481 IAC ch. 53

Hospice License Standards

This Iowa regulation establishes licensing standards for hospice programs under Iowa Code chapter 135J. Operators must obtain a biennial license from the Department of Inspections and Appeals, meet governing body, staffing, and interdisciplinary team requirements, and maintain written policies covering patient rights, care planning, quality assurance, and bereavement services. The chapter also sets standards for nursing, social work, counseling, volunteer, and spiritual services, as well as record-keeping obligations.

CHAPTER 53
HOSPICE LICENSE STANDARDS
Chapter rescission date pursuant to Iowa Code section 17A.7: 1/1/28
481—53.1(135J) Definitions. The use of the word “shall” indicates mandatory standards. The definitions 
set out in Iowa Code section 135J.1 shall be considered to be incorporated verbatim in the rules. As used in 
this chapter:
“Bereavement service” is emotional, psychosocial, and spiritual support and services provided before 
and after the death of the patient to assist with issues related to grief, loss, and adjustment.
“Care setting” means the place in which care is being given, for example, patient’s home, a hospital, a 
care facility or another place of residence.
“Family” means the immediate kin of the patient, including a spouse, parent, stepparent, brother, sister, 
stepbrother, stepsister, child, or stepchild. Additional relatives or individuals with significant personal ties 
to the hospice patient may be included in the hospice patient’s family.
“Home care provider” means a care agency that contracts with the hospice to provide services in the 
home of the hospice patient. The providers may include, but are not limited to, hospice aides, homemakers, 
nurses, occupational therapists or physical therapists.
“Primary caregiver” means the person with major responsibility for providing care to a hospice 
patient.
“Protocols” are defined as written sets of directions to be followed in performing procedures. These 
may be routine or may describe specific actions staff must follow when particular events occur.
“Psychosocial needs” involve a person’s mental and emotional life related to behavior to other people.
“Social services” are services provided by someone who has a bachelor’s or higher degree in social 
work.
“Spiritual counselor” may be clergy, a hospice employee, a volunteer or someone chosen by the 
patient.
“Utilization review” means a program to assess the kind of care delivered and to identify needs which 
may not have been met.
[ARC 6975C, IAB 4/5/23, effective 5/10/23]
481—53.2(135J) License. Application for an initial or renewal license may be obtained from the 
Department of Inspections and Appeals, Division of Health Facilities, Lucas State Office Building, Des 
Moines, Iowa 50319.
53.2(1) Prior to the issuance of a license each hospice must meet all the requirements set forth in this 
chapter.
53.2(2) The applicant shall submit a nonrefundable biennial license fee of $500. If a license lapses for 
failure to make timely application for renewal, an additional 25 percent is required.
53.2(3) Each hospice seeking licensure is surveyed before the initial license is issued and at least 
every 36 months thereafter.
53.2(4) Home care provider and inpatient facilities used by the hospice shall be inspected by the 
department to determine whether hospice regulations are met.
53.2(5) Hospices certified as Medicare providers by the department or accredited by an organization 
approved by the Centers for Medicare and Medicaid Services for federal certification will be licensed 
without inspection.
53.2(6) The department may not prohibit any entity from establishing or maintaining a hospice 
without a license.
53.2(7) The department may deny, suspend or revoke a license if the department finds that a hospice 
does not comply with these rules.
53.2(8) A license is issued only for the premises, person, hospital or facility named on the application. 
The license may not be transferred or assigned to another person or entity.
Inspections, Appeals, and Licensing[481]IAC 9/30/26 Ch 53, p.1
53.2(9) A license expires two years after the date issued unless it is suspended or revoked before that 
date.
This rule is intended to implement Iowa Code sections 135J.2 and 135J.4 to 135J.6.
[ARC 6975C, IAB 4/5/23, effective 5/10/23]
481—53.3(135J) Patient rights. Each hospice program shall have written policies and procedures that 
support, enhance and protect the human, civil, constitutional and statutory rights of all patients.
53.3(1) Patient rights include, but are not limited to, the right to:
a. Be treated with dignity and respect;
b. Be informed of the type of care and the services provided by the hospice program;
c. Information regarding diagnosis and prognosis and any change in either;
d. Review and participate in their plan of care; and
e. Privacy.
