This
rule was filed as 7 NMAC 12.2.
TITLE
7 HEALTH
CHAPTER
12 HOSPICE CARE
PART
2 REQUIREMENTS FOR INHOME
AND INPATIENT HOSPICE CARE
7.12.2.1 ISSUING AGENCY: New Mexico Department of Health, Public Health
Division, Health Facility Licensing and Certification Bureau
[10/31/96;
Recompiled 10/31/01]
7.12.2.2 SCOPE:
A. These regulations apply to any hospice
facility licensed or required to be licensed pursuant to these regulations
which provides inpatient hospice services on a twenty-four (24) hour basis.
B. These regulations apply to any hospital,
skilled nursing facility, or intermediate care facility which also provides
hospice services and is licensed or required to be licensed to provide these services
pursuant to these regulations.
C. These regulations apply to any agency
licensed or required to be licensed which provides hospice services in the
patient's own home.
[11/16/83,
5/8/90; Recompiled 10/31/01]
7.12.2.3 STATUTORY AUTHORITY: The regulations set forth herein are
promulgated by the secretary of the New Mexico department of health, pursuant
to the general authority granted under Section 9-7-6 (E) of the Department of
Health Act, NMSA 1978, as amended; and the authority granted under Sections
24-1-2 (D), 24-1-3 (I) and 24-1-5 of the Public Health Act, NMSA 1978, as
amended.
[11/16/83,
5/8/90, 10/31/96; Recompiled 10/31/01]
7.12.2.4 DURATION: Permanent
[10/31/96;
Recompiled 10/31/01]
7.12.2.5 EFFECTIVE DATE: October 31, 1996, unless a different date is
cited at the end of a Section or Paragraph.
[10/31/96;
Recompiled 10/31/01]
[Compiler’s
note: The words or paragraph, above, are no longer applicable. Later dates are now cited only at the end of
sections, in the history notes appearing in brackets.]
7.12.2.6 OBJECTIVE: The purpose of these regulations is:
A. Establish minimum standards for licensing
of hospice facilities and agencies that provide inhome and inpatient hospice
care.
B. To monitor hospice
facilities and agencies providing inhome and inpatient hospice services with
these regulations through surveys to identify any area which could be dangerous
or harmful to the patients, family, or staff.
[11/16/83,
5/8/90; Recompiled 10/31/01]
7.12.2.7 DEFINITIONS: For purposes of these regulations the
following shall apply:
A. "Administrator" means the person
appointed by the governing body to be in charge of the day-to-day operation of
a facility or agency providing hospice services.
B. "Applicant" means the individual
who, or organization which, applies for a license. If the applicant is an organization, then the individual signing
the application on behalf of the organization, must have authority from the
organization. The applicant must be the
owner.
C. "Bereavement" means a period of
mourning following the death of a loved one.
D. "Certified" means that a
determination has been made by the New Mexico department of health that a
health facility such as a hospital, skilled nursing facility or intermediate
care facility is in compliance with Conditions of Participation and Conditions
of Coverage under Title XVIII (Medicare) and/or Title XIX (Medicaid) of the
United States Federal Social Security Act.
E. "Dietitian" means a person eligible
or required to be licensed under the New Mexico Nutrition and Dietetics
Practice Act, Sections 61-7A-1 through 61-7A-15 NMSA 1978.
F. "Exploitation" of a patient/client
consists of the act or process, performed intentionally, knowingly, or
recklessly, of using any patient/client/residents money or property, for
another person's profit, advantage, or benefit. Exploitation includes but is not limited to:
(1) manipulating the patient/client/ resident
by whatever mechanism to give money or property to any agency staff or
management member;
(2) misappropriation or misuse of monies
belonging to a patient/client/ resident or the unauthorized sale, transfer or
use of a patient/client/residents property;
(3) loans of any kind from
patient/clients/resident to agency staff or management;
(4) accepting monetary or other gifts from a
patient/client/resident or their family with a value in excess of $25 or gifts
which exceed a total value of $300 in one year. All gifts received by agency operators, their families or staff
of the agency must be documented and acknowledged by the person giving the gift
and the recipient. Exception: Testamentary gifts, such as wills, are not,
per se, considered financial exploitation.
G. "Governing body" means the person,
persons, board of trustees, directors, or other body in which the final
authority and responsibility is vested in determining, implementing, and
monitoring policies governing the total operation of the hospice facility or
agency providing hospice services.
H. "Health certificate" means a completed New
Mexico department of health approved health certificate form signed by a
physician licensed in New Mexico or a public health nurse in one of the public
health division health offices who is acting for the state tuberculosis control
officer.
I. "Hospice agency" means an organization,
company, profit or non-profit corporation or any other entity which provides
hospice services in the patient's own home and is required to be licensed
pursuant to these regulations.
