Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 175 - HEALTH CARE FACILITIES AND SERVICES LICENSURE
Chapter 16 - HOSPICE SERVICES
Section 175-16-006 - STANDARDS OF OPERATION, CARE, AND TREATMENT

Universal Citation: 175 NE Admin Rules and Regs ch 16 ยง 006

Current through March 20, 2024

Each hospice must be organized to promote the attainment of its objectives and purposes. The major organizational divisions in each hospice must include a governing authority, administration, and a medical staff. In addition, the basic organization, responsibility, and operation of each licensed hospice must assure adequate protection to hospice patients and compliance with state statutes.

006.01 Governing Authority

A hospice must have a governing authority which assumes full legal responsibility for determining, implementing, and monitoring policies governing the hospice's total operation. The governing authority must designate an individual who is responsible for the day-to-day management of the hospice program. The governing authority must also ensure that all services provided are consistent with accepted standards of practice.

006.02 Administration

The hospice must organize, manage, and administer its resources to assure that each patient experiences care that optimizes the patient's comfort and dignity in a manner which is consistent with patient, family, or designee needs and desires.

006.03 Administrator

A hospice must have an administrator who has training and experience in hospice care or a related health care program. The administrator must be a person responsible for the management of the agency to the extent authority is delegated by the governing authority. A person must be designated in writing to act in the absence of the administrator. The administrator must have at least the following responsibilities:

1. Have bylaws, rules, or its equivalent which delineate how the governing authority conducts its business;

2. Oversee the management and fiscal affairs of the agency; and

3. Establish and implement written policies and procedures that encompass all care and treatment provided to patients. The policies and procedures are consistent with generally accepted practice, delineate the scope of services provided in the hospice, and encompass aspects to protect the health and safety of patients. These policies must be available for visual review to staff, patients, family and legal designees of the patients. Policies and procedures should include, but are not limited to:
a. Range of services to be provided;

b. Geographical areas to be served;

c. Criteria for admission, discharge, and transfer of patients; which ensure only individuals whose needs can be met by the hospice or by providers of services under contract to the hospice will be admitted as patients;

d. Policies and procedures describing the method to obtain and incorporate physician orders into the plan of care; and

e. Policies and procedures which require each employee of the hospice to report any evidence of abuse, neglect, or exploitation of any patient served by the hospice in accordance with Neb. Rev. Stat. § 28-372 of the Adult Protective Services Act or, in the case of a child, in accordance with Neb. Rev. Stat. § 28-711. The hospice must ensure any abuse, neglect, or exploitation must be reported.

006.04 Medical Director

A hospice must have a medical director who is a hospice employee or a contracted person who is a doctor of medicine or osteopathy who assumes overall responsibility for the medical component of the hospice's patient care program.

006.05 Staff Requirements

Each hospice must maintain sufficient number of staff with the required training and skills to provide those services necessary to meet the needs of each patient accepted for care. Each hospice must have job descriptions for each staff position, which include minimum qualifications required for the position.

16-006.05A Employment Eligibility: Each hospice must insure and maintain evidence of the following:
1. Staff Credentialing: Any staff who provide care or treatment for which a license, certification, registration, or credential is required must hold the license, certification, registration, or credential in accordance with applicable State laws and regulations. Each hospice must verify the licensure, registration, certification, or required credentials of staff prior to staff assuming job responsibilities.

2. If unlicensed staff assist in provision of care or treatment, these staff should be supervised by the appropriate licensed health care professional.

16-006.05B Health Status: Each hospice must establish and implement policies and procedures related to the staff's health to prevent the transmission of disease to patients.
16-006.05B1 Health History Screening: All employees must have a health history screening after accepting an offer of employment and prior to assuming job responsibilities. A physical examination is at the discretion of the employer based on results of the health history screening.

16-006.05C Criminal Background and Registry Checks: The hospice must complete and maintain documentation of pre-employment criminal background and registry checks on each unlicensed direct care staff.
16-006.05C1 Criminal Background Checks: The hospice must complete criminal background checks through a governmental law enforcement agency or a private entity that maintains criminal background information on each unlicensed direct care staff.

16-006.05C2 Registry Checks: The hospice must check for adverse findings on each unlicensed direct care staff on the following registries:
1. Nurse Aide Registry;

2. Adult Protective Services Registry;

3. Central Register of Child Protection Cases; and

4. Nebraska State Patrol Sex Offender Registry.

16-006.05C3 The hospice must:
1. Determine how to use the criminal background and registry information, except for the Nurse Aide Registry, in making hiring decisions;

2. Decide whether employment can begin prior to receiving the criminal background and registry information; and

3. Document any decision to hire a person with a criminal background or adverse registry findings, except for the Nurse Aide Registry. The documentation must the basis for the decision and how it will not pose a threat to patient safety or patient property.

16-006.05C4 The hospice must not employ a person with an adverse finding on the Nurse Aide Registry regarding patient abuse, neglect, or misappropriation of patient property.