53.3(2) A copy of these rights shall be provided to all individuals admitted to a hospice.
This rule is intended to implement Iowa Code section 135J.3(3).
481—53.4(135J) Governing body. The hospice shall have a local governing body which consists of 
people who represent the geographic area for which the hospice intends to provide service.
53.4(1) The governing body shall:
a. Develop a written mission statement, goals and objectives for the hospice and meet with sufficient 
regularity to ensure accomplishment of those goals and objectives;
b. Develop, amend and implement bylaws;
c. Assume responsibility for the total operation of the hospice;
d. Appoint an administrator whose qualifications and duties are defined in writing and who has 
authority to manage the business affairs and to direct all programs of the hospice;
e. Provide for medical direction by a licensed physician, including naming a qualified physician to be 
available in the medical director’s absence;
f. Provide appropriate, qualified personnel in sufficient quantity to ensure availability of hospice 
services listed below. Physician and nursing services and the provision of appropriate drugs shall be 
available 24 hours a day, seven days a week;
g. Develop and implement written policies and procedures relating to:
(1) Admission and discharge criteria,
(2) Response to referrals,
(3) Medical direction,
(4) Physician services,
(5) Nursing services,
(6) Nutritional services,
(7) Pharmacy services,
(8) Social services,
(9) V olunteer services,
(10) Spiritual services,
(11) Patient and family education,
(12) Bereavement services,
(13) Staff response to death at home and in institutions,
(14) Coordination and communication between all agencies serving the patient and family,
(15) Communication with community agencies, and
(16) Community education efforts;
h. Develop and implement written personnel policies; and
i. Develop and implement a written plan for review of the services delivered.
53.4(2) The governing body shall ensure that someone is responsible to:
a. Organize and direct the ongoing functions of the hospice program;
b. Meet the requirements of the written job descriptions;
Inspections, Appeals, and Licensing[481]Ch 53, p.2 IAC 9/30/26
c. Maintain liaison with the governing body and staff to ensure administrative control and 
professional supervision over all patient and family services furnished;
d. Provide orientation and in-service training for all staff which covers the physical, emotional, 
spiritual and social needs of hospice patients and their families during the final stages of illness, at death 
and during grief;
e. Plan, organize, implement, guide and evaluate the program;
f. Formulate and conduct a review of policies and procedures, including quality assurance; and
g. Ensure that all required reports and records are completed, submitted and maintained. This 
includes personnel, administrative and clinical records.
This rule is intended to implement Iowa Code section 135J.3.
[ARC 6975C, IAB 4/5/23, effective 5/10/23]
481—53.5(135J) Quality assurance and utilization review. The hospice must have a written procedure 
for individual assessment of care provided, a process for identifying problems and a system to report 
findings and recommendations for improving the quality of care delivered to the governing body.
53.5(1) The medical director, patient coordinator and social worker used by the hospice program 
shall review a minimum of a 10 percent sample of combined active and inactive clinical records of care 
delivered to hospice patients on a periodic and ongoing basis. A written summary shall be prepared 
for each individual assessment, commenting on the amount and kind of care delivered and including 
statements addressing any unmet needs.
53.5(2) All summaries of individual assessments shall be reviewed by the people responsible for 
coordinating quality assurance on a periodic and ongoing basis. A written report will be prepared 
addressing any identified problems with care, treatment services, availability of services and methods 
of care delivery.
53.5(3) The quality assurance reports shall be made available to the hospice administrator and 
governing body. The reports shall be reviewed by the governing body at least annually, and the review 
recorded in the governing body’s meeting minutes.
This rule is intended to implement Iowa Code section 135J.3(8).
[ARC 6975C, IAB 4/5/23, effective 5/10/23]
481—53.6(135J) Attending physician services. The patient or family shall designate an attending 
physician or physician associate who is responsible for managing necessary medical care. The attending 
physician shall:
1.  Have an active Iowa license pursuant to Iowa Code chapter 148 or 148C;
2.  Certify in conjunction with the medical director that each person requesting admittance is eligible 
as required by Iowa Code section 135J.1(3) for hospice care;
3.  Be responsible for the medical component of the plan of care;
4.  Participate in developing and revising the plan of care;
5.  Arrange for continuity of the medical management in the attending physician’s absence; and
6.  Monitor the condition of the patient and family by direct contact, or communication with the 
interdisciplinary team (IDT) and others.
