PURPOSE: This rule defines the minimum requirements for the provision of hospice services by state certified hospice programs.

1. (1) General Provisions.

   1. (A) Definitions Relating to Hospice Care Agencies.

      1. 1. Attending physician—a person who—

         1. A. Is licensed as a doctor of medicine

or osteopathy in this state or a bordering state; or

1. B. Is recognized by Missouri as a

nurse practitioner and who complies with the requirements of Chapter 335, RSMo, 20 CSR 2200-4.200, and 42 CFR 410.75; or

1. C. Is licensed as a physician assistant

1. (PA) in Missouri and who complies with the requirements in Chapter 334, RSMo, 20 CSR 2150-7.135, and 42 CFR 410.74(c); and

   1. D. Is identified by the patient, at the

time s/he elects to receive hospice care, as having the most significant role in the determination and delivery of the patient’s medical care.

1. 2. Automated dispensing system—a

mechanical system that performs functions that may include, but are not limited to, storing, packaging, or dispensing medications, and that collects, controls, and maintains all transaction information.

1. 3. Certified medication technician—a

person who has completed the certified medication technician training program approved by the Department of Health and Senior Services.

1. 4. Certified pharmacy technician—a

person who is credentialed by a nationally recognized pharmacy technician credentialing authority.

1. 5. Contracted provider—individuals or

entities who furnish services to hospice patients under contractual arrangements between the hospice and the contracted provider.

1. 6. Coordinating provider—any individu-

al or agency which independently provides services to the patient in their place of residence.

1. 7. Dietary counselor—an individual that

is currently eligible to be licensed as a dietitian in Missouri or recognized as a nutritionist.

1. 8. Direct employee—an individual paid

directly by the hospice.

1. 9. Emergency medication supply—a

limited number of prescription medications approved by the medical director and the pharmacist that may be administered to a patient in an emergency situation or for initial doses of a necessary medication when a pharmacist cannot provide medication services for a patient within a reasonable time based on the patient’s clinical needs at the time.

1. 10. Employee—an employee of the hos-

pice or an individual under contract who is appropriately trained and assigned to the hospice program. Employee also refers to a person volunteering for the hospice program.

1. 11. Family—broadly defined to include

not only persons bound by biology or legalities but also those who function for the patient in a familial way.

1. 12. Homemaker—a home health aide,

volunteer, or other individual who assists the patient/family with light housekeeping chores.

1. 13. Home health aide—a person who

meets the training, attitude, and skill requirements specified in the Medicare home health program (42 CFR 484.36).

1. 14. Hospice—a public agency or private

organization or subdivision of either that—

1. A. Is primarily engaged in providing

care to dying persons and their families; and

1. B. Meets the standards specified in 19

CSR 30-35.010 and in 19 CSR 30-35.030. If it is a hospice that provides inpatient care directly in a hospice facility, it must also meet the standards of 19 CSR 30-35.020.

1. 15. Hospice administrator—the employ-

ee designated by the governing body as responsible for the overall functioning of the hospice.

1. 16. Hospice patient—a person with a

terminal illness or condition for whom the focus of care is on comfort and palliation rather than cure.

1. 17. Legal representative—a person who

because of the patient’s mental or physical incapacity is legally authorized in accordance with state law to make health care decisions on behalf of the dying person.

1. 18. Licensed practical nurse—a person

licensed under Chapter 335, RSMo to engage in the practice of practical nursing.

1. 19. Meal preparation—meals planned,

offered, or served to all patients from prepared menus.

1. 20. Medical director—a person licensed

in this state or a bordering state as a doctor of medicine or osteopathy who assumes overall responsibility for the medical component of the hospice’s patient care program.

1. 21. Nutritionist—a person who has

graduated from an accredited four- (4-) year college with a bachelor’s degree including or supplemented by at least fifteen (15) semester hours in food and nutrition including at least one (1) course in diet therapy. 19 CSR 30-35

1. 22. Occupational therapist—a person

who is registered under Chapter 334, RSMo as an occupational therapist and licensed to practice in Missouri.

1. 23. Occupational therapy assistant—a

person who has graduated from an occupational therapy assistant program accredited by the Accreditation Council for Occupational Therapy Education and licensed to practice in Missouri.

