Code of Massachusetts Regulations
105 CMR - DEPARTMENT OF PUBLIC HEALTH
Title 105 CMR 141.000 - Licensure of Hospice Programs
Section 141.201 - Administration
Universal Citation: 105 MA Code of Regs 105.141
Current through Register 1543, March 14, 2025
(A) Administrator.
(1) Each hospice shall designate a hospice
administrator who is responsible to the governing body, either directly or
through the governing body's chief executive officer, for the administration
and management of the hospice.
(2)
The hospice administrator shall be a person who has a minimum of two years of
relevant experience in the health care, human services or related fields, which
shall include at least one year of supervisory/administrative
experience.
(3) The duties of the
administrator shall include but not be limited to:
(a) Directing the hospice and ensuring
implementation of policies and procedures regarding all activities and services
provided in the hospice, whether provided through staff employed directly by
the hospice, by volunteers or through contract arrangement;
(b) Designating, in writing, an alternate to
act in his or her absence;
(c)
Implementing administrative and personnel policies;
(d) Implementing an effective budgetary and
accounting system;
(e) Implementing
a quality assurance mechanism to assess the overall hospice program;
(f) Keeping the governing body informed of
the hospice's operations;
(g)
Appointing qualified hospice staff members when and where appropriate and
ensuring adequate staff education and evaluations;
(h) Developing and proposing an annual budget
for adoption by the governing body and managing the financial aspects of the
hospice;
(i) Ensuring that action
is taken to correct problems identified either through patient/ family record
reviews, fiscal audits, or as a result of patient/family
recommendations;
(j) Ensuring a
public education program through contact with community organization to inform
consumers about hospice care;
(k)
Ensuring that patient care services are appropriately coordinated;
and
(l) Ensuring incident reports
are submitted to the Department as required under 105 CMR 141.201(F).
(B) Clinical Services Coordinator.
(1) The
hospice shall designate an individual to be responsible for coordinating the
clinical services provided by the individuals providing care to hospice
patients. Clinical services include at least nursing, medical, social work and
counseling.
(2) The for clinical
services coordinator shall be a health care professional possessing academic
training and experience in direct patient care and shall be qualified to
coordinate the clinical services provided by the hospice.
(3) A staff person serving in another
position within the hospice may also be the clinical services coordinator if he
or she meets the requirements for both positions and can adequately carry out
the duties of both positions.
(C) Personnel Policies. Each hospice shall establish and maintain current written personnel policies and personnel practices and procedures that encourage good patient/family care. These policies and procedures shall be reviewed and updated annually and shall cover at least the following:
(1) Position descriptions for each category
of employee, volunteer, or contracted personnel which clearly identify
qualifications, duties, responsibilities and accountability of the individual
assuming the position. Work assignments shall be consistent with job
descriptions, qualifications and education.
(2) Orientation to hospice care for all
personnel, including employees of contracting agencies and
volunteers.
(3) Organized staff
support programs to help staff cope with their job responsibilities.
(4) Employee health policies that include, as
a minimum, adequate provisions for preventing the transmission of communicable
diseases.
(5) Regular evaluation of
staff performance.
(D) Requirement for Personnel to Be Vaccinated against Coronavirus Disease 2019 (COVID-19) Caused by the Virus SARS-CoV-2 and Influenza Virus
(1)
Requirement
for Personnel to Be Vaccinated against Coronavirus Disease 2019 (COVID-19)
Caused by the Virus SARS-CoV-2
(a)
Definitions.
1. For purposes of
105
CMR 141.201(D)(1), personnel
means:
a. an individual or individuals who
either work at or come to the hospice inpatient facility and who are employed
by or affiliated with the facility, whether directly, by contract with another
entity, or as an independent contractor, paid or unpaid including, but not
limited to, employees, members of the medical staff, contract employees or
staff, students, and volunteers, whether or not such individual(s) provide
direct patient care; or
b. an
individual or individuals who provides direct patient care and who is employed
by or affiliated with a hospice program that provides residential hospice
services, whether directly, by contract with another entity, or as an
independent contractor, paid or unpaid, including, but not limited to,
employees, members of the medical staff, contract employees or staff, students,
and volunteers.
2. For
purposes of
105
CMR 141.201(D)(1), COVID-19
vaccination means being up to date with COVID-19 vaccines as recommended by the
Centers for Disease Control and Prevention (CDC).
3. For purposes of
105
CMR 141.201(D)(1),
mitigation measures mean measures that personnel who are exempt from
vaccination must take to prevent viral infection and transmission.
(b) Each program shall ensure all
personnel have received COVID-19 vaccination in the timeframe specified in
Department guidelines, unless an individual is exempt from vaccination in
accordance with
105
CMR
141.201(D)(1)(e).
(c) Each program shall provide all personnel
with information about the risks and benefits of COVID-19
vaccination.
