Hospice Providing Direct Care in a Hospice Facility

PURPOSE: This rule defines the minimum requirements necessary for the construction and operation of hospice inpatient facilities in order to be certified as part of the hospice program. (1) A hospice that delivers care in a facility operated by the hospice and not otherwise licensed shall comply with this rule in addition to 19 CSR 30-35.010 and 19 CSR 30-35.030. (2) Each patient shall receive treatment, medications and diet as prescribed and shall be kept comfortable, clean, wellgroomed and protected from accident, injury and infection. (3) Organization and Management of Hospice Facilities. (A) 24-Hour Staffing. 1. The hospice shall provide 24-hour staffing which is sufficient to meet the patients’ total needs in accordance with the patient plan of care. 2. All hospices shall employ qualified staff at the ratio of no less than one for every ten (1:10) patients per shift, per patient unit, 24 hours a day. 3. Staffing personnel shall be on duty at all times on each patient-occupied floor, with no less than two staff personnel in a facility at all times. 4. Minimum staff personnel shall be no less qualified than one home health aide or companion/volunteer and one licensed practical nurse. 5. A registered nurse shall be available for telephone consultation or on-site visit as needed, 24 hours a day. 6. Facility personnel shall have a telephone access to administrative staff, 24 hours a day. (B) Disaster Preparedness. 1. The hospice shall have a written plan, annually rehearsed with staff, which includes procedures to be followed in the event of an internal or external disaster and for the care of casualties arising from disasters. 2. Each facility shall conduct quarterly fire drills so that each shift participates at least annually. (C) Meals Service Menu Planning and Supervision. The hospice shall: 1. Make available a practical freedom of choice diet offering at least three meals and snacks, or their equivalent, that accommodate patient’s needs and preferences each day at regular times, with not more than 14 hours between a substantial evening meal and breakfast; 2. Prepare and serve foods using methods that conserve nutritive value, flavor and appearance; 3. Give special attention to the texture of food served to patients who have chewing difficulty; 4. Provide assurance that hot food is served hot and cold food is served cold; 5. Give a minimum of 30 minutes for eating meals. Patients who eat slowly or who need assistance shall be given as much time to eat as necessary; 6. Make tray service and dining room service attractive for patients and ensure that each patient receives appropriate table service; 7. Provide each patient who is served meals in bed or in a chair not within the dining area with either a table, an overbed table or an overbed tray of sturdy construction which is positioned so that the patient can eat comfortably; 8. Provide assistance upon tray delivery to all patients requiring assistance at mealtimes, whether it be preparation of the food items or actual feeding. Dining room supervision shall be provided during meals; 9. Establish an identification system to assure that each patient receives the diet as ordered; 10. Provide sufficient equipment and personnel trained in their duties to assure adequate preparation and serving of food if meals are prepared on-site; 11. Review menus for special prescribed diets and approve in writing by either a qualified dietitian, a registered nurse, or a physician; 12. Keep a current record of purchased food to show the kind and amount of food purchased each month, if meals are prepared on-site; 13. Plan menus for all diets at least two weeks in advance if meals are prepared on-site. If cycle menus are used, the cycle shall cover a minimum of three weeks and shall be different each day of the week; 14. Make fresh water readily accessible to all patients at all times; 15. Procure, store, prepare, distribute and serve all food under sanitary conditions; 16. Permit family to bring, prepare and serve food to their loved one; and 17. Permit staff to prepare a single patient snack upon request. (D) Patient Areas. 1. The hospice shall design and equip areas for the comfort and privacy of each patient and family member. 2. The hospice shall have accommodations for family privacy after a patient’s death that do not infringe on other patients’ rights and decor which is homelike in design and function; 3. Patients shall be permitted to receive visitors, including small children, at any hour; 4. The facility shall have a policy regarding pets; and 5. Smoking may be permitted in the hospice consistent with the smoking policy of the facility. Smoking may be permitted in the patient’s room and in designated smoking areas. Individual patients may be permitted to smoke in their rooms with the consent of any other patients occupying the room and with the permission of his/her attending physician. If a patient is confined to bed or classified as not being responsible, smoking is permitted only under the direct supervision of an authorized individual. (E) Infection Control. 1. The hospice shall make disease-specific provision for isolating patients with infectious diseases. 2. Infectious waste management control. A. Every inpatient hospice facility shall write an infectious waste management plan with an annual review identifying infectious waste generated on-site, the scope of the infectious waste program and policies and procedures to implement the infectious waste program. The plan shall include at the least the following: administrator’s endorsement letter; introduction and purpose; objectives; phone number of responsible individuals; definition of those wastes handled by the facility; identification of responsible individuals; procedures for waste identification, segregation, containment, transport, treatment and disposal; emergency and contingency procedures and training; and educational procedures. B. Infectious waste shall be segregated from other wastes at the point of generation and shall be placed in distinctive, clearly marked, leakproof containers or plastic bags appropriate for the characteristics of the infectious waste. C. Containers for infectious waste shall be identified with the universal biological waste symbol. All packaging shall maintain its integrity during storage and transport. Infectious waste shall not be placed in a gravity disposal chute. D. Pending disposal, infectious waste shall be stored separately from other wastes in a room limited to staff access. E. When transported off the premises of the hospice, all infectious waste shall be packaged and transported as provided in sections 260.200–260.245, RSMo. F. Hospices generating 100 kilograms or less of infectious waste per month must comply with section 260.203.10, RSMo. 3. Written policies and procedures shall define and describe the scope and conduct of laundry and linen services. There shall be a mechanism for the review and evaluation on an annual basis of the quality of laundry services. 4. Written policies and procedures shall define and describe the scope and conduct of on-site cleaning of dietary ware. There shall be a mechanism for the review and evaluation on an annual basis of the quality of dietary-ware sanitizing services provided. (F) Pharmacy Services. The hospice shall comply with all provisions of 19 CSR 30-35.010 regarding medications. 