SECTION .0400 ‑ PERSONNEL

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 the rules set forth in 10A NCAC 41A, which is incorporated by reference, including subsequent amendments. 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 and editions. These editions shall include 29 CFR 1910.1030 Bloodborne Pathogens. Copies of Title 29 Part 1910 can be obtained online at no charge at https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS.

(b)  Hands‑on care team members shall have a baseline test for tuberculosis. Individuals who test positive shall demonstrate non‑infectious status prior to assignment in a patient's home. Individuals who have previously tested positive for the tuberculosis 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 Communicable Disease Branch of the North Carolina Department of Health and Human Services, Division of Public Health, 1905 Mail Service Center, Raleigh, NC 27699-1905 will provide free of charge guidelines for conducting and verification utilizing Form DHHS 3405 (Record of Tuberculosis Screening). Employees identified by agency risk assessment to be at risk for exposure shall be subsequently tested in accordance with Centers for Disease Control (CDC) guidelines, which is incorporated by reference with subsequent amendments and editions. A copy of the CDC guidelines can be obtained online at no charge at https://search.cdc.gov/search/?query=TB+testing+intervals&sitelimit=&utf8=%E2%9C%93&affiliate=cdc-main.

(c)  Written policies shall be established and implemented by the agency that 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 one year.

(d)  Job descriptions for every position, including volunteers involved in direct patient/family services, shall be established by the agency and shall include the position's qualifications and specific responsibilities. Hospice team member(s) shall be assigned only to duties that they are trained and competent to perform, or licensed to perform.

(e)  Personnel records shall be established and maintained for hospice team members, including paid and direct patient/family services volunteers. These records shall be maintained for one year after employment or volunteer service ends. When requested by the State surveyors, the records shall be available on the agency premises for inspection by the Department. The records shall include:

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

(2)           a job description with record of acknowledgment by the team member(s);

(3)           reference checks or verification of previous employment;

(4)           records of tuberculosis annual screening for hands-on care team members;

(5)           documentation of Hepatitis B immunization or declination for hands-on care team members;

(6)           bloodborne pathogen training for hands-on care team members, 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, or at least annually;

(8)           verification of team member(s) credentials;

(9)           records of the verification of competencies by agency supervisory personnel of skills required of hospice services personnel to carry out patient care tasks. 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;

Readopted Eff. January 1, 2021.