Required Patient Care Services

(A) A hospice shall provide directly or arrange, pursuant to a written agreement, for the provision of each of the following services at home, in the community and in inpatient facilities: physician services, nursing services, social services, direct service volunteer services, counseling services, and inpatient care for palliative reasons. (B) As needed, the hospice shall provide or arrange for the following services: (1) personal care homemaker; (2) home health aide; (3) therapeutic (dietary, occupational therapy, physical therapy, speech, hearing, respiratory therapy); (4) medical supplies and appliances; (5) pharmaceutical; and (6) respite services. (C) Physician Services. (1) Each hospice shall designate a physician to serve as Medical Director. The medical director shall have overall responsibility for the medical component of patient care and for ensuring achievement and maintenance of quality standards of professional medical care. (2) The duties of the medical director shall include but need not be limited to: (a) Designating another physician to serve as medical director in his or her absence. (b) Consulting and cooperating with the primary care provider or team maintaining the primary responsibility for the patient care pursuant to 105 CMR 141.204(C)(3). (c) Reviewing clinical material of the referring care provider to document: basic disease process; the drug regimen; and assessment of patient's health and prognosis at time of admission. (d) Performing an admission history and physical for each patient who has no other primary care provider. (e) Maintaining liaison with the patient's primary care provider or team and encouraging the patient's primary care provider or team to provide primary care to his or her patient in collaboration with the inter-disciplinary team. (f) Assisting in developing the plan of care for each patient/family with the coordination of the patient's primary care provider or team. (g) Attending and actively participating in interdisciplinary team meetings. (h) Reviewing the medical care provided in patients' homes, and in inpatient and outpatient health care facilities as applicable. (i) Maintaining 24 hour, seven days a week medical coverage when primary care providers are unavailable. (j) Acting as a consultant to patient's primary care provider and members of the interdisciplinary team; helping to develop and review patient/family care policies and procedures; serving on the interdisciplinary care team; and reporting to the administrator regarding medical care delivered to the hospice patient. (k) Participating in establishing written programmatic guidelines for symptom control (e.g., pain, nausea, vomiting, or other symptoms.) (3) A hospice must ensure that each patient has a physician, or a medical team, who maintains the primary responsibility for the patient's medical care. The physician may be the patient's attending physician or may be a physician, including the medical director, selected by the hospice. (4) Each patient's medical record shall clearly indicate the name of the physician or medical team who maintain the primary responsibility for the patient's medical care. (D) Nursing Services. (1) The hospice shall provide nursing services under the direction and supervision of a designated registered nurse qualified by education and experience to direct hospice nursing care. (2) Nursing services, including the services of a registered nurse, shall be available seven days a week, 24 hours a day. (3) The designated registered nurse responsible for supervising nursing services shall work in cooperation with the administrator and with the individual responsible for clinical services coordination in order to: (a) develop and implement nursing objectives, policies and procedures; (b) develop job descriptions for all nursing personnel; (c) establish staffing and on-call schedules to meet patient/family needs; (d) develop and implement orientation programs. (4) A registered nurse shall assess, identify, plan, and evaluate care for the patient/family based on nursing needs. (a) For hospice programs admitting pediatric patients, a registered nurse with clinical pediatric training and experience shall coordinate the implementation of the plan of care for each pediatric patient. (5) Nursing care shall be provided in accordance with recognized standards of nursing practice. (6) All nursing services shall be documented in the patient/family record. (E) Social Work Services. (1) The hospice shall provide social work services to the patient and family. (2) Social work services shall be directed by and shall be provided under the supervision of a licensed certified social worker with an MSW or a licensed independent clinical social worker. (3) Social work services shall be provided by a licensed social worker qualified by education and experience. (4) If social work services are provided solely by one individual, that individual shall be a licensed certified social worker with a MSW or a licensed independent clinical social worker. (5) The individual responsible for directing and supervising hospice social work services shall work in cooperation with the administrator and the individual responsible for clinical services coordination to: (a) develop and implement social work objectives, policies and procedures; (b) develop job descriptions for all social work personnel; (c) develop staffing and on-call schedules to meet patient/family needs; (d) develop and implement orientation programs. (6) A social worker shall assess the patient/family and identify psychosocial needs. (7) Social work services shall be available seven days a week, as needed. (8) Social work services