providing hospice services must ensure that substantially all core services are
routinely provided directly by hospice employees. The hospice services program
may contract for physician services. The hospice services program may use
contracted staff for nursing services, medical social services, and counseling
services if necessary to supplement hospice employees in order to meet the
needs of patients during periods of peak patient loads or under extraordinary
circumstances. If contracting is used, the hospice services program must
maintain professional, financial, and administrative responsibility for the
services and must assure that the qualifications of the individuals and
services meet the requirements specified in this rule.
Nursing services. The hospice service
program must provide nursing care and services by or under the supervision of a
registered nurse (R.N.) at all times.
Nursing services must be directed and staffed to assure the nursing needs of
patients are met.
2. Patient care
responsibilities of nursing personnel must be specified.
3. Hospice services must be provided in
accordance with recognized standards of practice.
A registered nurse may make the actual
determination and pronouncement of death under the following circumstances:
(i) The deceased was receiving the services
of a licensed home care organization providing Medicare-certified hospice
(ii) Death was
anticipated, and the attending physician and/or the hospice medical director
has agreed in writing to sign the death certificate. Such agreement must be
present with the deceased at the place of death;
(iii) The nurse is licensed by the state;
(iv) The nurse is employed by
the home care organization providing hospice services to the
Medical Social Services. Medical Social Services must be provided by a
qualified social worker under the direction of a physician.
(c) Physician Services. In addition to
palliation and management of terminal illness and related conditions, physician
employees of the hospice service program, including the physician member(s) of
the interdisciplinary group, must also meet the general medical needs of the
patients to the extent these needs are not met by the attending
Counseling services must be made available to both the patient and the family.
Counseling includes bereavement counseling, provided both prior to and after
the patient's death, as well as dietary, therapeutic, spiritual and any other
counseling services identified in the Plan of Care for the patient and family.
1. 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, services to be provided and the frequency of
2. Dietary counseling.
Dietary counseling, when required, must be provided by a qualified
counseling. Spiritual counseling must include notice as to the availability of
4. 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
Plan of Care. A written plan of care must be established and maintained for
each patient admitted to a hospice program and the care provided must be in
accordance with the plan.
of plan. The plan must be established by the attending physician, the medical
director or the physician's designee and the interdisciplinary group prior to
(b) Review of Plan.
The plan must be reviewed and updated as the patient's condition changes, but
at intervals of no more than fifteen (15) days, by the attending physician, the
medical director or the physician's designee and interdisciplinary group. These
reviews must be documented.
Content of plan. The plan must include an assessment of the individual's needs
and identification of the hospice services required, 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
Interdisciplinary Group. The organization providing hospice services must
designate an interdisciplinary group(s) composed of individuals who provide or
supervise the care and services offered by the hospice program:
Composition of Group. The hospice service
program must have an interdisciplinary group or groups that include at least
the following individuals who are employees of the hospice service program:
1. A doctor of medicine or
2. A registered
3. A social worker;
4. A pastoral or other
Group. The interdisciplinary group 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.
(c) If a hospice service program has more
than one interdisciplinary group, it must designate in advance the group it
chooses to execute the functions described in part (b) of this
Coordinator. The hospice service program must designate a registered nurse to
coordinate the implementation of the plan of care of each patient.
Volunteers. The hospice service program
may use volunteers, in defined roles, under the supervision of a designated
hospice program employee.
(a) Training. The
hospice program must provide appropriate orientation and training that is
consistent with acceptable standards of hospice practice.
Role. Volunteers may be used in
administrative or direct patient care roles.
1. Recruiting and retaining. The hospice must
document active and ongoing efforts to recruit and train volunteers.
2. Availability of clergy. The hospice
service program must make reasonable efforts to arrange for visits of clergy
and other members of religious organizations in the community to patients who
request such visits and must advise patients of this opportunity.
(6) Continuation of
Care. An organization providing hospice services must assist in coordinating
continued care should the patient be transferred or discharged from the hospice
program or the organization.
Short Term Inpatient Care. Short term inpatient care is available for pain
control, symptom management and respite services, and if not provided directly,
must be provided under a legally binding written agreement that meets the
requirements of subparagraph (b) of this paragraph in a licensed nursing home,
hospital, or residential hospice which meets the following minimum
Whether provided directly
or indirectly, the facility that provides short term inpatient care must
provide twenty-four (24) hour nursing services which are sufficient to meet
total nursing needs in accordance with the patient's plan of care. Each hospice
patient must receive treatments, medications, and diet as prescribed, and must
be kept comfortable, clean, well-groomed and protected from accident, injury
and infection. Each shift must include a registered nurse (R.N.) who provides
direct patient care.
