R432-150-10. Staff and Personnel

  (1) The administrator shall employ personnel who are able and competent to perform their respective duties, services, and functions.

  (a) The administrator, director of nursing or health services supervisor, and department supervisors shall develop job descriptions for each position including job title, job summary, responsibilities, qualifications, required skills and licenses, and physical requirements.

  (b) All personnel must have access to facility policy and procedure manuals and other information necessary to effectively perform duties and carry out responsibilities.

  (c) All personnel must be licensed, certified or registered as required by the Utah Department of Commerce. A copy of the license, certification or registration shall be maintained for Department review.

  (2) The facility shall maintain staffing records, including employee performance evaluations, for the preceding 12 months.

  (3) The facility shall establish a personnel health program through written personnel health policies and procedures.

  (4) The facility shall complete a health evaluation and inventory for each employee upon hire.

  (a) The health inventory shall obtain at least the employee's history of the following:

  (i) conditions that predispose the employee to acquiring or transmitting infectious diseases; and

  (ii) conditions which may prevent the employee from performing certain assigned duties satisfactorily.

  (b) The health inventory shall include health screening and immunization components of the employee's personnel health program.

  (c) Infection control shall include staff immunization as necessary to prevent the spread of disease.

  (d) 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.

  (i) 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.

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

  (e) All infections and communicable diseases reportable by law shall be reported by the facility to the local health department in accordance with R386-702-3.

  (5) The facility shall plan and document in-service training for all personnel.

  (a) The following topics shall be addressed at least annually:

  (i) fire prevention;

  (ii) review and drill of emergency procedures and evacuation plan;

  (iii) the reporting of resident abuse, neglect or exploitation to the proper authorities;

  (iv) prevention and control of infections;

  (v) accident prevention and safety procedures including instruction in body mechanics for all employees required to lift, turn, position, or ambulate residents; and proper safety precautions when floors are wet or waxed;

  (vi) proper use and documentation of restraints;

  (vii) resident rights;

  (viii) A basic understanding of the various types of mental illness, including symptoms, expected behaviors and intervention approaches; and

  (ix) confidentiality of resident information.

  (6) Any person who provides nursing care, including nurse aides and orderlies, must work under the supervision of an RN or LPN and shall demonstrate competency and dependability in resident care.

  (a) A facility may not have an employee working in the facility as a nurse aide for more than four months, on full-time, temporary, per diem, or other basis, unless that individual has successfully completed a State Department of Education-approved training and testing program.

  (b) The facility shall verify through the nurse aide registry prior to employment that nurse aide applicants do not have a verified report of abuse, neglect, or exploitation. If such a verified report exists, the facility may not hire the applicant.

  (c) If an individual has not performed paid nursing or nursing related services for a continuous period of 24 consecutive months since the most recent completion of a training and competency evaluation program, the facility shall require the individual to complete a new training and competency evaluation program.

  (d) The facility shall conduct regular performance reviews and regular in-service education to ensure that individuals used as nurse aides are competent to perform services as nurse aides.

  (7) The facility shall ensure that on all shifts, staff are available who are CPR certified, trained in emergency procedures and basic first aid, including the Heimlich maneuver.

  (8) The facility may utilize volunteers in the daily activities of the facility provided that volunteers are not included in the facility's staffing plan in lieu of facility employees.

  (a) Volunteers shall be supervised and familiar with resident's rights and the facility's policies and procedures.

  (b) Volunteers who provide personal care to residents shall be screened according to facility policy and under the direct supervision of a qualified employee.

  (9) An employee who reports suspected abuse, neglect, or exploitation shall not be subject to retaliation, disciplinary action, or termination by the facility for making the report.