This chapter is effective January 1, 2014. This chapter applies to all general hospice care programs that operate a hospice house. An operator of a hospice house shall also comply with all the requirements contained in COMAR 10.07.21 that are applicable to general hospice care programs. In addition to the definition contained in §B of this regulation, definitions set forth in COMAR 10.07.21.02 are applicable to this chapter. Terms Defined. “Hospice house” means a residence operated by a Maryland licensed general hospice care program that provides home-based hospice services to hospice patients in a home-like environment and the care is not billed as general inpatient care. “Primary hospice nurse” means the registered nurse who is assigned to oversee the nursing care of an individual hospice patient from the time of admission until the time of discharge. In this chapter, the following document is incorporated by reference: NFPA 101, The Life Safety Code, as adopted by the State Fire Prevention Commission in COMAR 29.06.01. A person may not operate a hospice house without first obtaining a license to operate a general hospice care program. Following an analysis of the number of beds the hospice house intends to serve and the individual needs of each resident, the general hospice care program shall develop a staffing plan that identifies the type and number of staff needed to provide the services required by this chapter. The staffing plan shall include on-site staff sufficient in number and qualifications to meet the 24-hour scheduled and unscheduled needs of the residents. Relief personnel shall be available at all times in the event that the regularly scheduled staff members are unavailable. The staffing plan shall be reviewed annually and as needed. The administrator of the general hospice care program shall identify a manager of the hospice house who has full responsibility for the day-to-day operations of the hospice house. The administrator shall evaluate the manager’s performance on an annual basis. In the absence of the hospice house manager, the hospice house shall remain under the continuous supervision of a designated individual with appropriate experience and training. The hospice house shall be staffed by sufficient numbers of personnel to ensure that the hospice house is capable of meeting the requirements of this chapter, and all applicable federal, State, and local laws and regulations. In addition to meeting all of the other qualifications and requirements for hospice employees, all hospice house staff shall participate in an orientation program and annual training to ensure competency in maintaining the hospice house and meeting the needs of residents in accordance with the plan of care. Staff who administer medications to residents shall meet all requirements of the Maryland Board of Nursing or Maryland Board of Physicians. Documentation of all required training shall be included in the employee’s personnel record. A hospice patient appropriate for care in their own home who does not require general inpatient services may be eligible for care in a hospice house, in accordance with the hospice house admission policy. Patients admitted to the hospice house or their representatives shall sign, before or at the time of admission, a patient agreement that: Is a clear and complete statement of commitments agreed to by the parties and the services provided in the hospice house; Is accurate, legible, and communicated in a language understandable to patient and family; and Conforms to all applicable federal, State, and local laws and requirements. The residential agreement shall include, at a minimum: The services to be provided by the hospice house; An explanation of the hospice house’s complaint or grievance procedure; Procedures to be followed in transferring the patient to another facility; The availability of secure storage of patient’s belongings; The patient’s and family’s rights and obligations concerning use of the hospice house, including common areas; Written plan and provisions for continued emergency preparedness services; An acknowledgement that the patient or the patient’s representative has reviewed all hospice house rules, requirements, restrictions, or special conditions that the general hospice program will impose on the patient; and Admission and discharge policies and procedures including: Those actions, circumstances or conditions which may result in the patient’s discharge from the hospice house; The procedures which the hospice house shall follow if it intends to discharge a patient without the patient’s agreement, thereby terminating the residential agreement; and The procedures which the patient shall follow if the patient wishes to terminate the residential agreement. The residential agreement shall include financial provisions, which include at a minimum: Rate structure and payment provisions covering: All rates to be charged to the patient, including but not limited to any non-service related charges; and Payment arrangements and fees, if known, for third-party services not covered by the residential agreement, but arranged for by either the patient, patient’s representative, or the hospice house; and Obligations of the hospice house and the patient, or the patient’s representative, as to: Handling the finances of the patient; Arranging and contracting for services not covered by the patient agreement; Disposition of the patient’s property upon discharge or death of the patient; Identification of the persons responsible for payment of all fees and charges and a clear indication of whether the person’s responsibility is or is not limited to the extent of the patient’s funds; Fair and reasonable billing, payment, and credit policies; The procedures the hospice house