J. "Hospice facility" means a building
equipped and staffed to provide hospice services to patients and family on a
twenty-four (24) hour basis and is required to be licensed pursuant to these
regulations.
K. "Hospice services" means a program of
palliative and supportive services which provides physical, psychological,
social and spiritual care for terminally ill patients and their family members.
L. "Inhome care" means hospice services
delivered in a private home or alternative home site to a single patient on an
intermittent basis.
M. "Inpatitne care" means hospice services
delivered to a patient who has been admitted to a hospice facility on a
continuous twenty-four (24) hour period.
N. "License" means the document
issued by the licensing authority pursuant to these regulations granting the
legal right to operate for a specified period of time, not to exceed one (1)
year.
O. "Licensee" means the person(s)
who, or organization which, has an ownership, leasehold, or similar interest in
the hospice facility and in whose name a license has been issued and who is
legally responsible for compliance with these regulations.
P. "Licensing authority" means the New Mexico
department of health.
Q. "Medical director" means a doctor of
medicine or osteopathy who assumes overall responsibility for the medical
component of a hospice facility or agency.
R. "NMSA" means the New Mexico
Statutes Annotated 1978 compilation, and all the revisions and compilations
thereof.
S. "Physician" means a person licensed
to practice medicine or osteopathy by the New Mexico board of medical
examiners, or the osteopathic medical examiners board.
T. "Plan of correction" means the plan
submitted by the licensee or representative of the licensee addressing how and
when deficiencies identified at time of a survey will be corrected.
U. "Policy" means a statement of
principle that guides and determines present and future decisions and actions.
V. "Procedure" means the action(s)
that must be taken in order to implement a policy.
W. "Registered nurse" means a person who
holds a certificate of registration as a registered nurse under the Nursing
Practice Act, Sections 61-3-1 to 61-3-30 NMSA 1978.
X. "Short term inpatient care" is care provided to a
hospice patient on a short term basis, either in a hospital or skilled nursing
facility for acute symptom control or in a skilled or intermediate care
facility for respite for the usual caregiver.
Y. "Social worker" means a person required
to be licensed under the Social Work Practice Act, Sections 61-31-1 through
61-31-25 NMSA 1978.
Z. "Staff" means the paid and
volunteer workers supervised by the hospice facility or hospice agency
administration.
AA. "Terminally ill" means a diagnosis by a
physician with a prognosis that a patient has six (6) months or less to live.
BB. "Variance" means an act on the
part of the licensing authority to refrain from pressing or enforcing
compliance with a portion or portions of these regulations for an unspecified
period of time where the granting of a variance will not create a danger to the
health, safety, or welfare of patients or staff of a hospice facility and is at
the sole discretion of the licensing authority.
CC. "Waive/waivers" means to refrain from
pressing or enforcing compliance with a portion or portions of these
regulations for a limited period of time provided the health, safety, or
welfare of patients and staff are not in danger. Waivers are issued at the sole discretion of the licensing
authority.
[11/16/83,
5/8/90, 10/31/96, 6/15/98; Recompiled 10/31/01]
7.12.2.8 STANDARD OF COMPLIANCE: The degree of compliance required throughout
these regulations is designated by the use of the words "shall"
or "must" or "may". "Shall" or "must" means
mandatory. "May" means
permissive. The use of the words "adequate",
"proper", "appropriate" and other similar
words means the degree of compliance that is generally accepted throughout the
professional field by those who provide hospice services to the public and are
governed by these regulations.
[5/8/90,
6/15/98; Recompiled 10/31/01]
7.12.2.9 INITIAL APPLICATIONS:
A. All initial applications shall be made on
forms provided by the licensing authority.
B. Shall be fully completed.
C. Signed by the person who shall be the
licensee.
D. And shall be notarized.
E. All initial applications shall be
accompanied by a resume and three (3) character references for the person in
charge of the day-to-day operation of the hospice.
(1)
References shall not be from a relative or employee.
(2) License fees are authorized by law, and
will be payable to the extent, if any, set out by other licensing authority
regulations.
[11/16/83;
Recompiled 10/31/01]
7.12.2.10 INITIAL LICENSURE PROCEDURES: No license shall be issued without the
following:
A. Receipt of the application with all
attachments listed in Section 9 [now 7.12.2.9 NMAC] of these regulations.
B. Survey conducted by the licensing authority.
[11/16/83;
Recompiled 10/31/01]
7.12.2.11 INITIAL SURVEY: Upon receipt of a properly completed
application and all required documentation an initial survey of the proposed
hospice facility or agency will be scheduled by the licensing authority.
