This Utah regulation establishes comprehensive licensing and operating standards for hospice programs and agencies, covering governance, administration, personnel qualifications, patient rights, clinical recordkeeping, quality assurance, and service delivery requirements. It applies to any entity advertising or operating as a hospice or hospice program of care providing services to terminally ill individuals, whether in home or inpatient settings. Operators must maintain interdisciplinary care teams, written policies and procedures, infection control programs, and pharmaceutical oversight. Freestanding and inpatient hospice facilities face additional physical environment and staffing requirements.
View official sourceDAS HOME BUILDING BOARD ARCHIVES DFCM FINANCE FLEET PURCHASING RISK RULES HOME CODE BULLETIN HELP ABOUT US CONTACT US QUICKLINKS STATE LOGIN Administrative Code Proposed Rules Open for Comment Rules on Rules Forms Agency Listing Rulemaking Process Administrative Procedure Act Research ` Health and Human Services Health Care Facility Licensing Rule 750: Hospice Rule Effective Date: 02/18/2025 Admin. Code Reference: R432-750 Rule Type: Current Rule Download PDF Download HTML Copy Link R432. Health and Human Services, Health Care Facility Licensing. R432-750. Hospice Rule. R432-750-1. Legal Authority. This rule is authorized by Section 26B-2-202. R432-750-2. Purpose. (1) A hospice licensee provides support and care for individuals with a limited life expectancy so that they might live as fully and comfortably as possible. (2) A hospice licensee offers services that: (a) are available in both the home and an inpatient setting; (b) are offered through an interdisciplinary team of professionals and volunteers; (c) neither hastens nor postpones death; (d) recognize dying as a normal process resulting from disease or injury; (e) prepares a patient and family to attain a degree of mental and spiritual preparation for death that is satisfactory to them through appropriate care and the promotion of a caring community sensitive to their needs; and (f) provides physical, psychosocial, spiritual, and bereavement care for a dying individual and their family. (3) This rule applies to a program advertising or presenting to be a hospice or hospice program of care, as defined in Section 26B-2-201, that provides, directly or by contract, hospice services to the terminally ill. R432-750-3. Definitions. Terms in this rule are defined in Rules R432-1 and R380-600. Additionally: (1) "Appropriate" means especially suitable, compatible, or fitting. (2) "Bereavement" means the period, usually occurring within the first year after the loss, when a person or group of people experiences, responds emotionally to, and adjusts to the loss by death of another person. (3) "Care" means to perceive and respond to the needs of another. (4) "Certification in cardiopulmonary resuscitation" refers to certification issued after completion of an in-person course, to include skills testing and evaluation on-site with a licensed instructor. (5) "Family" means a group of individuals who: (a) are of common ancestry; (b) have a personal commitment to one another; or (c) live in the same home. (6) "Grief" means the response to loss that often occurs in stages of varying length that are differentiated by changes in feeling, thought, and behavior. (7) "Hospice administrator" means the person the governing body appoints in writing that is accountable and responsible for implementing the policies and programs approved by the governing body. (8) "Hospice agency" means an entity that is primarily engaged in providing care to terminally ill individuals and their families and includes institutionally based hospice programs, freestanding public and proprietary hospice agencies, and any subdivision of an organization, public agency, hospital, or nursing home licensed to provide hospice services. (9)(a) "Hospice care" means the care given to the terminally ill and their family that occurs in a home or in a health facility and includes medical, palliative, psychosocial, spiritual, bereavement, supportive care, and treatment. (b) Hospice care includes responding to the scheduled and unscheduled needs of the patient and family 24 hours a day. (10) "Hospice inpatient facility" means a freestanding licensed hospice facility or designated hospice licensed hospice unit in an existing health care facility. (11) "Interdisciplinary team" means a team composed of an attending physician, medical director, nurse, social worker, pastoral care provider, volunteer, patient, patient's family, and any other professionals as indicated. (12) "OL" means the Office of Licensing in the Division of Licensing and Background Checks under the Department of Health and Human Services. (13) "Palliative care" means the care given to the terminally ill, focusing on the relief of distressing symptoms. (14) "Palliative treatment" means treatment and comfort measures directed toward relief of symptoms and pain management rather than treatment to cure. (15) "Pastoral care provider" means an individual who has experience in pastoral duties and is capable of providing for the hospice patient and patient family's spiritual needs, and is an individual who: (a) has received a degree from an accredited theological school; (b) by ordination or by ecclesiastical endorsement from the individual's denomination, has been approved to function in a pastoral capacity; or (c) has received certification in Clinical Pastoral Education that meets the requirements for the College of Chaplains. (16) "Primary care giver" means the family member or other person designated by the family who assumes the overall responsibility for the care of the patient in the home. (17) "Spiritual" means the patient and the patient's family beliefs and practices as they relate to the meaning of their life, death, and their connection to humanity that may or may not be of a religious nature. (18) "Terminal" means a state of disease characterized by a progressive deterioration with impairment of function that, without aggressive intervention, survival is anticipated to be six months or less. (19) "Volunteer" means an individual who has received appropriate orientation and training consistent with hospice philosophy and practice and who contributes time and talent to the hospice program without economic remuneration. R432-750-4. Governing Body and Administration. (1) The licensee shall ensure that the hospice agency is organized under a governing body that assumes full legal responsibility for the conduct and operations of the hospice agency. (2) The licensee shall develop