Sec.19a-495-5b. Short-term hospitals, special, hospice

(a) Physical plant:

(1) General

(A) A free-standing hospice facility or a distinct hospice unit shall provide all the elements described in this section and shall be built in accordance with the construction requirements described in this section. Appropriate modifications or deletions in space and other physical requirements may be made to these requirements when services are permitted by the Department of Public Health to be shared or purchased, or waived because of a distinct unit's size. Distinct units of hospice facilities, including outpatient, in-patient and hospice-based care programs, shall meet the requirements described in this section, provided that the structure physically permits, the relevant services are provided at the facility and each facility's hospice program requirements are met. Services provided by a short-term hospital, general shall not be considered to constitute a hospice program of care unless such hospital establishes a free-standing or distinct hospice unit to provide such services in which case the requirements of this section shall apply only to such free-standing or distinct hospice units.

(B) Construction plans and specifications, as well as program details, shall be submitted to and approved by the Department of Public Health prior to the start of construction.

(C) The facilities and distinct hospice units shall be of sound construction.

(D) Each application for license or renewal thereof shall be accompanied by a certificate of satisfactory inspection by the local fire marshal.

(E) Areas in which medical gases are used, shall meet the requirements of the National Fire Protection Association Standards 56A, 56B, 56F and such other rules, regulations, or standards which may apply.

(F) Equipment and furnishings shall be maintained in good condition, properly functioning and repaired or replaced when necessary.

(G) A short-term hospital, special, hospice shall secure licenses and any other required government authorization to provide hospice care services for terminally ill persons on a twenty-four hour basis in all settings including, but not limited to, a private home, nursing home and residential care home or specialized residence that provides supportive services and shall present to the department satisfactory evidence that the organization that provides the hospice services has the necessary qualified personnel to provide services in such settings.

(2) Site.

(A) The site of new hospice facilities shall be away from uses detrimental to hospice patients such as industrial development and facilities that produce noise, air pollution, obnoxious odors, or toxic fumes.

(B) Adequate roads and walks shall be provided within the property lines to the appropriate entrances to serve patients, visitors, staff and for receiving goods and produce. The walks and roads shall be maintained in a clear and safe condition.

(3) Access for persons who have a physical disability. Facilities should be accessible to and usable by persons who have a physical disability.

(4) Design. The design of a hospice facility shall provide comfort, warmth and safety, privacy and dignity for the patients. Every possible accommodation shall be made to avoid creating an institutional atmosphere. The facility shall provide as homelike an atmosphere as practicable.

(5) Waivers. Each service provided by a hospice facility shall conform to the appropriate requirements set forth in this section and each service shall be provided unless a written waiver is obtained from the Department of Public Health for good cause. A request for a waiver shall be in written form and accompanied by a narrative description of the hospice program. The waiver request shall identify the facility's needs and the rationale for such request.

(6) Nursing unit.

(A) A nursing unit shall consist of not more than thirty beds.

(B) Each patient room shall meet the following requirements:

(i) No patient room entrance shall be located more than one hundred twenty feet from the nurses' station, clean workroom and soiled workroom;

(ii) Maximum room capacity shall be four patients;

(iii) To provide ample room for patients, families and visitors; the minimum room area exclusive of toilet rooms, closets, lockers, wardrobes, alcoves, or vestibules shall be one hundred twenty square feet in single-bedrooms and one hundred square feet per bed in multibedrooms. In multibedrooms, a clearance of three feet, ten inches shall be available at the foot of each bed and six feet between the beds to permit the passage of beds;

(iv) Each room shall have a window which can be opened without the use of tools. The windowsill shall not be higher than three feet above the finished floor. If insulated glass windows are not used, storm windows shall be installed. All windows used for ventilation shall be provided with screens;

(v) Each room shall be located on an outside wall of the facility or hospice unit;

(vi) A nurse calling button shall be provided within easy access of each bed;

(vii) Room furnishings for each patient shall include an adjustable hospital bed with gatch spring, side rails, an enclosed bedside stand, an overbed table, an overbed light and a comfortable chair;

(viii) All floors shall be above the outside grade at the outside wall;

(ix) Each patient shall have a lockable wardrobe, locker or closet that is suitable for hanging full length garments and for storing personal effects;

(x) Each patient shall have access to a toilet room without entering the general corridor area. One toilet room shall serve no more than four beds and no more than two patient rooms. The toilet room shall contain a water closet, a lavatory, grab bar and an emergency call station; and

(xi) Cubicle curtains shall be installed for each bed in a multibedroom.

(7) Service area requirements for each nursing unit shall provide:

(A) Storage space for office supplies;

(B) Hand washing facilities conveniently located to each nurses' station and drug distribution station;

(C) Charting facilities for nurses and doctors at each nurses' station;

(D) Individual closets or compartments for the safekeeping of personal effects of nursing personnel at each nurse's station;

(E) A multipurpose room for conference and consultation with a minimum floor space of one hundred square feet;

(F) A clean workroom that contains a work counter, hand washing sink, locked storage facilities, covered waste receptacles and ready access to an autoclave;

(G) A soiled workroom for receiving and cleanup of equipment which contains a clinical sink or equivalent flushing rim fixture, sink equipped for hand washing, work counter, covered waste receptacle, covered linen receptacles and locked storage facilities;

(H) A drug distribution station with a locked room for the storage of drugs and biological products. The drug storage room shall be located so as to be under the visual control of the nursing or pharmacy staff. The drug storage and preparation area shall be of adequate size for proper storage, handling, preparation, and record keeping of all drugs and shall contain a work counter, refrigerator, hand sink with hot water, and necessary equipment such as a locked cabinet containers or drug carts;

(I) Clean linen storage in a separate closet or room sized to meet the needs of the unit. If a closed cart system is used, storage may be in an alcove;

(J) A nourishment station in a room which contains a stove, sink, equipment for serving nourishment between scheduled meals, refrigerator, storage cabinets, counter space and an icemaker-dispenser unit to provide ice for patients' service and treatment. This area is for patient, family and staff use and provisions shall be made for small appliance use and storage;

(K) An equipment storage room for I.V. stands, inhalators, air mattresses, walkers, and other patient equipment;

(L) An area out of the path of normal traffic that is adequate to accommodate two wheelchairs and one stretcher for the purpose of parking stretchers and wheelchairs;