16-006.05D Training: Each hospice must ensure staff receive training to perform job responsibilities.
16-006.05D1 Orientation: Each hospice must provide and maintain evidence of an orientation program for all new staff and, as needed, for existing staff who are given new assignments. The orientation program includes, but is not limited to:
1. Job duties and responsibilities;

2. Organizational structure;

3. Patient rights;

4. Patient care policies and procedures;

5. Personnel policies and procedures; and

6. Reporting requirements for abuse, neglect, and exploitation in accordance with the Adult Protective Services Act, Neb. Rev. Stat. § 28-372 or, in the case of a child, in accordance with Neb. Rev. Stat. § 28-711 and with hospice policies and procedures.

16-006.05D2 Ongoing Training: Each hospice must provide and maintain evidence of ongoing/continuous inservices or continuing education for staff. The hospice record must contain the date, topic, and participants.

16-006.05D3 Specialized Training: Each hospice must provide specialized training of staff to permit performance of particular procedures or to provide specialized care, whether as part of a training program or as individualized instruction, and have documentation of the training in personnel records.

16-006.05D4 Employment Record: The hospice must maintain a current employment record for each staff person. Information kept in the record must include information on the length of service, orientation, inservice, credentialing, performance, health history screening, and previous work experience.

006.06 Patient Rights

The governing authority must establish a bill of rights that will be equally applicable to all patients. The hospice must protect and promote the exercise of these rights. Patients must have the right to:

1. Choose care providers and communicate with those providers;

2. Participate in the planning of their care and receive appropriate instruction and education regarding the plan;

3. Request information about their diagnosis, prognosis, and treatment, including alternatives to care and risks involved, in terms that they and their families or designee can readily understand so that they can give their informed consent;

4. Refuse care and be informed of possible health consequences of this action;

5. Receive care without discrimination as to race, color, creed, sex, age, or national origin;

6. Exercise religious beliefs;

7. Be admitted for service only if the hospice has the ability to provide safe, professional care at the level of intensity needed;

8. Receive the full range of services provided by the hospice;

9. Confidentiality of all records, communications, and personal information;

10. Review and receive a copy of all health records pertaining to them;

11. Receive both an oral and written explanation regarding discharge if the patient moves out of the hospice's service area or transfers to another hospice; or if the hospice determines the patient is no longer terminally ill. Information regarding community resources must be given to the patient or his/her designee.

12. A hospice patient may be discharged for cause based on an unsafe care environment in the patient's home, patient non-compliance (including disruptive, abusive, or uncooperative behavior to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired); or failure to pay for services. The hospice must make a serious effort to resolve the problem(s) presented by the behavior or situation to assure that the proposed discharge is not due to the patient's use of necessary hospice services; document the problem(s) and the efforts made to resolve the problem(s) in the patient's medical record; and obtain a written physician's order from the patient's attending physician and the hospice medical director concurring with the discharge.

13. Voice complaints/grievances and suggest changes in service or staff without fear of reprisal or discrimination and be informed of the resolution;

14. Be fully informed of hospice policies and charges for services, including eligibility for third-party reimbursement, prior to receiving care;

15. Be free from verbal, physical, and psychological abuse and to be treated with dignity;

16. Expect pain relief. Measures will be instituted to ensure comfort;

17. Expect all efforts will be made to ensure continuity and quality of care in the home and in the inpatient setting;

18. Have his or her person and property treated with respect;

19. Be informed, in advance, about the care to be furnished, and any changes in the care to be furnished;

20. Formulate advance directives and have the hospice comply with the directives unless the hospice notifies the patient of the inability to do so. Advance directives include living wills, durable powers of attorney, powers of attorney for health care, or other instructions recognized by state law that relate to the provision of medical care if the individual becomes incapacitated; and

21. Be free from physical and chemical restraints that are not medically necessary.

All patients, guardians, or authorized designees upon the commencement of services must be given a copy of the bill of rights. The hospice must maintain documentation showing that it has complied with the requirements of 175 NAC 16-006.06.

16-006.06A In-Home Assessment and Consent: Authorized agents of the Department have the right, with the consent of the patient/designee, to visit patient's homes during the provision of hospice services in order to make an assessment of the quality of care being given to patients.
16-006.06A1 Consent: A patient/designee whose home is to be visited by an authorized representative of the Department must be notified by the hospice or the Department before the visit, to ascertain a verbal consent for the visit. A written consent form clearly stating that the patient voluntarily agrees to the visit must be presented to and signed by the patient/designee prior to observation of care or treatment by the Department representative. The hospice must arrange this visit.

16-006.06A2 Right to Refuse: All hospice patients have the right to refuse to allow an authorized representative of the Department to enter their homes for the purposes of assessing the provision of hospice services.

16-006.06B Competency of Patients
16-006.06B1 In the case of the patient adjudged incompetent under the laws of the State by a court of competent jurisdiction, the rights of the patient are exercised by the persons authorized under State law to act on the patient's behalf.

