Utah Administrative Code
Topic - Health
Title R432 - Health Care Facility Licensing
Rule R432-750 - Hospice Rule
Section R432-750-4 - Governing Body and Administration
Universal Citation: UT Admin Code R 432-750-4
Current through Bulletin 2024-06, March 15, 2024
(1) The licensee shall ensure that the hospice agency is organized under a governing body that assumes full legal responsibility for the conduct and operations of the agency.
(2) The licensee shall develop an organization chart that shows the administrative structure of the agency.
(3) The governing body is responsible to:
(a) comply with any federal
regulations, state rules, and local laws;
(b) adopt written policies and procedures
that describe functions or services of the hospice and protect patient
rights;
(c) adopt a statement that
there will be no discrimination because of race, color, sex, religion,
ancestry, disability status, sexual orientation, gender, or national
origin;
(d) develop and implement
bylaws that shall include at least:
(i) a
statement of purpose;
(ii) a
statement of qualifications for membership and methods to select members of the
governing board;
(iii) an outline
of the establishment, selection, and term of office for committee members and
officers;
(iv) a description of
functions and duties of the governing body officers and committees;
(v) a statement of the authority and
responsibility delegated to the hospice administrator; and
(vi) a policy statement relating to conflict
of interest of members of the governing body or employees who influence agency
decisions;
(e) meet at
least annually as stated in the bylaws;
(f) appoint by name and in writing, a
qualified hospice administrator who is responsible for the agency's overall
functions;
(g) notify the
department in writing 30 days before any proposed change in the hospice
administrator, identifying the name of the new hospice administrator, and the
effective date of the change;
(h)
review the written annual evaluation report from the hospice administrator and
document recommendations as necessary;
(i) provide resources and equipment to
provide a safe working environment for personnel; and
(j) establish a system of financial
management and accountability.
(4) The hospice administrator is responsible for the overall management of the agency and shall:
(a) designate in writing the name and title
of a qualified person who shall act as hospice administrator in the temporary
absence of the hospice administrator.
This designee shall have sufficient power, authority, and freedom to act in the best interests of patient safety and well-being.
(b) complete, submit, file, and
make available any records, reports, and documentation required by the
department;
(c) review agency
policies and procedures at least annually and recommend necessary changes to
the governing body;
(d) implement
agency policies and procedures;
(e)
organize and coordinate functions of the agency by delegating duties and
establishing a formal means of staff accountability;
(f) appoint the following, by name and in
writing:
(i) a physician or registered nurse
to provide general supervision, coordination, and direction for professional
services of the agency;
(ii) a
registered nurse to be the director of nursing services;
(iii) a person responsible for maintaining a
clinical record system on any patients;
(iii) the members and their terms of
membership in the interdisciplinary quality assurance committee;
(iv) other committees as deemed necessary,
describe committee functions and duties, and outline the selection, term of
office, and responsibilities of committee members; and
(g) maintain current written designations or
letters of appointment for the agency;
(h) employ or contract with competent
personnel whose qualifications are commensurate with job responsibilities and
authority, and who have the appropriate license or certificate of
completion;
(i) secure contracts
for services not directly provided by the hospice;
(j) develop a staff communication system
that:
(i) coordinates interdisciplinary team
services;
(ii) coordinates
implementation of plans of treatment;
(iii) utilizes services or resources to meet
patient needs; and
(iv) promotes an
orderly flow of information within the organization;
(k) implement a program of budgeting and
accounting;
(l) establish, when
appropriate, a billing system that itemizes services provided and charges
submitted to the payment source; and
(m) conduct an annual evaluation of the
agency's overall function and submit a written report of the findings to the
governing body.
(5) The hospice administrator or designee shall be available during the agency's hours of operation.
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