(d) Each program shall
notify all personnel of the COVID-19 vaccination requirements of
105
CMR 141.201(D)(1)(b) and
shall, at no cost to any personnel, provide or arrange for vaccination of all
personnel who cannot provide proof of current vaccination against COVID-19
unless an individual is exempt from vaccination in accordance with
105
CMR
141.201(D)(1)(e).
(e)
Exemptions.
1. Subject to the provisions set forth in
105
CMR 141.201(D)(1)(e)(ii), a
program shall not require an individual to receive a COVID-19 vaccine pursuant
to 105 CMR 141.201(D)(1)(b)
if the individual declines the
vaccine.
2. For any individual
subject to the exemption, a program shall require such individual take
mitigation measures, consistent with guidance from the Department.
3. An individual who is exempt from
vaccination shall sign a statement certifying that they are exempt from
vaccination and they received information about the risks and benefits of
COVID-19 vaccine.
(f)
Unavailability of Vaccine. A program shall not be
required to provide or arrange for COVID-19 vaccination during such times the
vaccine is unavailable for purchase, shipment, distribution, or administration
by a third party or when complying with an order of the Commissioner
restricting the use of the vaccine. A program shall obtain and administer
COVID-19 vaccine in accordance with
105
CMR 141.201(D)(1) as soon
as vaccine becomes available.
(g)
Documentation.
1. A
program shall require and maintain for each individual proof of current
vaccination against COVID-19 virus pursuant to
105
CMR 141.201(D)(1)(b) or the
individual's exemption statement pursuant to
105
CMR
141.201(D)(1)(e).
2. Each program shall maintain a central
system to track the vaccination status of all personnel.
3. If a program is unable to provide or
arrange for COVID-19 vaccination for any individual, it shall document the
reasons such vaccination could not be provided or arranged for.
(h)
Reporting and Data
Collection. Each program shall report information to the
Department documenting the program's compliance with the personnel vaccination
requirements of
105
CMR 141.201(D)(1) in
accordance with reporting and data collection guidelines of the
Commissioner.
(i)
105
CMR 141.201(D)(1)
establishes requirements for COVID-19 vaccination of hospice program personnel.
Nothing in 105 CMR 141.000 shall be read to prohibit hospice programs from
establishing policies and procedures for COVID-19 vaccination of personnel that
exceed the requirements set forth in
105
CMR 141.201(D)(1).
(2)
Requirement for
Personnel to Be Vaccinated against Influenza Virus.
(a)
Definitions.
1. For purposes of
105
CMR 141.201(D)(2), personnel
means:
a. an individual or individuals who
either work at or come to the hospice inpatient facility and who are employed
by or affiliated with the facility, whether directly, by contract with another
entity, or as an independent contractor, paid or unpaid including, but not
limited to, employees, members of the medical staff, contract employees or
staff, students, and volunteers, whether or not such individual(s) provide
direct patient care; or
b. an
individual or individuals who provide direct patient care and who is employed
by or affiliated with a hospice program that provides residential hospice
services, whether directly, by contract with another entity, or as an
independent contractor, paid or unpaid including, but not limited to,
employees, members of the medical staff, contract employees or staff, students,
and volunteers.
2. For
purposes of
105
CMR 141.201(D)(2), the
requirement for influenza vaccine or vaccination means immunization by either
influenza vaccine, inactivated or live; attenuated influenza vaccine including
seasonal influenza vaccine pursuant to
105
CMR 141.201(D)(2)(b) and/or
other influenza vaccine pursuant to
105
CMR
141.201(D)(2)(c).
3. For purposes of
105
CMR 141.201(D)(2),
mitigation measures mean measures that personnel who are exempt from
vaccination must take to prevent viral infection and transmission.
(b) Each program shall ensure all
personnel are vaccinated annually with seasonal influenza vaccine, consistent
with any guidelines of the Commissioner, unless an individual is exempt from
vaccination in accordance with
105
CMR 141.201(D)(2)(f).
(c) Each program also shall ensure
all personnel are vaccinated against other pandemic or novel influenza
virus(es) as specified in guidelines of the Commissioner, unless an individual
is exempt from vaccination in accordance with
105
CMR 141.201(D)(2)(f). Such
guidelines may specify:
1. The categories of
personnel to be vaccinated and the order of priority of vaccination of
personnel, with priority for personnel with responsibility for direct
care;
2. The influenza vaccine(s)
to be administered;
3. The dates by
which personnel must be vaccinated; and
4. Any required reporting and data collection
relating to the personnel vaccination requirement of
105
CMR
141.201(D)(2).
(d) Each program shall provide all personnel
with information about the risks and benefits of influenza vaccine.
(e) Each program shall notify all personnel
of the influenza vaccination requirements of
105
CMR 141.201(D)(2) and
shall, at no cost to any personnel, provide or arrange for vaccination of all
personnel who cannot provide proof of current immunization against influenza
unless an individual is exempt from vaccination in accordance with
105
CMR
141.201(D)(2)(f).