an organization chart that shows the administrative structure of the hospice agency. (3) The governing body shall: (a) adopt a policy that prohibits discrimination because of race, color, religion, ancestry, disability status, sexual orientation, gender, or national origin; (b) adopt written policies and procedures that describe functions or services of the hospice agency and protect patient rights; (c) appoint by name and in writing, a qualified hospice administrator who shall oversee the hospice agency's overall functions; (d) comply with any laws, rules and regulations; (e) develop and implement bylaws that include: (i) a description of functions and duties of the governing body officers and committees; (ii) a statement of purpose; (iii) an outline of the establishment, selection, and term of office for committee members and officers; (iv) a policy statement relating to any conflict of interest of members of the governing body or employees who influence the hospice agency decisions; (v) a statement of qualifications for membership and methods to select members of the governing board; and (vi) a statement of the authority and responsibility delegated to the hospice administrator; (f) ensure compliance with Rule R380-600 for program changes to include notifying the office in writing 30 days before any proposed change in the hospice administrator, identifying the name of the new hospice administrator, and the effective date of the change; (g) establish a system of financial management and accountability. (h) meet at least annually; (i) provide resources and equipment to provide a safe working environment for personnel; and (j) review the written annual evaluation report from the hospice administrator and document recommendations as necessary. (4) The hospice administrator shall oversee the overall management of the hospice agency and shall: (a) appoint the following, by name and in writing: (i) a physician or registered nurse to provide general supervision, coordination, and direction for professional services of the hospice agency; (ii) a registered nurse to be the director of nursing services; (iii) a person responsible for maintaining a clinical record system on any patients; (iii) the members and their terms of membership in the interdisciplinary quality assurance committee; and (iv) other committees as deemed necessary, describe committee functions and duties, and outline the selection, term of office, and responsibilities of committee members; (b) complete, submit, file, and make available any records, reports, and documentation required by OL; (c) conduct an annual evaluation of the hospice agency's overall function and submit a written report of the findings to the governing body; (d) develop a staff communication system that: (i) coordinates implementation of plans of treatment; (ii) coordinates interdisciplinary team services; (iii) promotes an orderly flow of information within the organization; and (iv) utilizes services or resources to meet patient needs; (e) designate in writing the name and position title of a qualified person, who has enough power, authority, and freedom to act in the best interest of patient safety and well-being, as hospice administrator in the temporary absence of the hospice administrator; (f) employ or contract with competent personnel whose qualifications are commensurate with job responsibilities and authority, who have the appropriate license or certificate of completion; (g) establish, when appropriate, a billing system that itemizes services provided and charges submitted to the payment source; (h) implement a program of budgeting and accounting; (i) implement hospice agency policies and procedures; (j) maintain current written designations or letters of appointment for the hospice agency; (k) organize and coordinate functions of the hospice agency by delegating duties and establishing a formal system of staff accountability; (l) review hospice agency policies and procedures at least annually and recommend necessary changes to the governing body; and (m) secure contracts for services not directly provided by the hospice agency. (5) The licensee shall ensure the hospice administrator or designee is available during the hours of operation. R432-750-5. Personnel. (1) The hospice administrator shall maintain qualified, competent personnel to perform their respective duties, services, and functions. (2) The licensee shall develop and implement written policies and procedures that address the: (a) contents of personnel files of employed and volunteer staff; (b) criteria for, and frequency of, performance evaluations; (c) frequency and documentation of in-service training; (d) job descriptions, qualifications, and validation of licensure or certificates of completion as appropriate for each position; (e) method and period of staff payment; (f) orientation for direct and contract employees, and volunteers; (g) staff benefits, including sick leave, vacation, and insurance; and (h) staff work schedules. (3) The licensee shall require that each employee provide proof of registration, certification, or licensure as required by the Utah Department of Commerce within 45 days of hire. (4)(a) The licensee shall establish and implement a policy and procedure for health screening of any hospice agency personnel. (b) The licensee shall ensure that an employee placement health evaluation is completed when an employee is hired. (c) The evaluation shall include at least a health inventory that outlines the employee's history of any: (i) condition that may prevent the employee from performing assigned duties satisfactorily; and (ii) condition that predispose the employee to acquiring or transmitting an infectious disease. (d) The licensee shall develop components of personnel health programs for employee health screening and immunizations in accordance with Rule R386-702. (e) Employee skin testing by the Mantoux Method or other FDA-approved invitro serologic test and follow-up for tuberculosis shall comply with Rule R388-804. (f) The licensee shall ensure that each employee is skin-tested for tuberculosis within two weeks of: (i) development of symptoms of tuberculosis; (ii) initial hiring; and (iii) suspected exposure to a person with active tuberculosis. (g) Each employee with a known positive reaction to skin tests is exempt from skin testing. (h) The licensee shall report any infections and communicable diseases reportable by law to the local health department in accordance with Section R386-702-3. (5) The licensee shall document that each employee, volunteer, and contract personnel is oriented to the hospice agency and