R432-102-11. Personnel Management Service

(1) The hospital shall provide sufficient 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) Written personnel policies and procedures shall include:

(a) job descriptions for each position, including job title, job summary, responsibilities, minimum qualifications, required skills and licenses, and physical requirements;

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

(3) All employees shall be oriented as to job requirements and personnel policies, and provided with job training beginning the first day of employment. Documentation shall be signed by the employee and supervisor to indicate basic orientation has been completed during the first month of employment.

(a) Registered nurses and licensed practical nurses shall receive additional orientations to include the following:

(i) concepts of treatment provided within the hospital for patients with chemical dependency/substance abuse diagnoses;

(ii) roles and functions of nurses in treatment programs for patients with chemical dependency/substance abuse diagnoses;

(iii) medications used in the treatment of chemical dependency/substance abuse diagnoses.

(b) In-service sessions shall be planned and held at least quarterly.

(c) Documentation shall be maintained to demonstrate that all staff have attended an annual in-service on the reporting requirements for abuse, neglect and exploitation for adults and children.

(4) The hospital shall ensure that all personnel are licensed, certified or registered as required by the Utah Department of Commerce. Copies of the license, registration, or certificate shall be maintained for Department review in the personnel files.

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

(a) Volunteers shall be screened by the administrator or designee and supervised according to hospital policy.

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