This rule is intended to implement Iowa Code section 135J.3(4).
[ARC 6975C, IAB 4/5/23, effective 5/10/23; Editorial change: IAC Supplement 6/10/26]
481—53.7(135J) Medical director. Each hospice shall have a medical director who is a physician licensed 
to practice medicine pursuant to Iowa Code chapter 148. The medical director shall:
1.  Be a member of the interdisciplinary team;
2.  Monitor the quality of care provided;
3.  Assist in providing assurance of the quality of care provided to the patient and family;
4.  Maintain liaison with the attending physician;
5.  Review clinical material from the patient’s attending physician to certify the prognosis as 
anticipated by that physician;
6.  Participate in providing direction for the medical component of care;
Inspections, Appeals, and Licensing[481]IAC 9/30/26 Ch 53, p.3
7.  Participate in resolving conflicts regarding care to be provided; and
8.  Participate in the development and review of patient care policies, procedures and protocols.
This rule is intended to implement Iowa Code section 135J.3(1).
[ARC 6975C, IAB 4/5/23, effective 5/10/23]
481—53.8(135J) Interdisciplinary team (IDT). The IDT shall establish a plan of care for each patient 
based on assessments performed by team members.
53.8(1) The interdisciplinary team shall include, but is not limited to, the:
a. Patient, to the extent the patient is able and willing to participate;
b. Hospice patient’s family, to the extent the family is able and willing to participate;
c. A doctor of medicine or osteopathy who is an employee of or under contract with the hospice;
d. Patient care coordinator;
e. Registered nurse;
f. Social worker; and may include
g. A pastoral or other counselor and others deemed appropriate by the hospice.
53.8(2) Within 48 hours of admission, the attending physician or registered nurse and at least one IDT 
team member shall develop an initial plan based on a preliminary assessment of the patient needs.
53.8(3) Within five calendar days of admission, the interdisciplinary team shall assess the needs of 
the patient and family. A care plan shall be based on these findings.
53.8(4) Within five calendar days of admission, the interdisciplinary team shall meet to develop a 
comprehensive written plan of care. The plan of care shall:
a. Identify the primary caregiver or an alternate arrangement for care;
b. List the needs of the patient and family;
c. List any intervention planned to meet the needs of the patient and family and the results expected 
from each intervention;
d. Indicate which team member(s) is responsible for each intervention;
e. Indicate the anticipated frequency of each intervention; and
f. Indicate the prognosis and expected disease process.
53.8(5) The IDT shall monitor and revise the plan of care on a regular basis. The team shall meet at 
least every 15 days and exchange information regarding the needs of the patient and family. Changes in the 
care plan shall be made when the needs of the patient or family change or when interventions do not result 
in the expected or intended response.
This rule is intended to implement Iowa Code section 135J.3(5).
[ARC 6975C, IAB 4/5/23, effective 5/10/23]
481—53.9(135J) Nursing services. Nursing services shall be planned and provided or supervised by a 
registered nurse who has a current Iowa license to practice nursing. The service shall be available 24 hours 
a day, seven days a week.
53.9(1) A registered nurse shall assess patient and family nursing needs and develop a nursing plan of 
care to meet these needs.
53.9(2) The nursing service staff shall:
a. Participate in IDT meetings to develop and amend the plan of care;
b. Provide nursing service in accordance with the overall plan of care developed by the IDT;
c. Consult with the patient and family regarding how to meet nursing and nursing-related needs of 
the patient;
d. Document nursing care given and observations made regarding patient, family reactions and 
status;
e. Consult with other care providers and the family to enhance continuity of care;
f. Develop and implement nursing service objectives, policies and procedures; and
g. Assign duties to nurses and hospice aides consistent with their education and experience.
