Current through Register Vol. 42, No. 11, August 30, 2024
(1)
Patients in need of health care which can be met by the hospice are admitted to
the hospice only upon the recommendation of, and remain under the care of, a
physician. Each patient or sponsor designates a physician.
(2) There is made available prior to or at
the time of admission patient information which includes current medical
findings, diagnoses, and orders from the physician for the immediate care of
the patient. A summary of prior treatments are made available at the time of
admission or within 48 hours thereafter. The following provisions are
applicable:
(a) If orders are from a physician
other than the attending physician, they shall be communicated to the attending
physician and verification of such shall be entered into the medical record by
the nurse who took the orders from the physician.
(b) Physician's verbal orders for drugs,
treatments, diets, etc., (e.g., oral orders, telephone orders, recopied orders,
standing orders) are reduced to writing on the physicians' order sheet by a
licensed nurse, physician, or pharmacist. They are dated and signed by the
person receiving or transcribing the order. Such orders are dated and signed by
the attending physician at the time of the next visit, but in no case longer
than 30 days after dating and recording the order. Dietary
counseling means education and interventions provided to the patient and
family regarding appropriate nutritional intake as the patient's condition
progresses and is provided by qualified individuals, which may include a
registered nurse, dietitian, or nutritionist, when identified in the patient's
plan of care.
(c) The attending
physician shall designate an alternate physician to attend the patient in
his/her absence.
(d) The hospice
has written procedures, available at the nurses' station, that provides for
having a physician available to furnish necessary medical care in case of
emergency.
(e) In each inpatient
hospice the physician shall write/dictate, date, and sign a progress note at
the time of each patient's visit or within 7 days.
(f) In each inpatient hospice any changes in
the interdisciplinary treatment team care plan shall be dated and signed by the
physician at the time of each visit or within 7 days.
(g) The physician is responsible for the
development of a discharge summary within 30 days after discharge or
death.
(h) Each inpatient hospice
must have a list of names and telephone numbers of physicians to be called in
the event of an emergency.
(3)
Documentation of emergencies,
accidents and injuries. All the hospices shall have policies and
procedures established relative to documentation of emergencies, accidents, and
injuries to patients and staff.
(a)
Sufficient information shall be documented in the medical record and/or on the
accident and incident record to reflect facts about the incident, injuries,
actions taken, and physician contacted. Dated and signed entries in the medical
record and/or the incident and accident record shall be made by the physician
and other appropriate hospice staff.
(b) The manager and appropriate staff shall
be provided written reports of accidents and injuries.
(c) These reports shall serve the medical
director and other appropriate staff as a basis for a written recommendation
for corrective action.
