Header:
TEXAS ADMINISTRATIVE CODE
TITLE 40. SOCIAL SERVICES AND ASSISTANCE
PART 1. DEPARTMENT OF AGING AND DISABILITY SERVICES
CHAPTER 97. LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES
SUBCHAPTER D. ADDITIONAL STANDARDS SPECIFIC T
Date:
08/31/2009
Document:
§ 97.403. Standards Specific to Agencies Licensed to Provide Hospice Services
(a) In addition to complying with the minimum standards in Subchapter C of this chapter (relating to Minimum Standards for All Home and Community Support Services Agencies), an agency that is licensed to provide hospice services, must also comply with the standards of this section. If licensed and certified to provide hospice services, an agency must also comply with the requirements of the Social Security Act and the regulations in Title 42, Code of Federal Regulations, Part 418.
(b) A person who is not licensed to provide hospice services may not use the word "hospice" in a title or description of a facility, organization, program, service provider or services or use any other words, letters, abbreviations, or insignia indicating or implying that the person holds a license to provide hospice services.
(c) A hospice must adopt and enforce a written policy relating to the provision of hospice services in accordance with this section. All covered services must be available 24 hours a day, seven days a week, during the last stages of illness, during death, and during bereavement, to the extent necessary for the palliation and management of terminal illness and related conditions. Services include, at a minimum:
(1) nursing;
(2) medical social services;
(3) counseling;
(4) volunteer care;
(5) bereavement counseling;
(6) coordination of short-term inpatient care;
(7) physician services; and
(8) medications.
(d) The hospice must have a medical director who:
(1) is a hospice employee, independent contractor, or volunteer;
(2) is a doctor of medicine or osteopathy licensed in the State of Texas; and
(3) assumes responsibility for the medical component of the hospice's client care program.
(e) The hospice must designate an interdisciplinary team or teams composed of individuals who provide or supervise the care and services offered by the hospice.
(1) The interdisciplinary team or teams must include at least the following individuals who are employees of the hospice:
(A) a physician;
(B) a registered nurse;
(C) a social worker; and
(D) a counselor.
(2) The interdisciplinary team must be responsible for the:
(A) participation in the establishment of the plan of care;
(B) provision and supervision of hospice care and services;
(C) periodic reviews and updates of the plan of care for each client receiving hospice care; and
(D) establishment of policies governing the day to day provision of hospice care and services.
(3) If the hospice has more than one interdisciplinary team, the hospice must designate in advance the team it chooses to execute the functions described in paragraph (2)(D) of this subsection.
(4) The hospice must designate a registered nurse to coordinate the implementation of the plan of care for each client.
(f) Subject to subsections (m) and (r) of this section, the hospice may arrange for another individual or entity to furnish services to the hospice clients. If services are provided under arrangement, the hospice must meet the following standards.
(1) The hospice program must assure the continuity of client and family care in home and outpatient and inpatient settings.
(2) The hospice must have a contract for the provision of arranged services. The contract must be signed by authorized representatives of the hospice as well as the contracting party. The contract must include the following:
(A) identification of the services to be provided;
(B) a stipulation that services may be provided only with the express authorization of the hospice;
(C) the manner in which the contracted services are coordinated, supervised, and evaluated by the hospice;
(D) the delineation of the role(s) of the hospice and the contractor in the admission process, client and family health assessment, and the interdisciplinary team case conferences;
(E) requirements for documentation that services are furnished in accordance with the agreement; and
(F) the qualifications of the personnel providing the services.
(3) The hospice must retain professional management responsibility for arranged services and ensure they are furnished in a safe and effective manner by persons meeting the qualifications under this chapter, and in accordance with the client's plan of care and the other requirements of this subsection.
(4) The hospice must retain responsibility for payment for services.
(5) The hospice must ensure that inpatient care is furnished only in a licensed facility that meets the requirements of subsection (w) of this section, and the hospice's arrangement for inpatient care must be described in a contract and must meet the requirements of paragraph (2) of this subsection. The contract, at minimum, must meet the following requirements:
(A) that the hospice furnishes to the inpatient provider a copy of the client's plan of care and specifies the inpatient services to be furnished;
(B) that the inpatient provider has established policies consistent with those of the hospice and agrees to abide by the client care protocols established by the hospice for its clients;
(C) that the medical record includes a record of all inpatient services and events, and that a copy of the discharge summary and, if requested, a copy of the medical record are provided to the hospice;
(D) include the party responsible for implementation of the provisions of the contract; and
(E) that the hospice retains responsibility for appropriate hospice care training (to include palliative and end of life issues) of the personnel who provide the care under the agreement.
