Current through Register Vol. 49, No. 9, September, 2024
SECTION 1:
AUTHORITY.
The following Rules and Regulations for Hospitals
and Related Institutions in Arkansas are duly adopted and
promulgated by the Arkansas State Board of Health pursuant to the authority
expressly conferred by the laws of the State of Arkansas in Ark. Code Ann.
§§
20-9-201 et.seq.,
20-7-123, and other laws of the
State of Arkansas.
SECTION
2:
PURPOSE.
These rules and regulations have been prepared for the purpose
of establishing a criterion for minimum standards for licensure, operation and
maintenance of hospitals and related institutions in Arkansas that is
consistent with current trends in patient care practices. By necessity they are
of a regulatory nature but are considered to be practical minimum design and
operational standards for these facilities. These standards are not static and
are subject to periodic revisions in the future as new knowledge and changes in
patient care trends become apparent. However, it is expected that facilities
will exceed these minimum requirements and that they shall not be dependent
upon future revisions in these standards as a necessary prerequisite for
improved services. Hospitals and related institutions have a strong moral
responsibility for providing optimum patient care and treatment for the
populations they serve.
SECTION
3:
DEFINITIONS.
The word shall as used in these regulations means
mandatory.
A. Administrator means the
person responsible for the management of any facility requiring licensure under
these regulations.
B. Department
means the Arkansas Department of Health.
C. Licensee means the person to whom a
license is issued for the purpose of operating the institution described in the
application for licensure, who shall be responsible for maintaining approved
standards for the institution of any state, county or local government unit and
any division, board or agency thereof.
D. State Health Officer means the Secretary
of the State Board of Health.
The following categories of facilities (G-Q), as defined
herein, established for the purpose of providing inpatient diagnostic care and
treatment for more than 24 hours for two or more persons not related to the
proprietor, may not be conducted or maintained in this state without being
licensed.
E. Alcohol/Drug
Abuse Inpatient Treatment Centers means a facility or distinct part of a
facility, in which services are provided for the diagnosis, treatment and
rehabilitation of alcohol and drug abuse; a facility which provides only
counseling and room and board is not included in this definition.
1. For the purpose of these regulations an
alcohol/drug abuse treatment center is a facility (either licensed as a
hospital or an established diagnostic unit of an acute psychiatric or
rehabilitation hospital) or a free-standing unit in which services are provided
over a continuous period, exceeding 24 hours for two or more persons not
related to the proprietor for the diagnosis, treatment and rehabilitation of
alcohol and drug abuse.
2. Alcohol
and drug abuse inpatient center regulations are to be applied in conjunction
with the Rules and Regulations for Hospitals and Related
Institutions in Arkansas where applicable. (See Section 45,
Alcohol/Drug Abuse Inpatient Treatment Centers.)
3. The requirements established for
alcohol/drug abuse inpatient treatment centers shall not be construed as
changes in the requirements already established for licensing of any health
care facility as delineated in these regulations.
F. Critical Access Hospital (CAH) means a
hospital located in a rural area that is:
1.
Located more than a 35 mile drive (or, in the case of mountainous terrain or in
areas with only secondary roads available, a 15 mile drive) from a hospital;
or
2. Provides 24 hour emergency
care services as determined necessary for ensuring access to emergency care in
each area served by a CAH;
3.
Provides staffing according to Rules and Regulations for Hospitals
and Related Institutions in Arkansas; and
4. Meets Centers for Medicare and Medicaid
Services (CMS) Conditions of Participation for Critical Access Hospitals;
or
5. Was operating as a licensed
Critical Access Hospital in Arkansas as of April 2007.
G. When a hospital converts to a CAH and then
at a later date decides to return to a full service with no limits on bed or
length of stay, the hospital shall be surveyed using the Life Safety Code under
which the hospital entered into the CAH program. The hospital shall be able to
show that it has continued to be licensed and complied consistently with the
Life Safety Code as a CAH.
H.
Emergency Services Facility means a facility that is licensed only for
emergency services. The Department is empowered to license hospitals which have
discontinued inpatient services to continue to provide emergency services if
there is no other hospital emergency service in the community Ark. Code Ann.
§
20-9-218.
I. General Hospital means any facility used
for the purpose of providing short-term inpatient diagnostic care and
treatment, including general medical care, surgical care, obstetrical care and
specialized services or specialized treatment.
J. Infirmary means any facility used for the
purpose of offering temporary medical care and/or treatment exclusively for
persons residing on a designated premise, e.g., schools, reformatories,
prisons, etc. and where the persons are kept for 24 hours or more.
K. Institution means, for the purpose of
these regulations, a facility which requires a license.
L. Maternity and General Medical Care
Hospital means any facility limited to providing short-term inpatient
obstetrical and general medical diagnostic care and treatment.
M. Maternity Hospital means any facility
limited to providing short-term inpatient obstetrical diagnostic care and
treatment.
N. Psychiatric Hospital
means any facility, or a distinct part of a facility, used for the purpose of
providing inpatient diagnostic care and treatment for persons having mental
disorders.
O. Recuperation Center
means any facility or distinct part of a facility, which includes inpatient
beds with an organized Medical Staff, and with medical services that include
physician services and continuous nursing services to provide treatment for
patients who are not in an acute phase of illness but who currently require
primarily convalescent or restorative services (usually post-acute hospital
care of relatively short duration). A facility that furnishes primarily
domiciliary care is not within this definition.
P. Rehabilitation Facility means, for the
purpose of these regulations, an inpatient care facility or a distinct part of
a facility, which provides rehabilitation services for two or more disabled
persons not related to the proprietor, for more than 24 hours through an
integrated program of medical and other restorative services. A disabled person
shall be considered to be an individual who has a physical or mental condition
which, if not treated, will probably result in limiting the performance or
activity of the person to the extent of constituting a substantial physical,
mental or vocational handicap.
Q.
Surgery and General Medical Care Hospital means any facility limited to
providing short-term inpatient surgical and general medical diagnostic care and
treatment.
The following categories (Q-R) of outpatient facilities may not
be conducted or maintained in this state without being licensed:
R. Outpatient Psychiatric Center
means a facility in which psychiatric services are offered for a period of 4 to
16 hours a day, and where, in the opinion of the attending psychiatrist,
hospitalization as defined in the present licensure law is not necessary. This
definition shall not include Community Mental Health Clinics and Centers, as
they now exist. The requirements established for outpatient psychiatric centers
shall not be construed as changes in the requirements already established for
the licensing of any health care facility, as delineated in these
Regulations.
S. Outpatient Surgery
Center (Ambulatory Surgery Center) means any facility in which surgical
services, other than minor dental surgery, are offered which require the use of
general or intravenous anesthetics and/or render the patient incapable of
taking actions for self-preservation under emergency conditions without
assistance from others, and where, in the opinion of the attending physician,
hospitalization is not necessary.
T. Observation is a designated patient status
as opposed to a designated area. Patients in observation status are those
patients requiring periodic monitoring and assessment necessary to evaluate the
patient's condition or to determine the need for possible admission to the
hospital in an inpatient status. Usually observation status shall be for 48
hours or less.
SECTION
4:
LICENSURE AND CODES.
A. Necessity for License. No hospital or
distinct part, recuperation center or distinct part, infirmary, rehabilitation
facility or distinct part, outpatient surgery center, or alcohol/drug abuse
inpatient treatment center or distinct part, outpatient psychiatric center or
emergency services facility, as defined in Section 3, Definitions, may be
established, conducted or maintained in the State without first obtaining a
license, with the exception of the following:
1. A facility operated by the Federal
Government; and
2. A First Aid
Station.
B. Application
for License.
1. An applicant shall file
applications under oath with the Department upon forms provided by Health
Facility Services and shall pay annual license fee as indicated by Ark. Code
Ann. §
20-9-214.
2. These fees shall be paid into the State
Treasury or refunded to the applicant if a license is denied. The application
shall be signed by the owner, if an individual or partnership, or in the case
of a corporation, by two of its officers, or in the case of a governmental
unit, by the head of the governmental department having jurisdiction over it.
The application shall set forth the full name and address of the institution
for which license is sought and such additional information as the Department
may require, including affirmative evidence of ability to comply with such
reasonable standards, rules and regulations as may be lawfully prescribed
hereunder. The application for annual license renewal shall be postmarked no
later than January 2 of the year for which the license is issued. The license
applicant for an existing institution postmarked after the date shall be
subject to a penalty of one dollar per day for each day and every day after
January 2.
3. A license issued
hereunder shall be effective on a calendar year basis and shall expire on
December 31 of each calendar year. A license shall be issued only for the
premises and persons in the application and shall not be transferable. If the
facility changes ownership the license shall expire. The license shall be
posted in a conspicuous place on the licensed premises. A license issued under
previous regulations shall be effective through the period for which it was
issued. The adequacy of cooperative agreements between hospitals in terms of
service provided by each hospital and the type of licenses issued to each
hospital shall be determined by the Arkansas Department of Health..
C. Facility Change of Ownership.
1. It shall be the responsibility of the
licensed entity to notify Health Facility
Services in writing at least 30 days prior to the effective
date of change of ownership.
2. The following information shall be
submitted to Health Facility Services for review and approval:
a. License application;
b. Request for Medicare Certification (where
applicable);
c. Legal documents,
ownership agreements, the license previously issued to the facility and other
information to support relicensure requirements; and
d. Licensure fee as indicated by Ark. Code
Ann. 20-9-214.
3. For the purpose of these regulations the
licensed entity is the party ultimately responsible for operating the facility.
The same entity also bears the final responsibility in decisions made in the
capacity of a Governing Body and for the consequences of these
decisions.
D. Facility
Name Change and/or Address.
1. The facility
shall notify Health Facility Services of any name and/or address
change;
2. The previously issued
license shall be returned to Health Facility Services; and
3. A fee, as indicated in Ark. Code Ann.
20-9-214, shall be submitted to
Health Facility Services for issuance of a new license.
E. Management Contract.
1. It shall be the responsibility of the
licensed entity to notify Health Facility Services in writing at least 30 days
prior to entering into a management contract or agreement with an organization
or firm. A copy of the contract or agreement shall also be submitted to Health
Facility Services for review to assure the arrangement does not materially
affect the license status.
2. An
organization or firm who contracts with the licensed entity to manage the
health care facility, subject to Governing Body approval of operational
decisions, is generally considered an agent rather than an owner. In such
instances a licensure change is not required.
F. Separate License. An individual license
shall be required for an institution maintained on separate premises even
though it is operated under the same management, except in cases where the
hospital management of a general hospital operates a detached building which
can be utilized in a limited way for general medical care. Separate licenses
are not required for separate buildings on the same grounds.
G. Temporary License. This license shall be
for less than one year and for a time specified on the temporary license by the
Department.
H. Revocation of
License. The Department is empowered to deny, suspend or revoke a license on
any of the following grounds:
1. Violation of
any of the provisions of Ark. Code Ann. §§
20-9-201 et. Seq.;
20-7-123 or the Rules and
Regulations lawfully promulgated hereunder; or
2. Permitting, aiding or abetting the
commission of any unlawful act in connection with the operation of the
institution. (Ark. Code Ann. §
20-9-215)
3. The right of appeal of any revocation
shall be as specified in the appeal procedure of the Arkansas Department of
Health.
NOTE: If services are to be temporarily suspended, afunctional
program, with plans and specifications as applicable, shall be submitted to
Health Facility Services for approval prior to such suspension.
I. Inspection. Any
authorized representative of the Department shall have the right to enter the
premises of any institution at any time in order to make whatever inspection
necessary in accordance with the minimum standards and regulations prescribed
herein.
J. Penalties.
1. Any person, partnership, association, or
corporation which establishes, conducts, manages, or operates any institution
defined herein, without first obtaining a license therefore as herein provided
or who violates any portion of this act or regulations lawfully promulgated
hereunder, shall be guilty of a misdemeanor and upon conviction thereof shall
be liable to a fine of not less than $25.00 nor more than $100.00 for the first
offense and not less than $100.00 nor more than $500.00 for each subsequent
offense and each day such institution operates after a first conviction shall
be considered a subsequent offense. (Ark. Code Ann. §
20-9-202.)
2. Any institution licensed by the authority
of these regulations that has received damage due to fire, tornado, earthquake,
man-made or natural disaster shall notify the Department by telephone
immediately and follow with a preliminary report within 48 hours and a complete
report when the incident has been thoroughly investigated. The submitted report
shall include, but not be limited to, damage to the building, damage estimates,
injuries to patients, staff and the public, etc. If the Department is not
notified, the institution shall be assessed a fine in the amount of $50.00 for
each day, or portion thereof, the incident is not reported or $500.00
maximum.
K. Codes. See
Section 47, Physical Facilities, K. List of Referenced Publications.
SECTION 5:
GOVERNING
BODY.
An institution shall have an organized Governing Body which
shall be legally responsible for maintaining quality patient care and
establishing policies for the facility. The Governing Body shall be legally
responsible for the conduct of the institution.
A. Governing Body Bylaws. The Governing Body
shall adopt written bylaws which shall be available to all members of the
Governing Body. The bylaws shall ensure:
1.
Maintenance of proper standards of professional work in the hospital;
2. The Medical Staff functions in conformity
with reasonable standards of competency;
3. The method of selecting members and
officers with terms and responsibilities delineated;
4. The selection of an Administrator or Chief
Executive Officer with responsibilities for operation and maintenance of the
facility delineated. In the absence of the Administrator, an alternate with
authority to act shall be designated;
5. Methods for establishing Governing Body
committees with the duties of each committee delineated;
6. Coordination of activities and general
policies of the departments and special committees;
7. Liaison between the Governing Body and
Medical Staff with quarterly documentation;
8. Quarterly Governing Body meetings with
maintenance of minutes signed by an officer;
9. Provision for formal approval of the
organization, bylaws, rules and regulations of the Medical Staff and their
services;
10. Admission of patients
by a physician, patient choice of physician and/or dentist and emergency care
by a physician. All institutions governed by these standards shall arrange for
one or more persons duly licensed to practice medicine to be called in an
emergency. All individuals, who are not hospital employees, who make entries
into the medical record, shall be credentialed through the Medical
Staff;
11. A method of
credentialing or appointing members to the Medical Staff and other authorized
staff;
12. Methods by which Quality
Assurance/Performance Improvement (QA/PI) is established; and
13. Establishment of a quorum to be met in
order to conduct business.
B. Governing Body Minutes. The Governing Body
minutes shall include at least the following information:
1. Review, approval and revision of the
Governing Body bylaws and the Medical Staff bylaws, Rules and
Regulations;
2. Election of
officers, as indicated in the bylaws;
3. Documentation that the liaison between the
Governing Body and Medical Staff is maintained;
4. Appointment and reappointment of the
Medical Staff and other authorized staff as indicated in the bylaws;
5. Review and approval of the hospital's
annual operating budget and capital expenditure plan;
6. Review and approval of reports received
from the Medical Staff and Administration; and
7. Review and approval of the Quality
Assurance/Performance Improvement (QA/PI) plan of the facility, at least
annually, also documentation of the quarterly Quality Assurance/Performance
Improvement (QA/PI) summaries.
SECTION 6:
MEDICAL STAFF.
All persons admitted and discharged to any institution governed
by these standards shall be under the care of a person duly licensed to
practice medicine in Arkansas (hereafter called physician). In institutions
where two or more physicians are allowed to practice there shall be an
organized Medical Staff. Members of the staff shall be qualified legally and
professionally for the positions to which they are appointed. Individuals who
are not hospital employees, who work in the hospital shall be credentialed
through the Medical Staff with approval from the Governing Body. (Refer to
Section 36, Specialized Services: Emergency Services.)
Note: See Ark. Code Ann. §
17-95-107 regarding requirements
for health care organizations that credential physicians/authorized staff to
use the Arkansas State Medical Board's Centralized Credentials Verification
Service (CCVS).
A. Credential Files of
the Medical Staff and Other Authorized Staff. An individual file shall be
maintained for each physician/other authorized staff practicing in the hospital
and shall include at least the following:
1.
Verification of age, year, and school of graduation and statement of
postgraduate or special training and experience;
2. Specific delineation of privileges
requested and granted;
3. A
detailed application signed by the applicant, the Chairman of the Credentials
Committee and an officer of the Governing Body;
4. Documentation of the applicant's agreement
to abide by the Medical Staff Bylaws and hospital requirements;
5. Verification of current Arkansas
license;
6. Verification of each
applicable physician's Drug Enforcement Agency (DEA) registration;
7. Verification of at least three
references;
8. Documentation of all
actions taken by the Medical Staff and Governing Board indicating the type of
privileges granted, approval of appointment/reappointment and other related
data;
9. Evaluation of members'
professional activities at the time of reappointment; and
10. Non-employee practitioners may be
screened through the Human Resources Department or another hospital designee.
The requested privileges and credentialing shall be approved by the Medical
Staff.
NOTE: Hospitals shall report to the Arkansas State Medical
Board the names of physicians whose hospital privileges have been terminated or
revoked for cause.
B. Medical Staff Bylaws. The Medical Staff
Bylaws shall include at least the following information:
1. A provision stating the Medical Staff
shall be responsible to the Governing Body of the facility for the quality of
medical care provided for patients in the hospital and for the ethical and
professional practices of members;
2. A provision stating the requirements for
medical and other authorized staff membership, including allied health
professionals;
3. A provision
stating the division of the Medical Staff and clinical departments;
4. A provision stating the election of
officers, responsibilities and terms;
5. A provision establishing Medical Staff
committees, functions, frequency of meetings and composition
(quorum);
6. A provision
establishing frequency of general Medical Staff meetings, specifying attendance
requirements;
7. A provision
establishing written minutes be maintained of all Medical Staff meetings and
the minutes shall be signed by the physician chairman;
8. A provision for an appeals process which
delineates the procedures for a physician or other authorized staff to follow
in challenging staff, that if ratified by the Governing Body, adversely affects
his/her appointment or reappointment to the Medical Staff;
9. A provision establishing the designation
of a specific physician who shall direct each clinical/diagnostic
service;
10. A provision
delineating requirements for maintaining accurate and complete medical records.
(See Health Information Services, Section 14.);
11. A provision for approval of the bylaws
and amendments by the Medical Staff and the Governing Body; and
12. Documentation of appointments,
reappointments and approval of requested privileges to the medical and other
authorized staff as specified in the bylaws, but at least every two
years.
C. Medical Staff
Minutes. Medical Staff minutes shall include at least the following:
1. Documentation of review of committee
reports including quarterly Quality Assurance/Performance Improvement
(QA/PI);
2. Review, approval and
revision of the Medical Staff Bylaws and Rules and Regulations;
3. Election of officers as specified by the
Bylaws; and
4. Documentation of
physicians designated as chairmen of the committees to direct the services
defined in the Medical Staff bylaws.
D. Quality Assurance/Performance Improvement
(QA/PI).
1. The organization shall develop,
implement and maintain an ongoing program to assess and improve the quality of
care and services provided. A multidisciplinary committee shall meet at least
quarterly to provide oversight and direction for the program; the hospital
shall maintain minutes of the meetings. A Quality Assurance/Performance
Improvement Plan shall be developed and maintained to describe the manner in
which QA/PI activities shall be conducted in the hospital. The QA/PI plan shall
be reviewed and approved by the Chief Executive Officer, Medical Staff and
Governing Body annually.
a. All hospital and
Medical Staff programs, services, departments and functions, including
contracted services related to patient care, shall participate in ongoing
quality assurance/performance improvement activities.
b. The hospital shall collect and assess data
on the functional activities identified as priorities in the QA/PI
plan.
c. Data collected shall be
benchmarked against past performance and/or national or local
standards.
d. Improvement
strategies shall be developed for programs, services, departments and functions
identified with opportunities for improvement.
e. The effectiveness of improvement
strategies and actions taken shall be monitored and evaluated, with
documentation of conclusions regarding effectiveness.
f. Identify and reduce medical errors and
adverse patient events.
g. Approved
organizational abbreviation list.
2. Scope of QA/PI Program. The QA/PI program
shall include, but not be limited to, ongoing assessment and improvement
activities regarding the following:
a. Access
to care, processes of care, outcomes of care and hospital-specific clinical
data, including applicable Peer Review Organization (PRO)/Quality
Assurance/Performance Improvement Organization (QA/PIO) data;
b. Customer satisfaction (patients and
families, physicians and employees);
c. Staff performance as it relates to the
staff as a whole when reviewing aspects of care;
d. Complaint resolution;
e. Utilization and discharge planning data;
and
f. Organizational
performance.
3. Program
Responsibilities. The Governing Body shall assume overall responsibility and
accountability for the organization-wide QA/PI program. The Governing Body,
Chief Executive Officer and Medical Staff shall ensure QA/PI activities,
address identified priorities and be responsible for the development,
implementation, monitoring and documentation of improvement
activities.
4. Reporting. QA/PI
activities shall be reported to the Governing Body on at least a quarterly
basis and shall be documented in the Governing Body meeting minutes.
5. Policies and Procedures. Policies and
procedures pertaining to the QA/PI program which are not contained within the
QA/PI plan shall be maintained in a manual, reviewed and approved
annually.
6. Program Evaluation. An
evaluation of the QA/PI program shall be conducted by the hospital and reported
to the Governing Body annually. The evaluation shall be based upon objective
data and shall include programs, services, departments and functions targeted
by the hospital for improvement, as well as those conducting ongoing QA/PI
activities. Changes in the QA/PI program and QA/PI plan shall be made in
response to the evaluation.
E. Discharge Planning. There shall be an
ongoing plan, consistent with available community and hospital resources, to
provide or make available social work, psychological and educational services
to meet the medically-related needs of the patients and to facilitate the
provision of follow-up care.
1. Discharge
planning shall be initiated at the time of the patient's admission.
2. The patients, along with necessary medical
information, shall be transferred or referred to appropriate facilities,
agencies or outpatient services as needed, for follow-up or ancillary
care.
3. There shall be a policy
and procedure developed for discharge planning.
F. Organ and Tissue Donation. The Governing
Body of each Acute Care Hospital shall cause to be developed appropriate
policies, procedures, and protocols for identifying and referring potential
organ and tissue donors. The written policies and procedures shall include but
not be limited to the following subjects:
1.
Determination and declaration of brain death;
2. Organ procurement procedures:
a. Identifying potential donors;
b. Referring potential donors; and
c. Obtaining consent.
3. Role of attending physician;
4. Role of the procurement coordinator
(employee of procurement agencies);
5. Reimbursement for cost of
donation;
6. Liabilities associated
with donation;
7. Agreement with
organ procurement agency designated by Center for Medicare and Medicaid
Services (CMS);
8. A consent
procedure which encourages reasonable discretion and sensitivity to the family
circumstances in all decisions regarding organ and tissue donations;
9. Determination by the organ procurement
agency personnel of the suitability of the organs and/or tissues for
transplantation; and
10.
Requirements for documentation in the patient's medical record that the family
of a potential organ donor has been advised of their right to donate or decline
to donate.
SECTION
7:
GENERAL ADMINISTRATION.
A. Each institution shall have an
Administrator responsible for the management of the institution. In the absence
of the Administrator, an alternate with authority to act shall be designated.
The responsibilities of the Administrator shall include:
1. Keeping the Governing Body fully informed
of the conduct of the hospital by submitting periodic written reports or by
attending meetings of the Governing Body;
2. Conducting interdepartmental meetings at
regular intervals and maintaining minutes of the meetings;
3. Preparing an annual operating budget of
anticipated income and expected expenditures; and
4. Preparing a capital expenditure plan for
at least a three year period.
B. Policies and procedures shall be provided
for the general administration of the institution and for each department,
section or service in the facility. All policies and procedures for departments
or services shall have evidence of ongoing review and/or revision. The first
page of each manual shall have the annual review date signature of the
department supervisor and/or person(s) conducting the review.
C. An accurate daily patient census sheet as
of midnight shall be available to the Department at all times.
D. The facility shall have visitation
policies determined by the Medical Staff, Governing Body and Administration
which shall include:
1. Limitation when
patient care is hindered or disrupted; and
2. Development by the Governing Body with
advice from the Medical Staff and Infection Control Committee regarding persons
under the age of 12 who visit critical care areas of the hospital.
E. Provisions shall be made for
safe storage of patients' valuables.
F. Animals such as cats, dogs, birds and fish
and aquatic animals shall not be permitted in health care facilities.
Exceptions shall be made for service animals, animals that participate in pet
therapy,fish and aquatic animals in approved aquariums. (See Section 25, Pet
Therapy Program.) All exceptions shall be approved by Health Facility Services.
1. Service animals shall be permitted only
under the following guidelines:
a. Only
animals specifically trained as service animals shall be allowed into the
facility.
b. Service animals shall
not be allowed into the facility if they are unhealthy, feverish, or suffer
from gastroenteritis, fleas or skin lesions.
c. Healthy, well-groomed animals shall be
allowed to enter the facility into areas that are generally accessible to the
public (i.e., lobbies, cafeteria, and nurses stations on unrestricted units).
The owner of the animal shall be directed to inquire about the possibility of a
visit before entering a patient's room. Authorization to visit shall be given
by a unit supervisor.
d. Service
animals shall be walked before entering the facility or shall be diapered in a
manner to prevent contamination of the facility environment with excreta.
Service animals shall not be fed within the facility.
e. Petting or playing with service animals by
hospital personnel or patients shall be prohibited.
f. Owners of service animals shall be
instructed to wash their hands before having patient contact.
g. Visiting with service animals shall be
restricted in the following circumstances:
1)
The patient is in isolation for respiratory, enteric or infectious diseases or
is in protective isolation;
2) The
patient, although not in protective isolation, is immunocompromised or has a
roommate that is;
3) The patient is
in an intensive care unit, burn unit or restricted access unit of the
hospital;
4) The patient or
roommate is allergic to animals or has a severe phobia; and
5) The patient or roommate is psychotic,
hallucinating or confused or has an altered perception of reality and is not
amenable to rational explanation.
h. Animals which become loud, aggressive or
agitated shall be removed from the facility immediately.
2. Fish and aquatic animals shall not be
permitted in health care facilities without prior written approval by Health
Facility Services. Aquariums shall be approved by the Medical Staff and
Infection Control Committee. (Turtles will not be considered for approval.)
a. Aquariums shall meet the following
requirements:
1) Aquariums shall be
self-contained, shock proof, break proof and quiet in operation.
2) Aquariums shall be constructed or
positioned in such a manner as to be leak-proof, spill proof and to preclude
patients or staff from having direct contact with the animals or water in the
aquarium.
3) Aquariums and
associated equipment shall be cleaned frequently by appropriately trained
personnel who do not have direct contact with patients or patient care
items.
4) Aquariums shall be placed
only in areas which are accessed by the general public. Aquariums shall not be
placed in critical care areas (i.e., nursing stations, surgery, patient rooms,
ICU, etc.)
5) Aquariums shall be
kept in a state of good repair at all times.
b. There shall be written procedures for
cleaning and caring for the aquarium.
c. There shall be written procedures for
dealing with clean up in the event there is a major accident concerning the
aquarium.
d. Fish or aquatic
animals shall be of varieties that do not bite, sting and are considered
non-toxic or non-poisonous.
G. Each facility shall develop and maintain a
written disaster plan which includes provisions for complete evacuation of the
facility and care of mass casualties. The plan shall provide for widespread
disasters as well as for a disaster occurring within the local community and
hospital facility. The disaster plan shall be rehearsed at least twice a year,
preferably as part of a coordinated drill in which other community emergency
agencies participate. One drill shall simulate a disaster of internal nature
and the other external. Written reports and evaluation of all drills shall be
maintained.
H. There shall be a
posted list of names, telephone numbers and addresses available for emergency
use. The list shall include the key hospital personnel and staff, the local
police department, the fire department, ambulance service, Red Cross and other
available emergency units. The list shall be reviewed and updated at least
every six months.
I. There shall be
rules and regulations governing the routine methods of handling and storing
flammable and explosive agents, particularly in operating rooms, delivery
rooms, laundries and in areas where oxygen therapy is administered.
J. All refrigerated areas, including
freezers, shall be provided with thermometers and records maintained to
document the temperatures checked on a daily or weekly basis, as
required.
K. The facility shall
provide access to appropriate educational references to meet the professional
and technical needs of hospital personnel.
L. A safety committee shall develop written
procedures for the reporting and prevention of safety hazards. The committee
shall meet at least quarterly or more frequently if necessary to fulfill safety
objectives. Minutes of the meeting shall be maintained.
M. All Departments and/or Services shall
receive annual education on safety, fire safety, back safety, infection
control, universal/standard precautions, disaster preparedness and confidential
information.
N. Any hospital or
related institution that closes shall meet the requirements for new
construction in order to be eligible for relicensure. Once a facility closes,
it is no longer licensed. The license shall be immediately returned to Health
Facility Services. To be eligible for licensure all the latest life safety and
health regulations shall be met. Refer to Section 4, Licensure and Codes, item
B., Application for License and item H., Revocation of Licenses.
O. The facility Administrator shall assure
the development of policies and procedures in accordance with Ark. Code Ann.
§
20-9-307 that, upon request of the
patient, an itemized statement of all services shall be provided within 30 days
after discharge or 30 days after request, whichever is later. The policy shall
include a statement advising the patient in writing of his/her right to receive
the itemized statement of all services.
P. The facility shall establish a process for
prompt resolution of patient grievances to include the following:
1. The facility shall inform each patient
whom to contact to file a grievance.
2. The Governing Body shall approve and be
responsible for the effective operation of the grievance process unless
delegated in writing to another responsible individual.
