Section R432-101-10 - Personnel Management Service(1) The licensee shall provide licensed, certified, or registered personnel who are able and competent to perform their respective duties, services, and functions.(2) The licensee shall ensure written personnel policies and procedures include: (a) job descriptions for each position, including: (iv) minimum qualifications; and(v) required skills, licenses, and physical requirements; and(b) a method to handle and resolve grievances from the staff.(3)(a) The licensee shall ensure each staff member has access to hospital policy and procedure manuals, a copy of their position description, and other information necessary to effectively perform duties and carry out responsibilities.(b) The licensee shall conduct a criminal background check with the Department of Public Safety for each employee before beginning employment.(c) The licensee shall maintain the security and confidentiality of any information obtained in the criminal background check.(4)(a) The licensee shall orient each employee to job requirements and personnel policies, and be provided job training beginning the first day of employment.(b) The licensee shall document, with signatures of the employee and supervisor, completion of basic orientation during the first 30 days of employment.(c) The licensee shall ensure registered nurses, licensed practical nurses, and psychiatric technologists receive additional orientation to the following: (i) concepts of treatment provided within the hospital;(ii) roles and functions of nurses in the treatment programs; and(iii) psychotropic medications.(d) The licensee shall hold in-service training sessions at least quarterly and ensure they are available to each employee.(e) The licensee shall establish a policy to outline in-service training attendance standards.(f) The licensee shall ensure licensed professional staff shall receive continuing education to keep informed of significant new developments and to be able to develop new skills.(g) The licensee shall ensure the following in-service training topics are addressed annually: (ii) review and drill of emergency procedures and evacuation plan;(iii) prevention and control of infections;(iv) training in the principles of emergency medical care and cardiopulmonary resuscitation for physicians, licensed nursing personnel, and others as appropriate;(v) proper use and documentation of restraints and seclusion;(vi) patients' rights, in accordance with Section R432-101-15;(vii) confidentiality of patient information;(viii) reporting abuse, neglect or exploitation of adults or children; and(ix) provision of age appropriate care to the population being served.(5)(a) The licensee may utilize volunteers in the daily activities of the hospital but volunteers may not be included in the licensee's staffing plan in place of hospital employees.(b) The administrator or designee shall screen volunteers and ensure they are supervised according to hospital policy.(c) The licensee shall ensure volunteers are familiar with the hospital's policies and procedures on volunteers, including patient rights and facility emergency procedures.(6)(a) The licensee shall ensure that any hospital personnel are licensed, registered, or certified as required by the Utah Department of Commerce.(b) The licensee shall maintain copies of the current license, registration or certification shall be in the personnel files.(c) The licensee's failure to ensure that the individual is appropriately licensed, registered or certified may result in sanctions to the facility license.Utah Admin. Code R432-101-10
Amended by Utah State Bulletin Number 2023-22, effective 11/1/2023