(g) Prior to the start of care, the hospice physician or registered nurse must make an initial health assessment visit to determine the immediate care and support needs of the client.
(1) The hospice physician or registered nurse must contact the client or client's representative within 24 hours of receiving the physician's referral for hospice care to schedule an appointment for the initial health assessment.
(2) The initial health assessment visit must be held within 48 hours after the hospice's receipt of the physician's referral for hospice care, unless ordered otherwise.
(3) After the initial health assessment is completed, services approved by the physician may be rendered.
(h) The hospice must perform and make available to each client admitted for hospice services a client-specific comprehensive health assessment that identifies the client's need for hospice care and the client's need for medical, nursing, social, emotional, and spiritual care which includes, but is not limited to, the palliation and management of the terminal illness and related conditions and support services for clients and their families.
(1) The hospice must complete the comprehensive health assessment in a timely manner consistent with the client's immediate needs, but no later than seven calendar days after the start of hospice care.
(2) The comprehensive health assessment must include:
(A) input from the appropriate interdisciplinary team member(s) and an assessment of: (i) each client's physical condition, including functional ability and nutritional status; (ii) each client's pain and other symptoms and the management of discomfort and symptom relief; (iii) the client's and the client's family's social and emotional well-being; (iv) the client's spiritual orientation and needs; (v) the survivor risk factors to be considered in developing the bereavement care plan; and (vi) any other information necessary to develop an effective, interdisciplinary plan of care;
(B) a review, repeated as necessary, of the client's medication list. The medication list must include all prescription and over-the-counter drugs to assure that all drugs are indicated and to identify any potential problems including, but not limited to: (i) ineffective drug therapy; (ii) significant side effects; (iii) significant drug interactions; (iv) significant drug and food interactions; (v) duplicate drug therapy; and (vi) noncompliance with drug therapy; and
(C) a system of measures that captures significant outcomes that are essential to optimal hospice care, that are used in the care planning and coordination of services, and that are an essential part of the hospice's quality assessment and performance improvement program. The measures include, but are not limited to: (i) pain; (ii) nutritional status; (iii) continence; (iv) respiratory comfort; (v) infections; (vi) skin integrity; (vii) level of consciousness; (viii) anxiety; (ix) depression; (x) client emotional well being and satisfaction, including anxiety and depression; (xi) spiritual well being; (xii) social well being; (xiii) family knowledge and understanding; and (xiv) client and family satisfaction.
(3) The comprehensive health assessment must be updated and revised:
(A) as frequently as the condition of the client requires, as determined by: (i) changes in the client's physical, social, emotional or spiritual status; (ii) family environment; or (iii) suboptimal response to care, treatments or therapies; and
(B) within 24 hours of the client's return home from an inpatient stay.
(i) A written plan of care must be established and maintained for each client admitted to the hospice program, and the care provided to a client must be in accordance with the plan. The plan of care must specify the care and services necessary to meet the client-specific needs identified in the comprehensive health assessment described in subsection (h) of this section, include all client care orders, reflect planned interventions for problems identified, and ensure that care and services are appropriate to the severity level of each client's and the client's family's specific needs.
(1) The plan must be established by the attending physician, the medical director or physician designee, and interdisciplinary team prior to providing care.
(2) The plan must be reviewed and updated as necessary, at intervals specified in the plan, by the attending physician, the medical director or physician designee and interdisciplinary team. These reviews must be documented. An updated plan must include information from the client's comprehensive health assessment and information concerning the client's progress toward outcomes as specified in the plan.