[5/8/90;
Recompiled 10/31/01]
7.12.2.12 ISSUANCE OF LICENSE: Upon completion of the initial survey and
determination that the hospice facility or agency is in compliance with these
regulations the licensing authority will issue a license.
[11/16/83,
5/8/90; Recompiled 10/31/01]
7.12.2.13 LICENSES:
A. Annual license: An annual license is issued for a one (1)
year period to a hospice facility which has met all requirements of these
regulations.
B. Temporary license: The licensing authority may, at its sole
discretion, issue a temporary license prior to the initial survey, or when the
licensing authority finds partial compliance with these regulations.
(1) A temporary license shall cover a period
of time, not to exceed one hundred twenty (120) days, during which the facility
must correct all specified deficiencies.
(2) In accordance with Section 24-1-5(D) NMSA
1978, no more than two (2) consecutive temporary licenses shall be issued.
C. Amended license: A licensee must apply to the licensing
authority for an amended license when there is a change of
administrator/director, or when there is a change of name for the facility.
(1) Application must be on a form provided by
the licensing authority.
(2) Application must be accompanied by the
required fee for amended license.
(3) Application must be submitted within ten
(10) working days of the change.
[11/16/83,
5/8/90, 10/31/96; Recompiled 10/31/01]
7.12.2.14 LICENSE RENEWAL:
A. Licensee must submit a renewal
application on forms provided by the licensing authority, along with the
required fee at least thirty (30) days prior to expiration of the current
license.
B. Upon receipt of renewal application and
required fee prior to expiration of current license, the licensing authority
will issue a new license effective the day following the date of expiration of
the current license if the facility is in substantial compliance with these
regulations.
C. If a licensee fails to submit a renewal
application with the required fee and the current license expires, the hospice
facility shall cease operations until it obtains a new license through the
initial licensure procedures. Section
24-1-5(A) NMSA 1978, as amended, provides that no health facility shall be
operated without a license.
[11/16/83,
5/8/90; Recompiled 10/31/01]
7.12.2.15 NON-TRANSFERABLE RESTRICTION ON
LICENSE: A license shall not be transferred by
assignment or otherwise to other persons or locations. The license shall be void and must be
returned to the licensing authority when any one of the following situations
occur:
A. ownership of the facility changes;
B. the facility changes location;
C. licensee of the facility changes;
D. the facility discontinues operation;
E. a facility wishing to continue operation
as a licensed hospice facility under circumstances 15.1 through 15.4 [now
Subsections A through D of 7.12.2.15 NMAC] above must submit an application for
initial licensure in accordance with Section 10 [now 7.12.2.10 NMAC] of these
regulations, at least thirty (30) days prior to the anticipated change.
[5/8/90,
10/31/96; Recompiled 10/31/01]
7.12.2.16 AUTOMATIC EXPIRATION OF LICENSE: A license will automatically expire at midnight
on the day indicated on the license as the expiration date, unless sooner
renewed, suspended, or revoked, or:
A. on the day a facility discontinues
operation;
B. on the day a facility is sold, leased, or
otherwise changes ownership and/or licensee;
C. on the day a facility changes location.
[11/16/83,
5/8/90, 10/31/96; Recompiled 10/31/01]
7.12.2.17 SUSPENSION OF LICENSE WITHOUT
PRIOR HEARING: In accordance with Section 24-1-5 (H) NMSA
1978, if immediate action is required to protect human health and safety, the
licensing authority may suspend a license pending a hearing, provided such
hearing is held within five (5) working days of the suspension, unless waived
by the licensee.
[11/16/83,
5/8/90; Recompiled 10/31/01]
7.12.2.18 GROUNDS FOR REVOCATION OR
SUSPENSION OF LICENSE, DENIAL OF INITIAL OR RENEWAL APPLICATION FOR LICENSE, OR
IMPOSITION OF INTERMEDIATE SANCTIONS OR CIVIL MONETARY PENALTIES: A license may be revoked or suspended, an
initial or renewal application for license may be denied, or intermediate
sanctions or civil monetary penalties may be imposed after notice and
opportunity for a hearing, for any of the following reasons:
A. failure to comply with any provision of
these regulations;
B. failure to allow survey by authorized representatives
of the licensing authority;
C. any person active in the operation of a
facility licensed pursuant to these regulations shall not be under the
influence of alcohol or narcotics or convicted of a felony;
D. misrepresentation or falsification of any
information on application forms or other documents provided to the licensing
authority;
E. discovery of repeat violations of these
regulations during surveys;
F. failure to provide the required care and services
as outlined by these regulations for the patients receiving care at the hospice
facility or from the hospice agency.
