Utah Administrative Code
Topic - Health
Title R432 - Health Care Facility Licensing
Rule R432-151 - Mental Disease Facility
Section R432-151-9 - Administration and Organization
Universal Citation: UT Admin Code R 432-151-9
Current through Bulletin 2024-06, March 15, 2024
(1) Program Director.
(a) The program director
shall be a qualified health professional with a minimum of one year's
experience in an established program for treatment of mental disease.
(b) The program director shall have a degree
in administration, psychology, social work, nursing, or medicine and be
licensed, certified or registered by the Utah Department of Commerce.
(c) The program director shall be appointed
in writing by the governing body, and shall be accountable for the overall
function of the program.
(d) The
program director shall be accountable, whether by performance or by delegation,
for the following functions:
(i) Develop
written short-term and long-term goals for the treatment program;
(ii) Develop written policy and procedures,
review them at least annually, and revise as necessary. Dates of review shall
be documented;
(iii) Utilize
quality assurance methods to assess efficiency and effectiveness of the
program;
(iv) Supervise the
development and implementation of each resident's individualized resident care
plan;
(v) Supervise appropriate
delivery of program modalities and services;
(vi) Integrate various aspects of the
treatment program;
(vii) Maintain
thorough clinical records for each resident;
(viii) Establish periodic reviews of each
resident care plan;
(ix) Provide
orientation for each new employee to acquaint them with the philosophy,
organization, practices, and goals of the treatment program;
(x) Provide in-service training for any
employee who has not achieved the desired level of competence;
(xi) Promote continuing education
opportunities for all employees to update and improve their skills.
(2) Professional Staff.
(a) The facility shall have administrative,
qualified health care professional, and support staff available to assess and
address resident needs within its scope of services.
(b) Qualified professional staff includes
psychiatrists, physicians, clinical psychologists, social workers, licensed
nurses, and other health care professionals in sufficient number to provide
services offered by the facility.
(c) When qualified professional staff members
other than nursing staff are not available on a full- time basis, they shall be
available on a part-time basis or by contract agreement to fulfill the
requirements and needs of the treatment programs offered.
(d) The professional staff shall determine
what qualifications are required to assume specific responsibilities.
(i) All members of the treatment team who
have been assigned specific responsibilities shall be qualified for that
position by training and experience.
(ii) Services shall be supervised by
qualified, licensed personnel.
(e) All staff shall be licensed, certified or
registered as required by the Utah Department of Commerce, Division of
Occupational and Professional Licensing.
(i)
The facility shall maintain documentation and copies of the license,
certification, or registration for Department review.
(ii) Failure to ensure that employees are
current for licensure, certification or registration may result in sanctions to
the facility license.
(f) The facility shall have a Health
Surveillance policy which conforms with
R432-150-10(4).
(3) Orientation.
(a) These rules shall apply in addition to
R432-150-10(5).
(b) All new employees shall be oriented to
job requirements, personnel policies, and job training beginning the first day
of employment.
(c) Documentation
shall be signed by the employee and supervisor to indicate basic orientation
has been completed during the first three months of employment.
(d) New employees shall receive orientation
to the following:
(i) Administration,
organization, policies and procedures, job training, responsibilities, and
philosophy of the treatment program;
(ii) Resident rights;
(iii) Safety and security procedures for
fire, disaster, and AWOL;
(iv)
Symptoms of residents with maladaptive behaviors;
(v) Training how to respond appropriately to
residents' sexual behavior;
(vi)
Suicide precautions;
(vii)
Procedures for first aid and medical emergencies;
(viii) Medical recording or charting;
medication sheets if pertinent to the job assignment;
(ix) Reporting abuse, neglect and
exploitation; and
(x) Quality
assurance objectives.
(e) Registered nurses and licensed practical
nurses will receive additional orientation to the following:
(i) Concepts of treatment for residents with
mental disease;
(ii) Roles and
functions of nurses in treatment programs for residents with mental
disease;
(iii) Nursing policy and
procedure manuals;
(iv)
Psychotropic medications.
(4) Staff growth and development.
(a) These rules shall apply addition to
R432-150-10(6).
(b) In-service sessions shall be planned in
advance and shall be held at least quarterly.
(c) In-service education shall be available
to all employees.
(i) Aides shall receive at
least the following training:
(A) Basic
health - to learn nursing skills in non-complicated nursing
situations;
(B) Basic first
aid;
(C) Communications;
(D) Introduction to human services;
(E) Understanding behavior - the resident's
and the staff's; appropriate and inappropriate behaviors; responsibility to
report undesirable behaviors to supervisors.
(ii) Licensed professional staff shall
receive continuing education to keep informed of significant new developments
and skills.
(iii) The facility
should make use of opportunities outside the facility, such as workshops,
institutes, seminars, and formal classes to supplement the facility's program
of continuing education.
Disclaimer: These regulations may not be the most recent version. Utah may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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