the job that they are hired to perform. Orientation shall include: (a) each duty for an individual who is trained, holds a certificate, or is licensed; (b) ethics, confidentiality, and patient rights training; (c) information about other community agencies, including emergency medical services; (d) job descriptions training; (e) opportunities for continuing education appropriate to the patient population served; (f) the policy related to volunteer documentation, charting, hours, and emergencies; (g) reporting requirements as outlined in Rule R380-600 including reporting when observing or suspecting abuse, neglect, and exploitation pursuant to Section 26B-6-205; (h) the functions of each hospice agency employee and the relationships between various positions or services; and (i) the hospice agency concept and philosophy of care. (6)(a) The licensee shall provide and document in-service training and continuing education for staff at least annually. (b) Members of the hospice agency interdisciplinary team shall have access to in-service training and continuing education appropriate to their responsibilities and to the maintenance of skills necessary for the care of the patient and family. (c) The training programs shall include the introduction and review of effective physical and psychosocial assessment and symptom management. (d) The licensee shall train personnel in appropriate Centers for Disease Control infectious disease protocols. (7) The hospice administrator shall appoint a person to coordinate the activities of the interdisciplinary team and to: (a) annually review and make recommendations, where appropriate, of hospice agency policies covering admissions and discharge, medical supervision, care plans, clinical records, and personnel qualifications; (b) assure that ongoing assessments of the patient and family needs and implementation of the interdisciplinary team care plans are accomplished; (c) assure that the team meets regularly to develop and maintain appropriate plans of care and to determine that staff will be assigned to each case; and (d) schedule adequate quality and quantity of any level of hospice care. (8) The licensee shall provide access to individual or group support for interdisciplinary team members to assist with stress or grief management related to providing hospice care. R432-750-6. Contracts. (1) The hospice administrator shall secure a legally binding written contract for the provision of arranged patient services. (2) The licensee shall make the contract or agreement available for review by the OL and ensure the contract or agreement includes: (a) a copy of the professional license of any contracted personnel; (b) a description of goods or services provided by the contractor to the hospice agency; (c) a description of the contractor's role in the development of plans of treatment and the process to keep hospice agency staff informed about the patient's needs or condition; (d) a statement that contract personnel shall perform according to hospice agency policies and procedures and shall conform to standards required by laws, rules, and regulations; (e) the effective and expiration dates of the contract; (f) the financial terms of the contract, including methods to determine charges, reimbursement, and the responsibility of contract personnel in the billing procedure; (g) the method of supervision of contract personnel and the manner in which services will be controlled, coordinated, and evaluated by the hospice agency; and (h) the terms of termination of the contract. R432-750-7. Acceptance and Termination. (1) The licensee shall develop written acceptance and termination policies and make these policies available to the public upon request. (2) The licensee shall make available to the public, upon request, information regarding the various services provided by the hospice agency and the cost of the services. (3) The licensee shall accept a patient for treatment if there is a reasonable expectation that the patient's needs can be met by the hospice agency regardless of the ability to pay for the services. The licensee shall base the acceptance determination on the following: (a) the patient, family or responsible person agrees that hospice care is appropriate and completes a signed informed consent document requesting hospice services, or if no primary care person is available, the licensee shall complete an evaluation to determine the patient's eligibility for service; (b) the patient's attending physician shall order hospice care; and (c) the licensee determines that the patient's place of residence is adaptable and safe for the provision of hospice services. (4) The licensee may end services to a patient if any of the following circumstances occur: (a) the family situation changes that affects the delivery of services; (b) the licensee can no longer provide quality care in the existing environment due to the safety of staff, patient, or family; (c) the patient is no longer terminal; (d) the patient moves from the geographic area served by the hospice agency; (e) the patient or family is uncooperative in efforts to attain treatment objectives; (f) the patient or family requests that hospice agency services be discontinued; or (g) the physician does not renew orders, or the patient changes their physician, and the licensee cannot obtain orders to continue services from the new physician. (5) Upon transfer from a home program to an inpatient facility, or the reverse, the transferring program staff shall forward the plan of care to the receiving program. R432-750-8. Patient Rights. (1)(a) The licensee shall establish and make available, written patient rights to the patient before or at admission and to the responsible individual, next of kin, sponsoring agency, representative payee, and the public upon request. (b) The licensee may determine how patient rights information is distributed in the hospice agency policy. (2) The licensee shall ensure that each patient receiving care has the right to: (a) be informed of personal health conditions, unless medically contraindicated and documented in the clinical record; (b) be treated with consideration, respect, and full recognition, of dignity and individuality, including privacy in treatment and in care for personal needs; (c) confidential treatment of personal and medical records and to approve or refuse the release of records to any individual outside the hospice agency, except in the case of transfer to another agency or health facility, or as required by law or third-party payment contract; (d) discontinue hospice care at any time they choose; (e) participate in the