1. The hospice shall employ or contract with a pharmacist. A. The pharmacist shall assist in the development of policies and procedures for medication use, shall advise the hospice on all other matters pertaining to the use of medications, shall serve as a member of, or consultant to, the interdisciplinary team and shall provide medication information to professional staff as required. B. A pharmacist shall be available on a twenty-four (24)- hour basis for emergencies. 2. Medication acquisition and labeling. A. Prescription medications shall be maintained as individual patient prescriptions or in an automated dispensing system. B. Each facility shall maintain an emergency medication supply. When the emergency medication supply is separate from an automated dispensing system and contains controlled substances the facility shall be registered with the Missouri Bureau of Narcotics and Dangerous Drugs. C. Automated dispensing systems may be controlled by the facility or may be controlled on-site or remotely by a pharmacy. (I) When an automated dispensing system is controlled by the facility: (a) A pharmacist shall be responsible for the operation of the automated dispensing system and training of facility staff in its use; (b) A pharmacist shall review and confirm each new medication order prior to administration of the first dose; (c) The facility shall have a policy and procedure to allow removal of initial doses of approved emergency medication supply medications in lieu of maintaining a separate emergency medication supply; (d) A pharmacist or pharmacy technician shall place medications in the automated dispensing system. Medications to be placed in the automated dispensing system shall be checked and approved by a pharmacist; (e) When the automated dispensing system contains controlled substances, the facility shall be registered with the Missouri Bureau of Narcotics and Dangerous Drugs and the Drug Enforcement Administration; and (f) When the automated dispensing system is for the purpose of an emergency medication supply only, subparts (b) and (c) of this part shall not apply and the facility shall not be required to be registered with the Drug Enforcement Administration. (II) When an automated dispensing system is controlled by a pharmacy: (a) A pharmacist shall review and confirm each new medication order prior to releasing the medication from the system; (b) The pharmacy and the facility shall have a policy and procedure to allow removal of initial doses of approved emergency medication supply medications when the automated dispensing system is used in lieu of maintaining a separate emergency medication supply; (c) A pharmacist or pharmacy technician shall place medications in the automated dispensing system. Medications to be placed in the automated dispensing system shall be checked and approved by a pharmacist; (d) The pharmacy shall comply with all requirements of paragraph 3. of this subsection; (e) The automated dispensing system shall be licensed by the Board of Pharmacy and shall be used in compliance with 20 CSR 2220-2.900; (f) When the automated dispensing system contains controlled substances it shall be registered with the Missouri Bureau of Narcotics and Dangerous Drugs and the Drug Enforcement Administration; and (g) When the automated dispensing system is for the purpose of an emergency medication supply only, subparts (a) and (e) of this part shall not apply and it shall not be required to be registered with the Drug Enforcement Administration. (III) A facility employee who registers with the Board of Pharmacy as a pharmacy technician shall be a nurse, certified pharmacy technician, or certified medication technician. The pharmacist shall be responsible for the training of the employee and shall supervise the employee in compliance with 20 CSR 2220-2.700 when pharmacy technician functions are being performed. D. Patient prescription medications shall be labeled with at least the patient name, medication name, strength and date dispensed. They shall also contain accessory information and the expiration date when applicable. E. Prescription medication labels shall not be altered by hospice staff and medications shall not be repackaged by hospice staff except as allowed by (3)(F)4.E. F. When the patient’s own medications are used, they shall be examined prior to use for suitability and positively identified by a pharmacist or nurse in writing. G. Non-prescription medications may be obtained as stock or individual patient supplies. They shall not be repackaged, except as allowed by (3)(F)4.E., and supplies for individual patients shall be labeled with the patient’s name. 3. Medication storage and control. A. All medications shall be stored in locked compartments under proper temperature controls, separate from food and other substances. Medications shall be accessible only to persons authorized to administer them, pharmacists or pharmacy technicians. B. Controlled substances shall be stored in locked compartments separate from other medications. C. The pharmacist shall inspect medication storage areas and the emergency medication supply monthly and shall document this inspection. D. Records of receipt and disposition of all controlled substances shall be maintained separate from other records. (I) Inventories of Schedule II controlled substances shall be reconciled each shift when they are not maintained in an automated dispensing system. (II) Inventories of Schedule III–V controlled substances shall be reconciled daily when they are not maintained in an automated dispensing system. (III) Inventories of controlled substances shall be reconciled at least every seventy-two (72) hours when they are maintained in an automated dispensing system. (IV) Receipt records shall include the date, source of supply, patient name and prescription number when applicable, medication name and strength, quantity and signatures of the supplier and receiver. (V) Administration records shall include the date, time, patient name, medication name, dose administered and signature of the person administering. (VI) Documentation of waste at the time of administration shall also include the reason for the waste and the signature of an authorized employee witness. E. The pharmacist shall review controlled substance record keeping monthly. F. All variances of controlled substance records shall be reported to the registered nurse coordinator and the pharmacist for review and investigation. G. All losses of controlled substances shall be reported to the Missouri Bureau of Narcotics and Dangerous Drugs and to other federal, state and local authorities when required. H. All controlled substance records shall be maintained for two (2) years. 4. Medication administration. A. Medication administration by the patient or a family member shall be ordered by the physician. Instructions for administration shall be provided. B. Non-controlled substances may be stored in a locked compartment in the patient’s room. C. Single doses of controlled substances may be placed in the locked compartment or provided directly to the patient or family member prior to the time of administration. D. Administration of the patient’s own medications brought to the facility shall be ordered by the authorized prescriber. E. Medications for administration when a patient temporarily leaves the facility shall be labeled by the pharmacy with instructions for administration, except that a single dose of each medication may be provided by the nurse in containers labeled with the patient’s name, medication name and strength, instructions for administration, and other necessary information. F. Medication administration shall be documented on a separate record. Administration by the patient or a family member shall be monitored by nursing staff and documented. 