reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 381 - REGULATIONS FOR THE LICENSURE OF HOME CARE ORGANIZATIONS › Part III - Skilled Services › Section 12VAC5-381-330 - Home attendants assisting with skilled services

Current through Register Vol. 40, No. 24, July 15, 2024
A. Home attendants assisting with providing
				  skilled services may:
1. Assist clients with
				  (i) activities of daily living, (ii) ambulation and prescribed exercise, and
				  (iii) other special duties with appropriate training and demonstrated
				  competency;
2. Administer normally
				  self-administered drugs as allowed by § 54.1-3408 of the Virginia Drug
				  Control Act (Chapter 34 (§ 54.1-3400 et seq.) of Title 54.1 of the Code of
				  Virginia);
3. Measure and record
				  fluid intake and output;
4. Take
				  and record blood pressure, pulse and respiration;
5. Record and report to the appropriate
				  health care professional changes in the client's condition;
6. Document services and observations in the
				  client's record; and
7. Perform any
				  other duties that the attendant is qualified to do by additional training and
				  demonstrated competency as allowed by state or federal guidelines.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 381 - REGULATIONS FOR THE LICENSURE OF HOME CARE ORGANIZATIONS › Part III - Skilled Services › Section 12VAC5-381-340 - Medical social services

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Medical social services shall be provided according to the medical plan of care
				  by or under the direction of a qualified social worker who holds, at a minimum,
				  a bachelor's degree with major studies in social work, sociology, or psychology
				  from a four-year college or university accredited by the Council on Social Work
				  Education and has at least two years experience in case work or counseling in a
				  health care or social services delivery system.
The organization shall have one year from January 1, 2006,
					 to ensure the designated individual meets the qualifications of this
					 standard.
B. The duties of
				  a social worker may include, but are not limited to:
1. Assessing the client's psychological
				  status;
2. Implementing a medical
				  plan of care and revising, as necessary;
3. Providing social work services including
				  (i) short-term individual counseling, (ii) community resource planning, and
				  (iii) crisis intervention;
4.
				  Providing consultation with the primary care physician and other health care
				  professionals regarding changes in the client's needs;
5. Preparing notes on the care or services
				  provided; and
6. Participating in
				  discharge planning.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 381 - REGULATIONS FOR THE LICENSURE OF HOME CARE ORGANIZATIONS › Part IV - Pharmaceutical Services › Section 12VAC5-381-350 - Pharmacy services

Current through Register Vol. 40, No. 24, July 15, 2024
A. All
				  prescription drugs shall be prescribed and properly dispensed to the client
				  according to the provisions of the Chapters 33 (§ 54.1-3300 et seq.) and
				  34 (§ 54.1-3400 et seq.) of Title 54.1 of the Code of Virginia and the
				  regulations of the Virginia Board of Pharmacy, except for prescription drugs
				  authorized by § 54.1-3408 of the Drug Control Act, such as epinephrine for
				  emergency administration, normal saline and heparin flushes for the maintenance
				  of IV lines, and adult immunizations, which may be given by a nurse pursuant to
				  established protocol.
B. Home
				  attendants may administer normally self-administered drugs as allowed by §
				  54.1-3408 of the Virginia Drug Control Act (Chapter 34 (§ 54.1-3400 et
				  seq.) of Title 54.1 of the Code of Virginia). Any other drug shall be
				  administered only by a licensed nurse or physician assistant.
C. The organization shall develop written
				  policies and procedures for the administration of home infusion therapy
				  medications that include, but are not limited to:
1. Developing a plan of care or
				  service;
2. Initiation of
				  medication administration based on a prescriber's order and monitoring of the
				  client for response to the treatment and any adverse reactions or side
				  effects;
3. Assessment of any
				  factors related to the home environment that may affect the prescriber's
				  decisions for initiating, modifying, or discontinuing medications;
4. Communication with the prescriber
				  concerning assessment of the client's response to therapy, any other client
				  specific needs, and any significant change in the client's condition;
5. Communication with the client's provider
				  pharmacy concerning problems or needed changes in a client's
				  medication;
6. Maintaining a
				  complete and accurate record of medications prescribed, medication
				  administration data, client assessments, any laboratory tests ordered to
				  monitor response to drug therapy and results, and communications with the
				  prescriber and pharmacy provider;
7. Educating or instructing the client,
				  family members, or other caregivers involved in the administration of infusion
				  therapy in the proper storage of medication, in the proper handling of supplies
				  and equipment, in any applicable safety precautions, in recognizing potential
				  problems with the client, and actions to take in an emergency; and
8. Initial and retraining of all organization
				  staff providing infusion therapy.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 381 - REGULATIONS FOR THE LICENSURE OF HOME CARE ORGANIZATIONS › Part V - Personal Care Services › Section 12VAC5-381-360 - Personal care services