3. The facility shall establish a clearly
explained procedure for the submission of a patient's written or verbal
grievance to the facility.
4. The
grievance process shall specify time frames for review of the grievance and the
provision of a response.
5. The
grievance process shall include a mechanism for timely referral of patient
concerns regarding quality of care to the Quality Assurance/Performance
Improvement Committee.
Q. A physician shall pronounce the patient
dead and document the date, time and cause of death
R. Patient care providers not employed by the
hospital, who are involved in direct patient care, shall follow hospital
policies and procedures.
SECTION
8:
PERSONNEL ADMINISTRATION.
A. Medical Attendance. The name, address and
telephone number of the physician(s) attending each patient shall be recorded
for ready reference.
B. Qualified
Personnel. The hospital shall maintain a sufficient number of qualified
personnel to provide effective patient care and all other related services.
There shall be personnel policies and procedures available. Provisions shall be
made for orientation and continuing education.
C. Minimum Age. Personnel who care for
patients shall be a minimum of 16 years of age. For any exceptions, see Subpart
C of Part 570 of Title 29 of the Code of Federal Regulations, Child Labor
Regulations No. 3.
D. Employee
Health. It shall be the responsibility of Administration, with advice and
guidance from the Medical Staff and/or Infection Control Committee, to
establish and enforce policies concerning pre-employment physicals and employee
health. The policies shall include but are not limited to:
1. Requirements for an up-to-date health file
for each employee;
2. Annual
testing of each employee for tuberculosis. Each employee, regardless of whether
the employee is a reactor, non-reactor or converter shall be tested or
evaluated in accordance with the applicable section of the Tuberculosis Manual
of the Arkansas Department of Health; and
3. Work restrictions placed on hospital
personnel who are known to be affected with any disease in a communicable stage
or to be a carrier of such disease, to be afflicted with boils, jaundice,
infected wounds, diarrhea or acute respiratory infections. Such individuals
shall not work in any area in any capacity in which there is the likelihood of
transmitting disease to patients, hospital personnel or other individuals
within the hospital or a potential of contaminating food, food contact
surfaces, supplies or any surface with pathogenic organisms.
E. The licensure rules and
regulations promulgated by the Arkansas Department of Health for hospitals and
other related institutions shall be available to all personnel. All personnel
shall be instructed in the requirements of the regulations pertaining to their
respective duties.
F. Job
descriptions shall be developed for each employee and shall include the
responsibilities or actual work to be performed. The job descriptions shall
include physical, educational and licensing or certification requirements for
each job.
G. Personnel records
shall be maintained for each employee and shall include current and background
information covering qualifications for employment, records of all required
health examinations, evidence of current registration, certification or
licensure of personnel subject to statutory regulation and an annual job
specific performance evaluation.
SECTION 9:
ADMINISTRATION
REPORTS.
A. All communicable diseases
shall be immediately reported to the Arkansas Department of Health. The
institution shall furnish pertinent required information related to the disease
to the local health unit or Arkansas Department of Health.
B. Occurrences which threaten the welfare,
safety or health of the public such as epidemic outbreaks, poisoning, etc.,
shall be reported either by phone or facsimile to the local or State Health
Officer. The institution shall furnish other pertinent required information
related to the occurrence to the local health unit or Arkansas Department of
Health.
SECTION 10:
PATIENT IDENTIFICATION.
Each patient admitted to the hospital shall have an
identification bracelet applied during the admission process.
SECTION 11:
PATIENT CARE
SERVICE.
A. Organization. Nursing
Services shall be directed by a nurse executive who is a
Registered Nurse qualified by advanced education and management
experience. The nurse executive's education and experience shall be directly
related to the facility's stated mission and to the nursing care needs of the
patient population.
1. The nurse
executive shall have overall authority for the development of organization-wide
nursing standards and policies and procedures that describe how patient care
needs are assessed, evaluated and met.
2. Development and implementation of the
organization's plans for providing nursing care to the patient shall be
approved by the nurse executive.
3.
Policies, procedures and standards shall be defined, documented and accessible
to the nursing staff in a written or electronic format. Each element shall be
approved by the nurse executive or designee prior to implementation.
4. The nurse executive and nursing staff
shall collaborate with appropriate Governing Body, Medical Staff, management
and other clinical leaders in developing, implementing, revising and monitoring
patient care improvement activities.
5. The nurse executive or designee shall be
responsible for orienting and maintaining adequate numbers of qualified staff
for patient care.
6. Staff meetings
shall be conducted at least monthly for the purpose of reviewing the quality of
nursing care provided. Meeting minutes and attendance shall be
maintained.
7. If the organization
provides clinical facilities for nursing students, there shall be a written
agreement that defines:
a. The facility's
responsibilities; and
b.
Responsibilities of the educational institution, including supervision of
students and responsibilities of the instructor.
8. Clinically relevant educational programs
shall be conducted at regularly scheduled intervals with not less than 12 per
year. There shall be documentation which includes program content, presenter,
date presented and signatures of attendees.
9. There shall be a continuous QA/PI program
that is specific to the patient care administered. The program shall reflect
nursing staff participation including reports to appropriate hospital
committees.
B.
Qualifications.
1. A current, valid license
to practice nursing in Arkansas shall be held by all nurses hired in the
facility as well as private duty and contract/pool nurses. There shall be a
procedure to assure all licenses are current.
2. Licensed nursing personnel shall practice
under the Nurse Practice Act of the State of Arkansas and current Arkansas
State Board of Nursing Rules and Regulations.
3. The qualifications required for each
category of nursing staff shall be in written policy. Job descriptions shall be
available for review.
4. There
shall be documented evidence of appropriate training for all nonlicensed staff
who are assigned patient care duties.
5. The nurse executive or designee(s)
participates with administration in decisions relative to the selection and
promotion of nursing personnel based on qualifications and capabilities and
recommends the termination of employment when necessary.
6. All licensed nursing personnel shall be
competent in life support measures.
C. Staffing.
There shall be an adequate number of Registered Nurses on duty
at all times and available for bedside care of any patient when needed on a 24
hour basis. In addition, there shall be sufficient Registered Nurses to staff
all patient care units. A Registered Nurse shall assign the nursing care of
each patient to other nursing personnel in accordance with the patient's needs
and the preparation and competence of the nursing staff. There shall be written
criteria to substantiate the assignments.
D. Evaluation and Review of Patient Care
Services.
1. There shall be established
working relationships with other services of the hospital, both administrative
and professional. The factors explaining the standard are as follows:
a. Registered Nurses confer with the
physicians relative to patient care;
b. Interdepartmental policies affecting
patient care are made jointly with the nurse executive or designee(s); and
c. Procedures are established for
scheduling laboratory and X-ray examinations, for ordering, securing and
maintaining supplies and equipment needed for patient care and for ordering
diets, etc.
2. There
shall be on-going review and evaluation of nursing care provided for patients.
a. A Registered Nurse plans, supervises and
evaluates the nursing care for each patient in all settings where nursing care
is provided.
b. Each patient shall
have a plan for provision of care. Each patient plan of care shall be current.
Plans indicate patient care required, how it is to be accomplished and the
methods, approaches, goals and modifications necessary to ensure best results
for the patient. The patient's plan of care shall be initiated upon
admission.
c. There shall be
documentation of the nursing care provided. The following information shall be
documented:
1) The initial patient
assessment;
2) Date and time of
treatments and/or dressing changes;
3) Medication Administration Record (MAR)
including the date, time, dosage and manner of administration and the initials
of the nurse administering the medication. When personnel other than nursing
administer medication and the MAR is not utilized, a record of that ancillary
department shall comply with this requirement and be included in the medical
record;
4) Date, time, dosage and
manner of administration of all PRN medications to include reason for
administration and results;
5)
Bedtime and between meal snacks or feedings and the percentage of diets
consumed;
6) Change in patient's
appearance and/or condition;
7)
Patient complaints; and
8) Mode of
discharge and to whom the patient was discharged. If a patient expires, the
time the physician was called, time arrived, the time the patient was
pronounced dead and the fact that relatives were present shall be recorded. (If
relatives were not present, a note shall be made regarding their notification
and disposition of the patient's belongings).
d. A Registered Nurse shall observe each
patient at least once per shift and the observations shall be documented in the
patient's medical record.
NOTE: Block charting and cosignatures are not
acceptable.
E. Patient Care Facilities and Equipment.
1. There shall be no more beds maintained in
the building than the number of beds for which the hospital is licensed except
in the case of a public disaster or national emergency and then only as a
temporary measure. Licensable hospital bed means every patient care bed with
the exception of bassinets and labor beds.
2. No beds shall be made up in the hallway or
on the floor except in case of emergency.
3. Children under the age of 16 years shall
not be cared for in a room with an unrelated adult patient.
4. Provisions shall be made for safe storage
of patients' valuables.
5. All
facilities for cleaning and storage of patient care supplies and equipment
shall be used only for the purpose for which they are designed.
6. Thermometers shall not come in contact
with more than one patient without disinfection or proper covers.
7. All single-use equipment used by a patient
shall either be sent home with the patient at the time of discharge or
destroyed..
8. Only currently
dated equipment and supplies shall be available for patient care. All equipment
shall be kept clean and in good condition.
Patients that remain in observation status for a period of 24
hours or more, shall have provided to them accommodations equivalent to the
accommodations they would have if they were admitted as an inpatient.
SECTION 12:
MEDICATIONS.
A. All medical
orders (medications and treatments) shall be in writing and signed by the
prescriber. Telephone/verbal orders should be used infrequently. When used they
shall be given only to licensed nurses and signed by the prescriber.
B. No medication shall be dispensed or
administered without a written order signed by a licensed prescriber. A
pharmacist may receive telephone or verbal orders for medications from a
prescriber and record them on the medical record.
C. Medications shall be administered by
licensed nursing personnel in accordance with the current Arkansas Nurse
Practice Act. Other personnel may administer medications only in accordance
with their current Practice Act (e.g., Respiratory, Physical
Therapy).
D. Blood transfusions and
intravenous medications administered by licensed nursing personnel shall be in
accordance with State law. If not administered by a Registered Nurse, only
licensed nursing personnel who have documentation of training shall be
permitted to administer blood transfusions and intravenous
medications.
E. There shall be an
effective hospital procedure for reporting transfusion reactions and adverse
medication reactions.
F. All
medications shall be properly labeled and stored in a specifically designated
medication cabinet, cart or room. At nursing stations, medications shall only
be accessible to licensed nursing personnel and pharmacists. In specialty units
and treatment areas, medications shall only be accessible to licensed nursing
personnel, pharmacists and designated licensed personnel consistent with that
unit (e.g., Respiratory, Physical Therapy).
G. Refrigeration shall be provided for the
proper storage of biologicals and other medications. Medications shall be
stored in a separate compartment or area from food. Employee foods and/or
medications shall be stored in a separate refrigeration area. An internal
thermometer shall be provided and checked daily (or at least weekly when the
unit is closed) with documentation to assure temperatures between 36º and
46º Fahrenheit (two to eight degrees Centigrade). Refrigerated controlled
substances shall meet the requirement for double-lock security.
H. Unused or damaged medications shall be
returned to the pharmacy. All medications with incorrect or soiled labels shall
be returned to the pharmacy for relabeling.
I. In addition to patients' medical records,
a record of the procurement and disposition of each controlled substance shall
be maintained at each nursing and specialty unit. Each entry on the disposition
record shall reflect the actual dosage administered to the patient, the
patient's name, the date, time and signature of the licensed person
administering the medication. (Licensed personnel who may legally administer
controlled substances shall include only those personnel authorized by their
current Practice Act.) Any error of entry on the disposition record shall
follow a policy for correction of errors and accurate accountability. If the
licensed person who procures the medication from the double-lock security is
not the licensed person who administers the medication, then both persons shall
sign the disposition record.
J.
When breakage or wastage of a controlled substance occurs, the amount given and
the amount wasted shall be recorded by the licensed person who wasted the
medication and verified by the signature of a licensed person who witnessed the
wastage. Documentation shall include or policy shall delineate how the
medication was wasted. In addition to the above referenced licensed personnel
(See I), licensed Pharmacists shall be allowed to witness wastage of controlled
substances. When a licensed person is not available to witness wastage, the
partial dose shall be sent to the Arkansas Department of Health, Pharmacy
Services and Drug Control for destruction.
K. There shall be an audit each shift change
of all controlled substances stocked on the unit. At nursing stations such
counts shall be recorded by the oncoming nurse and witnessed by the off-going
nurse. At other units, audits shall be performed by two licensed personnel. In
each case, both licensed personnel shall sign the record with notation made as
to date and time of the audit. If discrepancies are noted, the Director of
Nursing, the Department Director, as applicable, and the Director of Pharmacy
shall be notified. As with the witnessing of wastage, licensed Pharmacists
shall be allowed to witness controlled substance audits.
L. If specialty units are not staffed on
every shift, controlled substances shall be audited by two licensed personnel
on each shift that is covered by licensed personnel.
M. Controlled substances in areas that are
covered only by on-call personnel shall be audited each shift the area is used
and at least weekly; whichever time frame is less.
N. Solutions and medications for "external
use only" shall be kept separate from other medications.
O. When a patient is discharged, the unused
portion of the patient's medication may be sent home with the patient on direct
written order of the attending physician; and only after the medication has
been relabeled by the pharmacy. Documentation shall include the amount
dispensed to the patient and quantities shall be consistent with the immediate
needs of the patient.
P. Policies
and procedures shall be developed and implemented for the handling of
medications brought into the facility by the patient.
Q. All medication errors and adverse drug
reactions shall be reported to the attending physician. A copy of all
medications errors and adverse drug reactions shall be sent to the Director of
Nursing or designee, QA/PI Committee and when appropriate, to the Director of
Pharmacy.
R. Records generated by
Automatic Medication Distribution Devices shall comply with these regulations.
Policies and procedures for the usage of Automatic Medication Distribution
Devices shall be approved administratively by Health Facility Services prior to
their usage.
S. Drug Security.
1. The pharmacist, with support from the
Pharmacy and Therapeutics (P&T) Committee, is ultimately responsible for
drug security throughout the facility;
applicable licensed personnel at nursing and specialty units
shall maintain the daily security of medications at their respective
units.
2. Access to
medications shall be limited to designated licensed personnel at all
times.
3. Medications dispensed to
nursing and specialty units shall be kept locked in accordance with all Federal
and State regulations.
4.
Emergency-type medications (crash cart, crash kit), as approved by the P&T
Committee, shall be secured with a breakaway seal under the following
conditions:
a. The quantities of medication
are limited;
b. A list of
medications stocked with quantities listed is posted on the emergency cart or
container;
c. The breakage of the
seal clearly indicates that entry has occurred (and said broken seal cannot be
repaired without obvious evidence);
d. Any remaining medications shall be secured
and accessible only to licensed personnel whenever the seal has been broken and
before a new seal is installed;
e.
Applicable personnel shall check the cart for the integrity of the seal each
shift. Documentation shall reflect that the seal is intact. The emergency cart
shall be stored in an area observable by licensed personnel;
f. The quantities of a controlled substance
stocked in a cart or container shall be limited to a maximum of two single
doses of Schedule III, IV or V drugs. No Schedule II drugs shall be included in
this stock; and g. Pharmacy Services shall check the condition of the carts or
containers as part of the monthly inspections of nursing and specialty
units.
5. Controlled
substances maintained as floor stock at nursing and specialty units shall be
stored separately from other medication under double-lock security.
6. For patient safety, Schedule III, IV and V
controlled substances in unit dose packages and dispensed in quantities limited
to a maximum of a two day supply, may be stored with that patient's other
medication.
7. All medications
shall be locked in the absence of immediate visual supervision by licensed
personnel.
8. When a hospital
operates an outpatient pharmacy that stocks medications in various clinical
areas, stock lists, records and security measures shall be in compliance with
the requirements for nursing and specialty units.
9. Distribution of sample legend medications
shall not be permitted by hospitals. Samples are defined as any prescription
only medication which is not intended to be sold and is intended to promote the
sale of the medication.
10.
Medication security as provided by Automatic Medication Distribution Devices
shall comply with these regulations. Policies and procedures for security
provisions shall be approved administratively by Health Facility Services prior
to usage of Automatic Medication Distribution Devices.
SECTION 13:
RESTRAINTS.
A. Restraint use should be
implemented in the least restrictive manner possible, applied in accordance
with safe and appropriate techniques and ended at the earliest possible
time.
B. Each physician's order for
the application of restraints shall be time limited and shall include the type
of restraint to be used. Restraint orders shall not be written as a standing
order or on an as needed basis (PRN).
C. Restraints either physical or chemical
shall be applied only after less restrictive measures have failed. Restraints
shall not be used as a matter of convenience for the staff or as a tool for
disciplining the patient. When the use of a restraint is clinically indicated,
it shall be used only in accordance with the order of a physician.
D. Documentation of a comprehensive
assessment and modification to the plan of care shall include the less
restrictive measures attempted, justification for the continued need of
restraint and that the patient and/or significant other has been informed of
the reason for restraint use.
E.
Documentation in the patient's record regarding any type of restraint shall
include the time the restraint was applied, released and discontinued, as well
as evidence of continual assessment, monitoring and re-evaluation of the
patient's condition during the restraint incident.
F. When restraint use is ordered by other
than the attending physician, the attending physician shall be informed as soon
as possible.
G. Patients in leather
or locked restraints shall be under constant observation.
H. All staff that have direct patient contact
shall have ongoing education and training in the proper and safe use of
restraints.
SECTION 14:
HEALTH INFORMATION SERVICES.
A.
General Requirements.
1. A medical record
shall be maintained for each patient admitted for care in the hospital..
2. The original or a copy of the
original (when the original is not available) of all reports shall be filed in
the medical record.
3. The record
shall be permanent and shall be either typewritten or legibly written in blue
or black ink.
4. All typewritten
reports shall include the date of dictation and the date of
transcription.
5. All dictated
records shall be transcribed within 48 hours.
6. Errors shall be corrected by drawing a
single line through the incorrect data, labeling it as "Error," initialing and
dating the entry.
7. Additional
patient records room requirements are provided in Section 65, Physical
Facilities, Health Information Unit.
8. Disease, operation and physicians indices
shall be maintained (manual, abstract or computer). Records shall be indexed
within one month following discharge. Indices maintained on computer shall be
retrievable at any time for research or quality assurance/performance
improvement monitoring.
9. Records
of discharged patients shall be coded in accordance to accepted coding
practices. Records shall be coded within one month of the patient's dictated
discharge summary.
10. Relevant
educational programs shall be conducted at regularly scheduled intervals with
no less than 12 per year. There shall be written documentation with employee
signatures, program title/subject, presenter, date and outlines or narrative of
presented program.
11. A Master
Patient Index shall be maintained by the Health Information Services. Index
information shall include at least the full name, address, birth date and the
medical record number of the patient. The index may be maintained manually or
on computer and shall contain the dates of all patient visits to the facility.
If the Index is maintained on computer, there shall be a policy and procedure
on permanent maintenance.
12. Birth
certificates shall be completed according to the current rules and regulations
of Vital Records, Arkansas Department of Health.
13. A unit record system shall be maintained.
A unit record is defined as all inpatient and outpatient visits for each
patient being filed together in one unit.
14. A policy and procedure manual for the
Health Information Management Department shall be developed. The manual shall
have evidence of ongoing review and/or revision. The first page of each manual
shall have the annual review date, signature of the department supervisor
and/or person(s) conducting the review.
15. A qualified individual shall be employed
to direct the Health Information Department. If a Registered Health Information
Administrator (RHIA) or a Registered Health Information Technician (RHIT) is
not employed as Director on a full-time basis by the facility, a consultant
shall make periodic visits to evaluate functions of the Department and train
personnel.
16. All patient records,
whether stored within the Health Information Management Department or other
areas, either within the facility or away from the facility, shall be protected
from destruction by fire, water, vermin, dust, etc.
17. Medical records shall be considered
confidential. Only authorized personnel shall have access to the medical
records. All medical records (including those filed outside the department)
shall be secured at all times. If authorized personnel are not available, the
department shall be locked. Records shall be available to authorized personnel
from the Arkansas Department of Health.
18. Release of medical information shall be
restricted by the facility's policies and procedures.
19. All medical records shall be retained in
either the original, microfilm or other acceptable methods for 10 years after
the last discharge. After 10 years a medical record may be destroyed provided
the facility permanently maintains the information contained in the Master
Patient Index. Complete medical records of minors shall be retained for a
period of two years after the age of majority.
20. Procedures shall be developed for the
retention and accessibility of the patients' medical records if the hospital or
other facility closes. The medical records shall be stored for the required
retention period and shall be accessible for patient use.
21. All entries into the medical record shall
be legible. There shall be no erasures or obliterations of the original
information contained in a medical record.
22. Medical records shall be complete and
contain all required signed documentation (including physician reports) no
later than 30 days following the patient's discharge date.
23. Patient records shall be destroyed by
burning or shredding. Patient records shall not be disposed of in landfills or
other refuse collection sites.
24.
A QA/PI program shall be continuous and specific to the services.
25. In the event of a physician's death or
permanent incapacitation, incomplete medical records shall be reviewed in a
manner approved by the Medical Staff. Approval to file incomplete medical
records shall be obtained in a manner approved by the Medical Staff and a
statement explaining the circumstances be placed in each record.
B. Authentication of Medical
Record Entries.
1. Each entry into the
medical record shall be authenticated by the individual who is the source of
the information. Entries shall include all documents, observations, notes and
any other information included in the record.
2. Signatures shall be at least, the first
initial, last name and title. Computerized signatures may be either by code,
number, initials or the method developed by the facility.
3. The hospital's Medical Staff and Governing
Body shall adopt a policy regarding dictation that permits authentication by
electronic or computer generated signature. The policy shall identify those
categories of the staff within the hospital who are authorized to authenticate
patient records using electronic or computer generated signatures.
4. At a minimum, the policy shall include
adequate safeguards to ensure confidentiality.
a. Each user shall be assigned a unique
identifier which is generated through a confidential code.
b. The policy shall include penalties for
inappropriate use of the identifier.
c. The user shall certify, in writing, that
he or she is the only person authorized to use the signature code.
d. The hospital shall periodically monitor
the use of identifiers, the process by which the monitoring shall be conducted
shall be described in the policy.
5. The system shall make an opportunity
available to the user to verify that the document is accurate and the signature
has been properly recorded.
6. Each
report generated by a user shall be separately authenticated.
7. A user may terminate authorization for use
of electronic or computer generated signature upon written notice to the
Director of Health Information Services.
8. Rubber stamp signatures shall be
acceptable if a letter from the physician is on file explaining that the
physician shall be the only person using the stamp and the stamp shall remain
in his/her possession at all times. The signature stamp shall be the full legal
name of the physician with his/her professional title.
9. Transcribed reports dictated by other than
the attending physician shall be signed by the credentialed individual
dictating the report and the attending physician. Dictation of reports by other
than the attending physician is limited to history, physical, discharge summary
and progress notes. Reports dictated by resident physicians for training
purposes require only the signature of the attending physician.
C. Electronic Health Information.
1. Policies and procedures governing
electronic health information within the organization and with external
entities shall be adopted by the Governing Body.
2. The policies and procedures shall provide
for the use, exchange, security and privacy of electronic health information.
The policies and procedures shall provide for standardized and authorized
availability of electronic health information for patient care, administrative
purposes and research. The policies and procedures will be in compliance with
current guidelines and standards as established in federal and state
statutes.
D. Record
Content.
1. Identification data shall include
at least the following:
a. Patient's full name
- maiden name if applicable;
b.
Patient's address, telephone number and occupation;
c. Date of birth;
d. Age;
e. Sex;
f. Marital status (M.S.D.W.);
g. Dates and times of admission and
discharge;
h. Full name of
physician;
i. Name and address of
nearest relative or person or agency responsible for patient and occupation of
responsible party;
j. Name, address
and telephone number of person(s) to notify in case of emergency;
k. Medical record number; and
l. A general consent for medical treatment
and care. This shall be signed by the patient or guardian. Written or verbal
consent shall not release the hospital or it's personnel from upholding the
rights of it's patients including but not limited to the right to privacy,
dignity, security, confidentiality and freedom from abuse or
neglect.
2. Clinical
reports shall include the following and shall comply with listed requirements:
a. History and Physical Examination (HPE)
shall be in the patient's medical record within 48 hours of the patient's
admission to the facility. The HPE shall be documented by the attending
physician and shall contain the following:
1)
Family (medical) history and review of systems - if noncontributory, the record
shall reflect such;
2) Past medical
history;
3) Chief complaint(s) - a
brief statement of nature and duration of the symptoms that caused the patient
to seek medical attention as stated in the patient's own words;
4) Present illness with dates or approximate
dates of onset;
5) Physical
examination;
6) Provisional or
admitting diagnosis(es); and
7)
History and physical examinations may be completed up to 30 days prior to
admission if the physician updates the examination at the time of
admission.
b. Progress
notes shall be recorded, dated and signed. The frequency of the physician's
progress notes shall be determine by the patient's condition. Dictated progress
notes are acceptable, and shall be placed in the patient's medical record
within 48 hours.
c. Orders shall be
authenticated with a legible and dated signature in a timely manner as defined
by Medical Staff By-Laws. Telephone/verbal orders shall be recorded by
appropriate personnel and cosigned by the originator within 96 hours.
d. A discharge summary shall recapitulate the
significant findings and events of the patient's hospitalization and his/her
condition on discharge. This shall be documented by the attending physician
within 30 days of the patient's discharge. The final diagnosis shall be stated
in the discharge summary.
e.
Autopsy findings shall be documented in complete protocol within 60 days and
the provisional anatomical diagnosis shall be recorded within 72 hours. A
signed authorization for autopsy shall be obtained from the next of kin and
documented in the medical record before an autopsy is performed.
f. Original, signed diagnostic reports
(laboratory, X-rays, CAT SCANs, EKGs, fetal monitoring, EEGs) shall be filed in
the patient's medical record. Physicians' orders shall accompany all treatment
procedures. Fetal monitor and EEG tracings, may be filed separately from the
medical record if accessible when needed.
g. Reports of ancillary services (Dietary,
Physical Therapy, Respiratory Care, Social Services, etc.) shall be included in
the patient's medical record.
h.
Reports of Medical Consultation, if ordered by the attending physician, shall
be included in the patient's medical record within time frames established by
the Medical Staff.
E. Records of Complementary Departments. In
addition to the general record content requirements stated above, parts F., G.
and H. are required, as applicable.
F. Surgery Records.
1. A specific consent for surgery shall be
documented prior to the surgery/procedure to be performed, except in cases of
emergency, and shall include the date, time and signatures of the patient and
witness. Consent shall be obtained by the surgeon and documented in the
patient's medical record. (Abbreviations are not acceptable.)
2. A History and Physical Examination on
admission containing medical history and physical findings shall be documented
by the attending physician on the patient's medical record prior to surgery. In
cases of emergency surgery, an abbreviated physical examination, and a brief
description of why the surgery is necessary shall be written by the physician.
(See Section 14, Health Information Services, Record Content.)
3. An anesthesia report, including
preoperative evaluation and postoperative assessment, shall be documented by
the Anesthesiologist and/or Certified Registered Nurse Anesthetist (CRNA). The
pre-evaluation and post assessment shall be dated and timed.
a. Preoperative anesthesia evaluation shall
be completed prior to the patient's surgery.
b. Report of Anesthesia. A CRNA who has not
been granted authority by a facility, as a DEA registrant, to order the
administration of controlled substances shall give all orders as verbal orders
from the supervising physician, dentist, or other person lawfully entitled to
order an anesthetic.
c.
Postanesthesia assessment shall be documented in the medical record prior to
the patient's discharge, not to exceed 48 hours after the patient's surgery. If
the patient is in need of continued observation, the anesthetist shall be
readily available. Discharge criteria shall be established and approved by the
Medical Staff and Governing Body. If the patient meets the discharge criteria
within a three hour period postoperatively, a postanesthesia assessment is not
required.
4. An
individualized operative report shall be written or dictated by the physician
immediately following surgery and shall be signed within 72 hours. The report
shall describe (in detail) techniques, findings, pre and postoperative
diagnosis and tissues removed.
5. A
signed pathological report shall be maintained in the medical record of all
tissue surgically removed. A specific list of tissues exempt from pathological
examination shall be developed by the Medical Staff.
G. Obstetrical Records.
1. A pertinent prenatal record shall be
updated upon admission, or history and physical examination signed by the
physician shall be available upon the patient's admission and be maintained in
the patient's medical record.
2. A
record of labor and delivery, authenticated by the physician, shall be
maintained for every Obstetrical patient.
3. Documentation of the patient's recovery
from delivery shall be maintained.
4. Nurses' postpartum record, graphics and
nurses' notes shall be maintained.
H. Newborn Records.
1. A newborn history and physical examination
shall be completed by the physician within 24 hours of birth. The following
additional data shall be required:
a. History
of the newborn delivery (sex, date of birth, type of delivery and anesthesia
given the mother during labor and delivery); and
b. Physical examination (weight, date, time
of birth and condition of infant after birth).
2. There shall be a consent for circumcision
(if applicable).
3. A procedure
note for circumcision shall be documented by the physician.
4. A discharge note or summary shall be
documented by the physician describing the condition of the newborn at
discharge and follow-up instructions given to the mother.
5. Hospitals shall comply with State Law and
Health Department requirements for newborn testing. (See Table 10,
Appendix.)
6. Birth certificates
shall be completed on all infants born in the hospital, or admitted as a result
of birth in accordance with the requirements of Vital Records, Arkansas
Department of Health.
