19 CSR 30-35.010
Hospice Program Operations
PURPOSE: This rule defines the minimum requirements for the
provision of hospice services by state certified hospice programs.
PUBLISHER’S NOTE: The secretary of state has determined that
publication of the entire text of the material that is incorporated by
reference as a portion of this rule would be unduly cumbersome or
expensive. This material as incorporated by reference in this rule
shall be maintained by the agency at its headquarters and shall
be made available to the public for inspection and copying at no
more than the actual cost of reproduction. This note applies only
to the reference material. The entire text of the rule is printed here.
(1) General Provisions.
(A) Definitions Relating to Hospice Care Agencies.
1. Attending physician – a person who –
A. Is licensed as a doctor of medicine or osteopathy in
Missouri or a bordering state; or
B. Is recognized by Missouri as a nurse practitioner and
who complies with the requirements of Chapter 335, RSMo, 20
CSR 2200-4.200, and 42 CFR 410.75; or
C. Is licensed as a physician assistant (PA) in Missouri and
who complies with the requirements in Chapter 334, RSMo, 20
CSR 2150-7.135, and 42 CFR 410.74(c); and
D. Is identified by the patient, at the time the patient
elects to receive hospice care, as having the most significant
role in the determination and delivery of the patient’s medical
care.
2. Automated dispensing system—a mechanical system
that performs functions that may include, but are not limited
to, storing, packaging or dispensing medications, and that
collects, controls and maintains all transaction information.
3. Branch/multiple location—a location from which
a hospice provides services within a portion of the total
geographic area served by the parent hospice and the area
served by the branch/multiple location is contiguous to or part
of the area served by the parent hospice.
4. Certified medication technician—a person who has
successfully completed the certified medication technician
training program and any examination component required
in compliance with the standards in 19 CSR 30-84.020. The
certified medication technician shall remain current as a
certified nursing assistant with the Department of Health and
Senior Services in order to continue to be current as a certified
medication technician.
5. Certified pharmacy technician—a person who is
credentialed by a nationally recognized pharmacy technician
credentialing authority.
6. Contracted provider—individuals or entities who
furnish services to hospice patients under contractual
arrangements between the hospice and the contracted
provider.
7. Coordinating provider—any individual or agency
which independently provides services to the patient in their
place of residence.
8. Department—the Missouri Department of Health and
Senior Services.
9. Dietary counselor—an individual who is a registered
nurse, registered dietitian, nutritionist, physician assistant or
physician.
10. Direct employee—an individual paid directly by the
hospice.
11. Emergency medication supply—a limited number of
prescription medications approved by the medical director
and the pharmacist that may be administered to a patient
in an emergency situation or for initial doses of a necessary
medication when a pharmacist cannot provide medication
services for a patient within a reasonable time based on the
patient’s clinical needs at the time.
12. Employee—an employee of the hospice or an individual
under contract who is appropriately trained and assigned
to the hospice program. Employee also refers to a person
volunteering for the hospice program.
13. Family—broadly defined to include not only persons
bound by biology or legalities but also those who function for
the patient in a familial way.
14. Homemaker—a hospice aide, volunteer or other
individual who assists the patient/family with light
housekeeping chores.
15. Hospice—a public agency or private organization or
subdivision of either that–
A. Is primarily engaged in providing care to dying
persons and their families; and
B. Meets the standards specified in 19 CSR 30-35.010 and
in 19 CSR 30-35.030. If it is a hospice that provides inpatient care
directly in a hospice facility, it must also meet the standards of
19 CSR 30-35.020 and 19 CSR 30-35.030.
16. Hospice administrator—the employee designated by
the governing body as responsible for the overall functioning
of the hospice. Hospice administrators appointed by the
governing body after July 1, 2023, shall have the following:
A. Be a licensed practical nurse, be a licensed registered
nurse, or hold an undergraduate degree; and
B. Have at least one (1) year of administrative experience
in a related healthcare field.
17. Hospice aide—a person who meets the training and
skill requirements specified in the Medicare hospice program
at 42 CFR 418.76 which is incorporated by reference as last
amended on August 6, 2009, and published by the Office of
the Federal Register, 732 N. Capitol Street NW, Washington, DC
20401 or can be found at https://govinfo.gov. This rule does not
incorporate any subsequent amendments or additions.
18. Hospice patient—a person with a terminal illness
or condition for whom the focus of care is on comfort and
palliation rather than cure.