5. Other medication disposition. A. Medications may be sent with a patient at the time of discharge only if they have been labeled by the dispensing pharmacy with instructions for administration and ordered by the authorized prescriber. B. Records of this disposition shall include the date, patient name, prescription number, drug name and strength, quantity and signatures of the persons releasing and receiving the medications. C. Patient prescription medications that have been discontinued shall be destroyed within sixty (60) days if they are controlled substances or if they are not in unit-dose packaging. D. Patient prescription medications of expired patients shall be destroyed within five (5) days if they are controlled substances or if they are not in unit-dose packaging or if they were brought from home. E. Other expired or nonusable medications shall be destroyed within five (5) days. F. Medications shall be destroyed by a pharmacist and a nurse or two (2) nurses, and a record of destruction shall be maintained which includes the date, patient name, prescription number, medication name and strength, quantity, method of destruction and signatures of the persons destroying the medications. G. Unit-dose packaged medications returnable to the pharmacy shall be returned within ten (10) days. H. Medications shall not be transferred to other patients and shall not be removed from the facility by hospice staff, except those being returned to the pharmacy. (4) General Design and Construction Standards for New Inpatient Hospice Facilities. (A) Health and Safety Laws. The hospice shall meet all federal, state and local laws, ordinances, regulations and codes pertaining to health and safety, including but not limited to, provisions regulating construction, maintenance and equipment. 1. General Requirements. A. After October 30, 1996, a new hospice facility shall submit plans for approval to the Department of Health for the construction of a new facility, expansion or renovation of an existing state certified hospice or the conversion of an existing facility not previously and continuously state certified and operated as a hospice facility under section 197.250, RSMo. B. New hospice facilities shall be designed and constructed in conformance with this rule. C. This rule is not intended to restrict innovations and improvements in design or construction techniques. Accordingly, the Department of Health may approve plans and specifications which contain deviations from this rule. Requests for deviations from requirements on physical facilities shall be in writing to the Department of Health and shall contain information which determines that the respective intent or objectives of this rule have been met. Approvals for deviations shall be in writing and both requests and approvals shall be made a part of the permanent Department of Health records for the hospice. D. Where renovation or replacement work is done within an existing licensed facility, all new work, additions, or both, shall comply with the applicable sections of this rule. Where existing major structural elements make total compliance impractical or impossible, alternative proposals which result in an equivalency may be considered by the department. E. In renovation projects and additions to existing state certified hospice facilities, only that portion of the total facility affected by the project shall comply with the applicable sections of this rule. However, upon construction completion, the facility shall satisfy all functional requirements for state certified hospices. F. Those existing portions of the facility which are not included in the renovation but which are essential to the functioning of the complete facility as well as existing state certified building areas that receive less than substantial amounts of new work shall, at a minimum, comply with the state certification requirements which were in effect at the time that the existing portion of the building was state certified. G. All required fire exits shall be maintained throughout the construction and the work shall be phased as necessary to minimize disruption of the existing hospice operation. 2. Planning and Construction Procedures. A. Any hospice facility constructed or renovated after October 30, 1996 shall have plans and specifications prepared in conformance with Chapter 327, RSMo by an architect or engineer duly registered in Missouri. The owner of each new facility or the owner of an existing licensed inpatient hospice being added to or undergoing major alterations shall provide a program—scope of services—which describes space requirements, staffing patterns, departmental relationships and other basic information relating to the objectives of the facility. The program may be general but it shall include a description of each function to be performed, approximate space needed for these functions and the interrelationship of various functions and spaces. The program shall describe how essential services can be expanded in the future as the demand increases. Appropriate modifications or deletions in space requirements may be made when services are shared or purchased, provided the program indicates where the services are available and how they are to be provided. This program shall be submitted to the Department of Health for review along with the plans developed for the project. Schematic and preliminary plans showing the basic layout of the building and the general types of construction, mechanical and electrical systems and details may be submitted to the department before the larger and more complicated working drawings and specifications so that necessary corrections can be easily made before final plans are completed. Working drawings and specifications, complete in all respects, shall be prepared and submitted to the Department of Health for approval. These plans shall cover all phases of the construction project, including site preparation: paving; general construction; mechanical work, including plumbing, heating, ventilating and air conditioning; electrical work; and all built-in equipment, including elevators, kitchen equipment, cabinet work, and the like. B. The Department of Health shall be notified in writing within five (5) days after construction begins. Construction shall be in conformance with plans and specifications approved by the Department of Health. The department may elect to inspect the construction of hospice projects at any time during the development of the project. If construction of the project is not started within one (1) year or completed within a period of three (3) years after the date of the approval of the plans and specifications, the plans and specifications shall be resubmitted to the Department of Health for its approval and shall be amended, if necessary, to comply with the then current rules before construction work is started or continued. C. References in this rule to National Fire Protection Association (NFPA) publications are those contained in the 12-volume 1994 Compilation of NFPA Codes, Standards, Recommended Practices and Guides. Where there are discrepancies between referenced NFPA publication requirements and this rule, the requirements of this rule shall apply. D. The design and construction of hospices shall conform to the most stringent requirements of this rule and the local governing building code and zoning ordinances. 