Administrative Code

Virginia Administrative Code
2/3/2023

Part III. Hospice Program Services

Article 1
Hospice Services

12VAC5-391-300. Hospice services.

Article 1
Hospice Services

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.

B. Specific services provided according to the plan of care shall include:

1. Nursing services;

2. Counseling services;

3. Medical social services;

4. Physician services;

5. Physical therapy, occupational therapy, speech-language pathology;

6. Home attendant services;

7. Short-term inpatient care; and

8. Medical appliances and supplies, including drugs and biologicals, relevant to the patient's terminal illness.

C. There shall be a written transfer agreement with one or more hospitals sufficiently close to the hospice's service area to permit the transfer of patients if medical complications arise. Such agreement shall include, but is not limited to, interagency communication processes and coordination of the patient's plan of care, and shall clearly identify the services to be provided by each entity while the patient is at the hospital.

D. Provisions shall be made to obtain appropriate transportation in cases of emergency.

E. All prescription drugs shall be prescribed and properly dispensed to patients according to the provisions of 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 the prescription drugs authorized by § 54.1-3408 of the Drug Control Act, such as epinephrine for emergency administration, normal saline and heparin flushed for the maintenance of IV lines, and adult immunizations, which may be given by a nurse pursuant to established protocol.

F. The hospice program shall have an active program designed to prevent the occurrence of pressure sores or decubitis ulcers by the program's hospice clients.

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, Virginia Register Volume 27, Issue 11, eff. March 2, 2011.

12VAC5-391-310. Interdisciplinary group or IDG.

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.

B. The IDG shall:

1. Establish a coordinated plan of care for the services, supplies and medical appliances required for each patient;

2. Provide or supervise the care and services delivered; and

3. Periodically reassess each patient and update the patient's plan of care, as needed.

C. The IDG shall establish policies governing the day-to-day provision of the care and services. If the hospice program utilizes multiple IDGs, one IDG shall be designated in advance as responsible for establishing those policies.

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.

12VAC5-391-320. Plan of care.

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.

B. Services shall be provided according to the patient's plan of care. The plan of care shall be updated at intervals determined by the IDG and specified in the plan.

C. The plan of care shall be reviewed, approved and signed by the patient's attending physician or the hospice program's medical director after consultation with the patient's attending physician.

D. The attending physician shall be notified immediately of any changes in the patient's condition that indicates a need to alter the plan of 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.

12VAC5-391-330. Medical direction.

A. There shall be a medical director, who shall be a physician licensed by the Virginia Board of Medicine, responsible for the overall direction and management of the medical component of care. The individual shall have training and experience in the psychological and medical needs of the terminally ill.

B. The duties and responsibilities of the medical director shall include at least the following:

1. Consulting with attending physicians regarding pain and symptom management;

2. Reviewing patient eligibility for hospice services according to the law and the hospice program's admission policies;

3. Acting as a medical resource to the IDG;

4. Coordinating with attending physicians to assure a continuum of medical care in cases of emergency or in the event the attending physician is unable to retain responsibility for the patient's care;

5. Acting as medical liaison with physicians in the community; and

6. Determining, in consultation with the patient's physician, when a patient can no longer remain at home and should be moved to a congregate living facility of the patient's choosing.

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, Virginia Register Volume 37, Issue 14, eff. April 15, 2021.

12VAC5-391-340. Nursing services.

