Basic Hospice Functions

(1) Core Functions. A residential hospice must ensure that substantially all core services are routinely provided directly by hospice employees. A residential hospice may use contracted staff if necessary to supplement residential hospice employees in order to meet the needs of patients and residents. (a) Nursing services. The residential hospice must provide nursing care and services by, or under the supervision of, a registered nurse (R.N.) at all times. 1. Nursing services must be directed and staffed to assure the nursing needs of patients and residents are met. 2. Patient and resident care responsibilities of nursing personnel must be specified. 3. Hospice services and HIV care services must be provided in accordance with recognized standards of practice. 4. Nursing services include the authorization of a Registered Nurse to pronounce the death of a patient or resident. (b) Medical Social Services. Medical Social Services must be provided by a qualified social worker under the direction of a physician. (c) Physician Services. In addition to palliation and management of terminal illness and related conditions and HIV care, physician employees of the residential hospice including the physician member(s) of the interdisciplinary group, must also meet the general medical needs of the patients and residents to the extent these needs are not met by the attending physician. (d) Counseling Services. Counseling services must be made available to both the individual and the family. Counseling includes bereavement counseling, provided both prior to and after the patient’s or resident’s death, as well as dietary, therapeutic, spiritual and may include any other counseling services identified in the plan of care for the individual and family provided while the individual is a patient or resident of the residential hospice. 1. Bereavement counseling. There must be an organized program for the provision of bereavement services under the supervision of a qualified professional. The plan of care for these services should reflect family needs, services to be provided, and the frequency of services. 2. Dietary counseling. Dietary counseling, when required, must be provided by a qualified individual. 3. Spiritual counseling. Spiritual counseling must include notice to patients as to the availability of clergy. 4. Additional counseling. Counseling may be provided by other members of the interdisciplinary group as well as by other qualified professionals as determined by the residential hospice. (2) Plan of Care. STANDARDS FOR RESIDENTIAL HOSPICES CHAPTER 0720-23 A written plan of care must be established and maintained for each individual admitted to a residential hospice, and the care provided to an individual must be in accordance with the plan. (a) Establishment of plan. The plan must be established by the attending physician, the medical director or the physician’s designee and the interdisciplinary group prior to providing care. (b) Review of plan. The plan must be reviewed and updated as the patient’s condition changes, but at intervals of no more than fifteen (15) days, by the attending physician, the medical director or the physician’s designee and the interdisciplinary group. These reviews must be documented. (c) Content of plan. The plan must include an assessment of the individual’s needs and identification of the HIV care services or hospice services required including the management of discomfort and symptom relief. It must state in detail the scope and frequency of services needed to meet the patient’s or resident’s and family’s needs. (3) Interdisciplinary Group. The organization providing hospice services must designate an interdisciplinary group and groups composed of individuals who provide or supervise the care and services offered by the residential hospice: (a) Composition of Group. The residential hospice must have an interdisciplinary group or groups that include at least the following individuals who are employees of the residential hospice: 1. A doctor of medicine or osteopathy; 2. A registered nurse; 3. A social worker; and 4. A pastoral or other counselor. (b) Role of Group. The interdisciplinary group is responsible for: 1. Participation in the establishment of the plan of care; 2. Provision or supervision of the quality of hospice care and services and/or HIV care services; 3. Periodic review and updating of the plan of care for each individual receiving hospice care or HIV care; and 4. Establishing and maintaining policies governing the day-to-day provision of hospice care and services and/or HIV care and services. (c) If a residential hospice has more than one interdisciplinary group, it must designate in advance the group it chooses to execute the functions described in paragraph (b)4. of this section. (d) Coordinator. The residential hospice must designate a registered nurse to coordinate the implementation of the plan of care of each patient and/or resident. STANDARDS FOR RESIDENTIAL HOSPICES CHAPTER 0720-23 (e) Volunteers. The residential hospice may use volunteers, in defined roles, under the supervision of a designated residential hospice employee. 1. Training. The residential hospice must provide appropriate orientation and training that is consistent with acceptable standards of residential hospice practice. 2. Role. Volunteers may be used in administrative or direct patient or resident care roles. 3. Recruiting and retaining. The hospice must document active and ongoing efforts to recruit and train volunteers. 