(M) At least one bathtub or shower for each fifteen beds and one bathtub per nursing unit shall be of the free standing type with a clearance of three feet on three sides. Each tub or shower shall be located in an individual room or enclosure which provides space for a wheelchair and an attendant as well as dressing;

(N) A janitor's closet with a minimum size of twenty square feet which contains a floor receptor or service sink and locked storage space for housekeeping equipment and supplies;

(O) An isolation room for isolation medical treatment and control within the facility or through equivalent services in connection with a hospital. An isolation room located in a facility may be utilized as a regular patient room when not required for isolation purposes. Each such isolation room shall be a single patient room except as follows:

(i) Entrance shall be through a vestibule that contains a lavatory or sink equipped for hand washing, storage spaces for clean and soiled materials, and gowning facilities;

(ii) Provision shall be made for nursing observation of the patient from the vestibule;

(iii) A private toilet room containing a water closet and a bathtub or shower shall be provided for the exclusive use of the patient with direct entry from the patient bed area without passing through the vestibule;

(iv) A lavatory shall be provided for the exclusive use of the patient either in the patient room or in the private toilet room.

(P) A room for the examination of patients with a minimum floor area of one hundred ten square feet with a minimum dimension of nine feet excluding space for the vestibule, toilet, closets, and work counters, whether fixed or movable. The room shall contain a sink equipped for hand washing, work counter, storage facilities and a desk, counter or shelf space for writing;

(Q) A sitting room with not less than two hundred twenty-five square feet for every thirty beds;

(R) A patient dining area with fifteen square feet per patient to accommodate the total patient capacity of the facility which may be combined with the recreation area;

(S) A single recreation area of fifteen square feet per patient, an office for the director of arts and provisions for storage;

(T) An office for clergy and a chapel or space for religious purposes that shall be appropriately equipped and furnished;

(U) A separate room for the viewing of a deceased patient's body during bereavement until released to the responsible agent;

(V) A separate locked room or rooms for use as a pharmacy. This area shall be of adequate size to allow for efficient performance of all functions necessary for the provision of proper pharmaceutical services in the facility. The pharmacy shall be constructed so that it is not necessary to enter the pharmacy area to get to areas not directly related to the provision of pharmaceutical services. Proper lighting, a hand sink with hot water, refrigeration, humidity and separate temperature control in the pharmacy area shall be installed. Adequate space to accommodate specialized functions such as I.V. additive preparation, unit dose dispensing, drug information, manufacturing, as well as adequate storage space for bulk supplies, and office space for administrative functions shall be provided. Drug storage equipment such as a completely enclosed masonry room with a vault-type steel door, alarm system, safe, or locked cabinets as may be required to secure controlled substances and other drugs and biological products in compliance with applicable federal and state drug regulations, shall be located in the pharmacy area;

(W) A physical therapy area that includes a sink, cubicle curtains around treatment areas, storage space for supplies and equipment, a separate toilet room and office space;

(X) A dietary service area of adequate size that includes a breakdown and receiving area, storage space for four days food supply including cold storage, food preparation facilities with a lavatory, meal service facilities, dishwashing space in a room or alcove separate from food preparation and serving areas with commercial-type dishwashing equipment and space for receiving, scraping, sorting, and stacking soiled tableware, potwashing facilities, storage areas for supplies and equipment, waste storage facilities in a separate room easily accessible to the outside for direct pickup or disposal, office space(s) for dietitian and the food service manager, an icemaker-dispenser unit and a janitor's closet which contains a floor receptor or service sink and locked storage space for housekeeping equipment and supplies;

(Y) An entrance at grade level, sheltered from the weather, and able to accommodate wheelchairs;

(Z) A lobby with a reception and information counter or desk, waiting space, public toilet facilities, public telephones and a drinking fountain;

(AA) Offices for general business and storage, medical and financial records, and administrative and professional staffs with individual offices for administration, director of nursing, social services, and the medical director and separate spaces for private interviews relating to credit and admissions;

(BB) A medical records librarian's office or space, record review and dictating space, work area for sorting and recording, and a locked storage area for records;

(CC) A laundry area may be located either on the site of the facility or off the site of the facility for processing of linen;

(i) On-site processing requires the following:

(I) A laundry processing room with commercial-type equipment;

(II) A soiled linen receiving, holding and sorting room with hand washing facilities;

(III) Storage for laundry supplies;

(IV) Deep sink for soaking clothes;

(V) Clean linen storage, holding room and ironing area; and

(VI) Janitor's closet containing a floor receptor or service sink and locked storage space for housekeeping equipment and supplies.

(ii) Off-site processing requires the following:

(I) A soiled linen holding room with hand washing facilities; and

(II) A clean linen receiving, holding, inspection and storage room.

(iii) Each facility shall have a domestic type washer and dryer, located in a separate room, for patients' personal use.

(DD) A separate room or building for furnaces, boilers, electrical and mechanical equipment and building maintenance supplies;

(EE) A separate toilet room for employees of each sex with one water closet and one lavatory for each twenty employees of each sex;

(FF) Separate locker rooms for each sex containing individual lockers of adequate size for employee clothing and personal effects. The lockers shall be in an area divided from the water closets and lavatories; and

(GG) Separate employee dining space in the ratio of fifteen square feet per employee dining at one time that shall not be included in the space requirement for any other area.

(8) Construction requirements.

(A) Fixtures such as drinking fountains, telephone booths, vending machines, and portable equipment shall be located so as not to restrict corridor traffic or reduce the corridor width.

(B) Room's containing bathtubs, showers, and water closets, for use by patients, shall be equipped with doors and hardware that provide access from the outside in any emergency.

(C) The minimum width of all doors to rooms needing access for beds or stretchers shall be three feet, eight inches. Doors to patients' toilet rooms and other rooms needing access for wheelchairs shall have a minimum width of two feet, ten inches.

(D) Doors on all openings between corridors and rooms or spaces subject to occupancy, except elevator doors, shall be of the swing type. Openings to showers, baths, patient toilets and other small wet-type areas not subject to fire hazard are exempt from this requirement.

(E) Doors, except those to spaces such as small closets that are not subject to occupancy, shall not swing into corridors in a manner that might obstruct traffic flow or reduce the corridor width.

