and Leadership Committees
- 1006 – Interdisciplinary, Management and Support Teams
- 1007 – Hiring Procedures
- 1007a – Criminal and Police Record Checks
- 1008 Exit Interviews
- 1008a Exit Interview Guidelines
- 1009 – Workplace Harassment Discrimination and Violence Prevention Policy
- 1010 – Formal Education Training & Conferences
- 10-1005 – Reporting Relationship of the executive
- 1011 Performance Evaluations
- 1013 Human Resources Business Plan
- 1014 Employee and Volunteer Identification
- 1016 – Vacation Accruals, Utilization and Approvals
- 1019 Employees Access to Personnel File
- 1020 Reference Checks
- 1021 – Unscheduled Absence from Work
- 1023 The Salvation Army Code of Ethics
- 1024 Dress Code
- 1025 – Attendance Awareness Program
- 1028 – Confidentiality – Employee
- 1030 – Job Shadowing
- 1031 – Student Education
- 1032 – Salvation Army Retired Officers – Employment
- 1045 – Termination of Employment
- GV 01.009 – Operating Policy
- HR 06.002 Workplace Harassment, Discrimination and Violence Prevention
- HR 10.002 – Substance Impairment in the Workplace
Section 11 – Occupational Health and Safety
- 1101 – Responsibilities for OHS
- 1102 – Management of Occupational Accidents and WCB Reporting
- 1103 – Workplace Safety Inspectons
- 1104 – Joint Health Safety Committee
- 1105 – GHS_WHMIS
- 1106 – Code of Ethics for the Health and Safety Department
- 1110 – Communicable Disease Prevention & Management
- 1115 – Smoke-Free Workplace
- 1120 – Automatic External Defibrillator
- Tobacco, Smoking, & Vaping Reduction Act of Alberta – 2021
Section 12 – Promotion and Access Marketing Community Liaison
Section 13 – Funding and Fundraising
Section 14 – Education
Section 15 – Research
Section 16 – Legal Administrative
Section 17 – Infection Prevention and Control
- 1701 – Infection Prevention and Control Binder
- 1702 – Hand Hygiene
- 1703 – Environmental Cleaning
- 1704 – Handling Cleaning and Disinfection of Non-Critical Clinical Equipment
- 1705 – Influenza Immunization & Antiviral Prophylaxis for Employees Working at Agape Hospice
- 1710 – IPC Outbreak Management
- 1711 – Preparing and Handling Laboratory Specimens
- 1715 – Selection, Use and Maintenance of Mattresses and Pillows
- 1719 – Handling Contaminated Linens
- 1720 – Selection Cleaning and Disinfection of Resident Care Tub
- 1721 – Shower Cleaning and Disinfection
- 1722 – Pandemic Planning
- 1723 – Management of Waste and Sharps
Section 18 – Accounting
Section 19 – Information Systems
Section 20 – Property
Section 21 – Insurance
Section 23 – Dietary and Kitchen
- 2301 – Food Safety and Sanitation
- 2302 – Menu Planning
- 2303 – Receiving of donated meals – food
- 2304 – Dining Room Operating Rules
- 2305 – Care and Maintenance of Equipment Including Knives
- 2306 – Safe Operating Procedures for Knives and Slicers
- 2310 – Safe Operating Procedures for Material
- 2315 – Safe Operating Procedures for Portable Kitchen
- 2316 – Safe Operating Procedures for Mixers
- 2321 – Safe Operating Procedures for Using Box
- 2323 – Receiving Grocery Delivery or Donated Food Items
Section 24 – Maintenance
Section 25 – Material Management