1. 24. Pharmacist—a person licensed as a

pharmacist under Chapter 338, RSMo.

1. 25. Pharmacy technician—a person who

is registered as a pharmacy technician under Chapter 338, RSMo.

1. 26. Physical therapist—a person who is

licensed as a physical therapist under Chapter 334, RSMo.

1. 27. Physical therapy assistant—a person

who has graduated from at least a two- (2-) year college level program accredited by the American Physical Therapy Association and licensed to practice in Missouri.

1. 28. Physician—a physician as defined in

subparagraph (1)(A)1.A. of this rule.

1. 29. Registered nurse—a person licensed

under Chapter 335, RSMo to engage in the practice of professional nursing.

1. 30. Registered nurse coordinator—a reg-

istered nurse, who is a direct employee, designated by the hospice to direct the overall provisions of clinical services.

1. 31. Satellite/branch office—a location or

site from which a hospice provides services within a portion of the total geographic area served by the parent hospice and the area served by the satellite/branch office is contiguous to or part of the area served by the parent hospice.

1. 32. Skilled nursing—those services

which are required by law to be provided by a registered nurse or a licensed practical nurse.

1. 33. Snack—a single meal or item pre-

pared on demand which does not include food items that produce grease-laden vapors.

1. 34. Social worker—a person who has at

least a bachelor’s degree in social work from a school of social work accredited by the Council on Social Work Education.

1. 35. Speech language pathologist—a per-

son who is licensed under Chapter 345, RSMo as a speech therapist.

1. 36. Spiritual counselor—a person who is

ordained, commissioned, or credentialed according to the practices of an organized religious group and has completed, or will complete by August 1, 2003, one (1) unit of Clinical Pastoral Education (CPE); or has a minimum of a bachelor’s degree with emphasis in counseling or related subjects and has, within ninety (90) days of hire, completed specific training to include: common spiritual issues in death and dying; belief systems of AND SENIOR SERVICES

comparative religions related to death and dying; spiritual assessment skills; individualizing care to patient beliefs; and varied spiritual practices/rituals.

1. 37. Standing order—An order by an

authorized prescriber that can be implemented by other health care professionals when predetermined criteria are met as per 19 CSR 30-35.010(2)(E)3.–(2)(E)4.A., B., and C.

1. (B) Eligibility Requirements. A hospice shall have written admission criteria including the hospice’s policies regarding palliative care (that includes treatment modalities such as chemotherapy or radiation).

2. (C) Consent for Hospice Care.

   1. 1. A patient who wishes to receive hos-

pice care, shall sign a consent form for hospice services.

1. 2. The consent form shall include the

following:

1. A. Identification of the particular hos-

pice that will provide care to the patient;

1. B. The patient’s or representative’s

acknowledgment that s/he has been advised and has an understanding of the palliative nature of hospice care as it relates to the patient’s terminal illness;

1. C. The specific type of care and ser-

vices that may be provided as hospice care during the course of the illness.

1. (D) Discontinuance of Hospice Care.

   1. 1. A patient or legal representative may

discontinue the patient’s hospice care at any time.

1. 2. If a patient transfers to another

provider, including another hospice provider, the hospice transferring care shall provide to the receiving provider pertinent written information which shall include at a minimum:

1. A. Current medication profile;
2. B. Advance directive (if applicable);

and

1. C. Problems that require intervention

or follow-up.

1. 3. The hospice shall have written poli-

cies for hospice patient discharge which identify specific circumstances in which the patient is discharged.

1. A. The hospice shall immediately

notify the patient or representative and shall include the date that the discontinuance is effective.

1. B. Patient’s/family’s continuing care

needs, if any, are assessed at discharge, and the patient/family are referred to appropriate resources.

1. 4. The physician shall be notified in all

instances of discontinuance of hospice care and such notification shall be documented in the patient record.

1. (E) General Provisions.

   1. 1. A hospice shall maintain compliance

with the standards in 19 CSR 30-35.010 and in 19 CSR 30-35.030. A hospice that operates a facility for hospice care shall also maintain compliance with 19 CSR 30- 35.020.