[11/16/83,
5/8/90, 10/31/96; Recompiled 10/31/01]
7.12.2.19 HEARING PROCEDURES:
A. Hearing procedures for an administrative
appeal of an adverse action taken by the licensing authority against a hospice
facility as outlined in Section 17 and 18 [now Sections 17 and 18 of 7.12.2
NMAC] above will be held in accordance with Adjudicatory Hearings, New Mexico
department of health, 7 NMAC 1.2 (2-1-96) [now 7.1.2 NMAC].
B. A copy of the adjudicatory hearing
procedures will be furnished to a hospice facility or agency at the time an
adverse action is taken against its license by the licensing authority. A copy may be requested at any time by
contacting the licensing authority.
[11/16/83,
5/8/90, 10/31/96; Recompiled 10/31/01]
7.12.2.20 GOVERNING BODY: A hospice must have a governing body or
individual who assumes full legal responsibility for determining, implementing
and monitoring policies governing the hospice's total operations. The governing body must also ensure that all
services provided are consistent with accepted standards of practice. The governing body shall appoint an
administrator to implement its policies and procedures.
[11/16/83;
Recompiled 10/31/01]
7.12.2.21 INTERDISCIPLINARY TEAM: The hospice shall establish an
interdisciplinary team to provide or supervise the care and services offered by
the hospice.
A. The hospice must have an interdisciplinary
team that includes at least the following disciplines:
(1) a doctor of medicine or osteopathy;
(2) a registered nurse;
(3) a social worker;
(4) a
pastoral or other counselor.
B. The interdisciplinary team is responsible
for:
(1) establishment of the plan of care;
(2) provision or supervision of hospice care
and services;
(3) review and revision, at least every two weeks (see 29.2) [now
Subsection B of 7.12.2.29 NMAC], of the plan of care for each individual
receiving hospice care;
(4) establishment of written policies
governing the day-to-day provision of hospice care and services.
C. The hospice must designate a registered
nurse to coordinate the overall plan of care for each patient.
[11/16/83,
5/8/90; Recompiled 10/31/01]
7.12.2.22 CARE SERVICES: A hospice must ensure that all services
described below are provided directly by hospice staff, or under arrangements
made by the hospice as specified in Section 23 [now 7.12.2.23 NMAC] of these
regulations:
A. Nursing care provided by or under the supervision of a
registered nurse. Nursing care must be
available on call twenty-four (24) hours a day, seven (7) days each week;
B. Medical social services provided by a
social worker;
C. Physician's services performed by a
doctor of medicine or osteopathy;
D. Counseling services provided to the
terminally ill individual and the family members or other persons caring for
the individual. Bereavement counseling
must be available for a twelve (12) month period following the death of the
patient.
E. Short term inpatient care provided to
patients of a hospice agency in a facility licensed as a hospital or long term
care facility. Services provided in an
inpatient setting must conform to the written plan of care.
F. Volunteer services. The hospice facility or agency must have an
ongoing program to recruit, train, utilize, and retain volunteer staff.
(1) Volunteers may be used in administration
or direct patient care roles.
(2) Volunteers must work under the
supervision of a designated hospice facility or agency employee.
[11/16/83,
5/8/90; Recompiled 10/31/01]
7.12.2.23 ARRANGEMENTS FOR SERVICES: A hospice may arrange for another individual
or entity to furnish services to the hospice's patients. Services provided under arrangement must
meet the following standards:
A. The hospice shall have a written
agreement for the provision of such services.
B. The hospice ensures that inpatient care
is furnished only in a facility licensed as a hospital, skilled nursing
facility (nursing home), or intermediate care facility. For inpatient care furnished under
arrangements, the hospice must have an arrangement under which:
(1) The hospice furnished to the inpatient
provider, a copy of the individual's plan of care that specified the care that has
been furnished.
(2) The regimen described in the established
plan of care is continued while the individual receives care from the inpatient
provider.
(3) All inpatient services and events (e.g.
treatments, tests, consultations, evaluations, etc.) furnished by the inpatient
provider are entered in the hospice's medical record.
(4) The interdisciplinary team reviews the
medical record to ensure conformance with the established plan of care.
(5) A copy of the inpatient medical record
and discharge summary is retained as part of the hospice medical record.
[11/16/83,
5/8/90; Recompiled 10/31/01]
7.12.2.24 ANNUAL REVIEW: A hospice must conduct an annual comprehensive
self-assessment of the quality and appropriateness of care provided, including
inpatient care. The findings are to be
used by the hospice to correct identified problems and to revise hospice
policies, if necessary. A mechanism
must be established in writing for the collection of pertinent data to assist
in the evaluation process. The data to
be considered shall include, but are not limited to:
A. the number of patients receiving each
service offered;
B. the number of patient visits;
C. reasons for discharge;
D. a breakdown by diagnoses;
E. any sources of referral;
F. the number of patients not accepted and
the reasons therefor;
G. the total staff days, hours, or visits
for each service offered.
