Effective Date: 06/02/2010
Title: Section 793.5 - Personnel
793.5 Personnel. The governing authority shall ensure for all personnel:
(a) the development and implementation of written personnel policies and procedures, which are reviewed annually and revised as necessary;
(b) that personnel are qualified as specified in section 700.2 of this Title;
(c) that the health status of all new personnel is documented prior to the beginning of patient/family contact, to ensure that he/she is free from any health impairment that is of potential risk to the patient/family or to employees or that may interfere with the performance of duties;
(d) that a record of the following tests and examinations is maintained for all employees, and those volunteers who have direct patient/family contact:
(1) a certificate of immunization against rubella which means:
(i) a document prepared by a physician, physician's assistant, specialist's assistant, nurse practitioner or a laboratory possessing a laboratory permit issued pursuant to Part 58 of this Title, demonstrating a serologic evidence of rubella antibodies, or
(ii) a document indicating one dose of live virus rubella 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 a document described in (i) or (ii) of this paragraph which comes from a previous employer or the school which the employee attended as a student;
(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 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 dose 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 employee as having had measles disease, prepared by the physician, physician's assistant/specialist's assistant or nurse practitioner who diagnosed the employee's measles, or
(iv) a copy of a document described in (i), (ii) or (iii) of this paragraph which comes from a previous employer or the school which the employee attended as a student;
(3) if any licensed physician, physician's assistant/specialist's assistant or nurse practitioner certifies that immunization with measles or rubella vaccine may be detrimental to the employee's health, the requirements of paragraph (1) and/or (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 employee's health. The nature and duration of the medical exemption must be stated in the employee's employment medical record; and must be in accordance with generally accepted medical standards, (see, 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 employment or voluntary service 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; and
(5) an annual, or more frequent if necessary, health status assessment to assure that all personnel are free from health impairment that is of potential risk to the patient/family or to employees or that may interfere with the performance of his/her duties;
(e) that personal identification is produced by each applicant and verified by the program prior to retention of an applicant by the program;
(f) that prior patient contact, employment history from previous employers, if applicable, and recommendations from other persons unrelated to the applicant if not previously employed, are verified;
(g) 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 pre-employment physical examinations and health status assessments; performance evaluations; time and payroll records; dates of employment, resignations, dismissals and other pertinent data;
(h) that there is a current written job description for each position which delineates responsibilities and specific education and experience requirements; (i) that all personnel receive orientation to the concept of hospice care and the policies and procedures for the hospice operation, inservice education necessary to perform his/her responsibilities and continuing programs for development and support; and
(j) that an annual assessment of the performance and effectiveness of all personnel is conducted.
(k) that a program be implemented and enforced for the prevention of circumstances which could result in an employee or patient/client becoming exposed to significant risk body substances which could put them at significant risk of HIV infection during the provision of services, as defined in sections 63.1 and 63.9 of this Title.
(1) 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 the employee with each patient/client as an essential element for the prevention of bi-directional spread of HIV;
(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 staff development programs on the use of protective equipment, preventive practices, and circumstances which represent a significant risk for all employees whose job-related tasks involve, or may involve, exposure to significant risk body substances;
(iv) provision of personal protective equipment for employees which is appropriate to the tasks being performed;
(v) a system for monitoring preventive programs to assure compliance and safety.
(2) a hospice must implement and enforce a policy/procedure for the management of individuals who are exposed to significant risk body substances under circumstances which constitute significant risk of transmitting or contracting HIV infection. The policy/procedure shall include:
(i) a system for reporting to a designated individual in the hospice exposure thought to represent a circumstance which constitutes significant risk of transmitting or contracting HIV infection;
(ii) Evaluation of the circumstances of a reported exposure and services 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 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) assurances for protection of confidentiality for those involved in reported exposures.