12VAC5-391-10. Definitions.

The following words and terms when used in these regulations shall have the following meaning unless the context clearly indicates otherwise.

"Activities of daily living" means bathing, dressing, toileting, transferring, bowel control, bladder control and eating/feeding.

"Administer" means the direct application of a controlled substance, whether by injection, inhalation, ingestion or any other means, to the body of a patient by (i) a practitioner or by his authorized agent and under his supervision or (ii) the patient at the direction and in the presence of the practitioner as defined in §54.1-3401 of the Code of Virginia.

"Administrator" means a person designated, in writing, by the governing body as having the necessary authority for the day-to-day management of the hospice program. The administrator must be a member of the hospice staff. The administrator, director of nursing, or another clinical director may be the same individual if that individual is dually qualified.

"Attending physician" means a physician licensed in Virginia, according to Chapter 29 (§54.1-2900 et seq.) of Title 54.1 of the Code of Virginia, or licensed in an adjacent state and identified by the patient as having the primary responsibility in determining the delivery of the patient''s medical care. The responsibilities of physicians contained in this chapter may be implemented by nurse practitioners or physician assistants as assigned by the supervising physician and within the parameters of professional licensing.

"Available at all times during operating hours" means an individual is available on the premises or by telecommunications.

"Barrier crimes" means certain offenses specified in §32.1-162.9:1 of the Code of Virginia that automatically bar an individual convicted of those offenses from employment with a hospice program.

"Bereavement service" means counseling and support offered to the patient''s family after the patient''s death.

"Commissioner" means the State Health Commissioner.

"Coordinated program" means a continuum of palliative and supportive care provided to a terminally ill patient and his family, 24 hours a day, seven days a week.

"Core services" means those services that must be provided by a hospice program. Such services are: (i) nursing services, (ii) physician services, (iii) counseling services, and (iv) medical social services.

"Counseling services" means the provision of bereavement services, dietary services, spiritual and any other counseling services for the patient and family while the person is enrolled in the program.

"Criminal record report" means the statement issued by the Central Criminal Records Exchange, Virginia Department of State Police.

"Dedicated hospice facility" means an institution, place, or building providing room, board, and appropriate patient care 24 hours a day, seven days a week to individuals diagnosed with a terminal illness requiring such care pursuant to a physician''s orders.

"Dispense" means to deliver a drug to the ultimate user by or pursuant to the lawful order of a practitioner, including the prescribing and administering, packaging, labeling or compounding necessary to prepare the substance for that delivery as defined in §54.1-3401 of the Code of Virginia.

"Employee" means an individual who is appropriately trained and performs a specific job function for the hospice program on a full or part-time basis with or without financial compensation.

"Governing body" means the individual, group or governmental agency that has legal responsibility and authority over the operation of the hospice program.

"Home attendant" means a nonlicensed individual performing personal care and environmental services, under the supervision of the appropriate health professional, to a patient in the patient''s residence. Home attendants are also known as certified nursing assistants or CNAs, home care aides, home health aides, and personal care aides.

"Hospice" means a coordinated program of home and inpatient care provided directly or through an agreement under the direction of an identifiable hospice administration providing palliative and supportive medical and other health services to terminally ill patients and their families. A hospice utilizes a medically directed interdisciplinary team. A hospice program of care provides care to meet the physical, psychological, social, spiritual and other special needs that are experienced during the final stages of illness, and during dying and bereavement. Hospice care shall be available 24 hours a day, seven days a week.

"Inpatient" means services provided to a hospice patient who is admitted to a hospital or nursing facility on a short-term basis for the purpose of curative care unrelated to the diagnosed terminal illness. Inpatient does not mean services provided in a dedicated hospice facility.

"Interdisciplinary group" means the group responsible for assessing the health care and special needs of the patient and the patient''s family. Providers of special services, such as mental health, pharmacy, and any other appropriate associated health services may also be included on the team as the needs of the patient dictate. The interdisciplinary group is often referred to as the IDG.

"Licensee" means a licensed hospice program provider.

"Medical director" means a physician currently licensed in Virginia, according to Chapter 29 (§54.1-2900 et seq.) of Title 54.1 of the Code of Virginia, and responsible for the medical direction of the hospice program.

"Medical record" means a continuous and accurate documented account of services provided to a patient, including the prescription and delivery of the treatment or care.

