1. (1) The licensee shall organize the personnel management system to ensure personnel are competent to perform respective duties, services, and functions.

2. (2) The licensee shall ensure there are written policies, procedures, and performance standards that include:

   1. (a)(i) direct care staff having current cardiopulmonary resuscitation (CPR) certification, which requires:

      1. (ii) an in-person course, to include skills testing and evaluation on-site with a licensed instructor;
   2. (b) direct care staff receiving continued competency training in current patient care practices;
   3. (c) each employee receiving unit-specific training;

   4. (d) employee health screening, including tuberculosis skin testing:

      1. (i) within two weeks of:

         1. (A) development of symptoms of tuberculosis;
         2. (B) initial hiring; or
         3. (C) suspected exposure to a person with active tuberculosis;
      2. (ii) done by the Mantoux method or another Food and Drug Administration (FDA)-approved in vitro serologic test and follow-up for tuberculosis in accordance with Rule R388-804; and
      3. (iii) which may be exempt for an employee with a known positive reaction to skin testing;
   5. (e) Occupational Safety and Health Administration regulations regarding bloodborne pathogens being implemented and followed;
   6. (f) job descriptions for each position or employee; and
   7. (g) periodic employee performance evaluations.
3. (3) The licensee shall ensure that medical and professional personnel are registered, certified, or licensed as required by the Department of Commerce within 45 days of employment.
4. (4) The licensee shall maintain a copy of each current certificate, license, or registration available for department review.
5. (5) The licensee shall provide annual documented in-service training for direct care and housekeeping staff that addresses the requirements for reporting abuse, neglect, or exploitation of children or adults.

6. (6)(a) The licensee may utilize a volunteer in the daily activities of the hospital but a volunteer may not be included in the hospital staffing plan in lieu of hospital employees.

   1. (b) The licensee shall screen and supervise a volunteer according to hospital policy.
   2. (c) The licensee shall ensure that a volunteer is familiar with hospital volunteer policies, including patient rights and hospital emergency procedures.
7. (7) If the licensee participates in a professional graduate education program, the licensee shall ensure that there are policies and procedures specifying the patient care responsibilities and supervision of the graduate education program participants.

KEY: health care facilities

Date of Last Change: June 5, 2026

Notice of Continuation: August 22, 2025

Authorizing, and Implemented or Interpreted Law: 26B-1-202; 26B-2-202; 26B-2-203