(f)
Exemptions.
1. Subject to the provisions set forth in
105
CMR 141.201(D)(2)(f)(ii), a
program shall not require an individual to receive an influenza vaccine
pursuant to
105
CMR 141.201(D)(2)(b) or (c)
if the individual declines the vaccine.
2. For any individual subject to the
exemption, a program shall require such individual take mitigation measures,
consistent with guidance from the Department.
3. An individual who is exempt from
vaccination shall sign a statement certifying that they are exempt from
vaccination and they received information about the risks and benefits of
influenza vaccine.
(g)
Unavailability of Vaccine. A program shall not be
required to provide or arrange for influenza vaccination during such times the
vaccine is unavailable for purchase, shipment, distribution or administration
by a third-party or when complying with an order of the Commissioner
restricting the use of the vaccine. A program shall obtain and administer
influenza vaccine in accordance with
105
CMR 141.201(D)(2) as soon
as vaccine becomes available.
(h)
Documentation.
1. A
program shall require and maintain for each individual proof of current
vaccination against influenza virus pursuant to
105
CMR 141.201(D)(2)(b) or (c)
or the individual's exemption statement pursuant to
105
CMR
141.201(D)(2)(f).
2. Each program shall maintain a central
system to track the vaccination status of all personnel.
3. If a program is unable to provide or
arrange for influenza vaccination for any individual, it shall document the
reasons such vaccination could not be provided or arranged for.
(i)
Reporting and Data
Collection. Each program shall report information to the
Department documenting the facility's compliance with the personnel vaccination
requirements of105 CMR
141.201(D)(2), in accordance
with reporting and data collection guidelines of the Commissioner.
(j)
105
CMR 141.201(D)(2)
establishes requirements for influenza vaccination of hospice program
personnel. Nothing in 105 CMR 141.000 shall be read to prohibit hospice
programs from establishing policies and procedures for influenza vaccination of
personnel that exceed the requirements set forth in
105
CMR 141.201(D)(2).
(E) Administrative Records.
(1) Each hospice shall maintain current,
complete and accurate administrative records. The hospice shall make all
administrative records available promptly to any agent of the Department
seeking to determine compliance with 105 CMR 141.000.
(2) Administrative records shall include:
(a) updated articles of organization and
by-laws;
(b) minutes of the
meetings of the governing body;
(c)
an organizational chart; and
(d)
personnel records for each employee, including evidence of any required license
or registration number, documentation of any specialty certification,
documentation of initial training and ongoing annual training on dementia care
consistent with the requirements of
105
CMR 150.024 and
150.025 for employees
providing direct care to nursing home residents, education and job experience.
A hospice agency is not required to train an employee, consistent with the
requirements of
105
CMR 150.024: Staff Qualifications and
Training and
105
CMR 150.025: Content of
Training, if the employee has completed the required training at a
different location, provided the initial training and any ongoing training is
documented in the personnel record.
(F) Incident Reporting.
(1) All incidents
seriously affecting the health or safety of patients resulting from acts or
omissions of hospice program employees, including those working for the hospice
through a contract arrangement with another organization, and volunteers shall
be recorded and reported accurately to the Department within seven days of the
occurrence. Such reports shall be made in a format prescribed by the
Department.
(2) A hospice inpatient
facility shall also report immediately any of the following which occurs on
premises covered by its license:
(a) death
that is unanticipated, not related to the natural course of the patient's
illness or underlying condition, or that is the result of an error or other
incident as specified in guidelines of the Department;
(b) full or partial evacuation of the
facility for any reason;
(c)
fire;
(d) suicide;
(e) serious criminal acts;
(f) pending or actual strike action by its
employees, and contingency plans for operation of the program or facility;
or
(g) any other serious incident
or accident as specified in guidelines of the Department.
(3) A hospice program shall make available to
the Department all information that may be relevant to the Department's
investigation of any incident or complaint, regardless of how reported to the
Department.
(4) A hospice program
shall make all reasonable efforts to facilitate the Department's attempts to
interview any and all potential witnesses who may have information relevant to
the Department's investigation of any incident or complaint, regardless of how
reported to the Department.
(G) Patient Abuse, Mistreatment, Neglect or Misappropriation of Property. In accordance with 105 CMR 155.000: Patient and Resident Abuse Prevention, Reporting, Investigation, Penalties and Registry, hospice administrators and workers shall immediately report to the Department any suspected instance(s) of hospice patient abuse, mistreatment, neglect or misappropriation of hospice patient property.
(H) Grievance Procedure.
(1) The hospice patient has the right to
voice grievances without discrimination or reprisal. Such grievances include
those with respect to treatment that has been furnished as well as that which
has not been furnished.
(2) The
hospice program must promptly acknowledge and actively work to resolve all oral
and written patient grievances.
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