"Nursing services" means the patient care performed or supervised by a registered nurse according to a plan of care.

"OLC" means the Office of Licensure and Certification of the Virginia Department of Health.

"Operator" means any individual, partnership, association, trust, corporation, municipality, county, local government agency or any other legal or commercial entity responsible for the day-to-day administrative management and operation of the hospice.

"Palliative care" means treatment directed at controlling pain, relieving other symptoms, and focusing on the special needs of the patient and family as they experience the stress of the dying process. Palliative care means treatment to enhance comfort and improve the quality of a patient''s life during the last phase of his life.

"Patient" means a diagnosed terminally ill individual, with an anticipated life expectancy of six months or less, who, alone or in conjunction with designated family members or representatives, has voluntarily requested admission and been accepted into a licensed hospice program.

"Patient''s family" means the hospice patient''s immediate kin, including spouse, brother, sister, child or parent. Other relations and individuals with significant personal ties to the hospice patient may be designated as members of the patient''s family by mutual agreement among the patient, the relation or individual.

"Patient''s residence" means the place where the individual or patient makes his home.

"Person" means any individual, partnership, association, trust, corporation, municipality, county, local government agency or any other legal or commercial entity that operates a hospice.

"Plan of care" means a written plan of services developed by the interdisciplinary group to maximize patient comfort by symptom control to meet the physical, psychosocial, spiritual and other special needs that are experienced during the final stages of illness, during dying, and bereavement.

"Primary caregiver" means an individual that, through mutual agreement with the patient and the hospice program, assumes responsibility for the patient''s care.

"Progress note" means a documented statement contained in a patient''s medical record, dated and signed by the person delivering the care, treatment or service, describing the treatment or services delivered and the effect of the care, treatment or services on the patient.

"Quality improvement" means ongoing activities designed to objectively and systematically evaluate the quality of care and services, pursue opportunities to improve care and services, and resolve identified problems. Quality improvement is an approach to the ongoing study and improvement of the processes of providing services to meet the needs of patients and their families.

"Staff" means an employee who receives financial compensation.

"Supervision" means the ongoing process of monitoring the skills, competencies and performance of the individual supervised and providing regular face-to-face guidance and instruction.

"Terminally ill" means a medical prognosis that life expectancy is six months or less if the illness runs its usual course.

"The Center" means the Center for Quality Health Care Services and Consumer Protection of the Virginia Department of Health.

"Volunteer" means an employee who receives no financial compensation.

Statutory Authority

§§32.1-12 and 32.1-162.5 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 21, Issue 23, eff. November 1, 2005; amended, Volume 24, Issue 11, eff. March 5, 2008.

12VAC5-391-30. License.

A. A license to operate a hospice program is issued to a person.

B. The State Health Commissioner shall issue or renew a license to establish or operate a hospice program if the commissioner finds that the hospice program is in compliance with the law and this chapter.

C. A separate license shall be required for hospice programs maintained at separate locations, even though they are owned or are operated under the same management.

D. Every hospice program shall be designated by an appropriate name. The name shall not be changed without first notifying the center OLC.

E. Licenses shall not be transferred or assigned.

F. Any person establishing, conducting, maintaining, or operating a hospice program without a license shall be guilty of a Class 1 misdemeanor according to §32.1-27 of the Code of Virginia.

Statutory Authority

§§32.1-12 and 32.1-162.5 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 21, Issue 23, eff. November 1, 2005; amended, Volume 24, Issue 11, eff. March 5, 2008.

12VAC5-391-40. Exemption from licensure.

A. According to §32.1-162.2 of the Code of Virginia, this chapter is not applicable to a hospice established or operated for the practice of religious tenets of any recognized church or denomination that provides care and treatment for the sick by spiritual means without the use of any drug or material remedy, whether gratuitously or for compensation. Such a hospice shall comply with the statutes and regulations governing environmental protection and life safety.

B. The hospice program must file a request for exemption from licensure in writing to the Director director of the Center for Quality Health Care Services and Consumer Protection OLC. The request shall contain documentation explaining the hospice program''s relationship to the practice of religious tenets of a recognized church or denomination.

C. The hospice program shall be notified in writing that the exemption from licensure has been registered.

D. Exempt hospice programs shall remain subject to complaint investigations in keeping with state law.

Statutory Authority

§§32.1-12 and 32.1-162.5 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 21, Issue 23, eff. November 1, 2005; amended, Volume 24, Issue 11, eff. March 5, 2008.

