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Title: Section 794.5 Short-term Inpatient Service

Effective Date


Section 794.5 Short-term Inpatient Service.  

(a) Part 702 of this Title, section 717.3 of this Title and Part 14 of the Sanitary Code shall apply to hospice inpatient settings as applicable. 

(b) The hospice may provide short-term inpatient services for respite and for pain control and management of symptoms related to the terminal illness in a free-standing hospice facility, a skilled nursing facility or a general hospital. 

(c) The provision of inpatient services shall be consistent with applicable Federal requirements and with the definition of hospice as defined in section 700.2 of this Title, and shall include, but not be limited to: 

(1) 24-hour nursing services that meet the needs of all patients and are furnished in accordance with the patient’s plan of care, including the services of a registered professional nurse if a hospice patient has been admitted to inpatient services for other than respite care. Each patient must receive all nursing services as prescribed and must be comfortable, clean, well groomed, and protected from accident, injury and infection;  

(2) accommodations to enable families to store and prepare food brought in by the family; 

(3) accommodations to enable families to remain with the patient throughout the night; 

(4) flexible visitation policies which include 24-hour a day visiting privileges regardless of age of visitor; 

(5) provision of adequate and wholesome food and supplemental nourishments under the direction of a dietician; 

(6) flexibility in meal times and in selection of food based on individual needs of patients; 

(7) accommodations for recreational and religious activities; 

(8) adequate space for private small group interactions; 

(9) retention and use of personal possessions as space and safety permits; 

(10) a telephone accessible to the patient; and 

(11) oxygen available to each patient, as necessary. 

(d) In addition to meeting the provisions of section 794.2 of this Part and any applicable State and Federal requirements, contractual arrangements with a facility for inpatient services must include a written agreement describing the arrangements and the agreement shall specify that:  

(1) a member of the hospice interdisciplinary care group shall conduct onsite reviews of the inpatient services provided to ensure conformance with the established plan of care, at least weekly; 

(2) the hospice supplies the inpatient provider with a copy of the patient’s plan of care and specifies the inpatient services to be furnished; 

(3) the inpatient provider has established patient care policies consistent with those of the hospice and agrees to abide by the palliative care protocols and plan of care established by the hospice for its patients; 

(4) the hospice patient’s inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility;  

(5) upon discharge from the inpatient service, a copy of the discharge summary and if requested a copy of the inpatient medical record will be forwarded to the hospice and retained as part of the hospice clinical record; 

(6) the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement; 

(7) the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient’s care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented; and 

(8) a method for verifying that the requirements in paragraphs (d)(1) through (d)(6) of this section are met. 

(e) The hospice that provides inpatient care directly in its own facility must demonstrate compliance with all of the following standards: 

(1) ensuring that staffing for all services reflects its volume of patients, their acuity, and the level of intensity of services needed to ensure that plan of care outcomes are achieved and negative outcomes are avoided; 

(2) providing 24-hour nursing services that meet the nursing needs of all patients and are furnished in accordance with each patient’s plan of care;  

(3) providing pharmacy services under the direction of a licensed pharmacist responsible for evaluating the patient’s response to drug therapy, identification of potential drug reactions and recommend corrective action; 

(4) having a written policy for dispensing drugs accurately and maintaining records of receipt and disposition of controlled drugs; 

(5) maintaining a safe physical environment free of hazards for patients, staff, and visitors which includes: 

(i) addressing real or potential threats to health and safety of patients, others and property; 

(ii) having a written disaster plan in effect for managing power failures, natural disasters and other emergencies affecting the ability to provide care. The plan must be periodically reviewed and rehearsed with staff; 

(iii) developing and implementing procedures for routine storage and prompt disposal of trash and medical waste; light, temperature and ventilation/air exchanges; emergency gas and water supply; and scheduled and emergency maintenance and repair of all equipment;  

(6) ensuring that patient areas are designed to preserve the dignity, comfort, and privacy of patients; and 

(7) developing and implementing policies that meet federal standards for use of seclusion and restraints. 


VOLUME E (Title 10)