SECTION 15:
MEDICAL RECORD
REQUIREMENTS FOR OUTPATIENT SERVICES, EMERGENCY ROOM, OBSERVATION SERVICES AND
PSYCHIATRIC RECORDS.
A. Outpatient
Records. An outpatient record shall be completed for each outpatient and shall
include the following:
1. History and
physical examination of the patient (not applicable if for diagnostic services
and/or outpatient therapy services);
2. Orders and reports of diagnostic services
and outpatient therapy services;
3.
Patient's diagnosis and summary of treatment received recorded by the attending
physician;
4. Documentation of any
medications administered;
5.
Progress notes for subsequent clinic visits recorded by applicable disciplines
(practitioners);
6. Outpatient
surgery record requirements (See also item F. of Section 14, Health Information
Services.); and
7. Discharge
instructions.
B.
Emergency Room Records. An Emergency Room Record shall be completed for each
patient who presents for treatment at the Emergency Room and shall include the
following:
1. Patient
identification;
2. Date and the
following times:
a. Admission;
b. Time physician was notified of patient's
presence in the Emergency Room;
c.
Time of physician's arrival if applicable; and
d. Discharge.
3. History (when the injury or onset of
symptoms occurred);
4. Vital
signs;
5. Nurses' assessment and
physical findings;
6.
Diagnosis;
7. Record of treatment
including documentation of verbal orders and of medication quantities
administered with the initials of person(s) administering the medications.
Also, type and amount of local anesthetic, if administered;
8. Diagnostic reports with specific orders
noted;
9. Instructions to patients
for follow-up care (e.g., do not drive after receiving sedatives, return to
physician's office for removal of sutures in one week);
10. Disposition of case;
11. Signature of patient or his/her
representative;
12. Signed and
dated discharge order; and
13. The
ambulance record shall be transferred with the patient.
NOTE: Emergency Room Records shall be completed within 24 hours
of the patient's visit.
C. Observation Records. A record of every
patient admitted to an observation status shall be maintained. The observation
record shall include, at a minimum:
1. Patient
identification data;
2. Physician's
diagnosis and therapeutic orders dated and timed;
3. History and physical;
4. Physician's progress notes, including
results of treatment;
5. Nursing
assessment by a Registered Nurse;
6. Nursing observations;
7. Results of all diagnostic
testing;
8. Medication
Administration Record;
9.
Allergies;
10. Patient
education;
11. Plan for follow-up
treatment; and
12. Referrals.
NOTE: Observation records shall be completed on patients who
stay less than 24 hours.
D. Psychiatric Records. The basic medical
record requirements for psychiatric patients shall be the same as for other
patient records, with the following additions:
1. The identification data shall include the
patient's legal status (on the face sheet);
2. A proper consent or authority for
admission shall be included;
3. A
psychiatric evaluation shall be completed by the attending physician within 60
hours of admission which includes the following:
a. The patient's chief complaints and/or
reaction to hospitalization, recorded in patient's own words, if
possible;
b. History of present
illness including onset and reason for current admission;
c. Past history of any psychiatric problems
and treatment, including a record of patient's activities (social, education,
vocational, interpersonal and family relationships);
d. Past psychiatric history of patient's
family;
e. Mental status which
includes at least attitude and general behavior, affect, stream of mental
activity, presence or absence of delusions and hallucinations, estimate of
intellectual functions, judgment and an assessment of orientation and
memory;
f. Strengths such as
knowledge, interests, skills, aptitudes, experience, education and employment
status written in descriptive terms to be used in developing the Master
Treatment Plan; and
g. Diagnostic
impressions and recommendations.
4. A history and physical examination shall
be documented by a physician and shall include a neurological examination
within 24 hours of admission.
5.
Social service records, including report of interviews with patient, family
members and others shall be included for each admission. Social assessment and
plan of care shall be completed within 48 hours of admission.
6. Reports of consultation, psychological
evaluations, reports of electroencephalograms, dental records and reports of
special studies shall be included in the records when applicable.
7. An Interdisciplinary Master Treatment Plan
shall be developed for each patient and included in the medical record, within
60 hours of admission. The treatment plan shall involve all staff who have
contact with the patient and shall include (as a minimum):
a. Problems and needs relevant to admission
and discharge as identified in the various assessments, expressed in behavioral
and descriptive terms;
b. Strengths
(assets) including skills and interests;
c. Problems, both physical and mental, that
require therapeutic management;
d.
Long and short term goals describing the desired action or behavior to be
achieved. Goals shall be relevant, observable and measurable;
e. Treatment modalities individualized in
relation to patient's needs;
f.
Evidence of patient's involvement in formulation of the plan;
g. Realistic discharge and aftercare
plans;
h. Nursing assessment and
progress notes integrated into the Master Treatment Plan. Reviews and revisions
of the Nursing Plan of Care shall be as required under the Section 11, Patient
Care Service;
i. Signatures of all
staff involved;
j. Date Master
Treatment Plan was implemented; and
k. Staff
responsibilities.
8. The
treatment received by the patient shall be documented in such a manner and with
such frequency as to assure that all active therapeutic efforts such as
individual and group psychotherapy, medication therapy, milieu therapy,
occupational therapy, industrial or work therapy, nursing care and other
therapeutic interventions are included.
9. Progress notes shall be recorded by the
physician, social worker and others involved in active treatment modalities at
least as often as the patient is seen. The notes shall contain recommendations
for revisions in the treatment plan.
10. Nursing notes shall be written as
required under the Section 11, Patient Care Service.
11. The discharge summary shall include a
recapitulation of the patient's hospitalization and recommendations from
appropriate services concerning follow-up of aftercare, as well as a brief
summary of the patient's condition on discharge.
12. The psychiatric diagnosis contained in
the final diagnosis and included in the discharge summary shall be written in
the terminology of the current American Psychiatric Association's Diagnostic
and Statistical Manual.
SECTION 16:
PHARMACY.
All hospitals shall have adequate provision for pharmaceutical
services regarding the procurement, storage, distribution and control of all
medications. There shall be compliance with all federal and state regulations,
including Laws and Regulations -Arkansas State Board of
Pharmacy.
A.
Definitions.
1. Hospital Pharmacy means the
place or places in which drugs, chemicals, medicines, prescriptions or poisons
are prepared for distribution and administration for the use and/or benefit of
patients in a hospital licensed by the Arkansas Department of Health. The
Hospital Pharmacy shall also mean the place or places in which drugs,
chemicals, medicines, prescriptions or poisons are compounded for the
dispensing to hospital employees, members of the immediate families of hospital
employees, patients being discharged, and other persons in emergency
situations. Hospital Pharmacy shall also mean the provision of pharmaceutical
services as defined in the Pharmacy Practice Act by a pharmacist to a patient
of the hospital.
2. Hospital
Employee means any individual employed by the hospital whose compensation for
services or labor actually performed for a hospital is reflected on the payroll
records of a hospital.
3. Qualified
Hospital Personnel means persons other than Licensed Pharmacists who perform
duties in conjunction with the overall hospital pharmaceutical services for
inpatients.
4. Licensed Pharmacist
means any person licensed to practice pharmacy by the Arkansas State Board of
Pharmacy who provides pharmaceutical services as defined in the Pharmacy
Practice Act to patients of the hospital.
5. Unit Dose Distribution System is a
pharmacy-coordinated method of dispensing and controlling medications in
hospitals in which medications are dispensed in single unit packages for a
specific patient on orders of a physician where not more than a 24 hour supply
of said medication is dispensed, delivered, or available to the
patient.
6. Modified Unit Dose
Distribution System is a system that meets the requirement of a "Unit Dose
Distribution System," provided that up to a 72 hour supply may be sent to the
floor once a week if the system has been reviewed and approved administratively
by the Arkansas State Board of Pharmacy.
B. Hospitals maintaining and using mechanical
storage and delivery machines for legend drugs shall have such machines stocked
only by Pharmacy Services. Drugs may be obtained from such machines only by
licensed personnel in accordance with their Practice Act acting under the
prescribed rules of safety procedures as promulgated by the individual hospital
using said machine.
Limited amounts of Schedule II-V controlled substances may be
stocked in the machines,
provided the following requirements are met:
1. Pharmacy Services possesses the only key
necessary to stock the machine; and
2. Policies and Procedures specify the
licensed personnel having access and responsibility for the medications.
The person removing a medication for administration shall
record at least the patient's name and the name, strength and amount of
medication on a record that is maintained by the Pharmacy Department.
The record shall also be signed by the person removing the
medication. The removal of controlled substances shall comply with the record
keeping requirements of Section 12, Medications. Pharmacy Services shall audit
stock levels as needed to replace medications. Use of the machines shall not be
to circumvent adequate pharmaceutical services.
C. Compounding, Dispensing and Distributing.
1. Compounding. The act of selecting, mixing,
combining, measuring, counting or otherwise preparing a drug or
medication.
2. Dispensing. A
function restricted to licensed pharmacists, which involves the issuance of:
a. One or more doses of a medication in
containers other than the original, with such new containers being properly
labeled by the dispenser as to content and/or directions for use as directed by
the prescriber;
b. Medication in
its original container with a pharmacy prepared label that carries to the
patient the directions of the prescriber as well as other vital information;
and/or
c. A package carrying a
label prepared for nursing station use. The contents of the container may be
for one patient (individual prescription) or for several patients (such as a
nursing station medication container).
3. Distributing. Distributing, in the context
of this regulation, refers to the movement of a medication from a central point
to a nursing station medication center. The medication shall be in the
originally labeled manufacturer's container or in a prepackaged container
labeled according to federal and state laws and regulations, by a pharmacist or
under his direct and immediate supervision.
D. Pharmacy and Therapeutics Committee. There
is a committee of the Medical Staff to confer with the pharmacist in the
formulation of policies, explained as follows:
1. A Pharmacy and Therapeutics (P&T)
Committee, composed of at least one physician, the Administrator or
representative, the director of nursing service or representative and the
pharmacist is established in the hospital. It represents the organizational
line of communication and the liaison between the Medical Staff and the
pharmacist.
2. The Committee
assists in the formulation of broad, professional policies regarding the
evaluation, appraisal, selection, procurement, storage, distribution, use and
safety procedures in conformance with Food and Drug Administration and
manufacturers' bulletins on the safe administration of drugs and all other
matters relating to drugs in hospitals.
3. The Committee performs the following
specific functions:
a. Serves as an advisory
group to the hospital Medical Staff and pharmacist on matters pertaining to the
choice of drugs;
b. Develops and
approves the drug formulary and all drug lists annually and makes interim
revisions as needed;
c. Establishes
standards concerning the use and control of investigational drugs and research
in the use of recognized drugs;
d.
Evaluates clinical data concerning new drugs or preparations requested for use
in the hospital;
e. Makes
recommendations concerning drugs to be stocked on the nursing unit floors and
emergency drug stocks;
f. Prevents
unnecessary duplication in stocking drugs and drugs in combination having
identical amounts of the same therapeutic ingredients; and
g. Reviews and approves drug-related policies
and procedures.
4. The
Committee develops and approves policies and procedures for all nursing
personnel assigned the responsibility of preparing and administering
intravenous (IV) admixtures. The pharmacist shall be involved in the review of
the drug order, calculations and preparation whenever possible. The Committee
should consider the appropriate category of personnel (Registered Nurse or LPN)
and degree of training necessary to make judgments and calculations involved in
IV admixture programs.
5. The
Committee assures that medications dispensed to outpatients, Emergency Room
patients and discharged patients comply with all federal and state laws and
regulations.
6. The Committee meets
at least quarterly and reports to the Medical Staff by written
report.
E. Pharmacy
Operations. The hospital has a pharmacy directed by a licensed pharmacist. The
pharmacy is administered in accordance with accepted professional principles.
1. Pharmacy supervision. There is a pharmacy
directed by a licensed pharmacist defined as follows:
a. The Director of Pharmacy is trained in the
specialized functions of hospital pharmacy;
b. The Director of Pharmacy is responsible to
the administration of the hospital and Board of Pharmacy for developing,
supervising and coordinating all the activities of the Pharmacy Department and
all pharmacists providing professional services in the hospital; and
c. All licensed pharmacists who provide
pharmaceutical services as defined by the Pharmacy Practice Act shall practice
under policies, procedures and protocols approved by the Director of Pharmacy.
These policies, procedures and protocols shall be subject to review and
approval by the Board of Pharmacy.
F. Physical Facilities. Facilities are
provided for the storage, safeguarding, preparation and dispensing of drugs,
defined as follows:
1. Drugs are issued to
floor units in accordance with approved policies and procedures;
2. Drug cabinets on all units shall be
checked monthly by qualified pharmacy personnel. All floor stocks are properly
controlled;
3. A careful
determination of the functions of a department will regulate the space to be
allocated, the equipment necessary to carry out the functions and the number of
personnel required to utilize the equipment and to render a given volume of
service, as these functions relate to the frequency or intensity of each
function or activity. Adequate equipment shall specifically relate to services
rendered and functions performed by the hospital pharmacy. Equipment lists will
relate to the following services and functions:
a. Medication preparation;
b. Library reference facilities;
c. Record and office procedures;
d. Sterile product manufacturing;
e. Bulk compounding
(manufacturing);
f. Product control
(assay, sterility testing, etc.); and
g. Product development and special
formulations for medical staff.
4. Equipment and supplies necessary to the
hospital pharmacy's safe, efficient and economical operation shall include, but
not be limited to:
a. Graduates capable of
measuring from 0.1 ml up to at least 500 ml;
b. Mortars and pestles;
c. Hot and cold running water;
d. Spatulas (steel and
non-metallic);
e.
Funnels;
f. Stirring
rods;
g. Class A balance and
appropriate weights;
h. Typewriter
or other label printer;
i. Suitable
apparatus for production of small-volume sterile solutions;
j. Suitable containers and labels;
and
k. Adequate reference library to
include at least the following:
1) American
Hospital Formulary Service;
2)
Pharmacology text;
3) Each hospital
pharmacy shall have available for personal and patient use a current copy of:
The U.S.P. DI, three book set including "Drug Information for
the Healthcare Professional" (two volumes) and "Advice for the Patient" (one
volume) Or the two volume set "Facts and Comparisons" (one volume) and "Patient
Drug Facts" (one volume);
4)
Text on compatibility of parenteral products;
5) Current professional journals, such as:
a) Drug Intelligence and Clinical
Pharmacy;
b) Hospital Pharmacy; and
c) Journal of ASHP.
5. Special
locked storage space is provided to meet legal requirements for storage of
controlled drugs, alcohol and other prescribed drugs; and
G. Personnel. Personnel competent in their
respective duties are provided in keeping with the size and activity of the
department explained as follows:
1. The
Director of Pharmacy is assisted by an adequate number of additional licensed
pharmacists and other such personnel as the activities of the pharmacy may
require to ensure quality pharmaceutical services; and
2. The pharmacy, depending upon the size and
scope of its operations, is staffed by the following categories of personnel:
a. Chief Pharmacist (Director of
Pharmacy);
b. One or more assistant
chief pharmacists (Assistant Director of Pharmacy);
c. Staff pharmacists;
d. Pharmacy residents (where program has been
activated);
e. Trained
non-professional pharmacy helpers (qualified hospital personnel); and
f. Clerical help.
H. Emergency Pharmaceutical
Services. Through the Administrator of the hospital, the P&T Committee
shall establish policies and procedures that include, but are not limited to,
the following:
1. Upon admission to the
Emergency Room on an outpatient basis and when examined by the physician where
medications are prescribed to be administered, a record shall be kept on file
in the Emergency Room admission book or a copy of the Emergency Room medication
order shall be kept by the pharmacist to be readily accessible, for control and
other purposes, as required by these regulations;
2. If the physician wishes the patient to
have medication to be taken with them from the emergency room supplies, the
amounts to be taken shall be sufficient to last until medication may be
obtained from local pharmacies, in any case not to exceed a 48 hour supply. All
state and federal laws shall be observed concerning all records, labeling and
outpatient dispensing requirements; and
3. Take home prescriptions for
anti-infectives issued to patients at the time of discharge from the Emergency
Room, dispensed by a pharmacist shall be quantities consistent with the medical
needs of the patient.
I.
Pharmacy Records and Labeling. Records are kept of the transactions of the
pharmacy and correlated with other hospital records where indicated. All
medication shall be properly labeled. Such record and labeling requirements are
as follows:
1. The pharmacy establishes and
maintains, in cooperation with the accounting department, a satisfactory system
of records and bookkeeping in accordance with the policies of the hospital for:
a. Maintaining adequate control over the
requisitioning and dispensing of all drugs and pharmaceutical supplies;
and
b. Charging patients for drugs
and pharmaceutical supplies.
2. A record of procurement and disbursement
of all controlled drugs is maintained in such a manner that the disposition of
any particular item may be readily traced;
3. The pharmacist shall receive and provide
service pursuant to the perusal of the physician's original order or a direct
copy thereof, except in emergency situations wherein the pharmacist may provide
service pursuant to a verbal order or to an oral or written transcription of
the physician's order provided that the pharmacist shall receive and review the
original or direct copy;
4. A
record shall be maintained by the pharmacy and stored separately from other
hospital records for each patient (inpatient or outpatient) containing the name
of the patient, the prescribing physician, the name and strength of the drugs
prescribed, the name and manufacturer (or trademark), the quantity and the
pharmacist's initials for all medications dispensed;
5. The label of each medication container
prepared for administration to inpatients, shall bear the name and strength of
the medication, the expiration date and the lot or control number. The label on
the medication or the container into which the labeled medication is placed
shall bear the name of the patient and room number; and
6. The label of each outpatient's individual
prescription medication container bears the name of the patient, prescribing
physician, directions for use, and the name and strength of the medication
dispensed (unless directed otherwise by the physician) and the date of
dispensing.
J. Control
of Toxic or Dangerous Drugs. Policies are established to control the
administration of toxic or dangerous drugs with specific reference to the
duration of the order and the dosage, explained as follows:
1. The Medical Staff has established a
written policy that all toxic or dangerous medications not specifically
prescribed as to the time or number of doses, will be automatically stopped
after a reasonable time limit set by the staff;
2. The classifications ordinarily thought of
as toxic or dangerous drugs are controlled substances, anticoagulants,
antibiotics, oxytocics and cortisone products; and
3. All deteriorated non-sterile, non-labeled
or damaged medication shall be destroyed by the pharmacist, with the exception
of controlled substances. All controlled drugs (Schedule II, III, IV and V)
shall be listed and a copy sent, along with drugs to the Arkansas Department of
Health by registered mail or delivered in person for disposition.
K. Drugs to be Dispensed.
Therapeutic ingredients of medications dispensed are included (or approved for
inclusion) in the United States Pharmacopoeia, N.F. and U.S. Homeopathic
Pharmacopoeia, or Accepted Dental Remedies (except for any drugs unfavorably
evaluated therein) and drugs approved by Ark. Code Ann. §
17-92-503, or are approved for use
by the P&T Committee of the hospital staff, explained as follows:
1. The pharmacist, with the advice and
guidance of the P&T Committee, is responsible for the specifications as to
quality, quantity and source of supply of all drugs; and
2. There is available a formulary or list of
drugs accepted for use in the hospital which is developed and amended at
regular intervals by the P&T Committee.
L. Policy and Procedure Manual.
1. A policy and procedure manual pertaining
to the operations of the hospital pharmacy, with updated revisions adopted by
the P&T Committee of each hospital shall be prepared and maintained at the
hospital.
2. The policy and
procedure manual shall include at a minimum, the following:
a. Provisions for procurement, storage,
distribution and drug control for all aspects of pharmaceutical services in the
hospital;
b. Specialized areas such
as Surgery, Delivery, ICU and CCU units and Emergency Room stock and usage of
medication shall be specifically outlined;
c. A system of requisitioning supplies and
medications for nurses' stations stock shall be in written procedural form as
to limits of medications to be stocked in each nursing unit;
d. Detailed job descriptions and duties of
each employee by job title working in the Pharmacy Department shall be
developed and made a part of these policies and procedures; and
e. The Pharmacy Policy and Procedure Manual
shall be subject to review and approval by the Board of Pharmacy on request
from the Board.
M. Employee Prescription Medication.
1. There will be a prescription on file for
all prescription drugs dispensed to hospital employees and their immediate
families. These records will be kept separate from all inpatient
records.
2. The only person(s)
entitled to have employee prescriptions filled will be the employee listed on
the hospital payroll and members of their immediate family.
N. Patient Discharge Medication.
Any take-home prescription dispensed to patients at time of discharge from the
hospital shall be for drugs and quantities consistent with the immediate needs
of the patient.
O. Licensed
Pharmacist Personnel Requirements.
1. The
minimum requirements for licensed pharmacists in hospitals are:
a. A general hospital, surgery and general
medical care, maternal and general medical care hospital, chronic disease
hospital, psychiatric hospital and rehabilitative facility licensed for greater
than 50 beds, as determined by the institution license issued by the Arkansas
Department of Health, shall require the services of one (1) pharmacist on the
basis of forty (40) hours per week with such additional pharmacists as are
necessary, in the opinion of the Arkansas State Board of Pharmacy, to perform
required pharmacy duties as are necessary in keeping with the size and scope of
the services of the hospital pharmacy's safe, and efficient operation.
Hospitals providing specialized or unique patient care services may request
approval from the Arkansas State Board of Pharmacy to be exempt from the
requirement of a pharmacist on duty 40 hours per week. The request for
exemption shall provide adequate written documentation to justify the services
of a pharmacist such hours as are necessary to perform required pharmacy
services, followed by an appearance before the Arkansas State Board of Pharmacy
for final approval of the request;
b. The above classified hospitals, licensed
for 50 beds or less, as determined by the institution license issued by the
Arkansas Department of Health, shall require the services of a pharmacist such
hours as, in the opinion of the Arkansas State Board of Pharmacy and the
Arkansas State Board of Health, are necessary to perform required pharmacy
duties in keeping with the size and scope of the services of the hospital
pharmacy safe and efficient operation. The pharmacist shall be on site at least
five days per week to perform and review pharmacy dispensing, drug utilization
and drug distribution activities. A pharmacist shall be available to provide
emergency services to the staff when the pharmacy is closed;
c. Recuperation Centers, Outpatient Surgery
Centers and Infirmaries:
1) If the infirmary,
recuperation center, or outpatient surgery center has a pharmacy department, a
licensed pharmacist shall be employed to administer the pharmacy in accordance
with all state and federal laws regarding drugs and drug control;
2) If the infirmary, recuperation center, or
outpatient surgery center does not have a pharmacy department, it has
provisions for promptly and conveniently obtaining prescribed drugs and
biologicals from a community or institutional pharmacy;
3) If the infirmary, recuperation center, or
outpatient surgery center does not have a pharmacy department but does maintain
a supply of drugs, a licensed pharmacist shall be responsible for the control
of all bulk drugs and maintain records of their receipt and disposition. The
pharmacist shall dispense drugs from the drug supply, properly labeled and make
them available to appropriate nursing personnel;
4) All medication for patients shall be on
individual prescription basis.
2. A pharmacist in charge, who is employed at
any facility permitted by the Arkansas State Board of Pharmacy where a 40 hour
work week is required, may also be the pharmacist in charge at a hospital
licensed for 50 beds or less by the Arkansas Department of Health.
P. Responsibility of a Pharmacist
in Hospital Pharmacy.
1. The pharmacist is
responsible for the control of all medications distributed in the hospital
where he practices and for the proper provision of all pharmaceutical
services.
2. The following aspects
of medication distribution and pharmaceutical service are functions involving
professional evaluations or judgments and may not be performed by supportive
personnel:
a. Selection of the brand and
supplies of medication;
b.
Interpretation and certification of the medication ordered. This involves a
number of professional responsibilities such as the determination of:
1) Accuracy and appropriateness of dose and
dosage schedule;
2) Such items as
possible drug interactions, medication sensitivities of the patient, and
chemical and therapeutic incompatibilities; and
3) Accuracy of entry of medication order to
patient's medication profile.
c. Final certification of the prepared
medication.
Q. Pharmacy Technicians.
1. Pharmacy technician refers to those
individuals identified by the Arkansas State Board of Pharmacy.exclusive of
pharmacy interns, who are regular paid employees of the hospital and assist the
pharmacist in pharmaceutical services.
2. Supervision means that the responsible
pharmacist shall be physically present to observe, direct and supervise the
pharmacy technician at all times when the pharmacy technician performs acts
specified in this regulation. The supervising pharmacist is totally and
absolutely responsible for the actions of the pharmacy technician.
3. The pharmacist and pharmacy technician(s)
shall comply with all applicable sections of Laws and
Regulations of the Arkansas State Board of Pharmacy
with
regards to tasks, responsibilities, duties, ratios and supervision in the
hospital setting.
4. There shall be
documentation by each technician of all duties and tasks performed in the
preparation and processing of medication. The pharmacist shall be responsible
for the final check and verification of all technician duties and tasks. The
performance, check, and verification shall be recorded on a record maintained
by the department which shall include the signature, initial(s) or other
identifying mark of each person.
R. Operation of Pharmacy Department When
Pharmacist is Not Present.
1. A limited
supply of backup medications may be utilized for patient needs only at times
when the pharmacist is not present. This stock shall be accessible only to
approved licensed personnel. A record shall be maintained which identifies the
medication obtained and the personnel obtaining it. The pharmacist shall then
review this record when he returns to the facility to assure compliance with
the physician's orders. Medications shall be replaced to stock as
needed.
2. At no time will the
hospital pharmacy be open and in operation unless a licensed pharmacist is
physically present except:
a. Entrance may be
obtained for emergency medication as set forth in the Pharmacy Policy and
Procedure Manual when the pharmacy is closed outside its normal operation
hours. The Medical Staff shall approve a method by which individual nursing
personnel may be authorized by name and qualification to remove only one dose
if the drug is not of the unit dose packaging type; or, if the medication is
unit dosed, enough medication to last until the pharmacist returns can be
removed. A record listing all medications obtained should be maintained and the
pharmacist shall check for compliance with the physician's orders when he
returns to the facility. Controlled substances shall not be accessible unless
daily counts are performed and documented; and
b. When the pharmacist is summoned away from
the pharmacy and there are other qualified personnel left in the pharmacy, the
personnel left in the pharmacy shall perform only those functions authorized
within this regulation
3.
A pharmacist shall be available to provide medication consultation.
S. Medication Utilization. The
pharmacist, with the advice and guidance of the P&T Committee, shall
participate in:
1. Discussions of reports of
medication errors, with trends noted, conclusions made and recommendations
suggested. If there are no errors to report, this shall be stated;
2. Discussions of adverse drug reactions with
trends noted, conclusions made and recommendations suggested. Proper reports of
appropriate reactions shall be reported to the full Medical Staff and/or the
FDA reporting system. If there are no adverse reactions to report, this shall
be stated;
3. Reviews of results of
monitoring conducted according to approved criteria for antibiotics prescribed
for prophylactic and therapeutic reasons;
4. Reviews of other drug utilization in the
facility, as appropriate; and
5.
Formulation of an official record of each meeting maintained as minutes. The
written report shall be forwarded to the P&T Committee, QA/PI Committee,
and/or the Medical Staff for review and consideration, with at least a
quarterly frequency.
T.
Electronic Data Processing in Hospital Pharmacies. All hospitals utilizing
electronic data processing systems shall comply with Laws
and Regulations of the Arkansas State Board of
Pharmacy.
U.
Maintenance and Retention of Drug Records. All drug records, including but not
limited to, purchase invoices, official dispensing records, prescription and
inventory records shall be kept in such a manner that all data is readily
retrievable and shall be retained as a matter of record by the pharmacist for
at least two years.
V. The American
Society of Health-System Pharmacists Guidelines. The American Society of
Health-System Pharmacists' most recent statement on hospital drug control
systems and Guidelines for Institutional Use of Controlled Substances shall be
required reading by hospital pharmacists.
SECTION 17:
FOOD AND NUTRITION
SERVICES.
A. Administration.
1. The Food and Nutrition Services shall be
under the daily, including weekends, onsite supervision of a qualified
individual. The individual shall be at a minimum a certified dietary manager
and:
a. Be responsible for the daily
management of clinical and administrative dietetic aspects of the service by
formulating, reviewing and revising policies and procedures for all Food and
Nutrition Services practices;
b.
Ensure that all personnel in the service are oriented in their respective
duties;
c. Implement a maintenance
program to ensure food service facilities, equipment and utensils are
maintained in a safe, clean, sanitary manner and are replaced at specific
intervals or as needed;
d.
Participate on hospital-wide departmental committees as required;
e. Ensure that trained staff are maintained
for daily administrative and clinical nutrition practices. A minimum of a two
week current work schedule shall be posted and reflect all positions, including
the department director; and
f.
Develop, implement and maintain a system for record keeping relating to all
department functions dependent on the department's scope of services, e.g.,
patient assessments, counseling, diet instructions, temperatures, educational
programs, etc.
2.
Policies and procedures shall have evidence of ongoing review and/or revision.
The first page of each manual shall have the annual review date, signature of
the department supervisor and/or person(s) conducting the review.
3. Policies and procedures shall include:
a. Job descriptions and performance
evaluations;
b.
Orientation;
c. Preventive
maintenance;
d. Infection control
measures;
e. Safety practices; and
f. Cleaning of equipment and
applicable areas.
4.
Clinically relevant educational programs shall be conducted at regularly
scheduled intervals with not less than 12 per year. There shall be written
documentation with employee signature, program title/subject, presenter, date
and outline or narrative of presented program.
5. Nutrition Services shall have an ongoing
QA/PI Program that addresses both clinical and administrative issues. A
mechanism for reporting results of audits shall be provided, to include:
indicators monitored, thresholds/standards established, results, corrective
plan/corrective action taken and follow-up.
