This Alaska regulation establishes licensing and operating standards for hospice agencies (both full-service and volunteer) providing end-of-life care to terminally ill clients where they live. Operators must obtain a license, maintain a governing body, develop plans of care, meet staffing and service requirements, and comply with client rights, abuse prevention, and quality improvement obligations. The regulation also addresses admission criteria, interdisciplinary team composition, and scope of services for each agency type.
View official source7 AAC 12.310. Applicability and purpose of 7 AAC 12.310 - 7 AAC 12.349. (a) Except as provided in (b) of this section, and unless the department waives applicability under (e) of this section, the provisions of 7 AAC 12.310 - 7 AAC 12.349 apply to a public or private entity conducting, maintaining, or operating a hospice program that provides hospice care (1) where a client lives or stays; (2) for the treatment of physical, emotional, and mental symptoms of terminal illness; and (3) that is based on hospice philosophy. (b) A volunteer hospice agency is subject to the provisions of (1) this section; (2) 7 AAC 12.312 (Licensure); (3) 7 AAC 12.314 (Inspections); (4) 7 AAC 12.317 (Scope of Service: Volunteer Hospice Agency); (5) 7 AAC 12.318 (Admission Criteria); (6) 7 AAC 12.320 (Advance Health Care Directives; Client Rights), except 7 AAC 12.320 (b)(2)(I) and (L); (7) 7 AAC 12.321 (Abuse, Neglect, and Mistreatment); (8) 7 AAC 12.325 (Governing Body); (9) 7 AAC 12.329 (b) and (c) (Administration), dealing with program director requirements; (10) 7 AAC 12.336 (Volunteer Services); (11) 7 AAC 12.338 (a), (b), (c), and (k) (Hiring, Orientation, and Training); (12) 7 AAC 12.339 (Clinical and Administrative Records); (13) 7 AAC 12.340 (Employee Health); (14) 7 AAC 12.341 (Infection Control); (15) 7 AAC 12.344 (Contracts), except 7 AAC 12.344 (4); and (16) 7 AAC 12.349 (Definitions). (c) In addition to the applicable provisions of 7 AAC 12.310 - 7 AAC 12.349 , a hospice agency is subject to the applicable requirements described in 7 AAC 12.600 (a) and (i). (d) Nothing in 7 AAC 12.310 - 7 AAC 12.349 relieves a hospice agency from compliance with 42 C.F.R. Part 418 for certification of a hospice agency to participate in the Medicare program. Licensure under this chapter does not qualify a hospice agency for participation in the Medicare program. (e) The department will waive the applicability of this chapter for a hospice agency that provides proof that it is participating in the rural demonstration project under P.L. 108-173, title IV, sec. 409 (Medicare Prescription Drug, Improvement, and Modernization Act of 2003), and that it is in compliance with all applicable federal requirements for that project. A waiver issued under this subsection is void if the hospice agency ceases to participate in the project or ceases to be in compliance with applicable federal requirements. 7 AAC 12.312. Licensure. (a) Unless the department issues a waiver under 7 AAC 12.310 (e), an individual or entity must obtain a license from the department under 7 AAC 12.610 and this section if the individual or entity seeks to (1) conduct, maintain, or operate a hospice agency; (2) participate in conducting, maintaining, or operating a hospice agency; or (3) represent that the individual or entity will provide hospice services. (b) A hospice agency may have more than one office that is either a branch office or a subunit of the parent agency. Each parent agency and each branch office or subunit must be assigned a distinctive name. For purposes of this section, (1) a branch office is located in the same service area as the parent agency and shares administration, supervision, and service with the parent agency on a daily basis; a branch office is not required to be separately licensed under this chapter; and (2) a subunit is located outside the service area where the parent agency is located, and does not share administration, supervision, and services with the parent agency on a daily basis; a subunit must be separately licensed under this chapter. (c) The completed application submitted to the department must contain (1) the applicant's name and address; (2) the location of the hospice agency and each of its subunits and branch offices; (3) identification of each person administratively responsible for the hospice program, including each person's name, address, telephone number, and affiliation, if any, with a licensed home health agency, hospital, or other health care facility; (4) identification of the proposed service area; (5) a list of hospice services directly provided by the hospice agency; (6) a list of any hospice services to be provided through a contractual agreement, including each provider's name, address, and telephone number; and (7) any additional information specified by the department as necessary to determine that the applicant is a hospice agency. (d) The department will grant, deny, suspend, or revoke a license in accordance with AS 47.32 and this chapter. 7 AAC 12.314. Inspections. (a) The department will inspect each hospice agency, and may inspect each subunit or branch office of a hospice agency, after the initial application as specified in AS 47.32 and 7 AAC 12.610 , and subsequently as specified in AS 47.32 , 7 AAC 10.9600 - 7 AAC 10.9620 , and 7 AAC 12.925 . (b) The department will announce in advance any visit conducted in the home of a hospice client. The department will conduct the visit only with the client's permission. The department will consider the client's health in determining whether to visit the client in the home. A client's refusal to permit a home visit by the department does not affect the hospice agency's licensure. 7 AAC 12.316. Scope of service: full-service hospice agency. (a) A full-service hospice agency shall provide (1) physician or advanced practice registered nurse services to provide directed medical care that meets the client's medical needs for palliative care and management of terminal illness; (2) nursing care and services provided by or under the supervision of a registered nurse; (3) social work services provided in accordance with 7 AAC 12.335 ; (4) spiritual and emotional counseling services in accordance with 7 AAC 12.337 to the client, the client's family, and caregivers if these services are desired during the time the client is receiving hospice care; (5) bereavement counseling services in accordance with 7 AAC 12.337 to the client's family and caregivers after the client's death; (6) volunteer services in accordance with 7 AAC 12.336 ; (7) dietary counseling services in accordance with 7 AAC 12.337 ; (8) pharmaceutical hospice services in accordance with 7 AAC 12.343 ; (9) services related to the referral and transfer of clients for laboratory services that are provided by an organization other than the hospice; the referral and transfer services must be provided in accordance with a written plan that delineates available services and the procedures for referring and transferring clients; (10) services related to the transfer of specimens for laboratory services that are provided by an organization other than the hospice; the transfer services must be provided in accordance with a written plan that delineates available services and the procedures for transferring specimens; and (11) short-term respite care to the client's family