Missouri Code of State Regulations
Title 19 - DEPARTMENT OF HEALTH AND SENIOR SERVICES
Division 30 - Division of Regulation and Licensure
Chapter 35 - Hospices
Section 19 CSR 30-35.010 - Levels of Maternal and Neonatal Care Designations

Universal Citation: 19 MO Code of State Regs 30-35.010

Current through Register Vol. 49, No. 18, September 16, 2024

PURPOSE: This amendment clarifies and updates definitions and the minimum requirements for the provision of hospice services by state-certified hospices. These proposed changes enhance the state minimum requirements to reflect current industry standards and federal minimum standards for hospice operations in order to enhance the health and safety of Missourians receiving state-certified hospice services.

(1) General Provisions.

(A) Definitions Relating to Hospice Care Agencies.
1. Attending physician-a person who-
A. Is licensed as a doctor of medicine or osteopathy in Missouri or a bordering state; or

B. Is recognized by Missouri as a nurse practitioner and who complies with the requirements of Chapter 335, RSMo, 20 CSR 2200-4.200, and 42 CFR 410.75; or

C. Is licensed as a physician assistant (PA) in Missouri and who complies with the requirements in Chapter 334, RSMo, 20 CSR 2150-7.135, and 42 CFR 410.74(c); and

D. Is identified by the patient, at the time the patient elects to receive hospice care, as having the most significant role in the determination and delivery of the patient's medical care.

2. Automated dispensing system-a mechanical system that performs functions that may include, but are not limited to, storing, packaging or dispensing medications, and that collects, controls and maintains all transaction information.

3. Branch/multiple location-a location from which a hospice provides services within a portion of the total geographic area served by the parent hospice and the area served by the branch/multiple location is contiguous to or part of the area served by the parent hospice.

4. Certified medication technician-a person who has successfully completed the certified medication technician training program and any examination component required in compliance with the standards in 19 CSR 30-84.020. The certified medication technician shall remain current as a certified nursing assistant with the Department of Health and Senior Services in order to continue to be current as a certified medication technician.

5. Certified pharmacy technician-a person who is credentialed by a nationally recognized pharmacy technician credentialing authority.

6. Contracted provider-individuals or entities who furnish services to hospice patients under contractual arrangements between the hospice and the contracted provider.

7. Coordinating provider-any individual or agency which independently provides services to the patient in their place of residence.

8. Department-the Missouri Department of Health and Senior Services.

9. Dietary counselor-an individual who is a registered nurse, registered dietitian, nutritionist, physician assistant or physician.

10. Direct employee-an individual paid directly by the hospice.

11. Emergency medication supply-a limited number of prescription medications approved by the medical director and the pharmacist that may be administered to a patient in an emergency situation or for initial doses of a necessary medication when a pharmacist cannot provide medication services for a patient within a reasonable time based on the patient's clinical needs at the time.

12. Employee-an employee of the hospice or an individual under contract who is appropriately trained and assigned to the hospice program. Employee also refers to a person volunteering for the hospice program.

13. Family-broadly defined to include not only persons bound by biology or legalities but also those who function for the patient in a familial way.

14. Homemaker-a hospice aide, volunteer or other individual who assists the patient/family with light housekeeping chores.

15. Hospice-a public agency or private organization or subdivision of either that-
A. Is primarily engaged in providing care to dying persons and their families; and

B. Meets the standards specified in 19 CSR 30-35.010 and in 19 CSR 30-35.030. If it is a hospice that provides inpatient care directly in a hospice facility, it must also meet the standards of 19 CSR 30-35.020 and 19 CSR 30-35.030.

16. Hospice administrator-the employee designated by the governing body as responsible for the overall functioning of the hospice. Hospice administrators appointed by the governing body after July 1, 2023, shall have the following:
A. Be a licensed practical nurse, be a licensed registered nurse, or hold an undergraduate degree; and

B. Have at least one (1) year of administrative experience in a related healthcare field.

17. Hospice aide-a person who meets the training and skill requirements specified in the Medicare hospice program at 42 CFR 418.76 which is incorporated by reference as last amended on August 6, 2009, and published by the Office of the Federal Register, 732 N. Capitol Street, NW, Washington, DC 20401 or can be found at https://govinfo.gov. This rule does not incorporate any subsequent amendments or additions.