6. Time and duty schedules for all hourly
employees shall be maintained.
7.
Diet Manual shall be authorized by the Medical Staff, reviewed and revised, as
needed, to reflect current recognized dietary practices. A cover page shall be
affixed with the date of review and appropriate signatures and a copy of the
manual shall be located on each patient unit. Use of electronic diet manuals is
acceptable.
8. Menus shall:
a. Be planned/approved by the registered
dietitian and meet the nutritional needs of the patients in accordance with the
current recommended dietary guidelines of the Food and Nutrition Board,
National Research Council and the currently approved facility diet manual in
accordance with the written diet order.
b. Be dated at least one week in advance. The
current week's menus shall be posted and available in the kitchen. The meals
prepared and served shall correspond with the posted menu, or written diet
orders.
c. Not be restrictive in
nature (e.g., seasoning, fat, sodium, sugar content) unless required by a
modified/therapeutic diet order.
d.
Be of equivalent nutritional value when substitutions/changes are made.
Menus/production schedules, showing all changes, shall be retained for at least
30 days.
9. Diets shall
be in writing and signed by a physician or a mid-level practitioner if
privileged by the Medical Staff and Governing Body. Notification according to
facility policy shall be made to the Nutrition Services Department on a timely
basis, kept current and include current date, the patient's name, room number
and diet order.
B. Food
Services.
1. At least three meal equivalents
shall be served daily at regular intervals, approximately five hours apart. No
more than 15 hours shall elapse between the serving of the evening meal and the
morning meal. The meals shall be served at approximately the same hour each
day.
2. Food shall be prepared in
accordance with approved menus and standardized recipes and in a manner to
conserve nutritive value, flavor and appearance.
3. Food shall meet patient needs and shall be
attractive, palatable and served at proper temperatures.
4. An identification system shall be
implemented for patient trays to ensure that each patient receives the
appropriate diet as ordered.
5.
Nourishing bedtime snacks, appropriate to the patient's needs, shall be made
available
6. Only foods prepared
and stored under the direction of Nutrition Services, in accordance with the
Rules and Regulations Pertaining to Food Service
Establishments of the Arkansas Department of Health
shall
be served in a hospital.
7. All
individuals who assist patients in the preparation, heating, reheating,
consumption of food, sanitation of food ware and kitchen equipment, etc., while
in the facility or on the facility grounds, shall be under the direction of
Nutrition Services and in compliance with the Rules and
Regulations Pertaining to Food Service Establishments of the Arkansas
Department of Health. Documentation of educational
programs on food preparation, safety and sanitation shall be performed for all
applicable personnel (e.g., Occupational Therapy, Nursing) by Nutrition
Services at least annually.
8. Food
shall not be consumed in the kitchen.
9. Food shall be transported in a manner that
maintains safe food temperatures and prevents contamination. Food carts shall
not block corridors/exits, emergency equipment or patient doorways.
10. All storage containers/foodstuffs shall
be stored a minimum of 12 inches above the floor on non-porous, easily cleaned
racks, dollies or shelving, in a manner that protects the food (or food contact
surfaces) from splash and other contamination and permits easy cleaning of the
storage area.
11. Plastic milk
crates shall not be permitted for storing of food or equipment, except for the
intended use for milk storage.
12.
Temperature documentation of all food refrigerators/freezers in the kitchen and
cafeteria shall be performed a minimum of three times per day at opening,
mid-operation and closing of the department.
13. Temperature documentation of all
nourishment refrigerators/freezers in patient care areas shall be performed at
least daily
14. Proper temperatures
of vending machines containing potentially hazardous foods shall be ensured
daily by the facility. Vending machines shall be equipped with a thermometer,
easily visible to food service personnel for the purposes of monitoring the
temperature of the internal environment. These machines shall have the capacity
to render themselves inoperable if temperatures in excess of 40 degrees
Fahrenheit are maintained for more than two hours. Documentation of such
downtime shall be maintained to include remedial action taken.
15. If, for any reason, the refrigeration
equipment does not maintain the appropriate temperature, action shall be taken
and a record of remedial action and downtime shall be recorded and maintained
by the facility.
16. Temperature
documentation of the dishmachine shall be recorded with each meal and these
records shall be maintained by the facility. If the temperatures (and, if
applicable, dwell times) are not maintained properly, action shall be taken and
a record of remedial action, back-up procedures used and downtime shall be
maintained by the facility.
17. If
the facility uses a chemical method for sanitizing food preparation and serving
ware, a record of the water temperature, the chemical used and appropriate
parts per million (ppm) shall be maintained by the facility at each
use.
18. The temperature of the hot
and cold potentially hazardous foods shall be recorded at least at the
beginning and end of meal service that continues for more than 15 minutes. If
meal service lasts for 15 minutes or less, food temperature documentation is
required only at the beginning of food service.
19. Documentation of the testing/calibration
of food/refrigeration/freezer thermometers shall be performed according to
manufacturer's recommendations.
20.
Food thermometers shall be sanitized after each use and stored in a manner that
prevents contamination.
21. Only
dietary and authorized personnel shall be allowed in the kitchen.
22. Sanitation shall be in accordance with
the Rules and Regulations Pertaining to Food Service
Establishments of the Arkansas Department of Health
.
C. Food
Safety/Sanitation.
1. Whole eggs and raw meat
shall be stored separately and in a way that prevents contamination of other
food items in refrigerated units.
2. Reheated food shall attain a temperature
above 165º Fahrenheit prior to placement in steam tables, warmers, or
other hot food storage units. Steam tables, warmers or other food storage units
shall not be used for the rapid heating of potentially hazardous
food.
3. Disposable gloves shall be
worn to eliminate direct handling of food. Gloves shall be properly discarded
after being used, torn or contaminated.
4. Ground beef or ground beef products shall
be cooked to an internal temperature of 160ºFahrenheit or
higher.
5. Potentially hazardous
food shall be tempered or thawed only:
a. In
designated tempering units at a temperature not to exceed 45º
Fahrenheit;
b. In general
refrigeration units at a temperature not to exceed 40º
Fahrenheit;
c. As part of the
conventional cooking process; or
d.
In a microwave, provided the food is immediately transferred to conventional
cooking process.
6.
Potentially hazardous food that is left over shall be labeled as such with the
date and time it was removed from service.
7. Potentially hazardous food shall be
chilled to a temperature below 40° Fahrenheit and retained for no longer
than 48 hours.
8. Food contact
surfaces, i.e., cutting boards, of all equipment and utensils, shall be
sanitized by immersion for at least one-half minute in clean, hot water at a
temperature of at least 180º Fahrenheit or by any other method approved by
Health Facility Services. Counter tops and other huge industrial equipment
shall be washed down with concentrated solutions.
9. Clean linens, mopheads and cloths shall be
stored in a manner to prevent contamination prior to use.
10. Soiled linens, etc., shall be stored
covered, separately from clean linen, food storage, preparation and serving
areas. Containers for holding such items shall be made of non-absorbent
materials. Soiled linens shall be removed from the department daily.
11. Food inventory shall be handled on a
first-in, first-out basis. A system for labeling and dating canned, dry and
potentially hazardous foods shall be implemented.
12. Potentially hazardous frozen foods
removed from freezer storage to be thawed shall be labeled with the date of
pull from the freezer for thawing.
13. Supplies and perishable foods for a 24
hour period and nonperishable foods for a three day period shall be on the
premises to meet the requirements of the planned menus.
NOTE: These regulations are referenced to the
Rules and Regulations
Pertaining
to Food Service Establishments, of the
Arkansas Department of Health.
D. Clinical Services.
1. Clinical Dietitian/Nutritionist.
Shall be a registered dietitian, or registry eligible, and
evaluate and oversee the delivery of effective nutritional care based on
current, recognized nutritional practices. If not full-time, make regularly
scheduled visits to accomplish the following:
a. Review, revise and approve a current diet
manual for facility use;
b. Review,
revise, approve and implement nutritional care policy and procedures, standards
of nutritional care, nutritional care protocols and the Nutritional Services
QA/PI Program;
c. Coordinate
nutritional care through communication with other patient care
services;
d. Provide for the
initiation of nutrition screening of all patients upon admission and periodic
screening of patients during their hospital stay;
e. Provide for the nutritional evaluation of
patients at nutritional risk, as defined by the Medical Staff, and collaborate
with the physician on the findings of the evaluation;
f. Ensure competency of all nutritional
services personnel who perform assessments, counseling, develop care plans and
participate in discharge planning;
g. Provide to the facility evidence of
continuing education hours;
h.
Perform orientation, preceptorship and ongoing training/educational programs
for staff;
i. Review and revise
nutrition counseling/diet education practices that are individualized to
patient needs;
j. Monitor the
enforcement of all policies and procedures and practices relating to food
safety and sanitation;
k. Develop,
implement and maintain a system for recording data related to patient
care;
l. Collaborate with Nursing
and Pharmacy to provide food/drug interaction counseling; and
m. If the dietitian is a consultant, submit
reports to the facility Administrator reflecting services performed at each
regularly scheduled visit.
2. Nutritional Screening and Documentation.
a. Nutritional Screening shall be completed
within 24 hours of admission on all patients to determine nutritional risk and
notify the physician and dietitian of any patients that are at nutritional
risk.
b. Psychiatric, Alcohol and
Drug and Rehabilitation patients shall be rescreened seven days from the
initial screen and at least every 14 days thereafter.
3. Nutritional Evaluations and Care Plans.
a. A nutritional evaluation of patients at
nutritional risk, as reflected in the medical record, shall include as
appropriate:
1) The patient's percentage of
goal body weight range;
2) Abnormal
pertinent laboratory values;
3) The
patient's caloric and protein needs;
4) The percentage of food intake since
admission;
5) Determination of
abnormal intake or recent weight loss/gain prior to admission;
6) An objective evaluation of the patient's
compliance with a physician ordered diet prior to admission;
7) Pertinent food/drug
interactions;
8) An evaluation of
the patient's special feeding/nutrient/fluid needs; and
9) Patient's food preferences, dislikes,
allergies or intolerances.
b. The patient care plan on all patients
found to be at nutritional risk shall include the following nutritional
components, as appropriate:
1) The need for
individualized nutritional counseling;
2) Need for discharge planning;
3) Need for comprehensive nutritional
assessments to include further clinical, laboratory, social or nutritional data
to assist with the ongoing evaluation;
4) Need for follow-up care to evaluate the
effectiveness of the nutritional regimen; and
5) Any requests to the physician for
alterations or modifications to the ordered diet's nutrient content,
consistency, administration route/method or meal pattern as served in the
hospital in order to meet the nutritional needs and/or special feeding needs of
the patient.
4. Nutritional Counseling Documentation of
nutritional counseling shall include:
a.
Description of the individualized nutritional counseling;
b. Objective evaluation of the patient's
and/or significant other's understanding and ability to carry out the diet
order; and
c. Plans for continued
counseling and/or recommendations to the physician for post-discharge
counseling and evaluation of patient diet compliance.
5. Follow-up Nutritional Care.
a. Shall be performed at a minimum of every
72 hours with documentation in the patient's medical record when the patient is
at nutritional risk. If the patient's nutritional status is stable, follow-up
shall be at least every seven days.
b. Shall be documented in the patient's
medical record by a qualified designated Nutritional Services representative on
all patients at nutritional risk.
c. Shall be documented to include an
evaluation of the effectiveness of the prescribed nutrition regimen, changing
nutritional status/needs, nutritional counseling and/or recommendations to
improve patient nutritional care.
SECTION 18:
INFECTION CONTROL.
A. General.
1. The facility shall develop and use a
coordinated process that effectively reduces the risk of endemic and epidemic
nosocomial infections in patients, health care workers and visitors.
2. There shall be a comprehensive list of
communicable diseases for which patients shall be isolated and for which there
are visitation restrictions. The list, and other policies and procedures for
isolation, shall conform to the latest edition of the Centers for Disease
Control and Prevention, Atlanta, Georgia (CDC) Guidelines.
3. It shall be the duty of the Administrator
or his/her designee to report all infectious or communicable diseases in the
facility to the Arkansas Department of Health, Epidemiology, as required by the
Rules and Regulations Pertaining to Communicable Disease in
Arkansas (Ark. Code Ann. §§
20-7-109, 110.
4. The Administrator shall designate a
qualified individual who shall:
a. Coordinate
the activities of the Infection Control Committee;
b. Direct surveillance activities;
c. Ensure policies established by the
Committee are carried out; and
d.
Gather and report data regarding the hospital's nosocomial
infections.
5. There
shall be policies and procedures establishing and defining the Infection
Control program to include:
a. Definitions of
nosocomial infections and communicable diseases based on the current CDC
definitions;
b. Measures for
identifying, investigating and reporting nosocomial infections and communicable
diseases and a system of evaluating and maintaining records of infection among
both patients and health care workers which specify the type of infection from
the following site categories:
1)
Respiratory;
2)
Gastrointestinal;
3) Surgical
wounds;
4) Skin;
5) Urinary tract;
6) Septicemias; and
7) Use of intravascular catheters.
NOTE: The facility's system for surveillance, calculation and
evaluation of the incidence of nosocomial infections within the facility shall
conform to CDC's National Nosocomial Infections Surveillance System (NNIS) and
CDC publications as applicable.
c. Method(s) for calculating nosocomial
infection attack rates;
d. Measures
for assessing and identifying patients and health care workers at risk for
nosocomial infections and communicable diseases;
e. Methods for obtaining reports of
infections and communicable diseases in patients and health care workers in a
manner and time sufficient to limit the spread of infection;
f. A plan for monitoring and evaluating at
least the following areas or departments to ensure policies and procedures are
followed:
1) Inpatient and outpatient
surgery;
2) Delivery;
3) Nursery;
4) Central sterilization and
supply;
5) Housekeeping;
6) Laundry;
7) Food and Nutrition;
8) Laboratory;
9) Nursing;
10) Maintenance;
11) Invasive specialty laboratories (special
procedures);
12) Radiology;
and
13) End-Stage Renal
Disease.
g. Measures for
prevention of infections, at least those associated with the following:
1) Intravascular therapy;
2) Indwelling urinary catheters;
3) Tracheostomy;
4) Respiratory care;
5) Burns;
6) Immunosuppressed patients; and
7) Other factors which compromise a patient's
resistance to infection.
h. Measures for prevention of communicable
disease outbreaks, especially
Mycobacterium tuberculosis (TB). All plans for the prevention
of transmission of TB shall conform to the most current CDC Guidelines for
Preventing the Transmission of Mycobacterium Tuberculosis in Health Care
Facilities;
i. Isolation
procedures and requirements for infected, immunosuppressed patients and
patients colonized or infected with resistant organisms. Procedures shall
conform to the most current CDC Guidelines;
j. Provisions for education of patients and
their families concerning infections and communicable diseases to include hand
hygiene and any isolation precautions;
k. A plan for monitoring and evaluating all
aseptic, isolation and sanitation techniques employed in the facility to ensure
that approved infection control procedures are followed;
l. Techniques for:
1) Hand hygiene including procedures for soap
and water as well as alcohol based hand rub if used;
2) Respiratory protection;
3) Asepsis;
4) Sterilization;
5) Sanitary food preparation;
6) Disinfection;
7) Housekeeping;
8) Linen care;
9) Liquid and solid waste disposal of both
infectious and regular waste. Disposal of infectious waste shall conform to the
latest edition of the Rules and Regulations Pertaining to the Management of
Medical Waste from Generators and Health Care Related Facilities;
10) Needle disposal;
11) Separation of clean from dirty process;
and
12) Other means of limiting the
spread of contagion.
m.
Authority and indications for obtaining microbiological cultures from
patients;
n. A requirement that
disinfectants, antiseptics and germicides be used in accordance with the
manufacturer's directions;
o.
Employee health; and
p. Visitation
rules, especially for patients in isolation, critical care, pediatrics and
other special care units, including postpartum care.
6. There shall be an orientation program for
all new health care workers concerning the importance of infection control and
each health care worker's responsibility in the hospital's Infection Control
program. I. A liaison with the Infection Control Committee shall be maintained.
7. There shall be a plan for each
employee to receive annual educational programs as indicated based on
assessments of the Infection Control process. J. Records shall be maintained of
all autoclave loads, both routine and "flash," which shall include the date,
time, lot number (on routine loads), the time at temperature (where a recorder
is not available), item(s) sterilized and shall identify the person performing
the task.
8. The infection control
officer shall maintain a log of infectious and communicable diseases. K.
Autoclaves shall meet the following requirements:
9. No items shall be used past the expiration
date. 1. The efficacy of autoclaves, both for routine and "flash" use, shall be
determined weekly through the use of biological spore monitors;
B. Infection Control Committee. 2.
The results of all biological spore monitoring shall be reported to the
Infection Control Committee; and
1. There
shall be a multidisciplinary committee appointed by the Administrator to
develop, implement and monitor direction for the Infection Control program
based on services impacting the Infection Control process 3. Failures of the
biological spore test shall be brought to the attention of the Infection
Control Officer or designee immediately so the appropriate surveillance
measures can be initiated.
2. The
Medical Staff shall appoint a physician to serve as chairperson of the
Infection Control Committee. Additional physician members may be appointed.
NOTE: All materials sterilized from the date of the biological spore monitor
failure to the last successful biological spore monitor shall be resterilized
before use.
3. The Infection
Control Committee shall meet at least every two months. Minutes of the meetings
shall reflect the committee's actions in monitoring and directing the
hospital's Infection Control program. L. All autoclaves within the facility
shall be maintained in accordance with the manufacturer's written directions.
Records shall be maintained of all maintenance and repairs for the life of the
equipment.
4. The Infection Control
Committee shall fulfill the following responsibilities: M. Chemical indicators
for sterility shall be used with each cycle.
a. Assist in the development and approval of
all infection control policies and procedures within the facility; N. The
facility shall validate compliance and efficacy of the sterilization policy
through the quality review process. The sterilization policy shall describe the
mechanism used to determine the shelf life of sterilized packages. The
policyshall:
g. Ensure that an
antibiogram is prepared at least annually and compared to the previous one to
identify trends;
h. Monitor any
contractual services relative to infection control (e.g. waste management and
laundry) to ensure compliance with all applicable regulations; and
i. Review any special infection control
studies conducted within the facility.
C. Employee Health.
1. There shall be policies and procedures for
screening health care workers for communicable diseases and monitoring for
health care workers exposed to patients with any communicable
diseases.
2. There shall be
employee health policies regarding infectious diseases in the following
categories:
a. Health care workers affected
with any disease in the communicable stage;
b. A carrier of any communicable disease;
and
c. Health care workers affected
with boils, jaundice, infected wounds, diarrhea or acute respiratory
infections.
3. There
shall be policies which clearly state when health care workers shall not render
direct patient care.
4. There shall
be a plan for ensuring that each health care worker has an annual TB skin test
or is evaluated in accordance with guidelines approved by the Arkansas
Department of Health (Rules and Regulations Pertaining to
Communicable Disease; Section 1, Section 13 - Arkansas Department of Health
Tuberculosis Program Amendment 22394 Adopted in February,
1994).
5. There shall
be a plan for ensuring that all health care workers who are frequently exposed
to blood and other potentially infectious body fluids are offered immunizations
for Hepatitis B.
SECTION
19:
LABORATORY.
A.
General.
1. Each hospital shall provide
laboratory services onsite commensurate with the needs of patients that are
admitted. Provision shall be made for the performance of laboratory
examinations in the following categories:
a.
Chemistry;
b. Hematology;
c. Microbiology;
d. Immunology;
e. Immunohematology;
f. Urinalysis; and g. Pathology.
2. The requirements of the most
current rule of the Clinical Laboratory Improvement Amendments of 1988 (CLIA)
shall be met
3. All laboratory
testing that is performed at any site owned and/or operated by the facility
shall be approved, in writing, by the Governing Body. The Governing Body shall
authorize the director of the hospital laboratory to provide oversight of all
testing to ensure the quality of the laboratory services provided. A
comprehensive list of all testing sites shall be made available to the Medical
Staff.
4. A laboratory shall refer
specimens for testing only to a laboratory possessing a valid Clinical
Laboratory Improvement Amendments (CLIA) certificate authorizing the
performance of testing in the specialty or subspecialty of service for the
level of complexity in which the referred test is categorized.
5. Only results from the hospital laboratory
or from other approved laboratories, as determined by hospital policy, shall be
placed in the patient's medical record.
6. Laboratory tests shall be authorized by a
physician, dentist, or other person authorized by the Medical Staff and the
Governing Body to order laboratory examinations.
7. The laboratory shall maintain accurate
counts of total patient procedures for each specialty in which tests are
performed.
8. Current reference
material, such as textbooks, shall be available for every laboratory category
in which tests are performed.
9.
The laboratory shall make available to the Medical Staff a list of all tests
performed onsite, including the reference range for each test.
B. Personnel.
1. A member of the Medical Staff shall be
appointed to act as a liaison between the laboratory and the Medical
Staff.
2. The laboratory shall be
under the oversight of a pathologist who is board certified or eligible. A
pathologist who is not based at the hospital shall make at least a monthly
visit and submit a monthly written report to the Hospital Administrator.
NOTE: A hospital which provides only limited laboratory
services (e.g., blood gas laboratory only) shall not be subject to the
requirement of oversight of a pathologist.
3. The laboratory director, as defined by
CLIA 88, shall be responsible for the overall operation of the laboratory but
may delegate specific responsibilities to supervisory personnel. However, the
director remains responsible for ensuring that all duties are properly
performed and documented. The laboratory director shall be responsible for the
following:
a. Ensuring that testing systems
developed and used for each of the tests performed in the laboratory provide
quality laboratory services for all aspects of test performance, which includes
the pre-analytic, analytic and post-analytic phases of testing;
b. Ensuring that the physical plant and
environmental conditions of the laboratory are appropriate for the testing
performed and provide a safe environment in which employees are protected from
physical, chemical and biological hazards;
c. Ensuring that:
1) The test methodologies selected have the
capability of providing the quality of results required for patient
care;
2) Verification procedures
used are adequate to determine the accuracy, precision and other pertinent
performance characteristics of the method;
3) Laboratory personnel are performing the
test methods as required for accurate and reliable results;
d. Ensuring that the laboratory is
enrolled in a proficiency testing program approved by Health and Human Services
(HHS) for the testing performed and that:
1)
The proficiency testing samples are tested in the same manner as the patient
samples;
2) The results are
returned within the time frames established by the proficiency testing
program;
3) All proficiency testing
reports are reviewed by the appropriate staff to evaluate the laboratory's
performance and to identify any problems that require corrective
action;
4) An approved corrective
action plan is followed when any proficiency testing result is found to be
unacceptable or unsatisfactory;
e. Ensuring that the quality control and
quality assurance/performance improvement programs are established and
maintained to assure the quality of laboratory services provided and to
identify failures in quality as they occur;
f. Ensuring the establishment and maintenance
of acceptable levels of analytical performance for each test system;
g. Ensuring that all necessary remedial
actions are taken and documented whenever significant deviations from the
laboratory's established performance characteristics are identified and that
patient test results are reported only when the system is functioning
properly;
h. Ensuring that reports
of test results include pertinent information required for
interpretation;
i. Ensuring that
consultation is available to the laboratory's clients and to the Medical Staff
on matters relating to the quality of the test results reported and
interpretation concerning specific patient conditions;
j. Ensuring there is a sufficient number of
laboratory personnel with the appropriate education and either training or
experience to provide appropriate consultation, properly supervise and
accurately perform tests and report test results;
k. Ensuring all personnel have the
appropriate education and experience, receive the appropriate training for the
type of services offered, and have demonstrated that they can perform all
testing operations reliably to provide and report accurate results;
l. Ensuring there is documentation of
training for laboratory personnel who perform special procedures such as
arterial punctures and therapeutic phlebotomies;
m. Ensuring that qualified testing personnel
are on duty or on call at all times;
n. Ensuring that policies and procedures are
established for monitoring individuals who conduct pre-analytical, analytical
and post-analytical phases of testing to assure that they are competent and
maintain their competency to process specimens, perform test procedures and
report test results promptly and proficiently, and whenever necessary, identify
needs for remedial training or continuing education to improve skills. The
procedures for evaluation of the competency of the staff shall include, but are
not limited to the following:
1) Direct
observations of routine patient test performance, including patient
preparation, if applicable, specimen handling, processing and
testing;
2) Monitoring the
recording and reporting of test results;
3) Review of intermediate test results or
worksheets, quality control records, proficiency testing results and preventive
maintenance records;
4) Direct
observation of performance of instrument maintenance and function
checks;
5) Assessment of test
performance through testing previously analyzed specimens, internal blind
testing samples or external proficiency testing samples;
6) Assessment of problem solving
skills;
7) Evaluation and
documentation of the performance of all personnel with at least the following
frequency:
a) Semiannually during the first
year of employment in the laboratory;
b) Annually after the first year;
c) Prior to reporting patient test results if
test methodology or instrumentation changes;
o. Ensuring that an approved procedure manual
is available to all personnel responsible for any aspect of the testing
process;
p. Ensuring there is a
plan for providing continuing education for the laboratory staff and there is
documentation of each employee's participation.
q. Specifying the responsibilities and duties
of each consultant and each supervisor, as well as each person engaged in the
performance of the pre-analytic, analytic and post-analytic phases of
testing;
r. Specifying the
examinations and procedures each individual is authorized to perform, whether
supervision is required for specimen processing, test performance or result
reporting and whether supervisory or director review is required prior to
reporting patient test results;
4. There shall be a supervisor accessible at
all times when testing is performed.
5. Personnel responsible for day-to-day
supervision of the laboratory shall meet at least one of the following
qualifications:
a. A bachelor's degree in
medical technology from an accredited institution and at least one (1) year of
clinical laboratory training or experience relative to the specialties being
supervised;
b. A bachelor's degree
in a chemical, physical, biological or clinical laboratory science from an
accredited institution with at least two years of clinical laboratory training
or experience relative to the specialties being supervised;
c. An associate degree in a laboratory
science or medical laboratory technology from an accredited institution with at
least two years of clinical laboratory training or experience relative to the
specialties being supervised;
d. A
passing score on the Clinical Laboratory Technology Proficiency examination
approved by HHS (HEW) and at least six years of clinical laboratory experience
with at least two years of experience relative to the specialties being
supervised;
e. Employment as a
laboratory supervisor prior to January 1, 1995, in a hospital licensed by the
Arkansas Department of Health.
6. Testing personnel shall meet at least the
following qualifications:
a. Have earned a
high school diploma or equivalent;
b. Have documentation of training appropriate
for the testing performed prior to analyzing patient specimens. Such training
shall ensure that the individual has the following:
1) Skills required for proper patient
preparation and specimen collection, to include the following:
a) Labeling;
b) Handling;
c) Preservation or fixation;
d) Processing or preparation;
e) Transportation and storage.
2) The skills required for
implementing all standard laboratory procedures;
3) The skills required for performing each
test method and for proper instrument use;
4) The skills required for performing
preventive maintenance,
trouble-shooting and calibration procedures related to each
test performed;
5) A
working knowledge of reagent stability and storage;
6) The skills required to implement the
quality control policies and procedures of the laboratory;
7) An awareness of the factors that influence
test results;
8) The skills
required to assess and verify the validity of patient test results through the
evaluation of quality control sample values prior to reporting test
results.
C. Procedure Manual.
1. There shall be a procedure manual for the
performance of all analytical methods used by the laboratory readily available
and followed by laboratory personnel. Textbooks may be used as supplements but
shall not be used in lieu of the laboratory's written procedures for testing or
examining specimens. The procedure manual shall include, when applicable to the
test procedure, the following:
a.
Requirements for patient preparation, specimen collection and processing,
labeling, preservation and transportation, including criteria for specimen
rejection;
b. Procedures for
microscopic examinations, including the detection of inadequately prepared
slides;
c. Step-by-step performance
of the procedure, including test calculations and interpretation of
results;
d. Preparation of slides,
solutions, calibrators, controls, reagents, stains and other materials used in
testing;
e. Calibration and
calibration verification procedures;
f. The reportable range for patient test
results as verified by the laboratory;
g. Quality control procedures for each test
to include the following:
1) Type of
control;
2) Identity of
control;
3) Number of
controls;
4) Frequency of testing
controls;
5) Criteria for
determining acceptability of control results.
h. Remedial actions to be taken when any of
the following occur:
1) Calibration results
are unacceptable;
2) Control
results are unacceptable;
3)
Equipment or test methodologies fail;
4) Patient test values are outside the
laboratory's reportable range of patient test results;
5) The laboratory cannot report patient test
results within its established time frames;
6) Errors in reported patient test results
are detected.
i.
Limitations in methodologies, including interfering substances;
j. Reference ranges (normal
values);
k. A list of "panic
values" with written instructions for reporting such values;
l. Pertinent literature references;
m. Appropriate criteria for specimen storage
and preservation to ensure specimen integrity until testing is
completed;
n. The laboratory's
system for reporting patient test results;
o. Description of the course of action to be
taken in the event that a test system becomes inoperable;
p. Criteria for the referral of specimens,
including procedures for specimen submission and handling and for record
keeping.
2. The procedure
manual shall be reviewed, approved, signed and dated by the current director of
the laboratory or by an individual designated by the director in compliance
with the CLIA 88 requirements.
3.
Each revision or addition to the procedure manual shall be reviewed, approved,
signed and dated by the current director of the laboratory or by an individual
designated by the director in compliance with the CLIA 88
requirements.
