Utah Admin. Code R432-31-4 - Facility Policies and Procedures

(1) A licensee shall establish and implement policies and procedures that comply with Section 75A-3-106.
(2) A licensee shall ensure policies and procedures address the licensee's responsibility to:
(a) determine upon admission whether each individual has an OLST;
(b) ensure an OLST is done in accordance with Subsection 75A-3-106(3);
(c) identify circumstances when an individual with an OLST is offered the opportunity to change the order;
(d) identify circumstances when the facility would not follow an OLST;
(e) identify any individual who may be offered the opportunity to complete an OLST, including an individual who has:
(i) a serious illness and is likely to face a life-threatening health crisis;
(ii) declining cognitive abilities and lacks a surrogate or guardian to make decisions for them; or
(iii) specific preferences for end-of-life treatments;
(f) make a referral to the primary health care provider to create, replace, or change an OLST, if the licensee's services do not include the supervision of a physician, APRN, or physician assistant;
(g) maintain the OLST in the individual's medical record;
(h) only permit a qualified provider to assist with the completion of an OLST; and
(i) outline that they are not required to offer each individual the opportunity to complete an OLST.

Notes

Utah Admin. Code R432-31-4
Amended by Utah State Bulletin Number 2023-12, effective 6/12/2023 Amended by Utah State Bulletin Number 2025-05, effective 2/18/2025

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