18. Hospice patient-a person with a terminal illness or condition for whom the focus of care is on comfort and palliation rather than cure.

19. Legal representative-a person who because of the patient's mental or physical incapacity is legally authorized in accordance with state law to make health care decisions on behalf of the dying person.

20. Licensed practical nurse-a person licensed under Chapter 335, RSMo, to engage in the practice of practical nursing.

21. Meal preparation-meals planned, offered, or served to all patients from prepared menus.

22. Medical director-a person licensed in Missouri or a bordering state as a doctor of medicine or osteopathy who assumes overall responsibility for the medical component of the hospice's patient care program.

23. Nutritionist-a person who has graduated from an accredited four- (4)-year college with a bachelor's degree including or supplemented by at least fifteen (15) semester hours in food and nutrition including at least one (1) course in diet therapy.

24. Occupational therapist-a person who is licensed under Chapter 324, RSMo, as an occupational therapist and licensed to practice in Missouri.

25. Occupational therapy assistant-a person who has graduated from an occupational therapy assistant program accredited by the Accreditation Council for Occupational Therapy Education and licensed to practice in Missouri.

26. Pharmacist-a person licensed as a pharmacist under Chapter 338, RSMo.

27. Pharmacy technician-a person who is registered as a pharmacy technician under Chapter 338, RSMo.

28. Physical therapist-a person who is licensed as a physical therapist under Chapter 334, RSMo.

29. Physical therapy assistant-a person who has graduated from at least a two- (2)-year college level program accredited by the American Physical Therapy Association and licensed to practice in Missouri.

30. Registered nurse-a person licensed under Chapter 335, RSMo, to engage in the practice of professional nursing.

31. Registered nurse coordinator-a registered nurse, who is a direct employee, designated by the hospice to direct the overall provisions of clinical services.

32. Skilled nursing-those services which are required by law to be provided by a registered nurse or a licensed practical nurse.

33. Snack-a single meal or item prepared on demand which does not include food items that produce grease-laden vapors.

34. Social worker-a person who-
A. Has a Master of Social Work (MSW) degree from a school of social work accredited by the Council on Social Work Education and has one (1) year of social work experience in a health care setting; or

B. Has a baccalaureate degree in social work (BSW) from an institution accredited by the Council on Social Work Education; is supervised by an MSW as described in subparagraph (1)(A)34.A. of this rule and has one (1) year of social work experience in a health care setting; or

C. Has a baccalaureate degree from a school of social work accredited by the Council on Social Work Education and is employed by the hospice before December 2, 2008, and therefore is not required to be supervised by an MSW.

35. Speech language pathologist-a person who is licensed under Chapter 345, RSMo, as a speech language pathologist.

36. Spiritual counselor-a person who has education with emphasis in counseling or related subjects and has, within ninety (90) days of hire, completed specific training to include common spiritual issues in death and dying, belief systems of comparative religions related to death and dying, spiritual assessment skills, individualizing care to patient beliefs, and varied spiritual practices/rituals.

37. Standing order-An order by an authorized prescriber that can be implemented by other health care professionals when predetermined criteria are met as per 19 CSR 30-35.010(2) (E) 3.-(2)(E)4.A., B., and C.

(B) Eligibility Requirements. A hospice shall have written admission criteria including the hospice's policies regarding palliative care (that includes treatment modalities such as chemotherapy or radiation).

(C) Consent for Hospice Care.
1. A patient who wishes to receive hospice care, shall sign a consent form for hospice services.

2. The consent form shall include the following:
A. Identification of the particular hospice that will provide care to the patient;

B. The patient's or legal representative's acknowledgment that the patient or legal representative has been advised and has an understanding of the palliative nature of hospice care as it relates to the patient's terminal illness; and

C. The specific type of care and services that may be provided as hospice care during the course of the illness.

(D) Discontinuance of Hospice Care.
1. A patient or legal representative may discontinue the patient's hospice care at any time.