(F) Windows and outer doors shall be provided with insect screens. Windows shall either be designed to prevent accidental falls when they are open, or shall be provided with security screens.

(G) Dumbwaiters, conveyors, and material handling systems shall not open directly into a corridor or exitway but shall open into a room enclosed by construction having a fire-resistance of not less than two hours and provided with class B one and one-half hour labeled fire doors. Service entrance doors to vertical shafts containing dumbwaiters, conveyors, and material handling systems shall be not less than class B one and one-half hour labeled fire doors. Where horizontal conveyors and material handling systems penetrate fire-rated walls or smoke partitions, such openings shall be provided with class D one and one-half hour labeled fire doors for two hour walls.

(H) Thresholds and expansion joint covers shall be made flush with the floor surface to facilitate use of wheelchairs and carts.

(I) Grab bars shall be provided at all patient toilets, showers, and tubs. The bars shall have one and one-half inch clearance to walls and shall have sufficient strength and anchorage to sustain a load of two-hundred fifty pounds.

(J) Recessed soap dishes or an adequate soap dispensing system shall be provided at showers and bath tubs.

(K) Mirrors shall not be installed at hand washing fixtures in food preparation areas or in clean and sterile supply areas.

(L) Paper towel and soap dispensers and covered waste receptacles shall be provided at all hand washing facilities used by patients, medical, nursing or food handling staff.

(M) Lavatories and hand washing facilities shall be securely anchored to withstand an applied vertical load of not less than two hundred and fifty pounds on the front of the fixture.

(N) Handrails shall be provided on both sides of the corridor in patient occupied areas at a height of thirty-two inches above the floor;

(O) Ceiling heights shall be as follows:

(i) Rooms shall be at least eight feet in height except that storage rooms, toilet rooms, and other minor rooms shall be at least seven feet, eight inches in height. Suspended tracks, rails, and pipes located in the path of normal traffic shall be at least six feet, eight inches above the floor;

(ii) Corridors shall be at least eight feet in height.

(P) Enclosures for stairways, elevator shafts and vestibules, chutes and other vertical shafts, boiler rooms, and storage rooms of one hundred square feet or greater area shall be of a construction having a fire-resistance rating of not less than two hours.

(Q) Interior finish materials shall comply with the flame spread limitations and the smoke production limitations of the State Fire Safety Code. If a separate underlayment is used with any floor finish materials, the underlayment and finish materials shall be tested as a unit or equivalent provisions made to determine the effect of the underlayment on the flammability characteristics of the floor finish material.

(R) Facility or hospice unit insulation materials, unless sealed on all sides and edges, shall have a flame spread rating of twenty-five or less and a smoke developed rating of one hundred and fifty or less when tested in accordance with ASTM Standard E 84.

(S) Toxicity of materials. Materials that do not generate toxic products of combustion shall be given preference in selecting insulation and furnishings.

(T) Elevators:

(i) All floors within the facility, other than the main entrance floor shall be accessible by elevator:

(I) At least one hospital-type elevator shall be installed where one to sixty patient beds are located on any floor other than the main entrance floor;

(II) At least two hospital-type elevators shall be installed where sixty-one to two hundred patient beds are located on any floor other than the main entrance floor, or where the major inpatient services are located on a floor other than those containing patient beds.

(ii) The cars of hospital-type elevators shall have inside dimensions that shall accommodate a patient bed and attendants.

(9) Mechanical system requirements.

(A) General. Prior to the opening of the facility, all mechanical systems shall be tested, balanced and operated to ensure that the installation and performance of these systems conform to the requirements of the plans and specifications and are safe for patients and staff.

(B) Steam and hot water systems.

(i) Boilers shall have the capacity, based upon the net ratings published by the Institute of Boiler and Radiator Manufacturers, to supply the normal requirements of all systems and equipment. The number and arrangement of boilers shall be such that when one boiler breaks down or routine maintenance requires that one boiler be temporarily taken out of service, the capacity of the system shall be sufficient to provide hot water service for clinical, dietary, and patient use.

(ii) Boiler feed pumps, heating circulating pumps, condensate return pumps, and fuel oil pumps shall be connected and installed to provide normal and standby service.

(C) Air conditioning, heating and ventilating systems.

(i) All occupied areas shall be maintained at an inside temperature of seventy-five degrees Fahrenheit (twenty-four degrees Celsius) by heating and eighty degrees Fahrenheit (twenty-seven degrees Celsius) by cooling.

(ii) All air-supply and air-exhaust systems shall be mechanically operated. Fans serving exhaust systems shall be located at the discharge end of the system. The ventilation rates shown in table I are the minimum acceptable rates and shall not be construed as precluding the use of higher ventilation rates.

(iii) Outdoor intakes shall be located as far as practical from exhaust outlets of ventilating systems, combustion equipment stack, medical-surgical vacuum systems, plumbing vents stacks, or areas that may collect vehicular exhaust and other noxious fumes. The bottom of outdoor air intakes serving central systems shall be located as high as practical.

(iv) Corridor plenums shall not be used to supply air to or exhaust air from any room.

TABLE I General Pressure Relationships and Ventilation Of Certain Hospice Areas

Area Designation	Pressure Relationship to Adjacent Areas	Minimum Air Changes of Outdoor Air per Hour Supplied to Room	Minimum Total Air Changes Per Hour Supplied to Room	All Air Exhausted Directly to Outdoors	Recirculated Within Room units
Patient Room	E	2	2	Optional	Optional
Patient Room Corridor	E	2	4	Optional	Optional
Isolation Room	E	2	6	Yes	Yes
Isolation Room Alcove or Anteroom	E	2	10	Yes	No
Examination Room	E	2	6	Optional	Optional
Medication Room	P	2	4	Optional	Optional
Pharmacy	P	2	4	Optional	Optional
Treatment Room	E	2	6	Optional	Optional
X-Ray, Treatment Room	E	2	6	Optional	Optional
Physical Therapy	N	2	6	Optional	Optional
Soiled Workroom	N	2	10	Yes	No
Clean Workroom	P	2	4	Optional	Optional
Workroom	N	2	10	Yes	No
Viewing Room	N	Optional	10	Yes	No
Toilet Room	N	Optional	10	Yes	No
Bedpan Room	N	Optional	10	Yes	No
Bathroom	N	Optional	10	Yes	No
Janitor's closet	N	Optional	10	Yes	No
Sterilizer Equipment Room	N	Optional	10	Yes	No
Linen and Trash	N	Optional	10	Yes	No
P=Positive
N=Negative
E=Equal

(D) Plumbing and other piping systems.