1. 2. A hospice shall be primarily engaged

in providing the care and services described in 19 CSR 30-35.010 and in 19 CSR 30- 35.020 of this rule, and shall—

1. A. Provide twenty-four- (24-) hour

nursing coverage for telephone consultation and visits as needed;

1. B. Assure all other services that are

reasonable and necessary for the palliation and management of terminal illness and related conditions are available on a twenty-four- (24-) hour basis;

1. C. Provide bereavement counseling;

and

1. D. Assure services are provided in a

manner consistent with accepted standards of practice in accordance with local, state, and federal law.

1. 3. The hospice shall conduct criminal

background checks in accordance with state law.

1. 4. The hospice shall adhere to state and

federal law relating to advance directives.

1. (F) Patient Rights. The hospice shall have a written statement of patient rights which shall include, but need not be limited to, those specified herein:

   1. 1. Each patient of a hospice program

shall be informed in writing of his/her rights as recipients of hospice services;

1. 2. The hospice shall document that it

has informed patients of their rights in writing and shall protect and promote the exercise of these rights; and

1. 3. The patient’s family, representative,

or guardian may exercise the patient’s rights when all reasonable efforts to communicate with the patient have failed. These rights shall include:

1. A. The patient and family’s right for

respect of property and person;

1. B. The right to voice grievances

regarding treatment or care that is, or fails to be, furnished or regarding lack of respect of property by anyone who is furnishing services on behalf of the hospice and the patient/family shall not be subjected to discrimination or reprisal for doing so;

1. C. The right to be informed about

his/her care alternatives available from the hospice and payment resources;

1. D. The right to participate in the

development of the plan of care and planning changes in the care;

1. E. The right to be informed in

advance about the care to be furnished;

1. F. The right to be informed in advance

of the disciplines that will furnish care and the frequency of visits proposed to be furnished;

1. G. The right to be informed in

advance of any change in the plan of care before the change is made;

1. H. The right to confidentiality of the

clinical records maintained by the hospice and to be informed of the hospice’s policy for disclosure of clinical records;

1. I. The right to be informed in writing

of the extent to which payment may be required from the patient and any changes in liability within thirty (30) days of the hospice becoming aware of the new amount of the liability; and

1. J. The right to access the Missouri

home health and hospice toll-free hotline and to be informed of its telephone number, the hours of operations and its purpose for the receipt of complaints and questions regarding hospice services.

1. (G) Code of Ethics.

   1. 1. A hospice shall develop a written

code of ethics and have a process for reviewing ethical issues.

1. (H) Twenty-four- (24-) Hour Response.

   1. 1. The hospice shall have written poli-

cies and procedures defining access to all services, medications, equipment, and supplies during regular business hours, after hours and in emergency situations including a plan for prompt telephone response.

1. 2. Unscheduled non-emergent nursing

visits when indicated should normally occur within three (3) hours from the time the need is identified or as agreed upon by the hospice and patient.

1. 3. When clinically indicated, emergent

visits shall be made within ninety (90) minutes from the time the need is identified.

1. (I) Infection Control. The hospice shall identify person(s) responsible for implementing and monitoring an infection control program.

   1. 1. The infection control program shall

include a system for periodic review and update of infection control policies and procedures, a monitoring of practices and potential exposure to infection and of employee health and compliance with policies and procedures.

1. 2. The infection control policies and

procedures shall conform with accepted standards of practice and address personal hygiene, aseptic and isolation techniques, waste disposal, and supply and medication storage.

1. (J) Safety and Emergency Preparedness.

   1. 1. The hospice shall have safety and

emergency preparedness plans that conform with federal, state, and local requirements. Such plans shall include:

1. A. A plan for reporting, monitoring

and following up on all accidents, injuries, and safety hazards;

1. B. Documentation of monitoring

activity and follow-up actions; and

1. C. A safe and sanitary system for

identifying, handling, and disposing of hazardous wastes.

1. 2. The emergency preparedness plan

shall be rehearsed at least annually.

1. (K) Satellite/Branch Offices.

   1. 1. If the hospice represents to the public

that they have a satellite/branch office, there shall be—

1. A. A designated interdisciplinary

group with documented group meetings;

1. B. On-site maintenance of current

active patient records; and

1. C. Telephone reception during normal

business hours.

1. 2. The satellite office must be located

within one hundred (100) miles of the parent office.

1. 3. The standard of care and clinical ser-

vices shall be the same out of the satellite/branch office as the parent office.

