Current through Register No. 40, October 3, 2024
(a) The licensee
shall only admit those patients whose needs can be met by the HHCP.
(b) At the time of admission, personnel of
the HHCP shall:
(1) Provide, both orally and
in writing, to the patient, or the patient's guardian, agent, or surrogate
decision-maker, if applicable the HHCP's:
a.
Policy on patient rights and responsibilities, including a copy of the home
care clients' Bill of Rights, pursuant to
RSA
151:21-b;
b. Complaint procedure;
c. List of care and services that are
provided directly by the HHCP; and
d. List of the care and services that are
provided by contract;
(2) Obtain written confirmation acknowledging
receipt of the items in (1) above from the patient, their guardian, agent, or
surrogate decision-maker if applicable;
(3) Collect and record the following
information:
a. Patient's name, home address,
home telephone number, and date of birth;
b. Name, address and telephone number of an
emergency contact and guardian, agent, or surrogate decision-maker if
applicable;
c. Name of patient's
primary care provider and their address and telephone number;
d. Copies of all legal directives such as
durable power of attorney, legal guardian, or living will; and
e. Written and signed consent for the
provision of care and services; and
(4) Obtain documentation of informed consent
and consent for release of information.
(c) The hospice care provider shall ensure
that medical direction is provided either from the patients' attending licensed
practitioner or the hospice medical director.
(d) Patients who are admitted or accepted for
services shall:
(1) Be evaluated and assessed
by professional staff within 48 hours of admission; and
(2) Have an order for any service for which
such order is required by the practice acts of the person providing
care.
(e) Patients who
are accepted for services shall have a nursing assessment at the following
intervals to determine the level of care and services required by the patient:
(1) Within 48 hours of admission;
and
(2) Thereafter as required by
the CMS conditions of participation or at least every 90 days at a
minimum.
(f) The
assessment required by (e) above shall contain, at a minimum, the following:
(1) Pertinent diagnoses including mental
status;
(2) A pain assessment,
including symptom control and vital signs;
(3) A physical assessment;
(4) A cognition and mental status
assessment;
(5) A behavioral
assessment;
(6) A psychosocial
assessment;
(7) Medications and
treatment needs;
(8) Functional
limitations;
(9) Nutritional
requirements;
(10) Estimated
duration and frequency of care and services;
(11) Any equipment required; and
(12) Any safety precautions.
(g) In addition to the information
in (e) and (f) above, the initial nursing assessment shall include:
(1) Reactions of the patient and family
members to terminal illness;
(2)
History of the patient's and family coping strengths and weaknesses;
(3) Social and financial concerns;
and
(4) Spiritual beliefs and
desires of the patient.
(h) The licensee shall establish an
interdisciplinary hospice care team composed of at least:
(1) A licensed practitioner;
(2) A registered nurse;
(3) A social worker; and
(4) A spiritual and or bereavement
counselor.
(i) The
interdisciplinary hospice care team shall:
(1) Establish the care plan;
(2) Be the primary care delivery team for a
patient and his or her family through the total duration of hospice care;
and
(3) Be responsible for
supervising any patient care and services provided by others.
(j) The interdisciplinary team
shall, in conjunction with the patient and the patient's personal
representative, and their family, develop an individualized care plan, which
reflects the changing care needs of the patient and family.
(k) The care plan required by (j) above shall
include:
(1) The date the problem or need was
identified;
(2) A description of
the problem or need;
(3) The goal
for the patient;
(4) The action or
approach to be taken by HHCP personnel;
(5) The responsible person(s) or position;
and
(6) The interventions used to
address problems identified in the assessment including:
a. Medications ordered;
b. Pain control interventions, both
pharmacological and non-pharmacological;
c. Symptom management treatment;
and
d. Services required including
frequency of visits.
(l) The care plan required by (j) above shall
be:
(1) Developed in conjunction with the
patient and their guardian, agent, or surrogate decision maker;
(2) Completed no later than 5 days after
completion of the assessment;
(3)
Reviewed and revised every 15 days by the interdisciplinary team following the
completion of each assessment; and
(4) Made available to all personnel that
assist the patients.
(m)
The patient, the patient's family and guardian, agent, or surrogate decision
maker shall be notified in advance of all interdisciplinary team meetings and
be given the opportunity to participate in such meetings.
(n) The patient and their family shall be
encouraged to participate in all components of care, including:
(1) Assessment and problem
identification;
(2) Implementation
of the care plan; and
(3)
Evaluation and revision of the care plan, as needed.
