42 C.F.R. Subpart C—Conditions of Participation—General Provisions and Administration
Title 42 - Public Health
(a) Standard: Compliance. A hospice must maintain compliance with the conditions of this subpart and subparts D and E of this part. (b) Standard: Required services. A hospice must be primarily engaged in providing the care and services described in §418.202, must provide bereavement counseling and must— (1) Make nursing services, physician services, and drugs and biologicals routinely available on a 24-hour basis; (2) Make all other covered services available on a 24-hour basis to the extent necessary to meet the needs of individuals for care that is reasonable and necessary for the palliation and management of terminal illness and related conditions; and (3) Provide these services in a manner consistent with accepted standards of practice. (c) Standard: Disclosure of information. The hospice must meet the disclosure of information requirements at §420.206 of this chapter. [48 FR 56026, Dec. 16, 1983, as amended at 55 FR 50834, Dec. 11, 1990] A hospice must have a governing body that assumes full legal responsibility for determining, implementing and monitoring policies governing the hospice's total operation. The governing body must designate an individual who is responsible for the day to day management of the hospice program. The governing body must also ensure that all services provided are consistent with accepted standards of practice. The medical director must be a hospice employee who is a doctor of medicine or osteopathy who assumes overall responsibility for the medical component of the hospice's patient care program. Subject to the conditions of participation pertaining to services in §§418.80 and 418.90, a hospice may arrange for another individual or entity to furnish services to the hospice's patients. If services are provided under arrangement, the hospice must meet the following standards: (a) Standard: Continuity of care. The hospice program assures the continuity of patient/family care in home, outpatient, and inpatient settings. (b) Standard: Written agreement. The hospice has a legally binding written agreement for the provision of arranged services. The agreement includes at least the following: (1) Identification of the services to be provided. (2) A stipulation that services may be provided only with the express authorization of the hospice. (3) The manner in which the contracted services are coordinated, supervised, and evaluated by the hospice. (4) The delineation of the role(s) of the hospice and the contractor in the admission process, patient/family assessment, and the interdisciplinary group care conferences. (5) Requirements for documenting that services are furnished in accordance with the agreement. (6) The qualifications of the personnel providing the services. (c) Standard: Professional management responsibility. The hospice retains professional management responsibility for those services and ensures that they are furnished in a safe and effective manner by persons meeting the qualifications of this part, and in accordance with the patient's plan of care and the other requirements of this part. (d) Standard: Financial responsibility. The hospice retains responsibility for payment for services. (e) Standard: Inpatient care. The hospice ensures that inpatient care is furnished only in a facility which meets the requirements in §418.98 and its arrangement for inpatient care is described in a legally binding written agreement that meets the requirements of paragraph (b) and that also specifies, at a minimum— (1) That the hospice furnishes to the inpatient provider a copy of the patient's plan of care and specifies the inpatient services to be furnished; (2) That the inpatient provider has established policies consistent with those of the hospice and agrees to abide by the patient care protocols established by the hospice for its patients; (3) 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; (4) The party responsible for the implementation of the provisions of the agreement; and (5) That the hospice retains responsibility for appropriate hospice care training of the personnel who provide the care under the agreement. [48 FR 56026, Dec. 16, 1983; 48 FR 57282, Dec. 29, 1983] A written plan of care must be established and maintained for each individual admitted to a hospice program, and the care provided to an individual must be in accordance with the plan. (a) Standard: Establishment of plan. The plan must be established by the attending physician, the medical director or physician designee and interdisciplinary group prior to providing care. (b) Standard: Review of plan. The plan must be reviewed and updated, at intervals specified in the plan, by the attending physician, the medical director or physician designee and interdisciplinary group. These reviews must be documented. (c) Standard: Content of plan. The plan must include an assessment of the individual's needs and identification of the services including the management of discomfort and symptom relief. It must state in detail the scope and frequency of services needed to meet the patient's and family's needs. A hospice may not discontinue or diminish care provided to a Medicare beneficiary because of the beneficiary's inability to pay for that care. A hospice must demonstrate respect for an individual's rights by ensuring that an informed consent form that specifies the type of care and services that may be provided as hospice care during the course of the illness has been obtained for every individual, either from the individual or representative as defined in §418.3. A hospice must provide an ongoing program for the training of