16-006.06B2 In the case of the patient who has not been adjudged incompetent by the State court, any person designated in accordance with State law may exercise the patient's rights to the extent provided by the law.

006.07 Complaints/Grievances

Each hospice must establish and implement a process that promptly addresses complaints/grievances filed by patients or their designee. The process includes, but is not limited to:

1. A procedure for submission of complaints/ grievances that is made available to patients or designee;

2. Time frames and procedures for review of complaints/grievances and provision of a response; and

3. How information from complaints/grievances and responses are utilized to improve the quality of patient care and treatment.

006.08 Quality Assurance/Improvement

The hospice must conduct an ongoing comprehensive, integrated self-assessment of the quality and appropriateness of care provided, including inpatient care, home care, and care provided under arrangements. The hospice must use the findings to correct identified problems and to revise hospice policies if necessary. Those responsible for the quality assurance program must:

1. Implement and report on activities and mechanisms for monitoring the quality of patient care;

2. Identify and resolve problems; and

3. Make suggestions for improving patient care.

006.09 Patient Care and Treatment

Each hospice must establish and implement written policies and procedures that encompass all care and treatment provided to patients. The policies and procedures must be consistent with prevailing professional standards, delineate the scope of services provided in the hospice, and encompass aspects to protect the health and safety of patients.

16-006.09A Plan of Care: A written plan of care must be established and maintained for each individual admitted to a hospice program. A registered nurse must complete an initial assessment to evaluate the patient's immediate physical, psychosocial, emotional, and spiritual needs. This assessment initiates the plan of care. The care provided to the patient must be in accordance with this plan.
16-006.09A1 Establishment of the Plan: A comprehensive plan must be established, within five calendar days of the initial assessment, by the attending physician who has primary responsibility for the patient's care and treatment or a physician assistant or advanced practice registered nurse affiliated with the attending physician; the medical director; and interdisciplinary team.

16-006.09A2 Review of the Plan: The update of the comprehensive assessment must be accomplished by the hospice interdisciplinary team in collaboration with the individual's attending physician, if any, or a physician assistant or advanced practice registered nurse affiliated with the attending physician and must consider changes that have taken place since the initial assessment. It must include information on the patient's progress toward desired outcomes, as well as a reassessment of the patient's response to care. The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days.

16-006.09A3 Content of the Plan: The plan must include an assessment of the individual's needs and identification of the services 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 and family's needs.

16-006.09A4 Physician Order: Each hospice must have a process in place by which orders from a physician or representative are obtained, incorporated in the plan of care, and carried out.

16-006.09B Hospice Core Services: A hospice must ensure that substantially all the core services described in 175 NAC 16-006.09B 1 through 16-006.09B 4 are routinely provided directly by hospice employees (with the exception of the physician who can be contracted). A hospice may use contracted staff if necessary to supplement hospice employees to meet the needs of patients during periods of peak patient loads or under extraordinary circumstances. If contracting is used, the hospice must maintain professional, financial, and administrative responsibility for the services and must assure that the qualifications of staff and services provided meet the requirements specified in 175 NAC 16. Core services include nursing services, social services, physician services, and counseling services.
16-006.09B1 Nursing Services: The hospice must provide nursing care and services by or under the supervision of a registered nurse.
16-006.09B1a Nursing services must be directed and staffed to assure that the nursing needs of patients are met. The direction must be done in accordance with 172 NAC 99 Regulations Governing the Provision of Nursing Care

16-006.09B1b Patient care responsibilities of nursing personnel must be specified.

16-006.09B1c Services must be provided in accordance with recognized standards of practice.

16-006.09B2 Social Services: Social services must be provided by a qualified social worker, under the direction of a physician. All social work services must be provided in accordance with the plan of care and recognized standards of practice. The social worker must participate in the development, implementation, and revision of the patient's plan of care.

16-006.09B3 Physician Services: In addition to palliation and management of terminal illness and related conditions, physician employees of the hospice, including the physician member(s) of the interdisciplinary group, must also meet the general medical needs of the patients to the extent that these needs are not met by the attending physician.

16-006.09B4 Counseling Services: Counseling services must be available to both the individual and the family. Counseling includes bereavement counseling, provided before and after the patient's death, as well as dietary, spiritual, and any other counseling services for the individual and family provided while the individual is enrolled in the hospice.
16-006.09B4a Dietary Counseling: Dietary counseling, when required, must be provided by a licensed medical nutrition therapist or others whose scope of practice as defined by the Uniform Credentialing Act permits dietary counseling. Such individuals include, but are not limited to, a physician, a registered nurse, or a dietitian registered by the American Dietetic Association or an equivalent entity.

16-006.09B4b Spiritual Counseling: Spiritual counseling must include notice to patients as to the availability of clergy.

16-006.09B4c Additional Counseling: Counseling may be provided by other members of the interdisciplinary group as well as by other qualified professionals as determined by the hospice.

16-006.09B4d 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, as well as a clear delineation of services to be provided and the frequency of service delivery (up to one year following the death of the patient).