3. Site. A. Adequate paved pedestrian access shall be provided within the lot lines to the main entrance. Loading and unloading space for delivery vehicles shall be paved. B. Adequate paved parking shall be provided. Parking space needs shall be determined by the local zoning requirement and the operational program but shall not be less than one (1) space for each of the maximum number of staff persons on duty at any given time plus one (1) parking space for each licensed inpatient bed in the facility. C. Fire lanes shall be provided as required by local authority and kept clear to provide immediate access for fire fighting equipment. D. The site shall provide reasonable access for those individuals to be served by the facility. The facility shall be on an all-weather road for easy access by vehicular traffic. Consideration should be given to locating the hospice to provide easy access to public transportation services which may be available in the community. E. The site shall be located within the service area of a public fire department. 4. Roads, parking facilities, walks, ramps and entrances shall be accessible and usable by persons with various physical handicaps. A. At least one toilet, telephone and drinking fountain shall be provided on each floor of a hospice which is accessible for use by handicapped public and staff. B. Elevator controls and alarms shall be accessible to wheelchair occupants and shall be provided with tactile signage for the visually impaired. C. Design details for handicapped accessible facilities should be consistent with the Guidebook to: The Minimum Federal Guidelines of Requirements for Accessible Design published January 6, 1981, by the U.S. Architectural and Transportation Barriers Compliance Board. D. At least ten percent (10%) of the patient beds shall be located in handicapped-accessible rooms with accessible toilet rooms which open directly into the patient room. All other clinical areas to which patients have common access shall be handicapped-accessible. 5. Administrative and public areas shall be provided. A. All hospices shall provide adequate work areas to support the administrative personnel and governing body. The facilities shall allow business to be conducted in a setting which provides confidentiality and privacy as required. The administrative offices may be located remotely from a hospice inpatient unit or may be housed within the inpatient facility. B. Where administration is included within the inpatient facility, the following shall be provided: (I) Administrator’s office; (II) Business office including a work area for quality assurance; (III) Storage and work area for archived medical records; (IV) Conference room for governing board meetings and personnel in-service training; and (V) Office for director of patient-care services. C. Each inpatient hospice facility shall provide the following public areas in a location separated from the clinical and service areas of the facility: (I) Lobby/waiting room with reception; (II) Wheelchair accessible public toilet; (III) Wheelchair accessible public drinking fountain; and (IV) Wheelchair accessible public phone. 6. Design of patient-care units. A. One or more patient-care units shall be provided. Each unit shall not exceed a maximum of twenty (20) beds. B. Each patient-care unit shall be a continuous area which does not require patient-care traffic to traverse other areas and shall be restricted to only one (1) floor level. If justified by the program submitted under subparagraph (2) (A)2.A. of this rule, the department may consider approval of designs which provide for larger capacity patient-care units. C. The bed area in a patient room exclusive of toilet rooms, closets, alcoves or vestibules, shall not be less than one hundred twenty (120) square feet in a private room and not less than two hundred (200) square feet in a semi-private room. Heating units and lavatories may protrude into this space. D. No dimension for the bed area in any patient room shall be less than ten (10) feet. E. No patient room shall house more than two (2) patients. F. Each patient-care unit shall have not greater than fifty percent (50%) of its beds housed in semi-private rooms and the remaining rooms shall be limited to occupancy by one (1) patient. If justified by the program submitted under subparagraph (2)(A)2.A. of this rule, the department may consider approval of designs which provide other ratios of semi-private to private patient rooms. G. Each patient shall have access to a toilet room without entering the general corridor area. H. One (1) toilet may serve not more than two (2) adjacent rooms. I. The toilet room shall contain a lavatory and water closet and shall be sized to permit access for the patient and an assisting member of the staff. The lavatory may be omitted from the toilet room if a lavatory is provided in the patient room. J. At least one (1) patient room per patient-care unit shall be provided to be used for isolation. This unit shall have a toilet room equipped with a bathing facility which serves this room exclusively. K. Mirrors shall be provided in each patient room or adjoining toilet room. Mirrors shall be at least three (3) feet high located with the bottom edge no more than three feet four inches (3'4") above the floor. L. Patients shall have separate wardrobes, lockers or closets located within their respective patient rooms. A clothes rod and shelf shall be provided. M. One or more windows shall be provided, with the sash not more than three (3) feet above the floor and with a gross area of not less than ten percent (10%) of the floor area of the room. In each patient room at least one (1) window to the outside shall be operable. Patient room windows shall be exposed to an outside area not less than thirty (30) feet horizontally opposite the window which contains no construction or grading which would further diminish the view and the exposure of the window to natural light. N. Social spaces (dining, recreation, meditation) shall be provided throughout the facility with a cumulative area of not less than thirty (30) square feet per patient bed. One social space may serve more than one patient-care unit provided it is directly accessible from each unit and is sized proportionate to the total number of patient beds it serves. No social space shall be smaller than one hundred fifty (150) square feet in area. O. Unless bathing facilities are included in the toilets serving each patient room, central bathing facilities shall be provided in each patient-care unit at a ratio of not fewer than one for each ten (1:10) beds. P. Each bathing facility shall be located in its own room and shall be directly accessible from the general corridor. The bathing facility may be either a tub, shower or tub/shower combination. Q. However, at least one (1) handicapped accessible shower shall be provided on each patient unit. R. A locked cabinet for the storage of cleaning supplies shall be available in or near each bathroom. 