shall be delivered consistent with the patient/family care plan. (9) All social work services shall be documented in the patient/family record. (10) Social work services shall be provided in accordance with recognized standards of social work practice. (F) Direct Service Volunteer Services. (1) The hospice shall provide direct service volunteer services. (2) The hospice shall designate a coordinator of volunteer services who shall develop and implement a direct service volunteer program, coordinate the orientation, education, support and supervision of direct service volunteers, define the roles and responsibilities of direct service volunteers, and coordinate the utilization of direct service volunteers with other hospice staff. (3) The coordinator of volunteer services shall document successful completion of a training and orientation program for all direct service volunteers. (4) The orientation and training program for direct service volunteers shall address at least the following: (a) the hospice program's goals and services; (b) confidentiality and protection of patients/families rights; (c) procedures for responding to such situations as medical emergencies or deaths; (d) the physiological and psychological aspects of terminal disease; (e) family dynamics, coping mechanisms, and psychosocial and spiritual issues surrounding terminal disease, death and bereavement; (f) general communication skills. (5) A direct service volunteer shall be informed of a patient's condition and treatment to the extent necessary to carry out his functions. (6) Services provided by direct service volunteers shall be in accordance with the written plan of care and shall be documented in the clinical record. (7) Direct service volunteers shall have the necessary qualifications and skills to provide the prescribed service. (8) Any volunteer functioning in a professional capacity shall meet the standards of the appropriate profession. (9) The hospice shall have available direct service volunteers sufficient to meet the needs of patients/families. (G) Counseling Services. (1) The hospice shall provide counseling services to assist patients and families as needed and in accordance with the plan of care. (2) Counseling services shall be provided by professional staff or by volunteer staff under the professional supervision of a qualified counselor. (3) Bereavement Counseling. (a) The hospice shall provide bereavement services to the family following the patient's death. (b) Bereavement services shall provide support to enable an individual/family to adjust to experiences associated with death. (c) Bereavement services shall be available to the family for up to one year following the death of the patient. (d) Bereavement services shall be delivered consistent with the bereavement plan of care and with criteria for termination of such services and/or referral of the family to other agencies or providers. (e) Bereavement services shall be coordinated with other community resources judged by the interdisciplinary team to be useful to the family. (f) Bereavement services shall be under the direction and supervision of a person qualified by training and experience for the development, implementation and assessment of a plan of care to meet the needs of the bereaved. (g) All bereavement services provided shall be documented in the patient/family record. (4) Spiritual Counseling. (a) When spiritual counseling is provided to a patient/family by a hospice it shall be provided by a qualified interdisciplinary team member and/or through an arrangement with clergy and/or other spiritual counselors in the community. (b) Hospice spiritual services shall be provided as desired by the patient/family and shall include but need not be limited to the following: 1. spiritual counseling in keeping with the patients/family beliefs; 2. communication with and support of appropriate clergy or other spiritual counselors in the community; 3. consultation and education to patients/families and interdisciplinary team members. (c) When hospice spiritual services are provided through an arrangement with clergy or other spiritual counselors in the community there shall be documentation of ongoing communication between the clergy or other spiritual counselors and the interdisciplinary team members. (d) The hospice shall make reasonable efforts to arrange for visits of clergy or other spiritual counselors in the community to patients who request such visits and shall advise patient families of this opportunity. (e) Spiritual services shall be provided consistent with the plan of care and with criteria for termination of such services and/or referral to other agencies or providers. (f) Spiritual services provided shall be documented in the patient/family record. (5) Psychosocial/Supportive Counseling. (a) When psychosocial/supportive counseling is provided by the hospice, it shall be provided by qualified counselors who are licensed, if applicable. (b) A qualified counselor is an individual with an advanced degree in social work, psychology, mental health counseling, psychiatry or psychiatric nursing or the documented equivalent in education, training and/or experience and who has clinical experience appropriate to the counseling and casework needs of hospice patients/families. (H) Inpatient Care. (1) The hospice shall provide or arrange for short-term inpatient care for the control of pain and management of acute and severe clinical problems that cannot be managed in a home setting. (2) Inpatient care shall be provided in hospitals licensed pursuant to M.G.L. c. 111, § 51 or long term care facilities licensed pursuant to M.G.L. c. 111, § 71 with whom the hospice has entered into a written