19. Legal representative—a person who because of the
patient’s mental or physical incapacity is legally authorized
in accordance with state law to make health care decisions on
behalf of the dying person.
20. Licensed practical nurse—a person licensed under
Chapter 335, RSMo, to engage in the practice of practical
nursing.
21. Meal preparation—meals planned, offered, or served to
all patients from prepared menus.
22. Medical director—a person licensed in Missouri or a
bordering state as a doctor of medicine or osteopathy who
assumes overall responsibility for the medical component of
the hospice’s patient care program.
23. Nutritionist—a person who has graduated from an
accredited four- (4-) year college with a bachelor’s degree
including or supplemented by at least fifteen (15) semester
hours in food and nutrition including at least one (1) course in
diet therapy.
24. Occupational therapist—a person who is licensed
under Chapter 324, RSMo, as an occupational therapist and
licensed to practice in Missouri.
25. Occupational therapy assistant—a person who has
graduated from an occupational therapy assistant program
accredited by the Accreditation Council for Occupational
Therapy Education and licensed to practice in Missouri.
26. Pharmacist—a person licensed as a pharmacist under
Chapter 338, RSMo.
27. Pharmacy technician—a person who is registered as a
pharmacy technician under Chapter 338, RSMo.
28. Physical therapist—a person who is licensed as a
physical therapist under Chapter 334, RSMo.
29. Physical therapy assistant—a person who has
graduated from at least a two- (2-) year college level program
accredited by the American Physical Therapy Association and
licensed to practice in Missouri.
30. Registered nurse—a person licensed under Chapter
335, RSMo, to engage in the practice of professional nursing.
31. Registered nurse coordinator—a registered nurse, who
is a direct employee, designated by the hospice to direct the
overall provisions of clinical services.
32. Skilled nursing—those services which are required by
law to be provided by a registered nurse or a licensed practical
nurse.
33. Snack—a single meal or item prepared on demand
which does not include food items that produce grease-laden
vapors.
34. Social worker—a person who –
A. Has a Master of Social Work (MSW) degree from a
school of social work accredited by the Council on Social Work
Education and has one (1) year of social work experience in a
health care setting; or
B. Has a baccalaureate degree in social work (BSW)
from an institution accredited by the Council on Social
Work Education; is supervised by an MSW as described in
subparagraph (1)(A)34.A. of this rule and has one (1) year of
social work experience in a health care setting; or
C. Has a baccalaureate degree from a school of social
work accredited by the Council on Social Work Education
and is employed by the hospice before December 2, 2008, and
therefore is not required to be supervised by an MSW.
35. Speech language pathologist—a person who is
licensed under Chapter 345, RSMo, as a speech language
pathologist.
36. Spiritual counselor—a person who has education
with emphasis in counseling or related subjects and has,
within ninety (90) days of hire, completed specific training
to include common spiritual issues in death and dying, belief
systems of comparative religions related to death and dying,
spiritual assessment skills, individualizing care to patient
beliefs, and varied spiritual practices/rituals.
37. Standing order—An order by an authorized prescriber
that can be implemented by other health care professionals
when predetermined criteria are met as per 19 CSR 30-35.010(2)
(E)3.–(2)(E)4.A., B., and C.
(B) Eligibility Requirements. A hospice shall have written
admission criteria including the hospice’s policies regarding
palliative care (that includes treatment modalities such as
chemotherapy or radiation).
(C) Consent for Hospice Care.
1. A patient who wishes to receive hospice care, shall sign a
consent form for hospice services.
2. The consent form shall include the following:
A. Identification of the particular hospice that will
provide care to the patient;
B.
The
patient’s
or
legal
representative’s
acknowledgment that the patient or legal representative has
been advised and has an understanding of the palliative nature
of hospice care as it relates to the patient’s terminal illness; and
C. The specific type of care and services that may be
provided as hospice care during the course of the illness.
(D) Discontinuance of Hospice Care.
1. A patient or legal representative may discontinue the
patient’s hospice care at any time.
2. If a patient transfers to another provider, including
another hospice provider, the hospice transferring care shall
provide to the receiving provider pertinent written information
which shall include at a minimum—
A. Current medication profile;
B. Advance directive (if applicable);
C. Problems that require intervention or follow-up; and
D. Current hospice plan of care.
3. The hospice shall have written policies for hospice
patient discharge which identify specific circumstances in
which the patient is discharged.