(3) The plan must include:
(A) a comprehensive health assessment of the client's needs and identification of the services including the management of pain and symptom relief. The plan must state in detail the scope and frequency of services that are needed to meet the client's and family's needs;
(B) interventions to facilitate the management of pain and symptoms;
(C) frequency and mix of services necessary to meet the client and family specific needs identified in the comprehensive health assessment;
(D) measurable outcomes that the hospice anticipates will occur as a result of implementing and coordinating the plan of care;
(E) drugs and treatments necessary to meet the needs of the patient as identified in the health assessment;
(F) medical supplies and appliances necessary to meet the needs of the client identified in the health assessment; and
(G) client and family understanding, agreement, and involvement with the plan as desired.
(j) The interdisciplinary team may reassess the client for an appropriate level of care, as long as the reassessment does not reduce core services.
(k) The hospice must inform the client of the availability of short-term inpatient care for pain control, management, and respite purposes and the names of the facilities with which the agency has a contract agreement.
(l) The hospice must document reasonable efforts to arrange for visits of clergy and other members of spiritual and religious organizations in the community to clients who request such visits and must advise all clients of this opportunity.
(m) The hospice must ensure that substantially all the core services described in subsections (n) - (q) of this section are routinely provided directly by hospice employees. The hospice may use contracted staff if necessary to supplement its employees in order to meet the needs of clients during periods of peak client loads or under extraordinary circumstances. If contracting is used, the hospice must maintain professional, financial, and administrative responsibility for the services and assure that the qualifications of staff and services provided meet the requirements specified in subsections (n) - (q) of this section.
(n) The hospice must provide nursing care and services by or under the supervision of a registered nurse.
(1) Nursing services must be directed and staffed to assure that the nursing needs of the clients are met.
(2) Client care responsibilities of nursing personnel must be specified.
(3) Services must be provided in accordance with recognized standards of practice.
(o) Medical social services must be provided by a social worker who is licensed in the state of Texas to provide social work services and must be under the direction of a physician.
(p) In addition to palliation and management of terminal illness and related conditions, hospice physicians, including physician member(s) of the interdisciplinary team, must meet the general medical needs of the clients to the extent that these needs are not met by the attending physician. The hospice physician may meet these requirements either by directly providing the services or through coordination with the attending physician. If the attending physician is unavailable, the hospice physician is responsible for the care of the client.
(q) Counseling services must be available to both the client and the family. Counseling includes dietary, spiritual, and any other counseling services for the client and family provided while the client is enrolled in the hospice program as well as bereavement counseling provided after the client's death.
(1) Bereavement counseling service must be available to the family.
(A) There must be an organized program for the provision of bereavement services under the supervision of the interdisciplinary team, a social worker, a mental health professional, a counselor, or other person with documented evidence of training and experience in dealing with bereavement and structured training in bereavement counseling. Persons providing bereavement counseling must have documented evidence of training in personnel folders.
(B) The plan of care for these services must reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery. Services must be provided up to one year following the death of the client.
(2) Dietary counseling must be planned by a registered or licensed dietitian, a person who is eligible for registration by the American Dietetic Association, or an individual who has documented equivalency in education or training. Dietary counseling must meet specific client needs as described in the client's plan of care. Although a dietitian need not be a full-time employee, there must be a record of this individual's credentials on file in the hospice. Dietary counseling must be supervised by a registered or licensed dietitian or a registered nurse.
(3) Spiritual counseling must include notice to clients as to the availability of clergy as required under subsection (l) of this section. Spiritual counseling may be conducted by clergy or other members of a spiritual and religious organization of the client's choice.
(4) Counseling may be provided by other members of the interdisciplinary team as well as by other professionals qualified by license or education to perform the type of counseling provided as determined by the hospice. Counseling, other than bereavement, dietary, or spiritual must be provided by persons qualified by license or education to perform the type of counseling to be provided in accordance with the client's plan of care. The counseling requirements do not preclude other members of the interdisciplinary team or other professionals from serving in the capacity of counselor. Nonprofessional volunteers may be used for listening and social interaction with clients.
(r) The hospice must ensure that the services described in subsections (s) - (v) of this section are provided directly by hospice employees or under arrangements made by the hospice as specified in subsection (f) of this section. The hospice must maintain a system of communication and integration of services, whether provided directly or under arrangement, that ensures the identification of client needs and the ongoing liaison of all disciplines providing care.
(s) Physical therapy services, occupational therapy services, and speech-language pathology services must be available, and when provided, must be offered in a manner consistent with accepted standards of practice.
