Hospice Inpatient Unit Operations
Applies only if the Agency provides inpatient care directly in its own facility. Sets out the federal standards for staffing, 24-hour nursing (with an RN providing direct care on each shift when a patient is receiving general inpatient care), the physical environment, fire and building safety, patient areas and rooms, infection control, meals, pharmacy services, controlled drugs, restraint and seclusion, and reporting deaths associated with restraint or seclusion to CMS by the close of business the next business day.
About this policy
- Policy number
- DC-HSP-FAC-03
- Version
- 1.0
- Main rule
- 42 CFR §418.110
- Library
- Washington, DC hospice · 60 policies
- Category
- Hospice care
- Sections
- 20
In short
- This applies only if the Agency runs its own inpatient unit.
- When any patient is receiving general inpatient care, an RN gives direct care on every shift.
- Controlled drugs are kept locked, counted and recorded. Report any discrepancy at once.
- Restraint or seclusion is used only for immediate safety, on a physician’s order, never as a standing or as-needed order.
- A death linked to restraint or seclusion is reported to CMS by the next business day.
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. Staffing and Nursing
- 6. Physical Environment, Fire Protection and Building Safety
- 7. Patient Areas, Rooms and Facilities
- 8. Infection Control, Sanitation, Linen and Meals
- 9. Pharmacy Services and Controlled Drugs
- 10. Restraint and Seclusion
- 11. Death Reporting
- 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 staffing schedule for the last two weeks. Was there an RN giving direct care on every shift when a patient was receiving general inpatient care?
- Who is your pharmacist, and how are controlled drugs stored, counted and disposed of?
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