A. The hospice shall immediately notify the patient
or legal representative and shall include the date that the
discontinuance is effective.
B. Patient’s/family’s continuing care needs, if any, are
assessed at discharge, and the patient/family are referred to
appropriate resources.
4. The attending physician shall be notified in all instances
of discontinuance of hospice care and such notification shall
be documented in the patient record.
(E) General Requirements.
1. A hospice shall maintain compliance with the standards
in 19 CSR 30-35.010 and in 19 CSR 30-35.030. A hospice that
operates a facility for hospice care shall also maintain
compliance with 19 CSR 30-35.020.
2. A hospice shall be primarily engaged in providing the
care and services described in 19 CSR 30-35.010 and in 19 CSR
30-35.020 of this rule, and shall—
A. Provide twenty-four- (24-) hour nursing coverage for
telephone consultation and visits as needed;
B. Assure all other services that are reasonable and
necessary for the palliation and management of terminal
illness and related conditions are available on a twenty-four-
(24-) hour basis;
C. Provide bereavement counseling; and
D. Assure services are provided in a manner consistent
with accepted standards of practice in accordance with local,
state, and federal law.
3. The hospice shall conduct criminal background checks
in accordance with state law.
4. The hospice shall adhere to state and federal law relating
to advance directives.
(F) Patient Rights. The hospice shall have a written
statement of patient rights which shall include, but need not
be limited to, those specified herein—
1. Each patient of a hospice program shall be informed in
writing of his/her rights as a recipient of hospice services;
2. The hospice shall document that it has informed patients
of their rights in writing and shall protect and promote the
exercise of these rights; and
3. The patient’s family, legal representative, or guardian
may exercise the patient’s rights when all reasonable efforts to
communicate with the patient have failed. These rights shall
include—
A. The patient and family’s right for respect of property
and person, including the right to be free of abuse, neglect,
and/or misappropriation of funds;
B. The right to voice grievances regarding treatment or
care that is, or fails to be, furnished or regarding lack of respect
of property or person by anyone who is furnishing services
on behalf of the hospice and the patient/family shall not be
subjected to discrimination or reprisal for doing so;
C. The right to be informed about his/her care
alternatives available from the hospice and payment resources;
D. The right to participate in the development of the
plan of care and planning changes in the care;
E. The right to be informed in advance about the care to
be furnished;
F. The right to be informed in advance of the disciplines
that will furnish care and the frequency of visits proposed to be
furnished;
G. The right to be informed in advance of any change in
the plan of care before the change is made;
H. The right to confidentiality of the clinical records
maintained by the hospice and to be informed of the hospice’s
policy for disclosure of clinical records;
I. The right to be informed in writing of the extent to
which payment may be required from the patient and any
changes in liability within thirty (30) days of the hospice
becoming aware of the new amount of the liability; and
J. The right to access the Missouri home health and
hospice toll-free hotline and to be informed of its telephone
number, the hours of operations, and its purpose for the receipt
of complaints and questions regarding hospice services.
(G) Code of Ethics.
1. A hospice shall develop a written code of ethics and
have a process for reviewing ethical issues.
(H) Twenty-four- (24-) Hour Response.
1. The hospice shall have written policies and procedures
defining access to all services, medications, equipment, and
supplies during regular business hours, after hours, and in
emergency situations including a plan for prompt telephone
response.
2. Unscheduled non-emergent visits shall be provided as
agreed upon by the hospice and patient/caregiver.
3. When clinically indicated, emergent visits shall be made
within ninety (90) minutes from the time the need is identified.
(I) Infection Control.
1. The hospice shall identify person(s) responsible for
implementing, maintaining, and documenting an infection
control program for surveillance, identification, prevention,
control, and investigation of infections and communicable
diseases.
2. The infection control program shall include a system for
periodic review and update of infection control policies and
procedures; infection control education of staff, patients, and
caregivers; and monitoring for compliance with policies and
procedures.
3. The infection control policies and procedures shall
conform with accepted standards of practice, including the
use of standard precautions, to prevent the transmission of
infections and communicable diseases.
(J) Safety and Emergency Preparedness.
1. The hospice shall have a safety plan that includes—
A. Policies and procedures for reporting, monitoring,
and following up on all accidents, injuries, and safety concerns;
B. Documentation of monitoring activity and follow-up
actions; and
C. A safe and sanitary system for identifying, handling,
and disposing of hazardous wastes in compliance with all
federal, state, and local laws.