12VAC5-391-50. License application; initial and renewal.

A. The center OLC will provide prelicensure consultation and technical assistance to any person regarding the licensure process. The purpose of such consultation is to explain the regulation and to review an applicant''s proposed hospice program plans, forms, and other documents, as they relate to the regulation. Prelicensure consultations can be arranged after an initial application has been filed.

B. Licensure applications are obtained from the center OLC. The center OLC shall consider an application complete when all requested information and the appropriate fee, stated in 12VAC5-391-70, are submitted. If the center OLC finds the application incomplete, the applicant will be notified in writing of the incomplete application.

An incomplete application shall become inactive six months after it is received by the center OLC. Applicants must reapply for licensure with a completed application and application fee. An application for a license may be withdrawn at any time.

C. A completed application for initial licensure must be submitted at least 60 days prior to the hospice program''s planned opening date to allow the center OLC time to act on the application.

D. The activities and services of each applicant or licensee of a hospice license shall be subject to an inspection by the center OLC to determine if the hospice program is in compliance with the provisions of this chapter and state law. Hospice programs submitting an initial application shall receive an announced inspection prior to accepting patients.

E. Licenses are renewed annually. The center OLC shall make renewal applications available at least 60 days prior to the expiration date of the current license.

F. The hospice program shall submit the completed renewal application form along with any required attachments and the application fee by the date indicated in the cover letter. Providers operating dedicated hospice facilities shall include a copy of the facility deficiency report and plan of correction from their latest facility licensure inspection when applying to renew their hospice program license.

G. It is the hospice program''s responsibility to complete and return the renewal application to assure timely processing. Should a current license expire before a new license is issued, the current license shall remain in effect provided a complete and accurate application was filed on time.

H. Providers operating a dedicated hospice facility shall maintain compliance with the applicable licensure regulations described in 12VAC5-391-120. Failure to maintain compliance may be taken into consideration in the center''s OLC decision to renew a hospice program license.

Statutory Authority

§§32.1-12 and 32.1-162.5 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 21, Issue 23, eff. November 1, 2005; amended, Volume 24, Issue 11, eff. March 5, 2008.

12VAC5-391-60. Changes to or reissuance of a license.

A. It is the responsibility of the hospice program''s governing body to maintain a current and accurate license, including appropriate facility licensure if the hospice program operates a dedicated hospice facility.

B. A hospice program shall give written notification 30 working days in advance of any proposed changes that may require the reissuance of the license. Notices shall be sent to the attention of the Director director of the Center for Quality Health Care Services and Consumer Protection OLC.

The following circumstances require the reissuance of a license and payment of a fee:

1. A change in ownership or operator;

2. A change in hospice program name; or

3. Relocation of the hospice program''s administrative office.

C. The center OLC will evaluate written information about any planned changes in operation that affect the terms of the license or the continuing eligibility for a license. A licensing representative may inspect the hospice program during the process of evaluating a proposed change.

D. The hospice program will be notified in writing whether a license can be reissued or a new application is needed.

Statutory Authority

§§32.1-12 and 32.1-162.5 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 21, Issue 23, eff. November 1, 2005; amended, Volume 24, Issue 11, eff. March 5, 2008.

12VAC5-391-70. Fees.

A. The center OLC shall collect a fee of $500 for each initial and renewal license. Fees shall accompany the licensure application and are not refundable.

B. A processing fee of $250 shall be collected for each reissuance or replacement of a license and shall accompany the written request for reissuance or replacement.

C. In addition, a late fee of $50 shall be collected for a hospice program''s failure to file a renewal application by the date specified.

Statutory Authority

§§32.1-12 and 32.1-162.5 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 21, Issue 23, eff. November 1, 2005; amended, Volume 24, Issue 11, eff. March 5, 2008.

12VAC5-391-80. On-site inspections.

A. A center OLC representative shall make periodic unannounced on-site inspections of the hospice program as necessary, but not less often than biennially. The hospice program shall be responsible for correcting any deficiencies found during any on-site inspection, including deficiencies found during announced initial inspections. Compliance with all standards will be determined by the center OLC according to applicable law. The administrator will be notified whenever any item in the plan of correction is determined to be unacceptable.

