August 1, 2012
INPATIENT HOSPICE REGULATIONS
By: Nicole Dube, Associate Analyst
You asked how the state regulates inpatient hospice facilities.
Hospice is a coordinated program of palliative and supportive care (physical, psychological, social, and spiritual) for dying persons and their families provided by an interdisciplinary team of professionals and volunteers. The Department of Public Health (DPH) regulates (1) hospices that are either free-standing or distinct units within a healthcare facility and (2) homecare programs offered by an institutionally-based hospice. DPH regulations define “hospice” under the broader category of “short-term hospital, special hospice.” Currently, two facilities are licensed under this category: (1) Connecticut Hospice, Inc. located in Branford and (2) Atlantic Inpatient Hospice Unit located in St. Mary's Hospital in Waterbury.
On March 1, 2011, the department issued proposed regulations that would have created a second-tier licensure category called “hospice facilities.” The proposal would have made facilities that met Medicare's minimum regulatory requirements for inpatient hospice facilities eligible for DPH licensure (42 CFR § 418.110). These requirements are less stringent than DPH's short-term hospital special hospice regulations.
DPH held a public hearing on the proposed regulations in April 2011. The proposal was submitted to the Attorney General's office for final review in March 2012, after which it was submitted to the Regulations Review Committee for approval. In June 2012, the committee rejected the proposed regulations and asked DPH to make corrections; DPH has not yet resubmitted its corrected proposal for approval.
INPATIENT HOSPICE REGULATIONS
Current DPH regulations require inpatient hospice facilities to meet various requirements concerning physical plant, administration, staffing, records, and infection control. Home care programs offered by an institutionally-based hospice must also address the physical, psychological, and spiritual needs of the patient and family, and provide services 24 hours a day, seven days a week.
Each hospice must be managed by a governing board with full legal authority and responsibility for its conduct and the quality of medical care it provides. The board must adopt and enforce admission criteria on eligibility for hospice services, a patient bill of rights, medical by-laws, guidelines for community relations, and organizational rules and by-laws (Conn. Agencies Reg., § 19-13-D4b(b)).
The medical staff must include at least five physicians, one of whom serves as the chief, president, or medical director of the staff. All staff physicians must be licensed to practice medicine and surgery in Connecticut. The medical staff must adopt written by-laws and rules not inconsistent with those of the governing board. The medical director must ensure that (1) at least one physician is available on-site eight hours per day and (2) 24-hour on-call coverage is available (Conn. Agencies Reg., § 19-13-D4b(c)).
The hospice's nursing services must be directed by the director of hospice patient services. That individual must be a Connecticut-licensed, registered nurse (RN) and further qualified by experience in hospice, home health agency, or community health work (Conn. Agencies Reg., § 19-13-D4b(e)). The hospice must maintain a 1:6 ratio of RNs to patients and a 1:3 ratio of nurses or nurse's aides to patients.
The hospice must have a medical records department with adequate space and qualified personnel. A medical record, which must be kept confidential and secure, is maintained for everyone evaluated or treated as an out-patient or in-patient, or who received services in a hospice-based home care program (Conn. Agencies Reg., § 19-13-D4b(d)).
Each hospice is required to develop an infection prevention, surveillance, and control program to protect the patient, family, and personnel from infections and communicable diseases. The program must be approved by the facility's medical staff and the governing board (Conn. Agencies Reg., § 19-13-D4b(p)).
Other services hospice facilities must provide include pharmacy, social work, volunteer, artistic, palliative, respiratory care, specialized rehabilitative, pastoral care, dietary, and out-patient services (§ 19-13-D4b(e) to (r)). Diagnostic and palliative services include the services of a clinical laboratory and radiological services meeting all health department standards. The hospice can also enter into written agreements for other services (e.g., blood bank and pathological services) as necessary. All contracts must specify a 24 hour on-call availability (Conn. Agencies Reg., § 19-13-D4b(k)).
"Artistic" services refers to artistic opportunities provided by the hospice to the patient and family on a scheduled and intermittent basis. Artistic experiences must be coordinated by a qualified arts representative with a graduate degree and clinical experience in the arts or pastoral care. The arts director is a full member of the hospice's health care team (Conn. Agencies Reg., § 19-13-D4b(i)).
Pharmacy services must be directed by a licensed pharmacist (1) on a full-time basis if the hospice is a free-standing facility or (2) on a part-time basis if the hospice program is a dedicated unit within a healthcare facility. The scope of services must be consistent with patient needs as determined by the medical staff (Conn. Agencies Reg., § 19-13-D4b(f)).
Hospice facilities must meet a range of physical plant requirements. For example, nursing units can have no more than 30 beds, there can be no more than four patients in one room, single rooms must be at least 120 square feet, mutibedrooms must be at least 100 square feet per bed, and each patient must have access to a bathroom without entering the corridor (Conn. Agencies Reg., § 19-13-D4b(a)).
Hospice-Based Home Care Program Regulations
DPH regulations also address home care programs offered by institutionally-based hospices. They require health services to be of the highest quality and provided by a multidisciplinary, interactive, qualified hospice team. The program must address the physical, social, psychological, and spiritual needs of the patient and family and consist of 24 hours a day, seven days a week services (Conn. Agencies Reg., § 19-13-D4b(o)). The home care program must have the necessary personnel to meet patient needs including RNs, licensed practical nurses, and homemaker-home health aides. Personnel assigned by community service agencies must meet the qualification standards of the hospice for its employees. Accurate medical records must be kept for patients served under the home care program.