53.9(3) Persons who are employed by, volunteer with or work under contract to a licensed hospice 
organization may administer medications only if they are also a licensed nurse, a licensed physician or a 
certified medication aide.
Inspections, Appeals, and Licensing[481]Ch 53, p.4 IAC 9/30/26
This rule is intended to implement Iowa Code section 135J.3(2).
[ARC 6975C, IAB 4/5/23, effective 5/10/23]
481—53.10 Reserved.
481—53.11(135J) Coordinator of patient care. 
53.11(1) A registered nurse, social worker or health care administrator shall be designated to 
coordinate implementation of the plan of care for each patient.
53.11(2) The coordinator of patient care shall at least:
a. Coordinate all aspects of patient care to ensure continuity, including care by all service disciplines 
in all care settings;
b. Facilitate exchange of information among all personnel who provide services to ensure 
complementary efforts and support for objectives outlined in the plan of care;
c. Facilitate communication between caregivers, patient and family;
d. Maintain a roster of patients;
e. Maintain a schedule for IDT review of care plans; 
f. Chair IDT conferences;
g. Develop job descriptions for all nursing personnel;
h. Establish staff schedules to meet patient needs and ensure 24-hour service;
i. Develop and implement orientation and training programs;
j. Develop and implement performance evaluation for the nursing staff; and
k. Facilitate periodic meetings of the professional nursing staff to evaluate the nursing care provided 
by hospice personnel.
This rule is intended to implement Iowa Code section 135J.3(2).
[ARC 6975C, IAB 4/5/23, effective 5/10/23]
481—53.12(135J) Social services. Medical social services must be provided by a qualified social worker, 
under the direction of a physician. Social work services must be based on the patient’s psychosocial 
assessment and the patient’s and family’s needs and acceptance of these services.
53.12(1) Education and experience. A qualified social worker is a person who:
a. Has a master of social work (MSW) degree from a school of social work accredited by the Council 
on Social Work Education; or
b. Has a baccalaureate degree in social work from an institution accredited by the Council on Social 
Work Education; or
c. Has a baccalaureate degree in psychology, sociology, or other field related to social work and is 
supervised by an MSW as described in paragraph 53.12(1)“a”; and
d. Has one year of social work experience in a health care setting; or
e. Has a baccalaureate degree from a school of social work accredited by the Council on Social Work 
Education, was employed by the hospice before December 2, 2008, and is not required to be supervised by 
an MSW.
53.12(2) The social worker shall at least:
a. Consider the emotions and social support system of the patient;
b. Identify patient social service needs;
c. Participate on the IDT to develop and amend the plan of care;
d. Provide services in accordance with the plans of care developed by the IDT;
e. Document services provided and observations made regarding patient and family response and 
status; and
f. Cooperate and communicate with other providers and the family to enhance the continuity of care.
This rule is intended to implement Iowa Code section 135J.3(2).
[ARC 6975C, IAB 4/5/23, effective 5/10/23]
481—53.13(135J) Counseling services. Counseling is the process of helping people adjust to the grief 
of illness, dying and loss. Counseling shall be provided in accordance with the plan of care. When the 
Inspections, Appeals, and Licensing[481]IAC 9/30/26 Ch 53, p.5
interdisciplinary team identifies the need for additional counseling services, a team member shall be 
designated to make an appropriate referral. No referrals may be made without the agreement of the patient 
and the family.
This rule is intended to implement Iowa Code section 135J.3(2).
481—53.14(135J) Volunteer services. Each hospice shall provide volunteer services to meet patient and 
family needs. A coordinator of volunteer services shall be designated to implement written policies and 
procedures. V olunteers must be used in defined roles and under the supervision of a designated hospice 
employee. The hospice must maintain, document and provide volunteer orientation and training that is 
consistent with hospice industry standards.
This rule is intended to implement Iowa Code section 135J.3(2).
[ARC 6975C, IAB 4/5/23, effective 5/10/23]
481—53.15(135J) Spiritual counseling. Spiritual counseling shall be available to all patients and their 
families.
53.15(1) Spiritual counseling shall:
a. Be based on the beliefs and values of the patient and family; and
b. Be provided in accordance with the interdisciplinary plan of care.