planning of the hospice services, including referral to health care institutions or other agencies; (f) receive information about advanced directives; (g) receive information regarding patient rights and responsibilities; (h) receive information regarding services that the patient or a third-party payer may be responsible for and receive information on any change in charges; (i) receive information regarding the hospice services required to assist in the course of treatment; (j) receive proper identification by the individual providing hospice services; (k) refuse to participate in experimental research; (l) refuse treatment to the extent permitted by law and to be informed of the medical consequences if refused; and (m) treatment by personnel who provide care and are qualified through education and experience to carry out the services that they are responsible for providing. R432-750-9. Patient Records. (1)(a) The hospice administrator shall develop and implement record-keeping policies and procedures that address the use of patient records by authorized staff, content, confidentiality, retention, and storage. (b) The licensee shall ensure that records are organized in a uniform medical record format. (c) The licensee shall maintain an identification system to facilitate the location of each patient's current or closed record. (d) The licensee shall maintain an accurate, current record for each patient receiving service. (e) Each licensee who has a patient contact or provides a service shall ensure that a clinical note entry of that contact or service is made in the patient's record. (f) Any person making the entry shall date and authenticate the entry with the person's signature and job title. (g) The licensee shall document each service provided and the outcome of each service in the individual patient record. (2)(a) The licensee shall ensure that signed and dated physician's orders are incorporated into the plan of care and renewed at least every 90 days. (b) A copy of the order is acceptable as long as the original order is available on request. (3) The licensee shall ensure that each patient record contains the following information: (a) a signed, dated patient assessment that includes the following: (i) a description of the patient's functional limitations; (ii) a physical assessment noting chronic or acute pain and other physical symptoms and their management; (iii) a psychosocial assessment of the patient and family; (iv) a spiritual assessment; and (v) a written summary report of hospice services provided that is additionally sent to the patient's attending physician at least every 90 days; (b) a written and signed informed consent to receive hospice services; (c) a written plan of care; (d) contact information of: (i) the name and address of the nearest relative or responsible person; (ii) the name and telephone number of the person or family member who, in addition to hospice agency staff, provides care in the place of residence; and (iii) the name and telephone number of the physician with primary responsibility for patient care; (e) demographic information that includes the patient's age, name, address, patient date of birth; (f) diagnosis; (g) medications and treatments as applicable; (h) pertinent medical and surgical history if available; and (i) orders by the attending physician for hospice services. (4)(a) The person assigned to supervise or coordinate care for a patient shall complete a discharge summary when services to the patient are terminated. (b) The discharge summary shall include the reason for discharge and the name of the facility or agency if the patient is referred or transferred. (5) The licensee shall: (a) ensure that written consent is required for the release of patient information and photographing recorded information; (b) ensure that written procedures govern the use and removal of records and conditions for the release of patient information; (c) safeguard clinical record information against loss, destruction, and unauthorized use; and (d) send a copy of the record to the new facility or agency when a patient is transferred. (6)(a) The licensee shall provide an accessible area for filing and safe storage of medical records. (b) The licensee shall ensure that each patient record is retained for at least seven years after the last date of patient care. (c) The licensee shall transfer any patient records to a new owner upon a change of hospice agency ownership. R432-750-10. Quality Assurance. (1) The governing body shall evaluate the quality, appropriateness, and scope of services provided by the licensee at least annually to determine if the licensee has met its objectives. (2) An interdisciplinary quality assurance committee shall: (a) evaluate patient services at least quarterly and maintain a written report of findings; and (b) submit written recommendations to the hospice administrator. (3) The hospice administrator shall appoint the members of the quality assurance committee for a given term of membership. (4) The quality assurance committee shall include a minimum of three individuals who represent three different healthcare services. R432-750-11. Hospice Services. (1)(a) The licensee shall ensure that a unit of care includes the patient and the patient's family. (b) The licensee shall ensure that the patient, family, or other primary care individual participates in the development and implementation of the interdisciplinary care plan according to their ability. (2) The licensee shall ensure that written policies and procedures include: (a) a clearly defined and integrated administrative structure between in-home care and inpatient services; (b) a procedure for accepting referrals; (c) a procedure for completing an initial assessment and developing the interdisciplinary care plan; (d) a procedure for coordination of the care plan between in-home hospice and inpatient hospice care; (e) a procedure for providing for and documenting that the interdisciplinary team meets regularly to evaluate care and includes inpatient and in-home care staff; (f) a procedure for the appropriate transfer of care from hospice in-home care to hospice inpatient care and vice-versa where available; and (g) a requirement that the care plan is available to each team member for in-home and inpatient services. (3) The licensee: (a) may include ancillary staff when appropriate; (b) shall meet at least twice a month to develop and maintain an appropriate plan of care; and (c) shall provide hospice care. (4) The attending physician shall sign each patient's care plan and ensure it includes: (a) a description of each service provided, at