Current through Bulletin 2024-06, March 15, 2024
(1) The hospice administrator shall maintain
qualified personnel who are competent to perform their respective duties,
services, and functions.
(2) The
licensee shall develop and implement written policies and procedures that
address the following:
(a) job descriptions,
qualifications, and validation of licensure or certificates of completion as
appropriate for each position;
(b)
orientation for direct and contract employees, and volunteers;
(c) criteria for, and frequency of,
performance evaluations;
(d) work
schedules;
(e) method and period of
staff payment;
(f) staff benefits
including sick leave, vacation, and insurance;
(g) frequency and documentation of in-service
training; and
(h) contents of
personnel files of employed and volunteer staff.
(3) The licensee shall require that each
employee provide proof of registration, certification, or licensure as required
by the Utah Department of Commerce within 45 days of hire.
(4) The licensee shall establish and
implement a policy and procedure for health screening of any agency personnel.
(a) The licensee shall ensure that an
employee placement health evaluation is completed when an employee is hired.
The evaluation shall include at least a health inventory that outlines the
employee's history of:
(i) conditions that
predispose the employee to acquiring or transmitting infectious diseases;
and
(ii) conditions that may
prevent the employee from performing certain assigned duties
satisfactorily.
(b)
Employee health screening and immunizations components of personnel health
programs shall be developed in accordance with Rule R386-702 Communicable
Disease.
(c) Employee skin testing
by the Mantoux Method or other FDA approved in-vitro serologic test and follow
up for tuberculosis shall be done in accordance with Rule R388-804, Special
Measures for the Control of Tuberculosis.
(d) The licensee shall ensure that any
employees are skin-tested for tuberculosis within two weeks of:
(i) initial hiring;
(ii) suspected exposure to a person with
active tuberculosis; or
(iii)
development of symptoms of tuberculosis.
(e) Skin testing shall be exempted for any
employees with known positive reaction to skin tests.
(f) The facility shall report any infections
and communicable diseases reportable by law to the local health department in
accordance with Section
R386-702-3.
(5) The licensee shall document that any
employees, volunteers, and contract personnel are oriented to the agency and
the job that they are hired. Orientation shall include:
(a) the hospice concept and philosophy of
care;
(b) the functions of agency
employees and the relationships between various positions or
services;
(c) job
descriptions;
(d) duties that
persons are trained, hold certificates, or are licensed;
(e) ethics, confidentiality, and patient
rights;
(f) information about other
community agencies including emergency medical services;
(g) opportunities for continuing education
appropriate to the patient population served;
(h) policies related to volunteer
documentation, charting, hours, and emergencies; and
(i) reporting requirements when observing or
suspecting abuse, neglect, and exploitation pursuant to Section
62A-3-305.
(6) The licensee shall provide and document
in-service training and continuing education for staff at least annually.
(a) Members of the hospice interdisciplinary
team shall have access to in-service training and continuing education
appropriate to their responsibilities and to the maintenance of skills
necessary for the care of the patient and family.
(b) The training programs shall include the
introduction and review of effective physical and psychosocial assessment and
symptom management.
(c) The
licensee shall train personnel in appropriate Centers for Disease Control (CDC)
infectious disease protocols.
(7) The hospice administrator shall appoint a
person to coordinate the activities of the interdisciplinary team. This
individual shall:
(a) annually review and
make recommendations where appropriate of agency policies covering admissions
and discharge, medical supervision, care plans, clinical records, and personnel
qualifications;
(b) assure that
ongoing assessments of the patient and family needs and implementation of the
interdisciplinary team care plans are accomplished;
(c) schedule adequate quality and quantity of
any levels of hospice care; and
(d)
assure that the team meets regularly to develop and maintain appropriate plans
of care and to determine that staff will be assigned to each case.
(8) The licensee shall provide
access to individual or group support for interdisciplinary team members to
assist with stress or grief management related to providing hospice
care.
