(d) The governing body’s records shall reflect direct involvement in hospice policy development and oversight to include but not be limited to:

1. (1) Responsibilities of the administrator and medical director;
2. (2) Management of contracted services;
3. (3) Patient admission criteria;
4. (4) Patient and family involvement in patient care planning; and
5. (5) An ongoing, comprehensive self-assessment of the quality of care provided to patients.

(f) The governing body shall ensure:

1. (1) Nursing services, physician services, drugs, and biologicals are routinely available on a twenty-four-hour basis;
2. (2) All other services are available on a twenty-four-hour basis to the extent necessary to meet the needs of patients for care that is reasonable and necessary for the palliation and management of terminal illness and related conditions; and
3. (3) All services provided are consistent with accepted standards of practice.