16-006.09B5 Home Health Aide & Medication Aide: Each hospice that employs or contracts home health aides or medication aides must meet the following requirements for training and testing prior to providing care and services to patients. The home health aide services must be provided by a person who meets the training, attitude, and skill requirements specified in 175 NAC 14-006.04G. A hospice must ensure the following requirements are met.
16-006.09B5a Employ Qualified Aides: A hospice must employ only home health aides qualified to provide home health agency/hospice patient care.

16-006.09B5b Verify Competency: Each hospice must verify and maintain records of the competency of all home health aides employed by the agency, prior to the aide providing services in a patient's home.

16-006.09B5c Supervision: Each hospice must provide direction (Plan of Care/Assignment Sheet) written by the registered nurse (RN), and RN supervision of home health aides. A registered nurse must visit the home site at least every two weeks if aide services are provided with or without the aide being present. The visit must include an assessment of the aide services and review of the plan of care.

16-006.09B5d Inservice Program: A hospice must provide or make available to its home health aides four one-hour inservice programs per year on subjects relevant to hospice or home health care and must maintain documentation of such programs.

16-006.09B5e Permitted Acts: Home health aides may perform only personal care, assistance with the activities of daily living, and basic therapeutic care. A home health aide must only provide medication in compliance with the Medication Aide Act. Home health aides must not perform acts which require the exercise of nursing or medical judgment.

16-006.09B5f Qualifications: To act as a home health aide, a person must:
1. Be at least 18 years of age;

2. Be of good moral character;

3. Not have been convicted of a crime under the laws of this State or another jurisdiction, the penalty for which is imprisonment for a period of more than one year and which is rationally related to the person's fitness or capacity to act as a home health aide;

4. Be able to speak and understand the English language or the language of the hospice patient and the hospice staff member who acts as the home health aide's supervisor;

5. Meet one of the following qualifications and provide proof of meeting the qualifications to the hospice:
a. Has successfully completed a 75-hour home health aide training course which meets the standards described in Neb. Rev. Stat. § 71-6608.01;

b. Is a graduate of a practical or professional school of nursing;

c. Has been employed by a licensed hospice or a home health agency as a home health aide II prior to September 6, 1991;

d. Has successfully completed a course in a practical or professional school of nursing which included practical clinical experience in fundamental nursing skills and has completed a competency evaluation as described in Neb. Rev. Stat. § 71-6608.02;

e. Has successfully completed a 75-hour basic course of training approved by the Department for nursing assistants as required by Nev. Rev. Stat. § 71-6039 and has completed a competency evaluation as described in Neb. Rev. Stat. § 71-6608.02;

f. Has been employed by a licensed home health agency as a home health aide I prior to September 6, 1991 and has completed a competency evaluation as described in Neb. Rev. Stat. § 71-6608.02; or

g. Has met the qualifications equal to one of those contained in 175 NAC 16-006.09B 5f, item 5 in another state or territory of the United States; and

6. Has been listed on the Medication Aide Registry operated by the Department, if identified as a medication aide.

16-006.09B6 Homemaker Qualifications and Supervision: Homemaker services may include assistance in maintenance of a safe and healthy environment and services to enable the patient's family to carry out the plan of care. A member of the interdisciplinary team must coordinate homemaker services; the homemaker must be supervised by a member of the interdisciplinary team. Instructions for homemaker duties must be prepared by a member of the interdisciplinary team. Homemakers must report all concerns about the patient or the patient's family to the member of the interdisciplinary team who coordinates homemaker services.

16-006.09C Other Services: A hospice must ensure that the services in 175 NAC 16-006.09C 1 through 16-006.09C 5 are provided directly by hospice employees or under arrangements.
16-006.09C1 Volunteers: The hospice uses volunteers, in defined roles, under the supervision of a designated hospice employee and in accordance with the following requirements:
16-006.09C1a Training: The hospice must provide appropriate orientation and training that is consistent with acceptable standards of hospice practice.

16-006.09C1b Roles: Volunteers must be used in administrative or direct patient care roles.

16-006.09C1c Recruitment and Retention: The hospice must document active and ongoing efforts to recruit and retain volunteers.

16-006.09C1d Cost Saving: The hospice must document the cost savings achieved through the use of volunteers. Documentation must include:
1. The identification of necessary positions which are occupied by volunteers;

2. The work time spent by volunteers occupying those positions; and

3. Estimates of the dollar costs which the hospice would have incurred if paid employees occupied the positions.

16-006.09C1e Level of Activity: The hospice must document and maintain a volunteer staff sufficient to provide day-to-day administrative or direct patient care in an amount that, at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff. The hospice must document a continuing level of volunteer activity. The hospice must record expansion of care and services achieved through the use of volunteers, including the type of services and time worked.