7. Support and services areas. The following staff support and service areas shall be located directly accessible to each patient care unit: A. Clean work and storage facilities shall be equipped with counter and sink and storage space provided for clean linen and supplies; B. A separate soiled/decontamination utility room shall be equipped with a clinic sink (this fixture is not required where bedpan-flushing devices have been installed at each patient toilet), counter and sink and sufficient floor space shall be provided to accommodate storage containers for soiled linen, trash and infectious waste; C. Space shall be provided for secure storage of staff personal items; D. A staff station shall be located to provide visual supervision of the patient-care unit corridors. The station shall consist of a work counter and secure storage space for charts; E. A medication storage and preparation station which has a means of locked storage for all medications shall be equipped with a work counter, sink, and refrigerator; F. Separate locked storage facilities shall be provided in the station for controlled substances; G. If medications are held in each patient room, the room shall include separate locked storage facilities for each patient’s medications; H. A nourishment station shall be equipped with a work counter, sink, and refrigerator and shall be provided physically remote from the medication preparation station; I. Storage space shall be provided for mobile equipment used on the unit; J. A janitor’s closet shall be provided which is equipped with a mop sink and has sufficient space for the cleaning equipment and open supplies used to maintain the patientcare unit; and K. All clean support functions may be located in one clean workroom provided the room is carefully designed to provide adequate storage and function separations. 8. Food service facilities shall be designed and equipped to meet the requirements of the scope of services outlined as follows: A. Dietary facilities shall comply with 19 CSR 20-1.010; B. In hospice facilities where food is prepared on-site, the dietary facilities shall, as a minimum, have—a storage space including cold storage for four-day supply, space and equipment for food preparation to facilitate efficient food preparation and to provide for a safe and sanitary environment, conveniently located handwashing facilities, space for preparing food for distribution to patients, warewashing facilities which are isolated from the food preparation and serving area, and storage facilities for waste which is inaccessible for insects and rodents and accessible to the outside for pickup or disposal. C. The warewashing processes shall produce dietary ware which is free of pathogenic organisms; and D. In hospice facilities where the food service is provided through a vendor contract, dietary facilities shall, as a minimum, include space for receiving and holding the food transport equipment, utility connections for food transport equipment to maintain appropriate serving temperatures, and a holding area for soiled dietary ware transport equipment which is out of the patient area and located near the service entrance for pick-up. (B) Service Facilities Shall Meet the Following Standards: 1. Services including linen service. A. Service facilities shall be provided in each inpatient hospice facility and located to be out of the normal public and clinical traffic flow. B. A weather-protected service entrance shall be provided separate from entrances used by public and patients. C. Space and facilities shall be provided for the sanitary storage and disposal of waste. Exterior dumpsters will suffice provided they can be accessed under the protection provided at the service entrance. D. A general storage room shall be provided with an area not less than ten (10) square feet per bed for the first fifty (50) beds, plus eight (8) square feet per bed for the next twentyfive (25) beds, plus five square feet per bed for any additional beds over seventy-five (75). No storage room shall be less than one hundred (100) square feet of floor space. Off-site storage is acceptable, however, one half (1/2) of the required storage space shall be located in the inpatient hospice facility. General storage shall be concentrated in one area. E. Space shall be provided to house mechanical equipment. The space shall be adequate for initial installation and ongoing maintenance access for each component of the systems housed in it. Mechanical equipment shall not be installed in rooms designated to house other functions. F. A housekeeping room shall be provided with a janitor’s sink and space to store opened containers of cleaning supplies and housekeeping equipment used to maintain the facility. This room is not required if the hospice is maintained by a contract cleaning service which transports the necessary cleaning supplies and equipment to the facility on a daily basis. G. An oxygen storage room shall be provided. This room shall be enclosed with one-hour rated construction and shall have a powered or gravity vent to the outside. Permanent racks or fasteners shall be provided and used in the oxygen storage room to prevent accidental damage or dislocation of oxygen cylinders. In facilities storing quantities of oxygen less than one thousand five hundred (1,500) cubic feet in total, a power ventilated storage cabinet will comply. No ventilated gas storage facilities are required in hospices which store no medical gases within the building. H. Laundry services may be provided by the hospice operator or may be obtained through contract with a linen service vendor. If laundry for the facility is done commercially, either entirely or in part, space shall be provided for the sorting, processing and storing of both soiled and clean linen. Storage space shall be located to facilitate convenient pickup and delivery by commercial laundry personnel. Hospices with only one patient-care unit may accommodate these functions within the utility facilities provided in the unit’s staff support area. I. Hospice-operated laundry facilities shall be designed and procedures instituted to prevent cross-contamination of clean and dirty linen. The laundry room shall be in a separate room from the kitchen, patients’ rooms, the dining room and the bathrooms or the nursing utility room. Adequate space shall be provided in the laundry room for the storing, sorting and processing of soiled linen. The processes of the laundry operation shall be appropriate to the production of patient linens which are free of pathogenic organisms. Space shall be provided for the storage of clean linen in a separate room from the laundry. J. As may be required by the program, laundry facilities provided for cleaning patients’ clothing exclusively shall be located in the patient-care unit but in a room separate from other functions. A residential-style laundry equipment installation is acceptable. K. As required by the program, living and sleeping quarters, separate from patients’ facilities, shall be provided for the employees and their families who may reside in the facility; 2. Elevators. A. All inpatient hospice facilities having patient-care facilities located on any floor other than the main entrance floor shall have at least one (1) electric or electrohydraulic elevator. Hospice facilities with more than thirty (30) beds located on any floor other than the main entrance floor shall have at least two (2) elevators. Hospice facilities with more than two hundred (200) beds located on any floor other than the main entrance floor shall provide passenger and service elevators in numbers and at locations determined by a professionally conducted study of the hospice operation and its estimated vertical transportation needs. B. Inside dimensions of patient-use elevators shall be not less than five feet four inches (5'4") by eight feet (8')with a capacity of 3,500 pounds. Cab and hoistway doors shall be not less than three feet ten inches (3'10") clear opening. C. Elevators shall be equipped with an automatic leveling device of the two-way automatic maintaining type with an accuracy of plus or minus one-half inch. D. Elevator call buttons, controls and door safety stops shall be of a type that will not be activated by heat or smoke. E. Elevator