Hospital Personnel Requirements

(1) The governing body must ensure the following requirements are met: (a) Maintain personnel records on all employees which contain, but are not limited to: job title, job application, job qualifications, verification of credentials, performance evaluations, evidence of employee’s professional certification or licensure, and/or appropriate academic degrees when required by the job requirements and date of separation from employment with the facility; (b) Provide a mechanism for staff development and training which must include, but is not limited to, the following: 1. Patient rights, 2. Privacy rights and justification for searches and inspections of patients’ person and property, and, 3. Medications and their side effects; and (c) Assure that volunteers, if utilized, are in a supportive capacity under the supervision of an appropriate designated staff member.