(o) The care plan shall contain documentation
of the patient's or the patient's guardian, agent, or surrogate
decision-makers' acceptance or rejection of the initial care plan and all
subsequent revisions or updates.
(p) All staff of the HHCP shall carry out the
goals stated in the care plan.
(q)
The licensee shall develop a discharge plan with the input of the patient and
the guardian, agent, or surrogate decision-maker if any.
(r) Copies of the following documents shall
accompany the transferred patient:
(1) The
emergency data sheet;
(2) A copy of
the care plan; and
(3) A summary
that includes:
a. The date and time the
patient was transferred from the HHCP;
b. The place to which the patient was
transferred or discharged; and
c.
The condition of the patient at the time of transfer or discharge.
(s) Transfers may occur
without prior notification to the guardian or agent pursuant to an activated
POA or the licensed practitioner when the patient is in need of immediate
emergency care.
(t) Progress notes
shall be written by personnel, as appropriate, at the time of each visit and
shall include at a minimum:
(1) Changes in the
pateint's physical, functional, and mental abilities;
(2) Changes in the patient's behaviors such
as eating or sleeping patterns;
(3)
The patient's relief of pain, if applicable; and
(4) Newly identified needs of the patient and
their family.
(u)
Written notes shall be documented in the patient's record for:
(1) All care and services provided by
personnel and include the following:
a. Date
and time of the care or service;
b.
Description of the care or service;
c. Progress notes as required by (t) above;
and
d. Signature and title of the
person providing care or services; and
(2) Any reportable incident or occurrence
involving the patient when HHCP personnel are in the patient home, which shall
include the information required by
He-P
823.14(o) .
(v) For each patient accepted for care and
services by the HHCP, a current and accurate record shall be maintained,
including, at a minimum:
(1) The written
confirmation required by He-P 823.16(b) (2);
(2) The identification data required by He-P
823.16(b) (3);
(3) Consent and
medical release forms, as applicable;
(4) Pertinent medical information:
(5) All orders from a licensed practitioner,
including the date and signature of the licensed practitioner required by He-P
823.16(c);
(6) Copy of order
activating durable power of attorney, if applicable;
(7) Copy of DNR order, if
applicable;
(8) All assessments
required by He-P 823.16(d) and (e);
(9) All care plans required by He-P 823.16(j)
-(l) including documentation that the patient or patient's guardian, agent, or
surrogate decision-maker, if applicable, participated in the development of the
care plan;
(10) All written notes
required by He-P 823.16(u);
(11)
All progress notes as required by He-P 823.16(t);
(12) All daily medication records required by
He-P 823.17(d) (9)
;
(13) A discharge plan or transfer summary as
required by He-P 823.16(q) and (r) (3);
(14) Discharge documentation, which shall
include:
a. In the case of patient death:
1. Date and place of death; and
2. Bereavement follow-up plan; and
b. In the case of discharge other
than patient death:
1. Date and time of
patient discharge;
2. The physical,
mental, and medical condition of patient at discharge;
3. Discharge instruction and
referral;
4. Discharge summary;
and
5. Signed licensed
practitioner's order for discharge, if applicable; and
(15) Documentation of any patient
refusal of any care or services.
(w) Patient records shall be available to:
(1) The patient, their guardian, agent, or
surrogate decision-maker;
(2) HHCP
personnel as required by their job responsibilities and subject to the
licensee's policy on confidentiality;
(3) Any individual given written
authorization by the patient or their guardian,agent and surrogate decision
maker;
(4) Any individual
authorized by a court of competent jurisdiction; and
(5) The department or any individual
authorized by law.
(x)
The licensee shall develop and implement a method for the written release of
information in the patient record that is consistent with federal and state
statute.
(y) The HHCP shall store
the patient record in the primary or branch office except when they are being
utilized by the supervisory and direct care staff.
(z) Records shall be safeguarded against
loss, damage, or unauthorized use by being stored in locked containers,
cabinets, rooms, or closets except when they are being used by direct care
staff.
(aa) Records shall be
retained for a minimum of 4 years after discharge and in the case of minors,
until one year after reaching age 18, but no less than 4 years after
discharge.
(ab) The HHCP shall
arrange for storage of, and access to, patient records as required by (aa)
above in the event that the HHCP ceases operation.
(ac) If the HHCP is providing any of the
following services, they shall be licensed in accordance with the applicable
rules:
(1) Home health care provider agency;
or
(2) Case management provider
agency.
#9292, eff
10-9-08
