Hospice Inpatient Unit Operations
Applies only if the Agency operates its own hospice inpatient unit. Sets out the Department of Health approvals needed before building, adding beds or occupying space, and the federal inpatient standards: staffing and 24-hour nursing, physical environment, Life Safety Code and Health Care Facilities Code, patient areas and rooms, infection control, linen and meals, restraint and seclusion, death reporting, drugs, staff identification and emergency preparedness.
About this policy
- Policy number
- PA-HSP-FAC-03
- Version
- 1.0
- Main rule
- 42 CFR §418.110
- Library
- Pennsylvania hospice · 60 policies
- Category
- Hospice care
- Sections
- 20
In short
- This policy applies only if the Agency runs its own inpatient unit.
- A registered nurse gives direct care on every shift when any patient is receiving general inpatient care.
- Restraint or seclusion is a last resort, only on a physician order, never as a standing or as-needed order, and only by trained staff.
- A death linked to restraint or seclusion is reported to CMS by telephone by the close of the next business day.
- Know how to shelter in place and evacuate, and where the fire alarms, extinguishers and exits are.
What's inside
20 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (42 CFR §418.110)
- 5. Before Building, Adding Beds or Occupying Space
- 6. Staffing and Nursing
- 7. Fire Protection and Building Safety
- 8. Patient Areas, Rooms and Services
- 9. Restraint and Seclusion
- 10. Deaths Associated With Restraint or Seclusion
- 11. Drugs and Biologicals in the Unit
- 12. Emergency Preparedness for the Unit
- 13. Responsibilities
- 14. Records and Compliance Monitoring
- 15. Staff Training
- 16. References
- 17. Related Policies and Forms
- 18. Approval
- 19. Revision History
An inspector may ask
- Show me the Department of Health's approval to occupy this unit.
- Who is the registered nurse on duty on this shift, and which patients are receiving general inpatient care?
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