CHAPTER 53
HOSPICE LICENSE STANDARDS
481—53.1(135J) Definitions. The use of the word “shall” indicates mandatory standards. The definitions set out in Iowa Code section 135J.1 shall be considered to be incorporated verbatim in the rules. As used in this chapter:
“Bereavement service” is support offered during the bereavement period to the family and friends of someone who has died.
“Care setting” means the place in which care is being given, for example, patient’s home, a hospital, a care facility or another place of residence.
“Family” means the immediate kin of the patient, including a spouse, parent, stepparent, brother, sister, stepbrother, stepsister, child, or stepchild. Additional relatives or individuals with significant personal ties to the hospice patient may be included in the hospice patient’s family.
“Home care provider” means a care agency that contracts with the hospice to provide services in the home of the hospice patient. The providers may include, but are not limited to, home health aides, homemakers, nurses, occupational therapists or physical therapists.
“Primary caregiver” means the person with major responsibility for providing care to a hospice patient.
“Protocols” are defined as written sets of directions to be followed in performing procedures. These may be routine or may describe specific actions staff must follow when particular events occur.
“Psychosocial needs” involve a person’s mental and emotional life related to behavior to other people.
“Social services” are services provided by someone who has a bachelor’s or higher degree in social work.
“Spiritual counselor” may be clergy, a hospice employee, a volunteer or someone chosen by the patient.
“Utilization review” means a program to assess the kind of care delivered and to identify needs which may not have been met.
481—53.2(135J) License. Application for an initial or renewal license may be obtained from the Department of Inspections and Appeals, Division of Health Facilities, Lucas State Office Building, Des Moines, Iowa 50319.
	53.2(1) Prior to the issuance of a license each hospice must meet all the requirements set forth in this chapter.
	53.2(2) The applicant shall submit a nonrefundable biennial license fee of $500. If a license lapses for failure to make timely application for renewal, an additional 25 percent is required.
	53.2(3) Each hospice seeking licensure is surveyed before the initial license is issued and biennially before a license is renewed.
	53.2(4) Home care provider and inpatient facilities used by the hospice shall be inspected by the department to determine whether hospice regulations are met.
	53.2(5) Hospices certified as Medicare providers by the department or accredited by the Joint Commission on the Accreditation of Health Organizations will be licensed without inspection.
	53.2(6) The department may not prohibit any entity from establishing or maintaining a hospice without a license.
	53.2(7) The department may deny, suspend or revoke a license if the department finds that a hospice does not comply with these rules.
	53.2(8) A license is issued only for the premises, person, hospital or facility named on the application. The license may not be transferred or assigned to another person or entity.
	53.2(9) A license expires two years after the date issued unless it is suspended or revoked before that date.
This rule is intended to implement Iowa Code sections 135J.2 and 135J.4 to 135J.6.
481—53.3(135J) Patient rights. Each hospice program shall have written policies and procedures that support, enhance and protect the human, civil, constitutional and statutory rights of all patients.
	53.3(1) Patient rights include, but are not limited to, the right to:
	a. 	Be treated with dignity and respect;
	b. 	Be informed of the type of care and the services provided by the hospice program;
	c. 	Information regarding diagnosis and prognosis and any change in either;
	d. 	Review and participate in their plan of care; and
	e. 	Privacy.
	53.3(2) A copy of these rights shall be provided to all individuals admitted to a hospice.
This rule is intended to implement Iowa Code section 135J.3(3).
481—53.4(135J) Governing body. The hospice shall have a local governing body which consists of people who represent the geographic area for which the hospice intends to provide service.
	53.4(1) The governing body shall:
	a. 	Develop a written mission statement, goals and objectives for the hospice and meet with sufficient regularity to ensure accomplishment of those goals and objectives;
	b. 	Develop, amend and implement bylaws;
	c. 	Assume responsibility for the total operation of the hospice;
	d. 	Appoint an administrator whose qualifications and duties are defined in writing and who has authority to manage the business affairs and to direct all programs of the hospice;
	e. 	Develop the budget and monitor the fiscal affairs of the hospice;
	f. 	Provide for medical direction by a licensed physician;
	g. 	Provide appropriate, qualified personnel in sufficient quantity to ensure availability of hospice services listed below, 24 hours a day, seven days a week;
	h. 	Develop and implement written policies and procedures relating to:
	(1)	Admission and discharge criteria,
	(2)	Response to referrals,
	(3)	Medical direction,
	(4)	Physician services,
	(5)	Nursing services,
	(6)	Nutritional services,
	(7)	Pharmacy services,
	(8)	Social services,
	(9)	Volunteer services,
	(10)	Spiritual services,
	(11)	Patient and family education,
	(12)	Bereavement services,
	(13)	Staff response to death at home and in institutions,
	(14)	Coordination and communication between all agencies serving the patient and family,
	(15)	Communication with community agencies, and
	(16)	Community education efforts;
	i. 	Develop and implement written personnel policies; and
	j. 	Develop and implement a written plan for review of the services delivered.