[11/16/83;
Recompiled 10/31/01]
7.12.2.25 MEDICAL RECORDS: In accordance with accepted principles of
practice, the hospice must establish and maintain a clinical record for every
individual receiving care and services.
The record must be complete, promptly and accurately documented, readily
accessible to staff, and systematically organized to facilitate retrieval.
A. Each clinical record is a comprehensive
and chronological compilation of information.
Entries are made for all services provided. Entries are made and signed by the staff providing the
services. The record includes all
services whether furnished directly or under arrangements made by the
hospice. Each individual's record shall
contain:
(1) the initial and subsequent assessments;
(2) the plan of care;
(3) identification data;
(4) consent, authorization and election
forms;
(5) pertinent medical history;
(6) complete documentation of all services and
events (including evaluations, treatments, progress notes, etc.).
B. The hospice must safeguard the clinical
record against loss, destruction, and unauthorized use.
C. Clinical records shall be retained on
each patient for at least ten (10) years after hospice services have
ceased. Clinical records shall be
maintained for the requisite period even if the hospice discontinues
operations. If the patient is
transferred to another health facility, a copy of the record must be made
available to the receiving facility.
Consultation shall be provided to the receiving facility prior to
transfer.
[11/16/83,
5/8/90; Recompiled 10/31/01]
7.12.2.26 STAFF TRAINING: A hospice must provide an ongoing program of
employee psychological support, and continuing education of its staff in
hospice care. At least twelve (12)
clock hours of training per year in hospice care shall be provided.
[11/16/83;
Recompiled 10/31/01]
7.12.2.27 HEALTH CERTIFICATE: Prior to employment, any paid volunteer
staff working with patients shall present a certificate from a licensed
physician that the person is free from tuberculosis. All certificates shall be filed in the hospice office and be available
for inspection.
[11/16/83,
5/8/90; Recompiled 10/31/01]
7.12.2.28 STAFF SUPERVISION: A hospice shall ensure that licensed
professional staff are supervised as required under the relevant professional
licensing act. All other staff
including volunteers must be adequately supervised.
[11/16/83,
5/8/90; Recompiled 10/31/01]
7.12.2.29 PLAN OF CARE: A written plan of care must be established
and maintained for each individual admitted to a hospice program, and the care
provided to an individual must be in accordance with the plan.
A. A plan must be established by the
attending physician and interdisciplinary team within five (5) days of
admission to the program. The signed
orders, and the plan, shall be incorporated within the hospice medical record
within fourteen (14) days of admission.
B. The plan must be reviewed and updated, at
least every two (2) weeks, by the interdisciplinary team. These reviews must be documented, and plan
changes signed by the attending physician or the medical director as the
attending physician's designee.
C. The plan must be based upon assessment of
the individual's and family's needs and identification of the services
including the management of discomfort and symptom relief and describing any
isolation techniques for routine or specialized treatments.
[11/16/83,
5/8/90; Recompiled 10/31/01]
7.12.2.30 PATIENT RIGHTS: All hospice facilities and agencies licensed
pursuant to these regulations shall support, protect and enhance the rights of
patients.
[11/16/83,
5/8/90; Recompiled 10/31/01]
7.12.2.31 INFORMED CONSENT: Each hospice facility or agency must obtain
from each patient a signed informed consent form. The informed consent form shall specify the type of hospice care
and services that will be provided during the course of illness.
[11/16/83,
5/8/90; Recompiled 10/31/01]
7.12.2.32 AVAILABILITY OF SUPPLIES AND
APPLIANCES: Medical supplies and appliances, including
drugs and biologicals, must be available as needed for the palliation and
management of the terminal illness, although the hospice need not supply these
directly.
[11/16/83;
Recompiled 10/31/01]
7.12.2.33 SERVICES/INDIVIDUAL CARE:
A. Nursing services: The hospice facility shall provide
twenty-four (24) hour nursing services which are sufficient to meet the total
nursing needs of the patient and which are in accordance with each patient's
plan of care.
B. Treatments: Each patient shall receive treatments,
including medications and diet, as prescribed, and shall be kept clean,
well-groomed, comfortable and protected from accident, injury and infection.
C. Palliative care: Each patient shall be provided necessary
palliative procedures to meet individual needs as defined in the plan of care.
[5/8/90;
Recompiled 10/31/01]
7.12.2.34 PHARMACEUTICAL SERVICES: Each hospice facility shall maintain a
pharmaceutical service that is conducted in accordance with current standards
of practice and all applicable laws and regulations:
A. A pharmaceutical service shall be
directed by a licensed pharmacist.
B. The scope of pharmaceutical services
shall be consistent with the drug therapy needs of the patients as determined
by the physician.