contract, or hospice inpatient facilities directly owned and operated by a hospice program licensed pursuant to M.G.L. c.111, §57D. (3) Contracts for inpatient care shall, in addition to the provisions of 105 CMR 141.212, include, at a minimum, the following mutually agreed upon terms: (a) that the inpatient provider has established policies consistent with those of the hospice program and that the inpatient care facility agrees to abide by the patient care plan and protocol established by the hospice program; (b) that the hospital or long term care facility will provide the hospice with a copy of the discharge summary and, if requested, a copy of the entire medical record; and (c) that the hospice program shall make available appropriate hospice care training of hospital or long term care facility personnel who provide care under the agreement including staff orientation. (4) The hospice, with respect to the hospice inpatient facility directly owned and operated by the hospice program, shall: (a) meet the requirements of the federal Medicare Conditions of Participation for hospices that provide inpatient care directly (42 CFR 418.100); (b) meet at least the building and physical plant requirements set out at 105 CMR 141.220 and additional physical plant requirements set forth in the federal Medicare Conditions of Participation for hospices that provide inpatient care directly (42 CFR 418.110). 1. The space that constitutes a hospice inpatient facility shall be contiguous space. 2. If a hospice inpatient facility is located in a building that also houses other entities, the hospice inpatient facility shall not be used as a thoroughfare. (c) provide nursing services directly and meet the following additional nursing staffing requirements: 1. A registered nurse shall be designated as director of nursing (or equivalent title). He or she shall be a qualified registered nurse who has administrative authority, responsibility and accountability for the functions, activities and training of nursing services staff. 2. A registered nurse shall be on duty in the hospice inpatient facility to supervise nursing care and nursing personnel 24 hours a day. 3. One registered nurse may serve as both director of nursing and day shift nursing supervisor if he or she can carry out adequately the responsibilities of both positions. 4. Additional licensed nursing and other staff shall be provided to meet each patient's total care needs 24 hours a day. (d) develop written policies and procedures governing infection control. 1. Such policies shall provide for the proper disposal of infectious waste as required by 105 CMR 480.000: Storage and Disposal of Infectious or Physically Dangerous Medical or Biological Waste State Sanitary Code Chapter VIII; 2. If a hospice inpatient facility with an isolation room does not provide the mechanical exhaust ventilation in accordance with plans approved through standards set under 105 CMR 141.220, the facility’s policies must outline procedures for the transfer to a more appropriate facility of patients found to have any infectious disease transmitted by airborne pathogens. The hospice inpatient facility’s admission policies shall preclude the admission of patients with known infectious diseases transmitted by airborne pathogens if the facility’s isolation room does not meet the mechanical exhaust requirements in accordance with said standards. (e) meet the following dietary services requirements: 1. All hospice inpatient facilities shall provide adequate dietary services to meet the daily dietary needs of patients in accordance with written dietary policies and procedures. 2. All hospice inpatient facilities shall have sufficient numbers of adequately trained personnel to plan, prepare and serve the proper diets to patients. 3. All food service personnel shall be in good health, shall practice hygienic food handling techniques and shall comply with 105 CMR 590.000: State Sanitary Code Article X - Minimum Sanitation Standards for Food Service Establishments. 4. All hospice inpatient facilities that admit patients in need of a special or therapeutic diet shall provide for such diets to be planned, prepared and served as prescribed by the patient’s physician or primary care provider. All therapeutic diets shall be planned, prepared and served with consultation by a dietician. 5. All meals and snacks shall conform to the quality standards of 105 CMR 590.000: The State Sanitary Code. a. All food shall be maintained at safe temperatures. Food that is stored in a freezer shall be wrapped, identified and labeled with the date received and shall be used within the safe storage time appropriate to the type of food and the storage temperature. If not used within an appropriate time limit, the food shall be discarded. b. Equipment shall be provided and procedures established to maintain food at a proper temperature during serving and transportation. Hot foods shall be hot and cold foods shall be cold when they reach the patients. 6. All utensils, equipment, methods of cleaning and sanitizing, storage of equipment or food, the habits and procedures of food handlers, rubbish and waste disposal, toilet facilities and other aspects of maintaining healthful, sanitary and safe conditions relative to food storage, preparation and distribution of food shall be in compliance with local health codes and 105 CMR 590.000: State Sanitary Code Article X - Minimum Sanitation Standards for Food Service Establishments. (f) The medical director or physician designee shall conduct regular onsite visits to the inpatient facility, including daily visits if necessary to assess patient conditions and reevaluate medical orders of unstable patients.