The licensee shall:

(1) Employ sufficient, qualified staff to:

(a) Provide adequate patient services;

(b) Maintain the hospital free of safety hazards; and

(c) Implement fire and disaster plans;

(2) Develop and maintain a written job description for the administrator and each staff position;

(3) Maintain evidence of appropriate qualifications and current credentials prior to hiring, or granting or renewing clinical privileges or association of any health care professional;

(4) Verify work references prior to hiring staff;

(5) Assure all patient-care staff including those transporting patients and supervising patient activities, except licensed staff whose professional training exceeds first-responder training, have within thirty days of employment:

(a) Current cardiopulmonary resuscitation cards from instructors certified by the American Red Cross, American Heart Association, United States Bureau of Mines, or Washington state department of labor and industries; and

(b) Current first-aid cards from instructors certified as in (a) of this subsection;

(6) Provide and document orientation and appropriate training for all staff, including:

(a) Organization of the hospital;

(b) Physical layout of hospital, including buildings, departments, exits, and services;

(c) Fire and disaster plans, including monthly drills;

(d) Infection control;

(e) Specific duties and responsibilities;

(f) Policies, procedures, and equipment necessary to perform duties;

(g) Patient rights according to chapters 71.05 and 71.34 RCW and patient abuse;

(h) Managing patient behavior; and

(i) Appropriate training for expected duties;

(7) Make available an ongoing, documented, in-service education program, including but not limited to:

(a) For each staff person, training to maintain and update competencies needed to perform assigned duties and responsibilities; and

(b) For patient care staff, in addition to (a) of this subsection, the following training:

(i) Methods of patient care;

(ii) Using the least restrictive alternatives;

(iii) Managing assaultive and self-destructive behavior;

(iv) Patient rights pursuant to chapters 71.05 and 71.34 RCW;

(v) Special needs of the patient population, such as children, minorities, elderly, and individuals with disabilities;

(vi) Cardiopulmonary resuscitation; and

(vii) First-aid training;

(8) When volunteer services are used within the hospital:

(a) Designate a qualified employee to be responsible for volunteer services;

(b) Provide and document orientation and training according to subsections (6) and (7) of this section for each volunteer; and

(c) Provide supervision and periodic written evaluations of each volunteer working directly with patients;

(9) In addition to following WISHA requirements, protect patients from tuberculosis by requiring each staff person to have upon employment or starting service, and each year thereafter during the individual's association with the hospital:

(a) A tuberculin skin test by the Mantoux method, unless the staff person:

(i) Documents a previous positive Mantoux skin test, which is ten or more millimeters of induration read at forty-eight to seventy-two hours;

(ii) Documents meeting the requirements of this subsection within the six months preceding the date of employment; or

(iii) Provides a written waiver from the department or authorized local health department stating the Mantoux skin test presents a hazard to the staff person's health;

(b) A second test one to three weeks after a negative Mantoux skin test for staff thirty-five years of age or older; and

(c) A chest X-ray within seven days of any positive Mantoux skin test;

(10) Report positive chest X-rays to the appropriate public health authority, and follow precautions ordered by a physician or public health authority;

(11) Restrict a staff person's contact with patients when the staff person has a known communicable disease in the infectious stage which is likely to be spread in the hospital setting or by casual contact; and

(12) Maintain a record on the hospital premises for each staff person, during employment and for two years following termination of employment, including but not limited to:

(a) An employment application;

(b) Verification of required education, training and credentials;

(c) Documentation of contacting work references as required by subsection (4) of this section;

(d) Criminal history disclosure and background checks as required in WAC 246-324-030;

(e) Verification of current cardiopulmonary resuscitation, first-aid and HIV/AIDS training;

(f) Tuberculin test results, reports of X-ray findings, exceptions, physician or public health official orders, and waivers; and

(g) Annual performance evaluations.