File No. 35024

This rule was published in the August 1, 2011, issue (Vol. 2011, No. 15) of the Utah State Bulletin.

Health, Family Health and Preparedness, Licensing

Section R432-750-8


Notice of Proposed Rule


DAR File No.: 35024
Filed: 07/11/2011 01:10:32 PM


Purpose of the rule or reason for the change:

The purpose of this amendment is to clarify and align the tuberculosis testing requirements for licensed health care facilities in Utah. The clarifications are in accordance with current law and will be consistent with all health facility rules. This amendment was approved by the Health Facilities Committee on 11/17/2010. This committee has representation from a broad cross section of the entities affected by this rule.

Summary of the rule or change:

This amendment will require employee tuberculosis testing to be completed within two weeks of hire, after suspected exposure or development of symptoms.

State statutory or constitutional authorization for this rule:

  • Title 26, Chapter 21

Anticipated cost or savings to:

the state budget:

This rule amendment will have no effect on state budgets since there will be no change in current practice.

local governments:

This rule amendment will have no effect on local government budgets since there will be no change in current practice.

small businesses:

This rule amendment will have no effect on small businesses since there will be no change in current practice.

persons other than small businesses, businesses, or local governmental entities:

This rule amendment will have no effect on persons since there will be no change in current practice.

Compliance costs for affected persons:

This rule amendment will have no effect on persons since there will be no change in current practice.

Comments by the department head on the fiscal impact the rule may have on businesses:

Screening employees of health care facilities for tuberculosis is a justified fiscal cost to protect patients from being exposed to this deadly disease.

David Patton, PhD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Family Health and Preparedness, Licensing
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

  • Joel Hoffman at the above address, by phone at 801-538-6279, by FAX at 801-538-6024, or by Internet E-mail at
  • Carmen Richins at the above address, by phone at 801-538-9087, by FAX at 801-538-6024, or by Internet E-mail at

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:


This rule may become effective on:


Authorized by:

David Patton, Executive Director


R432. Health, Family Health and Preparedness, Licensing.

R432-750. Hospice Rule.

R432-750-8. Personnel.

The hospice administrator shall maintain qualified personnel who are competent to perform their respective duties, services, and functions.

(1) The agency shall develop and implement written policies and procedures that address the following:

(a) job descriptions, qualifications, and validation of licensure or certificates of completion as appropriate for the position held;

(b) orientation for direct and contract employees, and volunteers;

(c) criteria for, and frequency of, performance evaluations;

(d) work schedules; method and period of payment; fringe benefits such as sick leave, vacation, and insurance;

(e) frequency and documentation of in-service training; and

(f) contents of personnel files of employed and volunteer staff.

(2) Each employee must provide within 45 days of hire proof of registration, certification, or licensure as required by the Utah Department of Commerce.

(3) The agency shall establish and implement a policy and procedure for health screening of all agency personnel.

(a) An employee placement health evaluation to include at least a health inventory shall be completed when an employee is hired.

(b) The health inventory shall obtain at least the employee's history of the following:

(i) conditions that predispose the employee to acquiring or transmitting infectious diseases;

(ii) conditions which may prevent the employee from performing certain assigned duties satisfactorily;

(c) Employee health screening and immunizations components of personnel health programs shall be developed in accordance with R386-702 Communicable Disease Rule.

(d) Employee skin testing by the Mantoux Method or other FDA approved in-vitro serologic test and follow up for tuberculosis shall be done in accordance with R388-804 , Special Measures for the Control of Tuberculosis[ Control Rule].

(i) The licensee shall ensure that all employees are skin-tested for tuberculosis within two weeks of:

(A) initial hiring;

(B) suspected exposure to a person with active tuberculosis; and

(C) development of symptoms of tuberculosis.

(ii) Skin testing shall be exempted for all employees with known positive reaction to skin tests.

(e) All infections and communicable diseases reportable by law shall be reported by the facility to the local health department in accordance with R386-702-2.

(4) The hospice must document that all employees, volunteers, and contract personnel are oriented to the agency and the job for which they are hired.

(a) Orientation shall include:

(i) the hospice concept and philosophy of care;

(ii) the functions of agency employees and the relationships between various positions or services;

(iii) job descriptions;

(iv) duties for which persons are trained, hold certificates, or are licensed;

(v) ethics, confidentiality, and patients' rights;

(vi) information about other community agencies including emergency medical services;

(vii) opportunities for continuing education appropriate to the patient population served;

(viii) policies related to volunteer documentation, charting, hours and emergencies; and

(ix) reporting requirements when observing or suspecting abuse, neglect and exploitation pursuant to 62A-3-302.

(b) The hospice shall provide and document in-service training and continuing education for staff at least annually.

(i) Members of the hospice 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.

(ii) The training programs shall include the introduction and review of effective physical and psychosocial assessment and symptom management.

(c) The hospice shall train all personnel in appropriate Centers for Disease Control (CDC) infectious disease protocols.

(5) The hospice administrator shall appoint a person to coordinate the activities of the interdisciplinary team. This individual shall:

(a) annually review and make recommendations where appropriate of agency policies covering admissions and discharge, medical supervision, care plans, clinical records and personnel qualifications;

(b) assure that on-going assessments of the patient and family needs and implementation of the interdisciplinary team care plans are accomplished;

(c) schedule adequate quality and quantity of all levels of hospice care; and

(d) assure that the team meets regularly to develop and maintain appropriate plans of care and to determine which staff will be assigned to each case.

(6) The hospice program shall provide access to individual and/or group support for interdisciplinary team members to assist with stress and/or grief management related to providing hospice care.


KEY: health care facilities

Date of Enactment or Last Substantive Amendment: [November 6, 2000]2011

Notice of Continuation: September 27, 2007

Authorizing, and Implemented or Interpreted Law: 26-21-5; 26-21-6


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For questions regarding the content or application of this rule, please contact Joel Hoffman at the above address, by phone at 801-538-6279, by FAX at 801-538-6024, or by Internet E-mail at; Carmen Richins at the above address, by phone at 801-538-9087, by FAX at 801-538-6024, or by Internet E-mail at