2. If a patient transfers to another provider, including another hospice provider, the hospice transferring care shall provide to the receiving provider pertinent written information which shall include at a minimum-
A. Current medication profile;

B. Advance directive (if applicable);

C. Problems that require intervention or follow-up; and

D. Current hospice plan of care.

3. The hospice shall have written policies for hospice patient discharge which identify specific circumstances in which the patient is discharged.
A. The hospice shall immediately notify the patient or legal representative and shall include the date that the discontinuance is effective.

B. Patient's/family's continuing care needs, if any, are assessed at discharge, and the patient/family are referred to appropriate resources.

4. The attending physician shall be notified in all instances of discontinuance of hospice care and such notification shall be documented in the patient record.

(E) General Requirements.
1. A hospice shall maintain compliance with the standards in 19 CSR 30-35.010 and in 19 CSR 30-35.030. A hospice that operates a facility for hospice care shall also maintain compliance with 19 CSR 30-35.020.

2. A hospice shall be primarily engaged in providing the care and services described in 19 CSR 30-35.010 and in 19 CSR 30-35.020 of this rule, and shall-
A. Provide twenty-four- (24-) hour nursing coverage for telephone consultation and visits as needed;

B. Assure all other services that are reasonable and necessary for the palliation and management of terminal illness and related conditions are available on a twenty-four-(24-) hour basis;

C. Provide bereavement counseling; and

D. Assure services are provided in a manner consistent with accepted standards of practice in accordance with local, state, and federal law.

3. The hospice shall conduct criminal background checks in accordance with state law.

4. The hospice shall adhere to state and federal law relating to advance directives.

(F) Patient Rights. The hospice shall have a written statement of patient rights which shall include, but need not be limited to, those specified herein-
1. Each patient of a hospice program shall be informed in writing of his/her rights as a recipient of hospice services;

2. The hospice shall document that it has informed patients of their rights in writing and shall protect and promote the exercise of these rights; and

3. The patient's family, legal representative, or guardian may exercise the patient's rights when all reasonable efforts to communicate with the patient have failed. These rights shall include-
A. The patient and family's right for respect of property and person, including the right to be free of abuse, neglect, and/or misappropriation of funds;

B. The right to voice grievances regarding treatment or care that is, or fails to be, furnished or regarding lack of respect of property or person by anyone who is furnishing services on behalf of the hospice and the patient/family shall not be subjected to discrimination or reprisal for doing so;

C. The right to be informed about his/her care alternatives available from the hospice and payment resources;

D. The right to participate in the development of the plan of care and planning changes in the care;

E. The right to be informed in advance about the care to be furnished;

F. The right to be informed in advance of the disciplines that will furnish care and the frequency of visits proposed to be furnished;

G. The right to be informed in advance of any change in the plan of care before the change is made;

H. The right to confidentiality of the clinical records maintained by the hospice and to be informed of the hospice's policy for disclosure of clinical records;

I. The right to be informed in writing of the extent to which payment may be required from the patient and any changes in liability within thirty (30) days of the hospice becoming aware of the new amount of the liability; and

J. The right to access the Missouri home health and hospice toll-free hotline and to be informed of its telephone number, the hours of operations, and its purpose for the receipt of complaints and questions regarding hospice services.

(G) Code of Ethics.
1. A hospice shall develop a written code of ethics and have a process for reviewing ethical issues.

(H) Twenty-four- (24-) Hour Response.
1. The hospice shall have written policies and procedures defining access to all services, medications, equipment, and supplies during regular business hours, after hours, and in emergency situations including a plan for prompt telephone response.

2. Unscheduled non-emergent visits shall be provided as agreed upon by the hospice and patient/caregiver.

3. When clinically indicated, emergent visits shall be made within ninety (90) minutes from the time the need is identified.

(I) Infection Control.
1. The hospice shall identify person(s) responsible for implementing, maintaining, and documenting an infection control program for surveillance, identification, prevention, control, and investigation of infections and communicable diseases.