(t) Home health aide and homemaker services must be available and adequate in frequency to meet the needs of the clients. A home health aide must meet the training and competency evaluation requirements or the competency evaluation requirements as specified in § 97.701(d) - (f) of this title (relating to Home Health Aides).
(1) A registered nurse must visit the residence site no less frequently than every two weeks when aide services are being provided, and the visit must include an assessment of the aide services. The aide need not be present at each supervisory visit.
(2) Written instructions for client care must be prepared by a registered nurse.
(u) Medical supplies and appliances, including medications, must be provided as needed for the palliation and management of the terminal illness and related conditions.
(1) All medications must be administered in accordance with accepted standards of practice.
(2) The hospice must have and enforce a policy for the disposal of controlled medications maintained in the client's residence when those medications are no longer needed by the client.
(3) Medications must be administered only by the following individuals:
(A) a licensed nurse or physician;
(B) a permitted home health medication aide;
(C) the client if his or her attending physician has approved; or
(D) another individual acting in accordance with applicable federal and state laws, or as specified in the rules adopted by the Texas Board of Nursing in: (i) 22 TAC, Chapter 224 (Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments); and (ii) 22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions).
(4) The persons who are authorized to administer medications must be specified in the client's plan of care.
(v) Inpatient care must be available for pain control, symptom management, and respite purposes.
(1) Inpatient care must be provided by a licensed freestanding hospice or a hospital or nursing facility that meets the requirements specified in subsection (w)(1) and (5) of this section.
(2) A hospice must develop, implement, maintain and evaluate an ongoing, comprehensive integrated self assessment of the quality and appropriateness of care provided, including inpatient care, home care, and care provided under arrangement. The findings must be documented and used by the hospice to correct identified problems and to revise hospice policies if necessary. Corrective action must be taken and tracked to ensure that improvements are sustained over time.
(A) The hospice's quality assessment and performance improvement program must include, but not be limited to, the use of objective measures to demonstrate improved performance with regard to: (i) the system of measures that the hospice uses to determine if individual and aggregate outcomes are achieved compared to a previous time period; (ii) current clinical practice guidelines and professional practice standards applicable to hospice care; (iii) utilization data, as appropriate. This includes data, such as numbers of staff, types of visits, and inpatient care; and (iv) effectiveness and safety of services. This includes services such as parenteral therapy or infusion controlling devices, if provided; competency of clinical staff; promptness of service delivery; and appropriateness of responses to client and family problems.
(B) The hospice must set priorities for performance improvement, considering prevalence and severity of identified problems and giving priority to improvement activities that affect clinical outcomes. The hospice must immediately correct identified problems that directly or potentially threaten the care and safety of clients.
(w) A freestanding hospice that provides inpatient care directly must comply with the following standards in addition to the standards in subsections (a) - (v) of this section.
(1) The hospice must have on-site 24-hour nursing service provided by registered nurses and licensed vocational nurses sufficient in number to meet total nursing needs and in accordance with the client's plan of care.
(A) Each client must receive treatments, medications, and diet as prescribed, and must be kept comfortable, clean, well groomed, and protected from accident, injury, and infection.
(B) Each shift must include a registered nurse that provides and supervises direct client care.
(2) In addition to § 97.256 of this chapter (relating to Emergency Preparedness Planning and Implementation), a freestanding hospice facility must address the following core functions of emergency management in its written emergency preparedness and response plan: direction and control, communication, resource management, sheltering in place, evacuation, transportation, and training. The facility must maintain documentation of compliance with this paragraph.
(A) The portion of the plan on direction and control must: (i) designate a person by position, and at least one alternate, to be in charge during implementation of an emergency response plan, with authority to execute a plan to evacuate or shelter in place; (ii) include procedures the facility will use to maintain continuous leadership and authority in key positions; (iii) include procedures the facility will use to activate a timely response plan based on the types of disasters identified in the risk assessment; (iv) include procedures the facility will use to meet staffing requirements; (v) include procedures the facility will use to warn or notify facility staff about internal and external disasters, including during off hours, weekends, and holidays; (vi) include procedures the facility will use to maintain a current list of who the hospice will notify once warning of a disaster is received; (vii) include procedures the facility will use to alert critical facility personnel once a disaster is identified; and (viii) include procedures the facility will use to maintain a current 24-hour contact list for all staff.