4. Availability of clergy. The residential hospice must make reasonable efforts to arrange for visits of clergy and other members of religious organizations in the community to patients or residents who request such visits and must advise patients and/or residents of this opportunity. (4) Continuation of Care. A residential hospice must assist in coordinating continued care should the patient or resident be transferred or discharged from the residential hospice. (5) Drug and Treatments. Drugs and treatments shall be administered by appropriately licensed facility personnel acting within the scope of their license. Oral orders for drugs and treatments shall be given to appropriately licensed personnel acting within the scope of their licenses, immediately recorded, signed and dated, and countersigned and dated by the physician. (6) Performance Improvement Program. The residential hospice must ensure that there is an effective facility-wide performance improvement program to evaluate resident care and performance of the organization. The performance improvement program must be ongoing and have a written plan of implementation which assures that: (a) All organized services related to resident care, including services furnished by a contractor, are evaluated; (b) Nosocomial infections and medication therapy are evaluated; (c) All services performed in the facility are evaluated as to the appropriateness of diagnosis and treatment; (d) The residential hospice must have an ongoing plan, consistent with available community and facility resources, to provide or make available services that meet the medically related needs of its patients and/or HIV care residents; (e) The facility must develop and implement plans for improvement to address deficiencies identified by the performance improvement program and must document the outcome of the remedial action; (f) Performance improvement program records are not disclosable except when such disclosure is required to demonstrate compliance with this section; (g) Good faith attempts by the Performance Improvement Program Committee to identify and correct deficiencies will not be used as a basis for sanctions. (7) Infection Control. STANDARDS FOR RESIDENTIAL HOSPICES CHAPTER 0720-23 (a) The residential hospice must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases. (b) The administrator shall assure that an infection control committee, including the medical director and members of the nursing staff and administrative staff, develops guidelines and techniques for the prevention, surveillance, control and reporting of facility infections. Duties of the committee shall include the establishment of: 1. Written infection control policies; 2. Techniques and systems for identifying, reporting, investigating and controlling infections in the facility; 3. Written procedures governing the use of aseptic techniques and procedures in the facility; 4. Written procedures concerning food handling, laundry practices, disposal of environmental and patient and/or resident wastes, traffic control and visiting rules, sources of air pollution, and routine culturing of autoclaves and sterilizers; 5. A log of incidents related to infectious and communicable diseases; 6. Formal provisions to educate and orient all appropriate personnel in the practice of aseptic techniques such as handwashing, proper grooming, masking and dressing care techniques, disinfecting and sterilizing techniques, and the handling and storage of patient and/or resident equipment and supplies; and, 7. Continuing education for all facility personnel on the cause, effect, transmission, prevention, and elimination of infections. (c) The administrator, the medical director and a registered nurse must ensure that the facility-wide performance improvement program and training programs address problems identified by the infection control program and must be responsible for the implementation of successful corrective action plans in affected problem areas. (d) The facility shall develop policies and procedures for testing a patient’s or resident’s blood for the presence of the hepatitis B virus and the HIV (AIDS) virus in the event that an employee of the facility, a student studying at the facility, or other health care provider rendering services at the facility is exposed to a patient’s or resident’s blood or other body fluid. The testing shall be performed at no charge to the patient or resident, and the test results shall be confidential. (e) The facility and its employees shall adopt and utilize standard or universal precautions for preventing transmission of infections, HIV, and communicable diseases. (f) A Residential Hospice shall have an annual influenza vaccination program which shall include at least: 1. The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The Residential Hospice will encourage all staff and independent practitioners to obtain an influenza vaccination; STANDARDS FOR RESIDENTIAL HOSPICES CHAPTER 0720-23 2. A signed declination statement on record from all who refuse the influenza vaccination for reasons other than medical contraindications (a sample form is available at http://tennessee.gov/health/topic/hcf-provider); 3. Education of all employees about the following: (i) Flu vaccination, (ii) Non-vaccine control measures, and (iii) The diagnosis, transmission, and potential impact of influenza; 4. An annual evaluation of the influenza vaccination program and reasons for