	53.4(2) The governing body shall ensure that someone is responsible to:
	a. 	Organize and direct the ongoing functions of the hospice program;
	b. 	Meet the requirements of the written job descriptions;
	c. 	Maintain liaison with the governing body and staff to ensure administrative control and professional supervision over all patient and family services furnished;
	d. 	Provide orientation and in-service training for all staff which covers the physical, emotional, spiritual and social needs of hospice patients and their families during the final stages of illness, at death and during grief;
	e. 	Plan, organize, implement, guide and evaluate the program;
	f. 	Formulate and conduct a review of policies and procedures, including quality assurance; and
	g. 	Ensure that all required reports and records are completed, submitted and maintained. This includes personnel, administrative and clinical records.
This rule is intended to implement Iowa Code section 135J.3.
481—53.5(135J) Quality assurance and utilization review. The hospice must have a written procedure for individual assessment of care provided, a process for identifying problems and a system to report findings and recommendations for improving the quality of care delivered to the governing body.
	53.5(1) At least quarterly, the medical director, patient coordinator and social worker used by the hospice program shall review a minimum of a 10 percent sample of combined active and inactive clinical records of care delivered to hospice patients and families. A written summary shall be prepared for each individual assessment, commenting on the amount and kind of care delivered and including statements addressing any unmet needs.
	53.5(2) At least quarterly, all summaries of individual assessments shall be reviewed by the people responsible for coordinating quality assurance. A written report will be prepared addressing any identified problems with care, treatment services, availability of services and methods of care delivery.
	53.5(3) The quality assurance reports shall be made available to the hospice administrator and governing body. The reports shall be reviewed by the governing body at least annually, and the review recorded in the governing body’s meeting minutes.
This rule is intended to implement Iowa Code section 135J.3(8).
481—53.6(135J) Attending physician services. The patient or family shall designate an attending physician who is responsible for managing necessary medical care. The attending physician shall:
	1.	Have an active Iowa license to practice medicine pursuant to Iowa Code chapter 148, 150 or 150A;
	2.	Certify in conjunction with the medical director that each person requesting admittance is eligible as required by Iowa Code section 135J.1(3) for hospice care;
	3.	Be responsible for the medical component of the plan of care;
	4.	Participate in developing and revising the plan of care;
	5.	Arrange for continuity of the medical management in the attending physician’s absence; and
	6.	Monitor the condition of the patient and family by direct contact, or communication with the interdisciplinary team (IDT) and others.
This rule is intended to implement Iowa Code section 135J.3(4).
481—53.7(135J) Medical director. Each hospice shall have a medical director who is a physician licensed to practice medicine pursuant to Iowa Code chapter 148, 150 or 150A. The medical director shall:
	1.	Be a member of the interdisciplinary team;
	2.	Monitor the quality of care provided;
	3.	Assist in providing assurance of the quality of care provided to the patient and family;
	4.	Maintain liaison with the attending physician;
	5.	Review clinical material from the patient’s attending physician to certify the prognosis as anticipated by that physician;
	6.	Participate in providing direction for the medical component of care;
	7.	Participate in resolving conflicts regarding care to be provided;
	8.	Name a qualified physician to be available in the medical director’s absence; and
	9.	Participate in the development and review of patient and family care policies, procedures and protocols.
This rule is intended to implement Iowa Code section 135J.3(1).
481—53.8(135J) Interdisciplinary team (IDT). The IDT shall establish a plan of care for each patient and family based on assessments performed by team members.
	53.8(1) The interdisciplinary team shall include the:
	a. 	Patient;
	b. 	Hospice patient’s family;
	c. 	Attending physician;
	d. 	Medical director;
	e. 	Patient care coordinator;
	f. 	Staff nurse;
	g. 	Social worker;
	h. 	Coordinator of volunteer service; and may include
	i. 	A spiritual counselor and others deemed appropriate by the hospice.
	53.8(2) Prior to or on the day of admission, the attending physician and at least one IDT team member shall develop an initial plan based on a preliminary assessment of the patient and family needs.
