Utah Admin. Code R432-100-9 - Personnel Management Service

(1) The licensee shall organize the personnel management system to ensure personnel are competent to perform their respective duties, services, and functions.

(2) The licensee shall ensure there are written policies, procedures, and performance standards that include:

(a) job descriptions for each position or employee;

(b) periodic employee performance evaluations;

(c) employee health screening, including Tuberculosis testing, as follows:

(i) employee tuberculosis skin testing is done by the Mantoux method or other Food and Drug Administration (FDA) approved in vitro serologic test and follow-up for tuberculosis in accordance with Rule R388-804;

(ii) each employee is skin-tested for tuberculosis within two weeks of:

(A) initial hiring;

(B) suspected exposure to a person with active tuberculosis; and

(C) development of symptoms of tuberculosis; and

(iii) skin testing is exempted for an employee with known positive reaction to skin tests;

(d) each employee receives unit-specific training;

(e) direct care staff receive continued competency training in current patient care practices;

(f) direct care staff have current cardiopulmonary resuscitation certification. Completion of an in-person course, to include skills testing and evaluation on-site with a licensed instructor is required for CPR certification; and

(g) Occupational Safety and Health Administration regulations regarding blood borne pathogens are implemented and followed.

(3) The licensee shall ensure that medical and professional personnel are registered, certified, or licensed as required by the Utah Department of Commerce within 45 days of employment.

(4) The licensee shall maintain a copy of each current certificate, license, or registration available for department review.

(5) The licensee shall provide annual documented in-service training for direct care and housekeeping staff that addresses the requirements for reporting abuse, neglect, or exploitation of children or adults.

(6)

(a) The licensee may utilize a volunteer in the daily activities of the hospital but a volunteer may not be included in the hospital staffing plan in lieu of hospital employees.

(b) The licensee shall screen and supervise a volunteer according to hospital policy.

(c) The licensee shall ensure that a volunteer is familiar with hospital volunteer policies, including patient rights and hospital emergency procedures.

(7) If the licensee participates in a professional graduate education program, the licensee shall ensure that there are policies and procedures specifying the patient care responsibilities and supervision of the graduate education program participants.

Notes

Utah Admin. Code R432-100-9

Amended by Utah State Bulletin Number 2023-14, effective 7/6/2023 Amended by Utah State Bulletin Number 2025-01, effective 12/27/2024