Utah Admin. Code R432-750-5 - Personnel

(1) The hospice administrator shall maintain qualified, competent personnel to perform their respective duties, services, and functions.
(2) The licensee shall develop and implement written policies and procedures that address the:
(a) contents of personnel files of employed and volunteer staff;
(b) criteria for, and frequency of, performance evaluations;
(c) frequency and documentation of in-service training;
(d) job descriptions, qualifications, and validation of licensure or certificates of completion as appropriate for each position;
(e) method and period of staff payment;
(f) orientation for direct and contract employees, and volunteers;
(g) staff benefits, including sick leave, vacation, and insurance; and
(h) staff work schedules.
(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)
(a) The licensee shall establish and implement a policy and procedure for health screening of any hospice agency personnel.
(b) The licensee shall ensure that an employee placement health evaluation is completed when an employee is hired.
(c) The evaluation shall include at least a health inventory that outlines the employee's history of any:
(i) condition that may prevent the employee from performing assigned duties satisfactorily; and
(ii) condition that predispose the employee to acquiring or transmitting an infectious disease.
(d) The licensee shall develop components of personnel health programs for employee health screening and immunizations in accordance with Rule R386-702.
(e) Employee skin testing by the Mantoux Method or other FDA-approved invitro serologic test and follow-up for tuberculosis shall comply with Rule R388-804.
(f) The licensee shall ensure that each employee is skin-tested for tuberculosis within two weeks of:
(i) development of symptoms of tuberculosis;
(ii) initial hiring; and
(iii) suspected exposure to a person with active tuberculosis.
(g) Each employee with a known positive reaction to skin tests is exempt from skin testing.
(h) The licensee 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 each employee, volunteer, and contract personnel is oriented to the hospice agency and the job that they are hired to perform. Orientation shall include:
(a) each duty for an individual who is trained, holds a certificate, or is licensed;
(b) ethics, confidentiality, and patient rights training;
(c) information about other community agencies, including emergency medical services;
(d) job descriptions training;
(e) opportunities for continuing education appropriate to the patient population served;
(f) the policy related to volunteer documentation, charting, hours, and emergencies;
(g) reporting requirements as outlined in Rule R380-600 including reporting when observing or suspecting abuse, neglect, and exploitation pursuant to Section 26B-6-205;
(h) the functions of each hospice agency employee and the relationships between various positions or services; and
(i) the hospice agency concept and philosophy of care.
(6)
(a) The licensee shall provide and document in-service training and continuing education for staff at least annually.
(b) Members of the hospice agency 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.
(c) The training programs shall include the introduction and review of effective physical and psychosocial assessment and symptom management.
(d) The licensee shall train personnel in appropriate Centers for Disease Control infectious disease protocols.
(7) The hospice administrator shall appoint a person to coordinate the activities of the interdisciplinary team and to:
(a) annually review and make recommendations, where appropriate, of hospice 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) 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; and
(d) schedule adequate quality and quantity of any level of hospice care.
(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.

Notes

Utah Admin. Code R432-750-5
Amended by Utah State Bulletin Number 2023-10, effective 5/5/2023 Amended by Utah State Bulletin Number 2025-05, effective 2/18/2025

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