2. The infection control program shall include a system for periodic review and update of infection control policies and procedures; infection control education of staff, patients, and caregivers; and monitoring for compliance with policies and procedures.

3. The infection control policies and procedures shall conform with accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases.

(J) Safety and Emergency Preparedness.
1. The hospice shall have a safety plan that includes-
A. Policies and procedures for reporting, monitoring, and following up on all accidents, injuries, and safety concerns;

B. Documentation of monitoring activity and follow-up actions; and

C. A safe and sanitary system for identifying, handling, and disposing of hazardous wastes in compliance with all federal, state, and local laws.

2. The hospice shall have an emergency preparedness program that shall meet all federal, state, and local requirements and shall include at a minimum-
A. An emergency plan based on a facility and community all-hazards risk assessment;

B. Policies and procedures reviewed and updated at least annually;

C. A communication plan;

D. Training of staff; and

E. Annual exercises to test the emergency plan.

(K) Branch/Multiple Locations.
1. If the hospice represents to the public that they have a branch/ multiple location(s), each location shall be approved prior to serving patients. Each branch/multiple location(s) shall have a designated interdisciplinary group with documented group meetings, on-site maintenance of current active patient records, and telephone reception during normal business hours.

2. The branch/multiple locations shall be located within one hundred (100) miles of the parent office.

3. The standard of care and clinical services shall be the same out of the branch/multiple locations as the parent office.

(2) Administration.

(A) Governing Body.
1. A hospice shall have a governing body that assumes full legal responsibility for the hospice's total operation.

2. The governing body shall meet, at a minimum, once a year.

3. The governing body shall designate an administrator in writing and list the date the administrator was designated.

(B) Administrator Provisions.
1. The administrator organizes and directs the agency's ongoing functions; maintains ongoing liaison among the governing body, the interdisciplinary group(s) and the staff; employs qualified personnel; implements an effective budgeting and accounting system; and enforces written policies and procedures.

2. A person shall be authorized, in writing, to act in the absence of the hospice administrator.

3. A registered nurse coordinator shall be designated to direct the overall provisions of clinical services.

(C) Contracted Services.
1. A hospice may arrange for another individual or entity to furnish services to the hospice's patients except as otherwise provided in these regulations. If services are provided under contract, the hospice shall meet the following standards:
A. Assure the continuity of patient/family care in home, outpatient and inpatient settings;

B. Have a written agreement for the provision of contracted services. The agreement shall include the following:
(I) Identification of the services to be provided in accordance with the plan of care;

(II) The manner in which services are coordinated by the hospice to maintain hospice professional management responsibility;

(III) Delineation of the role(s) of the hospice and the contracted services;

(IV) Assurance that the contracted provider shall be appropriately licensed;

(V) Provision for transfer and updating the plan of care on inpatient admission (if applicable).

2. Such contracts shall not relieve the hospice of the primary responsibility for ensuring patient care or otherwise complying with these regulations.

(D) Plan of Care.
1. A written plan of care shall be established for each patient by the interdisciplinary group with attending physician involvement.

2. The plan shall be established within seven (7) days of admission.

3. The care provided to a patient shall be in accordance with the plan.

4. The plan shall include:
A. Identification of the patient's/family's problems and needs;

B. The scope and frequency of services needed to meet the patient's and family's needs and by whom the services will be provided, prescribed and required medical equipment, supplies, medications, treatments, and the level of care;

C. Realistic and achievable goals; and

D. All physician orders.

5. The plan shall be reviewed and updated by the interdisciplinary group at a minimum of every two (2) weeks. These reviews shall be documented in the patient record.

6. Documentation on the plan of care shall reflect the changing needs of the patient/family and the services required to meet those needs.

(E) Authorized Prescriber's Orders.
1. Medications, treatments and procedures shall be administered only with an order by an authorized prescriber.

2. Written orders shall be dated and signed at the time of writing.

3. Oral orders, including authorization to use a standing order, shall be received only by persons authorized within their scope of practice, immediately reduced to writing, signed and dated by the person receiving the order and signed and dated by the prescriber within 30 days.