for the relief of the client's daily care. (b) In addition to meeting the requirements of (a) of this section, the hospice agency shall evaluate each client's (1) access to emergency medical services, including ambulance service; (2) access to service, equipment, and supplies; (3) safety and emergency preparedness within the client's place of residence. (c) The hospice agency shall make nursing services, physician or advanced practice registered nurse services, and drugs and biologicals available on a 24-hour basis to the extent necessary to meet the client's needs for palliative care and management of terminal illness and related conditions. (d) The hospice agency shall arrange for short-term inpatient care if home care is not feasible for pain control, symptom management, and respite purposes. The agency shall ensure that any short-term inpatient care is provided in a licensed facility that is most appropriate to meet the client's needs. (e) The hospice agency shall offer hospice care in the least costly setting that can assure the quality of care and each type and amount of service that is necessary to meet the client's needs. (f) The hospice agency shall have a risk management program that includes procedures to investigate, analyze, and respond to client grievances related to client care. (g) The hospice agency shall develop and implement written policies and procedures consistent with this chapter that govern each service provided by the agency, including policies relating to confidentiality, training, and admissions. The policies and procedures must accurately describe the agency's goals, the methods by which the goals are achieved, and the mechanisms by which basic hospice care services are delivered. The agency shall review its policies and procedures at least annually. The program director shall document each review by dating and signing an attestation. The agency shall revise its policies and procedures if determined necessary by the agency or by the department to ensure that each policy and procedure is current and adequate for purposes of carrying out the agency's functions and maintaining consistency with this chapter. 7 AAC 12.317. Scope of service: volunteer hospice agency. (a) Subject to (b) of this section, a volunteer hospice agency shall provide each of, and only, the following services: (1) direct service volunteers; (2) spiritual and emotional support services to the client, the client's family, and caregivers if these services are desired during the time the client is receiving hospice care; (3) supervision, orientation, and training to direct service volunteers and other hospice staff; (4) bereavement counseling services to assist the client's family and caregivers in coping with grief experienced after the client's death; and (5) volunteer services in accordance with 7 AAC 12.336 . (b) A volunteer hospice agency may provide short-term respite care to the client's family for the relief of the client's daily care. (c) A volunteer hospice agency shall investigate, analyze, and respond to client grievances related to client care. (d) A volunteer hospice agency shall ensure that each client has a plan of care approved by the attending physician or advanced practice registered nurse, and by the program manager. (e) A volunteer hospice agency shall develop and implement written policies and procedures consistent with this chapter that govern each service provided by the agency, including policies relating to confidentiality, training, and admissions. The policies and procedures must accurately describe the agency's goals, the methods by which the goals are achieved, and the mechanisms by which basic hospice care services are delivered. The agency must review its policies and procedures at least annually. The program director shall document each review by dating and signing an attestation. The agency shall revise its policies and procedures if determined necessary by the agency or by the department to ensure that each policy and procedure is current and adequate for purposes of carrying out the agency's functions and maintaining consistency with this chapter. (f) Volunteer services in a volunteer hospice agency must be directed by a coordinator of volunteer services who shall (1) implement a direct service volunteer program; (2) coordinate the orientation, education, support, and supervision of direct service volunteers; and (3) coordinate the use of direct service volunteers with other hospice staff and community resources. 7 AAC 12.318. Admission criteria. (a) A hospice agency may accept a client for hospice care only if the hospice agency has a reasonable expectation that the hospice agency will adequately meet the client's needs. At the time an individual is accepted for care, or no later than two days after the day when care is initiated, the agency shall obtain written certification that the client has a terminal illness. If written certification cannot be obtained within two days, the agency shall obtain verbal certification within two days, and obtain written certification as follows: (1) for a volunteer hospice agency, within 21 days, from the attending physician; (2) for a full-service hospice agency, before billing for services, from the physician member of the interdisciplinary team or, if the team does not have a physician member, from the attending physician or another physician. (b) A full-service hospice agency shall obtain an updated certification of terminal illness at the end of each of the first two 90-day periods of care. If a client remains under the care of the agency for more than two 90-day periods, the agency shall reevaluate the client every 60 days afterwards with respect to the prognosis for life expectancy and shall consider whether transfer to another type of health care provider is indicated. (c) A hospice agency may not reject a client for hospice services based on race, color, national origin, age, sex, religion, or ethnicity. (d) A hospice agency may not terminate or reduce care provided to a client because of the client's inability to pay for the care. (e) In addition to meeting the applicable requirements of (a) - (d) of this section, a hospice agency shall consider the following factors before accepting a client for hospice services: (1) the adequacy and suitability of agency staff and resources to provide necessary services; (2) assessments of the client's medical, nursing, and social needs pertaining to the benefits derived from hospice care; (3) attitudes of the client and the client's family toward hospice care; (4) degree of client and family awareness of their respective rights and responsibilities; (5) the agency's ability to manage any medical emergency that is likely to occur, based on an assessment of known risk factors related to the client's condition; (6) the availability, ability, and willingness of others to participate in the client's care; (7) assurance that services can be effectively coordinated through liaison with organizations and individuals also providing care to the client. 