1. (2) Administration.

   1. (A) Governing Body.

      1. 1. A hospice shall have a governing

body that assumes full legal responsibility for the hospice’s total operation.

1. 2. The governing body shall meet, at a

minimum, once a year.

1. 3. The governing body shall designate

an administrator.

1. (B) Administrator Provisions.

   1. 1. The administrator organizes and

directs the agency’s ongoing functions; maintains ongoing liaison among the governing body, the interdisciplinary group(s) and the staff; employs qualified personnel; implements an effective budgeting and accounting system; and enforces written policies and procedures.

1. 2. A person shall be authorized to act in

the absence of hospice administrator.

1. 3. A registered nurse coordinator shall

be designated to direct the overall provisions of clinical services.

1. (C) Contracted Services.

   1. 1. A hospice may arrange for another

individual or entity to furnish services to the hospice’s patients except as otherwise provided in these regulations. If services are provided under contract, the hospice shall meet the following standards:

1. A. Assure the continuity of

patient/family care in home, outpatient, and inpatient settings;

1. B. Have a written agreement for the

provision of contracted services. The agreement shall include the following:

1. (I) Identification of the services to

be provided in accordance with the plan of care;

1. (II) The manner in which services

are coordinated by the hospice to maintain hospice professional management responsibility;

1. (III) Delineation of the role(s) of

the hospice and the contracted services;

1. (IV) Assurance that the contracted

provider shall be appropriately licensed;

1. (V) Provision for transfer and

updating the plan of care on inpatient admission (if applicable).

1. 2. Such contracts shall not relieve the

hospice of the primary responsibility for ensuring patient care or otherwise complying with these regulations.

1. (D) Plan of Care.

   1. 1. A written plan of care must be estab-

lished for each patient by the interdisciplinary group with the attending physician involvement.

1. 2. The plan shall be established within

seven (7) days of admission.

1. 3. The care provided to a patient shall be

in accordance with the plan.

1. 4. The plan shall include:

   1. A. Identification of the patient’s/fam-

ily’s problems and needs;

1. B. The scope and frequency of ser-

vices needed to meet the patient’s and family’s needs and by whom the services will be provided, prescribed and required medical equipment, supplies, medications, treatments and the level of care;

1. C. Realistic and achievable goals; and
2. D. All physician orders.
3. 5. The plan shall be reviewed and updat-

ed by the interdisciplinary group at a minimum of every two (2) weeks. These reviews shall be documented in the patient record.

1. 6. Documentation on the plan of care

shall reflect the changing needs of the patient/family and the services required to meet those needs.

1. (E) Authorized Prescriber’s Orders.

   1. 1. Medications, treatments, and proce-

dures shall be administered only with an order by an authorized prescriber.

1. 2. Written orders shall be dated and

signed at the time of writing.

1. 3. Oral orders, including authorization

to use a standing order, shall be received only by persons authorized within their scope of practice, immediately reduced to writing, signed and dated by the person receiving the order, and signed and dated by the prescriber within thirty (30) days.

1. 4. A standing order may be used as part

of the plan of care if the following guidelines are met: 19 CSR 30-35

1. A. Standing orders shall be in com-

pliance with all applicable state statutes and regulations and shall—

1. (I) Include the purpose or condi-

tions under which a standing order will be implemented;

1. (II) Be drug, treatment, or proce-

dure specific and not allow for non-prescriber’s choice;

1. (III) Be individualized, signed and

dated by the prescriber, and included in the patient’s record;

1. B. Agency policy shall define the time

frame for authorized prescriber notification when a standing order has been implemented; and

1. C. Standing order content shall be

reviewed and approved by the medical director at least annually.

1. (F) Interdisciplinary Group.

   1. 1. The hospice shall designate an inter-

disciplinary group or groups composed of qualified individuals who provide or supervise the care and services offered by the hospice. The interdisciplinary group shall meet no less often than every two (2) weeks.

1. 2. The interdisciplinary group shall

include at least the following individuals who are employees of the hospice:

1. A. A doctor of medicine or osteopa-

thy (may be contracted);

1. B. A registered nurse;
2. C. A social worker; and
3. D. A spiritual counselor.
4. 3. The interdisciplinary group shall be

responsible for—

1. A. Participation in the establishment,

review and updates of the plan of care;

1. B. Provision or coordination of hos-

pice care and services; and

1. C. Making recommendations regard-

ing policies governing the day-to-day provision of hospice care and services.