(i) Plumbing fixtures.

(I) The water supply spout for lavatories and sinks in patient care areas shall be mounted so that its discharge point is a minimum distance of five inches above the rim of the fixture. All fixtures used by medical and nursing staff and all lavatories used by food handlers shall be trimmed with valves that can be operated without the use of hands.

(II) Shower bases and tubs shall provide nonslip surfaces for standing patients.

(ii) Water supply systems.

(I) Systems shall be designed to supply water at sufficient pressure to operate all fixtures and equipment during maximum demand periods.

(II) Each water service main, branch main, riser, and branch to a group fixture shall be valved. Stop valves shall be provided at each fixture.

(III) Backflow preventers shall be installed on hose bibbs, laboratory sinks, janitors' sinks, bedpan flushing attachments, equipment that can be directly piped, and on all other fixtures to which hoses or tubing can be attached.

(IV) Water distribution systems shall be arranged to provide hot water at each hot water outlet at all times. Hot water at shower, bathing and hand washing facilities personal use shall not exceed one hundred twenty degrees Fahrenheit (forty-nine degrees Celsius.)

(iii) Hot water heaters and tanks.

(I) The hot water heating equipment shall have sufficient capacity to supply water at the temperatures and amounts indicated below. Water temperatures to be taken at hot water point of use or inlet to processing equipment.

Use	Clinical	Dietary	Laundry
Gallons (per hour Per Bed)	6 ½	4	4 ½
Temperature °(F)	110-120°	Wash 160°	180°
°(C)	43-49°	71°	82°
°(F)		Rinse 180°
°(C)		82°

(E) Medical gas and vacuum systems.

(i) Nonflammable medical gas systems. Nonflammable medical gas system installations shall be in accordance with the requirements of National Fire Protection Association Standards 56 F and such other rules, regulations or standards that may apply.

(ii) Clinical vacuum (suction) systems. Clinical vacuum system installations shall be in accordance with the requirements of National Fire Protection Association Standards 56 F and such other rules, regulations or standards that may apply. The vacuum system may either be a central system or a portable system.

(iii) One outlet of oxygen and one of vacuum of each bed shall be provided in each patient room.

(10) Electrical system requirements.

(A) General. All material including equipment, conductors, controls, and signaling devices shall be installed to provide a complete electrical system and shall comply with most recent available standards of Underwriters Laboratories, Inc., or other nationally recognized standards that may apply.

(B) Switchboards and power panels. Circuit breakers or fusible switches that provide disconnecting means and overcurrent protection for conductors connected to switchboard's and panelboards shall be enclosed or guarded to provide a dead-front type of assembly. The main switchboard shall be located in a separate enclosure accessible only to authorized persons. The switchboards shall be convenient for use, readily accessible for maintenance, clear of traffic lanes, and in a dry ventilated space free of corrosive fumes or gases. Overload protective devices shall be suitable for operating properly in the ambient temperature conditions.

(C) Panelboards. Panelboards serving lighting and appliance circuits shall be located on the same floor as the circuits the panelboards serve. This requirement does not apply to emergency system circuits.

(D) Lighting.

(i) All spaces occupied by people, machinery, and equipment within buildings, approaches to buildings, and parking lots shall have lighting.

(ii) Patients' rooms shall have general lighting and night lighting. A reading light shall be provided for each patient. General room illuminaries shall be switched at the entrance to the patient room. All switches for control of lighting in patient areas shall be of the quiet operating type. Night light circuits for each nursing unit shall be controlled at the nurses' stations.

(E) Receptacles or outlets.

(i) Patients' rooms. Each patient room shall have duplex grounding type receptacles as follows: Three duplex for each bed; two on one side and one on opposite side of the head of each bed; one for television and one on another wall.

(ii) Corridors. Duplex receptacles for general use shall be installed approximately fifty feet apart in all corridors and within twenty-five feet of ends of corridors.

(F) Nurses' calling system. In general patient areas, each room shall be served by at least one calling station and each bed shall be provided with a call button. Two call buttons serving adjacent beds may be served by one calling station. Calls shall register with floor staff and shall actuate a visible signal in the corridor at the patient's door, in the clean workroom, the soiled workroom, and the nourishment station of the nursing unit. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. In rooms containing two or more calling stations, indicating lights shall be provided at each station. Nurses' calling systems shall be audio visual and provide two-way voice communication and shall be equipped with an indicating light at each calling station, which lights and remains lighted as long as the voice circuit is operating. A nurses' call emergency button shall be provided at each patient's toilet, bath, shower room, dining room and sitting room.

(G) Emergency electric service.

(i) To provide electricity during an interruption of the normal electric supply, an emergency source of electricity shall be provided and connected to certain circuits for lighting and power. The source of this emergency electric service shall be an emergency generating set including the prime mover and generator which is located on the premises and shall be reserved exclusively for supplying the emergency electrical system.

(ii) The emergency generating set shall provide electricity:

(I) To illuminate means of egress and exit signs and directional signs;

(II) To operate all essential alarm systems including fire alarms activated at manual stations, water flow alarm devices of sprinkler system if electrically operated, fire and smoke detecting systems, and alarms required for non-flammable medical gas systems;

(III) To operate paging or speaker systems intended for communication during emergency;

(IV) For the general illumination and selected receptacles in the vicinity of the generator set;

(V) For specific task illumination and selected receptacles in medicine dispensing areas; treatment rooms; and nurses' stations;

(VI) To one duplex receptacle at each patient bed;

(VII) To the nurses' calling system;

(VIII) To operate equipment necessary for maintaining telephone service;

(IX) To the fire pump, if any; and

(X) To circuits that serve necessary equipment as follows:

(a) Equipment for heating patient occupied rooms, except that service for heating of general patient rooms shall not be required if the facility is served by two or more electrical services supplied from separate generators or a utility distribution network having multiple power input sources and arranged to provide mechanical and electrical separation so that a fault between the facility and the generating sources shall not likely cause an interruption of the facility service feeders;

(b) Elevator service shall reach every patient floor. Transfer devices shall be provided to allow temporary operation of any elevator for the release of persons who may be trapped between floors.