7 AAC 12.319. Plan of care. (a) The interdisciplinary team designated under 7 AAC 12.327 by a full-service hospice agency shall develop and maintain a written plan of care for each client admitted to a hospice program. The agency shall ensure that care provided to a client is in accordance with the plan of care. (b) The hospice agency shall review each client's plan of care and document each review in the client's clinical record. The agency shall update the plan of care at intervals specified in the plan of care, or more frequently if determined necessary by the (1) medical director; (2) attending physician; (3) advanced practice registered nurse responsible for the client's care; or (4) interdisciplinary team. (c) Each plan of care must address client and family problems and needs, goals and objectives, the frequency and type of services, the level of care to be provided, agreed-upon outcomes, prescribed or required medical equipment, and evidence of client and family understanding, agreement, and involvement with the plan of care. The interdisciplinary team shall consider the need for at least the following services when developing the plan of care: (1) social work services; (2) nursing care; (3) counseling; (4) pastoral care; (5) volunteer visits to provide comfort, companionship, and respite; (6) bereavement services to be provided for at least one year after the death of the person who is terminally ill; (7) medical services. (d) The hospice agency shall designate a registered nurse to coordinate each client's overall plan of care. (e) The hospice agency shall promptly alert the attending physician or advanced practice registered nurse of conditions that may require a change to a plan of care. The agency must obtain a verbal order from the attending physician or advanced practice registered nurse, or from the medical director, before making any change to a client's medical treatment. The agency shall ensure that signed written orders are in the client's file within 21 days after the verbal order was taken. 7 AAC 12.320. Advance health care directives; client rights. (a) Before initiation of care or services, a hospice agency shall provide each client who is 18 years of age or older, or the client's legal representative, with forms and information regarding (1) the client's right to make health care decisions, including the right to accept or refuse medical or surgical treatment, and the right to execute an advance health care directive and durable health care power of attorney; (2) agency policies for implementing the client's right to make health care decisions; (3) living wills and do-not-resuscitate orders; and (4) persons who can provide additional information concerning advance health care directives and durable health care powers of attorney. (b) The governing body of the hospice agency shall protect and promote the rights of each hospice client, by assuring that (1) before services are provided, the client and the client's family are informed orally and in writing, in a language the client and the client's family understand, of the respective rights and obligations of the agency and the client; the agency shall document receipt of the notification of these rights and obligations by the client and the client's family; (2) each client receiving hospice services has the right to (A) courteous and respectful treatment of person and property; (B) be free from physical and mental abuse, neglect, or mistreatment; (C) care or services from employees or contractors properly trained to perform assigned tasks; (D) proper identification by name and title of each employee, contractor, or volunteer who provides hospice care to that client; (E) the following information in advance of care or services: (i) the care and services to be provided; (ii) any changes in the care or services to be provided; (iii) the frequency of proposed visits for care or services; (iv) the agency's expectation of the client's responsibilities to participate in the client's own care or services; (v) the name of the person supervising the care or services, and how to contact the agency; (F) confidentiality with regard to information about the client's health, social life, and activities in the client's home; (G) have the client's medical history released only as required by law or as authorized by the client or the client's legal representative; (H) access information in the client's medical record within two working days after submitting a written request to the agency; (I) be informed, orally and in writing, before a service is initiated, of the expected source of payment for the care or services provided by the agency, its employees, or its contractors; the requirements of this subparagraph do not apply to a volunteer hospice agency; (J) submit a grievance to the agency about the service or lack of service provided by the agency, its employees, its contractors, or its volunteers; the agency shall (i) investigate and respond to the client or person who submitted the grievance; and (ii) provide information to the client or person who submitted the grievance about how to contact the department to file a complaint; (K) be informed of the reason for impending discharge, transfer to another agency or facility, change in the level of care, ongoing care requirements, and other available services and options, if needed; and (L) participate in developing the client's plan of care and changes in care or treatment. 7 AAC 12.321. Abuse, neglect, and mistreatment. (a) A hospice agency shall (1) develop and implement written policies and procedures that prohibit abuse, neglect, and mistreatment of clients; (2) document alleged or suspected incidents of abuse, neglect, or mistreatment by an employee, volunteer, or contractor; (3) investigate alleged or suspected incidents of abuse, neglect, or mistreatment; (4) take any necessary action to remove the potential for further abuse, neglect, or mistreatment of a client or further misappropriation of a client's property; (5) document the result of the investigation and the corrective action taken within five days after the agency becomes aware of an incident described in (2) and (3) of this subsection; (6) submit the documentation prepared under (5) of this subsection to the department; and (7) assure that an employee, volunteer, or contractor does not obtain a client's power of attorney in violation of AS 13.26.358 . (b) A hospice agency is subject to the reporting requirements of AS 47.17.020 and AS 47.24.010 . (c) A hospice agency shall contact the appropriate licensing authority to verify the disciplinary history of a potential employee or contractor who is required to hold a license to practice. 7 AAC 12.323. Quality improvement plan. (a) A full-service hospice agency shall conduct an ongoing comprehensive self-assessment of the quality and appropriateness of care provided, including inpatient care and care provided under contract. The agency shall document the findings from its self-assessment and use them to correct identified problems and to revise hospice policies as necessary. (b) A full-service hospice agency shall establish a quality improvement plan for continually (1) monitoring and evaluating care provided; (2) identifying existing and potential issues; and (3) proposing and implementing improvements, and reevaluating care provided to determine if further improvement is possible or necessary. (c) The plan required under (b) of this section must include an analysis of (1) a quarterly clinical record review conducted as required under (f) of this section; (2) data derived from client assessments; (3) current clinical practice guidelines and professional practice standards applicable to clients in the home; (4) utilization of services; (5) measures of staff performance; (6) medical and other professional evaluation of the agency's caregiving system; (7) client and family satisfaction surveys; and (8) client complaints and the resolution process for those complaints. (d) The quality improvement program must include problem identification, corrective action, and subsequent monitoring of identified problems. (e) A full-service hospice agency shall review a client's clinical record at least every 30 days during which the client receives hospice services to determine the adequacy of the plan of care and appropriateness of continued care. (f) The quarterly clinical review required under (c)(1) of this section must be conducted by a multidisciplinary team of health professionals representing the services provided by the hospice agency. The review must consist of at least 10 percent of both active and closed records in that quarter to determine if applicable state laws and agency policies are properly followed. 