will follow in the event the patient or representative can no longer pay for services provided for in the patient agreement or for services or care needed by the patient; and Terms governing the refund of any prepaid fees or charges in the event of a patient’s discharge from the hospice house or termination of the patient agreement. The hospice house shall maintain the patient agreement in the patient’s record. The hospice house shall: Maintain the privacy and confidentiality of a patient’s medical records; Release medical records or medical information about a patient only with the consent of the patient or patient’s representative, or as permitted by Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland; and Maintain and dispose of a resident’s medical records in accordance with Health-General Article, Title 4, Subtitle 4, Annotated Code of Maryland. A patient’s food preferences shall be assessed at the time of admission. The assessment shall be maintained in the patient record. Patients shall be provided meals and snacks as requested. Patients shall be offered 3 meals and additional snacks during each 24-hour period, 7 days a week in accordance with their individual daily nutritional needs and preferences and consistent with their plan of care. Food that is prepared at the hospice house shall be prepared in accordance with all State and local sanitation and safe food handling requirements. Food preparation areas are to be maintained in accordance with all State and local sanitation and safe food handling requirements. Hospice house staff shall prepare or arrange for the provision of special diets consistent with the plan of care. Hospice house staff shall obtain food from sources that comply with all local laws and regulations relating to food, food processing, food handling, and food labeling. Hospice house staff shall protect food from contamination while being stored, prepared, displayed, served, or transported. Hospice house staff shall promptly discard the following: Spoiled food; Swelled, rusty, or leaky canned food; and Foods exposed to fire, smoke, or water damage. The hospice house staff shall maintain kitchen surfaces, floors, walls, storage areas, equipment, appliances, and utensils in a clean and sanitary manner and in good repair. The hospice house staff shall provide refrigerator and freezer units operated in compliance with the manufacturer’s specifications. The hospice house staff shall provide all necessary personal care services to the patient in accordance with the plan of care and as desired by the patient. All medications shall be administered consistent with applicable requirements of COMAR 10.27.11. Medications and treatments shall be administered consistent with current medical orders and using acceptable professional standards of practice. All medications shall be stored in a secure location, at proper temperature. Each patient’s medications shall be stored in the original dispensed container; Each patient shall receive the medications that have been specifically prescribed for that patient in the manner that has been ordered. The hospice house staff shall document and report to the patient’s primary hospice nurse or the hospice nurse on call any symptoms or pain that are not relieved by the current medications and other interventions. The hospice house staff shall document and report to the patient’s primary hospice nurse or the hospice nurse on call any undesired side effects, adverse drug reactions, or medication errors. The medication administration documentation required under this regulation shall be recorded by a staff member at the time that the patient takes or receives medications on a medication administration report. This documentation shall be maintained in the patient record and include at minimum: Name of the patient; Date of birth; Diagnosis; Allergies; Significant adverse drug reactions; Name of the medication; Reason for the medication; Dose; Authorized prescriber’s name; Date of issuance, and Directions for use. Accounting for Narcotic and Controlled Drugs. The hospice house staff shall count and record controlled drugs at shift changes. All controlled substances and all medications with a high abuse potential in the hospice house’s location shall be maintained under a double lock system. The staff of the hospice house shall complete an incident report in accordance with hospice policy within 24 hours of having knowledge that an incident has occurred. All incident reports shall include: Time, date, place, and individuals present; Complete description of the incident; Response of the staff at the time; and Follow up action, including notification to the: Patient’s primary hospice nurse or hospice nurse on call; Patient’s representative or family; Patient’s attending physician or nurse practitioner; Hospice medical director; and Licensing or law enforcement authorities, when appropriate. Relocation within the Facility. The hospice house may not relocate a patient within the facility except in accordance with the terms and conditions of the residential agreement. Discharge. Discharge of a patient without the consent of the patient or the patient’s representative shall be in accordance with the residential agreement. When the patient is discharged or transferred to another facility, the hospice house shall provide to the receiving facility all information that is required to ensure that continuity of care and services is maintained. Within 30 days of the date of discharge, the hospice house shall: Give the patient or patient’s representative a final statement of account and refunds due; and Return any money, property, or valuables held in trust or custody by the hospice house. In addition to all other rights as a hospice patient, the patient residing in a hospice