1. Respite services
shall be staffed in accordance with the patient's Hospice Plan of
2. The Hospice Plan of Care
will state whether a registered nurse is required to provide direct care to the
services may be provided in an Assisted Care Living Facility so long as the
provisions of Rule 1200-08-27-.06(7)(b)-(g)
facility must be designed and equipped for the comfort and privacy of each
hospice patient and family member(s) by providing physical space for private
patient/family visiting, accommodations for family members to remain with the
patient throughout the night, accommodations for family privacy following a
patient's death and decor which is home-like in design and function.
(c) The hospice must furnish to the inpatient
provider a copy of the patient's plan of care and specify the inpatient
services to be furnished.
inpatient provider must have established policies consistent with those of the
hospice and agree to abide by the patient care protocols established by the
hospice for its patients.
medical record must include a record of all inpatient services and events. A
copy of the discharge summary must be provided to the hospice and, if
requested, a copy of the medical record is to be provided to the
(f) The written agreement
must designate the party responsible for the implementation of the provisions
of the agreement.
(g) The hospice
shall retain responsibility for appropriate hospice care training of the
personnel who provide the care under the agreement.
(8) Drugs and treatments shall be
administered by appropriately licensed agency personnel, acting within the
scope of their licenses. Oral orders for drugs and treatments shall be given to
appropriately licensed personnel acting within the scope of their licenses,
immediately recorded, signed and dated, and countersigned and dated by the
Improvement Program. Each agency must conduct an ongoing, comprehensive,
integrated, self-assessment of the quality and appropriateness of past and
present care provided, including inpatient care and contract services. The
written performance improvement plan findings are to be used by the hospice to
determine the appropriateness and effectiveness of the care provided and to
ascertain that professional policies are followed in providing these services.
The objectives of those responsible for the performance improvement program are
(a) To assist the agency in using
its personnel and facilities to meet individual and community needs;
(b) To identify and correct problems and/or
deficiencies which undermine quality of care and lead to waste of agency and
(c) To help
the agency make critical judgments regarding the quality and quantity of its
services through self-examination;
(d) To provide opportunities to evaluate the
effectiveness of agency policies and when necessary make recommendations to the
administration as to controls or changes needed to assure high standards of
(e) To provide data
needed to satisfy state licensure and federal certification requirements;
(f) To establish criteria to
measure the effectiveness and efficiency of the hospice services provided to
(a) There must be an active
performance improvement program for developing guidelines, policies, procedures
and techniques for the prevention, control and investigation of infections and
provisions must be developed to educate and orient all appropriate personnel
and/or family members in the practice of aseptic techniques such as handwashing
and scrubbing practices, proper hygiene, use of personal protective equipment,
dressing care techniques, disinfecting and sterilizing techniques, and the
handling and storage of patient care equipment and supplies.
(c) Continuing education shall be provided
for all agency patient care providers on the cause, effect, transmission,
prevention and elimination of infections, as evidenced by the ability to
verbalize/or demonstrate an understanding of basic techniques.
A Home Care Organization Providing
Hospice Services shall have an annual influenza vaccination program which shall
include at least:
1. The offer of influenza
vaccination to all staff and independent practitioners at no cost to the person
or acceptance of documented evidence of vaccination from another vaccine source
or facility. The Home Care Organization Providing Hospice Services will
encourage all staff and independent practitioners to obtain an influenza
Education of all employees about the
(i) Flu vaccination,
(ii) Non-vaccine control measures, and
(iii) The diagnosis, transmission,
and potential impact of influenza;
4. An annual evaluation of the influenza
vaccination program and reasons for non-participation; and
5. A statement that the requirements to
complete vaccinations or declination statements shall be suspended by the
administrator in the event of a vaccine shortage as declared by the
Commissioner or the Commissioner's designee.
(e) The agency shall develop policies and
procedures for testing a patient's blood for the presence of the hepatitis B
virus and the HIV (AIDS) virus in the event that an employee of the agency, a
student studying at the agency or other health care provider rendering services
at the agency is exposed to a patient's blood or other body fluid. The testing
shall be performed at no charge to the patient, and the test results shall be
(f) The agency and
its employees shall adopt and utilize standard precautions (per CDC) for
preventing transmission of infections, HIV and communicable diseases.