(B) The portion of the plan on communication must include procedures: (i) for continued communication, including procedures to maintain contact during an evacuation, with critical personnel and with all vehicles traveling in an evacuation caravan; (ii) to maintain an accessible, current list of the phone numbers of client family members, local shelters, prearranged receiving facilities, the local emergency management coordinator, emergency medical services, other healthcare providers, and local, state, and federal emergency management agencies; (iii) to notify staff, clients, families of clients, families of critical staff, prearranged receiving facilities, and others of an evacuation or the plan to shelter in place; (iv) to provide a contact number for out-of-town family members to call for information; and (v) to use the web-based system designed for facilities regulated by DADS to help each other relocate and track clients during disasters that require mass evacuations.
(C) The portion of the plan on resource management must include procedures: (i) to maintain contracts and agreements with multiple vendors for supplies and transportation; (ii) to develop accurate, detailed, and current checklists of essential supplies, staff, equipment, and medications; (iii) to designate responsibility for completing the checklists during disaster operations; (iv) for the safe and secure transportation of adequate amounts of food, water, medications, and critical supplies and equipment during an evacuation; and (v) to maintain a supply of sufficient resources for at least seven days to shelter in place, which must include:
(I) emergency power, including backup generators and accounts for maintaining a supply of fuel;
(II) potable water in an amount based on population and location;
(III) the types and amounts of food for the number and types of clients served;
(IV) extra pharmacy stocks of common medications; and
(V) extra medical supplies and equipment, such as oxygen, linens, and any other vital equipment.
(D) The portion of the plan on sheltering in place must: (i) be developed using information about the building's construction and Life Safety Code systems; (ii) describe the criteria to be used to decide whether to shelter in place versus evacuate; (iii) include procedures to assess whether the building is strong enough to withstand the various types of possible disasters and to identify the safest areas of the building; (iv) include procedures to secure the building against damage; (v) include procedures for collaborating with the local emergency management agency, fire, police, and emergency management system (EMS) agencies regarding the decision to shelter in place; (vi) include procedures to assign each task in the sheltering plan to facility staff; (vii) describe procedures to shelter in place that allow the facility to maintain 24-hour operations for a minimum of seven days to maintain continuity of care for the number and types of clients served; and (viii) include procedures to provide for building security.
(E) The portion of the plan on evacuation must: (i) include contracts with prearranged receiving facilities to provide hospice in-patient care, with at least one facility located at least 50 miles away; (ii) include procedures to identify and follow evacuation and alternative routes, and to notify the proper authorities of the decision to evacuate; (iii) include procedures to protect and transport client records and to match them to each client; (iv) include procedures to maintain a checklist of items to be transported with clients, including medications and assistive devices, and how the items will be matched to each client; (v) include staffing procedures the facility will use to ensure that staff accompany evacuating clients; (vi) include procedures to identify and assign staff responsibilities, including how clients will be cared for during evacuations, and a backup plan for lack of sufficient staff; (vii) include procedures facility staff will use to account for all individuals in the building during the evacuation and to track all individuals evacuated; (viii) include procedures for the use, protection, and security of the identifying information the facility will use to identify evacuated clients; (ix) include procedures facility staff will follow if a client becomes ill or dies in route; (x) include procedures to make a hospice counselor available to counsel evacuees; (xi) include the facility's policy on whether family of staff and clients can shelter at the hospice and evacuate with staff and clients; (xii) include procedures to coordinate building security with the local emergency management agency; (xiii) include procedures facility staff will use to determine when it is safe to return to the geographical area; (xiv) include procedures facility staff will use to determine if the building is safe for reoccupation; and (xv) be approved by the local emergency management coordinator at least annually and when updated.
(F) The portion of the plan on transportation must: (i) include procedures for using the facility's own vehicles or contracts with transportation vendors to provide suitable transportation for the type and number of clients being served; (ii) require contracted transportation vendors to provide written statements that describe how the vendors plan to fulfill their commitments in case of a disaster; (iii) include a backup plan facility staff will use in the event that the first transportation vendor overextended itself or does not show up; and (iv) include procedures to coordinate the facility's transportation needs with the local emergency management coordinator.