(c) Central suction systems serving medical functions;

(d) Laboratory fume hoods.

(H) The connection to the emergency electric services shall be of the delayed automatic type except for heating, ventilation, and elevators which may be either delayed automatic or manual.

(i) The emergency electrical system shall ensure that after interruption of the normal electric power supply the generator is brought to full voltage and frequency and connected within ten seconds through one or more primary automatic transfer switches to emergency lighting systems, alarm systems, blood banks, nurses' calling systems, equipment necessary for maintaining telephone service, and task illumination and receptacles in operating, delivery, emergency, recovery, and cardiac catherization rooms, intensive care nursing areas, nurseries, and other critical patient areas. All other lighting and equipment required to be connected to the emergency system shall either be connected through the primary automatic transfer switches, as described in this subparagraph, or through other automatic or manual transfer switches. Receptacles connected to the emergency system shall be distinctively marked. Storage-battery-powered lights, provided to augment the emergency lighting or for continuity of lighting during the interim of transfer switching immediately following an interruption of the normal service supply, shall not be used as a substitute for the requirement of a generator. Where stored fuel is required for emergency generator operation, the storage capacity shall be sufficient for not less than forty-eight hour continuous operation. When the generator is operated by fuel which is normally piped underground to the site from a utility distribution system, fuel storage facilities on the site shall not be required.

(11) Maintenance of systems and equipment. All electrical, gas, life safety, life support and critical systems shall be tested to ensure satisfactory performance prior to placing them into service and tested annually thereafter. Permanent records of all tests shall be maintained.

(b) Administration.

(1) The hospice shall be managed by a governing board with full legal authority and responsibility for the conduct of the hospice and the quality of medical care provided at the facility. Duties of the governing board shall include, but not be limited to:

(A) Adoption of the following in writing and upon adoption enforcing compliance with:

(i) admission criteria defining eligibility for hospice services;

(ii) guidelines for community relations;

(iii) a patient bill of rights;

(iv) medical by-laws after considering the recommendations, if any, of the medical staff;

(v) rules and by-laws which include the following:

(I) the purpose of the hospice;

(II) annual review of the rules and by-laws, which shall be dated and signed by the chairperson of the board;

(III) the powers and duties of the officers and committees of the governing body;

(IV) the qualifications, method of selection and terms of office of members and chairpersons of committees;

(V) a mechanism for approval of the appointments to the medical staff;

(VI) qualifications for appointment to the medical staff based upon background, competence, and adherence to the ethics of the profession;

(VII) a schedule of at least ten regular meetings per calendar year; and

(VIII) a specific policy governing conflict of interest of members.

(B) Establishment of a joint practice committee composed of representatives of medical staff, nursing staff, pharmacy staff, social work staff, arts and pastoral care staff, volunteer staff and the administrator or the administrator's designee.

(C) Appointment of the administrator who shall have one of the following:

(i) completed postgraduate training approved by the Association of University Programs in hospital administration;

(ii) attained three years experience as an assistant administrator;

(iii) served three years as a hospice administrator under a state approved hospice program; or

(iv) qualified by other experience approved by the Department of Public Health upon written application to the commissioner.

(2) The administrator shall be responsible to the governing board for the management and operation of the hospice and for the employment of personnel. The administrator shall attend meetings of the governing board and of the medical staff, employ personnel of good character and suitable temperament in sufficient numbers to provide satisfactory care for the patients.

(3) Outside services or resources as required by the facility or ordered by the physician shall be utilized only pursuant to written agreements. The responsibilities, function and terms of each agreement, including financial arrangements and charges, shall be specified therein and signed and dated by the chairperson of the board, or administrator of the hospice and the person or duly authorized official of the agency providing the service or resource.

(4) Any person may request hospice in-patient, out-patient and hospice-based home care services with the concurrence of a member of the medical staff of the facility.

(c) Medical staff.

(1) There shall be a medical staff of not fewer than five physicians, one of whom shall serve as a chief, president, or medical director of the medical staff and all of whom shall be licensed to practice medicine and surgery in Connecticut. The medical staff shall be composed of active medical staff, associate medical staff, courtesy medical staff, consulting medical staff and honorary medical staff.

(2) The medical staff shall adopt written by-laws and rules governing its own activities not inconsistent with any rule, regulation, or policy of the governing board, which by-laws and rules shall not become effective until approved by the governing board and shall be subject to rescission by the governing board, which shall include:

(A) requirements for admission to staff and for the delineation and retention of clinical privileges;

(B) method of control of clinical work, including written consultations for all clinical services that shall be properly entered in the patient's chart;

(C) analysis, review and evaluation of clinical practices within hospice in-patient, out-patient and hospice-based home care programs, to promote and maintain high quality care;

(D) a framework to ensure twenty-four hour, seven-day-a-week on-call availability, including physician home visits, and eight-hour-a-day on-site medical staff coverage;

(E) provision for monthly staff conferences unless clinical groups hold departmental or service conferences at least monthly, then general staff conferences shall be held at least four times each year, and each active staff member shall attend not less than ten departmental or general staff meetings or a combination thereof each year;

(F) establishment of committees including infection control, safety, quality assurance, pharmacy and therapeutics, medical record audit, patient care, and others as necessary; and

(G) procedures for recommending appointments to the medical staff, hearing complaints regarding the conduct of members and referring the same, with recommendations, to the governing board.

(3) Any patient's primary care community physician who is not a member of the hospice medical staff may request hospice services for the patient with the concurrence of a hospice medical staff member.

(4) Medical staff and departmental meetings shall be attended by at least fifty percent of the active staff members to be counted toward the mandatory meeting quotas. Minutes and a record of attendance shall be kept.

(5) There shall be a department of medicine under the direction of a physician licensed to practice medicine and surgery in Connecticut, who shall be responsible for supervising the quality of medical service.

(6) The chief, president, or medical director of the medical staff shall supervise the bereavement team which shall consist of himself, a consulting psychiatrist and one representative from each of the following services: volunteer, pastoral care, arts, social work and nursing.

(7) The medical staff shall provide and participate in a continuing program of professional education which shall include hospice-based home care programs scheduled on a regular basis with appropriate documentation of these activities.