non- participation; and 5. A statement that the requirements to complete vaccinations or declination statements shall be suspended by the administrator in the event of a vaccine shortage as declared by the Commissioner or the Commissioner’s designee. (g) Every residential hospice shall adopt appropriate policies regarding the testing of patients and staff for human immunodeficiency virus (HIV) and any other identified causative agent of acquired immune deficiency syndrome. (h) Precautions shall be taken to prevent the contamination of sterile supplies by soiled supplies. Sterile supplies shall be packaged and stored in a manner that protects the sterility of the contents. Decontamination and preparation areas shall be separated. (i) Space and facilities for housekeeping equipment and supply storage shall be provided in each service area. Storage for bulk supplies and equipment shall be located away from patient and resident care areas. The building shall be kept in good repair, clean, sanitary and safe at all times. (j) The facility shall appoint a housekeeping supervisor who shall be responsible for: 1. Organizing and coordinating the facility’s housekeeping service; 2. Acquiring and storing sufficient housekeeping supplies and equipment for facility maintenance; and, 3. Assuring the clean and sanitary condition of the facility to provide a safe hygienic environment for patients and/or residents and staff. Cleaning shall be accomplished in accordance with the infection control rules and regulations herein and facility policy. (k) Laundry facilities located in the residential hospice shall: 1. Be equipped with an area for receiving, processing, storing and distributing clean linen; 2. Be located in an area that does not require transportation for storage of soiled or contaminated linen through food preparation, storage or dining areas; 3. Provide space for storage of clean linen and for bulk storage within clean areas of the facility; and, STANDARDS FOR RESIDENTIAL HOSPICES CHAPTER 0720-23 4. Provide carts, bags or other acceptable containers appropriately marked to identify those used for soiled linen and those used for clean linen to prevent dual utilization of the equipment and cross contamination. (l) The facility shall name an individual who is responsible for laundry service. This individual shall be responsible for: 1. Establishing a laundry service, either within the residential hospice or by contract, that provides the facility with sufficient clean, sanitary linen at all times; 2. Knowing and enforcing infection control rules and regulations for the laundry service; 3. Assuring the collection, packaging, transportation and storage of soiled, contaminated, and clean linen is in accordance with all applicable infection control rules, regulations and procedures; and, 4. Assuring that a contract laundry service complies with all applicable infection control rules, regulations and procedures. (8) Hospice Aide Services. Aide Services must be available and adequate in frequency to meet the needs of the patients. (a) The hospice aide shall be assigned to a particular patient or resident by a registered nurse. Written instructions for patient or resident care shall be prepared by a registered nurse or therapist as appropriate. Duties may include the performance of simple procedures as an extension of therapy services, personal care, ambulation and exercises, reporting changes in the patient’s or resident’s condition and needs, and completing appropriate records. (b) The registered nurse, or appropriate professional staff member, shall monitor and assess the hospice aide’s competence in providing care, relationships and determine whether goals are being met. (c) There shall be regularly scheduled continuing in-service programs which include on- the-job training as issues are identified. (9) Physical therapy, occupational therapy, respiratory therapy and speech language pathology. (a) Physical therapy services, occupational therapy services, respiratory therapy services and speech language pathology services must be available, and when provided, offered in a manner consistent with accepted standards of practice. (b) Speech therapy services shall be provided only by or under supervision of a qualified speech language pathologist in good standing, or by a person qualified as a Clinical Fellow subject to Tennessee Board of Communications Disorders and Sciences Rule 1370-01-.10. (10) Medical supplies. Medical supplies and appliances including drugs and biologicals, must be provided as needed for the palliation and management of the terminal illness or conditions directly attributable to the terminal diagnosis. (a) Administration. All drugs and biologicals must be administered in accordance with accepted standards of practice, only by appropriately licensed employees of the hospice. STANDARDS FOR RESIDENTIAL HOSPICES CHAPTER 0720-23 (b) The residential hospice must have a policy for the disposal of controlled drugs when those drugs are no longer needed by the patient. (c) Drugs and biologicals may be administered by the patient or resident or his/her family member if the patient’s or resident’s attending physician has approved. (11) Medical Records. (a) A medical record containing past and current findings in accordance with accepted professional standards shall be maintained for every residential hospice patient and/or HIV care resident. The record must be complete, promptly and accurately documented, readily accessible and