1. (1) A licensee shall establish and implement policies and procedures that comply with Section 26B-2-802.

2. (2) A licensee shall ensure policies and procedures address the licensee's responsibility to:

   1. (a) determine upon admission whether each individual has an OLST;
   2. (b) ensure an OLST is done in accordance with Section 26B-2-802;
   3. (c) identify circumstances when an individual with an OLST is offered the opportunity to change the order;
   4. (d) identify circumstances when the facility would not follow an OLST;

   5. (e) identify any individual who may be offered the opportunity to complete an OLST, including an individual who has:

      1. (i) a serious illness and is likely to face a life-threatening health crisis;
      2. (ii) declining cognitive abilities and lacks a surrogate or guardian to make decisions for them; or
      3. (iii) specific preferences for end-of-life treatments;
   6. (f) make a referral to the primary health care provider to create, replace, or change an OLST, if the licensee's services do not include the supervision of a physician, APRN, or physician assistant;
   7. (g) maintain the OLST in the individual's medical record;

   8. (h) only permit a qualified provider to assist with the completion of an OLST; and

      1. (i) outline that the licensee is not required to offer each individual the opportunity to complete an OLST.

KEY: POLST, do not resuscitate, DNR, Life with Dignity Order, order for life-sustaining treatment

Date of Last Change: May 7, 2026

Notice of Continuation: January 24, 2022

Authorizing, and Implemented or Interpreted Law: 26B-2-202; 26B-2-802