Section R9-10-206. Personnel

An administrator shall ensure that:

1.        The qualifications, skills, and knowledge required for each type of personnel member:

a.         Are based on:

i.         The type of physical health services or behav- ioral health services expected to be provided by the personnel member according to the estab- lished job description, and

ii.        The acuity of the patients receiving physical health services or behavioral health  services from the personnel member according to the established job description; and

b.        Include:

i.         The specific skills and knowledge necessary for the personnel member to provide the expected physical health services and behavioral health services listed in the established job descrip- tion,

ii.        The type and duration of education that may allow the personnel member to have acquired the specific skills and knowledge for the per- sonnel member to provide the expected physi- cal health services or behavioral health services listed in the established job description, and

iii.      The type and duration of experience that may allow the personnel member to have acquired

the specific skills and knowledge for the per- sonnel member to provide the expected physi- cal health services or behavioral health services listed in the established job description;

2.        A personnel member’s skills and knowledge are verified and documented:

a.         Before the personnel member provides physical health services or behavioral health services, and

b.        According to policies and procedures;

3.        Sufficient personnel members are present on a hospital’s premises with the qualifications, skills, and knowledge necessary to:

a.         Provide the services in the hospital’s scope of ser- vices,

b.        Meet the needs of a patient, and

c.         Ensure the health and safety of a patient;

4.        Orientation occurs within the first 30 calendar days after a personnel member begins providing hospital services and includes:

a.         Informing a personnel member about Department rules for licensing and regulating hospitals and where the rules may be obtained,

b.        Reviewing the process by which a personnel mem- ber may submit a complaint about patient care to a hospital, and

c.         Providing the information required by policies and procedures;

5.        Policies and procedures designate the categories of per- sonnel providing medical services or nursing services who are:

a.         Required to be qualified in cardiopulmonary resusci- tation within 30 calendar days after the individual’s starting date, and

b.        Required to maintain current qualifications in car- diopulmonary resuscitation;

6.        A personnel record for each personnel member is estab- lished and maintained and includes:

a.         The personnel member’s name, date of birth, and contact telephone number;

b.        The personnel member’s starting date and, if appli- cable, ending date;

c.         Verification of a personnel member’s certification, license, or education, if necessary for the position held;

d.        Documentation of evidence of freedom from infec- tious tuberculosis required in R9-10-230(A)(5);

e.         Verification of current cardiopulmonary resuscita- tion qualifications, if necessary for the position held; and

f.         Orientation documentation;

7.        Personnel receive in-service education according to crite- ria established in policies and procedures;

8.        In-service education documentation for a personnel mem- ber includes:

a.         The subject matter,

b.        The date of the in-service education, and

c.         The signature of the personnel member;

9.        Personnel records and in-service education documenta- tion are maintained by the hospital for at least 24 months after the last date the personnel member worked; and

10.     Personnel records and in-service education documenta- tion, for a personnel member who has not worked in the hospital during the previous 12 months, are provided to the Department within 72 hours after the Department’s request.

Historical Note

New Section made by final rulemaking at 8 A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). Amended by final

rulemaking at 11 A.A.R. 536, effective March 5, 2005 (Supp. 05-1). Amended by exempt rulemaking at 19

A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt rulemaking at 20 A.A.R. 1409, pur- suant to Laws 2013, Ch. 10, § 13; effective July 1, 2014

(Supp. 14-2).