4. The laboratory
shall maintain a copy of each discontinued procedure for two years, with the
dates of initial use and discontinuance.
D. Record System.
1. The laboratory shall have policies and
procedures for a record system which shall assure positive identification of
patient specimens from the time of specimen collection until the time of test
completion and results reporting. The record system shall include provisions
for test requisitions, test records and test reports. The configuration of the
system may be established by the laboratory, provided all of the required
information is readily retrievable for at least two years.
2. The laboratory shall perform tests at the
written or electronic request of an authorized person.
3. Records of test requisitions or test
authorizations shall be retained for a minimum of two years.
4. The test requisition shall include:
a. Identification of the patient;
b. The name of the authorized person who
ordered the test;
c. The test(s)
requested;
d. The date the test is
to be performed;
e. For Pap smears,
the patient's last menstrual period, age or date of birth and indication of
whether the patient had a previous abnormal report, treatment or
biopsy;
f. Any additional
information relevant and necessary to a specific test to assure accurate and
timely testing and reporting of results (Examples: age, sex, current
medications, time of specimen collection, diagnosis, type of specimen,
fasting).
5. Records of
patient testing, including instrument printouts, shall be retained for at least
two years. Immunohematology records and transfusion records shall be retained
for at least five years. (Exception: If an instrument is interfaced with a
computer, and the electronic data cannot be edited, the instrument printouts do
not have to be retained.)
6. Test
records shall provide documentation of the information required for test
requisitions as well as the following information:
a. Unique identification of the patient
specimen;
b. The date and time of
specimen receipt into the laboratory;
c. The condition and disposition of specimens
that do not meet the laboratory's criteria for specimen
acceptability;
d. The tests and
date of performance of each;
e. The
time of completion of testing;
f.
The identity of the person who performs each test.
7. The laboratory report shall be sent
promptly to the authorized person who requested the test.
8. A duplicate of each test report, including
both preliminary and final reports, shall be retained for at least two years.
The duplicate may be retained electronically as long as it contains the exact
information sent to the individual ordering the test and utilizing the test
results. For test reports requiring an authorized signature or containing
personnel identifiers, the exact duplicate must include the signature or
identifiers. Immunohematology reports shall be retained for at least five
years, and pathology reports shall be retained for at least 10 years.
9. The test report shall include the
following:
a. Identification of the
patient;
b. Date of specimen
collection;
c. The test(s)
performed;
d. Test results and, if
applicable, the units of measurement;
e. Date results were reported;
f. The condition and disposition of specimens
that do not meet the laboratory's criteria for acceptability;
g. Any additional information relevant and
necessary for the interpretation of the results of a specific test (Examples:
Type of specimen, time of specimen collection, fasting).
10. The laboratory shall have policies and
procedures for referring patient specimens to reference laboratories, to
include:
a. Current list of reference
laboratories, with the following information:
1) CLIA number;
2) Specialties and subspecialties in which
the laboratory is certified;
3)
Expiration date of CLIA certificate;
b. Specimen submission and
handling;
c. Record keeping
system.
11. The
laboratory shall not revise results or information directly related to the
interpretation of results provided by a reference laboratory.
12. The laboratory shall retain an exact
duplicate of each reference laboratory report, including each preliminary and
corrected report, for at least two years. Pathology reports from reference
laboratories shall be retained for 10 years, and immunohematology reports shall
be retained for five years.
13. The
laboratory's report shall indicate the test(s) performed by a reference
laboratory and the name and address of each laboratory location at which a test
was performed.
E.
General Quality Control.
1. The laboratory
shall be constructed, arranged and maintained to ensure the space, ventilation
and utilities necessary for conducting all phases of testing.
2. The laboratory shall have appropriate and
sufficient equipment, instruments, reagents, materials and supplies for the
type and volume of testing performed and for the maintenance of quality during
all phases of testing.
3. The
manufacturer's instructions shall be followed when using an instrument, kit or
test system.
4. Components of
reagent kits of different lot numbers shall not be interchanged unless
otherwise specified by the manufacturer.
5. The laboratory shall define criteria for
those conditions that are essential for proper storage of reagents and
specimens and for accurate and reliable test system operation and test result
reporting. These conditions shall include if applicable water quality,
temperature, humidity and protection of equipment and instrumentation from
fluctuations and interruptions in electrical current that adversely affect
patient test results and test reports. There shall be documentation of the
remedial actions taken to correct problems with these conditions.
6. Reagents, solutions, culture media,
control materials, calibration materials and other supplies, as appropriate,
shall be labeled to indicate the following:
a. Identity and, when significant, titer,
strength or concentration;
b.
Recommended storage requirements;
c. Preparation and expiration
dates;
d. Other pertinent
information required for proper use.
7. Reagents, solutions, culture media,
control materials, calibration materials and other supplies shall be prepared,
stored and handled in a manner to ensure that they are not used when the
expiration date has been exceeded or when they have deteriorated or are of
substandard quality.
8. The
laboratory shall comply with the Food and Drug Administration (FDA) product
dating requirements of 21
CFR 610.53 for blood, blood products and
other biologicals and with labeling requirements in 21 FR 809.10 for all other
in vitro diagnostics. Any exception to the product dating requirements in
21 CFR
610.53 shall be granted by the FDA in the
form of an amendment of the product license, in accordance with
21 CFR
610.53(d). All exceptions
shall be documented by the laboratory.
9. Test methodologies and equipment shall be
selected and testing performed in a manner that provides test results within
the laboratory's stated performance specifications for each test.
10. Before the laboratory reports patient
test values using a new method or device, it shall first verify or establish
for each method the performance specifications for the following performance
characteristics, as applicable:
a.
Accuracy;
b. Precision;
c. Analytical sensitivity and specificity, to
include interfering substances;
d.
Reportable range of patient test results;
e. Reference range (normal values);
f. Any other performance characteristics
required for test performance;
The laboratory shall have documentation of the verification or
establishment of all applicable test performance specifications and shall
establish control and calibration procedures based upon those
specifications.
11. The laboratory shall perform maintenance
and function checks for all equipment, instruments and test systems according
to the manufacturers' instructions. If the manufacturer does not define
maintenance or function checks, the laboratory shall establish protocols
ensuring equipment, instruments or test systems perform accurately and
reliably. Maintenance and function checks shall be performed with at least the
frequency of the manufacturer's instructions.
12. All function checks and maintenance
activities shall be documented. The function checks shall be within the
laboratory's or manufacturer's established limits before patient testing is
conducted.
13. For each method or
device the laboratory shall perform calibration procedures:
a. At a minimum, in accordance with
manufacturer's instructions, if provided, using calibration materials provided
as specified, as appropriate, and with at least the frequency recommended by
the manufacturer; and
b. In
accordance with established laboratory criteria to include:
1) The number, type and concentration of
calibration materials, acceptable limits for calibration and the frequency of
calibration; and
2) Using
calibration materials appropriate for the methodology and, if possible,
traceable to a reference method or reference material of known value;
and
c. Whenever
calibration verification fails to meet the laboratory's established acceptable
limits for calibration verification.
14. For each method or device the laboratory
shall perform calibration verification procedures:
a. At a minimum, in accordance with the
manufacturer's instructions, if provided; and b. In accordance with established
laboratory criteria to include:
1) The number,
type and concentration of calibration materials, acceptable limits for
calibration verification, and frequency of calibration verification;
2) Calibration materials appropriate for the
methodology and, if possible, traceable to a reference method or reference
material of known value;
3)
Verification of the laboratory's established reportable range of patient test
results, which shall include at least a minimal (or zero) value, a mid-point
value, and a maximum value at the upper limit of that range;
4) Performance of calibration verification at
least every six months or when the following occur:
a) A complete change of reagents for a
procedure is introduced, unless the laboratory can demonstrate that changing
reagent lot numbers does not affect the range used to report patient test
results and control values are not adversely affected by reagent lot number
changes;
b) There is a major
preventive maintenance or replacement of critical parts that may influence test
performance;
c) Controls reflect an
unusual trend or shift or are outside the laboratory's acceptable limits and
other means of assessing and correcting unacceptable control values have failed
to identify and correct the problem;
d) The laboratory's established schedule for
verifying the reportable range for patient test results requires more frequent
calibration verification than specified by the
manufacturer.
15. All calibration and calibration
verification activities shall be documented.
16. Control Procedures - (Controls shall be
performed as defined or as otherwise defined under a specific category
heading.)
a. For each device the laboratory
shall evaluate instrument and reagent stability and operator variance in
determining the number, type and frequency of testing calibration or control
materials and establish criteria for acceptability used to monitor test
performance during a run of patient specimen(s). A run is an interval within
which the accuracy and precision of a testing system is expected to be stable,
but it cannot be greater than 24 hours or less than the frequency recommended
by the manufacturer. For each procedure, the laboratory shall monitor test
performance using calibration materials or control materials or a combination
thereof. Controls shall be performed as follows:
1) For qualitative tests, the laboratory
shall include a positive and a negative control with each run of patient
specimens. Internal procedural controls (both positive and negative) may be
used to satisfy this requirement.
2) For quantitative tests, the laboratory
shall include at least two samples of different concentrations of either
calibration materials, control materials, or a combination thereof with the
frequency not less than two levels per 24 hours of operation.
3) If calibration and control materials are
not available, the laboratory shall have an alternative mechanism to assure the
validity of patient test results.
4) Control samples shall be tested in the
same manner as patient test specimens.
5) When calibration or control materials are
used, statistical parameters (e.g., mean and standard deviation) for each lot
number of calibration or control material shall be determined through
repetitive testing. Levy-Jennings plots or other visual representation methods
shall be used to evaluate statistical data for trends and shifts. Weekly
supervisory review is required. Control values shall be evaluated as follows:
a) The stated values of assayed control
material may be used as the target values provided the stated values correspond
to the methodology and instrumentation employed by the laboratory and are
verified by the laboratory;
b)
Statistical parameters for unassayed materials shall be established over time
by the laboratory through concurrent testing with calibration materials or
control materials having previously determined statistical parameters; and
c) Control results shall meet the
laboratory's criteria for acceptability prior to reporting patient test
results.
17. The laboratory shall document all control
activities. Documentation shall be retained for a period of two years.
Immunohematology quality control records shall be retained for a period of five
years. Cytology and histopathology quality control records shall be retained
for a period of 10 years.
F. Chemistry.
1. The following requirements apply only to
blood gas analysis, regardless of the testing site:
a. Follow the manufacturer's instructions
regarding calibration of the blood gas analyzer;
b. Test at least one level of control
material each eight hours of patient testing;
c. Rotate the order in which the controls are
performed so that normal, alkalosis and acidosis levels are tested; and
d. Test one sample of calibration
material or control material each time patients are tested if the instrument
does not internally verify calibration at least every 30
minutes.
2. For
electrophoretic determinations:
a. At least
one control sample shall be used in each electrophoretic cell;
b. The control sample shall contain fractions
representative of those routinely reported in the patient specimens.
G. Hematology.
1. There shall be at least two levels of
controls for non-manual hematology testing systems each eight hours in which
patient testing is performed.
2.
There shall be at least one level of control for manual cell counts each eight
hours in which patient testing is performed.
3. Manual cell counts shall be performed in
duplicate with documentation of both counts. The laboratory shall establish
criteria for the acceptable difference between duplicate counts.
4. There shall be two levels of controls for
non-manual coagulation testing systems each eight hours in which patient
testing is performed and each time a change in reagents occurs.
5. Each individual shall test two levels of
controls before performing manual coagulation testing on patient samples and
each time a change in reagents occurs.
6. Manual coagulation tests on both patient
and control specimens shall be performed in duplicate with documentation of
both times. The laboratory shall establish criteria for the acceptable
difference between duplicate times.
7. Background counts of diluents shall be
performed daily and results recorded.
8. If the microhematocrit centrifuge is used,
the maximum packing time shall be determined at least every six
months.
9. The laboratory director
shall establish written criteria for abnormal cell morphology requiring review
by a qualified physician who is board-certified or board-eligible in either
pathology or hematology.
10 The
laboratory shall maintain a file of unusual hematology slides to be used in the
orientation, training and continuing education of laboratory
personnel.
H. Immunology.
1. The equipment, glassware, reagents,
controls and techniques for tests for syphilis shall conform to manufacturers'
specifications.
2. The laboratory
shall run serologic tests on patient specimens concurrently with a positive
serum control of known titer or controls of graded reactivity plus a negative
control. (If patient results are reported in terms of graded reactivity,
controls of graded reactivity shall be used; if patient results are reported as
a titer, controls of known titer shall be used with results reported as a
titer.)
3. The laboratory shall
employ controls that evaluate all phases of the test system to ensure
reactivity and uniform dosages when positive and negative controls alone are
not sufficient.
4. A facility
manufacturing blood and blood products for transfusion or serving as a referral
laboratory for such a facility shall meet the following:
a. Syphilis serology testing requirements of
21 CFR
606.65 (c&e) and 640.5(a);
b. HIV testing requirements of 21 CFR 610.45 ;
and
c. Hepatitis testing
requirements of 21 CFR
610.40.
I. Immunohematology.
1. There shall be provision for prompt ABO
blood grouping, D(Rho) typing, unexpected antibody detection, compatibility
testing and laboratory investigation of transfusion reactions, either through
the facility or under arrangement with an approved facility that is certified
in Immunohematology and Transfusion Services and Blood Banking under the
Clinical Laboratory Improvement Amendments of 1988 (CLIA 88).
2. If the facility does not provide
immunohematological or blood banking services onsite, there shall be a written
agreement with an outside laboratory or blood bank that governs the
procurement, transfer and availability of blood and blood products. The
agreement shall be reviewed and approved by the laboratory director.
3. The laboratory shall perform and document
ABO group and D(Rho) typing on all donor red cells received from outside
sources prior to transfusing.
4.
The laboratory shall perform ABO group and D(Rho) typing, unexpected antibody
detection, antibody identification and compatibility testing in accordance with
manufacturers' instructions, if provided, and as applicable, with 21 CFR Part
606 (with the exception of 21 CFR 606.20.a, Personnel) and 21
CFR 640 et seq.
5. The laboratory
shall perform ABO group by concurrently testing unknown red cells with anti-A
and anti-B grouping reagents. For confirmation of ABO group, the unknown serum
shall be tested with known A1 and B red cells. All reactions shall be
documented.
6. The laboratory shall
determine the D(Rho) type by testing and documenting the reaction of unknown
red cells with anti-D(Rho) blood grouping reagent.
7. If required in the manufacturer's package
insert for anti-D(Rho) reagents, the laboratory shall employ a control system
(Rh-hr control) capable of detecting false positive D(Rho) test
results.
8. Each day of use the
laboratory shall perform and document the following quality control checks for
each vial of antisera and reagent red cells:
a. Positive control only for ABO antisera,
ABO reagent red cells and antibody screening cells (at least one known
antibody); and
b. Positive and
negative controls for D(Rho) antisera, other antisera and anti-human globulin
(Coombs serum).
9.
Records shall identify the source and lot number of each reagent on each day of
use.
10. Policies and procedures to
ensure positive identification of a blood or blood product recipient shall be
established and followed.
11. Donor
blood and blood products shall be stored or maintained for transfusion under
conditions required to prevent deterioration and to ensure optimum integrity,
whether in the blood bank or in a remote storage refrigerator.
12. Donor blood shall be stored in a
refrigerator which meets the following criteria:
a. The refrigerator shall be connected to an
emergency power source;
b. An
audible alarm system shall monitor proper storage temperature and shall sound
at a location that is staffed 24 hours per day;
c. The refrigerator shall not be used for the
storage of hazardous or contaminated items;
d. The refrigerator shall have adequate space
to provide for segregated storage of the following:
1) Donor blood prior to completion of
tests;
2) Donor blood not suitable
for use; and
3) Autologous
units;
e. A temperature
recorder shall be connected to the refrigerator.
13. The high and low activation temperatures
of the alarm system shall be checked and documented at least quarterly. The
response to the activated alarm shall be documented.
14. The temperature recorder shall be
compared daily to a thermometer in the refrigerator. Results of the temperature
checks shall be documented.
15. The
temperature recorder chart shall be changed weekly, and the individual who
changes the chart shall initial and date it.
16. Written criteria shall be established for
daily inspection of the blood storage unit for:
a. Outdated blood;
b. Hemolysis;
c. Bacterial contamination; and
d. Unit integrity.
Blood shall be visually inspected at the time of issue. Results
of all inspections shall be recorded.
17. Records shall be maintained of all blood
or blood components received, crossmatched, transfused, expired or returned to
the supplier.
18. Patient's serum
less than 72 hours old shall be used in the compatibility procedure.
19. All blood for transfusions, except for
autologous transfusions, shall be tested for hepatitis and for HIV antibodies
before it is transfused. The tests for hepatitis and/or HIV antibodies may be
performed by the supplier or by the institution in which the blood is
transfused.
20. Samples of both
patient and donor blood shall be retained at least seven days following
transfusion.
21. Procedures shall
be established for the prompt investigation of all suspected transfusion
reactions The laboratory director shall review all suspected transfusion
reactions, and a report shall be given to a committee of the Medical
Staff.
22. Criteria shall be
established for the reissuing of donor blood to ensure that the blood has been
maintained under conditions required to ensure the safety of individuals being
transfused within the facility.
23.
Records of therapeutic phlebotomies shall be maintained, detailing the patient
name, date, time, amount drawn, phlebotomist and disposition of the blood.
Blood drawn as a therapeutic phlebotomy shall not be used for
transfusion.
24. A committee of the
Medical Staff shall fulfill the following responsibilities:
a. Establish criteria for the proper use of
blood and its components;
b.
Monitor the transfusion of blood and its components to ensure the established
criteria for proper use are met;
c.
Review the reports of suspected transfusion reactions;
d. Establish criteria for therapeutic
phlebotomies.
25. Blood
banking policies and procedures shall conform to the current Standards for
Blood Banks and Transfusion Services of the American Association of Blood
Banks.
J. Urinalysis.
1. Routine urinalysis shall be performed
within two hours of collection of the specimen unless the specimen is
refrigerated.
2. Manufacturers'
instructions shall be followed for all tests.
3. Two levels of controls shall be performed
and documented each day of patient testing utilizing an automated strip
reader.
4. A refractometer for
measuring urine specific gravity shall be checked each day of use with a low
(1.000) and upper level standard or control.
K. Microbiology.
1. Each day of use, the laboratory shall
evaluate the detection phase of direct antigen systems using an appropriate
positive and negative control organism or antigen extract. When direct antigen
systems include an extraction phase, the system shall be checked, each day of
use, using a positive organism.
2.
The laboratory shall check each batch or shipment of reagents, discs, stains,
antisera and identification systems (systems using two or more substrates) when
prepared or opened for positive and negative reactivity, as well as graded
reactivity, if applicable.
3.
Unless otherwise specified, each day of use the laboratory shall test staining
materials for intended reactivity to ensure predictable staining
characteristics.
4. The laboratory
shall check fluorescent stains for positive and negative reactivity each time
of use (unless otherwise specified).
5. The laboratory shall check each batch or
shipment of media for sterility, if it is intended to be sterile and sterility
is required for testing. Media shall be checked for its ability to support
growth and, as appropriate, selectivity/inhibition and/or biochemical
response.
6. The laboratory may use
the manufacturer's control checks of media provided the manufacturers' product
insert specifies that the manufacturer's quality control checks meet the
National Committee for Clinical Laboratory Standards (NCCLS) for media quality
control. The laboratory shall document that the physical characteristics of the
media are not compromised and report any deterioration of the media to the
manufacturer.
7. The laboratory
shall follow the manufacturer's specifications for using the media and be
responsible for the test results.
8. The following media shall be retested
using NCCLS standards for growth, inhibition and selectivity, as applicable:
a. Campylobacter agar;
b. Media for the selective isolation of
pathogenic Neisseria;
c. Media used
to isolate parasites, viruses, Mycoplasma, Chlamydia;
d. Mueller-Hinton media used for
antimicrobial susceptibility tests; and
e. Media commercially prepared and packaged
as a unit or system consisting of two or more different substrates, primarily
used for microbial identification.
9. The laboratory shall check positive and
negative reactivity with control organisms as follows:
a. Each day of use for catalase, coagulase,
beta-lactamase, and oxidase reagents and DNA probes;
b. Each week of use for Gram and acid-fast
stains and for bacitracin, optochin, ONPG, X and V discs or strips;
c. Each month of use for antisera;
d. Each week of use the laboratory shall
check XV discs or strips with a positive control;
e. For antimicrobial susceptibility tests,
the laboratory shall check each new batch of media and each lot of
antimicrobial discs or wells before or concurrent with initial use using
approved reference organisms:
1) The
laboratory's zone sizes or minimum inhibitory concentrations (MIC) for
reference organisms shall be within established limits before reporting patient
test results;
2) Each day tests are
performed the laboratory shall use the appropriate control organisms to check
the procedure unless adequate precision can be demonstrated. Once adequate
precision is demonstrated, the controls may be performed each week of use.
Documentation of precision studies is required.
10. Antibiotic sensitivities shall be
performed using a recognized method. If the Kirby-Bauer method is utilized:
a. Proper sized petri dishes shall be
used;
b. Disc zone sizes shall be
measured and recorded, or a template shall be used; and
c. A standardized inoculum shall be
used.
11. Records shall
reflect all tests used to isolate and identify organisms.
12. For laboratories performing
mycobacteriological testing, the laboratory shall:
a. Each day of use check the iron uptake test
with at least one positive and one negative acid-fast control organism. Check
all other reagents or test procedures used for identification with at least a
positive acid-fast control organism.
b. Each week of use check the fluorochrome
acid-fast stain's reactivity with a positive and a negative control
organism;
c. Each week of use check
the acid-fast stain's reactivity with a positive control organism; and
d. Each week of use, check the
procedure for susceptibility tests performed on Mycobacterium tuberculosis
isolated with a strain of Mycobacterium tuberculosis susceptible to all
antimycobacterial agents tested.
13. For laboratories conducting mycological
testing, the laboratory shall:
a. Each day of
use, if using the auxanographic medium for nitrate assimilation, check the
nitrate reagents with a peptone control;
b. Each week of use check the acid-fast
stain's reactivity with a positive and a negative control organism; and
c. Each day of use test each drug
for susceptibility tests with at least one control strain that is susceptible
to the drug and ensure that patient test results are reported only when control
results are within the laboratory's established control
limits.
14. For
laboratories performing parasitology tests, the laboratory shall:
a. Have available a reference collection of
slides or photographs and, if available, gross specimens for identification of
parasites and use these references in the laboratory for appropriate comparison
with diagnostic specimens;
b.
Calibrate and use the calibrated ocular micrometer for determining the size of
ova and parasites, if size is a critical parameter. Calibration of the
micrometer shall be checked annually or after microscope repair or major
maintenance. Documentation of the calibration is required; and
c. Check permanent stains each month of use
using a fecal sample control that will demonstrate staining
characteristics.
15. For
laboratories performing virology tests, the laboratory shall:
a. Have available host systems for the
isolation of viruses and identification methods that cover the entire range of
viruses that are etiologically related to clinical diseases for which services
are offered;
b. Maintain records
that reflect the systems used and the reactions observed; and
c. Simultaneously culture, for identification
tests, uninoculated cells or cell substrate controls as a negative control to
detect erroneous identification results.
16. A microbiological safety cabinet shall be
used when mycobacteriology or mycology cultures are manipulated. The cabinet
shall meet the following special requirements.
a. Have a face velocity of at least 75 feet
per minute;
b. Be connected to an
independent exhaust system;
c. Have
filters with 99.97 percent efficiency (based on the dioctylphthalate (DOP) test
method) in the exhaust system;
d.
Be designed and equipped to permit the safe removal, disposal and replacement
of contaminated filters; and e. Be provided with a means of
disinfection.
17.
Mycology, mycobacteriology or virology cultures shall be disinfected prior to
leaving the control of the laboratory.
L. Pathology (Histopathology and Cytology).
1. The ventilation system shall be adequate
to properly remove vapors, fumes and excessive heat.
2. Staining dishes shall be properly labeled
and covered when not in use.
3.
Flow charts that reflect the staining procedure used shall be
available.
4. A control slide of
known reactivity shall be included with each slide or group of slides for
differential or special stains. Reaction of the control slide with each special
stain shall be documented.
5. For
cytology stains:
a. All gynecologic smears
shall be stained using a Papanicolaou (PAP) or modified PAP staining
method;
b. Effective measures shall
be taken to prevent cross-contamination between gynecologic and non-gynecologic
specimens during the staining process;
c. Non-gynecologic specimens that have a high
potential for cross-contamination shall be stained separately from other
non-gynecologic specimens, and the stains shall be filtered or changed
following staining.
6.
All cytology slide preparations shall be retained for five years.
7. For histopathology:
a. All stained slides shall be retained at
least 10 years;
b. All specimen
blocks shall be retained at least two years; and
c. All remnants of tissue specimens shall be
retained in a manner that assures proper preservation of the tissue specimens
until the portions submitted for microscopic examination have been examined and
a diagnosis has been made.
8. An exact duplicate of each test report
shall be retained for at least 10 years.
9. The following reports shall be signed to
reflect the review of a board-certified pathologist, or, as applicable, another
individual meeting the qualifications specified in the CLIA requirements:
a. All tissue pathology reports;
b. All non-gynecologic cytology
reports;
c. All gynecologic
cytology reports on smears containing cells exhibiting reactive or reparative
changes, atypical squamous/glandular cells, premalignant or malignant
condition.
NOTE: If an electronic signature is used, the laboratory shall
ensure that only the authorized person can release the signature. Refer to
Section 14, Health Information Services.
10. The laboratory shall compare clinical
information, when available, with cytology reports and shall compare each
malignant and premalignant gynecology report with the histopathology report, if
available, and determine the causes of any discrepancies.
11. All tissues surgically removed shall be
examined by an anatomic pathologist. The Medical Staff shall develop a list of
tissues that need not be examined.
12. A frozen section diagnosis, as reported
to the surgeon, shall be documented and signed by the pathologist at the time
the frozen section is performed. The documentation may be on the requisition, a
patient test log, or a report form.
13. Autopsy services shall be under the
supervision of a board-certified pathologist.
14. Autopsy findings in a complete protocol
shall be filed in the patient's medical record within 60 days of the autopsy. A
provisional anatomical diagnosis shall be recorded within 72 hours after
autopsy. A duplicate copy of the autopsy report shall be maintained in the
laboratory autopsy file.
M. Radiobioassay.
1. Background checks shall be performed each
day at the proper window setting for each type of isotope being used, as
applicable.
2. Criteria for
unacceptable changes in background levels shall be established.
3. Safety precautions shall be written and
appropriately displayed. Film badges and/or rings shall be worn, as
applicable.
4. There shall be
written procedures to assure reliability of testing and safety of patients and
personnel.
5. All procedures for
safety and disposal of radioactive waste shall conform to the most current
Rules and Regulations for Control of Sources of Ionizing Radiation adopted and
promulgated by the Arkansas State Board of Health.
N. Quality Assurance/Performance Improvement.
1. Each laboratory shall establish a Quality
Assurance/Performance Improvement plan. The plan shall follow written policies
and procedures for a comprehensive program which monitors and evaluates the
ongoing and overall quality of the total testing process. The plan shall
evaluate the effectiveness of the laboratory's policies and procedures,
identify and correct problems, assure the accurate, reliable and prompt
reporting of test results, and assure the adequacy and competency of the staff.
As necessary, the laboratory shall revise policies and procedures based upon
the results of those evaluations.
2. All Quality Assurance/Performance
Improvement activities shall be documented.
3. The laboratory shall have an ongoing
mechanism for monitoring and evaluating the following:
a. The criteria established for patient
preparation, specimen collection, labeling, preservation and
transportation;
b. The information
solicited and obtained on the laboratory requisition for its completeness,
relevance and necessity for testing patient specimens;
c. The use and appropriateness of criteria
established for specimen rejection;
d. The completeness, usefulness and accuracy
of the test report information necessary for the interpretation or utilization
of test results;
e. The timely
reporting of test results based on testing priorities (STAT, routine,
manufacturer's instructions, etc.);
f. The accuracy and reliability of test
reporting and record storage and retrieval;
g. The effectiveness of corrective actions
taken for:
1) Problems identified during the
evaluation of calibration and control data for each test method;
2) Problems identified during the evaluation
of patient test values for the purpose of verifying the reference range of a
test method;
3) Errors detected in
previously reported test results.
h. The effectiveness of corrective actions
taken for any unacceptable, unsatisfactory or unsuccessful proficiency testing
results.
4.
Laboratories that perform the same testing using different methodologies or
instruments, or perform the same test at multiple testing sites, shall have a
system that twice a year evaluates and defines the relationship between test
results using different methodologies, instruments or test sites.
5. Laboratories that perform tests that are
not challenged with a proficiency testing program shall have a system for
verifying the accuracy and reliability of its test results at least twice per
year.
6. The laboratory shall have
a mechanism to identify and evaluate patient test results that appear
inconsistent with relevant criteria such as patient age, sex, diagnosis or
pertinent clinical data, when provided; distribution of patient test results,
when available; and relationship with other test parameters, when
available.
7. The laboratory shall
have an ongoing mechanism to evaluate the effectiveness of its policies and
procedures for assuring employee competence.
8. The laboratory shall have a system in
place to document problems that occur as a result of breakdowns in
communication between the laboratory and the authorized individual who orders
or receives the results of test procedures or examinations. Corrective actions
shall be taken, as necessary, to resolve the problems and minimize
communication breakdowns.
9. The
laboratory shall have a system in place to assure that all complaints and
problems reported to the laboratory are documented. Investigations of
complaints shall be made, when appropriate, and, as necessary, corrective
actions shall be instituted.