systematically organized to facilitate retrieval. Each clinical record is a comprehensive compilation of information. Entries are made for all services provided. Entries are made and signed by the person providing the services. The record includes all services whether furnished directly or under arrangements made by the hospice. Each individual’s record must contain: 1. The initial and subsequent assessments; 2. The plan of care; 3. Identification data; 4. Consent and authorization and election forms; 5. Pertinent medical history; and 6. Complete documentation of all services and events, including but not limited to evaluations, treatments and progress notes. (b) All medical records, either written, electronic, graphic or otherwise acceptable form, must be retained in their original or legally reproduced form for a minimum period of at least (10) years after which such records may be destroyed. However, in cases of patients or residents under mental disability or minority, their complete residential hospice records shall be retained for the period of minority or known mental disability, plus one (1) year, or ten (10) years following the discharge of the patient or resident, whichever is longer. Records destruction shall be accomplished by burning, shredding or other effective method in keeping with the confidential nature of the contents. The destruction of records must be made in the ordinary course of business, must be documented and in accordance with the residential hospice’s policies and procedures, and no record may be destroyed on an individual basis. (c) Even if the residential hospice discontinues operations, records shall be maintained as mandated by these rules and the Tennessee Medical Records Act (see T.C.A. § 68-11- 308). If a patient or resident is transferred to another health care facility or agency, a copy of the record or an abstract shall accompany the patient or resident when the residential hospice is directly involved in the transfer. (d) The residential hospice must have a procedure for ensuring the confidentiality of patient and resident records. Information from, or copies of, records may be released only to authorized individuals, and the facility must ensure that unauthorized individuals cannot gain access to, or alter, patient or resident records. Original medical records must be released by the facility only in accordance with federal and state laws. (e) For purposes of this rule, the requirements for signature or countersignature by a physician or other person responsible for signing, countersigning and entry may be STANDARDS FOR RESIDENTIAL HOSPICES CHAPTER 0720-23 satisfied by the electronic entry by such person of a unique code assigned exclusively to him or her, or by entry of other unique electronic or mechanical symbols, provided that such person has adopted same as his or her signature in accordance with established protocol or rules. (f) All entries must be legible, complete, dated and authenticated according to facility policy. (12) Pharmaceutical Services. (a) The residential hospice shall have pharmaceutical services that meet the needs of the residents and are in accordance with the Tennessee Board of Pharmacy statutes and regulations. The facility is responsible for developing policies and procedures that minimize drug errors. (b) Test reagents, germicides, and disinfectants shall be stored separately from drugs, devices and related materials. External drugs and related materials must be stored separately from internal drugs, devices and related materials. All drugs, devices and related materials must be properly labeled. They shall be properly stored in medicine compartments, including cabinets on wheels, or drug rooms. Such cabinets or drug rooms shall be kept securely locked when not in use and the key must be in the possession of the supervising nurse or other authorized persons. (c) Schedule II drugs must be stored behind two (2) separately locked doors at all times and accessible only to persons in charge of administering medication. (d) Every residential hospice shall comply with all state and federal regulations governing Schedule II drugs. (e) A notation shall be made in a Schedule II drug book and in the patient’s or resident’s nursing notes each time a Schedule II drug is given. The notation shall include the name of the patient or resident receiving the drug, name of the drug, the dosage given, the method of administration, the date and time given and the name of the physician prescribing the drug. (f) All oral orders shall be immediately recorded, designated as such and signed by the person receiving them and countersigned by the physician within ten (10) days. (g) All orders for drugs, devices and related materials must be in writing and signed by the practitioner or practitioners responsible for the care of the patient or resident. Electronic and computer-generated records and signature entries are acceptable. When telephone or oral orders must be used, they shall be: 1. Accepted only by personnel that are authorized to do so by the medical staff policies and procedures, consistent with federal and state law; and, 2. Signed or initialed by the prescribing practitioner according to residential hospice policy. (h) Medications not specifically limited as to time or number of doses when ordered are controlled by automatic stop orders or other methods in accordance with written policies. No Schedule II drug shall be given or continued beyond seventy-two (72) hours