Administration

(A) Administrator. (1) Each hospice shall designate a hospice administrator who is responsible to the governing body, either directly or through the governing body's chief executive officer, for the administration and management of the hospice. (2) The hospice administrator shall be a person who has a minimum of two years of relevant experience in the health care, human services or related fields, which shall include at least one year of supervisory/administrative experience. (3) The duties of the administrator shall include but not be limited to: (a) Directing the hospice and ensuring implementation of policies and procedures regarding all activities and services provided in the hospice, whether provided through staff employed directly by the hospice, by volunteers or through contract arrangement; (b) Designating, in writing, an alternate to act in his or her absence; (c) Implementing administrative and personnel policies; (d) Implementing an effective budgetary and accounting system; (e) Implementing a quality assurance mechanism to assess the overall hospice program; (f) Keeping the governing body informed of the hospice's operations; (g) Appointing qualified hospice staff members when and where appropriate and ensuring adequate staff education and evaluations; (h) Developing and proposing an annual budget for adoption by the governing body and managing the financial aspects of the hospice; (i) Ensuring that action is taken to correct problems identified either through patient/ family record reviews, fiscal audits, or as a result of patient/family recommendations; (j) Ensuring a public education program through contact with community organization to inform consumers about hospice care; (k) Ensuring that patient care services are appropriately coordinated; and (l) Ensuring incident reports are submitted to the Department as required under 105 CMR 141.201(F). (B) Clinical Services Coordinator. (1) The hospice shall designate an individual to be responsible for coordinating the clinical services provided by the individuals providing care to hospice patients. Clinical services include at least nursing, medical, social work and counseling. (2) The for clinical services coordinator shall be a health care professional possessing academic training and experience in direct patient care and shall be qualified to coordinate the clinical services provided by the hospice. (3) A staff person serving in another position within the hospice may also be the clinical services coordinator if he or she meets the requirements for both positions and can adequately carry out the duties of both positions. (C) Personnel Policies. Each hospice shall establish and maintain current written personnel policies and personnel practices and procedures that encourage good patient/family care. These policies and procedures shall be reviewed and updated annually and shall cover at least the following: (1) Position descriptions for each category of employee, volunteer, or contracted personnel which clearly identify qualifications, duties, responsibilities and accountability of the individual assuming the position. Work assignments shall be consistent with job descriptions, qualifications and education. (2) Orientation to hospice care for all personnel, including employees of contracting agencies and volunteers. (3) Organized staff support programs to help staff cope with their job responsibilities. (4) Employee health policies that include, as a minimum, adequate provisions for preventing the transmission of communicable diseases. (5) Regular evaluation of staff performance. (D) Requirement for Personnel to Be Vaccinated against Coronavirus Disease 2019 (COVID-19) Caused by the Virus SARS-CoV-2 and Influenza Virus (1) Requirement for Personnel to Be Vaccinated against Coronavirus Disease 2019 (COVID-19) Caused by the Virus SARS-CoV-2 (a) Definitions. 1. For purposes of 105 CMR 141.201(D)(1), personnel means: a. an individual or individuals who either work at or come to the hospice inpatient facility and who are employed by or affiliated with the facility, whether directly, by contract with another entity, or as an independent contractor, paid or unpaid including, but not limited to, employees, members of the medical staff, contract employees or staff, students, and volunteers, whether or not such individual(s) provide direct patient care; or b. an individual or individuals who provides direct patient care and who is employed by or affiliated with a hospice program that provides residential hospice services, whether directly, by contract with another entity, or as an independent contractor, paid or unpaid, including, but not limited to, employees, members of the medical staff, contract employees or staff, students, and volunteers. 2. For purposes of 105 CMR 141.201(D)(1), COVID-19 vaccination means being up to date with COVID-19 vaccines as recommended by the Centers for Disease Control and Prevention (CDC). 3. For purposes of 105 CMR 141.201(D)(1), mitigation measures mean measures that personnel who are exempt from vaccination must take to prevent viral infection and transmission. (b) Each program shall ensure all personnel have received COVID-19 vaccination in the timeframe specified in Department guidelines, unless an individual is exempt from vaccination in accordance with 105 CMR 141.201(D)(1)(e). (c) Each program shall provide all personnel with information about the risks and benefits of COVID-19 vaccination. (d) Each program shall notify all personnel of the COVID-19 vaccination requirements of 105 CMR 141.201(D)(1)(b) and shall, at no cost to any personnel, provide or arrange for vaccination of all personnel who cannot provide proof of current vaccination against COVID-19 unless an individual is exempt from vaccination in accordance with 105 CMR 141.201(D)(1)(e). (e) Exemptions. 