(G) The portion of the plan on training must include: (i) procedures that specify when and how the disaster response plan is reviewed with clients and family members; (ii) procedures to review the role and responsibility of a client able to participate with the plan; (iii) procedures for initial and periodic training for all facility staff to carry out the plan; (iv) the frequency for conducting disaster drills and demonstrations to ensure staff are fully trained with respect to their duties under the plan; and (v) procedures to conduct emergency response drills at least annually either in response to an actual disaster or in a planned drill, which may be in addition to, or combined with, the drills required by the Life Safety Code as specified in paragraph (4) of this subsection.
(3) The hospice must meet all federal, state, and local laws, regulations, and codes pertaining to health and safety, such as provisions regulating the following:
(A) construction, maintenance, and equipment for the hospice;
(B) sanitation;
(C) communicable and reportable diseases; and
(D) post-mortem procedures.
(4) Except as provided in this subsection, the hospice must meet National Fire Protection Association 101, Life Safety Code, 2000 Edition (NFPA 101), Chapter 18 (concerning new health care occupancies) and Chapter 19 (concerning existing health care occupancies), published by the National Fire Protection Association (NFPA). All documents published by the NFPA as referenced in this subsection may be obtained by writing the National Fire Protection Association, 1 Batterymarch Park, Quincy, Massachusetts 02169, or calling 1-800-344-3555.
(A) DADS recognizes the Centers for Medicare & Medicaid Services (CMS) waiver of specific provisions of the NFPA 101 required by this paragraph for a certified hospice for as long as CMS honors the waiver, if the waiver would not adversely affect the health and safety of the clients and rigid application of specific provisions of the NFPA 101 would result in unreasonable hardship for the hospice. DADS may waive specific provisions of the NFPA 101 for a licensed hospice, if the waiver would not adversely affect the health and safety of the clients; and rigid application of specific provisions of the NFPA 101 would result in unreasonable hardship for the hospice.
(B) Any existing facility of two or more stories that is not of fire-resistive construction and is participating on the basis of a waiver of construction type or height, may not house blind, nonambulatory, or physically disabled clients above the street-level floor unless the facility is one of the following construction types (as defined in the NFPA 101): (i) Type II (1,1,1)-protected noncombustible; (ii) fully-sprinklered Type II (0,0,0)-noncombustible; (iii) fully-sprinklered Type III (2,1,1)-protected ordinary; (iv) fully-sprinklered Type V (1,1,1)-protected wood frame; or (v) a facility that achieves a passing score on the Fire Safety Evaluation System (FSES) for Health Care Occupancies, NFPA 101A, Guide on Alternative Approaches to Life Safety, Chapter 4, Fire Safety Evaluation System for Health Care Occupancies, 2001 Edition published by the NFPA.
(5) The hospice must be designed and equipped for the comfort and privacy of each client and family member. The hospice must provide:
(A) physical space for private client and family visiting;
(B) accommodations for family members to remain with the client throughout the night;
(C) accommodations for family privacy after a client's death;
(D) decor that is homelike in design and function; and
(E) accommodations where clients are permitted to receive visitors at any hour, including small children.
(6) Client rooms must be designed and equipped for adequate nursing care and the comfort and privacy of clients. Each client's room must:
(A) be equipped with or conveniently located near toilet and bathing facilities;
(B) be at or above grade level;
(C) contain a suitable bed for each client and other appropriate furniture;
(D) have closet space that provides security and privacy for clothing and personal belongings;
(E) contain no more than four beds;
(F) measure at least 100 square feet for a single room or 80 square feet for each client for a multiclient room; and
(G) be equipped with a device for calling the staff member on duty.
(7) For an existing building, DADS recognizes the CMS waiver for the space and occupancy requirements of paragraph (6)(E) and (F) of this subsection for a certified hospice for as long as CMS honors the waiver, if DADS finds that the requirements would result in unreasonable hardship on the hospice if strictly enforced, and the waiver serves the particular needs of the clients and does not adversely affect their health and safety. For an existing building, DADS may waive the space and occupancy requirements of paragraph (6)(E) and (F) of this subsection for a licensed hospice for as long as it is considered appropriate, if it finds that the requirements would result in unreasonable hardship on the hospice if strictly enforced and the waiver serves the particular needs of the clients and does not adversely affect their health and safety.