53.15(2) If spiritual counseling is provided through a working relationship with clergy or other 
spiritual counselors in the community, there shall be ongoing communication between that counselor and 
the interdisciplinary care team.
53.15(3) There shall be written and implemented policies and procedures regarding spiritual 
counseling.
This rule is intended to implement Iowa Code section 135J.3(2).
481—53.16(135J) Optional services. Optional services are services provided by the hospice which are 
not required. Examples are hospice aide, therapy and respite. The following apply to the provision of all 
optional services provided by a hospice:
53.16(1) All service providers shall be oriented to the hospice concept and philosophy.
53.16(2) All services shall be provided in accordance with the interdisciplinary plan of care.
53.16(3) Written and implemented policies and procedures shall:
a. Identify service providers;
b. Identify the person who will supervise the provision of services;
c. Require documentation of services provided and patient and family response; and
d. Describe a mechanism for evaluating quality of care provided.
This rule is intended to implement Iowa Code section 135J.1(7).
[ARC 6975C, IAB 4/5/23, effective 5/10/23]
481—53.17(135J) Contracted services. A hospice may contract with other health care providers for the 
provision of all services.
53.17(1) Contracts shall be written and clearly delineate the authority and responsibility of each party 
to the contract.
53.17(2) The hospice shall maintain responsibility for coordinating and administering the hospice 
program.
53.17(3) Contracting for a service does not absolve the hospice of legal responsibility for provision of 
that service.
53.17(4) The hospice shall inform the patient whether the hospice is paying for the contracted 
services.
This rule is intended to implement Iowa Code section 135J.3(2).
481—53.18(135J) Short-term hospital services. Each hospice shall have a written agreement with a local 
or area hospital which promotes continuation of the hospice plan of care and training for hospital staff who 
care for hospice patients.
Inspections, Appeals, and Licensing[481]Ch 53, p.6 IAC 9/30/26
This rule is intended to implement Iowa Code section 135J.3(2).
481—53.19(135J) Bereavement services. Bereavement services shall be available to each family after the 
death of a patient and shall be provided in accordance with family needs.
53.19(1) Bereavement services shall include:
a. Exchange of information between people who provide bereavement services and team members 
who provided care before death;
b. Consideration of the family’s situation, including risk factors, used to develop a plan for services;
c. Identification of types of help or intervention to be available and provided;
d. Contact with the family after the death as required by their needs as documented in the plan of 
care; and
e. A process to assess family reactions and hospice referrals for intervention deemed appropriate by 
the IDT.
53.19(2) There shall be written and implemented policies and procedures governing the delivery of 
bereavement services.
This rule is intended to implement Iowa Code section 135J.3(6).
481—53.20(135J) Records. In accordance with accepted principles of medical record practice, each 
hospice shall maintain a centralized complete record on every individual receiving services. This record 
shall be preserved for at least six years following termination of services.
53.20(1) Each entry shall be dated and signed, including the name and title of the person who makes 
the entry.
53.20(2) The record shall include documentation of all services provided, whether furnished by the 
hospice or by contractual agreement. Each record shall include, but not be limited to:
a. Patient identification and demographic data;
b. Initial and subsequent assessments;
c. The plan of care;
d. Medical history;
e. Documentation of all services provided;
f. Consent and authorization forms;
g. Physicians’ orders;
h. Medication records;
i. Discharge summary; and
j. Discharge and transfer records.
53.20(3) The hospice shall have written and implemented policies to safeguard destruction or 
unauthorized use of patient records. Written procedures shall govern use and removal of records, conditions 
for release of information and identification by title of the person who may release records.
[ARC 6975C, IAB 4/5/23, effective 5/10/23]
These rules are intended to implement Iowa Code sections 135J.1 to 135J.6.
[Filed 4/12/90, Notice 12/27/89—published 5/2/90, effective 6/6/90]
[Filed ARC 6975C (Notice ARC 6878C, IAB 2/8/23), IAB 4/5/23, effective 5/10/23]
[Editorial change: IAC Supplement 6/10/26]
Inspections, Appeals, and Licensing[481]IAC 9/30/26 Ch 53, p.7