10.
The laboratory shall have a mechanism for documenting and assessing problems
identified during quality assurance/performance improvement reviews and
discussing them with the staff. The laboratory shall take corrective actions
that prevent reoccurrences.
11. The
laboratory shall maintain documentation of all quality assurance/performance
improvement activities, including problems identified and corrective actions
taken. All quality assurance/performance improvement records shall be available
and maintained for a period of two years.
O. Safety.
1. The physical plant and environmental
conditions of the laboratory shall provide a safe environment in which
employees, as well as all other individuals, are protected from physical,
chemical and biological hazards.
2.
Safety precautions shall be established, posted and observed to ensure
protection from physical, chemical, biochemical and electrical hazards as well
as biohazardous materials.
P. Point of Care Testing.
1. The requirements under this section apply
only to the following tests which employ simple and accurate methodologies, as
defined by the Centers for Disease Control and Prevention (CDC):
a. Dipstick or tablet reagent
urinalysis;
b. Fecal occult
blood;
c. Urine pregnancy tests
(visual color comparison);
d.
Hemoglobin by single analyte instrument with self-contained or component
features to perform specimen/reagent interaction, providing direct measurement
and readout;
e. Whole blood glucose
by devices approved for home use;
f. Spun microhematocrit;
g. Whole blood immunoassay for Helicobacter
pylori;
h. Rapid test for Group A
streptococcal antigen from throat swabs; and
i. Glycosylated hemoglobin (Hgb
Alc).
2. All testing
personnel shall have earned a high school diploma or equivalent.
3. There shall be documentation that prior to
testing patients' specimens each individual has received training for each test
to be performed and has demonstrated the ability to perform all testing
operations reliably.
4.
Manufacturer's instructions for each of the tests shall be available in each
area in which the specific test is performed and shall be followed by all
testing personnel.
5. Components of
reagent kits of different lot numbers shall not be interchanged unless
otherwise specified by the manufacturer.
6. Reagents, control and calibration
materials and other supplies shall be stored and handled in a manner to ensure
that they are not used when the expiration date has been exceeded or when they
have deteriorated or are of substandard quality.
7. Quality control procedures shall be
performed in accordance with the manufacturer's instructions, at a minimum.
Additional quality control procedures shall be performed as determined by the
director of the hospital laboratory.
8. Maximum packing time of the
microhematocrit centrifuge shall be determined at least every six
months.
9. The test record system
shall include at least the following:
a.
Identification of the patient;
b.
Name of the authorized person who ordered the test;
c. Test performed;
d. Date and time of test
performance;
e. Identity of the
person who performed the test;
f.
Test results; and
g. Any
additional information relevant and necessary for the interpretation of the
results of a specific test.
10. The configuration of the test system
shall be determined by the facility.
11. All required records shall be readily
retrievable for at least two years.
12. Point of Care Testing shall be included
in the hospital laboratory's Quality Assurance/Performance Improvement
program.
13. Any tests other than
those specified in P.1 above shall be subject to all of the requirements of
Section 19.
SECTION
20:
RADIOLOGICAL SERVICES.
A. Radiology.
1. Each hospital shall have shock-proof
diagnostic X-ray facilities.
2.
Radiological Services shall be under the direction of a physician, who is a
member of the Medical Staff.
a. The physician
director shall be certified (or eligible for examination) by the American Board
of Radiology.
b. At a minimum, a
board certified radiologist shall be available on a consultative basis.
Documentation of the radiologist's visits shall be required.
3. Radiological Services shall be
supervised by a technologist who is qualified by experience or education and
has at least two years technical experience.
4. A radiologic technologist with at least
two years training shall be on duty 24 hours or on call at all times.
5. Radiologic staff who use the radiologic
equipment and administer procedures shall have written verification of training
and shall have approval in writing by the physician director.
6. Radiologic technologists shall not
independently perform fluoroscopic procedures.
7. Radiologic staff who administer agents for
diagnostic purposes shall have written verification of training. . A current
list of radiology employees who administer agents for diagnostic purposes shall
be approved by the physician director and maintained by the facility.
8. Radiology personnel who participate in
direct patient care shall maintain competency in life support measures or the
equivalent.
9. Clinically relevant
educational programs shall be conducted at regularly scheduled intervals with
not less than 12 per year. There shall be written documentation with employee
signatures, program title/subject, presenter, date and outline or narrative of
presented program.
10. Policies and
procedures for the department shall have evidence of ongoing review and/or
revision. The first page of each manual shall have the annual review date,
signature of the department and/or person(s) conducting the review. Policies
and procedures shall include:
a. Job
descriptions for every type employee;
b. A written list of all tests/procedures
performed by the Radiology Department and the list shall be available to the
Medical Staff;
c. Infection control
measures;
d. The holding of
patients;
e. Orientation practices
for new employees;
f. Operation of
equipment;
g. Management of an
adverse reaction;
h. Cleaning and
disinfecting procedures; and
i.
Posting of signs.
11.
Radiology personnel shall receive yearly instruction in:
a. Safety precautions; and
b. Managing emergency radiation hazards and
accidents.
12. A
documented preventive maintenance and quality control program shall include:
a. Radiology personnel shall wear a whole
body monitoring device if they are likely to receive a radiation dose greater
than 10 percent of the annual total effective dose equivalent limit of five
rem. Monitoring of radiology personnel for exposure to radiation with
integration over a period not to exceed one month;
b. Preventive maintenance for all diagnostic
and therapeutic radiologic equipment to assure a safe working condition. Safety
and calibration checks shall be made according to manufacturer's directions,
not exceeding one year intervals;
c. Annual inspection of all leaded gloves,
aprons and similar protective devices at least once a year with documentation
to include: the name of the examiner, identification of the protective device
examined and the results plus corrective action taken;
d. Documentation of safety, calibration, and
inspection checks maintained for the life of the equipment; and
e. Remedial and corrective action recorded in
response to equipment "down time," with documentation to include: the piece of
equipment involved, time/date malfunction occurred, action taken, time/date
when the equipment became operational.
13. X-ray films shall not be stored in
radiologic examination rooms.
14.
X-ray films shall be filed according to a recognized filing system.
15. X-ray prescription/work requests shall be
authorized by a written and signed physician's order and shall include the
following:
a. Identification of the
patient;
b. Date the test was
ordered;
c. Physician's
name;
d. Concise statement as to
the reason why the X-ray/test was ordered; and e. Originator's
signature.
16. The
radiologic report shall be signed by a physician and shall be placed in the
medical record.
17. The
Radiological Services shall have an ongoing QA/PI program that addresses
patient care issues. A mechanism for reporting results of audits shall be
provided, to include: indicators monitored, thresholds/standards, results,
corrective plan/corrective action taken and follow-up.
18. This section establishes requirements for
radiology that are in addition to, not in substitution of the
Rules and Regulations for Control of Sources of Ionizing
Radiation.
19. Actual X-ray film shall be retained for
five years.
20. X-ray films and
reports shall be stored in a room that is equipped with a smoke detection
system. An extinguishing system shall be made available.
21. Locked security shall be ensured for the
written reports maintained in the X-ray file when the storage area is not under
the direct supervision of radiology personnel.
B. Nuclear Medicine Services.
1. Nuclear Medicine procedures shall be under
the direction of a physician, qualified in Nuclear Medicine, who is a member of
the Medical Staff.
2. Nuclear
Medicine services shall be supervised by a nuclear medicine technologist who
has completed certification requirements and has at least two years technical
experience.
3. Nuclear Medicine
staff who use the equipment and administer procedures shall have written
verification of training and shall have approval in writing by the physician
director and Medical Staff.
4. All
radioactive materials shall be purchased, stored, administered and disposed of
in a manner consistent with the requirements of the Rules
and Regulations for Control of Sources of Ionizing Radiation
or with the specific condition of a Radioactive Material License
issued pursuant to these regulations.
5. The policy and procedure manual shall be
reviewed annually and revised as necessary. Included in the manual shall be a
cover page with signatures of those reviewing the manual and a month/day/year
of review. The policies and procedures shall include:
a. Job description for each
employee;
b. A list of
tests/procedures performed by Nuclear Medicine;
c. Safety practices;
d. Management of an adverse
reaction;
e. Orientation for new
employees;
f. Operation of
equipment;
g. Cleaning and
disinfecting procedures; h. Posting of signs;
i. Quality control;
j. QualityAssurance/Performance
Improvement;
k. Clean up of
spills;
l. Receipt/disposal of
radioactive materials; and
m.
Radiation safety plan.
6.
All nuclear medicine personnel who participate in direct patient care shall
maintain competency in life support measures.
7. There shall be a documented preventive
maintenance and quality control program:
a.
Monitoring of nuclear medicine personnel for exposure to radiation shall be
integrated over a period not to exceed one month;
b. Nuclear medicine personnel shall wear a
whole body monitoring device if they are likely to receive a radiation dose
greater than 10 percent of the annual total effective dose equivalent limit of
five rem. They shall also wear an extremity monitoring device if they are
likely to receive a radiation dose to the extremity or skin greater than 10
percent of the skin or extremity dose limit of 50 rem;
c. All nuclear medicine equipment shall be
maintained in safe working condition. Preventive maintenance, safety and
calibration checks shall be made according to manufacturer's directions, not to
exceed one year interval;
d.
Documentation of all safety, calibration and inspection checks shall be
maintained for the life of the equipment; and
e. Remedial and corrective action shall be
recorded in response to equipment "down time." Documentation shall include: the
piece of equipment involved, time/date malfunction occurred, action taken, and
time/date when equipment became operational again.
8. The nuclear medicine "hot lab" shall be
kept locked when not under the direct supervision of authorized
personnel.
9. There shall be an
emergency eye wash available in the nuclear medicine "hot lab".
10. All nuclear medicine staff who administer
agents for diagnostic purposes shall have written verification of training and
approval by the physician director and individual(s) supervising the
training.
11. Clinically relevant
educational programs shall be conducted on regularly scheduled intervals at not
less than 12 per year. There shall be written documentation with employee
signature, program title/subject, presenter, date and outline or narrative of
presented program.
12. All nuclear
medicine requests shall be authorized by a written and signed physician's order
and shall include the following:
a.
Identification of the patient;
b.
Date;
c. Physician's
name;
d. Originator's signature;
and
e. Reason/justification for
the test.
13. The
nuclear medicine report shall be signed by a physician. The original shall be
placed in the medical record.
14.
Films shall not be stored in radiologic or nuclear medicine examination
rooms.
15. The storage of nuclear
medicine films shall comply with the guidelines under Section 20, Radiological
Services.
C. Guidelines
for Mobile Services. The Governing Body and Medical Staff shall approve the
provisions for establishing services in accordance with the following criteria:
1. General Considerations.
a. The installation is governed by the
following Arkansas Department of Health publications:
1)
Rules and Regulations
for Hospitals and Related Institutions in Arkansas,
Section 20, Radiological Services; and
2)
Rules and Regulations
for Control of Source of Ionizing Radiation.
b. Approvals shall be granted by
the Arkansas Department of Health:
1) Health
Facility Services; and
2) Radiation
Control and Emergency Management.
c. The mobile service provider shall maintain
fire, theft, general and professional liability insurance.
2. Operating Policies.
a. All examinations shall be authorized by a
written and signed physician's order;
b. Examinations shall be performed under the
direction of and interpreted by a qualified physician, with documented training
or experience, who is a member of the hospital's Medical Staff;
c. Examinations shall be performed by a
licensed radiologic technologist ;
d. The Radiology Department shall maintain
current policies and procedures for use of the mobile units to include
infection control and safety;
e.
All personnel who administer agents for diagnostic purposes shall have written
verification of training and approval by the physician director and
individual(s) supervising the training;
f. Hospital personnel shall transport
patients to and from the mobile unit according to hospital safety
policies;
g. Oxygen and emergency
medical supplies shall be maintained and readily available;
h. The hospital Pharmacy may provide
necessary medical supplies including contrast media, but proper handling and
control of dated items shall be ensured;
i. A log of all patients shall be
maintained;
j. Films shall be
maintained in the same manner as X-ray films;
k. Personnel who participate in direct
patient care shall be competent in life support measures; and
l. Contracted services shall be under current
agreement and the contractor shall fulfill all requirements of this
section.
3. Refer to
Section 56, Physical Facilities, Imaging Suite.
SECTION 21:
PHYSICAL THERAPY.
Licensed physical therapist means any person licensed to
practice physical therapy by the Arkansas State Board of Physical
Therapy.
The practice of licensed physical therapy assistants shall be
performed under the supervision of the licensed physical therapist. The
supervising therapist shall be readily available for consultations, evaluations
and establishment of each program prior to delegation of any treatments and
determination of patient discharge.
If physical therapy services are rendered by an individual who
does not meet at least the assistant-level qualifications (aide/technician), a
qualified physical therapist shall be on the premises and immediately available
to provide assistance and direction throughout the time the services are
rendered.
A. Physical therapy services
shall be provided under the direction of a physician member of the Medical
Staff.
B. Physical therapy services
shall be supervised by a physical therapist licensed by the Arkansas State
Board of Physical Therapy. Physical therapy assistants and aides shall comply
with all state licensure requirements.
C. A policy and procedure manual for Physical
Therapy shall be developed. The manual shall have evidence of ongoing review
and/or revision. The first page of each manual shall have the annual review
date, signature of the department supervisor and/or person(s) conducting the
review.
D. There shall be written
policies and procedures which shall include:
1. Job descriptions for each type of
employee;
2. Infection control
measures;
3. Standards of
care;
4. Criteria for assuring
continuous communication of the patient's therapy and progress to the
physician;
5. Assembly and
operation of equipment;
6. Physical
therapy services provided and a list of services made available to the Medical
Staff;
7. Documentation specifying
who may perform special procedures and give patient instruction; this shall be
verified by the physician director;
8. Safety practices;
9. Orientation practices for new employees;
and
10. Cleaning, disinfecting and
sterilizing procedures.
E. There shall be an adequate supply of
reference material for the physical therapist which shall include current
literature.
F. All physical therapy
prescriptions/work requests shall be authorized by a written and signed
physician's order.
G. Equipment
shall be adequate for the services offered and maintained in good repair.
1. Equipment shall be serviced, calibrated
and operated according to the manufacturer's directions.
2. All physical therapy equipment shall be
under the control of the physical therapy supervisor.
3. A preventive maintenance program shall be
implemented with periodic inspection of all equipment and appropriate records
maintained for the life of each piece of equipment.
4. All temperature-dependent patient use
equipment shall have the temperature checked and recorded before each patient
use or at least daily, if used, to ensure patient safety.
H. Physical therapy records for each patient
shall include:
1. Current written plan of
care;
2. Statement of treatment
objectives;
3. Statement of
patient's short-term and long-term rehabilitation potential;
4. Functional limitations;
5. Justification of continued rehabilitative
care; and
6. Documentation of daily
treatments.
I.
Clinically relevant educational programs shall be conducted on a regularly
scheduled interval not less than 12 times per year. There shall be written
documentation with employee signature, program title/subject, presenter, date
and outline or narrative of presented program.
J. All physical therapy personnel who
participate in direct patient care shall be competent in life support
measures.
K. There shall be an
ongoing QA/PI program.
L. Hospitals
which have swimming pools shall comply with applicable sections of
Rules and Regulations Pertaining to Swimming Pools and Other Related
Facilities.
M.
Contracted physical therapy services shall be under current agreement and the
contractor shall fulfill all requirements of this Section.
SECTION 22:
OCCUPATIONAL
THERAPY.
In facilities with an organized Occupational Therapy
Department, the following shall apply:
A. Occupational Therapy Services shall be
under the direction of a physician member of the Medical Staff.
B. Occupational Therapy Services shall be
supervised by a currently licensed therapist in the field of rehabilitation
services.
C. There shall be
sufficient occupational therapy supportive technical staff to provide
authorized Occupational Therapy Services.
D. The policy and procedure manual shall have
evidence of ongoing review and/or revision. The first page of each manual shall
have the annual review date, signature of the department supervisor and/or
person(s) conducting the review.
E.
There shall be written policies and procedures which shall include:
1. Job descriptions for every type of
employee;
2. Documentation
specifying who may perform special procedures and give patient instructions.
This shall be verified by the physician director;
3. Orientation practices for new
employees;
4. Occupational therapy
services provided and a list of services provided to the Medical Staff;
and
5. Safety practices.
F. Current reference material
shall be available for the occupational therapist.
G. All occupational therapy
prescriptions/work requests shall be authorized by a written and signed
physician's order.
H. Equipment
shall be adequate for the services offered and maintained in good repair.
1. Equipment shall be serviced, calibrated
and operated according to the manufacturer's directions.
2. All occupational therapy equipment shall
be under the control of the occupational therapy supervisor.
3. A preventive maintenance program shall be
implemented with periodic inspection of all equipment and appropriate records
maintained for the life of each piece of equipment.
4. All temperature-dependent patient use
equipment shall have the temperature checked and recorded before each patient
use.
When appropriate elements are planned and arranged for shared
use by physical therapy patients and staff, one or both services shall be
responsible for the preventive maintenance program and the retention of
records.
I.
Occupational therapy records for each patient shall include:
1. Current written plan of care;
2. Statement of treatment
objectives;
3. Statement of
patient's short-term and long-term rehabilitation potential;
4. Justification of any continued
rehabilitation care; and
5.
Documentation of the patient's condition and response to treatments.
J. Clinically relevant educational
programs shall be conducted on a regularly scheduled basis at not less than 12
per year. There shall be written documentation with employee signature, program
title/subject, presenter, date and outline or narrative of presented
program.
K. All occupational
therapy personnel shall maintain competency in life support measures.
L. There shall be an ongoing QA/PI
program.
M. Contracted occupational
therapy services shall be under current agreement and the contractor shall
fulfill all requirements of this Section.
SECTION 23:
SPEECH PATHOLOGY/AUDIOLOGY
SERVICES.
In facilities with an organized Speech Language
Pathology/Audiology Services Department, the following shall apply:
A. Speech Pathology/Audiology Services shall
be under the direction of a physician member of the Medical Staff.
B. Speech Pathology/Audiology Services shall
be supervised by a therapist who is currently licensed.
C. There shall be sufficient supportive
personnel to provide authorized speech pathology/audiology services.
D. There shall be documentation, verified by
the physician director, of who may perform special procedures and give patient
instructions.
E. Policies and
procedures shall have evidence of ongoing review and/or revision. The first
page of each manual shall have the annual review date, signature of the
department supervisor and/or person(s) conducting the review.
F. There shall be written policies and
procedures which shall include:
1. Job
descriptions for every type of employee;
2. Orientation procedures for new
employees;
3. Infection control
measures;
4. A listing of
services/treatments available to the Medical Staff; and
5. Safety practices.
G. Equipment shall be in good repair and
under the control of the therapist supervisor. Documentation of preventive
maintenance shall be maintained for the life of each piece of
equipment.
H. Current reference
material shall be available for the department.
I. Clinically relevant educational programs
shall be conducted on a regularly scheduled basis at not less than 12 per year.
There shall be written documentation with employee signature, program
title/subject, presenter, date and outline or narrative of presented
program.
J. All speech
pathology/audiology prescriptions/work requests shall be authorized by a
written and signed physician's order.
K. Speech Pathology/Audiology Services
records for each patient shall include:
1.
Current written plan of care;
2.
Statement of treatment objectives;
3. Statement of patient's short-term and
long-term rehabilitation potential;
4. Justification of any continued
rehabilitation care; and
5.
Documentation of progress notes following treatment given to
patients.
L. All Speech
Pathology/Audiology personnel shall maintain competency in life support
measures.
M. There shall be an
ongoing QA/PI program.
N.
Contracted Speech Pathology/Audiology Services shall be under current agreement
and the contractor shall fulfill all requirements of this Section.
SECTION 24:
RECREATIONAL
THERAPY.
In facilities with organized Recreational Therapy Services, the
following shall apply:
A. Recreational
Therapy Services shall be under the direction of a physician member of the
Medical Staff;
B. Recreational
Therapy Services shall be supervised by a therapist with current
certification;
C. There shall be
sufficient Recreational Therapy supportive staff to provide authorized
Recreational Therapy Services;
D.
There shall be documentation, verified by the physician director, of who may
perform special procedures and give patient instructions;
E. The policy and procedure manual shall have
evidence of ongoing review and/or revision. The first page of the manual shall
have the annual review date, signature of the department supervisor and/or
person(s) conducting the review;
F.
There shall be written policies and procedures which shall include:
1. Job descriptions;
2. Infection control measures;
3. Recreational Therapy Services provided and
a list of services shall be made available to the Medical Staff;
4. Orientation practices for new employees
and volunteer personnel;
5.
Assembly, operation and maintenance of all equipment;
6. Safety practices;
7. Security of supplies and tools;
and
8. Activities
off-campus.
G. All
equipment, tools and machines shall be in good repair and under the control of
the therapist supervisor. Documentation of preventive maintenance shall be
maintained for the life of each piece of equipment;
H. Current reference material shall be
available for the department;
I.
Clinically relevant educational programs shall be conducted on a regularly
scheduled basis at not less than 12 per year. There shall be written
documentation with employee signature, program title/subject, presenter, date
and outline or narrative of presented program;
J. All recreational therapy
prescriptions/work requests shall be authorized by a written and signed
physician's order and shall include:
1.
Identification of the patient;
2.
Date;
3. Physician's
name;
4. Type, frequency and
duration of treatment; and
5.
Originating signature.
K. Recreational Therapy Service records for
each patient shall include:
1. Current
written plan of care;
2.
Documentation of attendance by the therapist in team meetings and the
contribution by the therapist to the treatment plan;
3. Statement of treatment
objectives;
4. Statement of
patient's short-term and long-term rehabilitation potential;
5. Record of daily activity
participation;
6. Justification of
any continued rehabilitation care; and
7. Progress notes.
L. All Recreational Therapy personnel shall
maintain competency in life support measures;
M. There shall be an ongoing QA/PI
program;
N. If food and/or
nutritional service functions are offered, infection control, storage and
supervision shall be coordinated with the Dietary Department of the facility;
and
O. Contracted Recreational
Therapy Services shall be under current agreement and the contractor shall
fulfill all requirements of this Section.
SECTION 25:
PET THERAPY
PROGRAM.
Definitions.
"Program" means Pet Therapy Program.
"Pet" means an animal that has been specifically screened,
trained and authorized by the hospital to participate in the Program.
"Handler" means an individual who has been specifically
credentialed and authorized by the hospital to participate in, and to accompany
and control pets participating in, the Program.
A. The Program shall be approved by the
Governing Body, Medical Staff and the Infection Control Committee.
B. The Infection Control Committee shall, in
conjunction with a licensed Veterinarian, establish the Medical Criteria that
each pet shall meet in order to participate in the Program.
C. The hospital shall establish the
Behavioral Criteria that each pet shall meet before participating in the
Program.
D. A licensed Veterinarian
shall certify that a participating pet:
1.
Meets the hospital's medical criteria; and
2. Is free of communicable disease causing
organisms.
E. A licensed
Veterinarian, a local protection society or a pet therapy association or
society shall certify that a participating pet meets the Hospital's Behavioral
Criteria.
F. Pets found to have a
communicable disease shall be excluded from the Pet Therapy Program until the
pet is treated and has one negative culture, if culturing of the causative
agent is feasible. Pets expressing behavioral problems will be excluded from
the program until the behavioral problem is remedied.
G. Pets shall be bathed and groomed before
each hospital visit. Pets shall be free of fleas while visiting the
hospital.
H. The hospital shall
establish an orientation program for the handlers. Handlers shall attend this
program before participating in the Program. The orientation program shall
include, at least, patient confidentiality, appropriate infection control
measures, safety and appropriate emergency protocols. Records of the
orientation program shall be kept.
I. The hospital shall keep records of each
visit the pet makes. The records shall include, at least, the date, the
identity of the pet, the identity of the handler, all the patients visited; the
area in which the patient visits were made and any infectious condition the
patient had or any type isolation the patient was in at the time of the
visit.
J. The pet and handler shall
be escorted at all times by a staff member appropriate to the area visited.
Patient safety and confidentiality shall be maintained at all times.
K. The pet shall be under the direct
supervision of the handler at all times and shall be on a leash or in a crate
at all times while in the hospital. Other patients, visitors, and employees
shall be discouraged from petting the pet.
L. The Hospital shall provide an area to walk
the Pet. There shall be procedures for immediate clean up of all
accidents.
M. There shall be
procedures for patient hand washing, visit area clean up and cleaning of the
patient's room. If a pet visits a patient in bed, the bed linens will be
changed immediately after the visit. A barrier shall be placed over the bed if
the pet is placed directly on the patient's bed.
N. The attending physician in conjunction
with the Infection Control Officer, will determine the appropriateness of the
pet visits. The attending physician shall approve and order each pet visit. The
orders shall be documented in the medical record.
SECTION 26:
SPECIALIZED SERVICES:
SURGICAL SERVICES.
A. Organization and
Supervision.
1. An organizational plan shall
be developed.
2. Surgical Services
shall be under the medical direction of a qualified physician or a physician
committee.
3. A Surgical Services
Registered Nurse supervisor shall be accountable and responsible for patient
care.
4. Surgical Services shall
have written policies and procedures that include:
a. Operative and special consents;
b. Fire and disaster plans;
c. Environmental control;
d. Visitor and traffic control to include
allowance for no one other than staff or professionals without the expressed
consent of the physician and operating room supervisor;
e. Safety practices;
f. Infection control measures;
g. Care and disposition of surgical
specimens, cultures and foreign bodies;
h. Care of special equipment including
preventive maintenance contracts and records;
i. Emergency management;
j. Orientation of all personnel; and
k. Medication accountability.
(Refer to Section 11, Patient Care Service and Section 16,
Pharmacy.)
5. Clinically
relevant educational programs shall be conducted on a regularly scheduled basis
not less than 12 per year. There shall be written documentation with employee
signature, program title/subject, presenter, date and outline or narrative of
presented program.
6. A surgery
schedule shall be maintained in the surgery suite.
7. There shall be a continuous QA/PI program
that is specific to the patient care administered.
8. A current roster of physicians and
dentists with a delineation of each physician's and dentist's surgical
privileges shall be accessible and available in the confidential files of the
Surgical Services Registered Nurse and in the files of the hospital
administrator.
9. The following
information shall be maintained in the surgery services log:
a. Patient's full name;
b. Hospital number;
c. Surgeon;
d. Assistant surgeon;
e. Type of anesthetic and person
administering;
f. Pre and
postoperative diagnoses;
g.
Circulating nurse;
h. Scrub
nurse(s);
i. Procedures;
j. Complications;
k. Sponge, needle, and instrument
count;
l. Time of beginning and
ending of case; and
m. Other
persons present.
B. Environment, Equipment and Supplies.
1. A safe operating room environment shall be
established, controlled and consistently monitored.
2. At a minimum, the following general
equipment and supplies shall be in the surgical suite:
a. Call-in system;
b. Crash cart;
c. Cardiac monitor
d. Defibrillator;
e. Resuscitating equipment;
f. Suction equipment; and
g. Thoracotomy set.
3. Equipment and supplies necessary to meet
the requirements of the services provided:
a.
Stretcher;
b. Anesthetic equipment
and supplies;
c. Adjustable
operating table with waterproof pad;
d. Side tables;
e. Approved surgical light;
f. Medical gases;
g. 24 hour supply of sterile linen;
h. Wall clock; and
i. Equipment and supplies for timed scrubbing
technique.
C.
Staffing.
1. Surgical personnel including a
Registered Nurse shall be available to provide emergency surgical services on a
24 hour basis.
2. A Registered
Nurse shall be present in the operating room for the duration of the surgical
procedure. Additional auxiliary personnel shall be available as
necessary.
3. Only qualified
Registered Nurses may perform circulating duties in the operating
room.
4. There shall be
documentation of training and/or experience for all operating room personnel
assigned to surgical procedures.
SECTION 27:
SPECIALIZED SERVICES:
POSTANESTHESIA CARE UNIT.
A.
Postanesthesia Care Unit (PACU) Services shall be provided in a well organized
manner under the direction of a qualified physician and under the supervision
of a Registered Nurse.
B. Policies
and procedures shall have evidence of ongoing review and/or revision. The first
page of each manual shall have the annual review date, signature of the
department supervisor and/or person(s) conducting the review. Policies and
procedures shall include:
1. Lines of
authority and nursing supervision;
2. Transfer of patients from the Operating
Room to Postanesthesia Care Unit;
3. Criteria for discharge of patients from
the Postanesthesia Care Unit; and
4. The care of patients in the event the
Postanesthesia Care Unit closes (including provisions of adequate nursing
staff).
C. There shall
be adequate nursing staff in attendance with every patient during anesthesia
recovery.
D. A physician shall
order the discharge of the patient from the Postanesthesia Care Unit.
E. Equipment shall be available in accordance
with services provided.
F. The
Registered Nurse shall assess and document assessment of each PACU
patient.
G. Clinically relevant
educational programs shall be conducted on a regularly scheduled basis not less
than 12 per year. There shall be documentation which includes program content,
presenter, date and signatures of attendees.
H. There shall be an ongoing QA/PI program
that is specific to the patient care administered.
SECTION 28:
SPECIALIZED SERVICES:
AMBULATORY SURGERY SERVICES.
A. There
shall be policies and procedures specific to Ambulatory Surgery Services.
Policies and procedures for the department shall have evidence of ongoing
review and/or revision. The first page of each manual shall have the annual
review date, signature of the department supervisor and/or person(s) conducting
the review.
