Texas Hospice Licensing standards Part 2
Infection Control
An agency must adopt and enforce written policies addressing infection control, including preventing the spread of infectious and communicable diseases.The policies must:
Ensure compliance by the agency, employees, and contractors with:
The Communicable Disease Prevention and Control Act, HSC, Chapter 81;
The Occupational Safety and Health Administration (OSHA), Title 29 Code of Federal Regulations(CFR), Part 1910.1030 and Appendix A, relating to Bloodborne Pathogens; and
HSC, Chapter 85, Subchapter I, concerning preventing the transmission of human immunodeficiencyvirus and hepatitis B virus; and
Require documentation of infections that the client acquires while receiving services from the agency.
Biohazards, Special or Medical Waste
An agency must adopt and enforce a written policy for the safe handling and disposal of biohazardous waste and materials, if applicable.
The agency must provide both verbal and written instructions to clients regarding the proper procedure for disposing of sharps.
An agency that generates special or medical waste while providing home health services must dispose of the waste according to the requirements in 25 TAC §§1.131-1.137 (relating to Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities).
QAPI
An agency must maintain a Quality Assessment and Performance Improvement (QAPI) program that is implemented by a QAPI committee.
At a minimum, the QAPI committee must consist of the administrator;the supervising nurse or therapist, or the supervisor of an agency licensed to provide personal assistance services; and an individual representing the scope of services provided by the agency.
The QAPI committee must meet twice a year or more often, if needed.
The QAPI program must:
Be ongoing;
Be focused on client outcomes that are measurable; and
Have a written plan of implementation.
QAPI continued…
The program must include:
A system that measures significant outcomes for optimal care; and
An annual evaluation of the total operation, including services provided under contract or arrangement.
The QAPI committee must use the measures in care planning and coordination of services and events.
The measures must include (as appropriate for the scope of services provided by the agency):
An analysis of services furnished to clients (contained in active and closed records);
A review of:
Negative client outcomes;
Complaints and incidents of unprofessional conduct by licensed staff and misconduct by unlicensed staff;
Infection control activities; and
Medication administration and errors;
A determination that services have been performed as outlined in the service plan, care plan, or
plan of care; and
An analysis of client complaint and satisfaction survey data.
Coordination of services
An agency must adopt and enforce a written policy that requires effective coordination of care with all service providers involved in the care of a client;
this includes physicians, contracted health professionals, and other agencies.
The agency must document, in the client’s record, steps that were taken to coordinate services.
Independent Contractors and Service Providers
If the agency uses independent contractors, there must be a contract between each independent contractor that performs services and the agency.
Each contract must clearly designate:
That clients are accepted for care only by the licensed agency;
The services to be provided and how they will be provided (e.g., per visit, per hour, etc.);
The necessity to conform to all applicable agency policies, including personnel qualifications;
The plan of care or care plan to be carried out;
The manner in which services will be coordinated and evaluated by the agency (see “Coordination ofServices” above); and
The procedures for:submitting information and documentation regarding the client’s needs and services, including:
clinical and progress notes;
Scheduling of visits;
Periodic client evaluation or supervision; and
Determining charges and reimbursement.
Services provided by an agency under arrangement with another agency or organization must be provided under written agreement conforming to the requirements specified in this rule.
Backup Services / 24 hr. care
An agency must adopt and enforce a written policy to ensure that backup services are available when an agency employee or contractor is not available to deliver the services.
Backup services may be provided by an agency employee, a contractor, or the client’s designee who is willing and able to provide the necessary services.
An agency must adopt and enforce a written policy to ensure that clients are educated in how to access care from the agency or another health care provider after regular business hours.
Agency dissolution
The agency must adopt and enforce a written policy that describes the agency’s contingency plan.The plan must:
Be implemented in the event of dissolution to assure continuity of client care;
Be consistent with 40 TAC §97.295 (relating to Client Transfer or Discharge Notification Requirements); and
Comply with 40 TAC §97.217(a)(2) (relating to Agency Closure Procedures and Voluntary Suspension ofOperations).See the closure requirements in 40 TAC §97.602 (surrender or expiration of a license) for additional requirements.
Client Agreement/disclosure
An agency must provide the client or the client’s family a written agreement for services, which includes:
Notification of client rights;
Documentation that client was notified of the availability of medical power of attorney for health care,advanced directives, or “Do-Not-Resuscitate” orders;
Services to be provided;
Supervision by the agency of services provided;
Agency charges for services rendered if the charges will be paid in full or in part by the client or the client’s family, or on request;
A written statement that has procedures for filing a complaint in accordance with 40 TAC §97.282, regarding client rights; and
A client agreement to and acknowledgement of services by home health medication aides (if they are used).