2. The hospice shall have an emergency preparedness
program that shall meet all federal, state, and local
requirements and shall include at a minimum—
A. An emergency plan based on a facility and community
all-hazards risk assessment;
B. Policies and procedures reviewed and updated at least
annually;
C. A communication plan;
D. Training of staff; and
E. Annual exercises to test the emergency plan.
(K) Branch/Multiple Locations.
1. If the hospice represents to the public that they have a
branch/multiple location(s), each location shall be approved
prior to serving patients. Each branch/multiple location(s) shall
have a designated interdisciplinary group with documented
group meetings, on-site maintenance of current active patient
records, and telephone reception during normal business
hours.
2. The branch/multiple locations shall be located within
one hundred (100) miles of the parent office.
3. The standard of care and clinical services shall be the
same out of the branch/multiple locations as the parent office.
(2) Administration.
(A) Governing Body.
1. A hospice shall have a governing body that assumes full
legal responsibility for the hospice’s total operation.
2. The governing body shall meet, at a minimum, once a
year.
3. The governing body shall designate an administrator in
writing and list the date the administrator was designated.
(B) Administrator Provisions.
1. The administrator organizes and directs the agency’s
ongoing functions; maintains ongoing liaison among the
governing body, the interdisciplinary group(s) and the
staff; employs qualified personnel; implements an effective
budgeting and accounting system; and enforces written
policies and procedures.
2. A person shall be authorized, in writing, to act in the
absence of the hospice administrator.
3. A registered nurse coordinator shall be designated to
direct the overall provisions of clinical services.
(C) Contracted Services.
1. A hospice may arrange for another individual or entity
to furnish services to the hospice’s patients except as otherwise
provided in these regulations. If services are provided under
contract, the hospice shall meet the following standards:
A. Assure the continuity of patient/family care in home,
outpatient, and inpatient settings;
B. Have a written agreement for the provision of
contracted services. The agreement shall include the following:
(I) Identification of the services to be provided in
accordance with the plan of care;
(II) The manner in which services are coordinated by
the hospice to maintain hospice professional management
responsibility;
(III) Delineation of the role(s) of the hospice and the
contracted services;
(IV) Assurance that the contracted provider shall be
appropriately licensed;
(V) Provision for transfer and updating the plan of care
on inpatient admission (if applicable).
2. Such contracts shall not relieve the hospice of the
primary responsibility for ensuring patient care or otherwise
complying with these regulations.
(D) Plan of Care.
1. A written plan of care shall be established for each
patient by the interdisciplinary group with attending physician
involvement.
2. The plan shall be established within seven (7) days of
admission.
3. The care provided to a patient shall be in accordance
with the plan.
4. The plan shall include:
A. Identification of the patient’s/family’s problems and
needs;
B. The scope and frequency of services needed to meet
the patient’s and family’s needs and by whom the services
will be provided, prescribed and required medical equipment,
supplies, medications, treatments, and the level of care;
C. Realistic and achievable goals; and
D. All physician orders.
5. The plan shall be reviewed and updated by the
interdisciplinary group at a minimum of every two (2) weeks.
These reviews shall be documented in the patient record.
6. Documentation on the plan of care shall reflect the
changing needs of the patient/family and the services required
to meet those needs.
(E) Authorized Prescriber’s Orders.
1. Medications, treatments, and procedures shall be
administered only with an order by an authorized prescriber.
2. Written orders shall be dated and signed at the time of
writing.
3. Oral orders, including authorization to use a standing
order, shall be received only by persons authorized within their
scope of practice, immediately reduced to writing, signed and
dated by the person receiving the order, and signed and dated
by the prescriber within thirty (30) days.
4. A standing order may be used as part of the plan of care
if the following guidelines are met:
A. Standing orders shall be in compliance with all
applicable state statutes and regulations and shall—
(I) Include the purpose or conditions under which a
standing order will be implemented;
(II) Be drug, treatment, or procedure specific and not
allow for non-prescriber’s choice;
(III) Be individualized, signed and dated by the
prescriber, and included in the patient’s record;
B. Agency policy shall define the time frame for
authorized prescriber notification when a standing order has
been implemented; and
C. Standing order content shall be reviewed and
approved by the medical director at least annually.