its employees. A hospice must conduct an ongoing, comprehensive, integrated, self-assessment of the quality and appropriateness of care provided, including inpatient care, home care and care provided under arrangements. The findings are used by the hospice to correct identified problems and to revise hospice policies if necessary. Those responsible for the quality assurance program must— (a) Implement and report on activities and mechanisms for monitoring the quality of patient care; (b) Identify and resolve problems; and (c) Make suggestions for improving patient care. The hospice must designate an interdisciplinary group or groups composed of individuals who provide or supervise the care and services offered by the hospice. (a) Standard: Composition of group. The hospice must have an interdisciplinary group or groups that include at least the following individuals who are employees of the hospice: (1) A doctor of medicine or osteopathy. (2) A registered nurse. (3) A social worker. (4) A pastoral or other counselor. (b) Standard: Role of group. The interdisciplinary group is responsible for— (1) Participation in the establishment of the plan of care; (2) Provision or supervision of hospice care and services; (3) Periodic review and updating of the plan of care for each individual receiving hospice care; and (4) Establishment of policies governing the day-to-day provision of hospice care and services. (c) If a hospice has more than one interdisciplinary group, it must designate in advance the group it chooses to execute the functions described in paragraph (b)(4) of this section. (d) Standard: Coordinator. The hospice must designate a registered nurse to coordinate the implementation of the plan of care for each patient. The hospice in accordance with the numerical standards, specified in paragraph (e) of this section, uses volunteers, in defined roles, under the supervision of a designated hospice employee. (a) Standard: Training. The hospice must provide appropriate orientation and training that is consistent with acceptable standards of hospice practice. (b) Standard: Role. Volunteers must be used in administrative or direct patient care roles. (c) Standard: Recruiting and retaining. The hospice must document active and ongoing efforts to recruit and retain volunteers. (d) Standard: Cost saving. The hospice must document the cost savings achieved through the use of volunteers. Documentation must include— (1) The identification of necessary positions which are occupied by volunteers; (2) The work time spent by volunteers occupying those positions; and (3) Estimates of the dollar costs which the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) for the amount of time specified in paragraph (d)(2). (e) Standard: Level of activity. A hospice must document and maintain a volunteer staff sufficient to provide administrative or direct patient care in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff. The hospice must document a continuing level of volunteer activity. Expansion of care and services achieved through the use of volunteers, including the type of services and the time worked, must be recorded. (f) Standard: Availability of clergy. The hospice must make reasonable efforts to arrange for visits of clergy and other members of religious organizations in the community to patients who request such visits and must advise patients of this opportunity. The hospice and all hospice employees must be licensed in accordance with applicable Federal, State and local laws and regulations. (a) Standard: Licensure of program. If State or local law provides for licensing of hospices, the hospice must be licensed. (b) Standard: Licensure of employees. Employees who provide services must be licensed, certified or registered in accordance with applicable Federal or State laws. In accordance with accepted principles of practice, the hospice must establish and maintain a clinical record for every individual receiving care and services. The record must be complete, promptly and accurately documented, readily accessible and systematically organized to facilitate retrieval. (a) Standard: Content. Each clinical record is a comprehensive compilation of information. Entries are made for all services provided. Entries are made and signed by the person providing the services. The record includes all services whether furnished directly or under arrangements made by the hospice. Each individual's record contains— (1) The initial and subsequent assessments; (2) The plan of care; (3) Identification data; (4) Consent and authorization and election forms; (5) Pertinent medical history; and (6) Complete documentation of all services and events (including evaluations, treatments, progress notes, etc.). (b) Standard; Protection of information. The hospice must safeguard the clinical record against loss, destruction and unauthorized use.
Title 42: Public Health
PART 418—HOSPICE CARE
Subpart C—Conditions of Participation—General Provisions and Administration
§ 418.50 Condition of participation—General provisions.
§ 418.52 Condition of participation—Governing body.
§ 418.54 Condition of participation—Medical director.
§ 418.56 Condition of participation—Professional management.
§ 418.58 Condition of participation—Plan of care.
§ 418.60 Condition of participation—Continuation of care.
§ 418.62 Condition of participation—Informed consent.
§ 418.64 Condition of participation—Inservice training.
§ 418.66 Condition of participation—Quality assurance.
§ 418.68 Condition of participation—Interdisciplinary group.
§ 418.70 Condition of participation—Volunteers.
§ 418.72 Condition of participation—Licensure.
§ 418.74 Condition of participation—Central clinical records.