7 AAC 12.325. Governing body. A hospice agency must have a governing body that assumes full legal responsibility for determining, implementing, and monitoring the policies that govern operation of the hospice. In addition to meeting the applicable requirements of 7 AAC 12.630 , the governing body shall (1) adopt, and revise as necessary, written bylaws that provide for the (A) election or appointment of officers and committees; (B) appointment of a local advisory board of individuals who reside in the service area, if the governing body is outside the state; and (C) establishment of the frequency of meetings; (2) establish a written mission statement that is consistent with hospice philosophy; (3) designate as program director an individual who meets the requirements of 7 AAC 12.329 (b); (4) provide for systematic and effective communication between the community, governing body, and the program director of the hospice agency; (5) ensure that services provided are consistent with hospice philosophy and the requirements of this chapter; and (6) provide sufficient staff, supplies, and equipment to meet client needs. 7 AAC 12.326. Professional advisory committee. (a) The governing body of a full-service hospice agency shall appoint a professional advisory committee. The committee shall meet at least twice each year to advise and monitor the agency and shall report its findings in writing to the governing body. The committee must consist of (1) the program director; (2) a physician or advanced practice registered nurse; (3) a registered nurse; (4) a member of the public who resides in the agency's service area and who is not an owner or employee of the agency; and (5) at least one representative from one of the client care services provided by the agency. (b) At least once each year, the professional advisory committee shall conduct an overall program evaluation of the hospice agency and forward the results of that evaluation in writing to the governing body of the agency. The evaluation must include a review of (1) the agency's policies and procedures governing the scope of services offered, including acceptance and discharge of clients, medical supervision, plans of care, emergency care, the quality improvement program, and other relevant professional issues; and (2) the results of quality improvement activities conducted under 7 AAC 12.323 , including clinical record reviews. (c) The professional advisory committee shall maintain each agency review as a separate administrative record. (d) The hospice agency shall document the professional advisory committee's involvement and communication with the governing body and the director of the hospice agency. 7 AAC 12.327. Interdisciplinary team. (a) A full-service hospice agency shall designate an interdisciplinary team composed of individuals who provide or supervise the care and services offered by the agency. The interdisciplinary team must include at least a (1) physician; (2) registered nurse; (3) social worker described in 7 AAC 12.335 and 7 AAC 12.700 ; (4) pastoral or other spiritual counselor; and (5) volunteer coordinator or representative, if applicable. (b) If the agency provides one or more of the following services, the interdisciplinary team may also include a representative for that service: (1) physical therapy; (2) occupational therapy; (3) speech pathology; (4) home health services. (c) Nothing in this section precludes an agency from designating additional individuals to join the interdisciplinary team on a regular or as-needed basis. (d) The interdisciplinary team shall (1) participate in the development and maintenance of the plan of care for each client of the agency; (2) establish the policies governing the daily provision of hospice care and service; (3) schedule and attend interdisciplinary team conferences at a frequency that is based on client needs; (4) document conference findings and conclusions; and (5) review and make any necessary revision of each plan of care as required under 7 AAC 12.319 . (e) Each member of the interdisciplinary team must be qualified, in terms of applicable education and training. If the individual's profession requires licensing or certification, that license or certification must be current. The agency must maintain a written record for each team member that includes verification of applicable education, training, license, and certification. The agency shall review these records annually to ensure the records are current and accurate. 7 AAC 12.329. Administration. (a) A full-service hospice agency shall maintain administrative control over the services provided by the agency. The agency may not delegate administrative and supervisory functions to another agency, individual, or organization. The hospice agency shall describe in writing (1) the services provided by the agency; (2) the services provided by contract or another arrangement; and (3) the lines of authority for the delegation of responsibility to the client care level. (b) A full-service or volunteer hospice agency shall have a program director who is responsible for the daily management of the hospice program. The administrator of the agency may act as program director. The program director must have education, experience, and knowledge related to hospice care or related home health program care appropriate to the fulfillment of the responsibilities described in (c) and (d) of this section, as applicable. The agency shall develop written documentation setting out the responsibilities and authority of the program director. If the program director's position becomes vacant, the agency shall notify the department within 48 hours and provide, if available, the name of the replacement. The agency shall designate, in writing, a qualified individual to act in the capacity described in this subsection in the program director's absence. (c) The program director for a full-service or volunteer hospice agency shall (1) have authority to manage, and responsibility for managing, the business affairs and overall operation of the agency; (2) organize and direct the agency's ongoing functions; (3) implement and regularly evaluate policies and procedures for the management and operation of the hospice and evaluation of the overall program performance of the agency; (4) establish an organizational structure appropriate for directing the work of hospice employees, contractors, and volunteers in