4. A standing order may be used as part of the plan of care if the following guidelines are met:
A. Standing orders shall be in compliance with all applicable state statutes and regulations and shall:
(I) Include the purpose or conditions under which a standing order will be implemented;

(II) Be drug, treatment or procedure specific and not allow for non-prescriber's choice;

(III) Be individualized, signed and dated by the prescriber and included in the patient's record;

B. Agency policy shall define the time frame for authorized prescriber notification when a standing order has been implemented; and

C. Standing order content shall be reviewed and approved by the medical director at least annually.

(F) Interdisciplinary Group.
1. The hospice shall designate an interdisciplinary group or groups composed of qualified individuals who provide or supervise the care and services offered by the hospice. The interdisciplinary group shall meet as frequently as the patient's condition requires, but no less frequently than every fifteen (15) calendar days.

2. The interdisciplinary group shall include at least the following individuals who are employees of the hospice:
A. A doctor of medicine or osteopathy (may be contracted);

B. A registered nurse;

C. A social worker; and

D. A spiritual counselor.

3. The interdisciplinary group shall be responsible for-
A. Participation in the establishment, review and updates of the plan of care;

B. Provision or coordination of hospice care and services; and

C. Making recommendations regarding policies governing the day-to-day provision of hospice care and services.

(G) Clinical Services. The hospice shall routinely provide through direct employees the following services:
1. Nursing services.
A. Services shall be provided in accordance with recognized standards of practice.

B. Nursing services shall be staffed to assure that the nursing needs of patients are met.

C. A registered nurse shall conduct and document an initial assessment visit to assess the patient's immediate physical, psychosocial, emotional, and spiritual status and needs within forty-eight (48) hours of election. The ongoing assessment, planning, and provision of nursing services shall be the responsibility of the registered nurse.

D. When nursing services are delegated to a licensed practical nurse-
(I) The licensed practical nurse shall be supervised by a registered nurse who is available to the licensed practical nurse at least by phone during the hours that the licensed practical nurse is providing services or is on call; and

(II) The registered nurse shall make on-site supervisory visits at least monthly to assess and document that the licensed practical nurse is routinely providing nursing services in accordance with the plan of care.

E. The registered nurse shall develop a written aide assignment based upon the patient's/family's needs when hospice aide services are provided.

F. When aide services are being provided, a hospice registered nurse shall visit the home at least every two (2) weeks. The visit shall include an assessment of the aide services.

G. Written documentation shall show that the aide is providing services in accordance with the plan of care.

H. When an aide is permanently assigned to a hospice facility, the every two- (2-) week supervisory requirement does not apply, however there must be evidence of an annual performance review in the aide's personnel file.

2. Medical director services. The medical director shall be a direct or contract employee. The medical director's or designee's services and responsibilities include-
A. Consulting with attending physicians regarding pain and symptom control;

B. Reviewing patient appropriateness for hospice services;

C. Acting as medical resource for the interdisciplinary group;

D. Acting as liaison to physicians in the community;

E. Assuring medical services are provided in the event the medical needs of the patient are not met by the attending physician; and

F. Routinely attending the interdisciplinary group meetings.

3. Medical social services.
A. Medical social services shall be provided in accordance with recognized standards of practice.

B. Social services shall be staffed to assure that the medical social service needs of each patient and family are met.

C. The assessment, planning, and provision of medical social services shall be the responsibility of the social worker.

D. The social services assessment visit shall be completed within five (5) days of admission or sooner if indicated.

4. Spiritual care services.
A. Spiritual care shall be available to all patients and families.

B. The spiritual counselor is responsible for assuring there is a documented assessment of the spiritual needs of the patient and family within five (5) days of admission or sooner if indicated and that spiritual care provided reflects assessed needs.

C. The spiritual assessment shall include, at a minimum-
(I) The identification of any religious affiliation the patient and family may have; and

(II) The nature and scope of any spiritual concerns or needs identified.

D. A visit by the spiritual counselor shall be offered to each patient. If the patient declines spiritual counselor visits, the spiritual counselor will serve as a resource for other interdisciplinary team members assessing spiritual needs and providing care, and will be available to coordinate with other spiritual care providers the patient/family may have identified.