Client List and Services
An agency must maintain a current list of clients for each category of service licensed.The list must include:
The client’s name;
The identification or clinical record number;
The start of care date or admission date;
The certification period (if applicable);
Diagnosis(es) or functional assessment (as appropriate);
All services delivered to the client by the agency and under contract; and
All discipline(s) providing services.Initiation of Care An agency must adopt and enforce a written policy establishing the time frame for initiating care or services.
Notification of Discharge
Except in an emergency, an agency intending to transfer or discharge a client must:
Provide written notification to the client or the client’s parent, family, spouse, significant other, or legalrepresentative; and
Notify the client’s attending physician or practitioner if he is involved in the agency’s care of the client.
An agency must ensure delivery of the written notification no later than five days before the date on which the client will be transferred or discharged.
The agency must deliver the required notice by hand or by mail. If the agency delivers the written notice by mail:
The notice must be mailed at least eight working days before the date of discharge or transfer; and
The agency must speak with the client by telephone or in person to ensure the client’s knowledge of thetransfer or discharge at least five days before the date of discharge or transfer.
Documentation
An agency must keep the following in the client’s file:
A copy of the written notification provided to the client or the client’s parent, family, spouse, significantother, or legal representative;
Documentation of the personal contact with the client if the required notice was delivered by mail; and
Documentation that the client’s attending physician or practitioner was notified of the date of discharge.
Physician Delegation
An agency must adopt and enforce a written policy that states whether physician delegation will be honored by the agency.
If an agency accepts physician delegation, the agency must comply with the Medical Practice Act, Occupations Code, Chapter 157, concerning physician delegation.
Accepting Physician Delegation Physician delegation may be accepted if the following are received from the physician:
The name of the client;
The name of the delegating physician;
The task(s) to be performed;
The name(s) of the individual(s) to perform the task(s);
The time frame for the delegation order; and
If the task is medication administration, the medication to be given, route, dose, and frequency.
Receipt of Physician Orders
An agency must adopt and enforce a written policy describing protocols and procedures agency staff must follow when receiving physician’s orders.
The policy must address the time frame for countersignature of physician verbal orders.
Signed physician orders may be submitted via fax machine.The agency is not required to have the original signature on file but must be able to obtain an original signature if an issue surfaces that would require verification of an original signature.
Nurse Delegation
An agency must adopt and enforce a written policy to ensure compliance with the following rules adopted by the Board of Nursing (BON) for the State of Texas:
22 TAC, Chapter 224 (relating to Delegation of Nursing Tasks by Registered Professional Nurses toUnlicensed Personnel for Clients in Acute Care Environments); and
22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks Not RequiringDelegation in Independent Living Environments for Clients with Stable and Predictable Conditions).
Requirements for RN delegation for personal assistance services clients are located at 40 TAC §97.404 (relating to Standards Specific to Agencies Licensed to Provide Personal Assistance Services).
Medication Administration
An agency must adopt and enforce a written policy for maintaining a current medication list and a current medication administration record for clients to whom agency staff administer medications.
Administration of medications must be ordered by the client’s practitioner.
The medication list must be used to identify:Possible ineffective drug therapy;Adverse reactions;Significant side effects;Drug allergies; andContraindications.The agency must document in the medication administration record or clinical notes any medication that is not administered and the reason why it was not administered.
Client Record System
An agency must establish and maintain a client record system to ensure that care and services provided are completely and accurately documented, readily accessible, and systematically organized to facilitate the compilation and retrieval of information.
The agency must:
Establish a record for each client;
Adopt and enforce written procedures regarding use and removal of records, release of information, and theincorporation of clinical, progress, or other notes into the record;
Establish an area for original client record storage at the agency’s place of business;
Protect information against loss or damage; and
Ensure that each record is treated with confidentiality, is safeguarded against loss and unofficial use, and ismaintained according to professional standards of practice.The clinical record must be original, a microfilmed copy, an optical disc imaging system, or a certified copy.A signed paper record may include a physician’s stamped signature if certain requirements are met.
Client Records
The client record must include the following elements as applicable to the scope of services provided by the agency:
Application for services that includes all required information;
Initial health assessment;
Care plan, plan of care, or individualized service plan;
Clinical and progress notes, which must be written the day service is rendered and incorporated into the clientrecord within 14 working days;
Current medication list (if medication is administered by agency staff);
Medication administration record (if medication is administered by agency staff);
Records of supervisory visits;
Complete documentation of all known services and significant events;
Acknowledgement of receipt of a copy of the Rights of the Elderly (clients age 60 years and older);
Acknowledgement of client’s receipt of the agency’s policy regarding abuse, neglect, or exploitation of clients;
Documentation the client has been informed of how to register a complaint; andDischarge summary that includes the reason for the discharge.
Pronouncement of Death
An agency must adopt and enforce a written policy on pronouncement of death if that function is carried out by an agency RN.
The policy must be in compliance with HSC §671.001 (regarding Determination of Death and Autopsy Reports).