(a) Each facility, with the exception of
birth centers, hospice agencies that do not provide inpatient care on agency
premises, and intermediate care facilities for the mentally retarded, must have
a governing body that assumes responsibility for implementing and monitoring
policies that govern the facility's operation and for ensuring that those
policies are administered in a manner that provides quality health care in a
safe environment. The facility must provide to the department the name, title,
and mailing address for
(1) each owner of the
facility;
(2) each person who is
principally responsible for directing facility operations; and
(3) the person responsible for medical
direction.
(b) The
governing body shall
(1) adopt, and revise
when necessary, written bylaws providing for
(A) election or appointment of officers and
committees;
(B) appointment of a
local advisory board if the governing body is outside the state; and
(C) frequency of meetings;
(2) appoint an administrator, in
accordance with written criteria;
(3) maintain written records on the
appointment of members to the medical staff, and the granting of privileges
based on the recommendations of the medical staff;
(4) require medical staff to sign an
agreement to follow the bylaws of the medical staff;
(5) establish appeal procedures for
applicants for and members of the medical staff;
(6) provide resources and personnel as
necessary to meet patient needs; and
(7) provide adequate equipment and supplies
for the facility.
(c) In
addition to meeting the responsibilities of a governing body set out at (b) of
this section, the governing body of a critical access hospital shall
(1) make agreements with one or more
appropriate entities identified in
42 C.F.R.
485.603(c), as amended
through July 1, 1999 and adopted by reference, for credentialing of medical
staff and for review of the quality and effectiveness of the diagnosis and
treatment furnished by medical staff at the hospital; and
(2) if the hospital provides inpatient care
through mid-level practitioners under the offsite supervision of a physician,
participate in a rural health network as described in
42 C.F.R.
485.603(a), as amended
through July 1, 1999 and adopted by reference, and enter agreements with other
members of the network addressing the subjects described in
42 C.F.R.
485.603(b), as amended
through July 1, 1999 and adopted by reference.