1. (G) Clinical Services. The hospice shall routinely provide through direct employees the following services:

   1. 1. Nursing services.

      1. A. Services shall be provided in

accordance with recognized standards of practice.

1. B. Nursing services shall be staffed to

assure that the nursing needs of patients are met.

1. C. The assessment, planning, and

provision of nursing services shall be the responsibility of the registered nurse.

1. D. When nursing services are dele-

gated to a licensed practical nurse—

1. (I) The licensed practical nurse

shall be supervised by a registered nurse who is available to the licensed practical nurse at least by phone during the hours that the AND SENIOR SERVICES

licensed practical nurse is providing services or is on call; and

1. (II) The registered nurse shall make

at least monthly on-site visits and document that the licensed practical nurse is routinely providing nursing services in accordance with the plan of care.

1. E. The registered nurse shall develop

a written aide assignment based upon the patient’s/family’s needs when home health aide services are provided.

1. F. When aide services are being pro-

vided, a hospice registered nurse shall visit the home at least every two (2) weeks. The visit shall include an assessment of the aide services.

1. G. Written documentation shall show

that the aide is providing services in accordance with the plan of care.

1. H. When an aide is permanently

assigned to a hospice facility, the every two- (2-) week supervisory requirement does not apply, however there must be evidence of an annual performance review in the aide’s personnel file.

1. 2. Medical director services. The medi-

cal director shall be a direct or contract employee. The medical director’s or designee’s services and responsibilities include:

1. A. Consulting with attending physi-

cians regarding pain and symptom control;

1. B. Reviewing patient appropriateness

for hospice services;

1. C. Acting as medical resource for the

interdisciplinary group;

1. D. Acting as liaison to physicians in

the community;

1. E. Assuring medical services are pro-

vided in the event the medical needs of the patient are not met by the attending physician; and

1. F. Routinely attending the interdisci-

plinary group meetings.

1. 3. Medical social services.

   1. A. Medical social services shall be

provided in accordance with recognized standards of practice.

1. B. Social services shall be staffed to

assure that the medical social service needs of patients are met.

1. C. The assessment, planning, and

provision of medical social services shall be the responsibility of the social worker.

1. D. The social services assessment

visit shall be completed within seven (7) days of admission or sooner if indicated.

1. 4. Spiritual care services.

   1. A. Spiritual care shall be available to

all patients and families.

1. B. The spiritual counselor is responsi-

ble for assuring there is a documented assessment of the spiritual needs of the patient and family within seven (7) days of admission and that spiritual care provided reflects assessed needs.

1. C. The spiritual assessment shall

include, at a minimum:

1. (I) The identification of any reli-

gious affiliation the patient and family may have; and

1. (II) The nature and scope of any

spiritual concerns or needs identified.

1. D. A visit by the spiritual counselor

shall be offered to each patient. If the patient declines spiritual counselor visits, the spiritual counselor will serve as a resource for other interdisciplinary team members assessing spiritual needs and providing care, and will be available to coordinate with other spiritual care providers the patient/family may have identified.

1. 5. Bereavement care services.

   1. A. There shall be an organized pro-

gram for the provision of bereavement services under the supervision of a qualified professional who is a person with training or experience related to death, dying, and bereavement.

1. B. Within two (2) months following

the patient’s death, there shall be an assessment of risk of the bereaved individual and a plan of care that extends for one (1) year appropriate to the level of risk assessed.

1. C. In addition to the assessment, at

least one (1) bereavement visit (other than funeral attendance/visitation) shall occur within six (6) months after the death of the patient.

1. 6. Other clinical services. The hospice

shall provide the following services directly by hospice employees or through a contracted provider. The assessment, planning, and provision of these services shall be the responsibility of the applicable licensed or registered clinician.

1. A. Dietary counseling, when required,

shall be planned by a qualified dietary counselor.

1. B. Physical therapy services, occupa-

tional therapy services, and speech language pathology services shall be offered in a manner consistent with accepted standards of practice.

