6 CCR 1011-1 Chapter 22, pt. 6 - [Effective 3/17/2025] STAFFING AND PERSONNEL

6.1 Staffing

(A) Each facility shall be staffed with an appropriate number clinical providers and auxiliary staff with the appropriate clinical privileges to assure client safety at all times.

(B) There shall be sufficient clinical providers and auxiliary staff on duty to:

(1) Meet the demands for services routinely provided.

(2) Ensure adequate coverage during periods of high demand or emergency.

(3) Meet the total clinical, nursing, and other care needs of each client present at the facility at all times.

(C) A clinical provider or auxiliary staff member with the appropriate clinical privileges shall be present at the facility at all times when a birthing client or newborn is present postpartum through discharge.

(D) The following staff shall be present at each birth and until the client and newborn are stable postpartum:

(1) One of the facility's clinical providers, and a second person as follows:

(a) For clinical providers with clinical privileges that include the authority to determine the need for and administer intravenous fluids or medications, the second staff member may be another clinical provider, or a member of the auxiliary staff.

(b) For clinical providers with clinical privileges that do not include the authority to determine the need for and administer intravenous fluids or medications, the second staff member shall be a clinical provider or auxiliary staff member with clinical privileges that include the authority to determine the need for and administer intravenous fluids or medications.

(E) Clinical providers and auxiliary staff shall perform their duties in accordance with their individual professional scope of practice, not to exceed their governing body-approved clinical privileges.

6.2 Personnel policies and procedures

(A) The administrator shall ensure the development and implementation of written personnelpolicies and procedures including but not limited to the following:

(1) Conditions of employment.

(2) Orientation and training requirements, including the following topics, at a minimum:

(a) The facility's emergency preparedness plan.

(b) Infection control policies and procedures, as applicable to the position and responsibilities.

(c) Emergency care and emergent and non-emergent transport policies and procedures, as applicable to the position and responsibilities.

(d) The facility's scope of services.

(e) The facility's operational, clinical, and personnel policies and procedures, as applicable to the individual's position.

(f) Client rights and informed consent requirements.

(3) Supervision and management of employees.

(4) A requirement that all clinical providers and auxiliary or contracted staff have adult and neonatal resuscitation skills.

(5) Skill evaluation for auxiliary staff who are not regulated under Title 12 of the Colorado Revised Statutes.

(6) Protection of clients from exposure to communicable disease. The policy shall:

(A) Address pre-employment health requirements, if any.

(B) Identify which communicable diseases render an employee ineligible for duty and the process for restoring eligibility for duty.

(C) Require documentation that clinical providers and auxiliary staff are fully immunized against hepatitis B unless they refuse. If the employee refuses, the refusal shall be documented in the employee's personnel file, and the facility shall ensure the client is protected from exposure to hepatitis B.

(7) A requirement that all persons, including students, who examine, observe, or treat clients to wear identification stating, at minimum, the person's name and credentials.

6.3 Personnel files shall be maintained on the premises for all employees and contracted personnel. Such files shall contain, at a minimum, the following:

(A) The individual's job description, responsibilities, and governing body-approved clinical privileges.

(B) Evidence of current licensure, certification, registration, and training, as applicable to the individual's responsibilities and clinical privileges.

(C) Documentation of adult and neonatal resuscitation competency.

(D) Signed contracts for contracted personnel.

(E) Documentation that the individual has received orientation and training in accordance with the facility's personnel policies and procedures. At a minimum, the personnel file shall include documentation that the individual is familiar with and understands the following:

(1) The facility's emergency preparedness plan, including the individual's roles and responsibilities under the plan.

(2) The facility's infection control policies and procedures.

(3) The facility's policies and procedures regarding the emergency care and emergent and non-emergent transport of clients to a hospital, if applicable to the individual's position and clinical privileges.

(4) The facility's written emergent and non-emergent transport plan, as applicable to the individual's position and clinical privileges.

Notes

6 CCR 1011-1 Chapter 22, pt. 6

48 CR 04, February 25, 2025, effective 3/17/2025