5. Bereavement care services.
A. There shall be an organized program for the provision of bereavement services under the supervision of a qualified professional who is a person with training or experience related to death, dying, and bereavement.

B. Within two (2) months following the patient's death, there shall be an encounter (other than funeral attendance/visitation) to assess the risk of the bereaved individual(s). A plan of care shall be developed that extends for one (1) year following the death appropriate to the level of risk assessed.

C. At least one (1) additional bereavement encounter shall occur within six (6) months after the death of the patient.

6. Other clinical services. The hospice shall provide the following services directly by hospice employees or through a contracted provider. The assessment, planning, and provision of these services shall be the responsibility of the applicable licensed or registered clinician.
A. Dietary counseling, when required, shall be planned by a qualified dietary counselor.

B. Physical therapy services, occupational therapy services, and speech language pathology services shall be offered in a manner consistent with accepted standards of practice.
(I) Therapy services delegated to the physical therapy assistant or the occupational therapy assistant shall be supervised by a licensed physical therapist or registered occupational therapist as appropriate who is available to the physical therapy assistant or occupational therapy assistant at least by phone during the hours that the assistant is providing services.

(II) When the assistant is providing services to a patient, the licensed or registered therapist shall make a supervisory visit to the residence of the patient at least every thirty (30) days.

(III) Written documentation shall show that the assistant is providing therapy services in accordance with the plan of care.

C. Additional counseling services. Any additional counseling services provided by the hospice shall be provided by qualified personnel, coordinated with all hospice services, included in the plan of care and documented in the clinical record.

D. Waiver.
(I) These requirements shall be waived by the department for areas of the state in which no licensed therapists/dietitians/nutritionists are available provided a good faith effort to provide the service is being made.

(II) A hospice seeking this waiver shall submit a written request to the department along with evidence of efforts made by the hospice to provide the service. If approved, a request for waiver shall be resubmitted annually for review.

7. Hospice aide and homemaker services. Hospice aide and homemaker services shall be available to meet the needs of the patients.
A. If homemaker needs are identified, a member of the interdisciplinary group shall assign and coordinate the services.

B. Hospice aide services shall be provided by a qualified person as set forth in this rule at 19 CSR 30-35.010(1)(A) 17.

C. A hospice aide is not considered to have completed a training and competency program or a competency evaluation program if, since the individual's most recent completion of such program(s), there has been a continuous period of twenty-four (24) consecutive months during none of which the individual furnished services described in 42 CFR 418.76 for compensation.

D. The hospice aide shall follow written instructions for patient care which are prepared by a registered nurse who has physically assessed the patient. The hospice aide shall document care provided. Duties include, but shall not be limited to, the duties specified in the regulations pertaining to the Medicare hospice aide (42 CFR 418.76) .

E. Twelve (12) hours of in-service training per aide per twelve- (12-) month period shall be provided or assured by the hospice. The hospice shall maintain a record of in-service training provided.

(H) Medications. The hospice shall develop policies and procedures for the safe and effective use of medications, in accordance with accepted professional standards and applicable laws and regulations.
1. A medication list shall be maintained for each patient.

2. Medication orders shall include the medication name, dose, frequency, and route of administration.

3. Orders with variable doses or frequencies shall specify a maximum dose or frequency and the reason for administration.

4. Medications shall be provided on a timely basis and medication services shall be available on a twenty-four- (24-) hour basis for emergencies.

5. When controlled substance medications are delivered to the patient's residence by hospice staff, the date, patient name, medication name and strength, quantity indicated on the prescription container, and signatures of the hospice staff member and the receiver shall be documented.

6. The hospice shall identify and document any misuse of controlled substances and shall notify the prescriber.

7. Medication use shall be reviewed with the patient, family, or both and medication information, counseling, and education shall be provided when appropriate.

8. Current medication reference material shall be available to professional staff for all medications used.

9. Medications shall be administered by persons who have statutory authorization, the patient, or a family member.

10. Administration by the patient or by a family member shall be evaluated for appropriateness and ability and this evaluation documented by the nurse.