C. The pharmacist must develop policies and
procedures for ordering, storage, administration, disposal, and recordkeeping of
drugs and biologicals.
[5/8/90;
Recompiled 10/31/01]
7.12.2.35 MEDICATION ADMINISTRATION: Medications can only be administered by the
following individuals:
A. a licensed nurse or physician; or
B. a patient on order of the physician; or
C. a licensed respiratory therapist for drug
administration during respiratory therapy.
[5/8/90;
Recompiled 10/31/01]
7.12.2.36 DIETARY SERVICES: The hospice facility shall provide or
contract for a dietary service which meets the nutritional needs of each
client.
A. Supervision of the dietary services shall
be provided by:
(1) a dietitian; or
(2) a staff person experienced in food
service who shall receive consultation from a dietitian.
B. Other staff requirements: There shall be sufficient staff on duty to
meet the nutritional needs of the patients.
C. Meal services: The hospice facility must:
(1) Serve at least three (3) meals or their
equivalent each day at regular times with no more than fourteen (14) hours
between supper and breakfast.
(2) Snacks of nourishing quality shall be
available as needed by patients.
(3) To the extent medically possible, menus
will be planned in accordance with the recommended dietary allowances of the
food and nutrition board of the national research council, national academy of
sciences.
(a) For patients experiencing difficulties in
eating, every effort will be made to develop menus tolerated by the patient and
served at intervals tolerated by the patient.
(b) All medically prescribed special diets
shall be ordered by a physician and shall have menus developed by a
professional dietitian.
[5/8/90;
Recompiled 10/31/01]
7.12.2.37 SANITATION:
A. Storage and handling of food: All food shall be purchased, stored,
prepared, distributed and served under sanitary conditions which prevent
contamination.
B. All equipment, appliances and utensils used
in preparation or serving of food shall be maintained in a functional, sanitary
and safe condition.
C. The hospice facility will ensure that
requirements of the environmental health authority having jurisdiction are
met. The dietary area will be inspected
by the environmental health authority and the inspection results will be posted
in the dietary area. Exception: Hospice facilities with four (4) or less patients will be exempt
from this requirement if the environmental health authority waives this
requirement and a letter of the exemption is on file with the health facility
licensing and certification bureau.
[5/8/90;
Recompiled 10/31/01]
7.12.2.38 INFECTION CONTROL: The hospice facility shall develop and
implement an infection control program which shall have as its purpose the
protection of the patient, family, and facility personnel from infections
associated with patients admitted to home care, inpatient respite, or day care
programs.
A. The hospice facility shall develop
policies and procedures governing the infection control program.
(1) The hospice facility shall develop a
procedure to assure the infection control program is monitored on a monthly
basis.
(2) The hospice facility shall isolate only
those patients with diseases that are considered to be at a high risk for
transmission. Where applicable,
isolation rooms shall have access to private bathing, toileting, and
handwashing facilities. The room shall
be ventilated directly to the outside (there shall be no recirculation of the
air from any isolation room to any other room).
B. All biohazardous waste and/or infectious
material must be disposed of in accordance with:
(1) center for disease control currently
accepted guidelines for universal precautions.
(2) Occupational Safety and Health
Administration requirements in 29 Code of Federal Regulations 1910.
(3) state Environment Improvement Act
requirements.
(4) center of
disease control currently accepted recommended procedures for body substance
isolation.
[5/8/90;
Recompiled 10/31/01]
7.12.2.39 GENERAL BUILDING REQUIREMENTS: The building of the hospice facility shall
be constructed and maintained so that it is functional for the delivery of
services appropriate to the needs of the hospice patient.
A. The hospice facility shall meet all state
and local laws, regulations and zoning requirements.
B. The hospice facility shall meet the
requirements of the latest edition of the National Fire Protection Association,
Life Safety Code Handbook adopted by the New Mexico state fire marshal.
C. The hospice facility must meet the
requirements of the latest edition of the Uniform Building Code enacted by the
international conference of building officials, adopted by the New Mexico
construction industries division. Exception: Hospice facilities housing four (4) or less patients will be
required to meet residential occupancy building requirements.
[5/8/90;
Recompiled 10/31/01]
7.12.2.40 PATIENT LIVING AREA:
A. ROOMS:
(1) Each patient room shall be directly
accessible from a corridor, activity room, or common area.
(2) Each sleeping room shall have a clear window
or relite area of approximately one-tenth (1/10) of the usable floor area
providing for patient visibility of the out-of-doors.
(a) Windows shall be at least twenty-four
(24) feet from other buildings or the opposite wall of a court or at least ten
(10) feet from a property line, except on the street side.
(b) Outside window walls shall be at least
eight (8) feet from an outside public walkway.
