Section R432-750-4 - Governing Body and Administration(1) The licensee shall ensure that the hospice agency is organized under a governing body that assumes full legal responsibility for the conduct and operations of the agency.(2) The licensee shall develop an organization chart that shows the administrative structure of the agency.(3) The governing body is responsible to:(a) comply with any federal regulations, state rules, and local laws;(b) adopt written policies and procedures that describe functions or services of the hospice and protect patient rights;(c) adopt a statement that there will be no discrimination because of race, color, sex, religion, ancestry, disability status, sexual orientation, gender, or national origin;(d) develop and implement bylaws that shall include at least:(i) a statement of purpose;(ii) a statement of qualifications for membership and methods to select members of the governing board;(iii) an outline of the establishment, selection, and term of office for committee members and officers;(iv) a description of functions and duties of the governing body officers and committees;(v) a statement of the authority and responsibility delegated to the hospice administrator; and(vi) a policy statement relating to conflict of interest of members of the governing body or employees who influence agency decisions;(e) meet at least annually as stated in the bylaws;(f) appoint by name and in writing, a qualified hospice administrator who is responsible for the agency's overall functions;(g) notify the department in writing 30 days before any proposed change in the hospice administrator, identifying the name of the new hospice administrator, and the effective date of the change;(h) review the written annual evaluation report from the hospice administrator and document recommendations as necessary;(i) provide resources and equipment to provide a safe working environment for personnel; and(j) establish a system of financial management and accountability.(4) The hospice administrator is responsible for the overall management of the agency and shall: (a) designate in writing the name and title of a qualified person who shall act as hospice administrator in the temporary absence of the hospice administrator. This designee shall have sufficient power, authority, and freedom to act in the best interests of patient safety and well-being.
(b) complete, submit, file, and make available any records, reports, and documentation required by the department;(c) review agency policies and procedures at least annually and recommend necessary changes to the governing body;(d) implement agency policies and procedures;(e) organize and coordinate functions of the agency by delegating duties and establishing a formal means of staff accountability;(f) appoint the following, by name and in writing:(i) a physician or registered nurse to provide general supervision, coordination, and direction for professional services of the agency;(ii) a registered nurse to be the director of nursing services;(iii) a person responsible for maintaining a clinical record system on any patients;(iii) the members and their terms of membership in the interdisciplinary quality assurance committee;(iv) other committees as deemed necessary, describe committee functions and duties, and outline the selection, term of office, and responsibilities of committee members; and(g) maintain current written designations or letters of appointment for the agency;(h) employ or contract with competent personnel whose qualifications are commensurate with job responsibilities and authority, and who have the appropriate license or certificate of completion;(i) secure contracts for services not directly provided by the hospice;(j) develop a staff communication system that:(i) coordinates interdisciplinary team services;(ii) coordinates implementation of plans of treatment;(iii) utilizes services or resources to meet patient needs; and(iv) promotes an orderly flow of information within the organization;(k) implement a program of budgeting and accounting;(l) establish, when appropriate, a billing system that itemizes services provided and charges submitted to the payment source; and(m) conduct an annual evaluation of the agency's overall function and submit a written report of the findings to the governing body.(5) The hospice administrator or designee shall be available during the agency's hours of operation.Utah Admin. Code R432-750-4
Amended by Utah State Bulletin Number 2023-10, effective 5/5/2023