N.H. Admin. Code § He-P 823.16

Current through Register No. 45, November 7, 2024

Section He-P 823.16 - Patient Services

(a) The licensee shall only admit those patients whose needs can be met by the HHCP.

(b) At the time of admission, personnel of the HHCP shall:

(1) Provide, both orally and in writing, to the patient, or the patient's guardian, agent, or surrogate decision-maker, if applicable the HHCP's:

a. Policy on patient rights and responsibilities, including a copy of the home care clients' Bill of Rights, pursuant to RSA 151:21-b;

b. Complaint procedure;

c. List of care and services that are provided directly by the HHCP; and

d. List of the care and services that are provided by contract;

(2) Obtain written confirmation acknowledging receipt of the items in (1) above from the patient, their guardian, agent, or surrogate decision-maker if applicable;

(3) Collect and record the following information:

a. Patient's name, home address, home telephone number, and date of birth;

b. Name, address and telephone number of an emergency contact and guardian, agent, or surrogate decision-maker if applicable;

c. Name of patient's primary care provider and their address and telephone number;

d. Copies of all legal directives such as durable power of attorney, legal guardian, or living will; and

e. Written and signed consent for the provision of care and services; and

(4) Obtain documentation of informed consent and consent for release of information.

(c) The hospice care provider shall ensure that medical direction is provided either from the patients' attending licensed practitioner or the hospice medical director.

(d) Patients who are admitted or accepted for services shall:

(1) Be evaluated and assessed by professional staff within 48 hours of admission; and

(2) Have an order for any service for which such order is required by the practice acts of the person providing care.

(e) Patients who are accepted for services shall have a nursing assessment at the following intervals to determine the level of care and services required by the patient:

(1) Within 48 hours of admission; and

(2) Thereafter as required by the CMS conditions of participation or at least every 90 days at a minimum.

(f) The assessment required by (e) above shall contain, at a minimum, the following:

(1) Pertinent diagnoses including mental status;

(2) A pain assessment, including symptom control and vital signs;

(3) A physical assessment;

(4) A cognition and mental status assessment;

(5) A behavioral assessment;

(6) A psychosocial assessment;

(7) Medications and treatment needs;

(8) Functional limitations;

(9) Nutritional requirements;

(10) Estimated duration and frequency of care and services;

(11) Any equipment required; and

(12) Any safety precautions.

(g) In addition to the information in (e) and (f) above, the initial nursing assessment shall include:

(1) Reactions of the patient and family members to terminal illness;

(2) History of the patient's and family coping strengths and weaknesses;

(3) Social and financial concerns; and

(4) Spiritual beliefs and desires of the patient.

(h) The licensee shall establish an interdisciplinary hospice care team composed of at least:

(1) A licensed practitioner;

(2) A registered nurse;

(3) A social worker; and

(4) A spiritual and or bereavement counselor.

(i) The interdisciplinary hospice care team shall:

(1) Establish the care plan;

(2) Be the primary care delivery team for a patient and his or her family through the total duration of hospice care; and

(3) Be responsible for supervising any patient care and services provided by others.

(j) The interdisciplinary team shall, in conjunction with the patient and the patient's personal representative, and their family, develop an individualized care plan, which reflects the changing care needs of the patient and family.

(k) The care plan required by (j) above shall include:

(1) The date the problem or need was identified;

(2) A description of the problem or need;

(3) The goal for the patient;

(4) The action or approach to be taken by HHCP personnel;

(5) The responsible person(s) or position; and

(6) The interventions used to address problems identified in the assessment including:

a. Medications ordered;

b. Pain control interventions, both pharmacological and non-pharmacological;

c. Symptom management treatment; and

d. Services required including frequency of visits.

(l) The care plan required by (j) above shall be:

(1) Developed in conjunction with the patient and their guardian, agent, or surrogate decision maker;

(2) Completed no later than 5 days after completion of the assessment;

(3) Reviewed and revised every 15 days by the interdisciplinary team following the completion of each assessment; and

(4) Made available to all personnel that assist the patients.

(m) The patient, the patient's family and guardian, agent, or surrogate decision maker shall be notified in advance of all interdisciplinary team meetings and be given the opportunity to participate in such meetings.

(n) The patient and their family shall be encouraged to participate in all components of care, including:

(1) Assessment and problem identification;

(2) Implementation of the care plan; and

(3) Evaluation and revision of the care plan, as needed.

(o) The care plan shall contain documentation of the patient's or the patient's guardian, agent, or surrogate decision-makers' acceptance or rejection of the initial care plan and all subsequent revisions or updates.