(c) Operable windows or openings that serve
for ventilation shall be provided with proper screening.
(3) No room more than two (2) feet, six (6)
inches below grade shall be used for the housing of patients. Private patient rooms have at least one
hundred (100) square feet of usable floor space. Multi-patient rooms shall provide not less than eighty (80)
square feet of usable floor area per bed.
There shall not be less than seven and one-half (7 1/2) foot ceiling
height over the usable floor area.
(4) Each patient shall be provided an
enclosed space suitable for hanging garments and storage of personal belongings
within his or her room or in an area nearby patient rooms. There shall be a provision for secure storage
of patient valuables.
(5) Each patient shall be provided a bed
appropriate to the special needs and size of the patient with a cleanable
mattress which is in good repair and a cleanable or disposable pillow.
(6) Room furnishing
shall be provided and maintained in a clean and safe condition.
(7) Patient beds shall be spaced so that they
do not interfere with entrance, exit or traffic flow within the room. Patient rooms shall be of a dimension and
conformation allowing not less than three (3) feet between beds.
B. The hospice facility shall endeavor to
provide decor which is homelike in design and function.
[5/8/90;
Recompiled 10/31/01]
7.12.2.41 TOILET AND BATHING AREAS:
A. There shall be, minimally, one (1)
bathing facility for each six (6) patients within the inpatient hospice
facility, or major fraction thereof, (tub, shower, portable shower, portable
tub or equivalent).
B. Toilets shall be in a ratio of at least
one (1) toilet for every four (4) patients, or major fraction thereof.
C. Lavatories shall be provided in a ratio
of at least one (1) lavatory for each toilet located in toilet rooms(s). Lavatories shall be provided in a ratio of
at least one (1) per four (4) patients.
Lavatories shall be located at the entry of patient rooms used for
isolation.
D. At least one (1) toilet and lavatory
shall be provided on each floor for use by those who are not patients.
[5/8/90;
Recompiled 10/31/01]
7.12.2.42 CARPETING: Carpets may be used in patient and
non-patient occupied areas with the following exceptions: toilet rooms, bathing facilities, isolation
rooms, laundry rooms, utility rooms, examination or treatment rooms,
housekeeping closets:
A. Specifications for acceptable carpeting
include:
(1) carpet material which meets the standards
of the state fire marshal and is easily cleanable;
(2) pile tufts shall be a minimum of
sixty-four (64) per square inch or equivalent density;
(3)
rows shall be a minimum of eight (8) per square inch or equivalent
density.
B. Installation of carpet material:
(1) Pad and carpet shall be installed
according to manufacturer recommendations;
(2) Edges of
carpet shall be covered and cove or base shoe used at all wall junctures. Seams shall be sewn or bonded together with
manufacturer recommended cement.
[5/8/90;
Recompiled 10/31/01]
7.12.2.43 SPECIAL AREAS:
A. There shall be provision for adequate
personal privacy for personal and private activities such as toileting,
bathing, dressing, sleeping, communicating with family and time alone.
B. There shall be adequate visiting and
lounge areas. A ratio of fifteen (15)
square feet per patient bed and not less than one hundred eighty (180) square
feet per facility is required, excluding hallways and corridors.
C. There shall be adequate meeting rooms and
office areas for use by the interdisciplinary care team. Other rooms or areas may serve as meeting
rooms provided confidentiality is maintained.
D. The hospice facility must have:
(1) Physical space for private patient/family
visits;
(2) Accommodations for family members to
remain with the patient throughout the night;
(3) Accommodations for family privacy after a
patient's death.
E. A hospice facility will designate a room
exclusively for a nebulizer treatment room (if applicable). The room will have a minimum usable floor
area of one hundred (100) square feet.
The nebulizer room will be ventilated directly to the outside of the
building. (There shall be no recirculation
of the air from the nebulizer treatment room to other rooms of the facility.)
[5/8/90;
Recompiled 10/31/01]
7.12.2.44 LINEN AND LAUNDRY: The hospice facility shall have available at
all times a quantity of linen essential for proper care and comfort of
patients. Linens shall be handled,
stored, processed, and transported in such a manner as to prevent the spread of
infection.
A. A safe and adequate clean linen storage
area shall be provided with a supply of clean linen available for patient use.
B. Any laundry done in the facility shall be
done in a laundry room separate from the kitchen, dining area, clean and soiled
storage and handling areas.
C. The soiled laundry storage and sorting
area shall be in a well ventilated area separate from the clean linen handling
area, clean storage area, and food preparation areas. If linen or laundry is washed on the premises, an adequate supply
of hot water shall be available to provide water at a minimum of one hundred
sixty (160) degrees fahrenheit in the washing machine.