16-006.09C2 Laboratory Services: If the hospice engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the Food And Drug Administration, the testing must be in compliance with all applicable requirements of the Clinical Laboratory Improvement Amendments of 1988, as amended (CLIA). If the hospice chooses to refer specimens for laboratory testing to a reference laboratory, the referral laboratory must be certified in the appropriate specialties and subspecialties of services in accordance with the applicable requirements of the Clinical Laboratory Improvement Amendments of 1988, as amended (CLIA).

16-006.09C3 Physical Therapy, Occupational Therapy, Speech Language Pathology Services: Physical therapy services, occupational therapy services, and speech-language pathology services must be available, and when provided, the services must be provided within the scope of practice as defined by the Uniform Credentialing Act (UCA). Services must be provided by individuals appropriately credentialed under the UCA.

16-006.09C4 Clergy: The hospice must make reasonable efforts to arrange for visits of clergy and other members of religious organizations in the community to patients who request the visits and must advise patients of this opportunity

16-006.09C5 Medical Supplies/Equipment: Medical supplies/equipment and appliances, including drugs and biologicals, must be provided as needed for the palliation and management of the terminal illness and related conditions. The hospice must have a process designed for routine and preventative maintenance of equipment to ensure that it is safe and works as intended for the use in the patient's environment. The hospice must ensure that the patient/family/designee understand how to use the equipment and supplies.

16-006.09D Professional Management: Except for those core services described in 175 NAC 16-006.09B, a hospice may arrange for another individual or entity to furnish services to the hospice's patients. If services are provided under arrangement, the hospice must meet the following:
1. The hospice program assures the continuity of patient/family care in home, outpatient, and inpatient settings;

2. The hospice has a legally binding written agreement for the provision of arranged services. The agreement includes the following:
a. Identification of the services to be provided;

b. A stipulation that services may be provided only with the express authorization of the hospice;

c. The manner in which the contracted services are coordinated, supervised, and evaluated by the hospice;

d. The delineation of the role(s) of the hospice and the contractor in the admission process, patient/family assessment, and the interdisciplinary group care conferences;

e. Requirements for documenting that services are furnished in accordance with the agreement; and

f. The qualifications of the personnel providing the services;

3. The hospice retains professional management responsibility for those services and ensures that they are furnished in a safe and effective manner by qualified persons and in accordance with the patient's plan of care and other requirements of 175 NAC 16; and

4. The hospice ensures that inpatient care is furnished only in a facility which meets the requirements of a 24-hour registered nurse coverage in a skilled nursing facility and that also specifies, at a minimum:
a. The hospice furnishes to the inpatient provider a copy of the patient's care plan and specifies the inpatient services to be furnished;

b. The inpatient provider has established policies consistent with those of the hospice and agrees to abide by the patient care protocols established by the hospice for its patients;

c. The medical record includes a record of all inpatient services and events and that a copy of the discharge summary and, if requested, a copy of the medical record are provided to the hospice;

d. The party responsible for the implementation of the provisions of the agreement; and

e. The hospice retains responsibility for appropriate hospice care training of the personnel who provide the care under the agreement.

16-006.09E Interdisciplinary Team: The hospice must designate an interdisciplinary team composed of individuals who provide or supervise the care and services offered by the hospice.
16-006.09E1 Composition of Team: The interdisciplinary team must include at least the following individuals who are employees of the hospice (with the exception of the doctor of medicine or osteopathy who may be a contracted employee):
1. A doctor of medicine or osteopathy;

2. A registered nurse;

3. A social worker; and

4. A pastoral or other counselor.

16-006.09E2 Role of Team: The interdisciplinary team is responsible for:
1. Participation in the establishment of the plan of care;

2. Provision or supervision of hospice care and services;

3. Periodic review and updating of the plan of care for each individual receiving hospice care; and

4. Establishment of policies governing the day-to-day provision of hospice care and services.

16-006.09E3 If a hospice has more than one interdisciplinary team, it must designate in advance the team it chooses to execute the functions of the hospice.

16-006.09E4 The hospice must designate a registered nurse to coordinate the implementation of the plan of care for each patient. The plan of care must be updated as often as necessary but at least every 62 days.

16-006.09F Short Term Inpatient Care: A hospice must have an established agreement with a participating Medicare or Medicaid facility to provide short term care for pain control, symptom management, or respite purposes. Such care must be provided in one of the following:
1. An inpatient hospice; or

2. A hospital, skilled nursing facility, nursing facility, or intermediate care facility.

16-006.09F1 For inpatient respite, the RN must be available when required by the patient's plan of care.

006.10 Admission and Retention Requirements

A hospice must accept a patient only when it reasonably expects that it can adequately meet the patients medical, therapeutic, and social needs in the patient's permanent or temporary place of residence.

006.11 Administration of Medications

The hospice must establish and implement policies and procedures to ensure patients receive medications only as legally prescribed by a medical practitioner in accordance with the five rights and prevailing professional standards.