house has the right to: Privacy, including the right to have a staff member knock on the patient’s door before entering; Be free from mental abuse, verbal abuse, sexual abuse, physical abuse, neglect, involuntary seclusion, and exploitation; Be free from physical and chemical restraints; Manage personal financial affairs; Maintain legal counsel; Attend or not attend religious services as the patient chooses, and receive visits from members of the clergy; Possess and use personal clothing and other personal effects to a reasonable extent, and to have reasonable security for those effects in accordance with the hospice house’s security policy; Retain personal clothing and possessions as space permits with the understanding that the hospice house may limit the number of personal possessions retained at the facility for the health and safety of other patients; Meet or visit privately with any individual the patient chooses in accordance with patient and facility safety; and Have reasonable access to the private use of a telephone within the facility. Notice of Patient’s Rights. The hospice house shall: Place a copy of the patient’s rights as set forth in this regulation, in a conspicuous location, plainly visible and easily read by patients, staff, and visitors; and Provide a copy to the patient and patient’s representative on admission. The hospice house shall develop and implement policies and procedures prohibiting abuse, neglect, and exploitation of hospice house patients. Reports of Abuse, Neglect, or Exploitation. An employee of the hospice house who believes that a patient has been subjected to abuse, neglect, or exploitation shall report the alleged abuse, neglect, or exploitation within 24 hours to: The appropriate local Department of Social Services, Adult Protective Services office, or Child Protective Services; and One of the following: A local law enforcement agency; or The Office of Health Care Quality. Investigations. The hospice house shall: Thoroughly investigate all allegations of abuse, neglect, or exploitation and maintain on-site written documentation of the investigation; and Take appropriate action to prevent further incidents of abuse, neglect, or exploitation while the investigation is in progress. Immunity from Civil Liability; An individual who, acting in good faith, makes a report under this regulation has immunity from liability as described in Health-General Article, §19-347(g), Annotated Code of Maryland. Notice. The hospice house shall post signs that set forth the reporting requirements stated in §B of this regulation, conspicuously in the employee and public areas of the facility. A hospice house shall develop a policy and procedure related to restraint and seclusion. Relevant staff shall be trained in accordance with the facility’s policy and procedure related to restraint and seclusion. Patients have the right to be free from restraint or seclusion of any form which are imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and shall be discontinued at the earliest possible time. The type or technique of restraint or seclusion used shall be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm. The use of restraint or seclusion shall be: In accordance with a written modification to the patient’s plan of care; and Implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospice policy in accordance with applicable laws. All restraints shall be ordered by a physician and shall specify: The purpose of the restraint; The type of restraint to be used; and The length of time the restraint shall be used. Restraint and seclusion orders may not be on an as-needed basis. A patient may not remain in a restraint for more than 2 hours without a change in position and toileting opportunity. The patient’s primary hospice nurse or hospice nurse on call and hospice medical director or physician designee shall be consulted as soon as possible after the implementation of any restraint or seclusion to, as applicable: Review and modify the plan of care; and Determine if the hospice house is an appropriate setting for the patient at this time. The program shall notify the patient’s family or the patient’s representative each time a restraint is used. The facility, which includes buildings, common areas, and exterior grounds, shall be kept: In good repair; Clean; Free of any object, material, or condition that may create a: Health hazard, accident, or fire; or Public nuisance; and Free of insect infestations and rodents. The hospice house shall provide adequate storage space, which is protected from the elements, for: Excess supplies; Some personal possessions of patients; and Any other items in the patient’s room. Approved Source. A facility shall be served by water from an approved public water supply. If an approved public water supply is not available, a private water supply may be accepted if it is approved by the local jurisdiction in which the hospice house is located or a private certified vendor. Adequacy. The water supply shall be adequate in quantity and delivered under sufficient pressure to satisfactorily serve all fixtures in the facility. Hot Water Temperature. Hot water accessible to patients shall be blended externally to the hot water generator, by either individual point-of-use control valves of the anti-scald or thermostatic mixing valve type, to a maximum temperature of 120ºF and a minimum temperature of 110ºF at the fixture. The facility shall be served by an approved public sewage disposal system, if available. If an approved public sewage disposal system is not available, a private sewage disposal system may be accepted if approved by the local jurisdiction in which the program is located. The facility shall have policies and procedures in place to provide a secure