without a written order by the physician. STANDARDS FOR RESIDENTIAL HOSPICES CHAPTER 0720-23 (i) Medication administration records (MAR) shall be checked against the physician’s orders. Each dose shall be properly recorded in the clinical record after it has been administered. (j) Preparation of doses for more than one scheduled administration time shall not be permitted. (k) Medication shall be administered only by licensed medical or licensed nursing personnel or other licensed health professionals acting within the scope of their license. (l) Unless the unit dose package system is used, individual prescriptions of drugs shall be kept in the original container with the original label intact showing the name of the patient or resident, the drug, the physician, the prescription number and the date dispensed. (m) Legend drugs shall be dispensed by a licensed pharmacist. (n) Any unused portions of prescriptions shall be turned over to the patient or resident only on a written order by the physician. A notation of drugs released to the patient or resident shall be entered into the medical record. All unused prescriptions left in a residential hospice shall be destroyed on the premises and recorded by a pharmacist. Such record shall be kept in the residential hospice. (13) Laboratory Services. The residential hospice must maintain or have available, either directly or through a contractual agreement, adequate laboratory services to meet the needs of the patients and/or residents. The residential hospice must ensure that all laboratory services provided to its patients and/or residents are performed in a facility licensed in accordance with the Tennessee Medical Laboratory Act (TMLA). All technical laboratory staff shall be licensed in accordance with the TMLA and shall be qualified by education, training and experience for the type of services rendered. (14) Food and Dietetic Services. (a) The residential hospice must designate a person, either directly or by contractual agreement, to serve as the food and dietetic services director with responsibility for the daily management of the dietary services. (b) There must be a qualified dietitian, full-time, part-time, or on a consultant basis who is responsible for the development and implementation of a nutrition care process to meet the needs of patients and/or residents for health maintenance, disease prevention and, when necessary, medical nutrition therapy to treat an illness, injury or condition. (c) Menus must meet the needs of the patients and/or residents. 1. Therapeutic diets must be prescribed by the practitioner or practitioners responsible for the care of the patients and/or residents and must be prepared and served as prescribed. 2. Special diets shall be prepared and served as ordered. 3. Nutritional needs must be met in accordance with recognized dietary practices and in accordance with orders of the practitioner or practitioners responsible for the care of the patients and/or residents. STANDARDS FOR RESIDENTIAL HOSPICES CHAPTER 0720-23 4. A current therapeutic diet manual approved by the dietitian and medical director must be readily available to all medical, nursing, and food service personnel. (d) Education programs, including orientation, on-the-job training, inservice education, and continuing education shall be offered to dietetic services personnel on a regular basis. Programs shall include instruction in the use of equipment, personal hygiene, proper inspection, and the handling, preparing and serving of food. (e) A minimum of three (3) meals in each twenty-four (24) hour period shall be offered. A supplemental night meal shall be offered if more than fourteen (14) hours lapse between supper and breakfast. Additional nourishments shall be provided to patients and/ or residents with special dietary needs. A minimum of three (3) days supply of food shall be on hand. (f) Food shall be protected from dust, flies, rodents, unnecessary handling, droplet infection, overhead leakage and other sources of contamination whether in storage, while being prepared and served, and/or transported through hallways. (g) Perishable food shall not be allowed to stand at room temperature except during necessary periods of preparation or serving. Prepared foods shall be kept hot (140 °F or above) or cold (45 °F or less). Appropriate equipment for temperature maintenance, such as hot and cold serving units or insulated containers, shall be used. (h) Dishwashing machines shall be used according to manufacturer specifications. (i) All dishes, glassware and utensils used in the preparation and serving of food and drink shall be cleaned and sanitized after each use. (j) The cleaning and sanitizing of handwashed dishes shall be accomplished by using a three-compartment sink according to the current “U.S. Public Health Service Sanitation Manual.” (k) The kitchen shall contain sufficient refrigeration equipment and space for the storage of perishable foods. (l) All refrigerators and freezers shall have thermometers. Refrigerators shall be kept at a temperature not to exceed 45 °F. Freezers shall be kept at a temperature not to exceed 0 °F. (m) Written policies and procedures shall be followed concerning the scope of food services in accordance with the current edition of the “U.S. Public Health Service Recommended Ordinance and Code Regulating Eating and Drinking Establishments” and the current “U.S. Public Health Service Sanitation Manual” should be used as a guide to food sanitation.