10A NCAC 13k .0401       PERSONNEL

(a)  Written policies shall be established and implemented by the agency regarding infection control and exposure to communicable diseases consistent with 10A NCAC 41A.  These policies and procedures shall include provisions for compliance with 29 CFR 1910 (Occupational Safety and Health Standards) which is incorporated by reference including subsequent amendments.  Emphasis shall be placed on compliance with 29 CFR 1910.1030 (Airborne and Bloodborne Pathogens).  Copies of Title 29 Part 1910 can be purchased from the Superintendent of Documents, U.S. Government Printing Office, P.O. Box 371954, Pittsburgh, PA 15250‑7954 or by calling Washington, D.C. (202) 512‑1800.  The cost is twenty one dollars ($21.00) and may be purchased with a credit card.  Hands‑on care employees must have a baseline skin test for tuberculosis.  Individuals who test positive must demonstrate non‑infectious status prior to assignment in a patient's home.  Individuals who have previously tested positive to the tuberculosis skin test shall obtain a baseline and subsequent annual verification that they are free of tuberculosis symptoms.  The verification shall be obtained from the local health department, a private physician or health nurse employed by the agency.  The Tuberculosis Control Branch of the North Carolina Department of Health and Human Services, Division of Public Health, 1902 Mail Service Center, Raleigh, NC 27699-1902 will provide, free of charge guidelines for conducting verification and Form DEHNR 3405 (Record of Tuberculosis Screening).  Employees identified by agency risk assessment to be at risk for exposure are required to be subsequently tested at intervals prescribed by OSHA standards.

(b)  Written policies shall be established and implemented which include personnel record content, orientation, patient family volunteer training and in‑service education.  Records on the subject of in‑service education and attendance shall be maintained by the agency and retained for at least one year.

(c)  Job descriptions for every position, including volunteers involved in direct patient/family services, shall be established in writing which include qualifications and specific responsibilities.  Individuals shall be assigned only to duties for which they are trained and competent to perform and when applicable for which they are properly licensed.

(d)  Personnel records shall be established and maintained for all hospice staff, both paid and direct patient/family services volunteers.  These records shall be maintained at least one year after termination from agency employment.  When requested, the records shall be available on the agency premises for inspection by the Department.  The records shall include:

(1)           an application or resume which lists education, training and previous employment that can be verified, including job title;

(2)           a job description with record of acknowledgment by the staff;

(3)           reference checks or verification of previous employment;

(4)           records of tuberculosis annual screening for those employees for whom the test is necessary as described in Paragraph (a) of this Rule;

(5)           documentation of Hepatitis B immunization or declination for hands on care staff;

(6)           airborne and bloodborne pathogen training for hands on care staff, including annual updates, in compliance with 29 CFR 1910 and in accordance with the agency's exposure control plan;

(7)           performance evaluations according to agency policy and at least annually;

(8)           verification of staff credentials as applicable;

(9)           records of the verification of competencies by agency supervisory personnel of all skills required of hospice services personnel to carry out patient care tasks to which the staff is assigned.  The method of verification shall be defined in agency policy.


History Note:        Authority G.S. 131E‑202;

Eff. November 1, 1984;

Amended Eff. February 1, 1996; November 1, 1989.