Hospice Inpatient Unit Operations
Applies only if the Agency operates its own hospice inpatient unit. Sets out staffing and 24-hour nursing, the nurse call system, the physical environment and fire safety, patient areas and rooms, infection control, meals, restraint and seclusion with their time limits and death reporting, pharmacy services and controlled drugs, and the unit’s disaster plan and exercises.
About this policy
- Policy number
- TX-HSP-FAC-03
- Version
- 1.0
- Main rule
- 42 CFR §418.110
- Library
- Texas hospice · 59 policies
- Category
- Hospice care
- Sections
- 19
In short
- This applies only if we run our own inpatient unit.
- Every shift with a general inpatient patient must have an RN giving direct care.
- Restraint or seclusion only on a physician order, never as a standing or as-needed order, and only for immediate safety.
- A death linked to restraint or seclusion is reported to HHSC by phone within 24 hours.
- Controlled drugs stay locked. Report any count that does not match at once.
What's inside
19 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; 26 TAC §§558.870-558.871)
- 5. Staffing and Nursing
- 6. Physical Environment and Fire Safety
- 7. Patient Areas, Rooms and Services
- 8. Restraint and Seclusion
- 9. Deaths Associated with Restraint or Seclusion
- 10. Pharmacy and Controlled Drugs
- 11. Disaster Preparedness for the Unit
- 12. Responsibilities
- 13. Records and Compliance Monitoring
- 14. Staff Training
- 15. References
- 16. Related Policies and Forms
- 17. Approval
- 18. Revision History
An inspector may ask
- Show me the staffing for each shift this week. Was there an RN giving direct care on every shift with a general inpatient patient?
- Show me your restraint orders and one-hour face-to-face evaluations for the last restraint use.
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