Utah Admin. Code R432-750-4 - Governing Body and Administration

(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 hospice agency.

(2) The licensee shall develop an organization chart that shows the administrative structure of the hospice agency.

(3) The governing body shall:

(a) adopt a policy that prohibits discrimination because of race, color, religion, ancestry, disability status, sexual orientation, gender, or national origin;

(b) adopt written policies and procedures that describe functions or services of the hospice agency and protect patient rights;

(c) appoint by name and in writing, a qualified hospice administrator who shall oversee the hospice agency's overall functions;

(d) comply with any laws, rules and regulations;

(e) develop and implement bylaws that include:

(i) a description of functions and duties of the governing body officers and committees;

(ii) a statement of purpose;

(iii) an outline of the establishment, selection, and term of office for committee members and officers;

(iv) a policy statement relating to any conflict of interest of members of the governing body or employees who influence the hospice agency decisions;

(v) a statement of qualifications for membership and methods to select members of the governing board; and

(vi) a statement of the authority and responsibility delegated to the hospice administrator;

(f) ensure compliance with Rule R380-600 for program changes to include notifying the office 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;

(g) establish a system of financial management and accountability.

(h) meet at least annually;

(i) provide resources and equipment to provide a safe working environment for personnel; and

(j) review the written annual evaluation report from the hospice administrator and document recommendations as necessary.

(4) The hospice administrator shall oversee the overall management of the hospice agency and shall:

(a) 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 hospice 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; and

(iv) other committees as deemed necessary, describe committee functions and duties, and outline the selection, term of office, and responsibilities of committee members;

(b) complete, submit, file, and make available any records, reports, and documentation required by OL;

(c) conduct an annual evaluation of the hospice agency's overall function and submit a written report of the findings to the governing body;

(d) develop a staff communication system that:

(i) coordinates implementation of plans of treatment;

(ii) coordinates interdisciplinary team services;

(iii) promotes an orderly flow of information within the organization; and

(iv) utilizes services or resources to meet patient needs;

(e) designate in writing the name and position title of a qualified person, who has enough power, authority, and freedom to act in the best interest of patient safety and well-being, as hospice administrator in the temporary absence of the hospice administrator;

(f) employ or contract with competent personnel whose qualifications are commensurate with job responsibilities and authority, who have the appropriate license or certificate of completion;

(g) establish, when appropriate, a billing system that itemizes services provided and charges submitted to the payment source;

(h) implement a program of budgeting and accounting;

(i) implement hospice agency policies and procedures;

(j) maintain current written designations or letters of appointment for the hospice agency;

(k) organize and coordinate functions of the hospice agency by delegating duties and establishing a formal system of staff accountability;

(l) review hospice agency policies and procedures at least annually and recommend necessary changes to the governing body; and

(m) secure contracts for services not directly provided by the hospice agency.

(5) The licensee shall ensure the hospice administrator or designee is available during the hours of operation.

Notes

Utah Admin. Code R432-750-4

Amended by Utah State Bulletin Number 2023-10, effective 5/5/2023 Amended by Utah State Bulletin Number 2025-05, effective 2/18/2025