The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe:

(1) Employment criteria regarding discrimination consistent with chapter 49.60 RCW;

(2) Job descriptions that contain responsibilities and are consistent with health care professional credentialing and scope of practice as defined in relevant practice acts and rules;

(3) References for personnel, contractors and volunteers;

(4) Contracting process when using a contractor. The contract should include, at minimum, a description of the duties the contractor will perform, and a statement indicating that the contractor, not the employer, is responsible for withholding any necessary taxes. As with personnel and volunteers, contractors are subject to all applicable requirements in this chapter;

(5) Credentials of health care professionals that are current and in good standing;

(6) Criminal history background checks and disclosure statements for personnel, contractors, volunteers, students, and any other individual associated with the licensee having direct contact with children under sixteen years of age, people with developmental disabilities, or vulnerable persons according to RCW 43.43.830 through 43.43.842 and the following:

(a) Criminal history background checks must be processed through the Washington state patrol;

(b) Disclosure statements must be approved by the department; and

(c) All criminal history background checks and disclosure statements required under this chapter must be renewed within two years from the date of the previous check.

(7) Character, competence, and suitability determination conducted for personnel, contractors, volunteers, and students whose background check results reveal nondisqualifying convictions, pending charges, or negative actions. Factors to consider when making a determination include, but are not limited to:

(a) Whether there is a reasonable, good faith belief that they would be unable to meet the care needs of the patient;

(b) Level of vulnerability of the patient under their care;

(c) Behaviors since the convictions, charges, negative actions or other adverse behaviors;

(d) Pattern of offenses or other behaviors that may put the patient at risk;

(e) Number of years since the conviction, negative action, or other issue;

(f) Whether they self-disclosed the conviction(s), pending charge(s) and/or negative action(s);

(g) Other health and safety concerns; and

(h) Although a licensee may determine, based on their assessment process, that an employee is suitable to work with vulnerable patients, the department has the final authority to deny, revoke, modify, or suspend any professional credential it issues based on application and criminal background check information.

(8) Mandatory reporting:

(a) Mandatory reporters shall report failure to comply with the requirements of chapters 246-335 WAC and 70.127 RCW to the department. The report must be submitted on department forms. Reports must be submitted within fourteen calendar days after the reporting person has knowledge of noncompliance that must be reported;

(b) Mandatory reporters shall report suspected abandonment, abuse, financial exploitation, or neglect of a person in violation of RCW 74.34.020 or 26.44.030 to the department of social and health services and the proper law enforcement agency. Reports must be submitted immediately when the reporting person has reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred.

(9) In-person orientation to current agency policies and procedures and verification of skills or training prior to independently providing patient care. Examples of skills verification include written testing, skills observation, and evidence of previous training and experience such as the nursing assistant training detailed in WAC 246-841-400;

(10) Training on the use of telehealth or telemedicine for patient consultation and the transmission of health data, if applicable;

(11) Ongoing training pertinent to patient care needs;

(12) Safe food storage, preparation and handling practices consistent with the United States Food and Drug Administration's recommendations for "food safety at home" for personnel, contractors, and volunteers involved in food preparation services on behalf of patients. Personnel, contractors, and volunteers may not provide patients with homemade food items or baked goods that they themselves prepared;

(13) Current cardiopulmonary resuscitation (CPR) training consistent with agency policies and procedures for direct care personnel and contractors. Internet-based classroom training is only permissible when the demonstration of skills is hands on and observed by a certified trainer;

(14) Infection control practices, communicable disease testing, and vaccinations. Policies and procedures must include, at minimum:

(a) Standard precautions such as hand hygiene, respiratory hygiene and cough etiquette, and personal protective equipment;

(b) Availability of personal protective equipment and other equipment necessary to implement client plans of care;

(c) Tuberculosis (TB) infection control program. Key elements include, but are not limited to:

(i) Conducting a TB risk assessment for all new employees upon hire. Agencies must use a tuberculosis risk assessment form provided by the department. Based on risk assessment results, determine the agency's responsibility to conduct TB testing of new employees. If TB testing is required, follow the department's tuberculosis risk assessment form testing recommendations;

(ii) Conducting an annual assessment of new TB risk factors for all employees. Agencies must use a tuberculosis risk assessment form provided by the department. Based on risk assessment results, determine agency's responsibility to conduct TB testing of employees. Retesting should only be done for persons who previously tested negative and have new risk factors since the last assessment; and

(iii) Ensuring workers receive TB related training and education at the time of hire or during new employee orientation. Training and education must be consistent with the department's Tuberculosis program's online posted educational materials.

(d) Actions to take when personnel, volunteers, contractors, or clients exhibit or report symptoms of a communicable disease in an infectious stage in accordance with chapters 246-100 and 246-101 WAC;

(e) Exposure to bloodborne pathogens such as Hepatitis B and HIV, and other potentially infectious materials in compliance with the department of labor and industries chapter 296-823 WAC. Key elements include, but are not limited to:

(i) Conducting an initial risk assessment of the environment in which personnel, volunteers, and contractors perform their assigned duties to determine occupational exposure. The results of the risk assessment will inform policy and procedure development and level of employee training and education. Annually, agencies must determine if significant changes have occurred that would require a new risk assessment to be performed;

(ii) If the risk assessment concludes that workers have a reasonably anticipated risk of occupational exposure to blood and other potentially infectious materials, agencies must offer workers the Hepatitis B vaccine series at the agency's expense. Workers have the right to decline the Hepatitis B vaccine series; and

(f) Agencies must document an annual review of applicable state and federal health authority recommendations related to infection control practices, communicable disease testing, and vaccinations and update trainings and policies and procedures as necessary.

(15) Annual performance evaluations of all personnel and volunteers providing direct patient care, including on-site observation of care and skills specific to the care needs of patients; and

(16) Annual evaluations of services provided by contractors providing direct patient care.