B. The hospice program shall make available to the center OLC representative any necessary records and shall allow access to interview the agents, employees, contractors, and any person under its control, direction or supervision.

C. After the on-site inspection, the center OLC representative shall discuss the findings of the inspection with the administrator or designee.

D. The administrator shall submit, within 15 working days from the date of the deficiency report, an acceptable plan for correcting any deficiencies found during an on-site inspection. The plan of correction shall contain:

1. A description of the corrective action or actions to be taken and the personnel to implement and monitor the corrective action;

2. The expected correction date;

3. A description of the measures implemented to prevent a recurrence of the violation; and

4. The signature of the hospice program''s administrator.

E. The administrator shall be responsible for assuring the plan of correction is implemented and monitored so that compliance is maintained.

F. Completion of corrective actions shall not exceed 45 working days from the last day of the inspection.

Statutory Authority

§§32.1-12 and 32.1-162.5 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 21, Issue 23, eff. November 1, 2005; amended, Volume 24, Issue 11, eff. March 5, 2008.

12VAC5-391-90. Home visits.

A. As part of any inspection, a center an OLC representative may conduct home visits subject to obtaining consent from the patient and the patient''s family or caretaker.

B. The hospice program shall be responsible for arranging in-home visits with patients, family members, and caregivers for the center OLC representative.

C. The hospice program shall explain clearly to the patient, patient''s family or caretaker, that a home visit is voluntary and that refusal to consent to a home visit will in no way affect the patient''s care.

Statutory Authority

§§32.1-12 and 32.1-162.5 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 21, Issue 23, eff. November 1, 2005; amended, Volume 24, Issue 11, eff. March 5, 2008.

12VAC5-391-100. Complaint investigation.

A. The center OLC has the responsibility to investigate any complaints regarding alleged violations of this chapter and applicable law.

B. Complaints may be received in written or oral form and may be anonymous.

C. When the investigation is complete, the licensee and the complainant, if known, will be notified in writing of the findings of the investigation.

D. The administrator shall submit an acceptable plan for correcting any deficiencies found during a complaint investigation.

E. The administrator will be notified in writing whenever any aspect of the plan of correction is determined to be unacceptable.

F. The administrator shall be responsible for assuring the plan of correction is implemented and monitored so that compliance is maintained.

Statutory Authority

§§32.1-12 and 32.1-162.5 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 21, Issue 23, eff. November 1, 2005; amended, Volume 24, Issue 11, eff. March 5, 2008.

12VAC5-391-120. Dedicated hospice facilities.

A. Providers seeking to operate a dedicated hospice facility shall comply with the appropriate facility licensing regulation as follows:

1. Up to five patient beds, facilities shall be licensed as:

a. An assisted living facility pursuant to 22VAC40-71;

b. A hospital pursuant to 12VAC5-410; or

c. A nursing facility pursuant to 12VAC5-371; or

2. Six or more patient beds, facilities shall be licensed as:

a. An assisted living facility, pursuant to 22VAC40-71 with a classified Use Group of I-2;

b. A hospital pursuant to 12VAC5-410; or

c. A nursing facility pursuant to 12VAC5-371.

Facilities to be licensed as a hospital or a nursing facility shall obtain the applicable Certificate of Public Need (COPN).

B. Only patients diagnosed terminally ill shall be admitted to a dedicated hospice facility. The facility shall admit only those patients whose needs can be met by the accommodations and services provided by the facility.

C. Admission to a dedicated hospice facility shall be the decision of the patient in consultation with the patient''s physician. No patient shall be admitted to a hospice facility at the discretion of, or for the convenience of, the hospice provider.

D. No dedicated hospice facility shall receive for care, treatment, or services patients in excess of the licensed bed capacity. However, facilities licensed as a nursing facility may provide temporary shelter for evacuees displaced due to a disaster. In those cases, the facility may exceed the licensed capacity for the duration of that emergency only provided the health, safety, and well being of all patients is not compromised and the center OLC is notified.

E. No dedicated hospice facility provider shall add additional patient beds or renovate facility space without first notifying the center OLC and the applicable facility licensing authority. Center OLC notifications must be in writing to the Director director of the Center for Quality Health Care Services and Consumer Protection OLC.

F. The center OLC will not accept any requests for variances to this section.

Statutory Authority

§§32.1-12 and 32.1-162.5 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 21, Issue 23, eff. November 1, 2005; amended, Volume 24, Issue 11, eff. March 5, 2008.