11. Medication incidents, including medication errors and adverse medication reactions, shall be reported to the prescriber, the registered nurse coordinator, and the pharmacist.

12. The hospice shall have a policy for the disposal of controlled substances maintained in the patient's home when those medications are no longer needed by the patient. The policy shall include at a minimum, information shared with family regarding disposition of medications when no longer required.

13. Medications shall not be transferred to other patients and shall not be removed from the residence by hospice staff.

(I) Medical Supplies and Equipment.
1. The provision of medical supplies and equipment shall be coordinated as needed for the palliation and management of the terminal illness and related conditions. Hospices shall make every effort to assure that patient needs for medical supplies and equipment are met.

2. Hospice shall provide education for patient/family, employees and volunteers on the safe use of medical equipment.

3. Hospice shall provide evidence that all hospice-owned patient care related equipment has been inspected and maintained on an annual basis and in accordance with manufacturers specifications.

4. Hospice shall have policies and procedures for cleaning, storing, accessing and distributing hospice-owned equipment.

5. Supplies shall be stored and maintained in a clean and proper manner.

(J) Volunteers.
1. Each hospice shall document and maintain a volunteer staff sufficient to provide administrative and direct patient care hours in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice shall document a continuing level of volunteer activity.

2. Care and services through the use of volunteers, including the type of services and the time worked, shall be recorded.

3. The hospice shall document initial screening and active and ongoing efforts to recruit and retain volunteers.

4. The hospice shall provide task-appropriate orientation and training consistent with acceptable standards of hospice practice, that includes at a minimum-
A. Hospice philosophy, goals, and services;

B. The volunteer role in hospice;

C. Confidentiality;

D. Instruction in the volunteer's particular duties and responsibilities;

E. Whom to contact if in need of assistance or instruction regarding the performance of their specific duties and responsibilities; and

F. Documentation and record keeping as related to the volunteer's duties.

5. The hospice shall, in addition, provide orientation for patient care volunteers that includes at a minimum-
A. Concepts of death and dying;

B. Communication skills;

C. Care and comfort measures;

D. Psychosocial and spiritual issues related to death and dying;

E. The concept of hospice patient and family as the unit of care;

F. Procedures to be followed in an emergency or following the death of the patient;

G. Concepts of grief and loss;

H. Universal precautions;

I. Safety;

J. Patient/family rights;

K. Hospice and the nursing home; and

L. Alzheimer's disease and dementia-specific training as specified at 19 CSR 30-35.010(2)(M) 1.B.(XIII).

6. The hospice shall document orientation and ongoing in-services.

7. Volunteers functioning in accordance with professional practice acts shall show evidence of current professional standing and licensure, if applicable.

(K) Clinical Records.
1. In accordance with accepted principles of practice, the hospice shall establish and maintain a clinical record for every patient receiving care and services.

2. The record shall be complete, legible, readily accessible, and systematically organized to facilitate retrieval. Documentation shall be prompt and accurate.

3. Each clinical record shall be a comprehensive compilation of information. Entries shall be made for all services provided.

4. Entries shall be made and signed by the person providing the services.

5. The record shall include all services whether furnished directly or through contracted providers. Each clinical record shall contain-
A. Physician's orders;

B. Complete documentation of all assessments, services, visits, and events;

C. The plan of care and updates to the plan of care;

D. Identification data;

E. Consent form;

F. Pertinent medical history;

G. Determination of financial responsibility; and

H. Documentation of communication with coordinating providers.

6. The hospice shall safeguard the clinical record against loss, destruction, and unauthorized use.

(L) Facility Resident.
1. When the hospice patient resides in a nursing facility, the hospice collaborates with the nursing facility providing care to the patient/family to ensure coordination of services.

2. Collaboration activities shall include the following:
A. There shall be a coordinated single plan of care in the nursing facility which may be multiple documents, that:
(I) Reflects coordination and input from both the hospice and the nursing facility;

(II) Identifies the care and services which each shall provide; and

(III) Is updated to reflect changes in patient/family condition, needs and care.