16-006.11A Methods of Administration: When the hospice is responsible for the administration and provision of medication, it must be accomplished by the following methods:
16-006.11A1 Self Administration: Patients may be allowed to self-administer medication, with or without supervision, when the hospice determines that the patient is competent and capable of doing so and has the capacity to make an informed decision about taking medications in a safe manner. The hospice must develop and implement policies to address patient self-administration of medication, including:
1. Storage and handling of medications;

2. Inclusion of the determination that the patient may self-administer medication in the patient's plan of care; and

3. Monitoring the plan of care to assure continued safe administration of medications by the patient.

16-006.11A2 Licensed Health Care Professional: When the hospice uses a licensed health care professional for whom medication administration is included in the scope of practice, the hospice must ensure the medications are properly administered in accordance with prevailing professional standards.

16-006.11A3 Provision of Medications by a Person other than a Licensed Health Care Professional: When the hospice uses a person other than a licensed health care professional in the provision of medications, the hospice must follow 172 NAC 95 and 96. Each hospice must establish and implement policies and procedures:
1. To ensure that medication aides and other unlicensed persons who provide medications are trained and have demonstrated the minimum competency standards specified in 175 NAC 95-004;

2. To ensure that competency assessments and/or courses for medication aides and other unlicensed persons are provided in accordance with the provisions of 175 NAC 96-005;

3. That specify how direction and monitoring will occur when the hospice allows medication aides to perform the additional routine/acceptable activities authorized by 172 NAC 95-005, and as follows:
a. Provide routine medication; and

b. Provision of medications by the following routes;
(1) oral which includes any medication given by mouth including sublingual (placing under the tongue) and buccal (placing between the cheek and gum) routes and oral sprays;

(2) inhalation which includes inhalers and nebulizers, including oxygen given by inhalation;

(3) topical application of sprays, creams, ointments, and lotions and transdermal patches; and

(4) instillation by drops, ointments, and sprays into the eyes, ears and nose.

4. That specify how direction and monitoring will occur when the hospice allows medication aides to perform the additional routine/acceptable activities authorized by 172 NAC 95-005, and as follows:
a. Provision of PRN medications;

b. Provision of medications by additional routes including but not limited to gastrostomy tube, rectal, and vaginal; and/or

c. Participation in monitoring;

5. That specify how competency determinations will be made for medication aides and other unlicensed persons to perform routine and additional activities pertaining to medication provision;

6. That specify how written direction will be provided for medication aides and other unlicensed persons to perform the additional activities authorized by 175 NAC 95-009;

7. That specify how records of medication provision by medication aides and other unlicensed persons will be recorded and maintained;

8. That specify how medication errors made by a medication aide and adverse reactions to medications will be reported. The reporting must be:
a. Made to the identified person responsible for direction and monitoring;

b. Made immediately upon discovery; and

c. Documented in patient medical records;

9. When the hospice is not responsible for medication administration and provision the hospice must maintain responsibility for overall supervision, safety, and welfare of the patient;

10. Each hospice must have a policy for the disposal of controlled drugs maintained in the patient's home when those drugs are no longer needed by the patient.

16-006.11A4 Each hospice must have and implement policies and procedures for reporting any errors in administration or provision of prescribed medications to the patient's licensed practitioner in a timely manner upon discovery and a written report of the error prepared. Errors must include any variance from the five rights.

16-006.11A5 Each hospice must have policies and procedures for reporting any adverse reaction to a medication immediately upon discovery, to the patient's licensed practitioner and document the event in the patient's medical record.

16-006.11A6 Each hospice must establish and implement appropriate policies and procedures for those staff authorized to receive telephone and verbal, diagnostic and therapeutic and medication orders.

006.12 Record Keeping Requirements

Each hospice must maintain records and reports in a manner that ensures accuracy and easy retrieval.

16-006.12A Clinical Records: In accordance with acceptable principles of practice, the hospice must establish and maintain a clinical record for every individual receiving care and services. The record must be complete, promptly and accurately documented, readily accessible and systematically organized to facilitate retrieval. Entries must be made for all services provided, and must be made and signed by the person providing the services. The record must include 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 evaluations, treatments, progress notes, etc.).

16-006.12B Informed Consent: A hospice must demonstrate respect for an individual's rights by ensuring that an informed consent form that specifies the type of care and services that may be provided as hospice care during the course of the illness has been obtained for every individual, either from the individual or designee.

16-006.12C Protection of Information: The hospice must safeguard the clinical record against loss, destruction and unauthorized use. The patient has the right to confidentiality of their records maintained by the hospice. Patient information and/or records will be released only with consent of the patient or designee or as required by law.

16-006.12D Retention of Records: Patient records are retained in a retrievable form for at least five years after the death or discharge of the patient. Policies provide for retention even if the hospice discontinues operation. If a patient is transferred to another health care provider, a copy of the record or abstract must be sent with the patient. The records must be subject to inspection by an authorized representative of the Department.

16-006.12E Destruction of Records: Clinical records may be destroyed after five years following the last discharge date or date of death. All records must be disposed of by shredding, mutilation, burning, or other similar protective measures in order to preserve the patient's rights of confidentiality. Records or documentation of the actual fact of clinical record destruction must be permanently maintained.