12VAC5-391-130. Variances.

A. The center OLC can authorize variances only to its own licensing regulations, not to regulations of another agency or to any requirements in federal, state, or local laws.

B. A hospice program may request a variance to a particular regulation or requirement contained in this chapter when the standard or requirement poses a special hardship and when a variance to it would not endanger the safety or well-being of patients. The request for a variance must describe the special hardship to the hospice program and to the patients it serves. When applicable, the request should include proposed alternatives to meet the purpose of the requirements that will ensure the protection and well-being of patients. At no time shall a variance approved for one individual be extended to general applicability. If a variance is denied, expires, or is rescinded, routine enforcement of the regulation or portion of the regulation shall be resumed. The hospice program may at any time withdraw a request for a variance.

C. The center OLC shall have the authority to waive, either temporarily or permanently, the enforcement of one or more of these regulations provided safety, patient care and services are not adversely affected. The center OLC may attach conditions to the granting of the variance in order to protect persons in care.

D. The center OLC may rescind or modify a variance when (i) conditions change; (ii) additional information becomes known that alters the basis for the original decision; (iii) the hospice program fails to meet any conditions attached to the variance; or (iv) results of the variance jeopardize the safety, comfort, or well-being of persons in care.

E. Consideration of a variance is initiated when a written request is submitted to the Director director of the Center for Quality Health Care Services and Consumer Protection OLC. The center OLC shall notify the hospice program in writing of the receipt of the request for a variance.

F. The licensee shall be notified in writing if the requested variance is denied.

G. The hospice program shall develop procedures for monitoring the implementation of any approved variance to assure the ongoing collection of any data relevant to the variance and the presentation of any later report concerning the variance as requested by the center OLC.

Statutory Authority

§§32.1-12 and 32.1-162.5 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 21, Issue 23, eff. November 1, 2005; amended, Volume 24, Issue 11, eff. March 5, 2008.

12VAC5-391-150. Return of a license.

A. The circumstances under which a license must be returned include, but are not limited to (i) change in ownership or operator, (ii) change in hospice program name, (iii) relocation of the administrative office, (iv) discontinuation of any core services, and (v) establishment of a dedicated hospice facility.

B. The licensee shall notify its patients and the center OLC in writing 30 days prior to discontinuing any services.

C. If the hospice program is no longer operational, or the license is revoked or suspended, the license shall be returned to the center OLC within five working days. The licensee is responsible for notifying its patients and the center OLC where all medical records will be located.

Statutory Authority

§§32.1-12 and 32.1-162.5 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 21, Issue 23, eff. November 1, 2005; amended, Volume 24, Issue 11, eff. March 5, 2008.

Part II
Administrative Services

12VAC5-391-160. Management and administration.

A. No person shall establish or operate a hospice program, as defined in §32.1-162.1 of the Code of Virginia, without having obtained a license.

B. The hospice program must comply with:

1. This chapter (12VAC5-391);

2. Other applicable federal, state or local laws and regulations; and

3. The hospice program''s own policies and procedures.

When applicable regulations are similar, the more stringent regulation shall take precedence.

C. The hospice program shall submit or make available reports and information necessary to establish compliance with this chapter and applicable law.

D. The hospice program shall permit representatives from the center OLC to conduct inspections to:

1. Verify application information;

2. Determine compliance with this chapter;

3. Review necessary records and documents; and

4. Investigate complaints.

E. The hospice program shall notify the center OLC 30 working days in advance of changes effecting the hospice program, including the:

1. Location of the administrative office or mailing address of the hospice program;

2. Ownership or operator;

3. Services provided;

4. Administrator;

5. Hospice program name;

6. Establishment of a dedicated hospice facility; and

7. Closure of the hospice program.

F. The current license from the department shall be posted for public inspection.

G. Service providers or individuals under contract must comply with the hospice program''s policies and this chapter, as appropriate.

H. The hospice program shall not use any advertising that contains false, misleading or deceptive statements or claims, or false or misleading disclosures of fees and payment for services.

I. The hospice program shall have regular posted business hours and be fully operational during business hours. Patient care services shall be available 24 hours a day, seven days a week. This does not mean that a hospice program must accept new clients on an emergency basis during nonbusiness hours.