controls, alarm buttons and telephones shall be accessible to wheelchair occupants and usable by others with various physical disabilities. F. Elevator hoistway doors shall be fire rated to maintain the integrity of the fire-rated shaft enclosure; 3. Chutes and dumbwaiters. A. Chutes and dumbwaiters may be installed in hospice facilities as required by the operational program. B. Linen and trash chutes shall be of fire-resistant material and shall be installed with flushing ring, vent to atmosphere and floor drain at the floor of the chute discharge. An automatic sprinkler shall be provided at the top of each linen and trash chute. C. Service openings to chutes shall not be located in corridors or passageways but shall be located in a room having a fire-resistant construction of not less than one hour. Doors to the rooms shall be not less than 3/4-hour labeled doors equipped with an automatic closing device. D. Service openings to chutes and other vertical openings shall have an approved self-closing labeled fire door rating not less than the fire-resistant rating of the shaft in which the chute is installed. E. Chutes shall discharge directly into collection rooms separate from the incinerator, laundry or other services. Separate collection rooms shall be provided for trash and for linen. These rooms shall have a fire-resistant construction of not less than one hour. Doors to these rooms shall be not less than 3/4-hour labeled doors equipped with an automatic closing device. F. Dumbwaiters, conveyors and material-handling systems shall not open directly into a corridor or exitway but shall open into a room enclosed by construction having a fire resistance of not less than one hour and provided with a 3/4hour labeled fire door with a self-closing device. G. Where horizontal conveyors and material-handling systems penetrate fire-rated walls or smoke walls, the penetrations shall be protected to maintain the integrity of the wall; 4. General design, finish and life safety requirements. A. A continuous system of unobstructed corridors, referred to as required corridors, shall extend through the enclosed portion of each story of the building, connecting all rooms and spaces with each other and with all entrances, exitways and elevators, with the following exceptions: work suites such as the administrative suite and dietary area, which are occupied primarily by employed personnel, may have within them corridors or aisles as considered advisable, but are not subject to the regulations applicable to required corridors. Areas may be open to the required corridor system as permitted by NFPA 101 (1994), The Life Safety Code. B. The arrangement of the physical plant shall provide for separation of the administrative/business, service and public areas from patient service areas. C. Ceilings shall be at a height of at least eight feet. Ceilings in corridors, storage rooms, toilet rooms and other minor rooms shall not be less than seven feet six inches (7'6"). Suspended fixtures located in the path of normal traffic shall not be less than six feet eight inches (6'8") above the floor. D. Handrails may be provided on both sides of all corridors and aisles used by patients and, if provided, corridor handrails shall have ends return to the wall. E. New inpatient hospice facilities shall be designed and constructed in compliance with Chapters Five through Seven and Chapter Twelve of NFPA 101 (1994), Life Safety Code and NFPA 99 (1993) Standard for Health Care Facilities, NFPA 13 (1994) Standard for Installation of Sprinkler Systems and NFPA 90A (1993) Standard for the Installation of Air Conditioning and Ventilation Systems. Section 12-6 of NFPA 101 shall not apply to these facilities. F. Hardware on toilet room doors shall be operable from both the inside and the outside. All toilet room doors shall provide a net clear opening of not less than 32 inches. G. The corridor doors from all patient-use areas as well as all doors through which patients may need to pass for emergency exit shall be not less than thirty-six (36) inches wide. H. Every window in patient-use areas shall be provided with shades, curtains or drapes. Curtains and drapes shall be made of fabric which is treated to be or is inherently flameretardant. I. The floors of toilets, baths, utility rooms and janitor’s closets shall have smooth, waterproof surfaces which are wearresistant. The floors of kitchens and food preparation areas shall be waterproof, greaseproof, smooth and resistant to heavy wear. J. The walls of all rooms where food and drink are prepared, served or stored shall have a smooth surface with painted or equally washable finish. At the base they shall be waterproof and free from spaces which may harbor insects. The walls of kitchens, utility rooms, baths, warewashing rooms, janitor’s closets and spaces with sinks shall have waterproof, painted, glazed, or similar finishes to a point above the splash and spray line. K. The ceilings of all kitchens, sculleries and other rooms where food and drink are prepared shall be painted with washable paint. L. All casework in the facility shall be finished with at least a sealer on all interior surfaces. Casework with sinks installed in the counter shall be caulked to provide a watertight joint between the backsplash and the wall. M. All floor covering used in inpatient hospice facilities shall have either Class A or B fire ratings as required by Chapter Twelve of NFPA 101 (1994), The Life Safety Code. N. Stairways, ramps, elevator hoistways, light or ventilation shafts, chutes and other vertical openings between stories shall be enclosed with construction which is equal to or greater than the required floor assembly rating of the building’s construction type. O. The number of stories in a building housing a hospice facility shall be determined by counting the number of occupiable levels in the building regardless of their location at, above or below grade. P. Each room or patient-use area shall be conspicuously and unmistakably identifiable at its entrance by patients, visitors and staff. Q. All signage within six feet (6') of the floor shall be tactile to be usable by visually impaired persons. R. Fire-resistant ratings— (I) Definitions— (a) Fire-separation distance is the distance in feet measured from the building face to the closest interior lot line, to the centerline of a street or public way or to an imaginary line between two (2) buildings on the same property. (b) Fire-protection rating is the time in hours, or fractions of an hour, that an opening protective assembly will resist fire exposure as determined in accordance with the test procedures set forth in ASTM E119. (II) Exterior walls with a fire-separation distance less than five feet (5') shall have a fire-resistant rating of one (1) hour. (III) In exterior walls with a fire-separation distance of three feet or less, no openings will be allowed, from three feet (3') to five feet (5') no unprotected openings will be allowed, and protected openings will be allowed with a total aggregate area of fifteen percent (15%) of the wall surface. (IV) Approved fire protective assemblies shall be fixed, self-closing or equipped with approved automatic-closing devices, a fire-resistant rating of not less than three-quarters (3/4) of an hour shall be required. (V) Fire protective assemblies are not required where outside automatic sprinklers are installed for the protection of the exterior openings. The sprinklers shall be installed in accordance with NFPA 13; 5. Structural design. A. All new facilities and additions to all areas of