Status
Not open for further replies.

Dave K

Distinguished member
Joined
Jul 13, 2015
Messages
196
Reason
Other
Country
us
State
.
City
.
To California residents who are on hospice or will need hospice services in the future:

Below is the text of a letter I sent to the Director of the California Department of Public Health (CDPH) requesting clarification and enforcement of existing regulations that are being routinely ignored by hospice providers serving ALS patients in California. AARP has also sent a letter requesting the same action by the CDPH. Every California resident on this forum should:

(1) cut and paste my letter (beneath the asterisks below),
(2) print it on your own letterhead,
(3) mail it to the CDPH director, and
(4) email a copy to Cassie Dunham and Michael Egstad of the CDHP. Their email addresses are [email protected] and [email protected] (Cassie is in charge of home health, and Michael is in charge of hospice "facilities." As far as I can tell, no one is in charge of enforcing home hospice regulations, but one of these individuals will likely be assigned the task.)

In a nutshell, hospices in California seem unaware that California Health & Safety Code § 1749(c) actually requires them to comply with the Standards for Quality Hospice Care (http://www.calhospice.org/included/docs/regulatory/Standards_of_Quality_Hospice_Care.pdf). Sections. 3.1, 3.2, and 6.6(A)(1)(e) of those standards, together with existing CDPH rules, require that when tracheal suctioning and G-tube medicating are medically necessary for hospice care on a 24-hour basis, the care plan must provide that these interventions be performed by licensed or certified health workers. See, e.g., CDPH “Certification Facts,” p.31, http://bit.ly/1JSEtzw. This is an issue that directly affects many ALS patients in the final stages—hospices routinely fail to provide the licensed or certified personnel required for ALS patients’ medical care when their primary caregivers are forced to sleep or go to work. Instead, the hospices unlawfully advise the CALS to hire unlicensed, uncertified "personal attendants" to perform these necessary medical interventions. By improperly classifying these interventions as "custodial," health plans have been depriving late-stage PALS of the skilled medical help that they need. The below letter to the Director asks the CDPH to issue clarifying instructions to its Licensing and Certification Division offices and/or an All Facilities Letter reminding them to follow the rule of law and provide PALS on hospice with 24-hour skilled nursing when it is necessary. CALS and PALS should send a similar letter to the CDPH as soon as possible to provide maximum reinforcement of this effort to help ALS patients who are on hospice.

******************

July 10, 2015

Karen Smith, MD, MPH
Director, California Department of Public Health
PO Box 997377, MS 0500
Sacramento, CA 95899-7377

Dear Dr. Smith,

I write to you on behalf of all California Hospice patients who are seriously disabled and whose palliative care requires 24-hour tracheal suctioning and medication administered via gastric feeding tube. On behalf of these extremely vulnerable patients, I respectfully ask the Dept. of Public Health to clarify and enforce its existing rule that these tasks require the services of a licensed nurse or certified health personnel working under the supervision of an accountable licensed health care professional.

My wife has ALS and is on hospice. She has a tracheostomy that requires frequent suctioning to prevent her from suffocating on her own mucus, and a G-tube through which medicine must be given when she goes into spasm. She is completely paralyzed and cannot speak or move a finger to call for help. Because of this, a nursing home is not an option, as someone must be in the room with her at home around the clock to perform suctioning at a moment’s notice.

Unfortunately, her hospice provider will not provide skilled nursing services for necessary frequent tracheal suctioning and G-tube medicating when her primary caregiver (me) is forced to sleep. Instead, hospice providers typically give patients lists of agencies who provide “personal attendants” who are unlicensed and uncertified to perform tracheal suctioning and G-tube medicating. The problem with this is that the Department of Public Health has prohibited those agencies from helping patients in my wife’s condition. The Department has emphasized that suctioning and tube feeding of homebound patients are “nursing functions that must be performed by a licensed health care professional.” See CDPH “Certification Facts,” p.31 (Sept 2006), http://bit.ly/1JSEtzw. See also DHS letter re Licensed and Unlicensed Agencies and Allowable Services, answers 5 and 6. https://www.yumpu.com/en/document/view/32821461/department-of-health-services-cahsah. This is also consistent with AARC Clinical Practice Guidelines for tracheal suctioning, section 12.3. http://www.rcjournal.com/cpgs/pdf/06.10.0758.pdf (suctioning is to be performed by “Licensed or credentialed respiratory therapists or individuals with similar credentials (e.g., MD, RN)”).

The fact that a family member—exempt from the licensing requirement—has been trained to do the task is not a basis for assigning the task to an uncertified, non-exempt worker when the family member is unavailable. Even if an RN were permitted to delegate the task of tracheal suctioning to a Home Health Aide, the assistive personnel, while unlicensed, must nevertheless be certified by the State to perform tasks delegated by an RN. See California Standards for Quality Hospice Care, sec. 2.4(A)(3) (http://www.calhospice.org/included/docs/regulatory/Standards_of_Quality_Hospice_Care.pdf) (hospice home health aide must be State certified). It would be inconsistent to require State certification of personnel who bathe and dress a patient when the primary caregiver is unavailable, but not to require any license or certification for personnel who perform tracheal suctioning. A vulnerable, homebound patient is safeguarded by requiring the health worker’s State certification, which ensures basic medical training including sterile procedures, an ability to work competently under the direction and supervision of a registered nurse, a State criminal background check, up to date vaccinations from respiratory illnesses, and, in the case of hospice workers, special training in how to interact with dying patients and their families.

Importantly, if RNs delegate the function of tracheal suctioning or tube feeding, “the supervising RN has responsibility for the nursing care provided.” Board of Registered Nursing Regulations, “The RN as Supervisor,” http://www.rn.ca.gov/pdfs/regulations/npr-i-12.pdf. The patient is protected by this chain of accountability to a licensed health care provider.

Accordingly, the existing rule is that when an exempt family member is unavailable to perform the task, tracheal suctioning and G-tube medicating are always the responsibility of an accountable licensed health care professional. CDPH “Certification Facts,” supra, p.31, http://bit.ly/1JSEtzw.

The law requires a hospice care plan to specify the “frequency and mix of services necessary to meet the patient/family specific needs,” “and by what discipline, e.g., Registered Nurse, counselor, chaplain, etc.” Standards for Quality Hospice Care, supra, Secs. 3.1, 3.2, and 6.6(A)(1)(e). Therefore, to ensure that seriously disabled patients receive proper hospice care, the Dept. of Public Health should issue clarifying instructions to its Licensing and Certification Division offices and/or an All Facilities Letter, that when tracheal suctioning and G-tube medicating are medically necessary for hospice care on a 24-hour basis, the care plan must provide that these interventions be performed by licensed or certified health workers when the primary caregiver is unavailable.

Thank you for clarifying and enforcing the Department's rules regarding hospice care. We look forward to hearing back from you on this important issue.
 
Status
Not open for further replies.
Back
Top