Utah Admin. Code R432-102-11 - Personnel Management Service

(1) The licensee shall ensure there are enough medical and professional staff and support personnel who are able and competent to perform their respective duties, services, and functions to meet hospital service and patient care needs.

(2) The licensee shall ensure written personnel policies and procedures include:

(a) job descriptions for each position, including:

(i) job title;

(ii) job summary;

(iii) responsibilities;

(iv) minimum qualifications;

(v) required skills and licenses; and

(vi) physical requirements; and

(b) a method to handle and resolve grievances from the staff.

(3)

(a) The licensee shall orient each employee to job requirements and personnel policies, and provide job training beginning the first day of employment.

(b) The licensee shall maintain documentation signed by the employee and supervisor that verifies completion of basic orientation within the first month of employment.

(c) The licensee shall ensure registered nurses and licensed practical nurses receive additional orientations to include:

(i) concepts of treatment provided within the hospital for patients with substance use disorder diagnoses;

(ii) roles and functions of nurses in treatment programs for patients with substance use disorder diagnoses; and

(iii) medications used in the treatment of substance use disorder diagnoses;

(d) The licensee shall ensure:

(i) in-service sessions are planned and held at least quarterly; and

(ii) documentation is maintained to demonstrate that each staff member has attended an annual in-service on the reporting requirements for abuse, neglect, and exploitation for adults and children.

(4) The licensee shall ensure that personnel are licensed, certified, or registered as required by the Utah Department of Commerce and copies of the license, registration, or certificate are maintained in personnel files for department review.

(5) Volunteers may be utilized in the daily activities of the hospital but may not be included in the hospital's staffing plan in lieu of hospital employees. The licensee shall ensure volunteers are:

(a) screened by the administrator or designee and supervised according to hospital policy; and

(b) familiar with the hospital's policies and procedures on volunteers, including patient rights and facility emergency procedures.

Notes

Utah Admin. Code R432-102-11

Amended by Utah State Bulletin Number 2023-16, effective 7/28/2023