accordance with the agency's policies and procedures; (5) ensure that employees and ancillary staff receive orientation to their responsibilities and to the hospice program; (6) evaluate the functions and activities of employees and ancillary staff to assure conformance with applicable state and federal laws, agency policies and procedures, and applicable professional standards; (7) maintain a liaison between the governing body, any professional committee, and the employees and volunteers; (8) report to the governing body at least annually regarding agency operation; (9) ensure adequate continuing education and evaluation of staff; and (10) evaluate the recommendations of agency committees and consultants. (d) In addition to fulfilling the responsibilities described in (c) of this section, the program director for a full-service hospice agency shall (1) employ qualified personnel; (2) designate a nurse coordinator, and ensure the involvement of the nurse coordinator in decisions regarding employees and contract staff; and (3) ensure that the agency has an institutional budget plan that includes (A) an annual operating budget; and (B) a capital expenditure plan for the next three years. 7 AAC 12.331. Professional management. (a) A full-service hospice agency shall have a physician or advanced practice registered nurse to serve as medical director and assume overall responsibility for each client's care program. The medical director shall be a member of and oversee the interdisciplinary team and the professional advisory committee. The medical director's duties include verifying that certification of terminal illness has been issued in accordance with 7 AAC 12.318 (a)(2). (b) The program director shall designate a registered nurse to serve as the nurse coordinator. The nurse coordinator shall (1) supervise the agency's employees and contracted staff; (2) be available at all times for consultation during regular office hours or have a qualified designee if the nurse coordinator is on leave status or otherwise unavailable to the agency; (3) ensure that the agency has sufficient staff to meet patient needs; (4) be responsible for the development of nursing objectives, policies, and procedures consistent with hospice philosophy; (5) establish staffing and on-call schedules for nursing staff to ensure the availability of nursing services 24 hours a day, seven days a week; and (6) participate in the developing job descriptions and making employment decisions affecting hospice personnel who provide direct services. (c) The program director shall have authority over and responsibility for the (1) functions, activities, and evaluation of professional and ancillary staff to assure conformance with applicable state and federal laws, agency policies and procedures, and applicable professional standards; and (2) implementation of client care policies and procedures. (d) The agency shall provide nursing care and services by or under the supervision of a registered nurse. Nursing services must be directed and staffed to assure that each client's nursing needs are met. Hospice nursing services include (1) identifying the physical, psychosocial, and environmental needs of the client and the client's family; (2) conducting detailed and comprehensive assessments of each client upon admission and when significant changes occur in the client's condition; (3) addressing symptom management and comfort care needs; (4) implementing client teaching based on the client's needs consistent with agency policies and procedures, including demonstration, supervision, and evaluation; (5) documenting problems, appropriate goals, interventions, and client and family response to hospice care; (6) coordination of all client and family services; (7) supervision of other nursing personnel; and (8) preparation of clinical progress notes. 7 AAC 12.333. Hospice home health aide services. (a) A full-service hospice agency may provide home health aide services. If the agency provides home health aide services, those services must be provided (1) by a nurse aide with a current certification under AS 08.68.331 ; (2) in accordance with the plan of care; and (3) in accordance with written instructions (A) prepared by a registered nurse providing services under 7 AAC 12.331 ; and (B) that specify each task to be completed during a home visit. (b) A nurse aide employed by the agency shall (1) follow the current plan of care; (2) perform simple procedures as an extension of therapy services; (3) provide personal care, including bathing, hair care, oral hygiene, skin care, and hand and foot care; (4) assist the client with ambulating and exercise; (5) assist with the client's meal preparation or feeding; (6) assist with client-administered nonprescription and prescription medications by handing the client the medication bottle, or the medication that was prepared under the supervision of a physician, a registered nurse, or an advanced practice registered nurse; (7) report changes in the client's condition and needs; (8) complete appropriate records; and (9) take and record vital signs. (c) A registered nurse providing services under 7 AAC 12.331 shall make a supervisory visit to each client's residence at least once every two weeks, either to observe and assist when the nurse aide is present, or to assess relationships and determine whether goals identified in the plan of care are being met. The registered nurse shall directly observe the in-home performance of each nurse aide at least once each month. The agency shall maintain sufficient documentation to demonstrate that a nurse aide is evaluated for competency in (1) communication; (2) observation, reporting, and documentation of the client care provided; (3) maintenance of a clean, safe, and healthy environment; (4) provision of basic infection control procedures; (5) knowledge of basic nutrition and fluid intake, including food preparation techniques as appropriate; (6) reading and recording temperature, pulse, and respiration; (7) knowledge and observation of basic elements of body functioning and changes in body functioning that must be reported to the nurse aide's supervisor; (8) recognition of emergencies and knowledge of emergency procedures; (9) recognition of the physical, emotional, and developmental needs of, and ways to work with, clients served by the hospice, including respect for the client and the client's family, the client's privacy, and the client's property; (10) use of appropriate and safe techniques for the client's personal hygiene and grooming, including (A) a bed bath, sponge bath, tub bath, or shower bath; (B) sink, tub, or bed shampooing; (C) nail and skin care; (D) oral hygiene; and (E) toileting and elimination; (11) safe transfer techniques and ambulation; (12) normal range of motion and positioning; and (13) any other task that the agency may assign to the nurse aide. 7 AAC 12.334. Physical therapy services. A full-service hospice agency may provide physical therapy services. If the agency provides physical therapy services, the agency shall ensure that (1) the physical therapist and any physical therapist assistant meet the requirements of 7 AAC 12.690 ; and (2) in fulfilling supervisory duties required under 7 AAC 12.690 , the physical therapist makes supervisory visits to the client's residence at least every two weeks to (A) evaluate the effectiveness of the services furnished by any physical therapy assistant; and (B) document the client's condition in the clinical record. 