(d) Medical records.

(1) There shall be a medical record department with adequate space, equipment and qualified personnel including a medical record librarian or a person with training, experience and consultation from a medical record librarian.

(2) A medical record shall be maintained for every individual who is evaluated or treated as a hospice in-patient, out-patient or who received patient services in a hospice-based home care program.

(3) An in-patient record shall be started at the time of admission with identification, date, and a nurse's notation of condition on admission. To the in-patient record shall be added immediately an admission note and orders by the attending member of the active medical staff. A complete history and physical examination shall be recorded by a staff physician within twenty-four hours of admission, unless the patient is being followed by a primary physician who performed the patient's last history and physical examination within forty-eight hours and the referral to the hospice program is made within the same institution. A problem oriented medical record shall be completed by the primary care nurse within twenty-four hours of admission.

(4) All medical records shall be prepared accurately and physicians' entries completed promptly with sufficient information and progress notes to justify the diagnosis and warrant the treatment and palliation. Doctors' orders, nurses' notes and notes from other disciplines, shall be kept current in a professional manner and all entries shall be signed with a legally acceptable signature by the person responsible for making the order or note.

(5) The medical records shall be kept confidential and secured. Written consent of the patient or the patient's legally appointed representative shall be required for release of medical information except as provided in subsection (t) of this section.

(6) The medical records shall be filed and stored in a manner providing easy retrievability and shall be kept for not less than twenty-five years after discharge of patients, except that original medical records may be destroyed sooner if they are microfilmed by a process approved by the Department of Public Health.

(7) Completion of the medical records shall be accomplished within one day after discharge to a hospice-based home care program or within seven days of death.

(8) Persistent failure by a physician to maintain proper records of the physician's patients, promptly prepared and completed, shall constitute grounds for suspending or withdrawing the physician's medical staff privileges.

(e) Nursing Service.

(1) The nursing service shall be directed by the director of hospice patient care services who shall be a licensed registered nurse with baccalaureate degree in nursing and an active Connecticut license, and who is further qualified by one of the following:

(A) a master's degree from a program approved by the National League of Nursing or the American Public Health Association with not less than two years' full-time clinical experience under qualified supervision, in a hospice or home health care agency related community health program that included care of the sick; and

(B) not less than four years of full-time clinical experience in nursing, at least two of which were under qualified supervision in a hospice or home health care agency or community health program that included care of the sick.

(2) A registered nurse with a baccalaureate degree in nursing and an active Connecticut license and one of the following shall serve as a supervisor of hospice in-patient, out-patient and hospice-based home care program under the direction of the director of hospice patient care services:

(A) a master's degree from a program approved by the National League for Nursing or the American Public Health Association with not less than two full-time clinical experience under qualified supervision, one of which shall be in a health care institution and one of which shall be in a hospice or home health care agency or a related community health program; and

(B) not less than four years' full-time clinical experience in nursing under qualified supervision, one of which shall be in a health care institution and one of which shall be in a hospice or home health care agency or related community health program.

(3) The ratio of patients to registered nurses in the hospice shall not be less than one nurse to six patients per eight hour shift.

(4) The ratio of all nursing staff and nurses aides to patients shall not be less than one nurse or nurse aide to three patients.

(5) An organizational plan of the nursing service shall be established that shall delineate its mechanism for cooperative planning and decision making.

(6) Written nursing care and administrative policies and procedures shall be developed to provide the nursing staff with practical methods of meeting its responsibilities and achieving projected goals. Policies shall include, but not be limited to, the following:

(A) assigning the nursing care of patients to a primary care provider who develops a written pertinent care plan;

(B) standardized procedures for evaluation and study;

(C) a program of systematic professional and administrative review and evaluation of the services' effectiveness in relation to stated objectives;

(D) patient and family teaching programs;

(E) the development and implementation of staffing patterns that shall ensure efficient performance of departmental activities; and

(F) participation in the joint practice committee for the improvement of patient care including equal representation of practicing nurses and physicians, and continuous redefining of the scope of medical and nursing practice in the light of experience and patient care needs.

(7) There shall be staff development programs and educational opportunities for nursing personnel that include orientation and in-service education.

(f) Pharmaceutical service.

(1) The facility shall maintain an organized pharmaceutical service that is conducted in accordance with current standards of practice and all applicable laws and regulations.

(2) The pharmaceutical service shall be directed by a licensed pharmacist trained in the specialized functions of institutional pharmacy who shall serve the institution:

(A) on a full-time basis in a free-standing facility; and

(B) in a distinct unit identified as hospice on a part-time basis consonant with the size and scope of services of the institution.

(3) The scope of pharmaceutical services shall be consistent with the drug therapy needs of the patients as determined by the medical staff.

(4) There shall be an active medical staff committee, composed of a physician, the director of pharmacy, the director of patient care services, and a representative from administration that shall serve in an advisory capacity to the professional staff on matters relating to drugs and drug practices. Specific functions of this committee, which shall meet at least quarterly, shall include:

(A) development of board professional policies regarding the evaluation, selection, procurement, distribution, use, safe-practices and other matters pertinent to drugs and biological products in the facilities;

(B) development of basic formulary system of drugs for use in the facilities;

(C) monitoring and reporting adverse drug reactions in the facility, and introducing proper measures to minimize their incidence;

(D) reviewing and analyzing errors in the administration of drugs and biological products in the facility and taking appropriate action to minimize the recurrence of such incidents; and

(E) determining drug-use patterns and assisting in the setting of drug-use criteria relative to the facility's drug utilization review program.

(5) There shall be a current, written policy and procedures manual approved by the medical staff, pertaining to the drug and biological control system in the facility.

(g) Social work service.

(1) There shall be a written plan with clearly defined written policies governing the delivery of social work services in the hospice in-patient, out-patient and hospice-based home care program which shall include a procedure for reporting problem areas to the administrator, recommended solutions, and identifying actions taken. These policies shall incorporate the current standards, guidelines, and code of ethics determined by the National Association of Social Workers. The person having responsibility for the direction and supervision of the delivery of such services shall be a social worker with a master's degree from a school accredited by the Council of Social Work Education, who has not less than four years social work experience in a health care setting including one year in a supervisory capacity.

