R432-201-7. Governing Body and Management

(1) Governing Body.

The facility shall identify an individual or group to constitute the governing body of the facility.

(2) Duties and Responsibilities.

The governing body shall:

(a) exercise general policy, budget, and operating direction over the facility;

(b) set the qualifications for the administrator of the facility;

(c) appoint the administrator of the facility.

(3) Compliance with Federal, State, and Local Laws.

The facility shall be in compliance with all applicable provisions of federal, state and local laws, regulations and codes pertaining to health, safety, and sanitation.

(4) Administrator.

Each facility shall appoint, in writing, an administrator professionally licensed by the Utah Department of Commerce in a health care field.

(a) A copy of the administrator's license or credentials shall be posted alongside the facility's license in a place readily visible to the public.

(b) The administrator shall act as the administrator of no more than four small health care facilities and no more than a total of 60 beds in any type of licensed health care facility.

(c) The administrator shall have sufficient freedom from other responsibilities and shall be on the premises of the facility a sufficient number of hours in each business day (at least four hours per week for each six clients) and as necessary to properly manage the facility and respond to requests by the Department and the public.

(d) The administrator shall designate, in writing, the name and title of the person who shall act as administrator in his absence.

(i) This person shall have sufficient power, authority, and freedom to act in the best interests of client safety and well-being.

(ii) It is not the intent of this paragraph to permit an unlicensed de facto administrator to supplant or replace the designated, licensed administrator.

(5) Administrator Responsibilities.

(a) The administrator's responsibilities shall be included in a written job description on file in the facility and available for Department review.

(b) The job description shall include responsibility to insure the following duties are fulfilled:

(i) complete, submit, and file all records and reports required by the Department;

(ii) act as a liaison with the licensee, qualified mental retardation professional, QMRP, and other supervisory staff of the facility;

(iii) respond to recommendations made by the facility committees;

(iv) assure that employees are oriented to their job functions and receive appropriate and regularly scheduled in-service training;

(v) implement policies and procedures for the operation of the facility;

(vi) hire and maintain the required number of licensed and nonlicensed staff, as specified in these rules, to meet the needs of clients;

(vii) maintain facility staffing records for at least the preceding 12 months;

(viii) secure and update contracts for required professional and other services not provided directly by the facility;

(ix) verify all required licenses and permits of staff and consultants at the time of hire or effective date of contract;

(x) review all incident and accident reports and document action taken.

(A) Incident and accident reports shall be numbered and logged in a manner to account for all reports.

(B) Incident and accident reports shall have space for written comments by the administrator and, as appropriate, the attending physician and constituted committee.

(C) Original incident and accident reports shall be kept on file in the facility and shall be available for review by the Department.