R432-100-8. Personnel Management Service

  (1) The personnel management system is organized to ensure personnel are competent to perform their respective duties, services, and functions.

  (2) There shall be 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;

  (i) Employee skin testing by the Mantoux method or other FDA approved in-vitro serologic test and follow up for tuberculosis shall be done in accordance with R388-804, Special Measures for the Control of Tuberculosis.

  (ii) The licensee shall ensure that all employees are 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.

  (iii) Skin testing shall be exempted for all employees with known positive reaction to skin tests.

  (d) policies to ensure that all employees receive unit specific training;

  (e) policies to ensure that all hospital direct care staff receive continued competency training in current patient care practices;

  (f) policies to ensure that all hospital direct care staff have current cardiopulmonary resuscitation certification. Certification in Cardiopulmonary Resuscitation (CPR) refers to certification issued after completion of a course that is consistent with the most current version of the American Heart Association Guidelines for Health Care Provider CPR; and

  (g) policies to ensure that OSHA regulations regarding Blood Borne Pathogens are implemented and followed.

  (3) All personnel shall be registered, certified or licensed as required by the Utah Department of Commerce within 45 days of employment.

  (4) A copy of the current certificate, license or registration shall be available for Department review.

  (5) All direct care and housekeeping staff shall receive annual documented inservice training in the requirements for reporting abuse, neglect, or exploitation of children or adults.

  (6) Volunteers may be utilized in the daily activities of the hospital, but shall not be included in the hospital staffing plan in lieu of hospital employees.

  (a) Volunteers shall be screened and supervised according to hospital policy.

  (b) Volunteers shall be familiar with hospital volunteer policies, including patient rights and hospital emergency procedures.

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