New Jersey Administrative Code
Title 8 - HEALTH
Chapter 42C - HOSPICE LICENSING STANDARDS
Subchapter 3 - GENERAL REQUIREMENTS
Section 8:42C-3.4 - Personnel

Universal Citation: NJ Admin Code 8:42C-3.4

Current through Register Vol. 56, No. 6, March 18, 2024

(a) The hospice shall ensure that the duties and responsibilities of all personnel are described in job descriptions and in the policy and procedure manual for each service.

(b) All personnel of whom licensure, certification, or authorization to provide patient care is required shall be licensed, certified, or authorized under the appropriate laws or rules of the State of New Jersey.

(c) All personnel, both directly employed and under contract to provide direct care to patients, shall at all times wear or produce upon request employee identification.

(d) The hospice shall have policies and procedures for the maintenance of confidential personnel records for each employee, including at least his or her name, previous employment, educational background, license number with effective date and date of expiration (if applicable), certification (if applicable), verification of credentials and references, the criminal background check required pursuant to 42 CFR 418.114(d), health evaluation records, job description, and evaluations of job performance.

(e) All new personnel, both directly employed and under contract to provide direct patient care, as well as volunteers, shall receive an initial health evaluation which includes at least a documented history.

(f) Health records shall be maintained for each employee and volunteer. Employee, as well as volunteer, health records shall be confidential, and kept separate from personnel records.

(g) Employee, as well as volunteer, health records shall include documentation of all medical screening tests performed and the results.

(h) All personnel, both directly employed and under contract to provide direct care to patients, as well as volunteers, shall receive a Mantoux tuberculin skin test with five tuberculin units of purified protein derivative or have blood drawn for an interferon gamma release assay (IGRA).

1. The only exceptions are personnel with documented negative Mantoux skin test results (zero to nine millimeters of induration) within the last year, personnel with documented positive Mantoux skin test results (10 or more millimeters of induration), personnel who received appropriate medical treatment for tuberculosis or when medically contraindicated.

2. Results of the IGRA or Mantoux tuberculin skin tests shall be acted upon as follows:
i. Employees with an IGRA result of "positive" have latent TB infection, a "negative" result indicates no latent TB infection and employees with an "indeterminate" result shall repeat the IGRA.

ii. If the initial Mantoux tuberculin skin test result is between zero and nine millimeters of induration, the test shall be repeated one to three weeks later.

iii. If the IGRA result is "positive" or the Mantoux test result is 10 millimeters or more of induration, a chest x-ray shall be performed and, if necessary, followed by chemoprophylaxis or therapy.

3. The IGRA or Mantoux tuberculin skin test shall be administered to all agency personnel, both directly employed and under contract, and thereafter to all new personnel at the time of employment, as well as volunteers.
i. The IGRA or Mantoux tuberculin skin test shall be repeated on an annual basis for all persons who provide direct patient care and every two years for all other employees.

4. The facility shall maintain records of the results of employee Mantoux and IGRA tuberculin testing.

(i) All personnel, both directly employed and under contract to provide direct care to patients, as well as volunteers, shall be given a rubella screening test using the rubella hemagglutination inhibition test or other rubella screening test. The only exceptions are personnel who can document seropositivity from a previous rubella screening test or who can document inoculation with rubella vaccine, or when medically contraindicated.

1. The hospice shall inform each person in writing of the results of his or her rubella screening test.

2. The hospice shall maintain a list identifying the name of each person who is seronegative and unvaccinated to rubella.

3. The hospice shall offer rubella vaccination to all employees, contract personnel and volunteers.

(j) All personnel, both directly employed and under contract to provide direct care to patients, as well as volunteers, who were born in 1957 or later shall be given a (measles) rubeola screening test using the hemagglutination inhibition test or other rubeola screening test. The only exceptions are personnel who can document receipt of live measles vaccine on or after their first birthday, physician-diagnosed measles, or serologic evidence of immunity.

1. The hospice shall ensure that all personnel, both directly employed and under contract to provide direct care to patients, as well as volunteers, who cannot provide serologic evidence of immunity are offered rubella and rubeola vaccination.

(k) A hospice shall have available and comply with the guidelines listed below, incorporated herein by reference, as amended and supplemented:

1. CDC, "Immunization of Health-Care Personnel, Recommendations of the Advisory Committee on Immunization Practices (ACIP)" MMWR, Volume 60, No. RR07 (November 25, 2011), available at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htm and at https://www.cdc.gov/mmwr/pdf/rr/rr6007.pdf;

2. CDC, Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019. MMWR 2019;68:439-443, available on the CDC website at: https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm?s_cid=mm6819a3_w;

3. Bolyard, E.A., "Guideline for Infection Control in Health Care Personnel," June 1998, updated 2019, available on the CDC website at https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/index.html; and

4. Kuhar, D.T., et al., "Updated U.S. Public Health Service Guidelines for the Management of Occupation Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis," available on the CDC website at https://stacks.cdc.gov/view/cdc/20711.

Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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