Current through Bulletin 2024-06, March 15, 2024
(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.