Current through Register Vol. 40, No. 24, July 15, 2024
A. An
				  organization may provide personal care services in support of the client's
				  health and safety in his home. The organization shall designate a registered
				  nurse responsible for the supervision of personal care services.
B. The personal care services shall include:
1. Assistance with the activities of daily
				  living. A need for assistance exists when the client is unable to complete an
				  activity due to cognitive impairment, functional disability, physical health
				  problems, or safety. The client's functional level is based on the client's
				  need for assistance most or all of the time to perform the tasks of daily
				  living in order to live independently;
2. Administration of normally
				  self-administered drugs as allowed in § 54.1-3408 of the Virginia Drug
				  Control Act (Chapter 34 (§ 54.1-3400 et seq.) of Title 54.1 of the Code of
				  Virginia);
3. Taking and recording
				  vital signs, if specified in the plan of service;
4. Recording and reporting to the supervisor
				  any changes regarding the client's condition, behavior or appearance;
				  and
5. Documenting the services
				  delivered in the client's record.
Personal care services may also include the instrumental
					 activities of daily living related to the needs of the client.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 381 - REGULATIONS FOR THE LICENSURE OF HOME CARE ORGANIZATIONS › Part V - Personal Care Services › Form - FORMS (12VAC5-381)

Current through Register Vol. 40, No. 24, July 15, 2024
Application
					 for Home Care Organization Licensure (rev. 4/2021)
Renewal
					 Addendum for Licenses Expiring July 31, 2021 (eff.
					 4/2021)
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 381 - REGULATIONS FOR THE LICENSURE OF HOME CARE ORGANIZATIONS › Part V - Personal Care Services › Section - DOCUMENTS INCORPORATED BY REFERENCE (12VAC5-381)

Current through Register Vol. 40, No. 24, July 15, 2024
Personal Care Aide Training Curriculum, 2003 Edition,
					 Virginia Department of Medical Assistance Services.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part I - Definitions and General Information › Section 12VAC5-391-20 - Reserved

Current through Register Vol. 40, No. 24, July 15, 2024
Derived from Virginia Register Volume 21, Issue 23, eff.
					 November 1, 2005.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part I - Definitions and General Information › Section 12VAC5-391-30 - License

Current through Register Vol. 40, No. 24, July 15, 2024
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 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.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part I - Definitions and General Information › Section 12VAC5-391-40 - Exemption from licensure

Current through Register Vol. 40, No. 24, July 15, 2024
A. This
				  chapter is not applicable to hospice programs described in § 32.1-162.2 of
				  the Code of Virginia.
B. The
				  hospice program must file a request for exemption from licensure in writing to
				  the director of the 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.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part I - Definitions and General Information › Section 12VAC5-391-60 - Changes to or reissuance of a license

Current through Register Vol. 40, No. 24, July 15, 2024
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 of the 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.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part I - Definitions and General Information › Section 12VAC5-391-70 - Fees

Current through Register Vol. 40, No. 24, July 15, 2024
A. The 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.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part I - Definitions and General Information › Section 12VAC5-391-80 - On-site inspections

Current through Register Vol. 40, No. 24, July 15, 2024
A. A 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 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 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 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.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part I - Definitions and General Information › Section 12VAC5-391-90 - Home visits

Current through Register Vol. 40, No. 24, July 15, 2024
A. As part of
				  any inspection, 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 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.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part I - Definitions and General Information › Section 12VAC5-391-100 - Complaint investigation

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  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.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part I - Definitions and General Information › Section 12VAC5-391-110 - Criminal records checks