environment for the patient, family, and staff. The hospice house shall provide assist rails in stairways used by patients and for all toilets, showers, and bathtubs used by patients. The hospice house with a licensed capacity of 17 or more beds shall also provide assist rails on both sides of corridors used by patients. The facility shall be constructed consistent with: All applicable local fire and building codes; and The Life Safety Code, NFPA 101, including Chapter 24 of NFPA 101. Hand Extinguishers. Fire extinguishers shall be located on each floor and adjacent to, or in, special hazard areas, such as furnace rooms, boiler rooms, kitchens, or laundries. Fire extinguishers shall be of standard and approved types, and installed and maintained to be conveniently available for use at all times. The hospice house shall properly instruct staff in the use of fire extinguishers. Emergency Plan. The hospice house shall develop an emergency plan that includes procedures that will be followed before, during, and after an emergency. The emergency plan shall address: The evacuation, transportation, or shelter in-place of patients; Notification to families, staff, and the Office of Health Care Quality regarding the action that will be taken concerning the safety and well-being of the patients; Staff coverage, organization, and assignment of responsibilities; and The continuity of operation, including: Procuring essential goods, equipment, and services; and Relocation to alternate facilities. The Hospice House shall have a signed agreement with the facility that will house the program’s patients during an emergency evacuation. Upon request, the hospice house shall provide access to its emergency plan to local organizations for emergency management and for purposes of coordinating local emergency planning. The hospice house shall prepare a summary of its evacuation procedures to provide to the patient, family member, or legal representative upon request. The summary shall, at a minimum: List means of transportation to be used in the event of evacuation; List alternative facilities to be used in the event of evacuation; Describe means of communication with family members and legal representatives; and Describe the role of the patient, family member, or legal representative in the event of evacuation. Evacuation Plans. The facility shall conspicuously post individual floor plans with designated evacuation routes on each floor. Emergency Electrical Power Generator. Generator Required. A hospice house with 6 or more beds shall have an emergency electrical power generator on the premises. Generator Specifications. The power source shall be a generating set and prime mover located on the program’s premises with automatic transfer. The emergency generator shall: Be activated immediately when normal electrical service fails to operate; Come to full speed and load acceptance within 10 seconds; and Have the capability of 48 hours of operation from fuel stored on-site. Test of Emergency Power System. The program shall test the emergency power system once each month. During testing of the emergency power system, the generator shall be exercised for a minimum of 30 minutes under normal emergency facility connected load. Results of the test shall be recorded in a permanent log book that is maintained for that purpose. The emergency power system shall provide lighting in the following areas of the facility: Areas of egress and protection as required by COMAR 29.06.01 State Fire Prevention Code and Life Safety Code 101 as adopted by the State Fire Prevention Commission in COMAR 29.06.01; Nurses’ station; Medication area; An area for emergency telephone use; Boiler or mechanical room; Kitchen; Emergency generator location and switch gear location; If applicable, elevator, if operable on emergency power; If applicable, areas where life-support equipment is used; If applicable, common areas or areas of refuge; and If applicable, toilet rooms of common areas or areas of refuge. Emergency electrical power shall be provided for the following, if applicable: Nurses’ call system; At least one telephone in order to make and receive calls; Fire pump; Sewerage pump and sump pump; If applicable, an elevator, if required, for evacuation purposes; If necessary, heating equipment needed to maintain a minimum temperature of 70ºF (24ºC); If applicable, life support equipment; and Nonflammable medical gas systems. Common Areas or Areas of Refuge. If the emergency power system does not provide heat to all patient rooms and toilet rooms, the program shall provide common areas or areas of refuge for all patients. The areas shall meet the following requirements: The common area or areas of refuge shall maintain a minimum temperature of 70ºF (24ºC); and Heated toilet rooms shall be provided adjacent to the common areas or areas of refuge. Orientation. The hospice house shall: Orient staff to the emergency plan and to their individual responsibilities within 24 hours of the commencement of job duties; and Document completion of the orientation in the staff member’s personnel file through the signature of the employee. Drills. Fire Drills. The hospice house shall: Conduct fire drills at least quarterly on all shifts; and Document completion of each drill. Documentation. The hospice house shall: Have the documentation referenced in §K(1)(b) of this regulation signed by all staff who participated in the drill; and Maintain the documentation on file for a minimum of 2 years. Disaster Drill or Training Session. The hospice house shall: Conduct an annual disaster drill or training session, other than a fire drill, on all shifts; and Document completion of each disaster drill or training session. Documentation. The hospice house shall: Have the documentation