A. All nursing services shall be provided directly or under the supervision of a registered nurse, currently licensed by the Virginia Board of Nursing, who has education and experience in the needs of the terminally ill. Duties and responsibilities of the supervising nurse shall include:

1. Assuring that nursing services delivered are provided according to established hospice program policies;

2. Assuring that nursing services are available 24 hours a day, 7 days a week and that licensed practical nurses and home attendants work under the direct supervision of a registered nurse;

3. Participating in the development and implementation of orientation and in-service training hospice programs for all levels of nursing staff employed by the hospice program;

4. Acting as nurse liaison with staff and other agencies, hospice programs and individuals that have contractual agreements to provide nursing services;

5. Participating in quality improvement reviews and evaluations of the nursing services provided; and

6. Directing or supervising the delivery of nursing services.

B. Nursing services shall include:

1. Assessing a patient's needs and admission for service as appropriate;

2. Working with the IDG to develop a plan of care;

3. Implementing the plan of care;

4. Obtaining physician's orders when necessary;

5. Providing those services requiring substantial and specialized nursing skill;

6. Educating the patient and patient's family in the care of the patient, including pain management;

7. Evaluating the outcome of services;

8. Coordinating and communicating the patient's physical or medical condition to the IDG;

9. Preparing clinical notes; and

10. Supervising licensed practical nurses and home attendants providing delegated nursing services.

C. A registered nurse shall coordinate the implementation of each patient's plan of care.

D. If nursing duties are delegated, the hospice program shall develop and implement an organizational plan pursuant to 18VAC90-19-240 through 18VAC90-19-280.

E. Licensed practical nurses shall be currently licensed by the Virginia Board of Nursing.

F. The services provided by a licensed practical nurse may include:

1. Delivering nursing services according to the hospice program's policies and standard nursing practices;

2. Assisting the registered nurse in performing specialized procedures;

3. Assisting the patient with activities of daily living, including the teaching of self-care techniques;

4. Preparing equipment and supplies for treatment that requires adherence to sterile or aseptic techniques; and

5. Preparing clinical notes.

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, Virginia Register Volume 37, Issue 14, eff. April 15, 2021.

12VAC5-391-350. Home attendant services.

A. Services of the home attendants may include:

1. Assisting patients with (i) activities of daily living; (ii) ambulation and prescribed exercise; (iii) other special duties with appropriate training and demonstrated competency;

2. Administration of normally self-administered drugs in a patient's private residence 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. Taking and recording vital signs as indicated in the plan of care;

4. Measuring and recording fluid intake and output;

5. Recording and reporting to the health care professional changes in the patient's physical condition, behavior or appearance;

6. Documenting services and observations in the medical record; and

7. Performing any other duties that the attendant is qualified to do by additional training and demonstrated competency, within state guidelines.

B. Prior to the initial delivery of services, the home attendant shall receive specific written instructions for the patient's care from the appropriate health care professional responsible for the care.

C. Home attendants shall work under the supervision of the appropriate health care professional responsible for the patient's care.

D. The nurse responsible for supervising the home attendant shall make visits to the patient's home as frequently as necessary, but not less than every two weeks. The results of each visit shall be documented in the medical record.

E. Relevant in-service education or training for home attendants shall consist of at least 12 hours annually. In-service training may be in conjunction with on-site supervision.

F. Home attendants shall be able to speak, read and write English and shall meet one of the following qualifications before providing services to the hospice program's patients:

1. Have satisfactorily completed a nursing education hospice program preparing for registered nurse licensure or practical nurse licensure;

2. Have satisfactorily completed a nurse aide education hospice program approved by the Virginia Board of Nursing;

3. Have certification as a nurse aide issued by the Virginia Board of Nursing;

4. Be successfully enrolled in a nursing education hospice program preparing for registered nurse or practical nurse licensure and have currently completed at least one nursing course that includes clinical experience involving patient care; or

5. Have satisfactorily passed a competency evaluation that meets the criteria of 42 CFR 484.36 (b).

If the home attendant is a volunteer, the home attendant shall meet one of the qualifications listed in subdivisions 1 through 5 of this subsection or have satisfactorily completed training provided by a hospice program or other entity that meets the requirements of subsection G.

