1. (a) the development and implementation of written policies and procedures, which are reviewed annually and revised as necessary;
2. (b) the employment of personnel without regard to age, race, color, sexual orientation, religion, sex or national origin;
3. (c) that the health status of each employee is examined prior to the beginning of employment, which is sufficient in scope to ensure that the employee is free from a health impairment which is of potential risk to patients or which may interfere with the performance of his/her duties;

4. (d) that a record of the following tests, procedures and examinations is maintained for all employees:

   1. (1) a certificate of immunization against rubella which means:

      1. (i) a document prepared by a physician, physician's assistant, specialist's assistant, nurse practitioner, licensed midwife or a laboratory possessing a laboratory permit issued pursuant to Part 58 of this Title, demonstrating serologic evidence of rubella antibodies;
      2. (ii) a document indicating one dose of live virus rubella vaccine was administered on or after the age of 12 months, showing the product administered and the date of administration, and prepared by the health practitioner who administered the immunization; or
      3. (iii) a copy of a document described in subparagraph (i) or (ii) of this paragraph which comes from a previous employer or the school which the employee attended as a student; and

   2. (2) a certificate of immunization against measles, for all personnel born on or after January 1, 1957, which means:

      1. (i) a document prepared by a physician, physician's assistant, specialist's assistant, nurse practitioner, licensed midwife or a laboratory possessing a laboratory permit issued pursuant to Part 58 of this Title, demonstrating serologic evidence of measles antibodies;
      2. (ii) a document indicating two doses of live virus measles vaccine were administered with the first dose administered on or after the age of 12 months and the second dose administered more than 30 days after the first dose but after 15 months of age showing the product administered and the date of administration, and prepared by the health practitioner who administered the immunization;
      3. (iii) a document, indicating a diagnosis of the employee as having had measles disease, prepared by the physician, physician's assistant/specialist's assistant, licensed midwife or nurse practitioner who diagnosed the employee's measles; or
      4. (iv) a copy of a document described in subparagraph (i), (ii) or (iii) of this paragraph which comes from a previous employer or the school which the employee attended as a student;
   3. (3) if any licensed physician, physician's assistant/specialist's assistant, licensed midwife or nurse practitioner certifies that immunization with measles or rubella vaccine may be detrimental to the employee's health, the requirements of paragraph (1) and/or (2) of this subdivision relating to measles and/or rubella immunization shall be inapplicable until such immunization is found no longer to be detrimental to such employee's health. The nature and duration of the medical exemption must be stated in the employee's employment medical record and must be in accordance with generally accepted medical standards, (see, for example, the recommendations of the American Academy of Pediatrics and the Immunization Practices Advisory Committee of the U.S. Department of Health and Human Services);
   4. (4) for all personnel prior to employment or affiliation, except for personnel with no clinical or patient contact responsibilities who are located in a building or site with no patient care services, an initial individual tuberculosis (TB) risk assessment, symptom evaluation, and TB test (either tuberculin skin test or Food and Drug Administration [FDA] approved blood assay for the detection of latent tuberculosis infection), and annual assessments thereafter. Positive findings shall require appropriate clinical follow-up. The medical staff shall develop and implement policies regarding positive findings, including procedures for facilitating and documenting treatment for latent TB infection where indicated. Annual TB assessment shall include education, individual risk assessment, and follow-up tests as indicated; and
   5. (5) an annual, or more frequent if necessary, health status reassessment to assure freedom from health impairment which is of potential risk to the patients or might interfere with the performance of duties; and
   6. (6) documentation of vaccination against influenza, or wearing of a surgical or procedure mask during the influenza season, for personnel who have not received the influenza vaccine for the current influenza season, pursuant to section 2.59 of this Title;
   7. (7) documentation of COVID-19 vaccination or a valid medical exemption to such vaccination, pursuant to section 2.61 of this Title, in accordance with applicable privacy laws, and making such documentation available immediately upon request by the department, as well as any reasonable accommodation addressing such exemption.
5. (e) that a personnel file is maintained for each employee;

6. (f) that employees are qualified, as applicable, by:

   1. (1) holding professional licensure and demonstrating evidence of current registration from the New York State Education Department or the New York State Department of Health; and/or
   2. (2) meeting the definitional requirements of Parts 20, 94 and 700 of this Title; and/or
   3. (3) demonstrating evidence of current registration or certification from the appropriate agency, association, council or board;
7. (g) the assignment of duties and functions to each employee that are commensurate with his/her licensure, registration and/or certification, and experience and competence;
8. (h) that each employee is provided with a copy of policies regarding conditions of employment;
9. (i) that there is a current written job description for each position which delineates duties, functions, responsibilities, and specific education and experience requirements;
10. (j) that each new employee is provided with a planned orientation to the center's operation and personnel policies;
11. (k) that each employee, as applicable, receives on-the-job training necessary to perform his/her duties;
12. (l) that all staff receive education in the identification, assessment, reporting and referral of cases of suspected child abuse or maltreatment and identification and treatment of victims of domestic violence;
13. (m) the provision of in-service education and continuing education for all professional staff in order to maintain skills and current standards of professional practice;
14. (n) that a record is maintained for each employee which documents his/her attendance at orientation, on-the-job training and in-service education programs; and
15. (o) that each person delivering health care services wears identification indicating his/her name and title.

The operator shall ensure: