Ga. R. & Regs. 111-8-37

Hospices

These Georgia regulations establish licensing and operating requirements for hospices, including home care, residential hospice facilities, and inpatient hospice facilities. Operators must obtain a license from the Georgia Department of Community Health, comply with inspection and reporting requirements, maintain a qualified governing body and administrator, implement quality management programs, and uphold patient and family rights. The rules cover the full continuum of hospice services—from home-based palliative and terminal care to short-term inpatient and residential settings—and set standards for staffing, disaster preparedness, and incident reporting.

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Department 111

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Chapter 111-8

» Subject 111-8-37

Subject 111-8-37 RULE AND REGULATIONS FOR HOSPICES

Rule 111-8-37-.01 Title and Purpose

These rules shall be known as the Rules and Regulations for
 Hospices. The purpose of these rules is to provide for the inspection and
 issuance of licenses for hospices and to establish minimum requirements for
 facilities operating under hospice licenses.

Rule 111-8-37-.02 Authority

The legal authority for this Chapter is O.C.G.A § 
31-7-170
et seq.
,
 the "Georgia Hospice Law" and O.C.G.A. § 
31-2-4
et
 seq.

Rule 111-8-37-.03 Definitions

(1)

 Unless the
 context otherwise requires, these identified terms mean the following when used
 in these rules: 

(a)

 "Administrator" means the
 person, by whatever title used, to whom the governing body has delegated the
 responsibility for the day-to-day administration of the hospice, including the
 implementation of the policies and procedures adopted by the governing
 body.

(b)

 "Advanced and progressive
 disease" means a serious life-threatening medical condition which is
 irreversible and which will continue indefinitely, where there is no reasonable
 hope of recovery, but where the patient's medical prognosis is one in which
 there is a life expectancy of up to two years. The term does not include
 terminally ill patients as defined in paragraph (ee) of this rule.

(c)

 "Attending physician" means the physician
 identified by the hospice patient or the patient's representative as having
 primary responsibility for the hospice patient's medical care and who is
 licensed to practice medicine in this state.

(d)

 "Bereavement services" means the
 supportive services provided to the family unit to assist it in coping with the
 patient's death, including follow-up assessment and assistance through the
 first year after death.

(e)

 "Clergy" means an individual representative of a specific spiritual belief who
 has documentation of ordination or commission by a recognized faith group and
 who has completed at least one unit of clinical pastoral education from a
 nationally recognized provider.

(f)

 "Counseling" means those techniques used to help persons learn how to solve
 problems and make decisions related to personal growth, vocation, family,
 social, and other interpersonal concerns.

(g)

 "Department" means the Georgia Department
 of Community Health.

(h)

 "Dietitian" means a specialist in the study of nutrition who is licensed as
 required by O.C.G.A. § 
43-11A-1
et seq.
,
 the "Dietetics Practice Act."

(i)

 "Family unit" means the terminally ill person or person with an advanced and
 progressive disease and his or her family, which may include spouse, children,
 siblings, parents, and other relatives with significant personal ties to the
 patient.

(j)

 "Governing body" means
 the board of directors, trustees, partnership, corporation, association, or
 person or group of persons who maintain and control the operation of the
 hospice and who are legally responsible for its operation.

(k)

 "Home care" means hospice care primarily
 delivered in the residence of the hospice patient, whether that place is the
 patient's permanent or temporary residence. A hospice patient who considers his
 or her residence to be a licensed assisted living community, licensed nursing
 home, licensed intermediate care home, licensed personal care home, or
 residential hospice setting is considered to be receiving home care while a
 resident of that facility.

(l)

 "Hospice" means a public agency or private organization or unit of either
 providing to persons terminally ill and to their families, regardless of
 ability to pay, a centrally administered and autonomous continuum of palliative
 and supportive care, directed and coordinated by the hospice care team
 primarily in the patient's home but also on an outpatient and short-term
 inpatient basis and which is classified as a hospice by the Department. In
 addition, such public agency or private organization or unit of either may also
 provide palliative care to persons with advanced and progressive diseases and
 to their families, directed and coordinated by the hospice care team.

(m)

 "Hospice care" means both regularly
 scheduled care and care available on a 24 hour on-call basis, consisting of
 medical, nursing, social, spiritual, volunteer, and bereavement services
 substantially all of which are provided to the patient and to the patient's
 family regardless of ability to pay under a written care plan established and
 periodically reviewed by the patient's attending physician, by the medical
 director of the hospice program, and by the hospice care team.

(n)

 "Hospice care team" means an
 interdisciplinary working unit composed of members of the various helping
 professions (who may donate their professional services), including but not
 limited to: a physician licensed or authorized to practice in this state, a
 registered professional nurse, a social worker, a member of the clergy or other
 counselors, and volunteers who provide hospice care.

(o)

 "Inpatient care" means short-term,
 24-hour medically supervised care for the purpose of adjusting and monitoring
 the terminally ill patient's medications for pain control or managing acute or
 chronic symptoms that cannot be managed in another setting. Inpatient care is
 provided within the confines of a licensed hospital, a licensed skilled nursing
 facility, or a licensed inpatient hospice facility.

(p)

 "Inpatient hospice facility" means a
 facility that is licensed to provide acute inpatient care for hospice patients
 in beds that are not included in the certified bed capacity of another licensed
 facility.

(q)

 "License" means a
 license issued by the Department to the governing body to operate a
 hospice.

(r)

 "Medical director"
 means a physician licensed in this state who is a member of the hospice care
 team and is responsible for the direction and quality of the medical component
 of the care rendered by the hospice to patients.

(s)

 "Palliative care" means those
 interventions by the hospice care team which are intended to achieve relief
 from, reduction of, or elimination of pain and of other physical, emotional,
 social, or spiritual symptoms of distress to achieve the best quality of life
 for the patients and their families.

(t)

 "Patient" means a terminally ill
 individual receiving the hospice continuum of services, regardless of ability
 to pay and also means an individual with an advanced and progressive
 disease.

(u)

 "Patient
 representative" means an individual who, under applicable laws, has the
 authority to act on behalf of the patient where the patient is incapable of
 making decisions related to health care.

(v)

 "Personal care services" means assistance
 with activities of daily living, personal care, ambulation and exercise;
 provision of household services essential to health care at home; assistance
 with self-administration of medication; and preparation of meals.

(w)

 "Physician" means an individual who is
 licensed to practice medicine in this state by the Georgia Composite Medical
 Board.

(x)

 "Primary caregiver"
 means a person or entity designated in writing by the patient or the patient's
 representative who agrees to give and/or arrange for continuing support and
 care and who may advocate on behalf of the patient.

(y)

 "Professional counselor" means a person
 licensed or certified as a professional counselor or associate professional
 counselor as required by O.C.G.A. § 
43-10A-1
et seq.
,
 the "Professional Counselors, Social Workers, and Marriage and Family
 Therapists Licensing Law."

(z)

 "Registered nurse" means an individual who is currently licensed to practice
 nursing under the provisions of Article 1 of Chapter 26 of Title 43 of the
 Official Code of Georgia Annotated.

(aa)

 "Residential hospice facility" means a
 small home-like residential facility or unit that is a part of a licensed
 hospice program, designed, staffed, and organized to provide non-acute hospice
 care, 24-hours per day, seven days per week, under the supervision of the
 hospice physician and hospice registered nurses to terminally ill hospice
 patients and their family units.

(bb)

 "Respite care" means short-term
 inpatient or residential care provided for the patient to provide relief for
 that patient's family unit from the stress of providing care.

(cc)

 "Restraint" means any manual, physical,
 or mechanical method, device, material, or equipment that immobilizes or
 reduces the ability of a patient to move his or her arms, legs, body or head
 freely, not including devices, such as orthopedically prescribed devices,
 surgical dressings or bandages, protective helmets, or other methods that
 involve the physical holding of a patient for the purpose of conducting routine
 physical examinations or tests, or to protect the patient from falling out of
 bed, or to permit the patient to participate in activities without the risk of
 physical harm (this does not include a physical escort); or a drug or
 medication when it is used as a restriction to manage the patient's behavior or
 restrict the patient's freedom of movement and is not a standard treatment or
 dosage for the patient's condition.

(dd)

 "Social worker" means an individual who
 is qualified by education, training, and experience and licensed as required by
 law to perform social work for hospice patients and their family
 units.

(ee)

 "Terminally ill" means
 that the individual is experiencing an illness for which therapeutic
 intervention directed toward cure of the disease is no longer appropriate, and
 the patient's medical prognosis is one in which there is a life expectancy of
 six months or less.

(ff)

 "Volunteer" means a lay or professional person who provides, without
 compensation, support and assistance to the patient and the patient's family
 under the supervision of a member of the hospice staff unit in accordance with
 the plan of care developed by the hospice care team.

(2)

 As used in these rules and regulations,
 the singular indicates the plural and the plural the singular when consistent
 with the intent of these rules.

Rule 111-8-37-.04 Licensure Procedures

(1)

 Operating, establishing or maintaining a
 hospice in the State of Georgia without first obtaining a valid license from
 the Department is prohibited.

(2)

 Use of the term "hospice" to imply or indicate that a person or entity is
 providing hospice services to patients and their families unless the person or
 entity holds a valid license to provide hospice care is prohibited.

(3)

 A governing body desiring to operate a
 hospice must file with the Department an initial application on forms
 prescribed and made available by the Department. The application must be
 complete, accurate, and signed by the hospice administrator or the executive
 officer of the hospice's governing body and must include: 

(a)

 The applicant's name, address, phone
 number, and business e-mail address for receiving inspection reports and
 communications concerning the license from the Department.

(b)

Proof of ownership.
 In the
 case of corporations, partnerships, and other entities authorized by law, the
 applicant must provide a copy of its certificate of incorporation or other
 acceptable proof of its legal existence and authority to transact business
 within the state;

(c)

 A list of
 counties proposed to be served by the hospice; and

(d)

 A list of the locations of any additional
 hospice care facilities operated by the hospice on separate premises, as
 applicable, and the number of beds at such facilities.

(4)

 Knowingly supplying materially false,
 incomplete, or misleading information is grounds for denial or revocation of a
 license.

(5)

 Following evidence of
 substantial compliance with these rules and regulations and any provisions of
 law as applicable to the construction and operation of the hospice, the
 Department may issue a license to provide hospice services primarily to
 terminally ill patients in their own homes.

(6)

 An initial license may be issued for a
 period of six months to allow a new hospice to demonstrate its ability to
 comply with these rules and regulations. After becoming fully operational and
 demonstrating substantial compliance with the rules and regulations, the
 hospice shall become eligible for a regular license.

(7)

 Inpatient and residential services and
 palliative care services are not eligible to be licensed separately from
 hospice home care services.

(8)

 The
 license must be displayed in a prominent place in the hospice's administrative
 offices.

(9)

 Licenses are not
 transferable from one governing body to another or from one hospice location to
 another.

(10)

 Each planned change
 of ownership or lease or change of location must be disclosed to the Department
 at least 30 days prior to such change by submitting an application and the
 required fees from the proposed new owners or lessees for a new
 license.

(11)

 Changes in the
 hospice that require the submission of a new application and the issuance of a
 new license include a change in name, the addition of another service location,
 a change in the number of licensed beds if residential services are provided or
 a change in the scope of services provided. The new application that reflects
 the proposed change must be filed at least 30 days prior to the proposed
 change. Hospices licensed before the effective date of these rules desiring to
 change their scope of service solely to include palliative care to patients
 with advanced and progressive diseases who are not terminally ill, will not be
 required to pay an application change processing fee to add palliative care if
 the Department receives the palliative care change request within 180 days of
 these rules taking effect.

(12)

 A
 license is no longer valid and must be returned to the Department when the
 hospice ceases to operate, changes locations, is issued a new license or the
 license is suspended or revoked. The facility must notify referring individuals
 and entities of the closure and patients' families regarding the location of
 medical records.

(13)

 Temporary Inactive Status. 
If the hospice is closing for a period of
 less than 12 months, and plans to reopen under the same ownership, governing
 body, and name, the hospice may request to have the license placed on temporary
 inactive status. The hospice must submit its request in writing and provide a
 written plan for notifying referring individuals and entities of the closure
 and patients' families regarding the location of medical records. 

(a)

 When placed on temporary inactive status,
 the license must be returned to the Department within 10 days of closure and
 the hospice must not operate until the license has been reactivated.

(b)

 The hospice must request in writing that
 the permit be reactivated at least 30 days prior to the desired date of
 reopening. Prior to reactivation of the license, the hospice may be subject to
 inspection by the Department. If the license is not reactivated within 12
 months, the license is void.

(14)

 Multiple Hospice Locations.

 Separate applications and licenses are required for hospices operated at
 separate locations; however, the Department has the option of approving a
 single license for multiple hospice locations based on evidence that the
 hospice meets all of the following requirements: 

(a)

 All locations are owned and operated by
 the same governing body and conduct business under the same set of by-laws and
 the same trade name;

(b)

 Each
 location is responsible to the same governing body and central administration
 managed together under the same set of policies and procedures;

(c)

 The governing body and central
 administration demonstrate the capacity to adequately manage all locations and
 ensure the quality of care at all locations as evidenced by a prior history of
 satisfactory compliance with hospice regulations and appropriate
 staffing;

(d)

 Supervision and
 oversight at additional locations is sufficient to ensure that hospice care and
 services meet the needs of patients and the patients' family units;

(e)

 The medical director assumes
 responsibility for the medical component of the hospice's patient care at all
 locations;

(f)

 Additional locations
 provide the same full range of services and the same level and quality of care
 including timely responses, that is provided by the primary location;

(g)

 Each patient is assigned to a specific
 hospice care team responsible for ongoing assessment, planning, monitoring,
 coordination, and provision of care, which has ready access to the patient's
 clinical record;

(h)

 All hospice
 patients' clinical records that are requested by the Department at the time of
 inspection must be available at the hospice's primary location; and

(i)

 All locations maintain the same Medicare
 provider number, as applicable.

(15)

 Hospice Care Facilities.
 
Hospices desiring to provide facilities for residential and/or acute
 inpatient hospice services as a part of the licensed hospice must submit an
 application to the Department requesting a change in service level. The
 Department will not approve the change in service level that includes
 residential and/or inpatient hospice services, unless the hospice: 

(a)

 Is licensed and in substantial compliance
 with these rules and regulations that apply to home care hospice
 services;

(b)

 Submits a copy of the
 certificate of occupancy issued by local building officials for the facility or
 unit;

(c)

 submits evidence of
 compliance with the applicable provisions of the 
Life Safety Code®,
 
as enforced by the state fire marshal
;

(d)

 Provides evidence to the Department of
 compliance or ability to comply with all the applicable requirements of
 paragraph (14) of this rule relating to multiple hospice locations;
 and

(e)

 Demonstrates substantial
 compliance with all the applicable requirements of Rule
 , Hospice Care
 Facilities, as evidenced by an on-site inspection by the Department.

Rule 111-8-37-.05 Inspections and Investigations

(1)

 The hospice staff, any facilities where
 hospice care is being delivered, and the hospice patients must be accessible
 during all hours of operation to properly identified representatives of the
 Department for inspections and investigations relating to the hospice's
 license.

(2)

 The Department will
 periodically inspect each hospice to ensure that the licensee is providing
 quality care to its patients; provided, however, that a hospice is exempt from
 routine periodicon-site licensure inspection if it is certified as a hospice in
 accordance with federal regulations. Where the Department receives or becomes
 aware of a complaint alleging that the hospice is not acting in compliance with
 the requirements of these rules, the Department may conduct an inspection at
 any time to determine whether the licensed hospice is in compliance with these
 rules.

(3)

 For the purposes of any
 inspection, investigation, or survey conducted by the Department, the hospice
 must provide to properly identified representatives of the Department
 meaningful access to all books, records, papers, or other information related
 to the initial or continued licensing of the hospice.

(4)

 The hospice must submit to the
 Department, in a format acceptable to the Department, a written plan of
 correction in response to any inspection report of violations identified by the
 Department. The plan of correction must specify what the hospice will do by a
 date certain to correct each of the violations identified. The plan of
 correction must be submitted within 10 days of the hospice's receipt of the
 inspection report of violations. A plan of correction must be determined to be
 acceptable by the Department. Hospices may be allowed an additional 48 hours to
 revise any plan of correction deemed unacceptable by the Department. Failure to
 submit an acceptable plan of correction may result in the Department commencing
 enforcement procedures. The hospice must correct all violations
 cited.

Rule 111-8-37-.06 Reports to the Department

(1)

Patient Incidents Requiring
 Report.
 The hospice must report to the Department, on forms made
 available by the Department, within 24 hours or the next business day, whenever
 any of the following incidents involving patients occurs or the hospice has
 reasonable cause to believe that an incident involving a patient has occurred: 

(a)

 Any death of a hospice patient not
 related to the natural course of the patient's terminal illness or advanced and
 progressive disease, or any identified underlying condition;

(b)

 Any rape, assault, or any abuse, neglect
 or exploitation of a patient; and

(c)

 Any time a patient, who is admitted to a
 residential or inpatient hospice facility cannot be located, where there are
 circumstances that place the health, safety, or welfare of the patient or
 others at risk and the patient has been missing for more than eight
 hours.

(2)

 Where the
 hospice staff has reasonable cause to believe that a disabled adult or elder
 person has been the victim of abuse, other than by accidental means, or has
 been neglected or exploited, the hospice must report such information to an
 adult protection agency providing protective services as designated by the
 Department and to an appropriate law enforcement agency or prosecuting
 attorney.

(3)

 The hospice, through
 its peer review committee, must submit the reports of patient incidents listed
 in subparagraph (1)(a) through (c) of this rule. The Department will receive
 and retain such peer review reports concerning the listed incidents in
 confidence.

(4)

 Reports of patient
 incidents made through the peer review process must include: 

(a)

 The name of the hospice, the name of the
 administrator or site manager, and a contact telephone number for information
 related to the report;

(b)

 The date
 of the incident and the date the hospice became aware of the
 incident;

(c)

 The type of incident,
 with a brief description of the incident; and

(d)

 Any immediate corrective or preventative
 action taken by the hospice to ensure against the replication of the
 incident.

(5)

 The
 hospice must conduct an internal investigation of any of the patient incidents
 listed in subparagraph (1)(a) through (c) and must complete and retain on-site
 a written report of the results of the investigation within 45 days of the
 discovery of the incident. The complete report must be made available to the
 Department for inspection at the hospice office and contain at least: 

(a)

 An explanation of the circumstances
 surrounding the incident, including the results of a root cause analysis or any
 other detailed system analysis;

(b)

 Any findings or conclusions associated with the review; and

(c)

 A summary of any actions taken to correct
 identified problems associated with the incident and to prevent recurrence of
 the incident, and also any changes in procedures or practices resulting from
 the investigation.

(6)

 The hospice must report to the Department any pending involuntary discharge of
 a hospice patient initiated by the hospice. The report must be made no later
 than the time of notification to the patient of the pending
 discharge.

(7)

Other Events
 Requiring Report.

(a)

 The hospice must
 report in an acceptable format to the Department whenever any of the following
 events involving hospice operations occur or when the hospice becomes aware
 that any such events are likely to occur, to the extent that such events are
 expected to cause or cause a significant disruption of care for hospice
 patients:

1.

An external disaster or other
 community emergency situation; or

2.

An interruption of services vital to the
 continued safe operation of a hospice facility, such as telephone, electricity,
 gas, or water services.

(b)

 The hospice must make a report of the
 event within twenty-four hours or by the next regular business day from when
 the reportable event occurred or from when the hospice has reasonable cause to
 anticipate that the event is likely to occur. The report must include: 

1.

The name of the hospice, the name of the
 hospice administrator or site manager, and a contact telephone number for
 information related to the report;

2.

The date of the event, or the anticipated
 date of the event, and the anticipated duration, if known;

3.

The anticipated effect on care and services
 for hospice patients; and

4.

Any
 immediate plans the hospice has made regarding patient management during the
 event.

(c)

 Within 45
 days of the discovery of the event, the hospice must complete an internal
 evaluation of the hospice's response to the event where opportunities for
 improvement related to the hospice's disaster preparedness plan were
 identified. The hospice must make changes to the disaster preparedness plan as
 appropriate. The complete report must be available to the Department for
 inspection at the hospice office.

(8)

 While self-reported incidents made
 through the hospice's peer review process are received by the Department in
 confidence and not considered open records, where the Department's internal
 review determines that a rule violation related to any self-reported incident
 or event has occurred, the Department shall initiate a separate complaint
 investigation of the incident. The complaint investigation report and the
 report of any rule violation compiled by the Department arising either from the
 initial report received from the hospice or an independent source shall be
 subject to disclosure in accordance with applicable laws.

Rule 111-8-37-.07 Governing Body

(1)

 The hospice must have an established and
 functioning governing body that is responsible for the conduct of the hospice
 and that provides for effective hospice governance, management, and budget
 planning.

(2)

 The governing body
 must appoint an administrator and delegate to the administrator the authority
 to operate the hospice in accordance with these rules and management policies
 established and approved by the governing body.

(3)

 The governing body must appoint a medical
 director and delegate to the medical director the authority to establish and
 approve, in accordance with current accepted standards of care, all patient
 care policies related to medical care.

(4)

 The governing body must ensure that no
 member of the governing body, administration, staff associated or affiliated
 with the hospice, or family member of staff causes, encourages or coerces any
 patient or family member of a patient to: 

(a)

 name any person associated or affiliated with the hospice as a beneficiary
 under a will, trust, or life insurance policy;

(b)

 take out or otherwise secures a life
 insurance policy on any patient; or

(c)

 give or loan anything of value to a
 member of the governing body, administration, staff associated or affiliated
 with the hospice or family member of staff.

(5)

 The governing body must be responsible
 for determining, implementing, and monitoring the overall operation of the
 hospice, including the quality of care and services, management, and budget
 planning. The governing body must:

(a)

 Be
 responsible for ensuring the hospice functions within the limits of its current
 license granted by the Department;

(b)

 Ensure that the hospice provides
 coordinated care that includes at a minimum medical, nursing, social,
 spiritual, volunteer, and bereavement services that meet the needs of the
 patients;

(c)

 Ensure that the
 hospice is staffed and equipped adequately to provide the services it offers to
 patients, whether the services are provided directly by the hospice or under
 contract;

(d)

 Develop and make
 available to patients and their families, a description of services offered by
 the hospice, including patient eligibility for the various services and whether
 the hospice provides palliative care to patients who have not been determined
 to be terminally ill but have been diagnosed with an advanced and progressive
 disease;

(e)

 Ensure the development
 and implementation of effective policies and procedures that address the
 management, operation, and evaluation of the hospice, including all patient
 care services and those services provided by independent contractors;

(f)

 Ensure there is an individual authorized
 in writing to act for the administrator during any period the administrator is
 absent;

(g)

 Appoint an individual
 to assume overall responsibility for a quality assurance, utilization, and peer
 review program for monitoring and evaluating the quality and level of patient
 care in the hospice on an ongoing basis;

(h)

 Ensure that hospice advertisements are
 factual and do not contain any element that might be considered coercive or
 misleading;

(i)

 Ensure that hospice
 care to patients who have been determined to be terminally ill is provided
 regardless of the patient or the family unit's ability to pay; and

(j)

 Ensure that there are policies and
 procedures in place that specify the manner in which transitions across care
 sites and providers (e.g. hospital to home hospice) will be handled to ensure
 that communications are effective to address continuity of care issues for the
 patient.

(6)

 The
 governing body shall comply with the Rules and Regulations for Criminal
 Background Checks, Chapter 111-8-12, as applicable.

Rule 111-8-37-.08 Administrator

(1)

 Each hospice
 must have a qualified administrator, designated by the governing body, who must
 be responsible for the ongoing and day-to-day operation of the
 hospice.

(2)

 The hospice
 administrator must be either a Georgia-licensed health care professional, who
 has at least one year of supervisory or management experience in a hospice
 setting or an individual with education, training and experience in health
 services administration and at least two years of supervisory or management
 experience in a hospice setting. The term, licensed health care professional,
 includes the following who hold Georgia licenses: physicians, nurse
 practitioners, physicians' assistants, registered professional nurses, clinical
 social workers, physical therapists and psychologists, but does not include
 practical nurses.

(3)

 The hospice
 administrator must ensure that the hospice: 

(a)

 Implements policies and procedures for
 the provision of hospice care and palliative care to persons with advanced and
 progressive diseases, if it offers such services, which have been developed
 with interdisciplinary participation from the hospice care team;

(b)

 Employs qualified staff, including
 physicians, practitioners, nurses, social workers, clergy, volunteers, or other
 persons providing services at the hospice;

(c)

 Has implemented policies and procedures
 related to the management, operation, and evaluation of the overall performance
 of the hospice;

(d)

 Has a qualified
 director of nursing services along with sufficient qualified staff to meet the
 needs of patients admitted for hospice care and palliative care, if offered to
 persons with advanced and progressive diseases but who have not been determined
 to be terminally ill, and as outlined in the patients' plans of care;

(e)

 Provides an orientation, training, and
 supervision program for every employee and volunteer that addresses hospice
 care and palliative care for persons with advanced and progressive diseases,
 when offered, and the performance of the specific job to which the employee or
 volunteer is assigned;

(f)

 Ensures
 that the staff members complete their annual training and education program;
 and

(g)

 Ensures that there are
 effective mechanisms to facilitate communication among the hospice staff,
 hospice care team, and patients, their family units, and their legal guardians,
 if any.

(4)

 The hospice
 administrator shall comply with the Rules and Regulations for Criminal
 Background Checks, Chapter 111-8-12, as applicable.

Rule 111-8-37-.09 Quality Management

(1)

 The hospice must appoint an
 interdisciplinary quality management committee that reflects the hospice's
 scope of services. The committee must develop and implement a comprehensive,
 effective and ongoing quality management, utilization, and peer review program
 that evaluates, maintains and improves the quality of patient care provided,
 including the appropriateness of the level of service received by patients, and
 submits required patient incident reports to the Department.

(2)

 The quality management, utilization, and
 peer review program must establish and use written criteria as the basis to
 evaluate the provision of patient care. The written criteria must be based on
 accepted standards of care and must include, at a minimum, systematic reviews
 of:

(a)

 Appropriateness of admissions,
 continued stay, and discharge;

(b)

 Appropriateness of professional services and level of care provided;

(c)

 Effectiveness of pain control and symptom
 relief;

(d)

 Patient injuries, such
 as those related to falls, accidents, and restraint use;

(e)

 Errors in medication administration,
 procedures, or practices that compromise patient safety;

(f)

 Infection control practices and
 surveillance data;

(g)

 Patient and
 family complaints and on-call logs;

(h)

 Inpatient hospitalizations;

(i)

 Staff adherence to the patients' plans of
 care; and

(j)

 Appropriateness of
 treatment.

(3)

 Findings
 of the quality management utilization, and peer review program must be utilized
 to correct identified problems, revise hospice policies, and improve the care
 of patients.

(4)

 There must be an
 ongoing evaluation of the quality management, utilization, and peer review
 committee to determine its effectiveness, with the results of the evaluation
 presented at least annually for review and appropriate action to the medical
 staff and the governing body.

Rule 111-8-37-.10 Patient and Family Rights

(1)

 The hospice must ensure that patients and
 their families receive hospice care and palliative care for persons with
 advanced and progressive diseases, when offered, in a manner that respects and
 protects their dignity and ensures all patients' rights to: 

(a)

 Participate in the hospice voluntarily
 and sever the relationship with the hospice at any time;

(b)

 Receive only the care and services to
 which the patient and/or the patient's family have consented;

(c)

 Receive care in a setting and manner that
 preserves the patient's dignity, privacy, and safety to the maximum extent
 possible;

(d)

 Receive hospice care
 in a manner that neither physically nor emotionally abuses the patient, nor
 neglects the patient's needs;

(e)

 Receive care free from unnecessary use of restraints;

(f)

 Receive education in the availability and
 use of the hospice's grievance process for all patients;

(g)

 Communicate grievances, concerns or
 complaints to the hospice for prompt resolution;

(h)

 Refuse any specific treatment from the
 hospice without severing the relationship with the hospice;

(i)

 Choose their own private attending
 physician, so long as the physician agrees to abide by the policies and
 procedures of the hospice;

(j)

 Exercise the religious beliefs and generally recognized customs of their
 choice, not in conflict with health and safety standards, during the course of
 their hospice treatment and exclude religion from their treatment if they so
 choose;

(k)

 Have their family unit,
 legal guardian, if any, and their patient representative present any time
 during an inpatient stay, unless the presence of the family unit, legal
 guardian, if any, or patient representative poses a risk to the patient or
 others;

(l)

 Participate in the
 development of the patient's plan of care and any changes to that
 plan;

(m)

 Have maintained as
 confidential any medical or personal information about the patient;

(n)

 Continue hospice care and not be
 discharged from the hospice during periods of coordinated or approved
 appropriate hospital admissions;

(o)

 Be provided with a description of the
 hospice care provided and levels of care to which the patient is entitled
 depending upon whether the patient is terminally ill or suffering from an
 advanced and progressive disease, and any charges associated with such
 services;

(p)

 Review, upon request,
 copies of any inspection report completed by the Department within the two
 years preceding the request;

(q)

 Make self-determinations concerning medical care, which encompass the right to
 make choices regarding life-sustaining treatment, including resuscitative
 services;

(r)

 Continue to receive
 appropriate hospice care when terminally ill without regard for the ability to
 pay for such care; and

(s)

 Have
 communication of information provided in a method that is effective for the
 patient. If the hospice cannot provide communications in a method that is
 effective for the patient, attempts to provide such shall be documented in the
 patient's medical record.

(2)

 The hospice must provide to the patient,
 the patient's representative, and/or the patient's legal guardian oral and
 written explanations of the rights of the patient and the patient's family unit
 while receiving hospice care for the terminally ill and palliative care for
 persons with advanced and progressive diseases. The explanation of rights must
 be provided at the time of admission into the hospice.

(3)

 At the time of admission, the hospice
 must provide to the patient, the patient's representative, and the patient's
 legal guardian the contact information, including the website address of the
 Department, for reporting complaints about hospice care to the
 Department.

(4)

 The hospice shall
 post the following information in a public area at the facility: 

(a)

 A copy of the patient rights as outlined
 in Rule in
 a public area at the facility; and

(b)

 Contact information, including the
 website address of the Department, for reporting complaints about hospice care
 to the Department.

Rule 111-8-37-.11 Disaster Preparedness

(1)

 Every hospice must have a current
 disaster preparedness plan that addresses potential situations where services
 to patients may be disrupted and outlines appropriate courses of action in the
 event a local or widespread disaster occurs including communications with
 patients and their families and emergency management agencies.

(2)

 The disaster preparedness plan must
 include at a minimum plan for the following emergency situations: 

(a)

 Local and widespread severe weather
 emergencies or natural disasters, such as floods, ice or snowstorms, tornados,
 hurricanes, and earthquakes;

(b)

 Interruption of service of utilities, including water, gas, or electricity,
 either within the facility or patients' homes or within a local or widespread
 area; and

(c)

 Coordination of
 continued care in the event of an emergency evacuation of the
 area.

(3)

 If the hospice
 offers residential and/or inpatient services, in addition to the procedures
 specified in paragraph (2) of this rule, the plan must also include: 

(a)

 Fire safety and evacuation procedures and
 procedures for the provision of emergency power, heat, air conditioning, food,
 and water; and

(b)

 Plans for the
 emergency transport or relocation of all or a portion of the hospice patients,
 should it be necessary, in vehicles appropriate to the patients' conditions
 when possible, including written agreements with any facilities which have
 agreed to receive the hospice's patients in such situations, and notification
 of the patients' representatives.

(4)

 The hospice must have plans to ensure
 sufficient staffing and supplies to maintain safe patient care during the
 emergency situation.

(5)

 The plan
 must be reviewed and revised annually, as appropriate, including any related
 written agreements.

(6)

 Disaster
 preparedness plans for hospice care facilities must be rehearsed at least
 annually. Rehearsals must be documented to include staff and patient
 participants, a summary of any problems identified, and the effectiveness of
 the rehearsal. In the event an actual disaster occurs in any given year, the
 hospice may substitute the actual disaster's response in place of that year's
 rehearsal.

(7)

 Hospices must
 include emergency management agencies in the development and maintenance of
 their disaster preparedness plans and also provide copies of such plans to
 those agencies as requested.

(8)

 The Department may suspend any requirements of these rules and the enforcement
 of any rules where the Governor of the State of Georgia has declared that a
 state of emergency or disaster exists as a result of a public health
 emergency.

Rule 111-8-37-.12 Infection Control

The hospice must have an effective infection control program
 designed to reduce the transmission of infections in patients, health care
 workers, caregivers, families, visitors and volunteers.

(a)

 The hospice must develop an infection
 control surveillance plan that is tailored to meet the needs of the hospice and
 the hospice patients and includes both outcome and process
 surveillance.

(b)

 The hospice must
 develop and implement effective policies and procedures that address infection
 control issues in all components of the hospice. These policies and procedures
 shall be based on accepted standards of infection control, approved by the
 administrator and the medical director, and shall address at least the
 following: 

1.

Hand hygiene;

2.

Wound care;

3.

Urinary tract care;

4.

Respiratory therapy;

5.

Enteral therapy;

6.

Infusion therapy;

7.

Cleaning, disinfecting, and sterilizing
 patient care equipment;

8.

Isolation
 precautions;

9.

Handling, transport,
 and disposal of medical waste and laboratory specimens;

10.

Requirements for initial and annual health
 screenings for staff, including tuberculosis surveillance and required
 immunizations;

11.

Use of personal
 protective equipment and exposure reporting/follow-up;

12.

Work restrictions for staff with
 potentially infectious diseases;

13.

Evaluation of the patient and the home
 environment related to infection control risks;

14.

Outbreak investigation
 procedures;

15.

Dietary practices in
 hospice care facilities; and

16.

Reporting of communicable diseases, as
 required by law.

(c)

 The
 infection control program must be evaluated at least annually to ensure
 effectiveness of the program related to the prevention of the transmission of
 infections to patients, health care workers, caregivers, families, visitors and
 volunteers.

Rule 111-8-37-.13 Human Resources

(1)

 All persons providing services for a
 hospice must be qualified by education, training, and experience to carry out
 all duties and responsibilities assigned to them.

(2)

 All persons providing services for a
 hospice must receive an orientation to the hospice to include, but not be
 limited to:

(a)

 Hospice concepts and
 philosophy;

(b)

 Patient rights
 including abuse reporting requirements; and

(c)

 Hospice policies and procedures,
 including, but not limited to, disaster preparedness, fire safety and emergency
 evacuations, and reporting abuse and neglect.

(3)

 Where a patient does not have a
 do-not-resuscitate order, the hospice must ensure that all persons providing
 hands-on care directly to that patient on behalf of the licensed hospice have
 current certification in basic cardiac life support (BCLS) or cardiopulmonary
 resuscitation.

(4)

 The hospice must
 have an effective annual training and education program for all staff and
 volunteers who provide hands-on care to patients that addresses at a minimum: 

(a)

 Emerging trends in infection
 control;

(b)

 Recognizing abuse and
 neglect and reporting requirements;

(c)

 Patient rights; and

(d)

 Palliative care.

(5)

 The administrator and each staff member
 and volunteer who has direct contact with patients or their family units must
 receive an initial and annual health screening evaluation, performed by a
 licensed health care professional in accordance with accepted standards of
 practice, sufficient in scope to ensure that the staff and volunteers screened
 are free of communicable and health diseases that pose potential risks to
 patients, their family units, and other staff and volunteers.

(6)

 Human resource files must be maintained
 for the following individuals delivering any services associated with the
 written plan of care: each staff member, independent contractor, and volunteer.
 The files must contain the person's application, employment history, emergency
 contact information, evidence of qualifications, job description, evidence of
 initial and annual health screening, yearly skills competency assessments,
 evidence of verified licensure or certification, and criminal record check as
 appropriate, and evidence of orientation, education, and training. These files
 must be available for inspection by the appropriate enforcement authorities on
 the premises.

(7)

 Where the hospice
 contracts with a staffing agency to provide any services specified in a plan of
 care, the written contract must require the contracting agency to verify
 licensing credentials, where applicable, of contract workers to ensure that
 such workers meet the same qualifications and licensure requirements as
 specified for hospice employees providing such services directly. The hospice
 must retain a copy of the contract.

(8)

 The hospice must comply with the Rules
 and Regulations for Criminal Background Checks, Chapter 111-8-12, with respect
 to direct access employees and maintain documentation of a satisfactory
 fingerprint criminal record check determination in the individual's personnel
 file.

Rule 111-8-37-.14 Admissions, Discharges, and Transfers

(1)

Admissions.
 The hospice must
 not admit any patients unless the hospice believes that it is capable of
 meeting the care needs of the patients. The hospice must have written criteria
 that address the eligibility for admission into home hospice care, residential,
 or inpatient hospice care and palliative care for persons with advanced and
 progressive diseases, if such palliative care is offered.

(2)

Terminally Ill Patient Admissions
 for Home Care
. The hospice program offered to terminally ill patients in
 their homes must admit only patients that meet the following minimum criteria: 

(a)

 The patient has a referral from a
 physician who has personally evaluated the patient and diagnosed the patient as
 terminally ill, where the medical prognosis is less than six months of life if
 the terminal illness takes its normal course, and in need of hospice
 care;

(b)

 The patient has received
 from the hospice an initial assessment, performed by an appropriate
 representative of the hospice care team, that reflects a reasonable expectation
 that the patient's medical, nursing, and psychological needs can be met
 adequately by the hospice and further reflects that the patient has a need for
 and can benefit from hospice care;

(c)

 The patient has been given a description
 of the scope of services and has personally or through an authorized patient
 representative given informed consent in writing to receive hospice
 care;

(d)

 The patient has been
 certified in writing by the hospice to have an anticipated life expectancy of
 six months or less if the terminal illness takes its normal course;

(e)

 The patient lives within the hospices
 service area; and

(f)

 The patient
 has identified a primary caregiver. In the absence of a primary caregiver, the
 hospice must develop a detailed plan for meeting the daily care and safety
 needs of the patient.

(g)

 The
 hospice must ensure the development of an initial plan of care, within 24 hours
 of admission to the hospice, based on the initial assessment and with
 appropriate input from a physician or registered nurse to meet the immediate
 needs of the patient.

(h)

 The
 hospice must ensure that no terminally ill patient is excluded from
 participation in or denied benefits of any hospice care because of an inability
 to pay for such hospice care.

(3)

Inpatient Hospice
 Admissions.
 Hospices must admit to acute inpatient hospice care only
 those terminally ill patients who meet the following criteria: 

(a)

 The patient has an order from a physician
 to be transferred to inpatient status and requires any of the following: 

1.

Nursing care supervised by a registered
 nurse that cannot feasibly be provided in another hospice setting;

2.

Procedures that are necessary for pain
 control or acute or chronic symptom management;

3.

Medication adjustment, observation, or
 other stabilizing treatment; or

4.

Psycho-social monitoring; or

(b)

 Respite care.

(4)

Residential Hospice
 Admissions.
 In addition to the home care admissions, hospices that elect
 to offer residential services must admit to a residential facility only those
 terminally ill patients who do not require acute management of symptoms or
 stabilization in an inpatient care setting and who meet the following criteria:

(a)

 The patient lacks a sufficient number of
 capable and willing caregivers; or

(b)

 The patient's care needs are too complex
 and difficult for non-medical caregivers to perform confidently; or

(c)

 The patient's primary home is not
 suitable or available and/or the home cannot be adapted to meet the patient's
 needs; or

(d)

 The patient has no
 other home available or desires not to live at home.

(5)

Palliative Care Admission
 Requirements
. Hospices that elect to provide palliative care to persons
 with advanced and progressive diseases in any setting, other than an inpatient
 or residential hospice, must admit only those persons who meet the following
 criteria:

(a)

 have an order from a physician
 indicating the patient has an advanced and progressive disease;

(b)

 request the intervention of a hospice
 care team to alleviate suffering and achieve relief from physical, emotional or
 spiritual symptoms of distress to achieve the best quality of life for the
 person and his or her family; and

(c)

 have stated needs that the hospice
 believes it has the capability to meet.

(6)

Discharge Requirements.

(a)

 Once a hospice admits a patient who is
 terminally ill for hospice care, the hospice at its discretion must not
 discharge the patient unless either the patient freely and voluntary requests
 the discharge or the hospice determines that an involuntary discharge is
 necessary in accordance with these rules.

(b)

 No hospice is permitted to require or
 demand that a terminally ill patient request voluntary discharge from the
 hospice or require or demand a hospice patient to execute a request for
 voluntary discharge from the hospice as a condition for admission or continued
 care.

(c)

 In situations where the
 hospice identifies issues where the safety of the terminally ill patient, the
 patient's family unit, or a hospice staff member or volunteer is compromised,
 the hospice must make every effort to resolve the issues before considering the
 option of involuntary discharge.

1.

All such
 efforts for resolution by the hospice must be documented in the patient's
 record.

2.

If involuntary discharge
 is the elected option, the hospice must give no less than 14 days' notice of
 discharge to the terminally ill patient and the patient's representative,
 except in cases of imminent danger or immediate peril to the terminally ill
 patient, other terminally ill patients, or staff.

3.

The hospice must notify the Department of
 the pending involuntary discharge of a terminally ill patient at the time of
 patient notification.

(d)

 No terminally ill patient receiving
 hospice care may be discharged due to inability to pay for the hospice
 services.

(e)

 No hospice is
 permitted to discontinue hospice care for a terminally ill patient, nor
 discharge or transfer the patient, during a period of coordinated or approved
 appropriate hospital admission for the treatment of conditions related to the
 patient's terminal illness or any other condition.

(f)

 Hospices must assist in coordinating
 continued care should any hospice patient be transferred or discharged from the
 hospice.

Rule 111-8-37-.15 Assessment and Plan of Care

(1)

 The hospice must designate a hospice care
 team for each patient admitted by the hospice. The hospice care team must be
 composed of individuals who provide or supervise the care and services offered
 by the hospice.

(2)

 The hospice
 care team must include at least the following individuals: 

(a)

 A physician;

(b)

 A registered nurse;

(c)

 A social worker;

(d)

 A member of the clergy or other
 counselors; and

(e)

 Volunteers.

(3)

 The
 appropriate members of the hospice care team must provide a comprehensive
 assessment, as dictated by the identified needs of the patient, no later than
 five days after admission that includes at least medical, nursing,
 psychosocial, and spiritual evaluations of the patient, as well as the
 capability of the family unit in meeting the care needs of the patient and the
 need for bereavement services. 

(a)

 The
 assessment must be designed to trigger identification of any referral needed by
 the patient for additional services, including at a minimum: 

1.

Professional counseling;

2.

Spiritual counseling by a member of the
 clergy or other counselor;

3.

Bereavement services;

4.

Dietitian services; and

5.

Other therapeutic services, as
 needed.

(b)

 If
 additional services are identified for a terminally ill patient, the hospice
 must ensure that those services are provided by qualified individuals who must
 be added to the patient's hospice care team. Such qualified individuals
 include, but are not limited to:

1.

Other
 appropriately licensed counselors, as applicable to the patient's needs;
 and

2.

Volunteers who provide
 services for the patient.

(4)

 Based on the results of the assessment of
 the patient, the hospice care team must:

(a)

 Establish the plan of care; and

(b)

 Provide and supervise hospice care and services in accordance with accepted
 standards of care and the plan of care.

(5)

 The hospice care team must establish and
 maintain a written plan of care for each patient prior to providing care. 

(a)

 The plan of care must be developed with
 the input of the patient, the patient's family unit if designated by the
 patient, the patient's caregivers where the patient resides in a licensed
 facility, and the patient's representative, if any.

(b)

 The plan of care must detail the scope
 and frequency of services to be provided to meet the needs of the patient and
 the patient's family unit.

(c)

 The
 hospice care team must meet as a group to review each terminally ill patient's
 plan of care. The plan of care must be reviewed and updated as the patient's
 condition changes and as additional service needs are identified. The plan of
 care for terminally ill patients must be reviewed and updated at intervals of
 no more than 15 days. All reviews and updates shall be documented in the
 patient's medical record. Plans of care for patients receiving palliative care
 who have not been determined to be terminally ill will be reviewed and updated
 as the patient's condition changes or the patient requests additional
 services.

(d)

 Documentation of plan
 of care review for the terminally ill patient must include a record of those
 participating and must also include evidence of the attending physician's
 opportunity to review and approve of any revised plans of care. In the absence
 of the attending physician's written approval of the revised plan of care, the
 revised plan of care must have the written approval of the medical
 director.

(6)

 The
 hospice care team must ensure that the patient receives treatment free from
 restraints, unless use of such restraints has been determined by a physician to
 be necessary for a temporary period to protect the patient from injury. 

(a)

 Prior to using any restraint with a
 patient, the hospice care team must attempt less restrictive measures to
 accomplish the patient's treatment while affording the patient the maximum
 amount of personal freedom possible. The hospice must document the attempts at
 use of such less restrictive measures in the patient's medical
 record.

(b)

 If it is determined
 that restraints are necessary to prevent patient injury: 

1.

The hospice must obtain and document
 consent, specific to the type of restraint proposed, from the patient and/or
 the patient's representative for use of the restraint and such consent shall be
 obtained prior to the use of the restraint;

2.

There must be a physician's order for the
 restraint, specifying the type of restraint to be used and the circumstances
 under which the restraint is to be applied, which is subject to the following
 conditions:

(a)

 The physicians order must be
 time limited; and

(ii)

 The order for the
 restraint must be re-evaluated prior to subsequent orders for the
 restraint;

3.

The plan of care for the patient must
 include the plan and standard of care for use of the restraint, including the
 type and frequency of monitoring of the patient when the restraint is used. The
 plan must include maximum duration for each restraint application, with
 mandatory release at least every two hours, and a requirement that time, date,
 and duration of each restraint application are recorded and
 documented;

4.

The plan of care must
 include procedures to ensure that the patient's comfort and safety needs are
 addressed during any period of restraint use;

5.

The hospice must ensure safe and proper
 application and monitoring of the use of the restraint by adequately training
 staff and evaluating competency of each staff member treating patients in the
 use of the restraint and by directly observing staff performance with patients;
 and

6.

The hospice staff must
 provide training to other patient caregivers in safe and proper use and
 monitoring of the restraint. Such training must be documented in the patient's
 medical record.

(c)

 A
 positioning or securing device utilized during medical treatment procedures to
 temporarily maintain the patient's position or immobilize the patient will not
 be considered a restraint, provided such necessity is documented in the
 patient's plan of care and the physician orders it. Such devices must only be
 applied by trained nursing or medical personnel and the plan of care must
 require monitoring sufficient to ensure the patient's safety.

Rule 111-8-37-.16 Home Care

(1)

 The hospice must provide home care
 services to patients primarily in the patients' home. At least 51 percent of
 the total of all hospice care days, delivered by the hospice in the fiscal year
 to terminally ill patients must be delivered in the homes of the terminally ill
 patients.

(2)

 During home care
 visits, the hospice employee must provide continuing education for the patient
 and the patient's primary caregiver regarding the progression of the patient's
 illness and the patient's care needs.

(3)

 If, during the home care visit, there are
 observed or communicated significant changes in the patient's condition or
 needs, or if the hospice employee or volunteer observes that the patient's
 primary caregiver cannot provide the continuing support and care the patient
 requires, such findings must be communicated to the patient's hospice care team
 in a sufficiently timely manner to ensure that the patient's care and safety
 needs are addressed.

(4)

 When
 hospice services are provided to a patient who is a resident of a licensed
 nursing home, licensed intermediate care home, licensed personal care home or
 licensed assisted living community, or another licensed hospice operating an
 inpatient unit, there must be written communication evidencing an understanding
 between the hospice and the licensed facility that makes clear that the hospice
 takes full responsibility for professional management of the patient's hospice
 care and that the licensed nursing home, licensed intermediate care home,
 licensed personal care home or licensed assisted living community takes
 responsibility for the other services the patient needs or receives that the
 licensed facility is authorized to provide. 

(a)

 The written communication must clearly
 specify the patient-care activities and responsibilities that will be performed
 by the hospice employees and volunteers and those patient care tasks that will
 be performed by employees of the facility where the hospice patient resides.
 Hospice employees and volunteers must provide those services for which they are
 assigned responsibility in the hospice's plan of care for the
 patient.

(b)

 The written
 communication must specify an individual from the hospice and an individual
 from the facility where the patient resides who shall be responsible for
 communication between services providers regarding each patient's treatment and
 condition and for addressing any care issues. Such communication must be
 ongoing throughout the period of hospice service provision and must be
 documented in the patient's hospice medical record.

(c)

 The hospice must provide a copy of any
 self-determination documentation to the licensed nursing home, licensed
 intermediate care home, licensed personal care home or licensed assisted living
 community where the patient resides and must communicate with the facility as
 to the procedure for the appropriate implementation of any advance directive or
 physician's order for life sustaining treatment.

(5)

 If the hospice does not offer inpatient
 services directly, the hospice must have a contractual agreement with a
 licensed hospital, a licensed skilled nursing facility, or a licensed inpatient
 hospice for the provision of short-term, acute inpatient care and respite care
 for hospice patients.

(6)

 The
 hospice must arrange for transport services when necessary to transport hospice
 patients to and from inpatient hospice care.

Rule 111-8-37-.17 Medical Services

(1)

 Medical services must be under the
 direction of the medical director. In addition to palliation and management of
 the terminal illness and related conditions, physicians of the hospice,
 including the physician members of the hospice care team, must also address the
 basic medical needs of the patients to the extent that such needs are not met
 by each patient's attending physician or other physician of the patient's
 choice.

(2)

Medical
 Director.
 The medical director for the hospice must be a physician
 licensed to practice in this state and must have at least one year of
 documented experience on a hospice care team or in another setting managing the
 care of terminally ill patients. The medical director must: 

(a)

 Be either an employee of the hospice or
 work under a written agreement with the hospice;

(b)

 Have admission privileges at one or more
 hospitals commonly serving patients in the hospice's geographical
 area;

(c)

 Be responsible for the
 direction and quality of the medical component of the care provided to patients
 by the hospice care team, including designating a licensed physician, employed
 by the hospice or working under a written agreement, to act on his or her
 behalf in the medical director's absence;

(d)

 Participate in the interdisciplinary plan
 of care reviews, patient case review conferences, comprehensive patient
 assessment and reassessment, and the quality improvement and utilization
 reviews;

(e)

 Review the clinical
 material of the patient's attending physician that documents basic disease
 process, prescribed medicines, assessment of patient's health at time of entry
 and the drug regimen;

(f)

 Ensure
 that each terminally ill patient receives a face-to-face assessment, by either
 the medical director or the terminally ill patient's attending physician, or is
 measured by a generally accepted life-expectancy predictability scale for
 continued admission eligibility at least every six months, as documented by a
 written certification from the medical director or the terminally ill patient's
 attending physician that includes:

1.

The
 statement that the terminally ill patient's medical prognosis is for a life
 expectancy of six months or less if the terminal illness runs its natural
 course;

2.

The specific current
 clinical finding and other documentation supporting a life expectancy of six
 months or less if the illness takes its natural course for the terminally ill
 patient; and

3.

The signature of the
 physician.

(g)

 Communicate with each patient's attending physician and act as a consultant to
 attending physicians and other members of the hospice care team;

(h)

 Help to develop and review policies and
 procedures for delivering care and services to the patients and their family
 units;

(i)

 Serve on appropriate
 committees and report regularly to the hospice administrator regarding the
 quality and appropriateness of medical care;

(j)

 Ensure written protocols for symptom
 control and medication management are available; and

(k)

 Assist the administrator in developing,
 documenting and implementing a policy for discharge of patients from hospice
 care.

(3)

 In addition to
 the hospice medical director, the hospice may appoint additional hospice
 physicians who shall assist the medical director in the performance of his or
 her duties, as prescribed by the hospice.

(4)

 The medical director must assist the
 administrator in developing, documenting, and implementing effective policies
 and procedures for the delivery of physicians' services, for orientation of new
 hospice physicians, and for continuing training and support of hospice
 physicians. These policies and procedures must: 

(a)

 Ensure that a hospice physician is
 on-call 24 hours a day, seven days a week; and

(b)

 Provide for the review and evaluation of
 clinical practices within home care, residential, and inpatient hospices in
 coordination with the quality management, utilization, and peer review
 committee.

(5)

 Verbal
 orders for medications and controlled substances shall only be given to
 appropriately licensed staff members, acting within the scope of their
 licenses, and must be immediately recorded, signed, and dated by the licensed
 staff member receiving such order.

(a)

 The
 individual receiving the order shall immediately repeat the order and the
 prescribing physician must verify that the repeated order is correct. The
 individual receiving the order must document in the patient's medical record
 that the order was "repeated and verified."

(b)

 The hospice must provide a written copy
 of the order to the prescribing physician within 24 hours of such order or by
 the end of the next business day.

Rule 111-8-37-.18 Nursing Services

(1)

 The hospice shall have a system to make
 available nursing services 24-hours a day, seven days a week to meet the needs
 of the patients. 

(a)

 A registered nurse must
 be available at all times to provide or supervise the provision of nursing
 care.

(b)

 On-site nursing services
 must be made available within one hour of notification where the terminally ill
 patient and the patient with an advanced and progressive disease who has
 contracted for nursing services experiences a symptom-management crisis
 situation.

(c)

 The hospice must
 maintain an on-call log for all calls received after normal business hours, the
 records of which shall be kept for a period of two years.

(2)

 The hospice must designate a director of
 nursing who must be a Georgia-licensed registered nurse and who must be
 responsible for implementing a system for delivery, supervision, and evaluation
 of nursing and personal care services.

(a)

 The
 director of nursing must establish and implement effective policies and
 procedures for nursing and personal care services based on generally accepted
 standards of nursing practice.

(b)

 The director of nursing must ensure that nursing personnel are oriented to
 nursing policies and procedures and are qualified and competent for their
 assigned duties.

(c)

 The director
 of nursing must ensure the types and numbers of nursing personnel necessary to
 provide appropriate nursing care for each patient in the hospice.

(d)

 The director of nursing must ensure
 patient assignments are made that reflect a consideration of patient needs as
 well as nursing staff qualifications and competencies.

(3)

 Nursing staff must administer medications
 and other treatments in accordance with the physicians' orders, generally
 accepted standards of practice, and any federal and state laws pertaining to
 medication administration.

(4)

 When
 a patient who is terminally ill or whose death is anticipated and who is
 receiving hospice care from a licensed hospice dies, a physician assistant, a
 nurse practitioner, or a registered professional nurse licensed in this state
 and employed by the hospice at the time of the apparent death of such person,
 may make the determination and pronouncement of the patient's death in the
 absence of an attending physician. Such determination or pronouncement shall be
 made in writing on a form approved by the Department.

(5)

Personal Care Services.

 Personal care services must be available and provided in all components of the
 hospice to meet the needs of patients. The hospice may utilize licensed nurses
 or qualified personal care aides for the provision of personal care services. 

(a)

 Personal care aides considered qualified
 by training and experience to provide services to patients include: 

1.

 Georgia Certified Nursing Aides with
 current certification as such; or

2.

 Individuals who have completed and can
 provide validation or documentation of completion of a home health aide
 training and competency evaluation program conducted in a Medicare-certified
 home health agency; or

3.

 Individuals who have successfully completed a personal care aide-training
 program, provided by the hospice under the direction of a registered nurse,
 which meets the following requirements: 

(i)

 The personal care aide-training program must be conducted through classroom and
 supervised practical training totaling at least 75 hours;

(ii)

 At least 16 of the 75 hours of training
 shall be devoted to supervised practical training;

(iii)

 The individual being trained must
 complete at least 16 hours of classroom training before beginning the
 supervised practical training;

(iv)

 Supervised practical training must be provided either in a laboratory setting
 or in one of the components of the hospice in which the trainee demonstrates
 knowledge while performing tasks on an individual or patient under the direct
 supervision of a registered nurse or licensed practical nurse; and

(v)

 The personal care aide-training program
 must address each of the following subject areas: 

(I)

 Communications skills;

(II)

 Observation, reporting, and
 documentation of patient status and the care or service furnished;

(III)

 Reading and recording temperature,
 pulse, and respiration;

(IV)

 Basic
 infection control procedures;

(V)

 Basic elements of body functioning and changes in body function that must be
 reported to an aide's supervisor;

(VI)

 Maintenance of a clean, safe, and
 healthy environment;

(VII)

 Recognizing emergencies and knowledge of emergency procedures;

(VIII)

 The physical, emotional, and
 developmental needs of and ways to work with the populations served by the
 hospice, including the need for respect for the patient, the patient's privacy,
 and the patient's property;

(IX)

 Appropriate and safe techniques in personal hygiene and grooming that include: 

I.

 Bed bath;

II.

 Sponge, tub, or shower bath;

III.

 Shampooing in the sink, tub, or
 bed;

IV.

 Nail and skin care;

V.

 Oral hygiene; and

VI.

 Toileting and
 elimination;

(X)

 Safe
 transfer techniques and ambulation;

(XI)

 Normal range of motion and
 positioning;

(XII)

 Adequate
 nutrition and fluid intake, including preparing and assisting with
 eating;

(XIII)

 Any other task that
 the hospice may choose to have the personal care aide perform, as authorized by
 law; and

(XIV)

 Patient rights,
 including effectuating advance directives and abuse reporting
 requirements.

(b)

 Prior to providing care independently to
 patients, a registered nurse must observe personal care aides actually
 delivering care to patients and complete an initial competency evaluation for
 all personal care tasks assigned to the aide.

(c)

 Personal care aides must receive at least
 12 hours of continuing education annually regarding applicable aspects of
 hospice care and services.

(d)

 A
 registered nurse must prepare for each personal care aide written instructions
 for patient care that are consistent with the interdisciplinary plan of care
 and must make and document supervisory visits to the terminally ill patient's
 residence or living facility at least every two weeks to assess the performance
 of the personal care aide services.

(e)

 At least annually, there must be written
 evidence for each personal care aide that reflects that the personal care
 aide's performance of required job tasks was directly observed by a registered
 nurse and such performance was determined to be competent for all job tasks
 required to be performed.

Rule 111-8-37-.19 Other Services

Hospices must make supportive services available to both the
 patient and the patient's family unit, including, but not limited to,
 bereavement services provided both prior to and after the patient's death, as
 well as spiritual counseling and any other counseling services identified in
 the interdisciplinary plan of care for the patient and the patient's family
 unit.

(a)

Bereavement
 Services.
 Hospices must have an organized program for the provision of
 bereavement services under the supervision of a licensed professional counselor
 or licensed social worker or other professional determined, in compliance with
 applicable laws, to be qualified by training and education to provide the
 required supportive services. Bereavement services must be a part of the
 interdisciplinary plan of care and shall address the needs of the patient and
 the patient's family unit, the services to be provided, and the frequency of
 services. Bereavement services, including educational and spiritual materials
 and individual and group support services, must be available to the terminally
 ill patient's family unit for a period of at least one year following the
 terminally ill patient's death. Hospices must maintain documentation of all
 bereavement services.

(b)

Spiritual Counseling.
 Hospices must make available spiritual
 counseling and must notify patients and patients' family units as to the
 availability of clergy. In the delivery of spiritual counseling services,
 hospices must not impose any value or belief system on the patient or the
 patient's family unit.

(c)

Other Counseling. 
Additional counseling for the patient or the
 patient's family unit may be provided by other qualified members of the hospice
 care team as well as by other qualified professionals in accordance with state
 practice acts. Such counseling includes, but is not limited to, access to a
 licensed clinical social worker or professional counselor for the provision of
 counseling to the patient or the patient's family unit or primary caregiver on
 a short-term basis to resolve assessed clear or direct impediments to the
 treatment of the patient's medical condition.

(d)

Physical Therapy, Occupational
 Therapy, and Speech Language Pathology Services. 
Physical therapy
 services, occupational therapy services, and speech language pathology services
 must be available to the patient and, when provided, offered by qualified
 personnel, in accordance with state practice acts, in a manner consistent with
 accepted standards of practice.

(e)

Dietary and Nutritional Services. 
 Dietary and nutritional
 services, as required, must be available to all patients in all components of
 hospice care and provided or supervised by a licensed dietitian. Hospices must
 develop, document, and implement effective written policies and procedures for
 dietary and nutritional services.

Rule 111-8-37-.20 Volunteer Services

(1)

 The hospice must establish a program that
 utilizes volunteers to provide services to terminally ill patients and family
 units in accordance with patients' plans of care and/or to provide
 administrative support services for the hospice.

(2)

 The hospice must designate a coordinator
 of volunteer services who assists the administrator in developing, documenting,
 and implementing a volunteer services program.

(3)

 The hospice volunteer coordinator must
 establish and implement effective written policies and procedures relating to
 volunteer services. These policies and procedures must address at a minimum: 

(a)

 Recruitment and retention;

(b)

 Screening;

(c)

 Orientation;

(d)

 Scope of function;

(e)

 Supervision;

(f)

 Basic infection control;

(g)

 Ongoing training and support;
 and

(h)

 Documentation of volunteer
 activities; and

(i)

 Patient rights
 and reporting abuse and other serious incidents.

(4)

 Volunteer services must be provided
 without compensation.

Rule 111-8-37-.21 Pharmaceutical Services

(1)

 The hospice must provide for the
 procurement, storage, administration, and destruction of drugs and biologicals
 utilized for hospice care in accordance with accepted professional principles
 and in compliance with all applicable state and federal laws.

(2)

 The hospice must: 

(a)

 Ensure medication and pharmacy procedures
 are approved by a licensed pharmacist who is either employed directly or has a
 formal arrangement with the hospice;

(b)

 Ensure the availability of a licensed
 pharmacist on a 24-hour per day basis to advise the hospice staff regarding
 medication issues and to dispense medications;

(c)

 Ensure that any emergency drug kit placed
 in the hospice is in accordance with all applicable laws and rules and
 regulations:

(d)

 Ensure that drugs
 and biologicals are labeled in accordance with current accepted standards of
 practice;

(e)

 Ensure effective
 procedures for control and accountability of all drugs and biologicals
 throughout the hospice, including records of receipt, disposition, destruction,
 and reconciliation of all controlled substances and dangerous drugs;
 and

(f)

 Ensure that only licensed
 nurses or physicians, acting within the scope of their licenses, administer
 medications on behalf of the hospice, except for liquid morphine administered
 in accordance with O.C.G.A. § 
31-7-12.2(g)(7)(G)
.

(3)

 In the event of special circumstances
 under which the hospice is unavailable to administer liquid morphine to a
 hospice patient residing in an assisted living community, the hospice may train
 a certified medication aide at the community to administer the medication,
 subject to the following requirements: 

(a)

 The patient is under a physician's written order that contains specific
 instructions for indication, dosage, frequency and route of
 administration;

(b)

 The initial
 dose is administered by a licensed hospice health care professional;

(c)

 The hospice provides adequate training to
 ensure that the medication aide who will be administering the liquid morphine
 can do so safely and properly;

(d)

 The morphine administration training is repeated at least on an annual basis to
 ensure continuing competency; and

(e)

 The hospice maintains documentation of
 compliance with these requirements.

Rule 111-8-37-.22 Medical Supplies

The hospice must make available sufficient medical supplies
 and equipment for the palliative care and management of the illness or
 conditions directly attributable to the terminal diagnosis of terminally ill
 patients.

(a)

 If the hospice directly
 provides medical supplies and equipment, the hospice must: 

1.

Develop and implement effective policies
 and procedures to maintain the supplies and equipment in good working order per
 the manufacturers' recommendations;

2.

Ensure the safe handling and storage of
 supplies and equipment to ensure function and cleanliness;

3.

Instruct the caregiver on the use and
 maintenance of the equipment; and

4.

Replace supplies and equipment as essential
 for the care of terminally ill patients.

(b)

 If the hospice contracts for medical
 supplies and equipment services, the hospice must ensure that contract
 agreements include requirements consistent with subparagraph (a) of this rule
 and must ensure that contractors adhere to such agreements.

Rule 111-8-37-.23 Medical Records

(1)

 In accordance with accepted standards of
 practice, the hospice must establish and maintain a medical record for every
 patient admitted for care and services. The medical record must be complete,
 promptly and accurately documented, readily accessible, and systematically
 organized to facilitate retrieval and to support the provision of patient
 care.

(2)

 Entries must be made for
 all services provided and must be signed and dated on the day of delivery by
 the individual providing the services for inclusion in the patient's medical
 record within seven days. The record must include all services whether
 furnished directly or under arrangements made by the hospice.

(3)

 Each patient's medical record must
 contain: 

(a)

 Identification data;

(b)

 The initial and subsequent
 assessments;

(c)

 Pertinent medical
 and psychosocial history;

(d)

 Consent and authorization forms;

(e)

 The interdisciplinary plan of
 care;

(f)

 The name of the patient's
 attending physician; and

(g)

 Complete documentation of all services and events, including evaluations,
 treatments, progress notes, transfers, discharges, etc.

(4)

 The hospice must have the patient's
 medical record readily accessible and must safeguard the medical record against
 loss, destruction, and unauthorized use.

(5)

 Medical records must be preserved as
 original records, microfilms, or other usable forms and must be such as to
 afford a basis for complete audit of professional information. Hospices must
 retain all medical records at least until the sixth anniversary of the
 patient's death or discharge, and as otherwise required by law. If the patient
 is a minor, medical records must be retained for at least five years past the
 age of majority or, in the event the minor patient dies, for at least five
 years past the year in which the patient would have reached the age of
 majority. In the event the hospice ceases operation, the hospice must provide
 prior notice to the local community, referring providers and the Department of
 the location of the medical records and how such records may be
 retrieved.

Rule 111-8-37-.24 Hospice Care Facilities

(1)

 Hospices providing home care services may
 establish, as optional services, small home-like residential facilities or
 units, in order to provide 24-hour non-acute palliative hospice care, and/or
 inpatient units, in order to provide short-term, 24-hour acute hospice care to
 terminally ill hospice patients. Residential hospices built, or undergoing
 major renovations after the effective date of these rules must meet the
 Facility Guidelines Institute, Guidelines for Design and Construction of
 Residential Health, Care, and Support Facilities, including the provisions
 specifically applicable to hospices.