what interval, and by whom; (b) any pertinent diagnosis; (c) each objective, intervention, and goal of treatment, based upon needs identified in a comprehensive patient assessment; (d) the date the plan was initiated; (e) the dates of subsequent reviews; and (f) the name of patient. (5)(a) A hospice nurse may not give any medication or treatment requiring an order except when ordered by an individual legally authorized to issue the order. (b) The hospice nurse shall ensure an initial order and subsequent changes in the order for the administration of medication is signed by the person lawfully authorized to give the order and incorporated in the patient's record. (c) The licensee shall ensure that only licensed personnel may receive a telephone order and each telephone order is: (i) countersigned by the initiator within 15 days of the date of issue; and (ii) recorded immediately in the patient's medical record. (d) The licensee shall ensure an order for therapy services includes the specific procedures to be used and the frequency and duration of the services. (e) The attending physician shall review, sign, and date orders at least every 90 days. (f) Only licensed hospice agency employees may administer medications to patients. (g) A hospice agency employee shall administer medications and treatments as prescribed and recorded in the patient's record. R432-750-12. Physician Services. (1) The licensee shall ensure each patient admitted for hospice services, is under the care of a licensed physician, who provides the: (a) admitting diagnosis and prognosis; (b) approval for hospice care; (c) current medical findings; (d) pertinent orders regarding the patient's terminal condition; and (e) medications and treatment orders. (2) The hospice administrator shall appoint in writing a medical director who shall: (a) act as a liaison with physicians in the community; (b) act as a medical resource to the interdisciplinary team; (c) coordinate services with each attending physician to ensure continuity in the services provided if the attending physician cannot maintain responsibility for patient care; and (d) demonstrate understanding of hospice's psychosocial and medical aspects based on training and experience. R432-750-13. Nursing Services. (1) A registered nurse shall provide or direct nursing services. (2) Registered nursing personnel shall: (a) assign, supervise, and teach other nursing personnel and primary care individuals; (b) coordinate any services provided to members of the interdisciplinary team; (c) inform the physician and other personnel of changes in the patient's condition and needs; (d) initiate the plan of care and necessary revisions; (e) make the initial nursing evaluation visit; (f) participate in in-service training programs; (g) prepare clinical progress notes; (h) provide directly, or by contract, skilled nursing care; and (i) re-evaluate the patient's nursing needs as required. R432-750-14. Medical Social Work Services. (1) The licensee shall provide social work services by a social worker who has received a degree from an accredited school of social work and is licensed under Title 58, Chapter 60, the Mental Health Professional Practice Act. (2) The social worker shall participate in in-service training to meet the care needs of the patient and family. R432-750-15. Professional Counseling Services. (1) The licensee shall provide counseling services to patients either directly or by contract. These services may include dietary and other counseling services deemed appropriate to meet the patient's and family's needs. (2) The licensee shall ensure that individuals who provide counseling services, whether employed or contracted by the licensee, are licensed, certified, registered, or qualified through education, training, or experience according to law. R432-750-16. Pastoral Care Services. (1) The licensee shall provide pastoral services through a qualified staff person who has a working relationship with local clergy or spiritual counselors. (2) The licensee shall ensure that pastoral services include: (a) communication with and support of clergy or spiritual counselors in the community as appropriate; (b) consultation and education to patients and families and interdisciplinary team members as requested; and (c) spiritual counseling consistent with patient and family belief systems. R432-750-17. Volunteer Services. (1) Hospice agency volunteers may provide a variety of services as defined by the policies of each program and under the supervision of a designated and qualified hospice agency staff member. (2) The licensee shall ensure that each volunteer receives a minimum of 12 hours of documented orientation and training that includes: (a) care and comfort measures; (b) communication skills; (c) concepts of death and dying; (d) confidentiality; (e) family dynamics, coping mechanisms, psychosocial and spiritual issues surrounding the terminal disease, death, and bereavement; (f) infection control and safety; (g) patient's and family's rights; (h) procedures to follow in an emergency; (i) procedures to follow when a patient dies; (j) the hospice agency services, goals, and philosophy of care; (k) the physiological aspects of terminal disease; (l) the volunteer's role and documentation requirements; and (m) stress management. (3) The licensee shall maintain records of hours of services and activities provided by each volunteer. (4) The licensee shall have on file a copy of the certification, registration, or license of each volunteer providing professional services. R432-750-18. Bereavement Services. (1) The licensee shall ensure that bereavement services address the family needs following the death of the patient include: (a) assurance that each volunteer and staff member who provides bereavement services receives bereavement training; (b) making bereavement services available, as needed, to supervisors for at least one year; and (c) supervised bereavement services, an individual possessing a degree or documented training in a field that addresses psychological needs, counseling, and bereavement services. (2) The licensee shall ensure that bereavement services include the following: (a) a process for the assessment of possible pathological grief reactions and, as appropriate, referral for intervention; (b) an interchange of information between the team members regarding bereavement activities; and (c) survivor contact, as needed and documented, following a patient's death. R432-750-19. Other Services. (1) Other services offered by the licensee may include: (a) a certified nursing aide; (b) occupational therapy; (c) physical therapy; and (d) speech therapy. (2) A physician shall order each service provided directly by the licensee or through contract and the licensee shall ensure each service is documented in the clinical record. R432-750-20. Freestanding Hospice Inpatient Facilities. A freestanding hospice inpatient facility licensee shall additionally meet the Construction and Physical Environment requirements of Rules R432-4, R432-5, and R432-12, depending on facility size and type of patient admitted. R432-750-21. Hospice Inpatient Facilities. A hospice inpatient facility licensee shall additionally meet the requirements of Sections R432-750-23 through R432- 750-37. R432-750-22. Hospice Inpatient Facility Staffing Requirements. (1) A hospice inpatient facility licensee shall provide competent hospice-trained nursing staff 24 hours a day to meet the needs of a patient in accordance with the patient's plan of care. (2) The licensee shall ensure a hospice-trained registered nurse is on duty 24 hours a day to provide direct patient care and supervision of any nursing services. (3) Nursing services shall include treatments, medications, and diet as prescribed. R432-750-23. Infection Control. (1) The licensee shall develop and implement an infection control program to protect patients, family, and hospice personnel from community-associated infections. (2) The hospice administrator and medical director shall develop written policies and procedures governing the infection control program. (3) The licensee shall ensure that each employee wears clean garments or protective clothing and practices good personal hygiene and cleanliness. (4) The licensee shall develop and implement a system to investigate, report, evaluate, and maintain records of infections among patients and personnel. (5) The licensee shall comply with Occupational Safety and Health Administration, 29 CFR 1910.1030 (2001). R432-750-24. Pharmaceutical Services. (1) The licensee shall establish and implement written policies and procedures to govern the procurement, storage, administration, and disposal of any drugs and biologicals in accordance with federal and state laws. (2)(a) A licensed pharmacist shall supervise pharmaceutical services. (b) The licensee shall ensure the pharmacist advises the hospice and hospice interdisciplinary team regarding: (i) counseling staff on appropriate and new drugs; (ii) interactions of drugs; and (iii) procurement, storage, administration, disposal, and record-keeping of drugs and biologicals. (c) The licensee shall ensure the pharmacist conducts patient drug regimen reviews at least monthly, or more often if necessary, and make recommendations to physicians and hospice staff. (d) The licensee shall ensure the pharmacist inspects each drug storage area at least monthly. (3) The licensee shall: (a) establish and implement written policies and procedures for drug control and accountability; (b) maintain receipts and disposition of each controlled drug for accurate reconciliation; and (c) keep these records for accurate reconciliation. (4) The licensee shall ensure that pharmaceutical service drugs and biologicals are labeled based on currently accepted professional principles and include the appropriate accessory and cautionary instructions and the expiration date when applicable. (5) The licensee shall provide secure storage for medications and ensure medications that require refrigeration are maintained between 36 and 46 degrees Fahrenheit. (6)(a) The licensee shall provide separately locked compartments for the storage of controlled drugs as well as other drugs subject to abuse. (b) Per state and federal laws, only authorized personnel shall have access to the locked medication compartments. (7)(a) The pharmacist and a registered nurse shall dispose of any controlled drugs no longer needed by the patient. (b) The licensee shall maintain written documentation of the disposal. (8)(a) A hospice inpatient facility licensee shall maintain an emergency drug kit appropriate to the needs of the facility, assembled in consultation with the pharmacist, and readily available for use. (b) The pharmacist shall check and restock the emergency drug kit at least monthly. R432-750-25. Hospice Inpatient Facility Patient's Rights. (1) In addition to Section R432-750-9, the licensee shall honor each patient's right to: (a) be free of chemical and physical restraints for discipline or staff convenience; (b) be free of mental and physical abuse; (c) exercise their rights as a patient of the facility and as a citizen or resident of the United States; (d) have family members remain with the patient through the night; (e) have the family or the responsible person. informed by the hospice inpatient facility licensee of significant changes in the patient's condition or needs; (f) keep personal possessions and clothing as space permits; (g) leave the facility at any time and not be locked into any room, building, or on the facility premises during the day or night, except that the hospice inpatient facility licensee may lock doors at night for the protection of patients; (h) manage and control personal cash resources; (i) participate in religious and social activities of the patient's choice; (j) privacy during visits with family, friends, clergy, social workers, and advocacy representatives; (k) privacy for the family following a patient's death; (l) receive palliative treatment rather than treatment aimed at intervention for cure or prolongation of life; (m) receive visitors, including small children, at any hour; (n) refuse nutrition, fluids, medications, and treatments; and (o) send and receive mail unopened and have access to telephones to make and receive confidential calls. (2) The licensee shall post patient rights in a public area of the facility. (3) The licensee shall ensure restraints ordered to treat a medical condition comply with the requirements of Rule R432-150. R432-750-26. Report of Death. (1) The licensee shall have a written plan to follow when a patient dies that includes: (a) an authorization and release of the body to the funeral home; (b) documentation of the death; (c) the notification of the attending physician responsible for signing the death certificate; (d) the notification of the next of kin or legal guardian; and (e) the recording the time of death. (2) The licensee shall notify the OL of any death resulting from injury, accident, or other possible unnatural cause. R432-750-27. First Aid. (1) The licensee shall ensure that at least one staff person is on duty 24 hours a day who is certified in cardiopulmonary resuscitation and has training in basic first aid, the Heimlich maneuver, and