1. Subject to the provisions set forth in 105 CMR 141.201(D)(1)(e)(ii), a program shall not require an individual to receive a COVID-19 vaccine pursuant to 105 CMR 141.201(D)(1)(b) if the individual declines the vaccine. 2. For any individual subject to the exemption, a program shall require such individual take mitigation measures, consistent with guidance from the Department. 3. An individual who is exempt from vaccination shall sign a statement certifying that they are exempt from vaccination and they received information about the risks and benefits of COVID-19 vaccine. (f) Unavailability of Vaccine. A program shall not be required to provide or arrange for COVID-19 vaccination during such times the vaccine is unavailable for purchase, shipment, distribution, or administration by a third party or when complying with an order of the Commissioner restricting the use of the vaccine. A program shall obtain and administer COVID-19 vaccine in accordance with 105 CMR 141.201(D)(1) as soon as vaccine becomes available. (g) Documentation. 1. A program shall require and maintain for each individual proof of current vaccination against COVID-19 virus pursuant to 105 CMR 141.201(D)(1)(b) or the individual's exemption statement pursuant to 105 CMR 141.201(D)(1)(e). 2. Each program shall maintain a central system to track the vaccination status of all personnel. 3. If a program is unable to provide or arrange for COVID-19 vaccination for any individual, it shall document the reasons such vaccination could not be provided or arranged for. (h) Reporting and Data Collection. Each program shall report information to the Department documenting the program's compliance with the personnel vaccination requirements of 105 CMR 141.201(D)(1) in accordance with reporting and data collection guidelines of the Commissioner. (i) 105 CMR 141.201(D)(1) establishes requirements for COVID-19 vaccination of hospice program personnel. Nothing in 105 CMR 141.000 shall be read to prohibit hospice programs from establishing policies and procedures for COVID-19 vaccination of personnel that exceed the requirements set forth in 105 CMR 141.201(D)(1). (2) Requirement for Personnel to Be Vaccinated against Influenza Virus. (a) Definitions. 1. For purposes of 105 CMR 141.201(D)(2), personnel means: a. an individual or individuals who either work at or come to the hospice inpatient facility and who are employed by or affiliated with the facility, whether directly, by contract with another entity, or as an independent contractor, paid or unpaid including, but not limited to, employees, members of the medical staff, contract employees or staff, students, and volunteers, whether or not such individual(s) provide direct patient care; or b. an individual or individuals who provide direct patient care and who is employed by or affiliated with a hospice program that provides residential hospice services, whether directly, by contract with another entity, or as an independent contractor, paid or unpaid including, but not limited to, employees, members of the medical staff, contract employees or staff, students, and volunteers. 2. For purposes of 105 CMR 141.201(D)(2), the requirement for influenza vaccine or vaccination means immunization by either influenza vaccine, inactivated or live; attenuated influenza vaccine including seasonal influenza vaccine pursuant to 105 CMR 141.201(D)(2)(b) and/or other influenza vaccine pursuant to 105 CMR 141.201(D)(2)(c). 3. For purposes of 105 CMR 141.201(D)(2), mitigation measures mean measures that personnel who are exempt from vaccination must take to prevent viral infection and transmission. (b) Each program shall ensure all personnel are vaccinated annually with seasonal influenza vaccine, consistent with any guidelines of the Commissioner, unless an individual is exempt from vaccination in accordance with 105 CMR 141.201(D)(2)(f). (c) Each program also shall ensure all personnel are vaccinated against other pandemic or novel influenza virus(es) as specified in guidelines of the Commissioner, unless an individual is exempt from vaccination in accordance with 105 CMR 141.201(D)(2)(f). Such guidelines may specify: 1. The categories of personnel to be vaccinated and the order of priority of vaccination of personnel, with priority for personnel with responsibility for direct care; 2. The influenza vaccine(s) to be administered; 3. The dates by which personnel must be vaccinated; and 4. Any required reporting and data collection relating to the personnel vaccination requirement of 105 CMR 141.201(D)(2). (d) Each program shall provide all personnel with information about the risks and benefits of influenza vaccine. (e) Each program shall notify all personnel of the influenza vaccination requirements of 105 CMR 141.201(D)(2) and shall, at no cost to any personnel, provide or arrange for vaccination of all personnel who cannot provide proof of current immunization against influenza unless an individual is exempt from vaccination in accordance with 105 CMR 141.201(D)(2)(f). (f) Exemptions. 1. Subject to the provisions set forth in 105 CMR 141.201(D)(2)(f)(ii), a program shall not require an individual to receive an influenza vaccine pursuant to 105 CMR 141.201(D)(2)(b) or (c) if the individual declines the vaccine. 