G. Hospice programs may develop a 40-hour training program for volunteers. The program shall:

1. Include education addressing:

a. Goals of personal care;

b. Prevention of skin breakdown;

c. Physical and biological aspects of aging;

d. Physical and emotional needs of older adults;

e. Orientation to types of physical disabilities;

f. Personal care and rehabilitative services;

g. Body mechanics;

h. Home management;

i. Safety and accident prevention in the home;

j. Policies and procedures regarding accidents or injuries;

k. Food, nutrition, and meal preparation;

l. Special considerations in preparation of special diets;

m. Care of the home and personal belongings; and

n. Documentation requirements for Medicaid individuals.

2. Be conducted by a registered nurse who meets the requirements in 18VAC90-26-30.
3. Issue and maintain certificates of completion containing:

a. The instructor's printed name and signature;

b. The participant's printed name; and

c. The date of completion of the program.

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, Virginia Register Volume 28, Issue 4, eff. November 23, 2011; amended, Virginia Register Volume 37, Issue 14, eff. April 15, 2021.

12VAC5-391-360. Medical social services.

A. Social services shall be provided according to the plan of care 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 hospice program has one year from the effective date of this chapter to ensure the designated individual meets the qualifications of this standard.

B. The duties of the social worker may include, but are not limited to:

1. Conducting a complete psychosocial assessment of the patient and family and participating in the development of the plan of care at the time of the patient's admission;

2. Delivering or supervising the delivery of social services to the patient or the patient's family;

3. Reviewing and updating the plan of care as often as necessary;

4. Obtaining physician's orders for services, as necessary;

5. Assisting the patient and family with identifying and accessing community resources;

6. Reporting any changes in the emotional, social, or financial condition of the patient or family to the attending physician;

7. Acting as consultant to hospice program staff;

8. Participating in the quality improvement reviews and evaluation of social services;

9. Preparing clinical notes; and

10. Participating in discharge planning.

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.

12VAC5-391-370. Spiritual counseling and bereavement services.

A. The hospice program shall provide for the delivery of spiritual counseling and bereavement services that reflect the family's needs and desires and are delivered according to the overall plan of care.

B. Spiritual counseling may be provided through a working arrangement with individual clergy, clergy associations and other religious programs in the community or by clergy employed by the hospice program.

C. The hospice program shall provide bereavement services to the family for a minimum of one year after the patient's death.

D. The hospice program shall maintain a list of individuals who provide spiritual and bereavement services. The list shall be made available, upon request to patients, families, hospice program employees and contractors.

E. Arrangements for and delivery of spiritual counseling and bereavement services shall be documented in the patient's record.

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.

12VAC5-391-380. Dietary or nutritional counseling.

Dietary or nutritional counselors shall meet the requirements of Chapter 27.1 (§ 54.1-2730 et seq.) of Title 54.1 of the Code of Virginia and have at least two years experience in a health care food or nutrition delivery system.

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, Virginia Register Volume 37, Issue 14, eff. April 15, 2021.

12VAC5-391-390. Therapy services.

A. Physical therapy, occupational therapy, or speech therapy services shall be provided under the direction of an appropriately qualified therapist licensed or certified as required in Virginia. The therapy services provided may include, but are not limited to:

1. Assessing patient needs;

2. Participating, as necessary, in developing a patient's plan of care;

3. Implementing therapy services as documented in a patient's plan of care;

4. Evaluating the outcome of the services provided;

5. Educating the patient and family regarding the therapy services provided;

6. Providing therapy service consultation to other health care professionals;

7. Coordinating and communicating with the IDG regarding changes in the patient's needs;

8. Supervising therapy assistants and home attendants as appropriate;

9. Preparing clinical notes; and

10. Obtaining physician orders, when necessary.

B. The occupational therapy assistant shall practice under the supervision of a licensed occupational therapist.

C. The physical therapy assistant shall be currently licensed by the Virginia Board of Physical Therapists and shall practice under the supervision of a licensed physical therapist.

D. Duties of therapy assistants shall include, but are not limited to:

1. Performing services planned, delegated, and supervised by the appropriately licensed or certified therapist; and

2. Preparing clinical notes.

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.