(p) All staff of the HHCP shall carry out the goals stated in the care plan.

(q) The licensee shall develop a discharge plan with the input of the patient and the guardian, agent, or surrogate decision-maker if any.

(r) Copies of the following documents shall accompany the transferred patient:

(1) The emergency data sheet;

(2) A copy of the care plan; and

(3) A summary that includes:

a. The date and time the patient was transferred from the HHCP;

b. The place to which the patient was transferred or discharged; and

c. The condition of the patient at the time of transfer or discharge.

(s) Transfers may occur without prior notification to the guardian or agent pursuant to an activated POA or the licensed practitioner when the patient is in need of immediate emergency care.

(t) Progress notes shall be written by personnel, as appropriate, at the time of each visit and shall include at a minimum:

(1) Changes in the pateint's physical, functional, and mental abilities;

(2) Changes in the patient's behaviors such as eating or sleeping patterns;

(3) The patient's relief of pain, if applicable; and

(4) Newly identified needs of the patient and their family.

(u) Written notes shall be documented in the patient's record for:

(1) All care and services provided by personnel and include the following:

a. Date and time of the care or service;

b. Description of the care or service;

c. Progress notes as required by (t) above; and

d. Signature and title of the person providing care or services; and

(2) Any reportable incident or occurrence involving the patient when HHCP personnel are in the patient home, which shall include the information required by He-P 823.14(o) .

(v) For each patient accepted for care and services by the HHCP, a current and accurate record shall be maintained, including, at a minimum:

(1) The written confirmation required by He-P 823.16(b) (2);

(2) The identification data required by He-P 823.16(b) (3);

(3) Consent and medical release forms, as applicable;

(4) Pertinent medical information:

(5) All orders from a licensed practitioner, including the date and signature of the licensed practitioner required by He-P 823.16(c);

(6) Copy of order activating durable power of attorney, if applicable;

(7) Copy of DNR order, if applicable;

(8) All assessments required by He-P 823.16(d) and (e);

(9) All care plans required by He-P 823.16(j) -(l) including documentation that the patient or patient's guardian, agent, or surrogate decision-maker, if applicable, participated in the development of the care plan;

(10) All written notes required by He-P 823.16(u);

(11) All progress notes as required by He-P 823.16(t);

(12) All daily medication records required by He-P 823.17(d) (9) ;

(13) A discharge plan or transfer summary as required by He-P 823.16(q) and (r) (3);

(14) Discharge documentation, which shall include:

a. In the case of patient death:

1. Date and place of death; and

2. Bereavement follow-up plan; and

b. In the case of discharge other than patient death:

1. Date and time of patient discharge;

2. The physical, mental, and medical condition of patient at discharge;

3. Discharge instruction and referral;

4. Discharge summary; and

5. Signed licensed practitioner's order for discharge, if applicable; and

(15) Documentation of any patient refusal of any care or services.

(w) Patient records shall be available to:

(1) The patient, their guardian, agent, or surrogate decision-maker;

(2) HHCP personnel as required by their job responsibilities and subject to the licensee's policy on confidentiality;

(3) Any individual given written authorization by the patient or their guardian,agent and surrogate decision maker;

(4) Any individual authorized by a court of competent jurisdiction; and

(5) The department or any individual authorized by law.

(x) The licensee shall develop and implement a method for the written release of information in the patient record that is consistent with federal and state statute.

(y) The HHCP shall store the patient record in the primary or branch office except when they are being utilized by the supervisory and direct care staff.

(z) Records shall be safeguarded against loss, damage, or unauthorized use by being stored in locked containers, cabinets, rooms, or closets except when they are being used by direct care staff.

(aa) Records shall be retained for a minimum of 4 years after discharge and in the case of minors, until one year after reaching age 18, but no less than 4 years after discharge.

(ab) The HHCP shall arrange for storage of, and access to, patient records as required by (aa) above in the event that the HHCP ceases operation.

(ac) If the HHCP is providing any of the following services, they shall be licensed in accordance with the applicable rules:

(1) Home health care provider agency; or

(2) Case management provider agency.

N.H. Admin. Code § He-P 823.16

#9292, eff 10-9-08

Amended by Volume XXXVII Number 19, Filed May 11, 2017, Proposed by #12168, Effective 4/29/2017, Expires 10/26/2017.

Amended by Volume XXXVIII Number 45, Filed November 8, 2018, Proposed by #12642, Effective 10/9/2018, Expires 10/9/2028.