2. For any individual subject to the exemption, a program shall require such individual take mitigation measures, consistent with guidance from the Department. 3. An individual who is exempt from vaccination shall sign a statement certifying that they are exempt from vaccination and they received information about the risks and benefits of influenza vaccine. (g) Unavailability of Vaccine. A program shall not be required to provide or arrange for influenza vaccination during such times the vaccine is unavailable for purchase, shipment, distribution or administration by a third-party or when complying with an order of the Commissioner restricting the use of the vaccine. A program shall obtain and administer influenza vaccine in accordance with 105 CMR 141.201(D)(2) as soon as vaccine becomes available. (h) Documentation. 1. A program shall require and maintain for each individual proof of current vaccination against influenza virus pursuant to 105 CMR 141.201(D)(2)(b) or (c) or the individual's exemption statement pursuant to 105 CMR 141.201(D)(2)(f). 2. Each program shall maintain a central system to track the vaccination status of all personnel. 3. If a program is unable to provide or arrange for influenza vaccination for any individual, it shall document the reasons such vaccination could not be provided or arranged for. (i) Reporting and Data Collection. Each program shall report information to the Department documenting the facility's compliance with the personnel vaccination requirements of105 CMR 141.201(D)(2), in accordance with reporting and data collection guidelines of the Commissioner. (j) 105 CMR 141.201(D)(2) establishes requirements for influenza vaccination of hospice program personnel. Nothing in 105 CMR 141.000 shall be read to prohibit hospice programs from establishing policies and procedures for influenza vaccination of personnel that exceed the requirements set forth in 105 CMR 141.201(D)(2). (E) Administrative Records. (1) Each hospice shall maintain current, complete and accurate administrative records. The hospice shall make all administrative records available promptly to any agent of the Department seeking to determine compliance with 105 CMR 141.000. (2) Administrative records shall include: (a) updated articles of organization and by-laws; (b) minutes of the meetings of the governing body; (c) an organizational chart; and (d) personnel records for each employee, including evidence of any required license or registration number, documentation of any specialty certification, documentation of initial training and ongoing annual training on dementia care consistent with the requirements of 105 CMR 150.024 and 150.025 for employees providing direct care to nursing home residents, education and job experience. A hospice agency is not required to train an employee, consistent with the requirements of 105 CMR 150.024: Staff Qualifications and Training and 105 CMR 150.025: Content of Training, if the employee has completed the required training at a different location, provided the initial training and any ongoing training is documented in the personnel record. (F) Incident Reporting. (1) All incidents seriously affecting the health or safety of patients resulting from acts or omissions of hospice program employees, including those working for the hospice through a contract arrangement with another organization, and volunteers shall be recorded and reported accurately to the Department within seven days of the occurrence. Such reports shall be made in a format prescribed by the Department. (2) A hospice inpatient facility shall also report immediately any of the following which occurs on premises covered by its license: (a) death that is unanticipated, not related to the natural course of the patient’s illness or underlying condition, or that is the result of an error or other incident as specified in guidelines of the Department; (b) full or partial evacuation of the facility for any reason; (c) fire; (d) suicide; (e) serious criminal acts; (f) pending or actual strike action by its employees, and contingency plans for operation of the program or facility; or (g) any other serious incident or accident as specified in guidelines of the Department. (3) A hospice program shall make available to the Department all information that may be relevant to the Department’s investigation of any incident or complaint, regardless of how reported to the Department. (4) A hospice program shall make all reasonable efforts to facilitate the Department’s attempts to interview any and all potential witnesses who may have information relevant to the Department’s investigation of any incident or complaint, regardless of how reported to the Department. (G) Patient Abuse, Mistreatment, Neglect or Misappropriation of Property. In accordance with 105 CMR 155.000: Patient and Resident Abuse Prevention, Reporting, Investigation, Penalties and Registry, hospice administrators and workers shall immediately report to the Department any suspected instance(s) of hospice patient abuse, mistreatment, neglect or misappropriation of hospice patient property. (H) Grievance Procedure. (1) The hospice patient has the right to voice grievances without discrimination or reprisal. Such grievances include those with respect to treatment that has been furnished as well as that which has not been furnished. (2) The hospice program must promptly acknowledge and actively work to resolve all oral and written patient grievances.