1. (I) Therapy services delegated to

the physical therapy assistant or the occupational therapy assistant shall be supervised by a licensed physical therapist or registered occupational therapist as appropriate who is available to the physical therapy assistant or occupational therapy assistant at least by phone during the hours that s/he is providing services.

1. (II) When the assistant is providing

services to a patient, the licensed or registered therapist shall make a supervisory visit to the residence of the patient at least every thirty (30) days.

1. (III) Written documentation shall

show that the assistant is providing therapy services in accordance with the plan of care.

1. C. Additional counseling services.

Any additional counseling services provided by the hospice shall be provided by qualified personnel, coordinated with all hospice services, included in the plan of care and documented in the clinical record.

1. D. Waiver.

   1. (I) These requirements shall be

waived by the Department of Health for areas of the state in which no licensed therapists/dietitians/nutritionists are available provided a good faith effort to provide the service is being made.

1. (II) A hospice seeking this waiver

shall submit a written request to the department along with evidence of efforts made by the hospice to provide the service. If approved, a request for waiver shall be resubmitted annually for review.

1. 7. Home health aide and homemaker

services. Home health aide and homemaker services shall be available to meet the needs of the patients.

1. A. If homemaker needs are identified,

a member of the interdisciplinary group shall assign and coordinate the services.

1. B. Home health aide services must be

provided by a qualified person as set forth in 19 CSR 30-35.010(1)(A)10.

1. C. A home health aide is not consid-

ered to have completed a training and competency program, or a competency evaluation program if, since the individual’s most recent completion of such program(s), there has been a continuous period of twenty-four (24) consecutive months during none of which the individual furnished services described in 42 CFR 409.40 for compensation.

1. D. The home health aide shall follow

written instructions for patient care which are prepared by a registered nurse and document care provided. Duties include, but shall not be limited to, the duties specified in the regulations pertaining to the Medicare home health aide (42 CFR 484.36).

1. E. Twelve (12) hours of in-service per

aide per twelve- (12-) month period shall be provided or assured by the hospice. The hospice shall maintain a record of in-service provided.

1. (H) Medications. The hospice shall develop policies and procedures for the safe and effective use of medications, in accordance with accepted professional standards and applicable laws and regulations.

   1. 1. A medication list shall be maintained

for each patient.

1. 2. Medication orders shall include the

medication name, dose, frequency, and route of administration.

1. 3. Orders with variable doses or fre-

quencies shall specify a maximum dose or frequency and the reason for administration.

1. 4. Medications shall be provided on a

timely basis and medication services shall be available on a twenty-four- (24-) hour basis for emergencies.

1. 5. When controlled substance medica-

tions are delivered to the patient’s residence by hospice staff, the date, patient name, medication name and strength, quantity indicated on the prescription container, and signatures of the hospice staff member and the receiver shall be documented.

1. 6. The hospice shall identify and docu-

ment any misuse of controlled substances and shall notify the prescriber.

1. 7. Medication use shall be reviewed

with the patient, family, or both and medication information, counseling, and education shall be provided when appropriate.

1. 8. Current medication reference materi-

al shall be available to professional staff for all medications used.

1. 9. Medications shall be administered by

persons who have statutory authorization, the patient, or a family member.

1. 10. Administration by the patient or by a

family member shall be evaluated for appropriateness and ability and this evaluation documented by the nurse.

1. 11. Medication incidents, including

medication errors and adverse medication reactions, shall be reported to the prescriber, the registered nurse coordinator, and the pharmacist.

1. 12. The hospice must have a policy for

the disposal of controlled substances maintained in the patient’s home when those medications are no longer needed by the patient. The policy shall include at a minimum, information shared with family regarding disposition of medications when no longer required.

1. 13. Medications shall not be transferred

to other patients and shall not be removed from the residence by hospice staff.

1. (I) Medical Supplies and Equipment.

   1. 1. The provision of medical supplies and

equipment shall be coordinated as needed for the palliation and management of the terminal illness and related conditions. Hospices shall make every effort to assure that patient needs for medical supplies and equipment are met.

1. 2. Hospice shall provide education for

patient/family, employees, and volunteers on the safe use of medical equipment.

1. 3. Hospice shall provide evidence that

all hospice-owned patient care related equipment has been inspected and maintained on an annual basis and in accordance with manufacturers specifications.