existing licensed facilities which undergo major remodeling, in all their parts, shall be of sufficient strength to resist all stresses imposed by dead loads, live loads and lateral or uplift forces such as wind, without exceeding, in any of the structural materials, the allowable working stress established for these materials by generally accepted good engineering practice. B. Foundations shall rest on solid ground or properly compacted fill and shall be carried to a depth of not less than one foot below the estimated frost line or shall rest on leveled rock or load-bearing piles when solid ground is not encountered. When engineered fill is used, site preparation and placement of fill shall be done under the direct full-time supervision of the soils engineer. The soils engineer shall issue a final report on the compacted fill operation and certify its compliance with the job specifications. Reasonable care shall be taken to establish proper soil-bearing values for soil at the building site. If the bearing capacity of the soil is in question, a recognized load test may be used to determine the safe bearing value. Footings, piers and foundation walls shall be adequately protected against deterioration from the action of groundwater; 6. Electrical systems. A. The entire electrical system shall be designed, installed and tested in compliance with NFPA 70 (1993) The National Electrical Code and NFPA 99 (1993) Standard for Health Care Facilities. B. Emergency lighting shall be provided for exits, stairs and exit access corridors which shall be supplied by an emergency service and automatic electric generator or battery lighting system. This emergency lighting system shall be equipped with an automatic transfer switch. If battery lights are used, they shall be wet cell units or other rechargeable-type batteries equipped with automatic trickle charger. These units shall be rated at four (4) hours. C. Patient rooms shall have a minimum general illumination of ten foot-candles, a night-light and a patient’s reading light. The general illumination fixtures and the nightlight shall be switched at the patient room door. D. Ceiling lighting fixtures, if used, shall be of a type which are shaded or globed to minimize glare. E. Each patient room shall have not less than one duplex receptacle on each wall in the room. The spacing of receptacles around the perimeter of the room shall not be greater than twelve (12) feet. F. All occupied areas shall be adequately lighted as required by the duties performed in the space. G. Night-lights shall be provided in corridor, stairways and patient rooms. Toilets adjacent to patient rooms are not required to have night-lights. H. An electrically powered communication system shall be provided which allows staff to respond to patient calls regardless of patient location. I. An electrically powered fire alarm system shall be provided as required by NFPA 101 (1994) The Life Safety Code. The fire alarm system shall have an emergency back-up source of electrical power and a direct connection for notifying the fire department or fire department dispatch service. Fire alarm manual pull stations shall be provided at each exit and at each staff workstation in the patient-care units. Smoke detectors shall be installed in social space rooms which open directly to the corridor, in the vicinity of any smoke or fire door which is permitted to be held open by a magnetic hold-open device, and in the corridors at intervals not exceeding 30 feet. J. Portable fire extinguishers shall be provided as required by NFPA 101 (1994) The Life Safety Code and the local authority; 7. Mechanical systems. A. The heating, ventilation and air-conditioning systems shall be capable of providing temperature ranges between 72°F–80°F in all patient-care areas. The heating system shall be capable of maintaining a winter indoor temperature of not less than 72°F in all nonpatient areas. The air-conditioning system shall be capable of maintaining a summer indoor temperature of not more than 80°F in all nonpatient areas. B. The heating system shall have automatic controls adequate to provide comfortable conditions in all portions of the building at all times. C. Heating, ventilation and air-conditioning systems installed in inpatient hospice facilities shall be designed, installed and balanced in compliance with NFPA 90A (1993) Standard for the Installation of Air Conditioning and Ventilation Systems, and shall provide the pressure relationships and at least the minimum air change rates indicated in Table 1. TABLE 1—VENTILATION REQUIREMENTS Minimum Minimum Pressure Air Changes of Total Air All Air Relationship Outdoor Air Per Changes Per Exhausted Air Returned to Adjacent Hour Supplied Hour Supplied Directly From This Area Designation Areas to Room to Room to Outdoors Room Patient Room E 2 2 Optional Optional Patient Area Corridor and Patient Living Room P 2 2 Optional Optional Soiled Workroom and Soiled Linen Holding N Optional 6 Yes No Clean Staff Work Area P 2 6 Optional Optional Toilet Room N Optional 6 Yes No Clean Linen Storage P Optional 2 Optional Optional Designated Smoking Area N Optional 10 Yes No Food Preparation Area E 2 6 Yes No Warewashing N Optional 6 Yes No Dietary and General Storage V Optional 2 Optional Optional Linen and Trash Chute Room N Optional 6 Yes No Medical Gas Storage and Manifold Rooms N Optional 6 Yes No Administrative and Public Areas E 2 2 Optional Optional P = Positive N = Negative V = Variable E = Equal D. All air-moving, heating, ventilation and airconditioning equipment shall be equipped with at least one filter located upstream of the conditioning equipment. If a pre-filter is employed, the pre-filter shall be upstream of the conditioning equipment and the main filter shall be located farther downstream. All filters shall be easily accessible for maintenance. Filter frames shall be durable and carefully dimensioned and shall provide an airtight fit with the enclosing ductwork. All joints between the filter segments and the enclosing ductwork shall be sealed to preclude air leakage. E. Outside air intakes shall be located no less than 25 feet from exhaust outlets of ventilation systems, combustion equipment stacks, clinical suction discharges and plumbing vent stacks or from areas which may collect vehicular exhaust and other noxious fumes. F. Corridors shall not be used to supply air to or exhaust air from any room, except that air from corridors may be used to ventilate bathrooms, toilet rooms, janitor’s closets and small electrical or telephone closets opening directly onto corridors provided that ventilation can be accomplished by the undercutting of doors. The installation of louvers in corridor doors is prohibited. The space above the finished ceiling may be used as a plenum for return air only. G. Exhaust hoods in meal preparation areas shall comply with the requirements of NFPA 96 (1994). All hoods and cooktop surfaces in meal preparation areas shall be equipped with automatic fire suppression systems, automatic fan controls and fuel shutoff; 8. Plumbing systems. A. The entire plumbing system, its design, operation and maintenance shall comply with the requirements of all applicable local and state codes including the requirements set forth in this rule. B. Plumbing fixtures. (I) All plumbing fixtures shall be of nonabsorptive acid-resistant material. (II) Clinical sinks shall have a bedpan-flushing device and shall have an integral trap in which the upper portion of a visible trap seal provides a water surface. (III) Showers and tubs shall be provided with