(F) Interdisciplinary Group.
1. The hospice shall designate an interdisciplinary group
or groups composed of qualified individuals who provide or
supervise the care and services offered by the hospice. The
interdisciplinary group shall meet as frequently as the patient’s
condition requires, but no less frequently than every fifteen (15)
calendar days.
2. The interdisciplinary group shall include at least the
following individuals who are employees of the hospice:
A. A doctor of medicine or osteopathy (may be
contracted);
B. A registered nurse;
C. A social worker; and
D. A spiritual counselor.
3. The interdisciplinary group shall be responsible for—
A. Participation in the establishment, review and
updates of the plan of care;
B. Provision or coordination of hospice care and services;
and
C.
Making
recommendations
regarding
policies
governing the day-to-day provision of hospice care and
services.
(G) Clinical Services. The hospice shall routinely provide
through direct employees the following services:
1. Nursing services.
A. Services shall be provided in accordance with
recognized standards of practice.
B. Nursing services shall be staffed to assure that the
nursing needs of patients are met.
C. A registered nurse shall conduct and document
an initial assessment visit to assess the patient’s immediate
physical, psychosocial, emotional, and spiritual status and
needs within forty-eight (48) hours of election. The ongoing
assessment, planning, and provision of nursing services shall
be the responsibility of the registered nurse.
D. When nursing services are delegated to a licensed
practical nurse—
(I) The licensed practical nurse shall be supervised by
a registered nurse who is available to the licensed practical
nurse at least by phone during the hours that the licensed
practical nurse is providing services or is on call; and
(II) The registered nurse shall make on-site supervisory
visits at least monthly to assess and document that the licensed
practical nurse is routinely providing nursing services in
accordance with the plan of care.
E. The registered nurse shall develop a written aide
assignment based upon the patient’s/family’s needs when
hospice aide services are provided.
F. When aide services are being provided, a hospice
registered nurse shall visit the home at least every two (2)
weeks. The visit shall include an assessment of the aide services.
G. Written documentation shall show that the aide is
providing services in accordance with the plan of care.
H. When an aide is permanently assigned to a hospice
facility, the every two- (2-) week supervisory requirement
does not apply, however there must be evidence of an annual
performance review in the aide’s personnel file.
2. Medical director services. The medical director shall
be a direct or contract employee. The medical director’s or
designee’s services and responsibilities include—
A. Consulting with attending physicians regarding pain
and symptom control;
B. Reviewing patient appropriateness for hospice
services;
C. Acting as medical resource for the interdisciplinary
group;
D. Acting as liaison to physicians in the community;
E. Assuring medical services are provided in the event
the medical needs of the patient are not met by the attending
physician; and
F. Routinely attending the interdisciplinary group
meetings.
3. Medical social services.
A. Medical social services shall be provided in accordance
with recognized standards of practice.
B. Social services shall be staffed to assure that the
medical social service needs of each patient and family are
met.
C. The assessment, planning, and provision of medical
social services shall be the responsibility of the social worker.
D. The social services assessment visit shall be completed
within five (5) days of admission or sooner if indicated.
4. Spiritual care services.
A. Spiritual care shall be available to all patients and
families.
B. The spiritual counselor is responsible for assuring
there is a documented assessment of the spiritual needs of the
patient and family within five (5) days of admission or sooner
if indicated and that spiritual care provided reflects assessed
needs.
C. The spiritual assessment shall include, at a
minimum—
(I) The identification of any religious affiliation the
patient and family may have; and
(II) The nature and scope of any spiritual concerns or
needs identified.
D. A visit by the spiritual counselor shall be offered to
each patient. If the patient declines spiritual counselor visits,
the spiritual counselor will serve as a resource for other
interdisciplinary team members assessing spiritual needs and
providing care, and will be available to coordinate with other
spiritual care providers the patient/family may have identified.
5. Bereavement care services.
A. There shall be an organized program for the provision
of bereavement services under the supervision of a qualified
professional who is a person with training or experience
related to death, dying, and bereavement.
B. Within two (2) months following the patient’s death,
there shall be an encounter (other than funeral attendance/
visitation) to assess the risk of the bereaved individual(s). A
plan of care shall be developed that extends for one (1) year
following the death appropriate to the level of risk assessed.
C. At least one (1) additional bereavement encounter
shall occur within six (6) months after the death of the patient.