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Section 32.1-162.9:1 of the Code of Virginia requires hospice providers, as
				  defined in § 32.1-162.1 of the Code of Virginia, to obtain a criminal
				  record report on applicants for compensated employment from the Virginia
				  Department of State Police. Section 32.1-162.9:1 also requires that all
				  applicants for compensated employment in a hospice program provide a sworn
				  statement regarding their criminal history.
B. The criminal record report shall be
				  obtained within 30 days of compensated employment. It is the hospice program's
				  responsibility to ensure that its compensated employees have not been convicted
				  of any of the barrier crimes listed in § 32.1-162.9:1 of the Code of
				  Virginia.
C. The hospice program
				  shall not accept a criminal record report dated more than 90 days prior to the
				  date of compensated employment.
D.
				  Only the original criminal record report shall be accepted. An exception is
				  permitted for hospice programs using temporary staffing agencies for the
				  provision of substitute staff. The hospice program shall obtain a letter from
				  the temporary staffing agency containing the following information:
1. The name of the substitute staffing
				  person;
2. The date of employment
				  by the temporary staffing agency; and
3. A statement verifying that the criminal
				  record report has been obtained within 30 days of employment, is on file at the
				  temporary staffing agency, and does not contain any barrier crimes listed in
				  § 32.1-162.9:1 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part I - Definitions and General Information › Section 12VAC5-391-120 - Hospice facilities

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Providers seeking to operate a hospice facility shall comply with the
				  appropriate facility licensing regulation as follows:
1. Facilities with 16 or fewer beds shall be
				  licensed as a hospice facility pursuant to this chapter. Such facilities with
				  six or more beds shall obtain a Certificate of Use and Occupancy with a Use
				  Group designation of I-2; or
2.
				  Facilities with more than 16 beds shall be licensed as a hospital pursuant to
				  12VAC5-410 or as a nursing facility pursuant to 12VAC5-371. Such facilities
				  shall obtain the applicable Certificate of Public Need prior to the development
				  or construction of the facility.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part I - Definitions and General Information › Section 12VAC5-391-130 - Variances

Current through Register Vol. 40, No. 24, July 15, 2024
A. The 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 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 OLC may attach conditions to the granting of the variance in
				  order to protect persons in care.
D. The 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 of the OLC. The 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
				  OLC.
Statutory Authority
§§ 32.1-12 and 32.1-162.5 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part I - Definitions and General Information › Section 12VAC5-391-140 - Revocation or suspension of a license

Current through Register Vol. 40, No. 24, July 15, 2024
A. The commissioner is authorized to revoke
				  or suspend any license if the licensee fails to comply with the provisions of
				  Article 7 (§ 32.1-162.1 et seq.) of Chapter 5 of Title 32.1 of the Code of
				  Virginia or the regulations of the board.
Providers operating a dedicated hospice facility shall
					 also maintain compliance with the applicable licensure regulations as described
					 in 12VAC5-391-120. Failure to
					 maintain compliance may be taken into consideration when the commissioner
					 decides to revoke or suspend a hospice program license.
B. If a license is revoked, the commissioner
				  may issue a new license when the conditions upon which revocation was based
				  have been corrected and compliance with all provisions of the law and this
				  chapter has been achieved.
C.
				  Suspension of a license shall in all cases be for an indefinite time. The
				  suspension may be lifted and rights under the license fully or partially
				  restored at such time as the commissioner determines that the interests of the
				  public will not be jeopardized by resumption of services.
D. When a license is revoked or suspended,
				  the hospice program shall cease operations. If the hospice program continues
				  operating, the commissioner may request the Office of the Attorney General to
				  petition the circuit court of the jurisdiction in which the hospice program is
				  located for an injunction to cause such hospice program to cease
				  operations.
Statutory Authority
§§ 32.1-12 and 32.1-162.5 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part I - Definitions and General Information › Section 12VAC5-391-150 - Return of a license

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  circumstances under which a license must be returned include:
1. A change in ownership or
				  operator;
2. A change in program
				  name;
3. The relocation of the
				  administrative office;
4. The
				  discontinuation of any core services; and
5. The relocation of a hospice
				  facility.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part II - Administrative Services › Section 12VAC5-391-160 - Management and administration

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  No person shall establish or operate a hospice program or a hospice facility,
				  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.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part II - Administrative Services › Section 12VAC5-391-170 - Governing body

Current through Register Vol. 40, No. 24, July 15, 2024
A. The hospice
				  program shall have a governing body that is legally responsible for the
				  management, operation and fiscal affairs of the hospice program. The governing
				  body of the hospital, nursing facility or home health agency that operates a
				  hospice shall include in its internal organizational structure an identifiable
				  unit of hospice services.
B. The
				  governing body shall adopt written by-laws describing the hospice program
				  structure, including the:
1. Hospice
				  program's objectives;
2. Scope of
				  services;
3. Relationship of the
				  hospice program's services to other services operated by the governing body, if
				  applicable, or by written agreement with the governing body of an affiliated
				  medical service provider; and
4.
				  Establishment of a quality improvement committee.
At least every two years, the governing body shall review
					 and approve necessary changes to the program's by-laws.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part II - Administrative Services › Section 12VAC5-391-180 - Administrator