(2)

 The environment of the hospice care
 facility must be designed, equipped, and maintained in accordance with
 applicable life safety code requirements to provide for the comfort, privacy,
 and safety of no more than 25 patients and family members in any one
 self-contained, home-like unit. A hospice may operate multiple self-contained,
 home-like units of no more than 25 beds each, either at the same location or
 separate locations, provided that each unit is fully staffed to meet the needs
 of the hospice patients in that unit, the locations are within 35 miles of the
 principal location and the governing body does not have a history of poor
 compliance with licensure requirements. Hospice care facilities, whether
 residential, inpatient, or residential and inpatient facilities, must provide: 

(a)

 An emergency power source capable of
 providing electrical service for communication systems, alarm systems, egress
 lighting, and patient care areas;

(b)

 Décor and room configuration that is
 home-like in design and function;

(c)

 Space accommodations, other than patient
 rooms, for private patient/family visiting and grieving;

(d)

 Accommodations for at least one family
 member to remain with the patient throughout the night;

(e)

 Separate restrooms for staff and public
 use;

(f)

 A program to inspect,
 monitor and maintain biomedical, electrical equipment in proper and safe
 working order;

(g)

 Procedures that
 prevent infestations of insects, rodents, or other vermin or vectors;

(h)

 Security procedures sufficient for the
 protection of patients;

(i)

 Procedures for the safe management of medical gases;

(j)

 Procedures for infection control,
 including isolation of patients, in accordance with accepted
 standards;

(k)

 An environment that
 is clean, in good repair, and designed and equipped to minimize the spread of
 infection;

(l)

 Adequate lighting,
 ventilation, and control of temperature and air humidity; and

(m)

 An alternative power source to support
 the needs of the patients.

(3)

 Patient rooms and bathrooms must be
 designed and equipped to allow for easy access to the patient and for the
 comfort and safety of patients.

(4)

 Each residential and/or inpatient hospice care facility must provide rooms
 that:

(a)

 Measure at least 100 square feet for
 a single patient room or 80 square feet for each patient for a multi-patient
 room;

(b)

 Are private rooms, unless
 consent for a roommate is obtained and then only if the following requirements
 are met: 

1.

The hospice must provide an
 alternative temporary accommodation for a patient whose roommate is in a crisis
 situation;

2.

In no case shall more
 than two patients share a room;

(c)

 Are equipped with a bathroom with an
 adequate supply of hot water and with automatically regulated temperature
 control of the hot water;

(d)

 Are
 at or above grade level and have a window to the outside;

(e)

 Contain a suitable bed and mattress for
 each patient, suitable furniture that allows family to remain in the room
 overnight, chairs for seating, and closets or furniture for storage of personal
 belongings;

(f)

 Are equipped with a
 system for patients to summon for assistance when needed;

(g)

 Are equipped with a telephone in each
 room or telephones located in private areas convenient to bedrooms;
 and

(h)

 Have an adequate amount of
 clean bed linens, towels, and washcloths.

(5)

 In addition to complying with all other
 requirements of these rules and regulations, each facility that is newly
 constructed or expands its existing facility after the date these rules and
 regulations take effect shall also provide a tub or shower in each patient
 room.

(6)

 In addition to the
 hospice's applicable home-care policies and procedures, hospice care facilities
 must develop and implement additional policies and procedures for post-mortem
 care and for pronouncement of deaths, in accordance with applicable
 law.

(7)

 Hospice care facilities
 must have policies regarding smoking which apply to employees, volunteers,
 patients, and visitors.

(8)

 Hospice
 care facilities must ensure adequate staff are on duty at all times in order to
 meet the needs of patients, in accordance with patients' plans of care and in
 accordance with accepted standards of nursing and hospice care. Residential
 and/or inpatient hospice care facilities must provide: 

(a)

 At least two staff members on duty 24
 hours per day, seven days per week, with additional staff as needed to meet the
 needs of patients; and

(b)

 A
 registered nurse must direct and supervise all patient care in accordance with
 the needs of patients and the individual plans of care. 

1.

Residential hospice care facilities may
 utilize licensed practical nurses for patient care provided that a registered
 nurse supervises the care and is available on call at all times.

2.

Inpatient hospice care facilities must have
 a registered nurse present during each shift who provides direct patient
 care.

(9)

 Meals must be provided in accordance with established dietary practice and the
 dietary needs and wishes of patients. The hospice must: 

(a)

 Serve three meals a day with not more
 than 14 hours between a substantial evening meal and breakfast, unless
 medically contraindicated;

(b)

 Have
 a system for providing meals for patients outside the normal meal service
 hours, when requested;

(c)

 Have
 snacks available between meals and at night, as appropriate to each patient's
 needs and medical condition;

(d)

 Purchase, store, prepare, and serve food in a manner that prevents food borne
 illness;

(e)

 Ensure patient diets
 follow the orders of physicians;

(f)

 Ensure that a qualified staff member
 plans and supervises meals to ensure meals meet patient's nutritional needs and
 to ensure meals follow recommended dietary allowances and menu plans;
 and

(g)

 Ensure the services of a
 licensed dietitian to review meal plans and to consult in practical freedom of
 choice diets to ensure that patients' favorite foods are included in their
 diets whenever possible.

Rule 111-8-37-.25 Waivers and Variances

(1)

 A hospice may request a waiver or
 variance of a specific rule by application on forms provided by the
 Department.

(2)

 The Department may
 grant or deny the request for waiver or variance at its discretion. If the
 waiver or variance is granted, the Department may establish conditions that
 must be met by the hospice in order to operate under the waiver or variance.
 Waivers or variances may be granted with consideration of the following: 

(a)

Variance.
 A variance may be
 granted by the Department, at its discretion, upon a showing by the applicant
 that the particular rule or regulation that is the subject of the variance
 request should not be applied as written because strict application would cause
 undue hardship. The applicant must also show that adequate standards exist for
 affording protection for the health, safety, and care of patients, and these
 existing standards would be met in lieu of the exact requirements of the rule
 or regulation.

(b)

Waiver.
 
The Department may, at its discretion, dispense altogether with the
 enforcement of a rule or regulation by granting a waiver upon a showing by the
 applicant that the purpose of the rule or regulation is met through equivalent
 standards affording equivalent protection for the health, safety, and care of
 the patients.

(c)

Experimental Waiver or Variance.
 The Department may grant a waiver
 or variance, at its discretion, to allow experimentation and demonstration of
 new and innovative approaches to delivery of services upon a showing by the
 applicant that the intended protections afforded by the rule or regulation in
 question are met and that the innovative approach has the potential to improve
 service delivery.

(3)

 Waivers and variances granted by the Department must be for a time certain, as
 determined by the Department.

(4)

 The hospice may request a final review of the initial waiver or variance
 decision made by program staff to the chief of the Division of Healthcare
 Facility Regulation by filing a written request for review of the initial
 decision and providing any additional information which supports the request
 for review. The chief of the Division will issue a final decision on behalf of
 the Department.

(5)

 Where the
 Department has denied the application for a waiver or variance in writing, the
 Department will not consider a subsequent application for the same waiver or
 variance from the same hospice unless the applicant includes new evidence of a
 substantial change in the circumstances which formed the basis for the initial
 request.

Rule 111-8-37-.26 Enforcement

A hospice that fails to comply with licensing requirements as
 contained in the Rules and Regulations for Hospices, Chapter 111-8-37 and the
 Rules and Regulations for General Licensing and Enforcement Requirements,
 Chapter 111-8-25, is subject to civil and administrative actions brought by the
 Department to enforce licensing requirements as provided by applicable laws and
 rules. Such actions will be initiated in compliance with the Georgia
 Administrative Procedures Act, O.C.G.A. §§ 
50-13-1
et seq.
,
 
31-2-8
 and the Rules and
 Regulations for General Licensing and Enforcement Requirements, Chapter
 111-8-25.

However, the Department may suspend any requirements of these
 rules and the enforcement of any rules when the Governor of the State of
 Georgia has declared a public health emergency.

Rule 111-8-37-.27 Severability

In the event that any rule, sentence, clause, or phrase of
 any of these rules and regulations may be construed by any court of competent
 jurisdiction to be invalid, illegal, unconstitutional, or otherwise
 unenforceable, such determination or adjudication shall in no manner affect the
 remaining rules or portion thereof. The remaining rules or portions of rules
 shall remain in full force and effect, as if such rule or portions thereof so
 determined, declared, or adjudged invalid or unconstitutional were not
 originally a part of these rules.

Rule 111-8-37-.01 Title and Purpose
Rule 111-8-37-.02 Authority
Rule 111-8-37-.03 Definitions
Rule 111-8-37-.04 Licensure Procedures
Rule 111-8-37-.05 Inspections and Investigations
Rule 111-8-37-.06 Reports to the Department
Rule 111-8-37-.07 Governing Body
Rule 111-8-37-.08 Administrator
Rule 111-8-37-.09 Quality Management
Rule 111-8-37-.10 Patient and Family Rights
Rule 111-8-37-.11 Disaster Preparedness
Rule 111-8-37-.12 Infection Control
Rule 111-8-37-.13 Human Resources
Rule 111-8-37-.14 Admissions, Discharges, and Transfers
Rule 111-8-37-.15 Assessment and Plan of Care
Rule 111-8-37-.16 Home Care
Rule 111-8-37-.17 Medical Services
Rule 111-8-37-.18 Nursing Services
Rule 111-8-37-.19 Other Services
Rule 111-8-37-.20 Volunteer Services
Rule 111-8-37-.21 Pharmaceutical Services
Rule 111-8-37-.22 Medical Supplies
Rule 111-8-37-.23 Medical Records
Rule 111-8-37-.24 Hospice Care Facilities
Rule 111-8-37-.25 Waivers and Variances
Rule 111-8-37-.26 Enforcement
Rule 111-8-37-.27 Severability

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