6. Other clinical services. The hospice shall provide the
following services directly by hospice employees or through a
contracted provider. The assessment, planning, and provision
of these services shall be the responsibility of the applicable
licensed or registered clinician.
A. Dietary counseling, when required, shall be planned
by a qualified dietary counselor.
B. Physical therapy services, occupational therapy
services, and speech language pathology services shall be
offered in a manner consistent with accepted standards of
practice.
(I) Therapy services delegated to the physical
therapy assistant or the occupational therapy assistant shall
be supervised by a licensed physical therapist or registered
occupational therapist as appropriate who is available to the
physical therapy assistant or occupational therapy assistant at
least by phone during the hours that the assistant is providing
services.
(II) When the assistant is providing services to a
patient, the licensed or registered therapist shall make a
supervisory visit to the residence of the patient at least every
thirty (30) days.
(III) Written documentation shall show that the
assistant is providing therapy services in accordance with the
plan of care.
C. Additional counseling services. Any additional
counseling services provided by the hospice shall be provided
by qualified personnel, coordinated with all hospice services,
included in the plan of care and documented in the clinical
record.
D. Waiver.
(I) These requirements shall be waived by the
department for areas of the state in which no licensed
therapists/dietitians/nutritionists are available provided a good
faith effort to provide the service is being made.
(II) A hospice seeking this waiver shall submit a
written request to the department along with evidence of
efforts made by the hospice to provide the service. If approved,
a request for waiver shall be resubmitted annually for review.
7. Hospice aide and homemaker services. Hospice aide and
homemaker services shall be available to meet the needs of the
patients.
A. If homemaker needs are identified, a member of
the interdisciplinary group shall assign and coordinate the
services.
B. Hospice aide services shall be provided by a qualified
person as set forth in this rule at 19 CSR 30-35.010(1)(A)17.
C. A hospice aide is not considered to have completed a
training and competency program or a competency evaluation
program if, since the individual’s most recent completion
of such program(s), there has been a continuous period of
twenty-four (24) consecutive months during none of which
the individual furnished services described in 42 CFR 418.76 for
compensation.
D. The hospice aide shall follow written instructions
for patient care which are prepared by a registered nurse who
has physically assessed the patient. The hospice aide shall
document care provided. Duties include, but shall not be
limited to, the duties specified in the regulations pertaining to
the Medicare hospice aide (42 CFR 418.76).
E. Twelve (12) hours of in-service training per aide per
twelve- (12-) month period shall be provided or assured by
the hospice. The hospice shall maintain a record of in-service
training provided.
(H) Medications. The hospice shall develop policies and
procedures for the safe and effective use of medications,
in accordance with accepted professional standards and
applicable laws and regulations.
1. A medication list shall be maintained for each patient.
2. Medication orders shall include the medication name,
dose, frequency, and route of administration.
3. Orders with variable doses or frequencies shall specify a
maximum dose or frequency and the reason for administration.
4. Medications shall be provided on a timely basis and
medication services shall be available on a twenty-four- (24-)
hour basis for emergencies.
5. When controlled substance medications are delivered
to the patient’s residence by hospice staff, the date, patient
name, medication name and strength, quantity indicated on
the prescription container, and signatures of the hospice staff
member and the receiver shall be documented.
6. The hospice shall identify and document any misuse of
controlled substances and shall notify the prescriber.
7. Medication use shall be reviewed with the patient,
family, or both and medication information, counseling, and
education shall be provided when appropriate.
8. Current medication reference material shall be available
to professional staff for all medications used.
9. Medications shall be administered by persons who have
statutory authorization, the patient, or a family member.
10. Administration by the patient or by a family member
shall be evaluated for appropriateness and ability and this
evaluation documented by the nurse.
11. Medication incidents, including medication errors
and adverse medication reactions, shall be reported to
the prescriber, the registered nurse coordinator, and the
pharmacist.
12. The hospice shall have a policy for the disposal of
controlled substances maintained in the patient’s home when
those medications are no longer needed by the patient. The
policy shall include at a minimum, information shared with
family regarding disposition of medications when no longer
required.
13. Medications shall not be transferred to other patients
and shall not be removed from the residence by hospice staff.
(I) Medical Supplies and Equipment.
1. The provision of medical supplies and equipment shall
be coordinated as needed for the palliation and management
of the terminal illness and related conditions. Hospices shall
make every effort to assure that patient needs for medical
supplies and equipment are met.