Current through Register Vol. 40, No. 24, July 15, 2024
A. The governing
				  body shall appoint as administrator an individual who has evidence of at least
				  one year of training and experience in direct health care service delivery with
				  at least one year, within the last five years, of supervisory or administration
				  management experience in hospice care or a related health care delivery
				  system.
B. The administrator shall
				  have operational knowledge of Virginia's hospice laws and regulations and the
				  interrelationship between state licensure and other applicable state laws and
				  regulations as well as national certification or accrediting organizations such
				  as the Centers for Medicare and Medicaid Services and The Joint Commission
				  (formerly the Joint Commission on Accreditation of Healthcare
				  Organizations).
C. The
				  administrator shall be responsible for the day-to-day management of the hospice
				  program, including but not limited to:
1.
				  Organizing and supervising the administrative functions of the hospice
				  program;
2. Maintaining an ongoing
				  liaison with the governing body, the professional personnel and
				  staff;
3. Employing qualified
				  personnel and ensuring adequate employee orientation, training, education and
				  evaluation;
4. Ensuring the
				  accuracy of public information materials and activities;
5. Implementing an effective budgeting and
				  accounting system;
6. Maintaining
				  compliance with applicable laws and regulations and implementing corrective
				  action in response to reports of hospice program committees and regulatory
				  agencies;
7. Arranging and
				  negotiating services provided through contractual agreement; and
8. Implementing the policies and procedures
				  approved by the governing body.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part II - Administrative Services › Section 12VAC5-391-190 - Written policies and procedures

Current through Register Vol. 40, No. 24, July 15, 2024
A. The hospice program shall implement
				  written policies and procedures approved by the governing body.
B. All policies and procedures shall be
				  reviewed at least annually, with recommended changes submitted to the governing
				  body for approval, as necessary.
C.
				  Administrative and operational policies and procedures shall include:
1. Administrative records;
2. Admission and discharge
				  criteria;
3. Informed
				  consent;
4. Advance directives,
				  including Durable Do Not Resuscitate Orders;
5. Patient rights;
6. Pain assessment and management;
7. Medical supplies and appliances including
				  drugs and biologicals, disposal of controlled drugs when no longer needed by
				  patients, and handling of medications procured from a pharmacy of the patient's
				  choice;
8. Contract
				  services;
9. Transfer of patients
				  to an inpatient facility including arrangements for an ambulance and the
				  patient escort, when appropriate, to the facility by a professional staff
				  member of the hospice program;
10.
				  Medical social services;
11.
				  Quality improvement;
12.
				  Communicable and reportable diseases;
13. Post-mortem activities;
14. Mandated reporting of abuse, neglect, and
				  exploitation pursuant to §
											63.2-1606
				  of the Code of Virginia;
15.
				  Medical records, including confidentiality;
16. Record retention, including termination
				  of services;
17. Supervision and
				  delivery of services;
18.
				  Interdisciplinary group duties and responsibilities;
19. Bereavement and spiritual
				  services;
20. Volunteer
				  services;
21. Infection
				  control;
22. Special
				  services;
23. Emergency
				  preparedness;
24. Handling consumer
				  complaints; and
25. Approved
				  variances.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part II - Administrative Services › Section 12VAC5-391-200 - Financial controls

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  hospice program shall document financial resources to operate based on a
				  working budget showing projected revenue and expenses. Hospice programs
				  operating dedicated hospice facilities shall have financial resources to
				  operate based on a separate working budget showing projected revenue and
				  expenses.
B. All financial records
				  shall be kept according to generally accepted accounting principles
				  (GAAP).
C. All financial records
				  shall be audited at least triennially by an independent certified public
				  accountant or audited as otherwise provided by law.
D. The hospice program shall have documented
				  financial controls to minimize risk of theft or embezzlement.
Statutory Authority
§§ 32.1-12 and 32.1-162.5 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part II - Administrative Services › Section 12VAC5-391-210 - Personnel practices

