Effective Date: 07/31/2013
Title: Section 763.13 - Personnel
763.13 Personnel. The agency shall ensure for all personnel:
(a) the development and implementation of written personnel policies and procedures, which are reviewed and revised as necessary;
(b) (1) that qualifications as specified in section 700.2 of this Title are met;
(i) that the information required by Public Health Law section 3613(3)(a)-(f) has been entered into the home care services worker registry in accordance with Part 403 of this Title; and
(ii) a criminal history record check to the extent required by section 400.23 and Part 402 of this Title.
(c) that the health status of all new personnel is assessed prior to assuming patient care duties. The assessment shall be of sufficient scope to ensure that no person shall assume his/her duties unless he/she is free from a health impairment which is of potential risk to the patient or which might interfere with the performance of his/her duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter the individual's behavior. The agency shall require the following of all personnel prior to assuming patient care duties:
(1) a certificate of immunization against rubella which means:
(i) a document prepared by a physician, physician's assistant, specialist's assistant, nurse practitioner, licensed midwife or a laboratory possessing a laboratory permit issued pursuant to Part 58 of this Title, demonstrating serologic evidence of rubella antibodies, or
(ii) a document indicating one dose of live virus rublella vaccine was administered on or after the age of twelve months, showing the product administered and the date of administration, and prepared by the health practitioner who administered the immunization, or
(iii) a copy of the document described in subparagraph (i) or (ii) of this paragraph which comes from a previous employer or the school which the individual attended as a student; and
(2) a certificate of immunization against measles for all personnel born on or after January 1, 1957, which means:
(i) a document prepared by a physician, physician's assistant, specialist's assistant, nurse practitioner, licensed midwife or a laboratory possessing a laboratory permit issued pursuant to Part 58 of this Title, demonstrating serologic evidence of measles antibodies; or
(ii) a document indicating two doses of live virus measles vaccine were administered with the first dose administered on or after the age of 12 months and the second dose administered more than 30 days after the first does but after 15 months of age showing the product administered and the date of administration, and prepared by the health practitioner who administered the immunization; or
(iii) a document, indicating a diagnosis of the person as having had measles disease prepared by the physician, physician's assistant/specialist's assistant, licensed midwife or nurse practitioner who diagnosed the person's measles; or
(iv) a copy of the document described in subparagraph (i), (ii) or (iii) of this paragraph which comes from a previous employer or the school which the person attended as a student;
(3) if any licensed physician, physician's assistant, specialist's assistant, licensed midwife or nurse practitioner certifies that immunization with measles and/or rubella vaccine may be detrimental to the person's health, the requirements of paragraphs (1) and (2) of this subdivision relating to measles and/or rubella immunization shall be inapplicable until such immunization is found no longer to be detrimental to such person's health. The nature and duration of the medical exemption must be stated in the individual's personnel record and must be in accordance with generally accepted medical standards (for example, the recommendations of the American Academy of Pediatrics and the Immunization Practices Advisory Committee of the U.S. Department of Health and Human Services); and
(4) either tuberculin skin test or Food and Drug Administration (FDA) approved blood assay for the detection of latent tuberculosis infection, prior to assuming patient care duties and no less than every year thereafter for negative findings. Positive findings shall require appropriate clinical follow-up but no repeat tuberculin skin test or blood assay. The agency shall develop and implement policies regarding follow-up of positive test results;
(5) documentation of vaccination against influenza, or wearing of a surgical or procedure mask during the influenza season, for personnel who have not received the influenza vaccine for the current influenza season, pursuant to section 2.59 of this Title.
(d) that the health status of all personnel be reassessed as frequently as necessary, but no less than annually, to ensure that personnel are free from health impairments which pose potential risk to patients or personnel or which may interfere with the performance of duties;
(e) that a record of all tests, examinations, health assessments and immunizations required by this section is maintained for all personnel who have direct patient contact;
(f) that personal identification is produced by each applicant for employment and verified by the agency prior to hiring of an applicant by the agency;
(g) that prior to patient contact, employment histories from previous employers, if applicable, and recommendations from other persons unrelated to the applicant if not previously employed, are verified;
(h) that personnel records include, as appropriate, records of professional licenses and registrations; verifications of employment history and qualifications for the duties assigned; signed and dated applications for employment; records of physical examinations and health status assessments; performance evaluations; dates of employment, resignations, dismissals, and other pertinent data, provided that all documentation and information pertaining to an employee's medical condition or health status, including such records of physical examinations and health status assessments shall be maintained separate and apart from the non-medical personnel record information and shall be afforded the same confidential treatment given patient medical records under section 763.7 of this Part; (i) that time and payment records are maintained for all personnel;
(j) that there is a current written job description for each position which delineates responsibilities and any specific education, licensure and experience requirements;
(k) that an annual assessment of the performance and effectiveness of each person is conducted and documented in writing, including at least one home visit to observe performance if the person provides services in the home; and
(l) that all personnel receive orientation to the policies and procedures of the agency operation, inservice education necessary to perform his/her responsibilities and continuing programs for development and support. At a minimum:
(1) home health aides shall participate in 12 hours of inservice education per year; and
(2) personal care aides shall participate in six hours of inservice education per year.
(m)(1) that a program is implemented for the prevention of personnel or patients/clients becoming exposed to significant risk body substances which could put them at significant risk of HIV or other blood-borne pathogen infection as defined in sections 63.1 and 63.9 of this Title. Such a program shall include:
(i) use of scientifically accepted protective barriers during job-related activities which involve, or may involve, exposure to significant risk body substances. Such preventive action shall be taken by personnel with each patient/client and shall constitute an essential element for the prevention of bi-directional spread of HIV or other blood-borne pathogen;
(ii) use of scientifically accepted preventive practices during job-related activities which involve the use of contaminated instruments or equipment which may cause puncture injuries;
(iii) training at the time of employment and yearly personnel development programs on the use of protective equipment, preventive practices, and circumstances which represent a significant risk for all personnel whose job-related tasks involve, or may involve, exposure to significant risk body substances;
(iv) provision of personal protective equipment for personnel which is appropriate to the tasks being performed;
(v) a system for monitoring preventive programs to assure compliance and safety.
(2) that policies and procedures are implemented and enforced for the counseling, support and health care management of individuals who are exposed to significant risk body substances under circumstances which constitute significant risk of transmitting or contracting HIV or other blood-borne pathogen infection. They shall include:
(i) a system for reporting to a designated individual in the agency exposure thought to be a circumstance which constitutes significant risk of transmitting or contracting HIV or other blood-borne pathogen infection.
(ii) evaluation of the circumstances of a reported exposure and services for providing follow-up of the exposed individual which includes:
(a) medical and epidemiological assessment of the individual who is the source of the exposure, where that individual is known and available;
(b) if indicated epidemiologically, HIV or other blood-borne pathogen counseling and voluntary testing of the source individual. Disclosure of the HIV status of the source individual can be made with the express written consent of the protected individual, or a person authorized pursuant to law to consent to health care for the protected individual if such person lacks capacity to consent, or pursuant to court order, if the HIV status is not known to the exposed individual;
(c) appropriate medical follow-up of the exposed individual;
(iii) ensuring protection of confidentiality for those involved in reported exposures.