16-006.12F Other Hospice Records: The hospice must have and maintain the written policies and procedures governing services provided by the hospice.

16-006.12G Itemized Billing Statement: A hospice must provide, upon written request of a patient or a patient's representative and without charge, an itemized billing statement, including diagnostic codes. The billing statement must be provided within 14 days after the request.

006.13 Infection Control

Each hospice must have an infection control program to minimize sources and transmissions of infections and communicable diseases for services provided in patient home settings and if applicable, for the inpatient hospice facility, as follows:

1. Use of good handwashing techniques;

2. Use of safe work practices and personal protective equipment;

3. Proper handling, cleaning and disinfection of patient care equipment, supplies and linens; and

4. Patient teaching to include information concerning infections and modes of transmission, hygienic practices, methods of infection prevention, and methods for adapting available resources to maintain appropriate hygienic practices.

006.14 Environmental Services

The inpatient hospice must provide necessary housekeeping and maintenance to protect the health and safety of patients. Every detached building on the same premises used for care and treatment must comply with 175 NAC 16.

16-006.14A Housekeeping and Maintenance: The inpatient hospice's building and grounds must be kept clean, safe and in good repair.
1. The inpatient hospice must take into account patient habits and lifestyle preferences when housekeeping services are provided in the patient bedrooms/living area;

2. The inpatient hospice must provide and maintain adequate lighting, environmental temperatures and sound levels in all areas that are conducive to the care and treatment provided; and

3. All garbage and rubbish must be disposed of in a manner that prevents the attraction of rodents, flies, and all other insects and vermin. Disposal must be done in such a manner as to minimize the transmission of infectious diseases and minimize odor. The inpatient hospice must maintain and equip the premises to prevent the entrance, harborage, or breeding of rodents, flies, and all other insects and vermin.

16-006.14B Equipment, Fixtures, Furnishings: The inpatient hospice must provide and maintain all equipment, fixtures and furnishings clean, safe and in good repair.
1. The inpatient hospice must provide adequate equipment to meet patient needs as specified in each patient care plan;

2. Common areas and patient sleeping areas must be furnished with beds, chairs, sofas, tables, and storage items that are comfortable and reflective of patient needs and preferences. Furnishings may be provided by either the patient or the inpatient hospice;

3. The inpatient hospice must establish and implement a process designed for routine and preventative maintenance of equipment and furnishings to ensure that the equipment and furnishings are safe and function to meet their intended use.

16-006.14C Linens: The inpatient hospice must provide an adequate supply of bed, bath, and other linens as necessary for each patient.
1. The inpatient hospice must maintain an adequate supply of linens and towels that are clean and in good repair;

2. The inpatient hospice must establish and implement procedures for the storage and handling of clean and soiled linens; and

3. When the inpatient hospice launders bed and bath linens, water temperatures to laundry equipment must exceed 140 degrees Fahrenheit. Laundry may be appropriately sanitized or disinfected by another acceptable method in accordance with the manufacturer's instructions or other documentation.

16-006.14D Pets: If the inpatient hospice has a pet belonging to the inpatient hospice, the inpatient hospice must assure that the pet does not negatively affect the patients residing at the inpatient hospice. The inpatient hospice must have policies and procedures regarding pets that include:
1. An annual examination by a licensed veterinarian;

2. Vaccinations as recommended by the licensed veterinarian which must include at a minimum current vaccination for rabies for dogs, cats, and ferrets;

3. Provision of pet care necessary to prevent the acquisition and spread of fleas, ticks, and other parasites; and

4. Responsibility for the care and supervision of the pet by inpatient hospice staff.

16-006.14E Environmental Safety: The inpatient hospice must be responsible for maintaining the inpatient hospice in a manner that minimizes accidents.
1. The inpatient hospice must maintain the environment to protect the health and safety of patients by keeping surfaces smooth and free of sharp edges, mold or dirt; keeping floors free of objects and slippery or uneven surfaces and keeping the environment free of other conditions which may pose a potential risk;

2. The inpatient hospice must maintain all doors, stairways, passageways, aisles or other means of exit in a manner that provides safe and adequate access for care and treatment;

3. The inpatient hospice must provide water for bathing and handwashing at safe and comfortable temperatures:
a. The inpatient hospice must protect patients from burns and scalds secondary to unsafe water temperatures.

b. The inpatient hospice must establish and implement policies and procedures to monitor and maintain water temperatures that accommodate patient comfort and preferences but not to exceed the following temperatures:
(1) Water temperature at bathing fixtures must not exceed 115 degrees Fahrenheit;

(2) Water temperature at handwashing fixtures must not exceed 120 degrees Fahrenheit;

c. The inpatient hospice must establish and implement policies and procedures to ensure hazardous/poisonous materials are properly handled and stored to prevent accidental ingestion, inhalation, or consumption of the hazardous/poisonous materials by patients.

d. The inpatient hospice must restrict access to mechanical equipment which may pose a danger to patients.