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Personnel management and employment practices shall comply with applicable
				  state and federal laws and regulations.
B. The hospice program shall design and
				  implement a staffing plan that reflects the types of services offered and shall
				  provide qualified staff in sufficient numbers to meet the assessed needs of all
				  patients, including those patients residing in the provider's hospice facility,
				  if applicable.
C. Employees and
				  contractors shall be licensed or certified as required by the Department of
				  Health Professions.
D. The hospice
				  program shall implement a mechanism to verify professional
				  credentials.
E. Any person who
				  assumes the responsibilities of any staff position or positions shall meet the
				  minimum qualifications for that position or positions. Professional staff may
				  be assigned multiple job responsibilities provided the individual is
				  appropriately qualified.
F. The
				  hospice program shall obtain the required sworn statement and criminal record
				  check for each compensated employee as specified in § 32.1-162.9:1 of the
				  Code of Virginia.
G. Each employee
				  position shall have a written job description that includes:
1. Job title;
2. Duties and responsibilities required of
				  the position;
3. Job title of the
				  immediate supervisor; and
4.
				  Minimum knowledge, skills, and abilities or professional qualifications
				  required for entry level.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part II - Administrative Services › Section 12VAC5-391-220 - Indemnity coverage

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  governing body shall ensure the hospice program and its contractors have
				  appropriate indemnity coverage to compensate patients for injuries and losses
				  resulting from services provided.
B. To protect the interests of patients,
				  employees, and the hospice program from risks of liability, there shall be
				  indemnity coverage to include:
1. General
				  liability insurance covering personal property damages, bodily injuries,
				  product liability, liable and slander of at least $1 million comprehensive
				  general liability per occurrence; and
2. Malpractice insurance for all nursing and
				  medical professional employees consistent with § 8.01-581.15 of the Code
				  of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part II - Administrative Services › Section 12VAC5-391-230 - Contract services

Current through Register Vol. 40, No. 24, July 15, 2024
A. If the
				  hospice program contracts for services, there shall be a written agreement for
				  the provision of those services.
B.
				  The written agreement shall include, but is not limited to:
1. The services to be furnished by each party
				  to the contract;
2. The
				  contractor's responsibility for participating in developing plans of
				  care;
3. The manner in which
				  services will be controlled, coordinated, and evaluated by the hospice
				  program;
4. The procedures for
				  submitting clinical and progress notes, scheduling of visits, and periodic
				  patient evaluation;
5. The process
				  for payment for services furnished under the contract; and
6. Adequate indemnity coverage.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part II - Administrative Services › Section 12VAC5-391-240 - Patient rights

Current through Register Vol. 40, No. 24, July 15, 2024
A. The hospice
				  program shall establish and implement written policies and procedures regarding
				  the rights of patients. A copy of the patient's rights shall be displayed in
				  the hospice office for public review.
B. Written procedures to implement the
				  policies shall ensure that each patient is:
1. Treated with courtesy, consideration and
				  respect;
2. Assured the right to
				  privacy;
3. Assured confidential
				  treatment of his medical and financial records as provided by law;
4. Free from mental and physical abuse and
				  property exploitation;
5. Assured
				  the right to participate in the planning of his care, including appropriate
				  assessment and management of pain and the right to refuse services;
6. Served by individuals who are properly
				  trained and competent to perform their duties;
7. Assured the right to voice grievances and
				  complaints related to hospice program services without fear of
				  reprisal;
8. Advised, before care
				  is initiated, of the extent to which payment for services may be expected from
				  federal or state programs, and the extent to which payment may be required from
				  the patient;
9. Advised orally and
				  in writing of any changes in fees for services that are the patient's
				  responsibility. The hospice program shall advise the patient of these changes
				  as soon as possible but no later than 30 calendar days from the date the
				  hospice program became aware of the change;
10. Provided with advance directive and
				  Durable Do Not Resuscitate Order information prior to start of services;
				  and
11. Given five days oral and
				  written notice when the hospice program determines to terminate
				  services.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part II - Administrative Services › Section 12VAC5-391-250 - Complaints

Current through Register Vol. 40, No. 24, July 15, 2024
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.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part II - Administrative Services › Section 12VAC5-391-260 - Quality improvement