[5/8/90;
Recompiled 10/31/01]
7.12.2.45 UTILITY AND STORAGE FACILITIES:
A. Sufficient clean storage and handling
room(s) shall provide closed storage for clean and sterile supplies and
equipment.
B. Washing, disinfection, storage and other
handling of medical and nursing supplies and equipment shall be accomplished in
a manner which ensures segregation of clean and sterile supplies and equipment
from those that are contaminated.
C. Soiled utility room(s) shall provide:
(1) clinic service sink, siphon jet or equivalent;
(2) space for soiled linen or laundry
containers;
(3) counter top, double compartment sink, and
goose-neck spout or equivalent;
(4) storage for cleaning supplies and equipment.
[5/8/90;
Recompiled 10/31/01]
7.12.2.46 HOUSEKEEPING:
A. Adequate and clean housekeeping equipment
shall be maintained.
B. At least one (1) service sink and
housekeeping closet or enclosed cabinet equipped with shelving shall be provided
in a suitable setting within the facility or combined with a soiled utility
room. A clinic service sink may be
considered equivalent to a service sink.
[5/8/90;
Recompiled 10/31/01]
7.12.2.47 COMMUNICATIONS:
A. There shall be a telephone readily
available for patients to make and receive confidential calls.
B. There shall be at least one (1)
"non-pay" telephone per floor readily accessible in event of fire and
other emergencies.
C. A nurse call system shall be provided at
each bed and in each toilet room and bathing facility.
[5/8/90;
Recompiled 10/31/01]
7.12.2.48 WATER SUPPLY AND PLUMBING:
The
water supply and the waste and drainage system of the hospice shall be
maintained to avoid unsanitary conditions.
A. There shall be an adequate supply of hot
and cold running water under pressure.
B. Hot water shall be of a safe temperature
at all fixtures used by patients. Hot
water temperatures at bathing fixtures used by patients shall be automatically
regulated so as not to exceed one hundred and ten (110) degrees fahrenheit.
C. There shall be devices to prevent
backflow into the water supply system.
[5/8/90;
Recompiled 10/31/01]
7.12.2.49 HEATING: The heating system in all patient areas
shall be operated and maintained to provide a comfortable temperature of
between seventy (70) degrees and seventy-five (75) degrees fahrenheit.
[5/8/90;
Recompiled 10/31/01]
7.12.2.50 VENTILATION: There shall be ventilation for all rooms
used by patients and personnel sufficient to remove any objectionable odors,
excess heat, and condensation. Inside
rooms, including toilets, bath rooms, smoking rooms, and other rooms in which
excessive moisture, odors or contaminants originate shall be provided with
mechanical exhaust ventilation.
[5/8/90;
Recompiled 10/31/01]
7.12.2.51 LIGHTING: Adequate lighting appropriate to the
function shall be provided in all usable areas of the hospice.
A. Appropriate, adequate, and safe
electrical service shall be provided.
B. Adequate emergency lighting for means of
egress, (battery operated acceptable) shall be provided.
C. Adequate emergency power shall be
available, (battery operated acceptable).
[5/8/90;
Recompiled 10/31/01]
7.12.2.52 HANDICAP ACCESS: The hospice facility shall be accessible and
equipped to accommodate physically handicapped individuals.
[5/8/90;
Recompiled 10/31/01]
7.12.2.53 DISASTER PREPAREDNESS: The hospice facility shall have an
acceptable plan, periodically rehearsed with staff, with procedures to be
followed in the event of an internal or external disaster and for the care of
casualties (patients and personnel) arising from such disaster.
[5/8/90;
Recompiled 10/31/01]
7.12.2.54 RELATED REGULATIONS AND CODES: Hospice facilities providing inhome and
inpatient hospice services subject to these regulations are also subject to
other regulations, codes and standards as the same may, from time to time, be
amended as follows:
A. Health Facility Licensure Fees and
Procedures, New Mexico department of health, 7 NMAC 1.7 (10/31/96) [now 7.1.7
NMAC].
B. Health Facility Sanctions and Civil
Monetary Penalties, New Mexico department of health, 7 NMAC 1.8 (10/31/96) [now
7.1.8 NMAC].
C. Adjudicatory Hearings, New Mexico
department of health, 7 NMAC 1.2 (2-1-96) [now 7.1.2 NMAC].
[11/16/83,
5/8/90, 10/31/96; Recompiled 10/31/01]
HISTORY
OF 7.12.2 NMAC:
Pre-NMAC
History: The material in this Part was
derived from that previously filed with the State Records Center:
HED-83-9
(HSD), Regulations Governing Free Standing Hospice Licensing, 11/16/83.
HED
90-3 (PHD), Regulations Governing Inhome And Inpatient Hospice Care, 5/8/90.
History
of Repealed Material: [RESERVED]