12VAC5-391-395. Medication errors and drug reactions.

A. In the event of a medication error or adverse drug reaction, employees shall promptly notify the patient's physician, the medical director, the nurse and the patient's family and shall take action as directed. Adverse outcomes of medication errors or drug reactions shall also be reported to the OLC within 48 consecutive hours of the event.

B. Actions taken shall be documented in the patient's record.

C. The hospice program shall review all medication errors at least quarterly as part of its quality assurance program.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 27, Issue 11, eff. March 2, 2011.

12VAC5-391-400. Volunteer services.

A. The hospice program shall utilize trained volunteers to provide patient care, including the activities of daily living, and family support.

B. The hospice program shall have a plan delineating training, responsibilities, and supervision of all volunteers.

C. The hospice program shall demonstrate evidence of ongoing continuing education and recruitment activities for volunteers.

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.

Article 2
Other Special Services

12VAC5-391-410. Other special services.

Article 2
Other Special Services

A. Other special services may be offered at the option of the hospice program and may include, but are not limited to:

1. Respiratory therapy; and

2. Pharmacy therapy.

B. Special services may be provided by hospice program employees or through contractual arrangements with individuals or programs that are licensed or certified as required by law.

C. A patient's need for special services shall be documented in the plan of care prepared by the IDG.

D. The special service provider shall assess the patient's need, assist in the development of the plan of care, and provide services according to the plan of care.

E. The special service provider shall participate in the review and update of the plan of care.

F. The special service provider shall instruct the patient, family members, and hospice staff, as appropriate, in assisting with the treatments.

G. Special services provided shall be documented in the medical record.

H. The special service provider shall provide consultative services and in-service training to hospice program staff as 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.

12VAC5-391-420. Respiratory therapy.

Respiratory therapy services shall be provided by a respiratory therapist licensed in Virginia. The duties of the respiratory therapist shall include:

1. Assessing patient needs;

2. Participating with the IDG in developing a plan of care;

3. Implementing a plan of care and revising as necessary;

4. Evaluating the outcome of the care provided;

5. Educating the patient and family;

6. Providing consultation to other health care professionals;

7. Coordinating and communicating with the IDG regarding changes in the patient's needs;

8. Preparing clinical notes; and

9. Obtaining physician orders, when necessary.

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.

12VAC5-391-430. Pharmacy services.

A. All prescription drugs shall be prescribed and properly dispensed to the patient according to the provisions of 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 in the patient's private residence 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 hospice program shall develop written policies and procedures for the administration of infusion therapy medications that include:

1. Developing a plan of care;

2. Initiation of medication administration based on a prescriber's order and monitoring of the patient 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 patient's response to therapy, any other patient specific needs, any significant change in the patient's condition;

5. Communication with the patient's provider pharmacy concerning problems or needed changes in a patient's medication;

6. Maintaining a complete and accurate record of medications prescribed, medication administration data, patient 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 patient, 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 patient, and actions to take in an emergency; and

8. Initial training and retraining of all hospice program staff providing infusion therapy.

D. The hospice program shall employ a registered nurse who holds a current active license with the Virginia Board of Nursing, has completed training in infusion therapy and has the knowledge, skills, and competencies to safely administer infusion therapy to supervise medication administration by staff. This person shall be responsible for ensuring compliance with applicable laws and regulations, adherence to the policies and procedures related to administration of medications, and conducting periodic assessments of staff competency in performing infusion therapy.

E. Hospice and hospice facility employees who are authorized to possess, distribute, or administer medications to patients may store, dispense, or administer cannabidiol oil or THC-A oil to a patient who has:

1. Been issued a valid written certification for the use of cannabidiol oil or THC-A oil in accordance with subsection B of § 54.1-3408.3 of the Code of Virginia; and

2. Registered with the Board of Pharmacy.

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, Virginia Register Volume 28, Issue 4, eff. November 23, 2011; Volume 36, Issue 23, eff. August 6, 2020.

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