Each agency licensed by the department to provide any behavioral health service must maintain a personnel record for each person employed by the agency.

(1) The personnel record must contain all of the following:

(a) Documentation of annual training, including documentation that the employee successfully completed training on cultural competency.

(b) A signed and dated commitment to maintain patient (individual) confidentiality in accordance with state and federal confidentiality requirements.

(c) A record of an orientation to the agency that includes all of the following:

(i) An overview of the agency's policies and procedures.

(ii) The duty to warn or to take reasonable precautions to provide protection from violent behavior when an individual has communicated an actual imminent threat of physical violence against a reasonably identifiable victim or victims. Taking reasonable precautions includes notifying law enforcement as required and allowed by law.

(iii) Staff ethical standards and conduct, including reporting of unprofessional conduct to appropriate authorities.

(iv) The process for resolving client complaints and grievances.

(d) A copy of the staff member's valid current credential issued by the department for their scope of practice.

(2) Staff members who have received services from the agency must have personnel records that:

(a) Are separate from clinical records; and

(b) Have no indication of current or previous service recipient status.