emergency procedures. (2) The licensee, except those attached to a medical unit, shall ensure that a first aid kit is available at a designated location in the facility. (3) The licensee shall have a basic first aid manual approved by the American Red Cross, the American Medical Association, or a state, or federal health agency. R432-750-28. Safeguards for Patients Funds and Valuables. (1) The licensee shall safeguard patient cash resources, personal property, and valuables that have been entrusted to the licensee or hospice staff. (2)(a) The licensee may handle the patient's cash resources or valuables. (b) If the licensee accepts a patient's cash resources or valuables, the licensee shall safeguard the patient's cash resources in accordance with the following: (i) any money entrusted with the facility in a patient account over $150 is deposited in an interest-bearing account in a local financial institution within five days of receipt; (ii) each account is current with columns for debits, credits, and balance; (iii) each record of patient funds, and other valuables entrusted to the licensee for safekeeping, shall include a copy of the receipt furnished for funds received; (iv) each record of patient funds that is maintained as a drawing account shall include a control account for each receipt and expenditure, an account for each patient, and supporting receipts filed in chronological order; (v) the licensee or staff member may not use patient funds or valuables as their own or mingle them with own; (vi) the licensee shall ensure patient funds and valuables are separate, intact, and free from any liability that the licensee incurs in the use of the patient's funds or the institution's funds and valuables; and (vii) the licensee shall maintain accurate records of patient funds and valuables entrusted to the licensee. (3) The licensee shall maintain a separate account for patient funds specific to that hospice inpatient facility and may not commingle with patient funds from another hospice inpatient facility. (4)(a) The licensee shall return any money and valuables entrusted to the license on the day of discharge. (b) The licensee shall make any money and valuables maintained in an interest-bearing account available to the patient within three working days. (5) The licensee shall surrender the patient's money and valuables entrusted to the licensee to the responsible individuals or the hospice administrator of the estate within 30 days following the death of a patient, except in a case under investigation by the medical examiner. R432-750-29. Emergency and Disaster. (1) The licensee is responsible for the safety and well-being of patients in the event of an emergency or disaster. (2)(a) The licensee and the hospice administrator shall develop plans coordinated with the state and local emergency disaster authorities to respond to potential emergencies and disasters. (b) The plan shall outline the protection or evacuation of any patients and include arrangements for staff response, or provisions of additional staff to ensure the safety of any patient with physical or mental limitations. (c) Emergencies and disasters as referred to in this section include fire, severe weather, missing patients, interruption of public utilities, explosion, bomb threat, earthquake, flood, windstorm, epidemic, or mass casualty. (d) To assure prompt and efficient implementation, the licensee shall distribute and make available, the emergency and disaster response plan to any facility staff and patients. (e) The licensee and the hospice administrator shall review and update the plan as necessary to conform with local emergency plans. (f) The licensee shall make the plan available for review by the OL. (3) The licensee's emergency and disaster response plans shall address the following: (a) the assignment of personnel to specific tasks during an emergency; (b) delivery of essential care and services to facility occupants by alternate means; (c) delivery of essential care and services to facility occupants when additional individuals are housed in the hospice during an emergency; (d) delivery of essential care and services to facility occupants when personnel are reduced by an emergency; (e) instructions on how to contain a fire and how to use the facility alarm systems; (f) instructions on how to recruit additional help, supplies, and equipment to meet patient needs after an emergency or disaster; (g) maintenance of safe ambient air temperatures within the facility including: (i) the emergency heating is approved by the local fire department; (ii) the individual in charge shall take immediate action in the best interest of patients when the ambient air temperatures reach 58 degrees Fahrenheit or below, as it may constitute an imminent danger to the health and safety of the patients in the hospice; and (iii) the licensee shall have and implement a contingency plan regarding excessively high ambient air temperatures within the hospice that may exacerbate the medical condition of patients; (h) the name and telephone number of emergency medical personnel, fire department, paramedics, ambulance service, police, and other appropriate agencies; (i) the name of any individual to notify in an emergency in order of priority; (j) the name of the individual in charge and any individual with decision-making authority; and (k) the procedure to evacuate and transport patients and staff to a safe place within the hospice or to other prearranged locations. (4) The licensee shall ensure personnel and patients receive instruction and training in accordance with the plans to respond appropriately in an emergency and the licensee shall: (a) annually review the procedures with existing staff and patients; (b) document any drills, including the date, participants, problems encountered, and the ability of each patient to evacuate; and (c) hold simulated disaster drills semi-annually. (5)(a) The licensee shall ensure the hospice administrator is in charge during an emergency. (b) If not on the premises, the hospice administrator shall make every effort to report to the hospice, relieve subordinates, and take charge. (6) Each hospice inpatient facility licensee shall provide in-house any equipment and supplies required in an emergency including emergency lighting, heating equipment, food, potable water, extra blankets, a first aid kit, and a radio. (7) The licensee shall post the following information in appropriate locations throughout the facility to include: (a) evacuation routes, location of fire alarm boxes, and fire extinguishers; (b) the name of the individual in charge; and (c) the names