0116 Personnel -Noncompliance
(a) Each facility shall have specific procedures written and implemented for the
screening of prospective employees. Appropriate inquiries shall be made for
prospective employees. The facility shall have a personnel policy that considers
references and any convictions in accordance with IC 16-28-13-3.
0117 Personnel – Deficiency
(b) Staff shall be sufficient in number, qualifications, and training in accordance with
applicable state laws and rules to meet the twenty-four (24) hour scheduled and
unscheduled needs of the residents and services provided. The number,
qualifications, and training of staff shall depend on the skills required to provide for the
specific needs of the residents. A minimum of one (1) awake staff person, with
current CPR and first aid certificates, shall be on-site at all times. If fifty (50) or more
residents of the facility regularly receive residential nursing services or
administration of medication, or both, at least one (1) nursing staff person shall be on
site at all times. Residential facilities with over one hundred (100) residents regularly
receiving residential nursing services or administration of medication, or both, shall
have at least one (1) additional nursing staff person awake and on duty at all times for
every additional fifty (50) residents. Personnel shall be assigned only those duties for
which they are trained to perform. Employee duties shall conform with written job
0118 Personnel – Deficiency
(c) Any unlicensed employee providing more than limited assistance with the
activities of daily living must be either a certified nurse aide or a home health aide.
Existing facilities that are not licensed on the date of adoption of this rule and that
seek licensure within one (1) year of adoption of this rule have two (2) months in
which to ensure that all employees in this category are either a certified nurse aide or
a home health aide
0119 Personnel -Noncompliance
410 IAC 16.2-5-1.4(d)(1 – 6)
(d) Prior to working independently, each employee shall be given an orientation to
the facility by the supervisor (or his or her designee) of the department in which the
the employee will work. Orientation of all employees shall include the following:
(1) Instructions on the needs of the specialized populations:
(B) developmentally disabled;
(C) mentally ill;
(D) dementia; or
served in the facility.
(2) A review of the facility’s policy manual and applicable procedures, including:
(A) organization chart;
(B) personnel policies;
(C) appearance and grooming policies for employees; and
(D) residents’ rights.
(3) Instruction in first aid, emergency procedures, and fire and disaster preparedness,
including evacuation procedures.
(4) Review of ethical considerations and confidentiality in resident care and records.
(5) For direct care staff, personal introduction to, and instruction in, the particular
needs of each resident to whom the employee will be providing care.
(6) Documentation of the orientation in the employee’s personnel record by the
the person supervising the orientation.
0120 Personnel -Noncompliance
(e) There shall be an organized in-service education and training program planned in
advance for all personnel in all departments at least annually. Training shall include,
but is not limited to, residents’ rights, prevention and control of infection, fire
prevention, safety, accident prevention, the needs of specialized populations served,
medication administration, and nursing care, when appropriate, as follows:
(1) The frequency and content of in-service education and training programs shall be
in accordance with the skills and knowledge of the facility personnel. For nursing
personnel, this shall include at least eight (8) hours of in-service per calendar year and
four (4) hours of in-service per calendar year for non-nursing personnel.
(2) In addition to the above required in-service hours, staff who have contact with
residents shall have a minimum of six (6) hours of dementia-specific training within
six (6) months and three (3) hours annually thereafter to meet the needs or
preferences, or both, of cognitively impaired residents effectively and to gain
understanding of the current standards of care for residents with dementia.
(3) In-service records shall be maintained and shall indicate the following:
(A) The time, date, and location.
(B) The name of the instructor.
(C) The title of the instructor.
(D) The names of the participants.
(E) The program content of in-service.
The employee will acknowledge attendance by written signature.
0121 Personnel -Noncompliance
(f) A health screen shall be required for each employee of a facility prior to resident
contact. The screen shall include a tuberculin skin test, using the Mantoux method (5
TU, PPD), unless a previously positive reaction can be documented. The result shall
be recorded in millimeters of induration with the date given, date read, and by whom
administered. The facility must assure the following:
(1) At the time of employment, or within one (1) month prior to employment, and at
least annually thereafter, employees and nonpaid personnel of facilities shall be
screened for tuberculosis. The first tuberculin skin test must be read prior to the
employee starting work. For health care workers who have not had a documented
negative tuberculin skin test result during the preceding twelve (12) months, the
baseline tuberculin skin testing should employ the two-step method. If the first step is
negative, a second test should be performed one (1) to three (3) weeks after the first
step. The frequency of repeat testing will depend on the risk of infection with
(2) All employees who have a positive reaction to the skin test shall be required to
have a chest x-ray and other physical and laboratory examinations in order to
complete a diagnosis.
(3) The facility shall maintain a health record of each employee that includes reports
of all employment-related health screenings.
(4) An employee with symptoms or signs of active disease, (symptoms suggestive of
active tuberculosis, including, but not limited to, cough, fever, night sweats, and
weight loss) shall not be permitted to work until tuberculosis is ruled out.
0122 Personnel – Deficiency
(g) The facility must prohibit employees with a communicable disease or infected skin
lesions from direct contact with residents or their food if direct contact will transmit
the disease. An employee with signs and symptoms of communicable disease,
including, but not limited to, an infected or draining skin lesion shall be handled
according to a facility’s policy regarding direct contact with residents, their food, or
resident care items until the condition is resolved. Persons with suspected or proven
active tuberculosis will not be permitted to work until determined to be noninfectious
and documentation is provided for the employee record.
0123 Personnel -Nonconformance
(h) The facility shall maintain current and accurate personnel records for all
employees. The personnel records for all employees shall include the following:
(1) The name and address of the employee.
(2) Social Security number.
(3) Date of beginning employment.
(4) Past employment, experience, and education, if applicable.
(5) Professional licensure or registration number or dining assistant certificate or
letter of completion, if applicable.
(6) Position in the facility and job description.
(7) Documentation of orientation to the facility, including residents’ rights, and to the
specific job skills.
(8) Signed acknowledgment of orientation to residents’ rights.
(9) Performance evaluations in accordance
(10) Date and reason for separation.
0124 Personnel -Nonconformance
(i) The employee personnel record shall be retained for at least three (3) years
following termination or separation of the employee from employment.