7 AAC 12.335. Social work services. (a) A full-service hospice agency shall provide social work services required by 7 AAC 12.316 (a)(3) (1) under the direction of a physician or advanced practice registered nurse; and (2) by a social worker who (A) has a master's degree from a social work curriculum accredited by the Council on Social Work Education; and (B) is licensed as a clinical social worker or a master social worker under AS 08.95 . (b) The social worker must be available to the extent necessary to meet the needs of clients and their families for care that is reasonable and necessary for palliative care and management of terminal illness and related conditions. (c) In addition to performing the duties set out in 7 AAC 12.700 (a)(1) - (6), the social worker shall provide ongoing psychosocial assessment of the family's capacity to cope with the client's terminal condition. 7 AAC 12.336. Volunteer services. (a) A hospice agency shall ensure that each volunteer provides care and services in accordance with the client's plan of care, and under the supervision of a designated hospice employee. (b) The agency shall develop and maintain policies and procedures that address the following with respect to volunteers in the program: (1) recruitment, retention, and dismissal; (2) screening; (3) orientation; (4) scope of function; (5) supervision; (6) ongoing training and support; (7) team conferencing; (8) records of volunteer activities; (9) bereavement services. (c) A volunteer is subject to the applicable requirements of 7 AAC 12.338 . (d) The hospice agency shall document active and ongoing efforts to recruit and retain volunteers. 7 AAC 12.337. Counseling services. (a) A full-service hospice agency shall develop an organized program to provide spiritual, emotional, bereavement, and other counseling services under the supervision of a qualified professional. Counseling services may include the provision of written material, social reorientation, and group support. (b) While the client is receiving hospice care, a full-service hospice agency shall make available spiritual, emotional, and other counseling services to the client and to the client's family as reasonable and necessary for palliative care and management of terminal illness and related conditions. (c) A full-service hospice agency shall make available bereavement counseling to assist the client's family and caregivers in coping with grief experienced after the client's death. (d) Any spiritual counseling, if desired by the client or the client's family, must be provided by a pastoral or spiritual counselor recognized by the governing body to be capable of providing spiritual, religious, and emotional support to the client and, as necessary, the client's family. The hospice agency may not request or require the client or the client's family to accept any value or belief system. The pastoral or spiritual counselor shall (1) regularly reassess the spiritual needs of the client and the client's family related to the changing status of the client's terminal condition; (2) support and assist the client, the client's family, or both; (3) develop and maintain contact, subject to the client's approval, with the client's identified religious representative; and (4) be a member of the interdisciplinary team. (e) A full-service hospice agency shall make available dietary counseling to the client, the client's family, or caregivers, as necessary, including counseling that will assist the family or caregiver in preparing food for the client. The agency shall ensure that dietary counseling is related to the client's needs rather than the personal needs of the family or caregiver. Dietary counseling shall be provided to clients who experience difficulty in meeting nutritional needs, including clients with dysphasia or other swallowing problems, problems with enteral feedings, or nutritional issues resulting from nausea, vomiting, or the dying process. Dietary counseling must be provided by a registered nurse or other person with relevant education or training. In this subsection, "enteral feeding" means the delivery of liquid feedings through a tube for individuals who have a functioning gastrointestinal tract, but are unable to orally ingest adequate nutrients to meet their metabolic and nutritional needs. 7 AAC 12.338. Hiring, orientation, and training. (a) A full-service or volunteer hospice agency shall require each volunteer and each direct service provider (1) to submit a written application; (2) to undergo a screening interview and an interview after training; (3) to receive the orientation and training required (A) under (b), (c), and (k) of this section, if a volunteer; and (B) under (b) - (k) of this section, if a direct service provider; (4) to submit a confidentiality statement, signed by the volunteer or direct service provider, in which the volunteer or direct service provider agrees to follow the program's policy regarding confidentiality; and (5) if the volunteer or direct service provider will transport individuals, to provide proof of (A) the motor vehicle liability insurance required under AS 28.22.019 ; and (B) a valid driver's license issued by this state. (b) Before allowing a volunteer or direct service provider to provide a hospice service, a full-service or volunteer hospice agency shall ensure that the individual receives an orientation of at least four hours that is specific to hospice services. The agency shall document this orientation within the first week of employment. (c) A full-service or volunteer hospice agency shall develop policies and procedures that define the agenda of the orientation. The orientation must include at least the following subjects: (1) hospice philosophy; (2) personal death awareness; (3) communication skills; (4) personnel issues; (5) identification of hospice resource people; (6) stress management; (7) ethics and confidentiality; (8) stages of dying; (9) funeral arrangements. (d) A full-service hospice agency shall develop policies and procedures to ensure that each indirect service volunteer receives an orientation applicable to the duties the volunteer will perform. (e) A full-service hospice agency shall provide an educational program that offers a comprehensive overview of hospice philosophy and hospice care. The agency shall provide a minimum of 18 hours of education within a one-year period for each direct service provider delivering hospice care. The four hours of orientation training required under (b) of this section may be counted as part of the 18 hours required under this subsection. The educational program must include at least the following subjects: (1) hospice philosophy; (2) family dynamics; (3) pain and symptom management; (4) grief, loss, and transition; (5) psychological perspectives on death and dying; (6) spirituality; (7) communication skills; (8) volunteer roles; (9) multidisciplinary management. (f) Documentation of completion of the education program described in (e) of this section is transferable from one hospice agency to another. (g) A full-service hospice agency shall provide a program of continuing training directed at the maintenance of appropriate skill levels for hospice employees who provide services to clients and their families. (h) In addition to meeting the other