B. Policies and
procedures shall include:
1. Scheduling of
patients for surgery;
2. Admission
and discharge criteria;
3.
Perioperative patient care;
4.
Operative and special consents;
5.
Obtaining a documented history and physical on the patient's medical record
prior to the procedure. Refer to Health Information Services, Section
14;
6. Preoperative assessment
procedures required by the Medical Staff; and
7. Medication accountability. (Refer to
Section 11, Patient Care Service, Section 12, Medications and Section 16,
Pharmacy.)
C. A
physician shall order the discharge of the patient from the facility.
D. For additional requirements refer to
Patient Care Service, Section 11, Specialized Services: Surgical Services,
Section 26 and Specialized Services: Postanesthesia Care Unit, Section
27.
SECTION 29:
SPECIALIZED SERVICES: ANESTHESIA SERVICES.
A. Organization and Staffing. Anesthesia
Services shall be provided in a well organized manner under the direction of a
qualified physician. The service is responsible for all anesthesia
administered.
B. Those
administering anesthesia shall be credentialed by Medical Staff and approved by
the Governing Body. A current roster, with delineation of privileges for those
administering anesthesia, shall be maintained and readily available.
C. Anesthesia shall be administered by the
following:
1. Anesthesiologist;
2. Physician qualified to administer
anesthesia; or
3. Certified
Registered Nurse Anesthetist (CRNA) under the supervision of a
physician.
D. Written
policies and procedures specific to Anesthesia Services shall have evidence of
ongoing review and/or revision. The first page of the manual shall have the
annual review date, signature of the department supervisor and/or person(s)
conducting the review.
E. Policies
and procedures shall include:
1. Preanesthesia
evaluation;
2. Approved anesthesia
agents;
3. Methods of delivery of
anesthesia;
4. Intraoperative
anesthesia record;
5.
Postanesthesia follow-up report;
6.
Mechanism for routine checking and maintenance of anesthesia machines and
equipment for safe use;
7.
Medication accountability. See Section 16, Pharmacy, Section 11, Patient Care
Service, and Section 12, Medications;
8. Responsibilities in the discharge of
patients from the Postanesthesia Care Unit. See Section 27, Postanesthesia Care
Unit; and
9. Infection control
measures.
F. All
medications and anesthesic agents administered to the patient shall be ordered
by the prescriber and/or anesthesia provider. This includes preoperative as
well as intraoperative and postoperative medications.
G. There shall be an ongoing QA/PI program
that is specific to the patient care administered.
SECTION 30:
SPECIALIZED SERVICES:
LABOR, DELIVERY, LABOR DELIVERY RECOVERY (LDR), LABOR DELIVERY RECOVERY POST
PARTUM (LDRP), POST PARTUM AND MATERNAL-CHILD EDUCATION.
A. Labor Room and/or LDR, LDRP Room.
1. Provisions shall be made for patients in
labor in either a designated labor room and/or birthing room. Rooms used only
for labor shall be in close proximity to the delivery room. Furniture, washable
wallpaper, pictures, radio, television and other items may be used as long as
the needs of the mother and baby are not compromised. Items selected shall be
made of durable materials, with a smooth, impervious surface which can be
easily cleaned and disinfected.
2.
All beds used for labor shall be equipped with side rails.
3. There shall be equipment and supplies
available for the examination and preparation of patients in labor, which shall
consist of the following:
a. Precipitous
delivery tray;
b.
Stethoscope;
c. Suction
equipment;
d. Sterile
gloves;
e. Emergency medications as
approved by the Pharmacy and Therapeutics Committee and supplies to include
laryngoscopes, airways, endotracheal tubes and infant ambu bags; and
f. Fetal monitoring device.
4. A physician shall be
immediately available when Oxytocin is administered. "Immediately available"
shall be determined by the hospital's administrative staff, Medical Staff and
Governing Body.
5. Father or
support persons may be allowed with the patient during labor unless medically
contraindicated.
B.
Delivery Areas.
1. Hospitals offering
delivery and maternity services shall comply with the requirements of this
Section. (See Section 14, Health Information Services and Section 11, Patient
Care Service.)
2. General operating
rooms may not be used for deliveries, except for major surgical deliveries.
Delivery rooms shall be separate from operating rooms and shall not be used for
any other purpose, with the exception of a tubal ligation immediately following
a delivery. Delivery rooms may be used for Caesarean sections provided the
usual operating room equipment is used, and surgical policies and procedures
related to the delivery are made a part of the labor and delivery
manual.
3. The following equipment
and supplies shall be provided:
a. Supply of
medications as approved by the Pharmacy and Therapeutics Committee;
b. Infant identification and supplies.
Identification shall be done in the delivery room at the time of birth and
shall remain in place during the entire period of hospitalization.
Identification information shall be sufficient to identify the infant(s) with
one mother. Identification bands shall be waterproof plastic with tag inserts
written in waterproof ink;
c.
Heated bassinet, crib or incubator;
d. Supply of prophylaxis medication for the
prevention of infant blindness. The medication shall be administered within one
and one-half hours of the time of birth per written order of the
physician;
e. Commercially
manufactured delivery table/birthing bed with a waterproof non-conductive table
pad;
f. Side tables for instruments
and other necessary equipment;
g.
Approved surgical light;
h. Wall
clock;
i. Equipment and supplies
for timed scrub technique and an approved disinfectant soap;
j. Apgar score chart;
k. Suction equipment (infant and
adult);
l. Sphygmomanometer; and
m. Fetal monitoring
device.
C.
Organization.
1. Delivery services shall be
under the direction of a qualified physician and under the supervision of a
Registered Nurse. A Registered Nurse shall be present during labor, delivery
and post delivery of each patient. The birth shall be attended by a physician
or a certified nurse midwife with hospital privileges.
2. Patients shall be provided with direct
care by a Registered Nurse during labor, delivery, recovery and postpartum.
a. All patients in active labor shall be
attended and/or monitored.
b.
Qualified nurses, in adequate numbers shall be provided to meet the needs of
each patient.
3. An
on-call schedule shall be provided to ensure that a physician with obstetrical
privileges is readily available to perform obstetrical services at all times.
"Readily available" shall be determined by the hospital's administrative staff,
Medical Staff and Governing Body.
4. Qualified Registered Nurses shall always
be available in-house for labor and delivery patients. When there are no
patients, on-call staff may be utilized if approved by the Medical Staff and
Governing Body.
5. Procedures for
obtaining the mother's Rh factor shall be provided by the facility or
documented by the mother's attending physician upon admission.
6. When a patient presents to the hospital
for evaluation, the physician shall be notified.
7. Policies and procedures shall include:
a. Immediate delivery;
b. Obstetrical emergencies;
c. Setting up and cleaning the delivery room,
LDR or LDRP room and C-section room;
d. Equipment requirements;
e. Visitation;
f. Climate control (physical);
g. Infection control measures; h. Aseptic
techniques;
i. Intermittent rooming
in;
j. Anesthesia;
k. Deliveries occurring outside the delivery
area;
l. Infectious patients; and
m. Infant security.
8. A permanent record of all
deliveries shall be maintained. There shall be a reasonable attempt to collect
current information to include the following:
a. Mother's name, date of birth, maiden name,
father's name if available, hospital number, gravida-para, ABO type, Rh factor
and length of gestational period; and
b. Baby's sex, race, date of birth, time of
birth, weight, apgar score and baby identification band number.
D. Anesthesia.
1. Only a physician, anesthesiologist or
Certified Registered Nurse Anesthetist (CRNA) shall be permitted to initiate
and reinject continual epidural or caudal anesthesia and to initiate or
continue general or regional anesthesia.
2. A physician shall be immediately available
if CRNAs are administering anesthesia. "Immediately available" shall be
determined by the hospital's administrative staff, Medical Staff and Governing
Body.
3. The permanent record shall
contain the names of the physician, anesthesiologist, anesthetist or
CRNA.
E. Postpartum
Care.
1. Policies and procedures shall be
developed specific to the care of maternity patients.
2. Maternity patients shall not be routinely
cared for in rooms with patients admitted for diagnosis other than
maternity.
3. After an observation
period, the infant may stay in the room with the mother for the duration of the
hospital stay.
4. Mothers with
infection, fever or other condition that could adversely affect the safety and
welfare of others shall be immediately segregated and isolated in a separate
room.
F. Maternal-Child
Education. The hospital shall develop an educational program for the care of
the obstetrical patient and infant. Policies and procedures shall include:
1. Personal hygiene;
2. Dietary instruction;
3. Care of episiotomy and perineum;
4. Care of incision;
5. Breast care;
6. Exercise program;
7. Car seat safety (Arkansas State
Law);
8. Preventive
health;
9. Referral services;
and
10. Infant care.
SECTION 31:
NURSERY SERVICES.
The newborn nursery shall be under the direct supervision of a
Registered Nurse with clinical skills in newborn nursing. The newborn nursery
shall be located within or adjacent to the postpartum unit. The following
requirements shall apply to all nurseries:
A. Nurseries shall not be used for any other
purpose and shall never be left unattended when occupied.
B. Infants born outside the hospital or with
proven or potential infections shall be isolated from other infants in the
Nursery. Infants with infections, skin rash or diarrhea shall be immediately
separated and isolated.
C.
Isolettes shall not serve as a sole means of isolation. Provisions for
isolation shall be provided.
D. The
following equipment shall be provided in nurseries:
1. Individual approved type hospital
bassinets. Wicker or woven type bassinets shall not be used;
2. Metal or approved plastic diaper and waste
containers. The lids on these containers shall be operated by a foot control or
equivalent device;
3. Infant
scales;
4. Blankets and
linen;
5. Suction equipment;
and
6. Incubators suitable for the
care of premature infants provided in the ratio of at least one incubator to 20
bassinets.
E. Infant
emergency supplies:
1. Emergency medications
approved by the Pharmacy and Therapeutics Committee;
2. Infant laryngoscope;
3. Suction catheters;
4. Endotracheal tubes;
5. Stylets; and
6. Infant airways and IV supplies.
F. Strict hand hygiene techniques
shall be maintained by all personnel . A clean barrier shall be used by anyone
handling the infant.
G. Infant
clothing shall be furnished by the hospital; however, if the mother wishes to
provide clothing for the infant, hospital personnel shall examine the clothing
to make sure it meets hospital requirements. Diapers shall be available in
necessary quantities.
H. Formula
Feedings.
1. Any individually packaged,
presterilized formula delivered by an outside source shall be approved by the
facility.
2. There shall be an
adequate supply of sterile disposable ready-to-use formula bottles
available.
3. Formulas shall be
stored in enclosed cabinets.
4. The
expiration date shall be checked on each bottle prior to infant
feeding.
5. Policies and procedures
shall be developed in conjunction with the Infection Control Committee
regarding the handling, labeling and storing (separately) of breast
milk.
6. Individual nipple shields
and breast pumps used in infant feeding shall be cleaned according to hospital
infection control policies and procedures.
7. If the facility has a breast milk bank the
policies and procedures shall be submitted to and approved by the Arkansas
Department of Health and hospital Infection Control Committee.
I. Rooming-In Service. Hospitals
providing a newborn nursery may provide rooming in for infants on an
intermittent or 24 hour basis based on the mother's request.
SECTION 32:
SPECIALIZED
SERVICES: CRITICAL CARE.
A Critical Care Unit is a section of the hospital where
intensive care nursing, necessary monitoring and treatment equipment and
supplies are provided to those patients who, in the opinion of the attending
physician, require such specialized services.
A. Staffing.
1. Critical Care Units shall be staffed with
a Registered Nurse each shift.
2.
All critical care nursing staff shall be oriented and trained in life support
measures, interpretation of dysrhythmias and shall demonstrate competency in
critical care nursing specific to patient types. Competency in the specific
areas shall be maintained.
B. Policies and Procedures. Procedures shall
include:
1. Admission and continuing stay
criteria;
2. Discharge
criteria;
3.
Triage/transfer;
4. Use of
protocols; and
5. Definition of the
clinical scope of the hospital's critical care service.
C. Equipment. Equipment shall include:
1. Suction;
2. Diagnostic monitoring equipment to include
electrocardiographic monitoring;
3.
"Crash Cart" containing emergency medications and supplies;
4. Defibrillator;
5. Wall clock;
6. Accommodations to maintain privacy;
and
7. Weighing device for bed
patients.
D. Isolation.
An isolation room shall be available for the treatment of potentially
infectious or immunosuppressed critical care patients.
E. Pediatric Critical Care. If the facility
offers critical care for the pediatric patient there shall be:
1. Policies, procedures and equipment
specific to the needs of pediatric patients; and
2. Nursing staff oriented and trained in life
support measures, interpretation of dysrhythmias and competency in critical
care nursing specific to the pediatric patient.
SECTION 33:
SPECIALIZED SERVICES:
DENTAL SERVICES.
A. Dental Services
shall comply with the requirements of this section. (See Section 14, Health
Information Services, Section 11, Patient Care Services, Section 16, Pharmacy
and all applicable Sections.)
B.
Patients admitted to the hospital for dental care shall be given the same
medical appraisal as those admitted to other services. The care of dental
patients shall be the dual responsibility of the dentist and a physician on the
hospital staff.
C. Dental services
shall be under the direction of a dentist.
D. Policies and procedures shall be
provided.
SECTION 34:
SPECIALIZED SERVICES: CENTRAL STERILIZATION AND SUPPLY.
A. Each hospital shall provide central
medical and surgical supply services with facilities that are responsible for
processing, sterilizing, storing, distributing supplies and equipment to all
units of the hospital. (Refer to Section 66, Physical Facilities, Central
Medical and Surgical Supply Department, for space and equipment
requirements.)
B. The central
sterilization and supply service shall be under the direct supervision of a
Registered Nurse or other qualified person who is trained in management,
aseptic procedures, supply processing and control methods which are applicable
to central sterilization and supply service.
C. Policies and procedures shall have
evidence of ongoing review and/or revision. The first page of each manual shall
have the annual review date, signature of the department and/or person(s)
conducting the review.
D. Policies
and procedures shall include:
1. Job
descriptions;
2. Infection control
measures;
3. Assembly and operation
of equipment;
4. Safety
practices;
5. Orientation for new
employees;
6. Care and cleaning of
equipment;
7. Evaluation of:
a. Cleaning effectiveness; and
b. Sterilizing effectivenes.
8. Receiving, decontaminating,
cleaning, preparing, disinfecting and sterilizing reusable items;
9. Assembling and wrapping of packs (to
include the double-wrapped techniques);
10. Storage and distribution of sterile
equipment/medical supplies;
11. Use
of chemical indicators and biological spore tests for sterilizers;
12. Recalling and disposing/reprocessing of
outdated sterile supplies;
13.
Cleaning and disinfecting of surfaces, utensils, and equipment;
14. Specifications for cold-liquid
sterilization and gas sterilization (if used); and
15. Collection and disposal of supplies
recalled by the manufacturer.
E. There shall be an ongoing QA/PI program
specific to the area.
F.
Precautions shall be exercised to prevent the mixing of sterile and unsterile
supplies and equipment. The precautions shall be set forth in written
policies.
G. Procedures shall be
developed for unloading and transporting flash sterilized items. The procedures
shall be developed with the assistance of the Infection Control Committee and
shall provide for the aseptic transfer within the physical constraints of the
facility.
H. Relevant educational
programs shall be conducted on a regularly scheduled basis not less than 12 per
year. There shall be written documentation with employee signature, program
title/subject, presenter, date and outline or narrative of presented
program.
I. A liaison with the
Infection Control Committee shall be maintained.
J. Records shall be maintained of all
autoclave loads, both routine and "flash," which shall include the date, time,
lot number (on routine loads), the time at temperature (where a recorder is not
available), item(s) sterilized and shall identify the person performing the
task.
1. Autoclaves shall meet the following
requirements:
2. The efficacy of
autoclaves, both for routine and "flash" use, shall be determined weekly
through the use of biological spore monitors:
3. The results of all biological spore
monitoring shall be reported to the Infection Control Committee; and
4. Failures of the biological spore test
shall be brought to the attention of the Infection Control Officer or designee
immediately so the appropriate surveillance measures can be initiated.
NOTE: All materials sterilized from the date of the biological
spore monitor failure to the last successful biological spore monitor shall be
resterilized before use.
K. All autoclaves within the facility shall
be maintained in accordance with the manufacturer's written directions. Records
shall be maintained of all maintenance and repairs for the life of the
equipment.
L. Chemical indicators
for sterility shall be used with each cycle
M. The facility shall validate compliance and
efficacy of the sterilization policy throught the quality review process. KThe
sterilization policy shall describe the mechanism used to determine the shelf
life of sterilized packages. The policy shall:
1. Be consistent with published industry
standards (AAMI and APIC).
2.
Stress that sterility is related to integrity of pack regardless of whether
expiration dating or event-related expiration is utilized.
O. Event-related/Indefinite dating of sterile
packs is acceptable.
|
ALLOWABLE SHELF LIFE |
Double-wrapped Muslin, Paper or
Polypropylene |
Use for rapid turn-around items only in well controlled
environment, [LESS THAN] 30 days |
Double-wrapped Muslin, Paper or Polypropylene Placed in
a Plastic Dust Cover Then Heat Sealed or Bonded |
Indefinite |
Peel Pack (Paper, Plastic or Tyvek/Mylar) |
Indefinite |
Rigid Containers, Caskets, Etc. |
Per Manufacturer's Instructions |
NOTE:
1. Stock
rotation shall be based on the "first in-first out" principle.
2. Sterile storage areas shall maintain a
temperature 75ΕF and a relative humidity of 70%. Ventilation shall be
10 air changes per hour and shall follow clean to dirty flow.
3. The interior of the dust cover shall not
be considered sterile.
4.
Indefinitely dated items shall be labeled with the date of sterilization and
state "contents sterile unless package is damaged." Packages that are wet,
dropped on the floor, compressed or torn shall be rejected.
5. The lot number or control number and
expiration statement shall be visible through the package or another tag shall
be placed on the outside.
6.
Containers for sterilization systems shall be scientifically proven suitable
for the specific sterilization cycle used; the container system shall be
verified as the correct one for the cycle. (Manufacturer's instructions shall
be followed.)
7. Double-wrapped
shall mean the end results of the wrapping technique will yield an envelope
within an envelope.
8. The date of
sterilization and load control number shall be placed on each sterilized
pack.
P. Flash
(autoclaving) shall be restricted to unplanned or emergency situations. Flash
sterilization shall never be used as a convenience to compensate for inadequate
inventories of instruments or implantables. Flash sterilization of implantables
shall be restricted to the direst circumstances.
Q. Items which are to be flash sterilized
shall be cleaned and decontaminated before the sterilization process.
R. Traffic areas in which flash sterilization
is carried out shall be restricted to authorized personnel wearing surgical
attire consisting of surgical scrubs, shoe covers, masks and hair covers. The
sterilizer shall not be located adjacent to any potential sources of
contamination such as scrub sinks, clinical sinks or hoppers, wash sinks, linen
or trash disposal areas.
S. For
flash sterilization, minimal time at effective temperature shall conform to the
following:
AUTOCLAVE |
LOAD |
MINIMAL TIME AT TEMPERATURE |
Gravity |
Nonporous (Simple Metal Instruments) |
3 minutes at 132ΕC
(270ΕF) |
Gravity |
Porous (Towels, Rubber, Plastic) Nonporous
Mix |
10 minutes at 132ΕC
(270ΕF) |
Gravity |
Nonporous with Lumens, Deep Grooves, Sliding
Parts |
10 minutes at 132ΕC
(270ΕF) |
Gravity/Prevacuum |
Complex Devices, Air-powered Drills |
Per Manufacturer=s Instructions |
Prevacuum |
Nonporous |
3 minutes at 132ΕC
(270ΕF) |
Prevacuum |
Porous/Nonporous |
4 minutes at 132ΕC
(270ΕF) |
T.
Items that previously have been packaged, sterilized, and issued, but not used
may be returned to the sterile storage area if the integrity of the packaging
has not been compromised and there is no evidence of contamination; such items
may be dispensed when needed.
Items that previously have been packaged, sterilized and issued
to the patient care units or other areas where the environment is not
controlled shall be discarded if they are single use items, or unwrapped and
reprocessed through decontamination if they are reusable.
U. Sterile materials shall be stored eight to
ten inches from the floor and at least 18 inches from the ceiling and at least
two inches from outside walls. Items shall be positioned so that packages are
not crushed, bent, compressed, or punctured and sterility is not
compromised.
V. All sterilization
techniques other than steam (plasma, ethylene oxide, chemical, etc.) shall
follow the manufacturer's directions and meet all state and federal
regulations.
SECTION 35:
SPECIALIZED SERVICES: RESPIRATORY CARE.
A. Respiratory Care Services shall be under
the direction of a physician member of the Medical Staff.
B. Respiratory Care Services, including
equipment, shall be supervised by a qualified and trained respiratory
therapist.
C. There shall be
sufficient personnel qualified and trained in respiratory care to provide
respiratory care services.
1. Services may be
performed by an assistant only when a qualified and trained respiratory
therapist is readily available for consultation; and
2. Personnel qualified and trained in
respiratory care shall be on the premises whenever continuous ventilatory
support is provided to patients.
D. All respiratory care personnel shall
maintain competency in:
1. Life support
measures;
2. Isolation techniques;
and
3. Safety techniques for oxygen
and oxygen equipment.
E.
The policy and procedure manual shall have evidence of ongoing review and/or
revision. The first page of the manual shall have the annual review date and
signature of the department supervisor and/or person(s) conducting the
review.
F. Policies and procedures
shall include:
1. Job descriptions;
2. Documentation, verified by the physician
director, of who may perform special procedures and give patient
instructions;
3. Safety
practices;
4. Handling, storage and
dispensing of therapeutic gases;
5.
Infection control measures;
6.
Assembly and operation of equipment;
7. Posting of "no smoking," "oxygen in use,"
or "oxygen precautions" signs;
8.
Respiratory care services provided and a list of services shall be available to
the Medical Staff;
9. Steps to take
in the event of an adverse reaction;
10. Cleaning, disinfecting and sterilizing
procedures; and
11. Orientation
policies for new employees.
G. Clinically relevant educational programs
shall be conducted on a regularly scheduled basis not less than 12 per year.
There shall be written documentation with employee signature, program
title/subject, presenter, date and outline or narrative of presented
program.
H. If arterial blood gases
are performed the Respiratory Care department shall subscribe to a nationally
recognized proficiency testing program for blood gases and meet the quality
control requirements for clinical laboratories.
I. The Respiratory Care Service shall have
sufficient equipment and adequate facilities appropriate for safety and
effective provision of care.
1. Equipment
shall be serviced calibrated, and operated according to manufacturers'
directions.
2. An approved safety
system shall be used with therapeutic gases.
3. Resuscitation, ventilatory and oxygenation
support equipment shall be available for patients of all sizes.
4. Ventilators for continuous assistance or
controlled breathing shall be equipped with alarm systems.
5. A preventive maintenance program shall be
implemented and records maintained for the life of the equipment.
J. All Respiratory Care
prescription/work requests shall specify the type, frequency and duration of
each treatment, and, as required, the type and dose of medication and the type
of diluent and oxygen or medical air.
K. Respiratory Care reports of blood gas
results shall be prepared in duplicate and signed by the therapist responsible
for the procedure/test. The original shall be placed in the patient's medical
record and the copy retained in the department file.
L. Accurate records shall be maintained
regarding the type and duration of each treatment given. These records shall be
correlated with the patient's medical record.
M. Respiratory Care documentation for each
patient shall include:
1. Current written plan
of care to include goals and objectives;
2. Instructions to patient or patient's
family; and
3. Type and duration of
the treatment given.
N.
When oxygen is being administered to a patient:
1. "No Smoking," "oxygen in use," or "oxygen
precautions," signs shall be posted;
2. Patients, visitors and personnel shall be
apprised of the fire hazard; and
3.
If the patient is in a tent, alcohol or rub-on lotion shall not be
used.
O. Oxygen shall be
humidified in accordance with physician's orders.
P. If reusable reservoirs are used to
humidify the oxygen, the reservoirs shall be cleaned and disinfected to a
high-level of disinfection. (A high-level disinfection can be expected to kill
all microorganisms with the exception of high numbers of bacterial endospores.
Only sterile solutions and diluents shall be used in humidification and
nebulizing equipment. Nebulizers (in-line and hand-held), between treatments on
the same patient, shall be disinfected to a high level and rinsed in sterile
water or, if a small volume medication nebulizer, air dried. All other
semicritical equipment shall be cleaned and disinfected in accordance with the
Center for Disease Control and Prevention's Guidelines.
Q. After use, all equipment shall be returned
to a central location for thorough cleaning, servicing and disinfecting before
use on another patient.
R. There
shall be an ongoing QA/PI program.
S. Contracted Respiratory Care Services shall
be under current agreement and the contractor shall fulfill all requirements of
this section.
NOTE: The National Fire Protection Association Vol. 99, Health
Care Facilities, is a mandatory reference for developing safety regulations for
Respiratory Care Services.
SECTION 36:
SPECIALIZED SERVICE:
EMERGENCY SERVICES.
NOTE: Federal EMTALA requirements apply
A. Every licensed hospital shall have a
dedicated emergency department. The following hospitals are excepted:
1. Psychiatric hospitals;
2. Rehabilitation hospitals; and
3. Long term acute care hospitals.
B. The hospital's emergency
department shall have organized services and procedures for any
emergency.
C. Diagnostic and
treatment equipment, medications, supplies and space shall be adequate in terms
of the size and scope of services provided.
D. An inventory list of all supplies and
equipment including all items on the crash cart, shall be checked each shift
and after each use.
E. The location
and telephone number of the nearest poison control center and a list of poison
antidotes shall be posted in the emergency department.
F. Staffing.
1. Each patient presenting to the emergency
department shall have a medical screening examination by a qualified medical
personnel. The examination shall be completely documented. If a physician is
not present, the qualified medical personnel shall contact the physician
requested by the patient or the physician on call to discuss the assessment
findings and patient's condition. Physician shall determine disposition of the
patient.
2. Arrangements shall be
provided, such as a duty or on-call roster, to ensure a physician is available
for all emergency patients as determined by the screening examination.
Arrangements shall be made for obtaining specialized medical
services.
3. The Emergency Service
shall be under the supervision of a Registered Nurse. All patient care
personnel assigned to the emergency department shall receive orientation and be
competent in life support measures.
4. The Registered Nurse shall assume the
responsibility for the nursing functions of the Emergency Services. This
includes:
a. Supervision;
b. Evaluation of the patient's emergency
nursing care needs;
c. The
assignment of nursing care for each patient to other nursing personnel in
accordance with the patient's needs and the preparation and competence of the
nursing staff;
d. Supplies and
equipment;
e. The emergency
department record (See Section 7, General Administration and Sections 15,
Medical Record Requirements for Outpatient Services, Emergency Room and
Observation Services.); and f. Maintenance of an emergency department
log.
5. Emergency
Medical Technician (EMT). Pursuant to the Arkansas Emergency
Medical Service Act Ark. Code Ann. §§
20-13-201 et.seq., if a hospital
allows an Arkansas Certified Emergency Medical Technician to perform specified
procedures within the Emergency Room or be a member of a hospital code team the
following action shall be taken:
a.
The Medical Staff shall approve the privileges granted to the individual EMT
with concurrence of the hospital's Governing Body. Specific policies governing
the supervision and the procedures to be performed by an EMT shall be developed
by the Medical Staff and approved by the hospital's Governing Body. In no event
shall an EMT perform a procedure that he/she is not certified to do by the
Office of Emergency Services of the Arkansas Department of Health;
b. Approved EMT's shall function in
accordance with physician's orders and under the direct supervision of either
the physician or Registered Nurse responsible for Emergency Services;
c. Students in EMT training programs approved
by the Office of Emergency Medical Services of the Arkansas Department of
Health shall be trained by qualified instructors within the hospital under
guidelines established by the Medical Staff and approved by the Governing Body;
and
d. A roster with the
delineation of privileges shall be maintained and readily available.
G. Medications. (See
Section 16, Pharmacy and Section 12, Medications.)
H. Emergency Services Facility. The Arkansas
Department of Health may license under Ark. Code Ann. §
20-9-218, hospitals which have
discontinued inpatient services to continue to provide emergency services if
there is no other hospital Emergency Service in the community.
1. The Emergency Services Facility shall be
subject to inspection and to all other provisions of Ark. Code Ann.
§§
20-9-201 et. seq. and
20-13-201 et. seq., as
amended.
2. The Emergency Services
Facility shall have agreements with licensed hospitals to accept patients who
are in need of inpatient hospital services.
3. An emergency facility shall not have
licensed inpatient beds, however, at least one holding/observation bed shall be
provided for patient use not to exceed 24 hours.
4. Emergency Service Facilities shall
provide, or contract to provide emergency ambulance services licensed by the
Arkansas Department of Health, that include radio communication and patient
telemetry. It is further required that contractual agreements be made for
patient air transport services.
5.
Policies and procedures shall be developed and approved by Health Facility
Services of the Arkansas Department of Health, prior to issuance of a license,
and the facility may not provide services without a license.
6. Clinically relevant educational program
shall be conducted on a regularly scheduled basis not less than 12 per year.
There shall be documentation which includes program content, presenter, date
presented and signatures of attendees.
7. There shall be an ongoing QA/PI program
that is specific to the patient care administered.
SECTION 37:
SPECIALIZED
SERVICE: PSYCHIATRIC SERVICES.
A.
