1. (1) The facility shall document that new staff orientation and ongoing in-service training is based on current written facility policies and procedures.
2. (2) The facility shall ensure any on-duty personnel has access to the facility's written policies and procedures.
3. (3) The facility shall implement a standardized orientation program for each employment position, including the time required to complete training.
4. (4) The facility shall develop and implement a written in-service training program that identifies the topics and frequency of training, including an annual review of facility policies and procedures.

5. (5) The facility shall maintain personnel records documenting that each employee is qualified and competent to perform respective duties and responsibilities through:

   1. (a) appropriate licensure or certification;
   2. (b) continuing education;
   3. (c) experience;
   4. (d) ongoing in-service training; and
   5. (e) orientation.
6. (6) The facility shall keep personnel records for terminated employees for a minimum of four years after the termination date.

KEY: health care facilities, mammography

Date of Last Change: June 5, 2026

Notice of Continuation: August 13, 2021

Authorizing, and Implemented or Interpreted Law: 26B-2-202; 26B-2-602; 42 U.S.C. 263b; 21 CFR 900.12(c)(2)