nonslip surfaces. (IV) Water closets in patient areas shall be quiet operating types. (V) Stools in patient toilet facilities shall be the elongated bowl type with nonreturn stops, backflow preventers and silencers. Seats shall be the split type and white in color. (VI) Grab bars or handrails shall be provided adjacent to all bathtubs. (VII) All lavatories shall be trimmed with valving operable without the use of hands. C. Water supply systems. (I) A reliable source of potable water shall be provided at the site to supply water in sufficient quantities to meet the various use demands of the hospice. The source of water shall have been tested and approved by the Missouri Department of Natural Resources. (II) The water supply systems shall be designed to supply water at sufficient pressure to operate all fixtures and equipment during maximum demand periods. (III) Each water service main, branch main, riser and branch to a group of fixtures shall be valved. Stop valves shall be provided at each fixture. (IV) Reduced pressure backflow preventers shall be installed on water service entrance, hose bibbs, janitors’ sinks, bedpan-flushing attachments, and on all other fixtures to which hoses or tubing can be attached. The installation of backflow preventors shall provide safeguards against waterline expansion. (V) The water supply system shall be designed to provide hot water at each hot water outlet at all times. The water-heating equipment shall have sufficient capacity to supply five gallons of water at 120°F per hour per bed for hospice fixtures and eight gallons per bed for kitchen and laundry. Lesser capacities may be accepted upon submission of the calculation for the anticipated demand of all fixtures and equipment in the building. Hot water at showers and bathing facilities shall not exceed 110°F. Hot water at handwashing facilities shall not exceed 120°F. Hot water circulating mains and risers shall be run from the hot storage tank to a point directly below the highest fixture at the end of each branch main. D. Drainage systems. (I) All fixtures and equipment shall be connected through traps to soil and waste piping and to the sewer and they shall all be properly vented to the outside. (II) Courts, yards and drives which do not have natural drainage from the building shall have catch basins and drains to low ground, storm-water drainage system or dry wells. (III) The building sanitary drain system shall be piped in cast iron, steel, copper or plastic. (IV) Building sewers shall discharge into a community sewerage system when available. If such a system is not available, a facility providing sewage treatment shall conform to the rules of the Department of Natural Resources. (V) Drainage piping shall not be installed within the ceiling or exposed in food preparation centers, food service facilities, food storage areas and clean linen storage rooms; special precautions shall be taken to protect any of these areas from possible leakage or condensation from necessary overhead drainage piping systems. These special precautions include requiring noncorrosive drip troughs with a minimum four-inch outside diameter to be installed under the drainage pipe in the direction of slope to a point where the pipe leaves the protected space and terminates at that point—usually at a wall. The trough shall be supported with noncorrosive strap hangers and screws from the pipe above. Trough joints and hanging screw penetrations shall be sealed to maintain watertight integrity throughout. E. Natural or liquefied petroleum (LP) gas systems. (I) Where gas-fire equipment is used, all gas piping, fittings, tanks and specialties shall be provided and installed in compliance with NFPA 54 (1992), NFPA 58 (1992), and the instructions of the gas supplier, except where more strict requirements are stated. Where liquefied petroleum gas (LPG) is used, compliance with the rules of the Missouri Department of Agriculture is also required. (II) Where gas piping enters the building below grade, it shall have an outside vent as follows: a concrete box shall be made 18 inches by 18 inches with three-inch thick walls, of a height to rest on top of the entering gas pipe, and the top of the box to coming within six inches of top grade. The box shall be filled with coarse gravel. A one-inch upright vent line shall be to 1/2 the depth of the box and extend 12 inches above grade with a screened U-vent looking down. The vent line shall be anchored securely to the building wall. (III) Gas outlets and gas-fired equipment shall not be installed in any patients’ bedrooms. F. Where a piped central medical gas distribution system is installed, the oxygen piping, outlets, manifold rooms, and storage rooms shall be installed in accordance with the requirements of Chapter 4 of NFPA 99 (1993); and 9. Fire prevention and general operating requirements. A. The hospice facility shall be maintained in a manner which provides a clean safe environment for the delivery of patient care and shall, until remodeled or renovated with the approval of the Department of Health, remain compliant with the codes and regulations under which the facility was constructed. B. Exitways shall always be maintained free of obstructions. C. Curtains, drapes and cubicle curtains shall be maintained in a manner which does not compromise their fire-resistant properties. D. Smoking may be permitted in the patient’s room by the patient only, and designated smoking areas by others. Designated smoking areas shall be ventilated as required by Table 1 of this rule. Modification of the patient room ventilation system is not required to permit occasional authorized smoking by a patient. E. All waste containers shall be of noncombustible construction. F. Electrical systems and medical gas systems shall be tested according to the provisions of NFPA 99 (1993) and shall be modified as necessary to comply with the operational requirements of that standard. (5) General Design and Construction Standards for Existing Inpatient Hospice Facilities. (A) Any inpatient hospice facility existing and in continuous operation prior to the date of October 30, 1996, will upon receipt of application for licensure, be inspected by the Department of Health to determine compliance with this rule. Where existing physical conditions cause strict compliance to be difficult to achieve, the department may determine that the intent of the new construction rules has been satisfied through the establishment of acceptable equivalency conditions. The provision of fire alarm and detection systems, automatic extinguishment systems, building compartmentation and the presence of staff trained consistent with the facility’s disaster preparedness plan are factors which will be considered in determining fire safety compliance equivalency. The ability of the existing facility to meet the programmatic needs of the patients, their family, staff and public in an accessible and sanitary environment will be considered in determining functional equivalency. Existing inpatient hospice facilities shall provide the department evidence of compliance with all local regulations and codes as well as evidence that the existing operation is in good standing with the health facility licensure programs administered by Department of Social Services/Division of Aging. Existing inpatient hospice facilities shall be operated and licensed exclusively under the provisions of section 197.250, RSMo. AUTHORITY: section 197.270, RSMo 2000.* 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. *Original authority: 197.270, RSMo 1992, amended 1993.