J. The hospice program shall accept a patient only when the hospice program can adequately meet that patient''s needs.

K. The hospice program must have an emergency preparedness plan in case of inclement weather or natural disaster to include contacting and providing essential care to patients, coordinating with community agencies to assist as needed, and maintaining current information on patients who would require specialized assistance.

Statutory Authority

§§32.1-12 and 32.1-162.5 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 21, Issue 23, eff. November 1, 2005; amended, Volume 24, Issue 11, eff. March 5, 2008.

12VAC5-391-250. Complaints.

A. The hospice program shall establish and maintain complaint handling procedures that specify the:

1. System for logging receipt, investigation and resolution of complaints;

2. Format of the written record;

3. Method in which the adult protective services unit of the local social services department is to be informed and for what complaints; and

4. Description of the appeal rights if a complainant is not satisfied with the resolution.

B. The hospice program shall designate staff responsible for complaint resolution, including:

1. Complaint intake, including acknowledgment of complaints;

2. Investigation of the complaint;

3. Review of the investigation of findings and resolution of the complaint; and

4. Written notification to the complainant of the proposed resolution within 30 days from the date of receipt of the complaint.

C. The patient or his designee shall be given a copy of the hospice program''s procedures for filing a complaint at the time of admission to service. The hospice program shall provide each patient or his designee with the name, mailing address, and telephone number of the:

1. Hospice program contact person;

2. State Ombudsman; and

3. Center for Quality Health Care Services and Consumer Protection Complaint Unit of the OLC.

D. The hospice program shall maintain documentation of all complaints received and the status of each complaint from date of receipt through its final resolution. Records shall be maintained from the date of the last licensure inspection and for no less than three years.

Statutory Authority

§§32.1-12 and 32.1-162.5 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 21, Issue 23, eff. November 1, 2005; amended, Volume 24, Issue 11, eff. March 5, 2008.

12VAC5-391-280. Medical record system.

A. The hospice program shall maintain an organized medical record system according to accepted standards of practice. Written policies and procedures shall specify retention, reproduction, access, storage, content, and completion of the record.

B. Medical record information shall be safeguarded against loss or unauthorized use.

C. Medical records shall be confidential. Only authorized personnel shall have access as specified in state and federal law.

D. Provisions shall be made for the safe storage of the original record and for accurate and legible reproductions of the original.

E. Policies shall specify arrangements for retention and protection of records if the hospice program discontinues operation and shall provide for notification to the center OLC and the patient of the location of the records.

F. An accurate and complete medical record shall be maintained for each patient receiving services and shall include, but shall not be limited to:

1. Patient identifying information;

2. Identification of the attending physician;

3. Admitting information, including a patient history;

4. A psychosocial and spiritual assessment, including information regarding composition of the household, safety issues in the physical environment, coping skills of the family and the patient, and identification of the individuals to be instructed in the care of the patient;

5. Physical assessment;

6. Documentation and results of all medical tests ordered by the physician or other health care professionals and performed by the hospice program''s staff;

7. Physician''s orders;

8. The plan of care including, but not limited to, the type and frequency of each service to be delivered by hospice program or contract service personnel and appropriate assessment and management of pain;

9. Medication sheets that include the name, dosage, frequency of administration, route of administration, date started, changed or discontinued for each medication, and possible side effects;

10. Copies of all summary reports sent to the attending physician;

11. Documentation of patient rights review;

12. Services provided, including any volunteer services; and

13. A discharge summary that includes continuing symptom management needs.

G. Signed and dated progress notes by each individual delivering service shall be written on the day the service is delivered and incorporated in the medical record within seven working days.

H. All services provided to the patient by the hospice program shall be documented in the patient''s medical record.

I. Entries in the medical record shall be current, legible, dated and authenticated by the person making the entry. Errors shall be corrected by striking through and initialing.

J. Verbal orders shall be documented within 24 hours in the medical record by the health care professional receiving the order and shall be countersigned by the health professional initiating the order according to the procedures of the hospice program.

K. Originals or reproductions of individual patient medical records shall be maintained in their entirety for a minimum of five years following discharge or date of last contact unless otherwise specified by state or federal requirements. Records of minors shall be kept for at least five years after the minor reaches 18 years of age.

Statutory Authority

§§32.1-12 and 32.1-162.5 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 21, Issue 23, eff. November 1, 2005; amended, Volume 24, Issue 11, eff. March 5, 2008.