(g) Precautions shall be taken to prevent the
contamination of sterile and clean supplies by soiled supplies. Sterile
supplies shall be packaged and stored in a manner that protects the sterility
of the contents.
Home Health Aide/Hospice Aide Services. Home Health Aide Services must be
available and adequate in frequency to meet the needs of the patients.
(a) The home health aide shall be assigned to
a particular patient by a registered nurse. Written instructions for patient
care shall be prepared by a registered nurse or therapist as appropriate.
Duties may include the performance of simple procedures as an extension of
therapy services, personal care, ambulation and exercises, household services
essential to health care at home, assistance with medications that are
ordinarily self-administered, reporting changes in the patient's condition and
needs, and completing appropriate records.
(b) The registered nurse, or appropriate
professional staff member if other home health services are provided, shall
make a supervisory visit to the patient's residence at least monthly, either
when the aide is present to observe and assist or when the aide is absent
(preferably alternating visits), to assess the aide's competence in providing
care and determine whether goals are being met.
(c) There shall be continuing in-service
programs on a regularly scheduled basis with on-the-job training during
supervisor visits as issues are identified.
(12) Physical Therapy, Occupational Therapy
and Speech Language Pathology Services. Physical therapy services, occupational
therapy services, and speech language pathology services must be available and
when provided, offered in a manner consistent with accepted standards of
services shall be provided only by or under supervision of a qualified speech
language pathologist in good standing, or by a person qualified as a Clinical
Fellow subject to Tennessee Board of Communications Disorders and Sciences Rule
Medical Supplies. Medical supplies and
appliances, including drugs and biologicals, must be provided as needed for the
palliation and management of the terminal illness or conditions directly
attributable to the terminal diagnosis.
Administration. All drugs and biologicals must be administered in accordance
with accepted standards of practice and only by appropriately licensed
employees of the hospice.
hospice must have a policy for the disposal of controlled drugs maintained in
the patient's home or temporary place of residence when those drugs are no
longer needed by the patient.
Drugs and biologicals may be administered by the patient or his/her family
member if the patient's attending physician has approved.
(a) A medical record containing past and
current findings in accordance with accepted professional standards shall be
maintained for every patient receiving hospice services. In addition to the
plan of care, the record shall contain: appropriate identifying information;
name of physician; all medications and treatments; and signed and dated
clinical notes. Clinical notes shall be written the day on which service is
rendered and incorporated no less often than weekly; copies of summary reports
shall be sent to the physician; and a discharge summary shall be dated and
signed within 7 days of discharge.
(b) A home care organization providing
hospice services is authorized to receive and appropriately act on a written
order for a plan of care for a patient concerning a home health service signed
by a physician that is transmitted to the agency by electronically signed
electronic mail. Such order that is transmitted by electronic mail shall be
deemed to meet any requirement for written documentation imposed by this
(c) All medical
records, either written, electronic, graphic or otherwise acceptable form, must
be retained in their original or legally reproduced form for a minimum period
of at least ten (10) years after which such records may be destroyed. However,
in cases of patients under mental disability or minority, their complete agency
records shall be retained for the period of minority or known mental
disability, plus one (1) year, or ten (10) years following the discharge of the
patient, whichever is longer. Records destruction shall be accomplished by
burning, shredding or other effective method in keeping with the confidential
nature of the contents. The destruction of records must be made in the ordinary
course of business, must be documented and in accordance with the agency's
policies and procedures, and no record may be destroyed on an individual
(d) Even if the agency
discontinues operations, records shall be maintained as mandated by this
Chapter and the Tennessee Medical Records Act (T.C.A. §§
68-11-308). If a patient is
transferred to another health care facility or agency, a copy of the record or
an abstract shall accompany the patient when the agency is directly involved in
(e) Medical records
information shall be safeguarded against loss or unauthorized use. Written
procedures govern use and removal of records and conditions for release of
information. The patient's written consent shall be required for release of
information when the release is not otherwise authorized by law.
(f) For purposes of this rule, the
requirements for signature or countersignature by a physician or other person
responsible for signing, countersigning or authenticating an entry may be
satisfied by the electronic entry by such person of a unique code assigned
exclusively to him or her, or by entry of other unique electronic or mechanical
symbols, provided that such person has adopted same as his or her signature in
accordance with established protocol or rules.