B. Services usually identified as hospice services shall remain the responsibility of the hospice, and are provided or arranged by the hospice to meet the needs of the patient at the same level that the hospice normally furnishes to patients in their homes.

C. A registered nurse is designated from the hospice to coordinate the implementation of the plan of care, and to respond to questions and concerns from the nursing facility.

D. The hospice shall provide education to nursing facility staff that includes at a minimum:
(I) The purpose and nature of hospice care;

(II) Services provided by the hospice;

(III) Care plan coordination;

(IV) When and how to contact hospice staff.

3. The hospice shall document education provided and/or education offered and declined by the nursing home.

4. The hospice shall enter into arrangements only with nursing facilities which are appropriately licensed.

(M) Employee Training and Orientation.
1. Each hospice shall provide initial orientation for each direct employee that is specific to the employee's job duties.
A. All employees shall be oriented to-
(I) Hospice philosophy, goals, and services;

(II) Confidentiality;

(III) Specific job duties;

(IV) Hospice policies and procedures as appropriate to the position.

B. Patient care employees shall also be oriented to-
(I) Interdisciplinary group function and responsibility;

(II) Communication skills;

(III) Physical, psychosocial, and spiritual assessment;

(IV) Plan of care;

(V) Symptom management;

(VI) Universal precautions;

(VII) Patient/family safety issues;

(VIII) Patient/family rights;

(IX) Documentation;

(X) Concepts of grief and loss;

(XI) Facility resident care;

(XII) Levels of hospice care; and

(XIII) Alzheimer's disease and related dementias. Hospice agencies shall provide dementia-specific training about Alzheimer's disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients, or consumers with Alzheimer's disease or related dementias.
(a) At a minimum, the training required shall address the following areas:
I. An overview of Alzheimer's disease and related dementias;

II. Communicating with persons with dementia;

III. Behavior management;

IV. Promoting independence in activities of daily living; and

V. Understanding and dealing with family issues.

(b) Employees or independent contractors who do not provide direct care for, but may have daily contact with, persons with Alzheimer's disease or related dementias shall receive dementia-specific training that includes at a minimum:
I. An overview of Alzheimer's disease and related dementias; and

II. Communicating with persons with dementia.

(c) Dementia-specific training about Alzheimer's disease and related dementias shall be incorporated into orientation for-
I. New employees with direct patient contact;

II. Independent contractors with direct patient contact; and

III. Employees who do not provide direct care for, but may have daily contact with, persons with Alzheimer's disease or related dementias. The training shall be provided annually and updated as needed.

C. Ongoing in-service training shall include a broad range of topics that reflect identified educational needs.

D. The hospice shall document initial orientation and in-service topics presented.

2. Volunteers are exempt from these provisions, except for dementia-specific training as specified at 19 CSR 30-35.010(2) (M) 1.B.(XIII), as their orientation and in-service requirements are defined in 19 CSR 30-35.010(2)(J) 4., 5., and 6.

3. Contract employees shall receive orientation to dementia-specific training as specified at 19 CSR 30-35.010(2) (M) 1.B.(XIII), confidentiality, hospice philosophy, and to their specific job duties.

(N) Quality Assessment and Performance Improvement.
1. The hospice shall follow a written plan for assessing and improving program operations which includes:
A. Goals and objectives;

B. The identity of the person responsible for the program; and

C. A method for resolving identified problems.

2. The plan and performance improvement activities shall be reviewed at least annually by a designated group and the governing body and revised as appropriate.

3. When problems are identified in the provision of hospice services, the hospice shall document any evidence of corrective actions taken, including ongoing monitoring, revisions of policies and procedures, educational intervention, and changes in the provision of services.

4. The effectiveness of actions taken to improve services or correct identified problems shall be evaluated.

5. A designated group shall review and document the quality assessment and performance improvement activities and monitor corrective actions.

*Original authority: 197.270, RSMo 1992, amended 1993 and 660.050, RSMo 1984, amended 1988, 1992, 1993, 1994, 1995, 2001.

Disclaimer: These regulations may not be the most recent version. Missouri may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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