requirements of this section, a full-service hospice agency shall conduct in each service area an orientation program for each new employee and annual in-service training for all employees, including volunteers and contractors, that covers the following topics: (1) agency policies and procedures; (2) job duties and responsibilities specific to each employee's job; (3) recognition of and responses to potential fire, emergency, and home safety hazards; (4) principles and techniques of infection control; the agency shall verify that its employees, contractors, and volunteers who provide client care, receive training on (A) universal precautions; in this subparagraph, "universal precautions" means the infectious control precautions that are recommended by the United States Department of Health and Human Services, Centers for Disease Control and Prevention, to be used to prevent the transmission of blood-borne germs such as human immunodeficiency virus and hepatitis B virus; (B) the prevention, transmission, and treatment of tuberculosis, in accordance with 7 AAC 12.650 (a)(1); (5) ethics and confidentiality; (6) applicable state and federal law and the agency's policies and procedures; (7) functions of other employed health personnel, including functions of hospice volunteers; (8) coordination of services within the agency and with community services. (i) A full-service hospice agency shall require cardiopulmonary resuscitation (CPR) training every two years for each employee who works directly with clients. (j) To meet the training requirements of this section, a full-service hospice agency shall provide a nurse aide with at least 12 hours of in-service training each calendar year combined with six hours of additional training during the first year of employment. The 12 hours of in-service training must be based on the training needs identified through supervisory visits and the needs of the client being served by the agency. The agency shall provide training for all care duties not included in the basic competency skills identified in 7 AAC 12.333 (c). (k) A full-service or volunteer hospice agency shall provide or arrange for a volunteer training and continuing education program that provides, at a minimum, (1) orientation and training for new volunteers to acquaint them with the philosophy, organization, services, practices and goals of the hospice program; (2) the psychosocial and psychological aspects of terminal disease; (3) family dynamics and psychosocial issues surrounding terminal disease, death, and bereavement; (4) communication skills; and (5) initial and continued training needs specific to the duties, responsibilities and competency of each volunteer. 7 AAC 12.339. Clinical and administrative records. (a) A hospice agency shall establish and maintain a clinical record for each client receiving care and services. The record must provide for identification, security, confidentiality, control, retrieval, and preservation of client care data and information. Each clinical record must be a comprehensive compilation of information. The agency shall ensure that entries are (1) made for all services provided, whether furnished directly by or indirectly through the agency; and (2) made and signed by the staff providing the services. (b) Each client's clinical record must contain (1) appropriate identifying information; (2) assessments by appropriate personnel; (3) the client's plan of care; (4) the name of the attending physician or advanced practice registered nurse; (5) signed and dated progress notes; (6) copies of summary reports sent to the attending physician or advanced practice registered nurse; (7) a signed client release or consent form; (8) documentation of informed consent regarding the initiation of care and treatment and changes in the plan of care; (9) evidence that the client was informed regarding advance health care directives and client rights as described in 7 AAC 12.320 ; (10) copies of any transfer information sent with the client; and (11) a discharge summary, if appropriate. (c) Clinical progress notes must be written or dictated on the day that care or service is provided. The clinical progress notes must be incorporated into the client's clinical record within seven days. (d) A hospice agency shall have written policies and procedures to ensure that clinical records are (1) legibly written in ink or typed, and suitable for photocopying; (2) readily available to authorized personnel during operating hours of the agency; (3) protected from damage; (4) if electronic, protected by security software designed to ensure confidentiality; (5) retained for at least five years after the date of discharge, or in the case of a minor, three years after the client turns 21 years of age; agency policies and procedures must provide for record retention even if the agency discontinues operation; (6) disposed of using a method that will prevent retrieval and subsequent use of information; and (7) transferred with the client if the client transfers to another agency or health facility; the transferred record may be (A) a copy; or (B) an abstract and a summary report. (e) In addition to maintaining clinical records as described in this section, a hospice agency shall maintain administrative records that, at a minimum, include (1) minutes of governing body meetings; (2) all receipts and expenditures; and (3) training provided to paid staff and volunteers. 7 AAC 12.340. Employee health. A hospice agency shall have an employee health program that meets the requirements of 7 AAC 12.650 . The agency shall require contractors and volunteers performing patient care or services for the agency to meet the requirements of 7 AAC 12.650 . 7 AAC 12.341. Infection control. A hospice agency shall develop and implement written policies and procedures applicable to all agency staff that (1) minimize the risk of transmitting infection in all client care or services; and (2) provide for the safe handling and disposal of pathological, biohazardous, or infectious materials. 7 AAC 12.342. Central supply; medical supplies and appliances. (a) A full-service hospice agency is subject to this section unless the agency provides inpatient care on agency premises. An agency that provides inpatient care on agency premises shall comply with 7 AAC 12.730 . A hospice agency that is subject to this section shall maintain a separate area for the (1) storage of sterile supplies and materials to protect those supplies and materials from contamination; and (2) cleaning, disinfection, or sterilizing, as appropriate under (b) of this section. (b) A hospice agency that is subject to this section shall develop and implement policies and procedures for (1) identifying supplies or equipment that, because of the intended use, must be cleaned, disinfected, or sterilized to decrease the risk of infection; (2) cleaning, disinfecting, sterilizing, and storage of nondisposable supplies and equipment to prevent contamination and the transmission of infection through use; (3) identifying potentially infectious materials that must be treated before disposal; (4) handling, packaging, and disposing of materials and sharp instruments contaminated by pathological, biohazardous, or infectious waste; and (5) maintaining a system for identifying and preventing usage of supplies with questionable sterility. (c) A hospice agency that is subject to this section shall provide medical supplies and appliances, including drugs and biologicals, as needed for palliative care and management of terminal illness. The agency shall have a written policy to recommend to the client, the client's family, or the caregiver the destruction, or disposal, as appropriate, of drugs, including scheduled drugs, chemicals, and biologicals that are used in the care of the client and maintained in a client's home if the drugs, chemicals, or biologicals have expired or are no longer needed by the client. 