	53.8(3) Within seven calendar days of admission the interdisciplinary team shall assess the needs of the patient and family. A care plan shall be based on these findings.
	53.8(4) Within seven calendar days of admission the interdisciplinary team shall meet to develop a comprehensive written plan of care. The plan of care shall:
	a. 	Identify the primary caregiver or an alternate arrangement for care;
	b. 	List the needs of the patient and family;
	c. 	List any intervention planned to meet the needs of the patient and family and the results expected from each intervention;
	d. 	Indicate which team member(s) is responsible for each intervention;
	e. 	Indicate the anticipated frequency of each intervention; and
	f. 	Indicate the prognosis and expected disease process.
	53.8(5) The IDT shall monitor and revise the plan of care on a regular basis. The team shall meet weekly and exchange information regarding the needs of the patient and family. Changes in the care plan shall be made when the needs of the patient or family change or when interventions do not result in the expected or intended response.
This rule is intended to implement Iowa Code section 135J.3(5).
481—53.9(135J) Nursing services. Nursing services shall be planned and provided or supervised by a registered nurse who has a current Iowa license to practice nursing. The service shall be available 24 hours a day, seven days a week.
	53.9(1) A registered nurse shall assess patient and family nursing needs and develop a nursing plan of care to meet these needs.
	53.9(2) The nursing service staff shall:
	a. 	Participate in IDT meetings to develop and amend the plan of care;
	b. 	Provide nursing service in accordance with the overall plan of care developed by the IDT;
	c. 	Consult with the patient and family regarding how to meet nursing and nursing-related needs of the patient;
	d. 	Document nursing care given and observations made regarding patient, family reactions and status;
	e. 	Consult with other care providers and the family to enhance continuity of care;
	f. 	Develop and implement nursing service objectives, policies and procedures;
	g. 	Develop job descriptions for all nursing personnel;
	h. 	Establish staff schedules to meet patient and family needs and ensure 24-hour service;
	i. 	Develop and implement orientation and training programs;
	j. 	Develop and implement performance evaluation for the nursing staff;
	k. 	Assign duties to nurses consistent with their education and experience; and
	l. 	Facilitate periodic meetings of the professional nursing staff to evaluate the nursing care provided by hospice personnel.
	53.9(3) Persons who are employed by, volunteer with or work under contract to a licensed hospice organization may administer medications only if they are also a licensed nurse, a licensed physician or a certified medication aide.
This rule is intended to implement Iowa Code section 135J.3(2).
481—53.10 Reserved.
481—53.11(135J) Coordinator of patient care. A registered nurse, social worker or health care administrator shall be designated to coordinate implementation of the plan of care for each patient.
The coordinator of patient care shall at least:
	1.	Coordinate all aspects of patient care to ensure continuity, including care by all service disciplines in all care settings;
	2.	Facilitate exchange of information among all personnel who provide services to ensure complementary efforts and support for objectives outlined in the plan of care;
	3.	Facilitate communication between caregivers, patient and family;
	4.	Maintain a roster of patients;
	5.	Maintain a schedule for IDT review of care plans; and
	6.	Chair IDT conferences.
This rule is intended to implement Iowa Code section 135J.3(2).
481—53.12(135J) Social services. Social services shall be planned and provided or supervised by a person who has at least a bachelor’s degree in social work from a school approved by the council on social work education. The social worker shall at least:
	1.	Consider the emotions and social support system of the patient and family;
	2.	Assess the ability of the family and the patient to function socially and to deal with their emotions;
	3.	Identify patient and family social service needs;
	4.	Participate on the IDT to develop and amend the plan of care;
	5.	Provide services in accordance with the plans of care developed by the IDT;
	6.	Document services provided and observations made regarding patient and family response and status; and
	7.	Cooperate and communicate with other providers and the family to enhance the continuity of care.
This rule is intended to implement Iowa Code section 135J.3(2).
481—53.13(135J) Counseling services. Counseling is the process of helping people adjust to the grief of illness, dying and loss. Counseling shall be provided in accordance with the plan of care. When the interdisciplinary team identifies the need for additional counseling services, a team member shall be designated to make an appropriate referral. No referrals may be made without the agreement of the patient and the family.
This rule is intended to implement Iowa Code section 135J.3(2).
481—53.14(135J) Volunteer services. Each hospice shall provide volunteer services to meet patient and family needs. A coordinator of volunteer services shall be designated to implement written policies and procedures.
