Utah Admin. Code 432-200-8

Current through Bulletin No. 2024-21, November 1, 2024

Section R432-200-8 - Administration and Organization

(1) The licensee shall comply with laws and licensure requirements and for the organization, management, operation and control of the facility to include the following:

(a) compliance with any federal, state and local laws, rules and regulations;

(b) develop and implement by-laws, policies and procedures relative to the general operation of the facility, including the health care of the residents and the protection of their rights;

(c) develop a policy that states the facility will not discriminate on the basis of race, color, sex, religion, ancestry or national origin in accordance with Section 13-7-1;

(d) appoint, in writing, a qualified administrator to be responsible for the implementation of facility by-laws and policies and procedures, and for the overall management and daily operation of the facility;

(e) secure and update contracts for professional and other services;

(f) receive and respond to inspection reports issued by the department; and

(g) provide the department with written notification of a change in administrator at least 30 days before the administrator change and no more than 5 days after the administrator change.

(2)

(a) The administrator shall maintain a current professional license in good standing issued by the Utah Department of Commerce in a health care field.

(b) The administrator shall post a copy of the administrator's license or credentials with the facility license in a place readily visible to the public.

(c) The administrator shall act as the administrator of no more than four small health care facilities at any one time. The maximum number of beds is limited to 60.

(d) The administrator shall have enough freedom from other responsibilities to be on the premises of the facility enough hours in the business day and as necessary to properly manage the facility and respond to requests by the department.

(e) The administrator shall designate, in writing, the name and title of the person who shall act as administrator in their absence.

(f) The administrator's designee shall have enough power, authority and freedom to act in the best interests of resident safety and well-being.

(g) The licensee may not permit an unlicensed de facto administrator to supplant the designated, licensed administrator.

(3) The administrator shall:

(a) complete, submit and file records and reports required by the department;

(b) act as a liaison between the licensee and other staff of the facility, and respond to recommendations of the quality assurance committee;

(c) ensure that employees are oriented to their job functions and receive appropriate in-service training;

(d) implement policies and procedures for the operation of the facility;

(e) hire and maintain the required number of staff as specified in this rule to meet the needs of residents;

(f) maintain facility staffing records for 12 months;

(g) secure and update contracts required for professional and other services not provided directly by the facility;

(h) verify required licenses and permits of staff and consultants at the time of hire and effective date of contract; and

(i) review incident and accident reports and take appropriate action.

(4) The administrator of each facility shall retain a licensed physician to serve as medical director or advisory physician on a consulting basis according to resident and facility needs.

(5) The medical director or advisory physician shall:

(a) develop written resident care policies and procedures including the delineation of responsibilities of attending physicians;

(b) review resident care policies and procedures annually with the administrator;

(c) serve as liaison between the resident's physician and the administrator;

(d) serve as a member of the quality assurance committee;

(e) review incident and accident reports at the request of the administrator to identify health hazards to residents and employees; and

(f) act as consultant to the health services supervisor in matters relating to resident care policies.

(6)

(a) The administrator shall employ qualified personnel who are able and competent to perform their respective duties, services and functions.

(b) The administrator shall develop job descriptions including:

(i) job title;

(ii) job summary;

(iii) responsibilities;

(iv) qualifications, required skills and licenses; and

(v) physical requirements for each position or employee.

(c) The administrator shall conduct and document periodic employee performance evaluations.

(d) The administrator shall ensure that personnel have access to the facility's policies and procedures manuals, resident care policies, therapeutic manuals and other information necessary to effectively perform their duties and carry out their responsibilities.

(7) The administrator shall establish a policy and procedure for the health screening of facility personnel.

(8) The administrator shall ensure that dietary staff and staff who handle food obtain and maintain a food handler's permit from the local health department.

(9) The licensee shall provide documented in-service training for employees. Annual training shall address the following topics:

(a) fire prevention;

(b) accident prevention and safety procedures including instruction in the following:

(i) body mechanics for employees required to lift, turn, position or transfer residents;

(ii) proper safety precautions when floors are wet or are being cleaned; and

(iii) safety precautions and procedures for heat lamps, hot water bottles, bathing and showering temperatures;

(c) review and drill of emergency procedures and evacuation plan;

(d) prevention and control of infections as outlined in Rule R432-150;

(e) confidentiality of resident information;

(f) resident rights;

(g) behavior management and proper use and documentation of restraints;

(h) oral hygiene and first aid;

(i) training in the principles of cardiopulmonary resuscitation for licensed nursing staff and others as appropriate;

(j) training in habilitative care; and

(k) reporting abuse, neglect and exploitation.

(10) Intermediate Care Facilities for Individuals with Intellectual Disabilities shall ensure that employees receive specialized training regarding the care of children and youth with intellectual disabilities when there are individuals under 22 years of age in the facility.

Utah Admin. Code R432-200-8

Amended by Utah State Bulletin Number 2024-03, effective 1/22/2024