1. 4. Hospice shall have policies and pro-

cedures for cleaning, storing, accessing, and distributing hospice-owned equipment.

1. 5. Supplies shall be stored and main-

tained in a clean and proper manner.

1. (J) Volunteers.

   1. 1. Each hospice shall document and

maintain a volunteer staff sufficient to provide administrative and direct patient care hours in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice shall document a continuing level of volunteer activity.

1. 2. Care and services through the use of

volunteers, including the type of services and the time worked, shall be recorded.

1. 3. The hospice shall document initial

screening and active and ongoing efforts to recruit and retain volunteers.

1. 4. The hospice shall provide task-appro-

priate orientation and training consistent with acceptable standards of hospice practice, that includes at a minimum:

1. A. Hospice philosophy, goals, and

services;

1. B. The volunteer role in hospice;
2. C. Confidentiality;
3. D. Instruction in the volunteer’s par-

ticular duties and responsibilities;

1. E. Whom to contact if in need of

assistance or instruction regarding the performance of their specific duties and responsibilities; and

1. F. Documentation and record keeping

as related to the volunteer’s duties.

1. 5. The hospice shall, in addition, pro-

vide orientation for patient care volunteers that includes at a minimum:

1. A. Concepts of death and dying;
2. B. Communication skills;
3. C. Care and comfort measures;
4. D. Psychosocial and spiritual issues

related to death and dying;

1. E. The concept of hospice patient and

family as the unit of care;

1. F. Procedures to be followed in an

emergency or following the death of the patient;

1. G. Concepts of grief and loss;
2. H. Universal precautions;
3. I. Safety;
4. J. Patient/family rights;
5. K. Hospice and the nursing home;

and

1. L. Alzheimer’s disease and dementia-

specific training as specified at 19 CSR 30- 35.010(2)(M)1.B.(XIII). 19 CSR 30-35

1. 6. The hospice shall document orienta-

tion and ongoing in-services.

1. 7. Volunteers functioning in accordance

with professional practice acts must show evidence of current professional standing and licensure, if applicable.

1. (K) Central Clinical Records.

   1. 1. In accordance with accepted princi-

ples of practice, the hospice shall establish and maintain a clinical record for every patient receiving care and services.

1. 2. The record shall be complete, legible,

readily accessible, and systematically organized to facilitate retrieval. Documentation shall be prompt and accurate.

1. 3. Each clinical record shall be a com-

prehensive compilation of information. Entries shall be made for all services provided.

1. 4. Entries shall be made and signed by

the person providing the services.

1. 5. The record shall include all services

whether furnished directly or through contracted providers. Each clinical record shall contain—

1. A. Physician’s orders;
2. B. Complete documentation of all

assessments, services, and events including:

1. (I) The physical condition of the

patient;

1. (II) The psychosocial status of the

patient/family;

1. (III) The spiritual status of the

patient/family; and

1. (IV) Potential bereavement compli-

cations;

1. C. The plan of care;
2. D. Identification data;
3. E. Consent form;
4. F. Pertinent medical history;
5. G. Determination of financial respon-

sibility; and

1. H. Documentation of communication

with coordinating providers.

1. 6. The hospice shall safeguard the clini-

cal record against loss, destruction, and unauthorized use.

1. (L) Facility Resident.

   1. 1. When the hospice patient resides in a

nursing facility, the hospice collaborates with the nursing facility providing care to the patient/family to ensure coordination of services.

1. 2. Collaboration activities shall include

the following:

1. A. There shall be a coordinated single

plan of care in the nursing facility which may be multiple documents, that—

1. (I) Reflects coordination and input

from both the hospice and the nursing facility;

1. (II) Identifies the care and services

which each shall provide; and AND SENIOR SERVICES

1. (III) Is updated to reflect changes in

patient/family condition, needs, and care.

1. B. Services usually identified as hos-

pice services shall remain the responsibility of the hospice, and are provided or arranged by the hospice to meet the needs of the patient at the same level that the hospice normally furnishes to patients in their homes.

1. C. A registered nurse is designated

from the hospice to coordinate the implementation of the plan of care, and to respond to questions and concerns from the nursing facility.