	53.14(1) Each volunteer shall have at least 14 hours of education provided by the hospice before being assigned to a patient and family. The following topics shall be included in the educational program:
	a. 	Hospice concept and philosophy;
	b. 	Symptom control;
	c. 	Infection control;
	d. 	Home care skills;
	e. 	Safety measures and transfer techniques;
	f. 	Stress management;
	g. 	Communication needs;
	h. 	Psychosocial needs;
	i. 	Spiritual needs;
	j. 	Death, dying and grief; and
	k. 	Funerals and alternative rituals.
	53.14(2) The hospice shall offer at least two hours of in-service training each quarter.
This rule is intended to implement Iowa Code section 135J.3(2).
481—53.15(135J) Spiritual counseling. Spiritual counseling shall be available to all patients and their families.
	53.15(1) Spiritual counseling shall:
	a. 	Be based on the beliefs and values of the patient and family; and
	b. 	Be provided in accordance with the interdisciplinary plan of care.
	53.15(2) If spiritual counseling is provided through a working relationship with clergy or other spiritual counselors in the community, there shall be ongoing communication between that counselor and the interdisciplinary care team.
	53.15(3) There shall be written and implemented policies and procedures regarding spiritual counseling.
This rule is intended to implement Iowa Code section 135J.3(2).
481—53.16(135J) Optional services. Optional services are services provided by the hospice which are not required. Examples are home health aide, therapy and respite. The following apply to the provision of all optional services provided by a hospice:
	53.16(1) All service providers shall be oriented to the hospice concept and philosophy.
	53.16(2) All services shall be provided in accordance with the interdisciplinary plan of care.
	53.16(3) Written and implemented policies and procedures shall:
	a. 	Identify service providers;
	b. 	Identify the person who will supervise the provision of services;
	c. 	Require documentation of services provided and patient and family response; and
	d. 	Describe a mechanism for evaluating quality of care provided.
This rule is intended to implement Iowa Code section 135J.1(7).
481—53.17(135J) Contracted services. A hospice may contract with other health care providers for the provision of all services.
	53.17(1) Contracts shall be written and clearly delineate the authority and responsibility of each party to the contract.
	53.17(2) The hospice shall maintain responsibility for coordinating and administering the hospice program.
	53.17(3) Contracting for a service does not absolve the hospice of legal responsibility for provision of that service.
	53.17(4) The hospice shall inform the patient whether the hospice is paying for the contracted services.
This rule is intended to implement Iowa Code section 135J.3(2).
481—53.18(135J) Short-term hospital services. Each hospice shall have a written agreement with a local or area hospital which promotes continuation of the hospice plan of care and training for hospital staff who care for hospice patients.
This rule is intended to implement Iowa Code section 135J.3(2).
481—53.19(135J) Bereavement services. Bereavement services shall be available to each family after the death of a patient and shall be provided in accordance with family needs.
	53.19(1) Bereavement services shall include:
	a. 	Exchange of information between people who provide bereavement services and team members who provided care before death;
	b. 	Consideration of the family’s situation, including risk factors, used to develop a plan for services;
	c. 	Identification of types of help or intervention to be available and provided;
	d. 	Contact with the family after the death as required by their needs as documented in the plan of care; and
	e. 	A process to assess family reactions and hospice referrals for intervention deemed appropriate by the IDT.
	53.19(2) There shall be written and implemented policies and procedures governing the delivery of bereavement services.
This rule is intended to implement Iowa Code section 135J.3(6).
481—53.20(135J) Records. In accordance with accepted principles of medical record practice, each hospice shall maintain a centralized complete record on every individual receiving services. This record shall be preserved for at least three years following termination of services.
	53.20(1) Each entry shall be dated and signed, including the name and title of the person who makes the entry.
	53.20(2) The record shall include documentation of all services provided, whether furnished by the hospice or by contractual agreement. Each record shall include, but not be limited to:
	a. 	Patient identification and demographic data;
	b. 	Initial and subsequent assessments;
	c. 	The plan of care;
	d. 	Medical history;
	e. 	Documentation of all services provided;
	f. 	Consent and authorization forms;
	g. 	Physicians’ orders;
	h. 	Medication records;
	i. 	Discharge summary; and
	j. 	Discharge and transfer records.
	53.20(3) The hospice shall have written and implemented policies to safeguard destruction or unauthorized use of patient records. Written procedures shall govern use and removal of records, conditions for release of information and identification by title of the person who may release records.
These rules are intended to implement Iowa Code sections 135J.1 to 135J.6.
[Filed 4/12/90, Notice 12/27/89—published 5/2/90, effective 6/6/90]