New Jersey Administrative Code › Title 8 - HEALTH › Chapter 42C - HOSPICE LICENSING STANDARDS › Subchapter 3 - GENERAL REQUIREMENTS › Section 8:42C-3.4 - Personnel

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The hospice shall ensure that the duties and
				responsibilities of all personnel are described in job descriptions and in the
				policy and procedure manual for each service.
(b) All personnel of whom licensure,
				certification, or authorization to provide patient care is required shall be
				licensed, certified, or authorized under the appropriate laws or rules of the State
				of New Jersey.
(c) All personnel, both
				directly employed and under contract to provide direct care to patients, shall at
				all times wear or produce upon request employee identification.
(d) The hospice shall have policies and procedures
				for the maintenance of confidential personnel records for each employee, including
				at least his or her name, previous employment, educational background, license
				number with effective date and date of expiration (if applicable), certification (if
				applicable), verification of credentials and references, the criminal background
				check required pursuant to 42 CFR
				418.114(d), health evaluation
				records, job description, and evaluations of job performance.
(e) All new personnel, both directly employed and
				under contract to provide direct patient care, as well as volunteers, shall receive
				an initial health evaluation which includes at least a documented history.
(f) Health records shall be maintained for each
				employee and volunteer. Employee, as well as volunteer, health records shall be
				confidential, and kept separate from personnel records.
(g) Employee, as well as volunteer, health records
				shall include documentation of all medical screening tests performed and the
				results.
(h) All personnel, both
				directly employed and under contract to provide direct care to patients, as well as
				volunteers, shall receive a Mantoux tuberculin skin test with five tuberculin units
				of purified protein derivative or have blood drawn for an interferon gamma release
				assay (IGRA).
1. The only exceptions are personnel
				with documented negative Mantoux skin test results (zero to nine millimeters of
				induration) within the last year, personnel with documented positive Mantoux skin
				test results (10 or more millimeters of induration), personnel who received
				appropriate medical treatment for tuberculosis or when medically
				contraindicated.
2. Results of the IGRA
				or Mantoux tuberculin skin tests shall be acted upon as follows:
i. Employees with an IGRA result of "positive"
				have latent TB infection, a "negative" result indicates no latent TB infection and
				employees with an "indeterminate" result shall repeat the IGRA.
ii. If the initial Mantoux tuberculin skin test
				result is between zero and nine millimeters of induration, the test shall be
				repeated one to three weeks later.
iii.
				If the IGRA result is "positive" or the Mantoux test result is 10 millimeters or
				more of induration, a chest x-ray shall be performed and, if necessary, followed by
				chemoprophylaxis or therapy.
3. The IGRA or Mantoux tuberculin skin test shall
				be administered to all agency personnel, both directly employed and under contract,
				and thereafter to all new personnel at the time of employment, as well as
				volunteers.
i. The IGRA or Mantoux tuberculin skin
				test shall be repeated on an annual basis for all persons who provide direct patient
				care and every two years for all other employees.
4. The facility shall maintain records of the
				results of employee Mantoux and IGRA tuberculin testing.