1. D. The hospice shall provide educa-

tion to nursing facility staff that includes at a minimum:

1. (I) The purpose and nature of hos-

pice care;

1. (II) Services provided by the hos-

pice;

1. (III) Care plan coordination;
2. (IV) When and how to contact hos-

pice staff.

1. 3. The hospice shall document educa-

tion provided and/or education offered and declined by the nursing home.

1. 4. The hospice shall enter into arrange-

ments only with nursing facilities which are appropriately licensed.

1. (M) Employee Training and Orientation.

   1. 1. Each hospice shall provide initial ori-

entation for each direct employee that is specific to the employee’s job duties.

1. A. All employees shall be oriented

to—

1. (I) Hospice philosophy, goals, and

services;

1. (II) Confidentiality;
2. (III) Specific job duties;
3. (IV) Hospice policies and proce-

dures as appropriate to the position.

1. B. Patient care employees shall also

be oriented to—

1. (I) Interdisciplinary group function

and responsibility;

1. (II) Communication skills;
2. (III) Physical, psychosocial, and

spiritual assessment;

1. (IV) Plan of care;
2. (V) Symptom management;
3. (VI) Universal precautions;
4. (VII) Patient/family safety issues; (VIII) Patient/family rights;
5. (IX) Documentation;
6. (X) Concepts of grief and loss;
7. (XI) Facility resident care;
8. (XII) Levels of hospice care; and (XIII) Alzheimer’s disease and

related dementias. Hospice agencies shall provide dementia-specific training about Alzheimer’s disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients, or consumers with Alzheimer’s disease or related dementias.

1. (a) At a minimum, the training

required shall address the following areas:

1. I. An overview of Alzheimer’s

disease and related dementias;

1. II. Communicating with per-

sons with dementia;

1. III. Behavior management;
2. IV. Promoting independence

in activities of daily living; and

1. V. Understanding and dealing

with family issues.

1. (b) Employees or independent

contractors who do not provide direct care for, but may have daily contact with, persons with Alzheimer’s disease or related dementias shall receive dementia-specific training that includes at a minimum:

1. I. An overview of Alzheimer’s

disease and related dementias; and

1. II. Communicating with per-

sons with dementia.

1. (c) Dementia-specific training

about Alzheimer’s disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be provided annually and updated as needed.

1. C. Ongoing in-service training shall

include a broad range of topics that reflect identified educational needs.

1. D. The hospice shall document initial

orientation and in-service topics presented.

1. 2. Volunteers are exempt from these pro-

visions, except for dementia-specific training as specified at 19 CSR 30-35.010 (2)(M)1.B.(XIII), as their orientation and inservice requirements are defined in 19 CSR 30-35.010(2)(J)4., 5., and 6.

1. 3. Contract employees shall receive ori-

entation to dementia-specific training as specified at 19 CSR 30-35.010(2)(M)1.B.(XIII), confidentiality, hospice philosophy, and to their specific job duties.

1. (N) Performance Improvement.

   1. 1. The hospice shall follow a written

plan for assessing and improving program operations which includes:

1. A. Goals and objectives;
2. B. The identity of the person respon-

sible for the program; and

1. C. A method for resolving identified

problems.

1. 2. The plan and performance improve-

ment activities shall be reviewed at least annually by a designated group and the governing body and revised as appropriate.

1. 3. When problems are identified in the

provision of hospice services, the hospice shall document any evidence of corrective actions taken, including ongoing monitoring, revisions of policies and procedures, educational intervention, and changes in the provision of services.

1. 4. The effectiveness of actions taken to

improve services or correct identified problems shall be evaluated.

1. 5. A designated group shall review and

document the performance improvement activities and monitor corrective actions.

AUTHORITY: section 197.270, RSMo 2016.* Original rule filed March 8, 1996, effective Oct. 30, 1996. Rescinded and readopted: Filed Jan. 3, 2001, effective Aug. 30, 2001. Amended: Filed Sept. 11, 2007, effective March 30, 2008. ** Amended: Filed July 9, 2020, effective Jan. 30, 2021. *Original authority: 197.270, RSMo 1992, amended 1993. **Pursuant to Executive Order 21-07, 19 CSR 30-35.010, paragraph (1)(A)1. was suspended from April 9, 2020 through August 31, 2021 and part (2)(M)1.B.(XIII) was suspended from April 22, 2020 through August 31, 2021.