2. Hospice shall provide education for patient/family,
employees, and volunteers on the safe use of medical
equipment.
3. Hospice shall provide evidence that all hospice-owned
patient care related equipment has been inspected and
maintained on an annual basis and in accordance with
manufacturers specifications.
4. Hospice shall have policies and procedures for cleaning,
storing, accessing, and distributing hospice-owned equipment.
5. Supplies shall be stored and maintained in a clean and
proper manner.
(J) Volunteers.
1. Each hospice shall document and maintain a volunteer
staff sufficient to provide administrative and direct patient care
hours in an amount that, at a minimum, equals five percent
(5%) of the total patient care hours of all paid hospice employees
and contract staff. The hospice shall document a continuing
level of volunteer activity.
2. Care and services through the use of volunteers,
including the type of services and the time worked, shall be
recorded.
3. The hospice shall document initial screening and active
and ongoing efforts to recruit and retain volunteers.
4. The hospice shall provide task-appropriate orientation
and training consistent with acceptable standards of hospice
practice, that includes at a minimum—
A. Hospice philosophy, goals, and services;
B. The volunteer role in hospice;
C. Confidentiality;
D. Instruction in the volunteer’s particular duties and
responsibilities;
E. Whom to contact if in need of assistance or instruction
regarding the performance of their specific duties and
responsibilities; and
F. Documentation and record keeping as related to the
volunteer’s duties.
5. The hospice shall, in addition, provide orientation for
patient care volunteers that includes at a minimum—
A. Concepts of death and dying;
B. Communication skills;
C. Care and comfort measures;
D. Psychosocial and spiritual issues related to death and
dying;
E. The concept of hospice patient and family as the unit
of care;
F. Procedures to be followed in an emergency or
following the death of the patient;
G. Concepts of grief and loss;
H. Universal precautions;
I. Safety;
J. Patient/family rights;
K. Hospice and the nursing home; and
L. Alzheimer’s disease and dementia-specific training as
specified at 19 CSR 30-35.010(2)(M)1.B.(XIII).
6. The hospice shall document orientation and ongoing inservices.
7. Volunteers functioning in accordance with professional
practice acts shall show evidence of current professional
standing and licensure, if applicable.
(K) Clinical Records.
1. In accordance with accepted principles of practice, the
hospice shall establish and maintain a clinical record for every
patient receiving care and services.
2. The record shall be complete, legible, readily
accessible, and systematically organized to facilitate retrieval.
Documentation shall be prompt and accurate.
3. Each clinical record shall be a comprehensive
compilation of information. Entries shall be made for all
services provided.
4. Entries shall be made and signed by the person
providing the services.
5. The record shall include all services whether furnished
directly or through contracted providers. Each clinical record
shall contain—
A. Physician’s orders;
B. Complete
documentation
of
all
assessments,
services, visits, and events;
C. The plan of care and updates to the plan of care;
D. Identification data;
E. Consent form;
F. Pertinent medical history;
G. Determination of financial responsibility; and
H. Documentation of communication with coordinating
providers.
6. The hospice shall safeguard the clinical record against
loss, destruction, and unauthorized use.
(L) Facility Resident.
1. When the hospice patient resides in a nursing facility,
the hospice collaborates with the nursing facility providing
care to the patient/family to ensure coordination of services.
2. Collaboration activities shall include the following:
A. There shall be a coordinated single plan of care in
the nursing facility which may be multiple documents, that—
(I) Reflects coordination and input from both the
hospice and the nursing facility;
(II) Identifies the care and services which each shall
provide; and
(III) Is updated to reflect changes in patient/family
condition, needs, and care.
B. Services usually identified as hospice services shall
remain the responsibility of the hospice, and are provided or
arranged by the hospice to meet the needs of the patient at
the same level that the hospice normally furnishes to patients
in their homes.
C. A registered nurse is designated from the hospice
to coordinate the implementation of the plan of care, and to
respond to questions and concerns from the nursing facility.
D. The hospice shall provide education to nursing
facility staff that includes at a minimum—
(I) The purpose and nature of hospice care;
(II) Services provided by the hospice;
(III) Care plan coordination;
(IV) When and how to contact hospice staff.
3. The hospice shall document education provided and/or
education offered and declined by the nursing home.
4. The hospice shall enter into arrangements only with
nursing facilities which are appropriately licensed.
