TITLE
8 SOCIAL SERVICES
CHAPTER
370 OVERSIGHT OF LICENSED HEALTHCARE
FACILITIES AND COMMUNITY BASED WAIVER PROGRAMS
PART
19 REQUIREMENTS FOR INHOME
AND INPATIENT HOSPICE CARE
8.370.19.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.370.19.1
NMAC - N, 7/1/2024]
8.370.19.2 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 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.
[8.370.19.2
NMAC - N, 7/1/2024]
8.370.19.3 STATUTORY AUTHORITY: The regulations set forth herein are
promulgated pursuant to the general authority granted under Subsection E of
Section 9-8-6 NMSA 1978, as amended; and the authority granted under Subsection
D of Section 24-1-2, Subsection I of Section 24-1-3, and Section 24-1-5 of the
Public Health Act, NMSA 1978, as amended. Section 9-8-1 et seq. NMSA 1978
establishes the health care authority (authority) as a single, unified
department to administer laws and exercise functions relating to health care
purchasing and regulation.
[8.370.19.3
NMAC - N, 7/1/2024]
8.370.19.4 DURATION: Permanent.
[8.370.19.4
NMAC - N, 7/1/2024]
8.370.19.5 EFFECTIVE DATE: July 1, 2024, unless a different date is
cited at the end of a section.
[8.370.19.5
NMAC - N, 7/1/2024]
8.370.19.6 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.
[8.370.19.6
NMAC - N, 7/1/2024]
8.370.19.7 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 health care
authority 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) 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 health care authority 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 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. "Inpatient care"
means hospice services delivered to a patient who has been admitted to a
hospice facility on a continuous 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 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 health care authority.
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 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.
[8.370.19.7
NMAC - N, 7/1/2024]
8.370.19.8 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.
[8.370.19.8
NMAC - N, 7/1/2024]
8.370.19.9 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 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.
[8.370.19.9
NMAC - N, 7/1/2024]
8.370.19.10 INITIAL LICENSURE PROCEDURES: No license shall be issued without the
following:
A. Receipt of the
application with all attachments listed in Section 9 of these regulations.
B. Survey conducted
by the licensing authority.
[8.370.19.10
NMAC - N, 7/1/2024]
8.370.19.11 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.
[8.370.19.11
NMAC - N, 7/1/2024]
8.370.19.12 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.
[8.370.19.12
NMAC - N, 7/1/2024]
8.370.19.13 LICENSES:
A. Annual license: An annual license is issued for a one 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 120 days, during which the facility must correct
all specified deficiencies.
(2) In accordance with Subsection D of Section
24-1-5 NMSA 1978, no more than two 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 10
working days of the change.
[8.370.19.13
NMAC - N, 7/1/2024]
8.370.19.14 LICENSE RENEWAL:
A. Licensee must
submit a renewal application on forms provided by the licensing authority,
along with the required fee at least 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. Subsection A of Section 24-1-5 NMSA 1978, as
amended, provides that no health facility shall be operated without a license.
[8.370.19.14
NMAC - N, 7/1/2024]
8.370.19.15 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 found
in Subsections A through D of 8.370.19.15 NMAC above must submit an application
for initial licensure in accordance with 8.370.19.10 NMAC of these regulations,
at least 30 days prior to the anticipated change.
[8.370.19.15
NMAC - N, 7/1/2024]
8.370.19.16 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 or licensee;
C. on the day a
facility changes location.
[8.370.19.16
NMAC - N, 7/1/2024]
8.370.19.17 SUSPENSION OF LICENSE WITHOUT PRIOR
HEARING: In accordance with Subsection
H of Section 24-1-5 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 working daysof the
suspension, unless waived by the licensee.
[8.370.19.17
NMAC - N, 7/1/2024]
8.370.19.18 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.
[8.370.19.18
NMAC - N, 7/1/2024]
8.370.19.19 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 above
will be held in accordance with adjudicatory hearings, New Mexico health care
authority, 8.370.2 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.
[8.370.19.19
NMAC - N, 7/1/2024]
8.370.19.20 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.
[8.370.19.20
NMAC - N, 7/1/2024]
8.370.19.21 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 8.370.19.29 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.
[8.370.19.21
NMAC - N, 7/1/2024]
8.370.19.22 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 of these regulations:
A. Nursing care provided by or under the supervision of a
registered nurse. Nursing care must be
available on call 24 hours a day, seven 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 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.
[8.370.19.22
NMAC - N, 7/1/2024]
8.370.19.23 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.
[8.370.19.23
NMAC - N, 7/1/2024]
8.370.19.24 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.
[8.370.19.24
NMAC - N, 7/1/2024]
8.370.19.25 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.
[8.370.19.25
NMAC - N, 7/1/2024]
8.370.19.26 STAFF TRAINING: A hospice must provide an ongoing program of
employee psychological support, and continuing education of its staff in
hospice care. At least 12 clock hours of
training per year in hospice care shall be provided.
[8.370.19.26
NMAC - N, 7/1/2024]
8.370.19.27 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.
[8.370.19.27
NMAC - N, 7/1/2024]
8.370.19.28 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.