referenced in §L(1)(b) of this regulation signed by all staff who participated in the drill or training; and Keep the documentation on file for a minimum of 2 years. The hospice house shall prohibit indoor smoking in accordance with COMAR 10.19.04 and COMAR 10.12.27. Common Areas. The hospice house shall provide common areas for the use of patients and families. The common areas shall be of a size and furnished to accommodate the number of family members reasonably expected to attend the number of patients provided for by the hospice house capacity. Public Toilets. The hospice house shall provide public restrooms that are sufficient in number, and appropriately located, to serve family members and visitors. Dining Area. The hospice house shall provide a well-lit, adequately ventilated, and appropriately furnished dining area for the use of patients, families, and visitors. Kitchen. The hospice house shall have a kitchen that has adequate: Storage, refrigerator, and freezer space for perishable and nonperishable foods; Food preparation area or areas with cleanable surfaces; Space and equipment to wash, sanitize, and store utensils; Space to store and clean garbage cans within or outside the kitchen; Ice making capabilities; and Equipment for the preparation of food. Patient rooms shall be of a size and with furnishings adequate for the hospice residence staff to provide care of the patient as required by the plan of care. Patient rooms shall provide accommodation for one family member to remain with the patient through the night. Patient rooms shall be for the private use of the assigned patient or patients. If a patient in a double occupancy room requests dividers, curtains, or screens between the beds to ensure privacy, the hospice house shall furnish them. The hospice house shall provide adequate closet or wardrobe space, conveniently located to allow each patient to keep personal items. Toilets. The hospice house shall provide toilets in a separate room or compartment with latching hardware for privacy. Lavatories. Buildings with one to eight occupants shall have a minimum ratio of one lavatory to four occupants. Buildings with nine or more occupants shall have a minimum ratio of one lavatory to four occupants and a minimum of one lavatory for each floor on which a patient room is located. Bathtubs or Showers. The hospice house shall provide patients with bathtubs or showers that are enclosed in a separate room or compartment that ensures privacy. The hospice house shall provide sufficient light to meet the patient’s needs. Common use areas, such as entrances, hallways, inclines, ramps, cellars, attics, storerooms, kitchens, and laundries, shall have sufficient artificial lighting to prevent accidents and promote efficient service. The hospice house may not use space heaters unless approved by the State or local fire authorities. Minimum Temperature. The facility shall have a system that provides in areas used by patients a minimum temperature of 70ºF in cold weather and a maximum temperature of 80ºF in hot weather. Temperature Control. The hospice house shall provide for each resident's room: A thermostat; or An approved mechanical device for modulating a room’s temperature, such as adjustable vanes in a hot air vent. The hospice house shall ensure that all rooms and areas have sufficient ventilation to prevent excessive heat, steam, condensation, smoke, and other noxious odors. The hospice house shall provide forced mechanical exhaust ventilation or an approved equivalent for: All bathing compartments; Toilet rooms; Any area used for toileting; and Soiled utility rooms. The hospice house shall furnish laundry service, either on-site or off-site. The hospice house shall ensure that the laundry is: Adequate to meet the needs of the patients; Processed and handled in a manner to prevent the spread of infection; and Adequately sanitized by the use of sufficient hot water or appropriate chemical representatives, or a combination of both. The hospice house shall ensure that patient and facility laundry is washed and dried separately. Unless otherwise agreed by the program and the patient, dry cleaning services are not considered part of laundry services in this regulation. The hospice house shall maintain an infection control program that protects patients, staff, and others by preventing and controlling infections and communicable diseases. The hospice house shall follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions. The infection control program shall include the following: Education of employees, contracted providers, patients, and family members about infection control, including their role in preventing the spread of infection and communicable diseases through daily activities; Techniques for hand washing, respiratory protections, asepsis, as well as other means for limiting the spread of contagion; Measures for the: Screening and evaluation of health care workers, including all hospice staff, volunteers, and contract workers, including agency nurses and housekeeping staff for communicable diseases; and Evaluation of staff and volunteers exposed to patients with non-treated communicable diseases; and Monitoring staff for compliance with hospice policies and procedures related to infection control. A hospice house shall have a policy and procedure related to pet visitations. Visiting dogs and cats shall have proof of a current rabies vaccination on file. If another patient has an allergy or a respiratory condition that is aggravated by an animal, the animal shall remain outside of areas where that resident may be. The hospice house has the right to restrict any pet from the hospice house. Health-General Article, §19-903, Annotated Code of Maryland Effective date: June 10, 2013 (40:11 Md. R. 975)