16-006.14F Disaster Preparedness and Management: The inpatient hospice must establish and implement disaster preparedness plans and procedures to ensure that patient care and treatment, safety, and well-being are provided and maintained during and following instances of natural (tornado, flood, etc.) or other disasters, disease outbreaks, or other similar situations. The plans and procedures must address and delineate:
1. How the hospice will maintain the proper identification of each patient to ensure that care and treatment coincide with the patient's needs;

2. How the hospice will move patients to points of safety or provide other means of protection when all or part of the building is damaged or uninhabitable due to natural or other disaster;

3. How the hospice will protect patients during the threat of exposure to the ingestion, absorption, or inhalation of hazardous substances or materials;

4. How the hospice will provide food, water, medicine, medical supplies, and other necessary items for care and treatment in the event of a natural or other disaster; and

5. How the hospice will provide for the comfort, safety, and well-being of patients in the event of 24 or more consecutive hours of:
a. Electrical or gas outage;

b. Heating, cooling, or sewer system failure; or

c. Loss or contamination of water supply.

16-006.14F1 For other hospice patients, the hospice must establish and implement disaster preparedness plans and procedures to ensure that:
1. Patients and families are educated on how to handle patient care and treatment, safety, and well-being during and following instances of natural (tornado, flood, etc.) and other disasters, disease outbreaks, or other similar situations; and

2. How staff is educated on disaster preparedness and staff safety is assured.

006.15 Inpatient Hospice Services Requirements

A hospice that provides inpatient care directly must comply with 175 NAC 16-006 and 16-007.

16-006.15A 24-Hour Nursing Services: The inpatient hospice provides 24-hour nursing services which are sufficient to meet total nursing needs and which are in accordance with the patient plan of care. Each patient receives treatments, medications, and diet as prescribed, and is kept comfortable, clean, well-groomed, and protected from accident, injury, and infection. Each shift must include a registered nurse who provides direct patient care, when there is a patient in the facility receiving inpatient care for pain control and/or symptom management.

006.16 Food Service

The inpatient hospice must insure that the daily nutritional need of all patients are met, including any diet ordered by the attending physician. Food service must include but is not limited to:

1. Providing food service directly or through a written agreement;

2. Ensure a staff member is trained or experienced in food management or nutrition with the responsibility of:
a. Planning menus which meet the nutritional needs of each patient, following the orders of the patient's physician; and

b. Supervising the meal preparation and service to ensure that the menu plan is followed;

3. Be able to meet the needs of the patient's plan of care; nutritional needs, and therapeutic diet.

4. Procure, store, prepare, distribute, and serve all food under sanitary conditions and in accordance with the Food Code.

006.17 Pharmaceutical Services

The hospice provides appropriate methods and procedures for the dispensing and administering of drugs and biologicals. Whether drugs and biologicals are obtained from community or institutional pharmacists or stocked by the inpatient hospice, the inpatient hospice is responsible for drugs and biologicals for its patients, insofar as they are covered under the program and for ensuring that pharmaceutical services are provided in accordance with accepted professional principles and appropriate State laws.

16-006.17A Licensed Pharmacist: The hospice must employ a licensed pharmacist or have a formal agreement with a licensed pharmacist to advise the hospice on ordering, storage, administration, disposal, and record keeping of drugs and biologicals.

16-006.17B Orders for Medications: A physician must authorize the administration of all medications for the patient. If the medication order is verbal:
1. The physician must give it only to a licensed nurse, pharmacist, physician assistant, or another physician; and

2. The individual receiving the order must record and sign it immediately and have the prescribing physician sign it in a manner consistent with good medical practice.

16-006.17C Administering Medications: Medications are administered only by one of the following individuals:
1. A licensed nurse or physician;

2. The patient; or

3. Other individual in accordance with applicable State laws.

16-006.17D Control and Accountability: The pharmaceutical service has procedures for control and accountability of all drugs and biologicals throughout the inpatient hospice. Drugs are dispensed in compliance with State laws. Records of receipt and disposition of all controlled drugs are maintained in sufficient detail to enable accurate reconciliation. The pharmacist determines that drug records are in order and that an account of all controlled drugs is maintained and reconciled.

16-006.17E Labeling of Drugs and Biologicals: The labeling of drugs and biologicals is based on currently accepted professional principles, and includes the appropriate accessory and cautionary instructions, as well as the expiration date when applicable.

16-006.17F Storage: In accordance with State laws, all drugs and biologicals are stored in locked compartments under proper temperature controls and only authorized personnel have access to the keys. Separately locked compartments are provided for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1970 and other drugs subject to abuse, except under single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. An emergency medication kit is kept readily available

16-006.17G Drug Disposal: Controlled drugs no longer needed by the patient are disposed of in compliance with State requirements. In the absence of State requirements, the pharmacist and registered nurse dispose of the drugs and prepare a record of the disposal.

Disclaimer: These regulations may not be the most recent version. Nebraska 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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