[8.370.19.28
NMAC - N, 7/1/2024]
8.370.19.29 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
days of admission to the program. The
signed orders, and the plan, shall be incorporated within the hospice medical
record within 14 days of admission.
B. The plan must be
reviewed and updated, at least every two 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.
[8.370.19.29
NMAC - N, 7/1/2024]
8.370.19.30 PATIENT RIGHTS: All hospice facilities and agencies licensed
pursuant to these regulations shall support, protect and enhance the rights of
patients.
[8.370.19.30
NMAC - N, 7/1/2024]
8.370.19.31 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.
[8.370.19.31
NMAC - N, 7/1/2024]
8.370.19.32 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.
[8.370.19.32
NMAC - N, 7/1/2024]
8.370.19.33 SERVICES/INDIVIDUAL CARE:
A. Nursing
services: The hospice facility shall
provide 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.
[8.370.19.33
NMAC - N, 7/1/2024]
8.370.19.34 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.
[8.370.19.34
NMAC - N, 7/1/2024]
8.370.19.35 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.
[8.370.19.35
NMAC - N, 7/1/2024]
8.370.19.36 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 meals or their
equivalent each day at regular times with no more than 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.
[8.370.19.36
NMAC - N, 7/1/2024]
8.370.19.37 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 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.
[8.370.19.37
NMAC - N, 7/1/2024]
8.370.19.38 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 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.
[8.370.19.38
NMAC - N, 7/1/2024]
8.370.19.39 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 or fewer
patients will be required to meet residential occupancy building requirements.
[8.370.19.39
NMAC - N, 7/1/2024]
8.370.19.40 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 of the usable floor area
providing for patient visibility of the out-of-doors.
(a) Windows shall be at least 24 feet
from other buildings or the opposite wall of a court or at least 10 feet from a
property line, except on the street side.
(b) Outside window walls shall be at
least eight 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 feet, six
inches below grade shall be used for the housing of patients. Private patient rooms have at least 100
square feet of usable floor space.
Multi-patient rooms shall provide not less than 80 square feet of usable
floor area per bed. There shall not be
less than seven and one-half 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 their 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 feet between beds.
B. The hospice
facility shall endeavor to provide decor which is homelike in design and
function.
[8.370.19.40
NMAC - N, 7/1/2024]
8.370.19.41 TOILET AND BATHING AREAS:
A. There shall be, minimally,
one bathing facility for each six 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 toilet for every four patients, or major fraction
thereof.
C. Lavatories shall
be provided in a ratio of at least one lavatory for each toilet located in
toilet rooms(s). Lavatories shall be
provided in a ratio of at least one per four patients. Lavatories shall be located at the entry of
patient rooms used for isolation.
D. At least one
toilet and lavatory shall be provided on each floor for use by those who are
not patients.
[8.370.19.41
NMAC - N, 7/1/2024]
8.370.19.42 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 64
per square inch or equivalent density;
(3) rows shall be a minimum of eight 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.
[8.370.19.42
NMAC - N, 7/1/2024]
8.370.19.43 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 15 square feet per patient bed and not less than 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 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.)
[8.370.19.43
NMAC - N, 7/1/2024]
8.370.19.44 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 160 degrees fahrenheit in the washing machine.
[8.370.19.44
NMAC - N, 7/1/2024]
8.370.19.45 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.
[8.370.19.45
NMAC - N, 7/1/2024]
8.370.19.46 HOUSEKEEPING:
A. Adequate and clean
housekeeping equipment shall be maintained.
B. At least one
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.
[8.370.19.46
NMAC - N, 7/1/2024]
8.370.19.47 COMMUNICATIONS:
A. There shall be a
telephone readily available for patients to make and receive confidential
calls.
B. There shall be at
least one "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.
[8.370.19.47
NMAC - N, 7/1/2024]
8.370.19.48 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 110
degrees fahrenheit.
C. There shall be
devices to prevent backflow into the water supply system.
[8.370.19.48
NMAC - N, 7/1/2024]
8.370.19.49 HEATING: The heating system in all patient areas shall
be operated and maintained to provide a comfortable temperature of between 70 degrees
and 75 degrees fahrenheit.
[8.370.19.49
NMAC - N, 7/1/2024]
8.370.19.50 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.
[8.370.19.50
NMAC - N, 7/1/2024]
8.370.19.51 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).
[8.370.19.51
NMAC - N, 7/1/2024]
8.370.19.52 HANDICAP ACCESS: The hospice facility shall be accessible and
equipped to accommodate physically handicapped individuals.
[8.370.19.52
NMAC - N, 7/1/2024]
8.370.19.53 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.
[8.370.19.53
NMAC - N, 7/1/2024]
8.370.19.54 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 health care authority, 8.370.3 NMAC.
B. Health Facility
Sanctions and Civil Monetary Penalties, New Mexico health care authority, 8.370.4
NMAC.
C. Adjudicatory hearings,
New Mexico health care authority, 8.370.2 NMAC.
[8.370.19.54
NMAC - N, 7/1/2024]
HISTORY
OF 8.370.19 NMAC: RESERVED