N.Y. Comp. Codes R. & Regs. tit. 10 § 794.3 : DEPARTMENT OF HEALTH — Medical Facilities — State Hospital Code — Hospice Operation — Organization and Administration — Personnel

The governing authority shall ensure for all personnel, which includes direct employees, contract staff and volunteers:

(a) the development and implementation of written personnel policies and procedures, which are reviewed annually and revised as necessary;

(b) that personnel are qualified as specified in section 700.2 of this Title;

(c) that the health status of all new personnel is assessed prior to the beginning of patient/family contact. The assessment shall be of sufficient scope to ensure that no person shall assume his/her duties unless he/she is free from a health impairment that is of potential risk to the patient/family or to employees or that may interfere with the performance of his/her duties including the habituation or addiction to depressants, stimulants, alcohol, or other drugs or substances which may alter the individual's behavior;

(d) that a record of the following tests and examinations is maintained for all employees, and those volunteers who have direct patient/family contact:

(1) a certificate of immunization against rubella which means:

(i) a document prepared by a physician, physician assistant, specialist assistant, nurse practitioner or a laboratory possessing a laboratory permit issued pursuant to Part 58 of this Title, demonstrating a serologic evidence of rubella antibodies, or

(ii) a document indicating one dose of live virus rubella vaccine was administered on or after the age of 12 months, showing the product administered and the date of administration, and prepared by the health practitioner who administered the immunization, or

(iii) a copy of a document described in subparagraph (i) or (ii) of this paragraph which comes from a previous employer or the school which the employee attended as a student;

(2) a certificate of immunization against measles, for all personnel born on or after January 1, 1957, which means:

(ii) a document indicating two doses of live virus measles vaccine were administered with the first dose administered on or after the age of 12 months and the second dose administered more than 30 days after the first dose but after 15 months of age showing the product administered and the date of administration, and prepared by the health practitioner who administered the immunization, or

(iii) a document, indicating a diagnosis of the employee as having had measles disease, prepared by the physician, physician assistant/specialist assistant or nurse practitioner who diagnosed the employee's measles, or

(iv) a copy of a document described in subparagraph (i), (ii) or (iii) of this paragraph which comes from a previous employer or the school which the employee attended as a student;

(3) if any licensed physician, physician assistant/specialist assistant or nurse practitioner certifies that immunization with measles or rubella vaccine may be detrimental to the employee's health, the requirements of paragraph (1) and/or (2) of this subdivision relating to measles and/or rubella immunization shall be inapplicable until such immunization is found no longer to be detrimental to such employee's health. The nature and duration of the medical exemption must be stated in the employee's employment medical record and must be in accordance with generally accepted medical standards (see, for example, the recommendations of the American Academy of Pediatrics and the Immunization Practices Advisory Committee of the U.S. Department of Health and Human Services);

(4) for all personnel prior to employment or affiliation, except for personnel with no clinical or patient contact responsibilities who are located in a building or site with no patient care services, an initial individual tuberculosis (TB) risk assessment, symptom evaluation, and TB test (either tuberculin skin test or Food and Drug Administration (FDA) approved blood assay for the detection of latent tuberculosis infection), and annual assessments thereafter. Positive findings shall require appropriate clinical follow-up . The hospice shall develop and implement policies regarding follow-up of positive test results, including procedures for facilitating and documenting treatment for latent TB infection where indicated. Annual TB assessment shall include education, individual risk assessment, and follow-up tests as indicated;

(5) documentation of any immunization(s) required by the department;

(6) documentation of vaccination against influenza, or wearing of a surgical or procedure mask during the influenza season, for personnel who have not received the influenza vaccine for the current influenza season, pursuant to section 2.59 of this Title; and

(7) an annual, or more frequent if necessary, health status assessment to assure that all personnel are free from health impairment that is of potential risk to the patient/family or to employees or that may interfere with the performance of his/her duties;

(8) documentation of COVID-19 vaccination or a valid medical exemption to such vaccination, pursuant to section 2.61 of this Title, in accordance with applicable privacy laws, and making such documentation available immediately upon request by the Department, as well as any reasonable accommodation addressing such exemption.

(e) that a record of all tests, examinations, health assessments and immunizations required by this section is maintained for all personnel who have direct patient contact;

(f) that personal identification is produced by each applicant and verified by the program prior to retention of an applicant by the program;

(g) that prior to patient contact, employment history from previous employers, if applicable, and recommendations from other persons unrelated to the applicant if not previously employed, are verified;

(h) that personnel records include, as appropriate, records of professional licenses and registrations; verifications of employment history and qualifications for the duties assigned; signed and dated applications for employment; records of pre-employment physical examinations and health status assessments; criminal background check; performance evaluations; time and payroll records; dates of employment, resignations, dismissals, inservice training and other pertinent data; provided that all documentation and information pertaining to an employee's medical condition or health status, including such records of physical examinations and health status assessments shall be maintained separate and apart from the non-medical personnel record information and shall be afforded the same confidential treatment given patient clinical records under section 794.4 of this Part;

(i) that time and payment records are maintained for all personnel;

(j) that there is a current written job description for each position which delineates responsibilities and specific education and experience requirements;

(k) that all personnel, including hospice employees, volunteers and contract staff with direct patient and family contact, receive orientation to the concept of hospice care, his or her specific job duties, and the policies and procedures for the hospice operation, in-service education necessary to perform his/her responsibilities and continuing programs for development and support.

(1) At a minimum home health aides shall participate in 12 hours of in-service education per year, which may occur while the aide is furnishing care. In-service may be offered by any organization and must be supervised by a registered nurse; and

(2) advanced home health aides shall participate in 18 hours of in-service education per year which must include medication management, infection control, and injection safety, and must be directly supervised by a registered professional nurse.

(l) that employees providing care in the home display proper and current identification, including name, title and current photograph of care provider and name of the program providing the service, to be returned to the program upon termination of employment; and

(m) that an annual assessment of the performance and effectiveness of all personnel is conducted. Such assessment shall include an assessment of skills and competence of individuals providing care including volunteers and include:

(1) written policies and procedures describing the methods of competency assessment, which shall be implemented; and

(2) training and education to personnel to improve competency in areas identified by the assessment process as requiring such improvement.

N.Y. Comp. Codes R. & Regs. Tit. 10 § 794.3

Amended New York State Register August 31, 2016/Volume XXXVIII, Issue 35, eff. 8/31/2016

Amended New York State Register December 12, 2018/Volume XL, Issue 50, eff. 12/12/2018

Amended New York State Register December 16, 2020/Volume XLII, Issue 50, eff. 12/16/2020

Amended New York State Register June 22, 2022/Volume XLIV, Issue 25, eff. 6/22/2022