(8) The hospice must provide bathroom facilities. The bathroom facilities must include the following:
(A) an adequate supply of hot water at all times for client use; and
(B) plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by clients.
(9) The hospice must have available at all times a quantity of linen essential for the proper care and comfort of clients. Linens must be handled, stored, processed, and transported in such a manner as to prevent the spread of infection.
(10) The hospice must make provisions for isolating clients with infectious diseases.
(11) The hospice must provide and supervise meal service and menu planning. The hospice must:
(A) serve at least three meals or their equivalent each day at regular times, with not more than 14 hours between a substantial evening meal and breakfast;
(B) procure, store, prepare, distribute, and serve all food under sanitary conditions;
(C) have a staff member trained or experienced in food management or nutrition if the staff member responsible for dietary services is not a dietitian. (i) The person must:
(I) be a graduate of a dietetic technician or dietetic assistant training program, correspondence or classroom, approved by the American Dietetic Association; or
(II) be a graduate of a state-approved course that provided 90 or more hours of classroom instruction in food service supervision and must have experience as a supervisor in a health care institution with consultation from a dietitian; or
(III) have training and experience in food service supervision and management in a military service equivalent in content to the program in this paragraph. (ii) The staff member is responsible for:
(I) planning menus that meet the nutritional needs of each client. The menus must follow the orders of the client's physician and, to the extent medically possible, follow the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences (Recommended Dietary Allowances, 10th ed., 1989, available from the Printing and Publications Office, National Academy of Sciences, Washington, D.C. 20418). The menus must be approved by a licensed dietitian. The hospice must use written guidelines for substitutions that are approved by the licensed dietitian; and
(II) supervising the meal preparation and meal service that is conducted to ensure that the menu plan is followed; and
(D) have the menus for those clients who require medically prescribed special diets. The menus must be planned by a dietitian who monitors the preparation and serving of meals to ensure that the client accepts the special diet.
(12) The hospice must provide appropriate methods and procedures for dispensing and administering medications. Whether medications are obtained from community or institutional pharmacists or stocked by the facility, the facility must be responsible for medications for its clients, insofar as they are covered under the program, and for ensuring that pharmaceutical services are provided in accordance with accepted professional principles and appropriate federal and state laws.
(A) The hospice must employ a licensed pharmacist or have a formal agreement with a licensed pharmacist to advise the hospice on ordering, storage, administration, disposal, and record keeping of medications.
(B) A physician must order all medications for the client.
(C) If the medication order is verbal, the physician must give it only to a licensed nurse, pharmacist, or another physician.
(D) If the medication order is verbal, the individual receiving the order must record and sign it immediately and have the prescribing physician sign it in a manner consistent with good medical practice.
(E) Medications must be administered only by one of the following individuals: (i) a licensed nurse or physician; (ii) a permitted home health medication aide or an employee as specified in the rules adopted by the Texas Board of Nursing in:
(I) 22 TAC, Chapter 224; or
(II) 22 TAC, Chapter 225; or (iii) the client if his or her attending physician has approved.
(F) The pharmaceutical service must have procedures for control and accountability of all medications throughout the facility. Medications must be dispensed in compliance with federal and state laws. Records of receipt and disposition of all controlled medications must be maintained in sufficient detail to enable an accurate reconciliation. The pharmacist must determine that medication records are in order and that an account of all controlled medications is maintained and reconciled.
(G) The labeling of medications must be based on currently accepted professional principles, and must include the appropriate accessory and cautionary instructions, as well as the expiration date when applicable.
(H) In accordance with state and federal laws, all medications must be stored in locked compartments under proper temperature controls and only authorized personnel must have access to the keys. Separately locked compartments must be provided for storage of controlled medications listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, 21 United States Code, § 801 et seq. and other medications that are subject to abuse, except under single-unit package medication distribution systems in which the quantity stored is minimal and a missing dose is readily detected. An emergency medication kit must be kept readily available.
(I) Controlled medications no longer needed by the client must be disposed of in compliance with state requirements. The pharmacist and registered nurse must dispose of medications and prepare a record of the disposal.
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