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  hospice program shall implement an on-going, comprehensive, integrated,
				  self-assessment program of the quality and appropriateness of care provided,
				  including services provided under contract. The quality improvement program
				  shall address actual patient outcomes (results of care), clinical,
				  administrative, and cost-of-care issues. The findings shall be used to correct
				  identified problems and revise policies and practices, as necessary. Exclusive
				  concentration on administrative or cost-of-care issues does not fulfill this
				  requirement.
B. The following areas
				  shall be evaluated to identify unacceptable or unexpected trends or occurrences
				  that influence patient outcomes (results of care):
1. Staffing patterns and clinical
				  performance;
2. Admissions and
				  discharges;
3. Supervision
				  appropriate to the level of service;
4. Emergency preparedness plan;
5. Medical records;
6. Appropriateness and effectiveness of pain
				  management;
7. Patient satisfaction
				  and complaint resolution;
8.
				  Infection control;
9. Staff
				  concerns; and
10. Provision of
				  services appropriate to patient needs.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part II - Administrative Services › Section 12VAC5-391-270 - Infection control

Current through Register Vol. 40, No. 24, July 15, 2024
A. The hospice
				  program shall implement a program to reduce the risk of infection.
B. Infection control activities shall
				  include, but are not limited to:
1. Staff,
				  patient, patient family or caregiver education regarding infection
				  risk-reduction behaviors;
2. Use of
				  universal precautions;
3. Handling,
				  storing, processing and transporting of regulated medical waste according to
				  applicable procedures;
4. Handling,
				  storing, processing and transporting supplies and equipment in a manner that
				  prevents the spread of infection; and
5. Monitoring of staff performance of
				  infection control practices.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part II - Administrative Services › Section 12VAC5-391-280 - Medical record system

Current through Register Vol. 40, No. 24, July 15, 2024
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 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.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part II - Administrative Services › Section 12VAC5-391-290 - Discharge

Current through Register Vol. 40, No. 24, July 15, 2024
A. Patients shall
				  receive five days oral and written notice of a transfer or discharge initiated
				  by the hospice program except under the following circumstances:
1. When a medical emergency exists;
2. For the welfare of the patient or the
				  welfare of employees; or
3. The
				  welfare of other patients in a dedicated hospice facility operated by the
				  hospice program.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part III - Hospice Program Services › Article 1 - Hospice Services › Section 12VAC5-391-300 - Hospice services

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each
					 hospice shall provide a coordinated program of services encompassing the
					 hospice philosophy that:
1. The unit of care
					 consists of the patient, the primary caregiver, and the patient's
					 family;
2. Emphasizes in-home
					 care;
3. A designated
					 interdisciplinary group supervises the patient's care;
4. A patient's symptoms and physical pain
					 will be appropriately assessed and managed;
5. Services are available 24 hours a day, 7
					 days a week;
6. Inpatient care is
					 provided in an atmosphere as home-like as practical;
7. Bereavement services are available to the
					 family after the death of the patient; and
8. Trained volunteers are utilized to perform
					 specific job functions in the hospice service delivery system.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part III - Hospice Program Services › Article 1 - Hospice Services › Section 12VAC5-391-310 - Interdisciplinary group or IDG

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
					 hospice program shall designate an interdisciplinary group or groups to provide
					 or supervise the care and services offered by the hospice program. The IDG
					 shall consist of:
1. The patient, the
					 patient's primary caregiver, and patient's family;
2. The attending physician;
3. The medical director;
4. A registered nurse;
5. The social worker;
6. The pastoral or other counselor;
					 and
7. Volunteers, if
					 applicable.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 391 - REGULATIONS FOR THE LICENSURE OF HOSPICE › Part III - Hospice Program Services › Article 1 - Hospice Services › Section 12VAC5-391-320 - Plan of care

Current through Register Vol. 40, No. 24, July 15, 2024
A. At the time of a
					 patient's admission to the hospice program, the IDG shall develop and maintain
					 a plan of care, including but not limited to:
1. Identification of the primary caregiver,
					 or an alternative in the absence of a primary caregiver, to ensure the
					 patient's needs will be met;
2. The
					 patient's diagnosis and prognosis;
3. Assessment of the patient's family
					 medical, physical, psychosocial, spiritual and bereavement needs,
					 identification of the services required to meet those needs and plans for
					 providing the services through the IDG, contractual providers, and community
					 resources;
4. A comprehensive
					 assessment of pain, as warranted by the patient's condition and the scope of
					 services provided by the hospice program;
5. Services to be provided, including (i)
					 specific procedures, (ii) treatment modalities, and (iii) frequency and
					 duration of the services ordered;
6. Special dietary or nutritional needs, when
					 applicable;
7. Medical equipment,
					 supplies, medications, and specialized therapies when applicable;
8. Identification of the members of the staff
					 designated to carry out the plan of care; and
9. Physician orders, including any orders to
					 change the plan when appropriate.