(2) The social work staff may include baccalaureate social workers with at least one year of social work experience in a health care setting.

(3) There shall be a social work department with an adequate staff to meet the medically related social and emotional needs of the patient and family.

(4) Social work services shall be provided in accordance with the plan for treatment. The social worker shall assist and work with the interdisciplinary team in identifying significant social and emotional factors related to care. The scope of social work services shall include: assisting in pre-admission and discharge planning; conducting medico-social assessment; counseling the patient and family on an individual and group basis; identifying, utilizing, and working to develop appropriate community resources; and maintaining adequate records relating to social work services that shall be included in the patient's medical record.

(5) There shall be continuing staff development programs and educational opportunities for social work personnel that include orientation and in-service education.

(h) Pastoral care service.

(1) The hospice shall have adequate pastoral care services in the in-patient, outpatient and hospice-bed home care program, twenty-four hour on-call availability, and a well defined written plan and policies for pastoral care services available at the request of the patient.

(2) The plan for pastoral care services shall ensure the supervision of the delivery of such services by an ordained and a qualified individual with a graduate theological degree and at least five years pastoral and clinical experience. The method for providing pastoral care to a patient or family shall be planned and developed in consultation with representatives of administration, medical staff, nursing staff, other departments and services that are involved in direct patient care, and representatives of the community. The director of pastoral care services shall be considered a member of the health care team, and may participate in all staff meetings.

(3) There shall be continuing staff development programs and educational opportunities for the pastoral care staff including orientation and in-service education.

(i) The arts.

(1) The hospice shall provide extensive opportunities for experiences in the arts to the patients and families and for staff consultation as appropriate. The arts shall be available to hospice patients both on a scheduled and intermittent basis. Designated arts staff members who are providing such experiences shall be available on a scheduled on-call basis.

(2) These artistic experiences shall be directed and coordinated by a qualified representative of the arts with a graduate degree and clinical experience in a hospital based setting in the arts or pastoral care and not less than five years supervisory experience in the arts and education who, in consultation with hospice staff members and community artist representatives, shall define the need, choose an appropriate art form and select the artist or means to provide this experience.

(3) The director of the arts shall be considered a full-fledged member of the health care team, with participation in all staff meetings. Written policies for the arts shall be developed and reviewed at least annually. Adequate records relating to artistic services rendered shall be included in the patient's medical record.

(4) The arts staff shall complete a program of orientation to hospice and shall have appropriate in-service education programs on a quarterly basis.

(j) Volunteer service.

(1) A director of volunteers shall be employed full-time to plan, organize and direct a comprehensive volunteer services program for the in-patient, out-patient and hospice-based home care program. The director shall have a bachelor's degree in psychology, sociology, therapeutic recreation, or a related field and one year of employment in a supervisory capacity in a volunteer services program or an associate's degree and three years of supervisory experience in a volunteer services program.

(2) The director shall:

(A) Plan, direct and implement the recruitment of volunteers;

(B) orient and provide for a program of training which includes, direct involvement, on-call service and staff support;

(C) evaluate performances and effectiveness of each volunteer annually;

(D) periodically review and revise policies and procedures; and

(E) coordinate the utilization of volunteers with other directors as appropriate.

(3) There shall be continuing staff development programs and educational opportunities for the volunteer services staff to include at least the following: orientation and in-service education.

(k) Diagnostic and palliative services. Services, under competent medical supervision, shall be provided for necessary diagnostic and palliative procedures to meet the needs of the hospice in-patient, out-patient, and hospice-based home care program. This shall include the services of a clinical laboratory and radiological services which shall meet all applicable standards of the Department of Public Health. In addition there may be written agreements for other services including blood bank and pathological services as determined by patient needs. All contracts shall specify twenty-four hour on-call availability.

(l) Respiratory care services. There shall be a written plan with clearly defined written policies and procedures governing the delivery of respiratory care services that shall include a procedure for reporting problem areas to the administrator, recommendations, solutions, and identifying action taken. Services, under direct medical supervision, shall be provided as necessary to meet the needs of the hospice programs, which shall meet all applicable standards of the Department of Public Health. Any contract for such services shall specify twenty-four hour on-call availability for hospice in-patient, out-patient, and hospice-based home care programs.

(m) Specialized rehabilitative services. There shall be a written plan with clearly defined written policies and procedures governing the delivery of rehabilitative services that shall include a procedure for reporting problem areas to the administrator, recommendations, solutions, and identifying action taken. Any contracts for such services shall specify twenty-four hour on-call availability for hospice inpatient, out-patient, and hospice-based home care programs.

(n) Dietary service.

(1) There shall be an organized dietetic service, directed by a full-time food service supervisor. The food service supervisor shall be an experienced cook knowledgeable in food service administration and therapeutic diets. The service shall employ an adequate number of individuals to perform its duties and responsibilities.

(2) There shall be written policies and procedures governing all dietetic activities.

(3) The service shall have at least one qualified part-time certified dietitian-nutritionist, with a baccalaureate degree and major studies in food and nutrition who is qualified for membership in and registration by the Academy of Nutrition and Dietetics' Commission on Dietetic Registration. The administration of the nutritional aspects of patient care shall be under the direction of the dietitian whose duties shall include:

(A) recording nutritional histories of in-patients;

(B) interviewing patients regarding their food habits and preferences;

(C) counseling patient and family concerning normal or modified diets and encouraging patients to participate in planning their own modified diets and instructing patient and family in food preparation; and

(D) participating in appropriate hospice rounds and medical conferences;

(E) coordinating activities with the food service supervisor.

(4) Educational programs shall be offered to dietetic service employees including orientation, on-the-job training, personal hygiene, the inspection, handling, preparation, and serving of food, and the proper cleaning and safe operation of equipment.

(o) Hospice-based home care program.

(1) The health care services of the hospice-based home care program shall be in accordance with accepted standards of practice, applicable law and hospice policies and shall be provided by the interdisciplinary team as defined in section 19a-495-6a(a)(21) of the Regulations of Connecticut State Agencies. The program of care shall provide medical and health care services for the palliative and supportive care and treatment only for the terminally ill and their families. The hospice-based home care program encompasses the physical, social, psychological and spiritual needs of the patient and family and consists of services on a twenty-four hour basis, seven days per week. The services of hospice-based home care program shall include bereavement service, medical nursing, homemaker home health aide, pharmaceutical, dietary, pastoral care, arts, volunteers, diagnostic and palliative, social work, respiratory care, specialized rehabilitative, infection control and, as needed, inpatient and out-patient hospice services shall be available to hospice-based home care patients and their families.

