Hospice Care: Providing

Title 22 §87633

If a hospice waiver has been granted by CCLD to the facility, the hospice waiver document (usually a letter on CCLD letterhead) should be posted prominently in the facility near the facility's license.  The number of hospice residents permitted in the facility at any one time will be included on the waiver.   The facility's responsibilities to hospice residents are individually discussed.

Selecting a Hospice Agency

The right to select a hospice agency is reserved to the resident and his/her responsible party.  A facility may suggest a particular hospice agency, and may even hold a hospice agency license itself, but under no circumstances is the resident required to contract with the agency suggested by the RCFE.  CONSUMERS ARE ALLOWED TO USE ANY HOSPICE AGENCY THEY CHOOSE.  Further, and per Title 22, the contract for hospice services is between the resident and the hospice agency, not between the facility and the hospice agency.  However, the facility is responsible for ensuring that the hospice care plan developed for the resident complies with the requirements of Title 22, and that all the resident's care needs are being met at all times (regardless of the specific responsibility of the facility or the hospice agency).

All contracted hospice agencies must be both licensed by the state and certified by the Medicare program.

Hospice Care Plans

A written hospice care plan must be developed for each terminally ill resident by that resident's hospice agency, and agreed to by the Licensee and the resident (or the resident's responsible party), prior to the initiation of hospice services in the facility for that resident.  All hospice care plans must be fully implemented by the facility and by the hospice agency.   It is the facility's responsibility to ensure that the plan is current, accurately matches the services being provided and that the resident's needs are being met AT ALL TIMES.

The plan, which shall be maintained in the facility for each hospice resident, must include the following:

(1) The name and contact information (including 24-hour emergency phone number) of the hospice agency and the resident's physician;

(2) Designation of the resident's primary contact person at the hospice agency, and primary and alternate caregivers at the facility

(3) A full description of services to be provided by hospice agency (including type and frequency of services)

(4) A full description of services that are the responsibility of the facility (including storage and handling of medication, the maintenance and use of medical supplies and equipment, etc.). "The plan shall neither require nor recommend that facility personnel other than a skilled professionals preform any procedures that must legally be provided by an appropriately skilled professional" (Title 22 § 87633).  This includes the administration of medications.   For procedures related to the appropriate assistance with medications as performed by facility staff see Medication Management.

(5) Identification of the training needed, which staff members need this training, and who will provide the training regarding the facility's responsibilities to the hospice resident. 

General training topics include turning and repositioning the resident, incontinence care, skin breakdown, hydration, etc.  Additionally, it is the facility's responsibility to ensure that all staff are knowledgeable about each individual resident's anticipated dying process so as to adequately meet the care plan requirements. 

The hospice agency is required to provide training to facility staff regarding the specific needs (current and on-going) of the individual resident under their care.

(6) A description of all hospice services to be provided or arranged in the facility, by persons other than the facility or hospice agency (i.e. clergy, resident's family and friends).

CCLD may require, at any time, a revision of the hospice care plan if the plan is not fully implemented or if it determines that a revision is necessary to protect the health and safety of the resident.

Medications

As a resident's dependency and frailty increases, his ability to self-administer medications will  likely diminish.  By regulation, facility staff are only allowed to assist in self-administration of medications.  If a resident requires someone else to administer medications, that someone  must be a skilled medical professional. 

Once self-administration is no longer possible, two options remain:

(1) A skilled medical professional can administer medications to the resident.  As hospice agency nurses do not remain at the facility 24/7, but rather make rounds to a number of facilities on a given day, it is important to establish in the care plan who else will be available to administer medications.  If the facility has a skilled medical professional on-staff, then that authorized person may administer. 

(2) Another option is that the hospice agency train a resident’s family member(s) or friend(s) how to properly administer medications.  Such designations must be documented in the hospice care plan.  If a skilled medical professional is not available, nor an authorized family or friend, medications may not be administered by facility staff, or any other paid aide or personal attendant, and the resident will need to be placed into a higher level of care.  Please note also that Title 22 specifies that fellow residents may not be considered a “friend” or “relative” who is able to administer medications.

Additional notes: (1) Morphine pumps are allowed in RCFEs but must be administered by the resident or appropriately skilled professional, and its use must be documented in the hospice care plan.  (2) Nasogastric tubes (aka feeding tubes) and serious infections are not allowed in RCFEs.

Restricted Health Conditions (§ 87612)

Title 22 states that a facility does not need the approval of CCLD to care for a hospice resident with a restricted health condition provided the resident is currently receiving hospice care and the restricted health condition is addressed in the hospice care plan.  Also see Restricted Health Conditions.

Hospital Beds and Bed Rails

Hospital beds and full bed rails are permissible if the hospice care nurse indicates they are necessary in the hospice care plan.  Otherwise, half bed rails that are used only to assist a resident with mobility are allowed within the RCFE setting. Written authorization from a physician is required to be maintained in the residents file if half bed rails are to be used for any reason for any resident. (§ 87608)

Fire Clearance

If a hospice resident becomes bedridden, the facility may accept and/or retain the resident provided they notify the local fire authority within 48 hours of the estimated length of time the resident will be bedridden.

Records

Facilities are required to maintain the following hospice care records:  

  • An accurate hospice care plan
  • A record of all hospice-related staff training provided
  • A record of dosages of medications that are centrally stored for each resident receiving hospice services in the facility 

Other documentation includes:

  • The resident’s (or resident’s Health Care Surrogate Decision Maker’s) written request for retention and hospice services in the facility, as well as any Advance Health Care Directive, Request to Forego Resuscitative measures, and/or Do-Not-Resuscitate Form.
  • Contact info of hospice agency and emergency contacts
  • A copy of the written certification statement of the resident’s terminal illness from the director or physician of the hospice agency, and the resident’s individual physician (if they have one)
  • If the hospice resident shares a room with another, a statement signed by the resident’s roommate that she is aware of the resident’s condition, and voluntarily agrees to grant access to shared living spaces to the hospice agency, caregivers, friends, family and others.  (The roommate may verbally, or in writing withdraw the agreement at any time and alternative arrangements must be made to accommodate the needs of the hospice resident.)