(M) Employee Training and Orientation.
1. Each hospice shall provide initial orientation for each
direct employee that is specific to the employee’s job duties.
A. All employees shall be oriented to—
(I) Hospice philosophy, goals, and services;
(II) Confidentiality;
(III) Specific job duties;
(IV) Hospice policies and procedures as appropriate to
the position.
B. Patient care employees shall also be oriented to—
(I) Interdisciplinary group function and responsibility;
(II) Communication skills;
(III) Physical, psychosocial, and spiritual assessment;
(IV) Plan of care;
(V) Symptom management;
(VI) Universal precautions;
(VII) Patient/family safety issues;
(VIII) Patient/family rights;
(IX) Documentation;
(X) Concepts of grief and loss;
(XI) Facility resident care;
(XII) Levels of hospice care; and
(XIII) Alzheimer’s disease and related dementias.
Hospice agencies shall provide dementia-specific training
about Alzheimer’s disease and related dementias to their
employees and those persons working as independent
contractors who provide direct care to or may have daily
contact with residents, patients, clients, or consumers with
Alzheimer’s disease or related dementias.
(a) At a minimum, the training required shall
address the following areas:
I. An overview of Alzheimer’s disease and related
dementias;
II. Communicating with persons with dementia;
III. Behavior management;
IV. Promoting independence in activities of daily
living; and
V. Understanding and dealing with family issues.
(b) Employees or independent contractors who do
not provide direct care for, but may have daily contact with,
persons with Alzheimer’s disease or related dementias shall
receive dementia-specific training that includes at a minimum—
I. An overview of Alzheimer’s disease and related
dementias; and
II. Communicating with persons with dementia.
(c) Dementia-specific training about Alzheimer’s
disease and related dementias shall be incorporated into
orientation for—
I. New employees with direct patient contact;
II. Independent contractors with direct patient
contact; and
III. Employees who do not provide direct care
for, but may have daily contact with, persons with Alzheimer’s
disease or related dementias. The training shall be provided
annually and updated as needed.
C. Ongoing in-service training shall include a broad
range of topics that reflect identified educational needs.
D. The hospice shall document initial orientation and inservice topics presented.
2. Volunteers are exempt from these provisions, except for
dementia-specific training as specified at 19 CSR 30-35.010 (2)
(M)1.B.(XIII), as their orientation and in-service requirements
are defined in 19 CSR 30-35.010(2)(J)4., 5., and 6.
3. Contract employees shall receive orientation to
dementia-specific training as specified at 19 CSR 30-35.010(2)
(M)1.B.(XIII), confidentiality, hospice philosophy, and to their
specific job duties.
(N) Quality Assessment and Performance Improvement.
1. The hospice shall follow a written plan for assessing and
improving program operations which includes—
A. Goals and objectives;
B. The identity of the person responsible for the program;
and
C. A method for resolving identified problems.
2. The plan and performance improvement activities shall
be reviewed at least annually by a designated group and the
governing body and revised as appropriate.
3. When problems are identified in the provision of
hospice services, the hospice shall document any evidence
of corrective actions taken, including ongoing monitoring,
revisions of policies and procedures, educational intervention,
and changes in the provision of services.
4. The effectiveness of actions taken to improve services or
correct identified problems shall be evaluated.
5. A designated group shall review and document the
quality assessment and performance improvement activities
and monitor corrective actions.
AUTHORITY: sections 192.2000 and 197.270, RSMo 2016.* Original
rule filed March 8, 1996, effective Oct. 30, 1996. Rescinded and
readopted: Filed Jan. 3, 2001, effective Aug. 30, 2001. Amended:
Filed Sept. 11, 2007, effective March 30, 2008. ** Amended: Filed
July 9, 2020, effective Jan. 30, 2021. Amended: Filed Sept. 15, 2022,
effective March 30, 2023.
*Original authority: 192.2000, RSMo 1984, 1988, 1992, 1993, 1995, 2001, 2014, and
197.270, RSMo 1992, amended 1993.
**Pursuant to Executive Order 21-07, 19 CSR 30-35.010, part (2)(M)1.B.(XIII) was suspended from
April 22, 2020 through August 31, 2021. Pursuant to Executive Order 21-09, 19 CSR 30-35.010,
paragraph (1)(A)1. was suspended from April 9, 2020 through December 31, 2021.