(2) An organizational structure designed to effectively implement the requirements as described in subdivision (1) of this subsection. The medical director and the director of patient care services shall be vested with the overall coordination of the hospice-based home care program. The hospice-based home care program shall have a supervisor who shall meet the requirements of subparagraphs (e)(2)(A) or (B) of this section.

(3) The patient's primary care community physician, who is not a member of the hospice medical staff, shall be granted the privilege of requesting services provided by the hospice-based home care program in concurrence with a member of the hospice medical staff and on condition that the physician shall continue to be the primary care provider for the patient while the patient is at home under the auspices of the home care program.

(4) There shall be twenty-four hour, seven-day-a-week on-call availability of the hospice medical director or the hospice medical director's designee designee and the hospice home care nurse whether or not community service agency nurses are available. All physicians who provide medical services to patients in the hospice-based home care program, whether or not such physicians are members of the hospice medical staff, shall be evaluated as part of the regular hospice medical care evaluation program.

(5) There shall be a written policy and procedure manual implementing the objectives of the hospice-based home care program that shall include a description of the scope of services, criteria for admission and discharge, follow-up policies, and uniform standards to be adopted by the patient's primary care community physician.

(6) The hospice-based home care program shall have necessary personnel to meet the needs of patients, including: licensed registered nurses, licensed practical nurses, and homemaker-home health aides. Personnel assigned by community service agencies to provide services to the program's patients shall meet qualification standards equivalent to those required by hospice for employees in its home care program. When volunteer services are used, volunteers shall be trained and supervised by the hospice director of volunteers or other appropriate hospice directors, and those who provide professional services shall meet the requirements of qualification and performance applied to paid staff and functions. Hospice-based home care program personnel shall be involved in educational programs relating to their activities, including orientation, regularly-scheduled, in-service training programs, workshops, institutes, or continuing education courses to the same extent as other hospice personnel.

(7) There shall be a program of systematic, professional and administrative review and evaluation of the program's effectiveness in relation to its stated objectives.

(8) An accurate medical record shall be maintained for every patient receiving services provided through the home care program.

(9) Arrangements for the provision of basic or major services by a participating community agency or individual provider shall be documented by means of a written agreement or contract. All hospice services available to patients in the in-patient and out-patient program shall be readily available to the home care program patients.

(p) Infection control.

(1) Each hospice shall develop an infection prevention, surveillance and control program that shall have as its purpose the protection of patient, family and personnel from hospice or community associated infections in patients admitted to the hospice in-patient, out-patient, and home care program.

(2) The infection prevention, surveillance, and control program of each hospice shall be approved by the medical staff and adopted by the governing board. The program shall become part of the by-laws of the medical staff.

(3) A hospice infection control committee shall be established to supervise infection control and report on its activities with recommendations on a regular basis to the medical director. The membership of the committee shall include a physician who shall be the chairperson, a representative from nursing service, hospital administration, pharmacy, dietary service, laundry, housekeeping and the local health director.

(4) The infection control committee shall:

(A) adopt working definitions of hospice-associated infections;

(B) develop standards for surveillance of incidents of hospice-related infection and conditions predisposing patients to infection;

(C) monitor and report infections in all patients, including patients in the home care program, and environmental conditions with infection potential;

(D) evaluate the potential for environmental infection, including identification whenever possible of hospice-associated infections and periodic review of the clinical use of antibiotics in patient care; and

(E) develop preventive measures including aseptic techniques, isolation policy, and a personnel health program.

(5) There shall be an individual employed by the hospice who is qualified by education or experience in infection prevention, surveillance, and control to conduct these aspects of the program as directed by the infection control committee. The employee shall be directly responsible to, and be a member of, the infection control committee. The employee shall make a monthly written report to the committee at its monthly meeting.

(6) The infections control committee shall meet at least monthly and:

(A) review information obtained from day-to-day surveillance activities of the program;

(B) review and revise existing standards; and

(C) report to the medical director.

(7) There shall be regular in-service education programs regarding infection prevention, surveillance and control for hospice personnel. Documentation of these programs shall be available to the Department of Public Health for review.

(q) General.

(1) The hospice shall have an adequate laundry service, housekeeping and maintenance services.

(2) Proper heat, hot water, lighting and ventilation shall be maintained at all times.

(3) The hospice shall ensure the health, comfort and safety of the patients at all times.

(4) When a patient ceases to breathe and has no detectable pulse or blood pressure, the body shall be moved to the bereavement room in the same institution pending completion of the medical certification portion of the death certificate by a person authorized to complete such medical certification in accordance with section 7-62b of the Connecticut General Statutes. The facility shall make available a room that shall provide for the dignified holding of the body of the deceased person where the body of the deceased person shall not be exposed to the view of patients or visitors, but where the family and friends of the deceased may view the body.

(r) Out-patient services.

(1) The hospice out-patient service shall meet the same standards of quality as applied to in-patient care, considering the inherent differences between in-patients and out-patients with respect to their needs and modes of treatment.

(2) The out-patient service shall be provided with services and personnel necessary to meet the needs of patient and family.

(3) There shall be a policy and procedure manual developed for the effective implementation of the objectives of the out-patient service including criteria for eligibility for out-patient care.

(4) There shall be a program of systematic professional and administrative review and evaluation of the service's effectiveness.

(5) Facilities for the out-patient service shall be conducive to the effective care of the patient.

(6) An accurate medical record shall be maintained for every patient receiving care provided by the out-patient service.

(s) Emergencies: Provision shall be made to maintain essential services during emergency situations.

(t) Record availability: It is an explicit condition for the initial issuance of or the retention or renewal of a license to any person to operate and maintain a hospice that all records, memos and reports, medical or otherwise be maintained on the premises of the facility and that said records shall be subject to inspection review and copying by the Department of Public Health upon demand, including personnel and payroll records. Failure to grant access to the Department of Public Health shall result in the denial of, revocation of, or a determination not to renew the license.

(Effective July 31, 2012)