7 AAC 12.343. Pharmaceutical hospice services. (a) A full-service hospice agency is subject to this section unless the agency provides inpatient care on agency premises. An agency that provides inpatient care on agency premises shall comply with 7 AAC 12.680 . A hospice agency that is subject to this section shall develop policies and procedures for the dispensing and administering of drugs and biologicals related to hospice treatment. Whether drugs and biologicals are obtained from a pharmacist or are stocked by the agency, the agency is responsible for ensuring that (1) drugs and biologicals are provided as needed for its clients for palliative care and the management of the terminal illness and related conditions; and (2) pharmaceutical services are provided in accordance with the client's plan of care, the agency's written policies and procedures, and applicable federal, state, and municipal statutes, ordinances, and regulations, including AS 08.68 , AS 08.80 , 12 AAC 44 , and 12 AAC 52 . (b) Only a physician or advanced practice registered nurse may order medications for the client. If the medication order is verbal, (1) the physician or advanced practice registered nurse may give the order only to a licensed nurse, pharmacist, or another physician or advanced practice registered nurse; and (2) the individual receiving the order must record and sign it immediately and have the prescribing physician or advanced practice registered nurse sign it within 21 days after the date of signature. (c) Medication may be administered only by a licensed nurse or, if the attending physician or advanced practice registered nurse has approved, by (1) the client; (2) a member of the client's family; or (3) a caregiver designated by the client. 7 AAC 12.344. Contracts. If a hospice agency contracts with another entity or agent to perform services for or provide resources to the agency, the agency shall monitor and control those services and resources. In addition to meeting the requirements of 7 AAC 12.910 , the agency shall ensure that the contract (1) provides that clients are accepted for care or services only by the contracting agency; (2) requires the contractor to conform to all applicable agency policies, including personnel qualifications; (3) delineates the role of the hospice and of the contractor in the admission process, patient and family assessment, and the interdisciplinary team care conferences; (4) specifies the contractor's responsibility for participating in developing a plan of care; this paragraph does not apply to a volunteer hospice agency; (5) specifies that the contracted services may be provided only with the express authorization of the agency; (6) specifies the manner in which the agency will control, coordinate, and evaluate the care or services; and (7) identifies the procedures for payment for services furnished under the contract. 7 AAC 12.349. Definitions. In 7 AAC 12.310 - 7 AAC 12.349 , unless the context requires otherwise, (1) "advance health care directive" means an instruction described in AS 13.52 regarding the provision or nonprovision of health care; (2) "agency" means hospice agency; (3) "bereavement counseling" means emotional support services to assist a client's family or caregivers in coping with the client's death; (4) "client" means an individual with a terminal illness who has been accepted to receive hospice care; (5) "direct service" means service provided directly to a client receiving services in a hospice program; (6) "employee" means a paid staff person designated by the hospice agency to provide services to a client or the client's family under the direction of the plan of care for the client; "employee" includes an individual providing services to the client or the client's family under contract with the hospice agency; (7) "family" means (A) individuals related to a client by blood, marriage, or court decree; and (B) one or more individuals who have a significant personal relationship with a client and who have been designated, by mutual agreement between each individual and the client, as members of the client's family; (8) "full-service hospice agency" means a hospice agency that provides, and charges a fee for, the services described in 7 AAC 12.316 ; (9) "hospice home health aide" means an individual employed by or under contract with a hospice agency to provide hospice services as specified in 7 AAC 12.333 ; (10) "hospice philosophy" has the meaning given the term in the definition of "hospice services" in AS 47.32.900 ; (11) "hospice services" has the meaning given in AS 47.32.900 ; (12) "medical director" means a physician or advanced practice registered nurse who oversees the medical components of hospice services and the interdisciplinary team; (13) "palliative care" means care provided for the reduction or abatement of pain, for physical symptoms, and for psychosocial or spiritual needs of an individual with a terminal illness; "palliative care" includes physician or advanced practice registered nurse services, skilled nursing care, social work services, volunteer services, and bereavement services; "palliative care" does not include treatment provided solely to cure a medical condition or disease or to artificially prolong life; however, treatment that is curative in nature may be provided if the purpose of the treatment is to reduce or abate pain or other symptoms, or to slow the progression or reduce the psychological effects of the terminal illness; (14) "plan of care" means (A) for a hospice agency other than a volunteer hospice agency, a written service delivery plan developed and maintained under 7 AAC 12.319 by the interdisciplinary team, in conjunction with the client, to reflect the client's changing care needs; and (B) for a volunteer hospice agency, the plan described in 7 AAC 12.317 (d); (15) "program director" means the individual designated by the governing body of a hospice agency to be responsible for the daily operations of the agency; (16) "respite care" means care provided to an individual with a terminal illness to provide temporary relief to a primary caregiver; (17) "service area" means the geographical area in which a hospice agency regularly provides services to individuals; (18) "short-term inpatient care" means care provided to an individual with a terminal illness, in an inpatient setting, for brief periods of time for the purpose of pain control or acute or chronic symptom management; (19) "terminal illness" means an illness for which an individual has a life expectancy of less than six months if the illness runs its normal course, and for which the individual is no longer receiving curative treatment; (20) "volunteer" means a trained individual who works for a hospice agency without compensation; (21) "volunteer hospice agency" means a hospice agency that provides all direct client care at no charge.