and telephone numbers of emergency medical personnel, agencies, and appropriate communication and emergency transport systems. (8) The licensee shall post emergency telephone numbers at each nursing station. (9) Fire drills and fire drill documentation shall comply with Rule R710-4. R432-750-30. Food Service. (1) The licensee may provide dietary services directly, or through a written agreement with a food service provider. (2) The licensee's food service shall comply with Rule R392-100. (3) The licensee shall maintain, for OL review, any inspection reports by the local health department. (4) If the licensee accepts patients requiring therapeutic or special diets, the hospice shall have an approved dietary manual for reference when preparing meals. (5) The licensee shall ensure dietary staff receive a minimum of four hours of documented in-service training each year. (6) The licensee shall employ or contract with a certified dietitian to provide documented quarterly consultation if serving patients requiring therapeutic diets. (7) The licensee shall ensure that enough food service personnel are on duty to meet the needs of patients. (8) The cook and other kitchen staff may not perform concurrent duties outside the food service area while performing food service duties. (9) The licensee shall ensure any person that prepares or serves food has a current food handler's permit. R432-750-31. Nutrition and Menu Planning. (1) The licensee shall provide at least three meals daily. (2) The licensee shall ensure meals are served with no more than a 14-hour interval between the evening meal and breakfast unless a substantial snack is available in the evening. (3) The licensee shall make between-meal snacks of nourishing quality available on a 24-hour basis. (4) The licensee shall provide and plan a different menu each day of the week. (5) The licensee shall ensure that patients' favorite foods are included in their diets when possible. (6) The licensee shall maintain at least a one-week supply of non-perishable food and a three-day supply of perishable food. (7) The licensee shall ensure that any food is nutritious, of good quality, and appealing to the patient. R432-750-32. Pets in the Facility. (1) The licensee may allow patients to keep household pets such as dogs, cats, birds, fish, and hamsters if permitted by local ordinances. (2) The licensee shall ensure that: (a) each pet is clean and disease-free; (b) each pet that is not confined is under leash control or voice control; (c) each pet that resides at the facility has documented current vaccinations; (d) the pet environment is clean; and (e) each small pet is in an appropriate enclosure. (3)(a) Upon approval of the hospice administrator, a family member may bring a patient's pets to visit. (b) The hospice administrator shall ensure that the visiting pets have current vaccinations. (4)(a) A licensee that allows birds shall have procedures that prevent the transmission of psittacosis. (b) Procedures shall ensure minimal handling of droppings and placing of droppings into a closed plastic bag for disposal. (5) Pets may not be permitted in food preparation, storage, or central dining areas, or in any area where their presence would create a significant health or safety risk to others. R432-750-33. Laundry Services. (1) The licensee shall provide laundry services to meet the needs of the patients. (2) If the licensee contracts for laundry services, the licensee shall obtain a signed, dated agreement detailing any services provided. (3) Each licensee that provides in-house laundry services shall ensure: (a) clean bed linens are changed as often as necessary, but no less than twice each week; (b) laundry equipment is in good repair; (c) a supply of clean linen is maintained to meet the needs of the patients; (d) personnel handle, store, process, and transport linens in a manner to minimize contamination by air-borne particles and to prevent the spread of infection; (e) soiled linen and clothing are stored separate from clean linen and not allowed to accumulate in the facility; and (f) the laundry area is separate and apart from any room where food is stored, prepared, or served. R432-750-34. Maintenance Services. (1) The licensee shall provide maintenance services to ensure that equipment, buildings, furnishings, fixtures, spaces, and grounds are safe, clean, operable, and in good repair. (2)(a) The licensee shall conduct a pest control program through a licensed pest control contractor or a qualified employee to ensure the absence of rodents. (b) The licensee shall maintain, for OL review, documentation of the pest control program. (3) The licensee shall maintain entrances, exits, steps, and outside walkways in a safe condition with regard to ice, snow, and other hazards. R432-750-35. Waste Storage and Disposal. The licensee shall provide facilities and equipment for the sanitary storage and treatment or disposal of any categories of waste, including hazardous and infectious wastes, if applicable, using techniques acceptable to the Department of Environmental Quality and the local health authority. R432-750-36. Water Supply. (1) The licensee shall ensure that hot water provided to patient tubs, showers, whirlpools, and hand washing facilities is regulated for safe use within a temperature range of 105 to 120 degrees Fahrenheit. (2) Thermostatically controlled automatic mixing valves may be used to maintain hot water at the required temperatures. R432-750-37. Housekeeping Services. (1) The licensee shall provide housekeeping services to maintain a clean, sanitary, and healthful environment. (2) If the licensee contracts for housekeeping services with an outside entity, the licensee shall obtain a signed and dated agreement that details the services provided. (3)(a) The licensee shall provide safe and secure storage of cleaners and chemicals. (b) The licensee shall lock chemicals in a secure area to prevent unauthorized access or potential access by children or disoriented patients. (4) Personnel engaged in housekeeping or laundry services may not be concurrently engaged in food service or patient care. (5) The licensee shall establish and implement policies and procedures to govern the transition of housekeeping personnel to food service or direct patient care duties. R432-750-38. Penalties. Any person who violates this rule may be subject to the penalties in Rule R380-600 and Title 26B, Chapter 2, Part 7, Penalties and Investigations. KEY: health care facilities Date of Last Change: February 18, 2025 Notice of Continuation: August 6, 2026 Authorizing, and Implemented or Interpreted Law: 26B-2-202; 26B-2-204