Psychiatric care units in general hospitals shall meet the construction
requirements of Section 52, Psychiatric Nursing Unit, and shall in all respects
comply with the requirements of Section 48, Physical Facilities, Patient
Accommodations (Adult Medical, Surgical, Communicable or Pulmonary Disease)
except furniture, equipment and supplies may be modified by the attending
physician on an individual patient basis as verified by signed
orders.
B. General Requirements.
1. Each psychiatric care unit shall have a
written plan describing the organization of services or the arrangement for the
provision of such services to meet patient needs.
2. The services shall include, but not be
limited to, diagnostic evaluation, individual or group therapy, consultation
and rehabilitation.
3. The unit
shall be under the direction and management of a psychiatrist who is qualified
by training and experience for examination by the American Board of Psychiatry
and Neurology or the American Osteopathic Board of Neurology and Psychiatry and
licensed in the State of Arkansas.
4. The Program Director of the unit shall be
an individual with at least two years administrative experience.
5. The unit shall furnish, through the use of
qualified personnel, psychological services, social work services, occupational
therapy, recreational therapy and psychiatric nursing.
6. The unit shall have a qualified Director
of Nursing with a Master's Degree or be qualified by education and experience
in the care of the mentally ill. If the director does not meet the
qualifications, there shall be regular documented consultation by a qualified
Registered Nurse.
7. Staffing for
the unit shall ensure the presence in the unit of a Registered Nurse at all
times. There shall be adequate numbers of Registered Nurses, Licensed Practical
Nurses, and mental health workers to provide the care necessary under each
patient's active treatment program.
8. The unit shall provide or have available,
psychological services to meet the needs of the patients.
9. There shall be a social service staff to
provide services in accordance with accepted standards of practice and
established policies and procedures.
10. The unit shall provide a therapeutic
activities program. The program shall be appropriate to the needs and interests
of the patients and be directed toward restoring and maintaining optimal levels
of physical and psychosocial functioning.
11. There shall be a procedure for referrals
for needed services.
12. There
shall be adequate space, equipment and supplies for services to be provided
effectively and efficiently in functional surroundings that are readily
accessible to the patients. All space, equipment and facilities, both within
the psychiatric facility and those utilized outside the facility, shall be well
maintained and shall meet applicable federal, state and local requirements for
safety, fire, health and sanitation.
13. Policies and procedures shall have
evidence of ongoing review and/or revision. The first page of each manual shall
have the annual review date, signature of the department director and/or
person(s) conducting the review.
14. Clinically relevant educational program
shall be conducted on a regularly scheduled basis not less than 12 per year.
There shall be written documentation with employee signature, program
title/subject, presenter, date and outline or narrative of the presented
program.
15. Staff meetings shall
be held at least monthly. Dated minutes of each meeting shall be kept in
writing.
16. There shall be an
ongoing program for orientation of staff.
17. All psychiatric services personnel shall
maintain competency in life support measures.
18. There shall be an ongoing QA/PI
program.
C. Medical
records shall include at least:
1.
Identification data including patient's legal status;
2. Admitting psychiatric diagnosis as well as
diagnoses of medical problems;
3.
Reason for the patient's admission;
4. Social service records including reports
of interviews with patients, family members and others and a social history and
assessment;
5. Psychiatric
evaluation (See Section 15, Medical Record Requirements for Outpatient
Services, Emergency Room, Observation Services and Psychiatric Records);
and
6. Treatment plan (See Section
15, Medical Record Requirements for Outpatient Services, Emergency Room,
Observation Services and Psychiatric Records).
D. Medications. (See Section 16,
Pharmacy.)
E. Food and Nutritional
Services. (See Section 17, Food and Nutrition Services.)
F. Organization of psychiatric nursing units
and services in general hospitals:
1. Medical
direction shall be provided by a qualified psychiatrist and under the
supervision of a Registered Nurse, qualified by training and experience in
psychiatric nursing.
2. In addition
to the requirements set forth for Nursing Services in Section 11, Patient Care
Service, policies and procedures shall be developed specific to the care of the
psychiatric patient.
G.
Supplies and equipment shall be commensurate with the type of services
offered.
H. Medical Records (See
Section 15, Medical Record Requirements for Outpatient Services, Emergency
Room, Observation Services and Psychiatric Records).
SECTION 38:
SPECIALIZED SERVICE: CARE
OF PATIENTS WITH PULMONARY DISEASE IN GENERAL HOSPITALS.
A. In addition to the Patient Care Services
requirements set forth in Section 11, the policies and procedures shall include
specialized procedures specific to respiratory disease patients and shall
include:
1. Collection of sputum;
2. Utilization of respiratory care;
3. Skin test procedures;
4. Tuberculosis control program for
personnel;
5. Follow-up service for
patients after discharge from the hospital; and
6. Provision for individual patient's plan of
care.
SECTION
39:
AMBULATORY SURGERY CENTERS.
A. General. Any facility in which surgical
services, other than minor dental surgery, are offered which require the use of
anesthesia, that renders the patient unable to be responsible for their
actions, and where, in the opinion of the attending physician, hospitalization
is unnecessary, shall be considered ambulatory surgery centers and shall
conform with the following sections:
1.
Section 3, Definitions;
2. Section
4, Licensure and Codes;
3. Section
5, Governing Body;
4. Section 6,
Medical Staff;
5. Section 7,
General Administration;
6. Section
11, Patient Care Service (Nursing);
7. Section 12, Medications;
8. Section 14, Health Information
Services;
9. Section 16,
Pharmacy;
10. Section 18, Infection
Control;
11. Section 19 A, C.2 and
F, Laboratory;
12. Section 20,
Radiological Services;
13. Section
26, Specialized Services: Surgical Services;
14. Section 28, Specialized Services:
Outpatient Surgical Services;
15.
Section 29, Specialized Services: Anesthesia Services;
16. Section 34, Specialized Services: Central
Sterilization and Supply; Exclude Sections:
17. Section 14, Health Information Services,
Obstetrical Records; 18. Section 14, Health Information Services, Newborn
Records;
19. Section 15, Medical
Record Requirements for Outpatient Services, Emergency Room, Observation
Services and Psychiatric Records;
20. Section 40, Outpatient Psychiatric
Centers;
21. Section 41,
Rehabilitation Hospitals and Units;
22. Section 43, Psychiatric Hospitals;
and
23. Section 44,
Infirmaries.
B.
Staffing. There shall be an adequate number of Registered Nurses on duty at all
times and available for bedside care of any patient when needed. There shall be
Registered Nurses to staff all patient care areas. A Registered Nurse shall
assign the nursing care of each patient to other nursing personnel in
accordance with the patient's needs and the preparation and competence of the
nursing staff. There shall be written criteria to substantiate the
assignment.
C. Discharge criteria
shall be established and approved by the Medical Staff and Governing
Body.
D. Surgical records shall
include documentation stating the patient meets discharge criteria and is
discharged from the facility accompanied by a responsible adult.
E. Diagnostic and treatment services provided
through contract shall be from a source approved by the Department. Such
services shall be monitored by the Ambulatory Surgery Center.
F. Surgical procedures performed in the
Ambulatory Surgery Center shall be those which are:
1. Commonly performed on an inpatient basis
in hospitals, but may be safely performed in an Ambulatory Surgery
Center;
2. Not of a type which are
commonly performed, or which may be safely performed, in physicians' offices;
and
3. Limited to those requiring a
dedicated operating room (or suite), and generally requiring a postoperative
recovery room or short term (not overnight) rooms.
G. Surgical procedures shall not be of a type
that generally result in extensive blood loss; require major or prolonged
invasion of body cavities; directly involve major blood vessels; or generally
emergency or life threatening in nature.
H. The Ambulatory Surgery Center shall have a
written agreement with a local hospital for transfer of a patient in a medical
emergency of a nature which cannot be handled in the Ambulatory Surgery
Center.
I. The Ambulatory Surgery
Center shall comply with Section79, Physical Facilities,
Freestanding Ambulatory Surgery Centers.
J. The Ambulatory Surgery Center shall comply
with Section 46, Physical Environment.
K. Extended Recovery Time.
1. Scope/Limitations of Services.
a. The extended recovery time service shall
be approved by the Health Facility Services prior to implementation of the
service.
b. Ambulatory Surgery
Centers shall have the capability to provide care for post-surgical patients
requiring continued nursing or medical treatment, but whose condition does not
warrant acute hospitalization. The extended recovery period shall not exceed 23
hours and 59 minutes. The extended recovery period shall be limited to:
1) Observation;
2) Control of nausea/vomiting;
3) Replacement of fluids; and
4) Pain management.
c. Patients shall be screened prior to
surgery and prior to admission to the overnight area to ascertain that
established admission criteria is met.
d. Services shall not include intensive
nursing care, continuous monitoring due to the instability of vital signs,
administration of IV cardiac or anti-hypertensive drugs or treatment of any
unstable underlying medical condition.
e. If a question arises as to whether or not
a patient is an appropriate candidate for extended stay, the decision shall be
made by the Medical Director or Administrator.
2. Admission Criteria.
a. Physician's order shall be obtained for
transfer to extended stay;
b.
Stable vital signs and 02 saturation level;
c. Oriented to person, place and time (a
return to preoperative mentation);
d. Presence of satisfactory airway;
e. Absence of significant bleeding;
f. Stabilized or resolution of any acute
problem;
g. Movement of extremities
following regional anesthetic;
h.
Level of consciousness which permits patient to call for nurse;
i. Recovery will require 23 hours 59 minutes
or less prior to discharge;
j. The
surgeon and anesthesia provider (or their designee of similar training and
expertise) shall be present or immediately available. "Immediately available"
shall be determined by the administrative staff, Medical Staff and Governing
Body; and
k. Patient assessment and
orientation shall be recorded in the medical record.
3. Discharge Criteria.
a. Discharge shall be done in keeping with
the same criteria established for the discharge of any patient from the
Ambulatory Surgery Center.
b. The
patient shall be discharged within 23 hours and 59 minutes of his/her admission
to extended recovery by the surgeon or anesthesiologist or his/her
designee.
c. If the patient's
condition is such that discharge is deemed inappropriate, arrangements shall be
made for hospital transfer.
d.
Postoperative prescription orders and instructions shall be given to the
patient and responsible adult with an understanding of instructions verbally by
the person(s) receiving them and a copy retained in the medical
record.
4. Transfer
Requirements to Acute Care Facility.
a.
Patients who require continuous monitoring due to the instability of vital
signs;
b. Patients who require
administration of IV cardiac or anti-hypertensive drugs;
c. Patients who require treatment of any
unstable underlying medical condition;
d. Patients whose pain management or
observation requires longer than 23 hours and 59 minutes;
e. Patients who have a lowered level of
consciousness than their preoperative status; and
f. Patients who exhibit current or potential
airway complications.
5.
Supervision of Extended Recovery Care.
a.
Ambulatory Surgery Centers shall provide adequate supervision of extended stay
area to assure quality patient care and safety.
b. The extended stay area shall be staffed
with a minimum of two caregivers at all times.
1) At least one of the caregivers shall be a
Registered Nurse.
2) All caregivers
shall be Basic Cardiac Life Support (BCLS) certified and shall be fully
oriented and trained.
3) At least
one Registered Nurse on duty at all times shall be Advanced Cardiac Life
Support (ACLS) certified.
4) The
anesthesiologist (or designee) and the surgeon (or designee) shall be present
or immediately available. "Immediately available" shall be determined by the
administrative staff, Medical Staff and Governing Body.
6. Emergency Procedures.
a. Any emergency or life-threatening
situation shall be handled in a manner that provides the most appropriate and
rapid care to best meet the patient needs.
b. Local Emergency Medical Services (EMS)
shall be notified that regular hours are being extended on the days patients
required extended recovery care.
c.
Appropriate drugs, supplies and equipment shall be immediately available to the
area, including a fully stocked crash cart with defibrillator and oxygen
tank.
d. Transfer agreements to a
local acute care hospital and ambulance transportation covering the Ambulatory
Surgery Center shall include the extended stay area.
7. Medications.
The Ambulatory Surgery Center shall have provisions for
obtaining prescribed drugs and biologicals to meet the needs of the population
served. In addition, policies and procedures shall be developed and implemented
for the handling of medications brought into the facility by patients. Should
it be necessary to administer a patient's own medications, a signed physician's
order shall be in the medical record identifying the medications(s) along with
the route and directions for use.
8. Medical Records.
a. Ambulatory Surgery Centers shall have an
expanded medical record for patients in extended stay.
b. The same medical record shall be utilized
that was initiated upon admission for surgery.
c. A discharge note shall be written upon
discharge from acute recovery care.
d. An admission note, to include a patient
assessment by a Registered Nurse, shall be included when the patient is
received in the extended care area.
e. Pertinent observations, treatments and
medications shall be documented in the nurses' notes.
f. A closing entry or discharge summary shall
include information/observations regarding the patient's condition and the care
provided throughout the extended care.
g. Patient food allergies and preferences
shall be documented. Meal intake and toleration of diet shall be documented by
nursing personnel in the nurses' notes.
9. Patient Nutrition.
a. If meals are prepared onsite, the Food and
Nutrition Services shall be supervised by a qualified individual on the days
the facility is open. A qualified individual shall be at a minimum a certified
dietary manager.
b. The food
preparation area shall included at a minimum:
1) Refrigerator/freezer;
2) Microwave oven;
3) Hand hygiene sink with towel and soap
dispensers;
4) Counter
space;
5) Garbage cans with
cover;
6) Storage area for food,
food preparation equipment and tableware; and
7) A three compartment sink, if disposables
are not utilized at all times.
c. If meals are not prepared onsite, the food
served to the patient shall be obtained from a food service establishment that
operates in accordance with the Arkansas Department of Health Rules
and Regulations Pertaining to Food Service
Establishments.
d.
Leftover foods shall not be stored for future patient use.
10. Physical Facilities.
Extended stay may permit patient sleeping accommodations in the
post-anesthesia recovery area.
11. Staffing.
a. At least one Registered Nurse shall be on
duty at all times while the center is in operation, with supportive personnel
as needed.
b. Non-nursing
personnel, i.e., aides, housekeeping, etc. shall be assigned in sufficient
numbers and with sufficient training to meet the patient's needs.
12. Security Procedures.
a. Measures shall be employed to ensure the
security of patients, families, physicians and employees while at the center
after normal working hours.
b. The
parking lot shall be well-lit.
c.
At least two employees shall be present inside the facility when patients are
present.
13. Quality
Assurance/Performance Improvement/Risk Management Plan
a. Ambulatory Surgery Centers shall assure
the same QA/PI plan is followed for extended recovery care patients as general
patients.
b. Each extended recovery
patient shall receive the same Patient Satisfaction Questionnaire as general
surgical patients upon discharge from the facility.
c. Each extended recovery care patient shall
receive a postoperative call if they are discharged to home. If they are
discharged to an alternate health care facility (i.e., rehab) a discharge
summary shall be obtained upon discharge from that facility.
d. During the first year of extended recovery
services a quarterly report of the plan review shall be sent to Health Facility
Services, Arkansas Department of Health.
SECTION 40:
OUTPATIENT
PSYCHIATRIC CENTERS.
Any facility in which psychiatric services are offered for a
period of 4 to 16 hours a day, and where, in the opinion of the attending
psychiatrist, hospitalization, as defined in the present licensure law, is not
necessary, is considered an Outpatient Psychiatric Facility. This definition
does not include Community Mental Health Clinics and Centers as they now exist.
Such facilities shall conform with applicable sections if those services are
provided within the facility. Such facilities shall conform with applicable
sections of Section80, Physical Facilities, Outpatient Care Facilities.
A. General Requirements.
1. Each psychiatric facility shall have a
written plan describing the organization of outpatient services or the
arrangement for the provision of such services to meet patient needs.
2. The outpatient services shall include, but
not be limited to, diagnostic evaluation, individual or group therapy,
consultation and rehabilitation.
3.
The center shall be under the direction and management of a psychiatrist who is
qualified by training and experience requirements for examination by the
American Board of Psychiatry and Neurology or the American Osteopathic Board of
Neurology and Psychiatry and licensed in the State of Arkansas.
4. The Program Director of the Outpatient
Center shall be an individual with at least two years of administrative
experience.
5. The center shall
furnish, through the use of qualified personnel, psychological services, social
work services, occupational therapy, recreational therapy and psychiatric
nursing.
6. The center shall have a
qualified Director of Nursing with a Master's Degree or be qualified by
education and experience in the care of the mentally ill. If the director does
not meet the qualifications, there shall be regular documented consultation by
a qualified Registered Nurse.
7.
Staffing for the center shall insure the presence in the center of a Registered
Nurse during the hours the unit is open. There shall be adequate numbers of
Registered Nurses, Licensed Practical Nurses and mental health workers to
provide the care necessary under each patient's active treatment
program.
8. The center shall
provide or have available, psychological services to meet the needs of the
patients.
9. There shall be a
social service staff to provide services in accordance with accepted standards
of practice and established policies and procedures.
10. The center shall provide a therapeutic
activities program. The program shall be appropriate to the needs and interests
of the patients and be directed toward restoring and maintaining optimal levels
of physical and psychosocial functioning.
11. There shall be a procedure for referrals
for needed services that are not provided directly by the facility.
12. There shall be adequate space, equipment
and supplies for outpatient services to be provided effectively and efficiently
in functional surroundings that are readily accessible and acceptable to the
patients and community services. All space, equipment and facilities, both
within the psychiatric facility and those utilized outside the facility, shall
be well maintained and shall meet applicable federal, state and local
requirements for safety, fire, health and sanitation.
13. Policies and procedures shall have
evidence of ongoing review and/or revision. The first page of each manual shall
have the annual review date, signature of the department supervisor and/or
person(s) conducting the review.
14. Clinically relevant educational program
shall be conducted on a regularly scheduled basis not less than 12 per year.
There shall be written documentation with employee signature, program
title/subject, presenter, date and outline or narrative of the presented
program.
15. Regular staff meetings
shall be held at least monthly. Dated minutes of each meeting shall be kept in
writing.
16. There shall be an
ongoing program for orientation of staff.
17. There shall be an ongoing QA/PI
program.
B. Medical
records shall include at least:
1.
Identification data including patient's legal status;
2. Admitting psychiatric diagnosis as well as
diagnoses of medical problems;
3.
The reasons for the patient's admission to this level of care;
4. Social service records including reports
of interviews with patients, family members and others and a social history and
assessment;
5. Psychiatric
evaluation (See Section 37, Specialized Services: Psychiatric
Services.);
6. Treatment plan (See
Section 37, Specialized Services: Psychiatric Services.); and
C. Medications. Outpatient
Services utilizing medications in therapeutic programs shall fulfill the
requirements in Section 16, Pharmacy.
D. Food and Nutritional Services. (See
Section 17, Food and Nutrition Services.)
E. Physical Facilities. The Outpatient
Psychiatric Centers shall comply with Section80, Physical Facilities,
Outpatient Care Facilities.
SECTION
41:
REHABILITATION HOSPITALS AND UNITS.
A. General Requirements.
1. Rehabilitation Hospital means a hospital
or a distinct part of a hospital as designated in Section 3, Definitions, of
these regulations which is used for the primary purpose of providing
rehabilitative services as so defined and shall comply with Sections 1,
Authority, through Section 38, Specialized Services: Care of Patients with
Pulmonary Disease in General Hospitals. Each hospital or unit shall have the
capability of providing or arranging for emergency services 24 hours per day,
seven days per week.
2. Any
comprehensive physical rehabilitative program shall provide through the use of
qualified professional personnel, at a minimum, the following clinical
services:
a. Physical therapy;
b. Occupational therapy;
c. Speech therapy; and
d. Social services or psychological services.
NOTE: May be provided under contract or arrangement on an as
needed basis.
3. A
physician qualified by training, experience and knowledge of rehabilitative
medicine shall be appointed as the Medical Director.
4. Nursing Services shall be under the direct
supervision of a Registered Nurse who has a Master's Degree or be qualified by
education and experience in Rehabilitative Nursing. If the Registered Nurse
does not have the required credentials, a Master's prepared Registered Nurse
shall be available as a consultant. The number of Registered Nurses, Licensed
Practical Nurses and other nursing personnel shall be adequate to formulate and
carry out the nursing components of the individual treatment plan for each
patient. There shall be a Registered Nurse on duty 24 hours per day, seven days
per week, to plan, assign, supervise and evaluate nursing care and to provide
for the delivery of nursing care to patients.
5. A physician licensed in the State of
Arkansas shall be responsible for each patient's general medical condition as
needed. Medical services shall be available 24 hours per day, seven days per
week as needed. Upon admission there shall be written orders for the immediate
care of the patient.
6. Policies
and procedures shall be developed. The manual shall have evidence of ongoing
review and/or revision. The first page of the manual shall have the annual
review date, signature of the department supervisor and/or person(s) conducting
the review.
7. Clinically relevant
educational programs shall be conducted on a regularly scheduled basis not less
than 12 per year. There shall be written documentation with employee signature,
program title/subject, presenter, date and outline or narrative of the
presented program.
8. Regular staff
meetings shall be held at least monthly. Dated minutes of each meeting shall be
kept in writing.
9. There shall be
an ongoing QA/PI program.
B. Special Medical Record Requirements.
(Refer also to Section 14, Health Information Services.) The medical record
shall include:
1. Reason for referral to
physical rehabilitation services or admission to the comprehensive physical
rehabilitation program;
2. History
and physical examination including patient's clinical condition, functional
strengths and limitations, indications and contra-indications for specific
physical rehabilitative services and prognosis;
3. Goals of treatment and the treatment plan,
including any problem that may affect the outcome of physical rehabilitation
services, and criteria for the discontinuation of services;
4. Interdisciplinary treatment plans to
include measurable goals of treatment and criteria for discharge. The plan
shall include ongoing assessments as required by the patient's medical
condition. Documentation of patient and family in the development of the
treatment plan and resolution of problems and rehabilitation
potential;
5. A discharge summary
that includes recommendations for further care;
6. Patient evaluation procedures, including
treatment plan for each patient based on the functional assessment and
evaluation. The initial treatment plan shall be developed within 24 hours, and
a comprehensive individualized plan developed no later than one week after
admission and updated at least monthly. The plan shall state the rehabilitative
problem, goals and required therapeutic services, as well as prognosis,
anticipated length of stay and discharge disposition;
C. Physical Environment. The Rehabilitation
Facility shall comply with Section 46, Physical Environment.
D. Physical Facilities. The Rehabilitation
Facility shall comply with Section81, Physical Facilities, Rehabilitation
Facilities.
SECTION 42:
RECUPERATION CENTERS.
Any facility which includes inpatient beds with an organized
Medical Staff, and with medical services including physician services and
continuous nursing services to provide treatment for patients who are not in an
acute phase of illness but who currently require primarily convalescent or
restorative services, shall be considered a recuperation center and shall
comply with applicable Sections 1, Authority, through 76, Physical Facilities,
Electrical Standards.
A.
QualityAssurance/Performance Improvement, Infection Control, Pharmacy and
Therapeutics and Utilization Review.
1. The
Recuperation Center shall maintain a Quality Assurance/Performance Information
Committee consisting of the Nurse Manager, Medical Director and at least three
other members of the center's staff, which shall meet at least quarterly to
provide oversight and direction for the center's quality assurance/performance
information activities. Minutes of the Quality Assurance/Performance
Improvement Committee shall be maintained.
2. QA/PI activities shall include ongoing
monitoring, with identification of opportunities for improvement, actions taken
and evaluation of the results of actions. QA/PI activities shall be reported at
least quarterly to the Medical Staff and Governing Body through the
hospital-wide QA/PI program.
3.
Reporting of all infection control, medication and utilization review issues
specific to the center shall be evident in the minutes of the hospital-wide
Infection Control, Pharmacy and Therapeutics and Utilization Review Committees.
Frequency of reporting shall be defined in policies and procedures consistent
with State laws.
B.
Patient identification. Patient armbands shall not be routinely used.
Reasonable measures shall be used to identify patients.
C. Restraints. (See Section 13,
Restraints.)
D. Documentation
Requirements.
1. An assessment of the
patient's needs shall be completed by a Registered Nurse on
admission.
2. Each assessment shall
be coordinated with all health professionals.
3. The interdisciplinary team shall develop a
comprehensive care plan based on the patient's identified needs, measurable
goals of treatment, methods of intervention and documentation of resolution or
continuance. There shall be documentation of the patient and family's
participation in the development of the care plan.
4. Verbal/telephone orders shall be reduced
to writing and countersigned by the physician.
E. Physical Environment. The requirements in
Section 48, Physical Facilities, Patient Accommodations (Adult Medical,
Surgical, Communicable or Pulmonary Disease) shall apply to recuperation
centers with the following exceptions:
1. The
patient dining, recreation and day room(s) may be in separate or adjoining
rooms and shall have a total of 35 square feet per patient bed.
2. Patient corridors shall have handrails on
both sides of the corridors. A clear distance of one and one-half inches shall
be provided between the handrail and the wall. The top of the gripping surface
of handrails shall be 32 inches minimum and 36 inches maximum above the finish
floor. Ends of handrails and grab bars shall be constructed to prevent snagging
the clothes of patients. Exception, special care areas such as those serving
children.
F. Health
Information Services. Applicable parts of item D. of Section 14, Health
Information Services and Section 15, Medical Record Requirements for Outpatient
Services, Emergency Room, Observation Services and Psychiatric
Records.
G. Nursing Services. A
Registered Nurse shall observe each patient at least once per shift and the
observations shall be documented in the patient's medical record.
SECTION 43:
PSYCHIATRIC
HOSPITALS.
A. General. Any facility
used for the primary purpose of providing inpatient diagnostic care and
treatment of persons having mental disorders shall be considered a psychiatric
hospital and shall conform with Section 1, Authority, through Section 24,
Recreational Therapy and applicable portions of Section82, Physical Facilities,
Psychiatric Hospitals and Alcohol/Drug Abuse Inpatient Treatment Centers of
these regulations.
B. Personnel.
The hospital shall furnish, through the use of qualified personnel,
psychological services, social work services, occupational therapy,
recreational therapy and psychiatric nursing. Provisions shall be made for
specialty medical requirements, i.e., neurologist, internist, etc. Each
hospital or unit shall have the capability of providing or arranging emergency
services 24 hours per day, seven days per week.
1. A board-certified psychiatrist shall be
the Medical Director. The Medical Director shall coordinate the Psychiatric
Services in conjunction with other medical, nursing, therapy, and hospital
administration.
2. The diagnosis,
care and treatment for patients shall be under the direction of a
psychiatrist.
3. The unit shall
have a qualified Director of Nursing with a Master's Degree or be qualified by
education and experience in the care of the mentally ill. If the director does
not meet the qualifications, there shall be regular documented consultation by
a qualified Registered Nurse.
4.
All personnel working within an area of psychiatric patients shall be trained
in psychiatric patient care.
5.
Policies and procedures shall be developed specifically for Psychiatric
Services.
C. Seclusion
and Restraints.
1. Seclusion. Patients shall
be placed in seclusion only on the written order of the physician.
Documentation shall reflect time in seclusion, frequency of observation and
frequency of re-evaluation for continued seclusion.
2. Restraints (Mechanical).
a. The Medical Staff shall establish criteria
for use.
b. If locked restraints
are used a designated staff member shall have possession of the key and keep
the patient under constant observation.
c. A schedule shall be developed for
releasing the restraints.
d.
Restraints shall be used only as a last resort for prevention of harm
self-inflicted or to others.
3. Patients shall be grouped according to age
(children, adolescents and adults), sex and treatment needs. Patients with
communicable diseases shall be isolated.
D. Health Information Services. (See Section
14, Health Information Services.)
E. Special Precautions.
1. Special precautions shall be taken so
medications and controlled substances are not accessible to patients.
2. Sharp instruments, knives, ice picks or
other objects which could be used for homicidal or suicidal purposes, shall not
be available to patients.
F. Patient Identification.
If the facility does not choose to follow Section 10, Patient
Identification, they shall take three pictures of the patient at the time of
admission. Pictures shall be attached:
1. To the medication sheet;
2. To the face sheet of the patient's medical
record; and
3. In the dietary
department.
G. Physical
Environment. A Psychiatric hospital shall comply with Section 46, Physical
Environment.
H. Clinically relevant
educational programs shall be conducted on a regularly scheduled basis not less
than 12 per year. There shall be documentation which includes program content,
presenter, date presented and signatures of attendees.
I. There shall be an ongoing QA/PI program
that is specific to patient care.
J. Physical Facilities. A psychiatric
hospital shall comply with Section82, Physical
Facilities, Psychiatric Hospitals and Alcohol/Drug Abuse
Inpatient Treatment Centers.
SECTION 44:
INFIRMARIES.
An infirmary shall be considered a facility established for the
purpose of offering temporary medical care and/or treatment exclusively for
persons residing on a designated premise, e.g., schools, reformatories,
correctional institutions, etc.
A.
Compliance. Infirmaries shall comply with applicable parts of Section 10,
Patient Care Service, through Section 13, Restraints. Infirmaries shall comply
with all applicable parts of:
1. Section 5,
Governing Body and Section 6, Medical Staff. The infirmary shall have an
organized Governing Body or in its absence, a person shall be legally
responsible for maintaining quality patient care, establishing policies for the
infirmary and shall be legally responsible for the conduct of the
infirmary;
2. Section 6, Medical
Staff. The infirmary shall be under the direction of a qualified physician who
shall be responsible for the medical care and treatment rendered;
3. Item A. of Section 11, Patient Care
Service. The infirmary shall be under the supervision of a Registered Nurse on
the day tour of duty. Evening and night tours shall be staffed with licensed
nursing personnel. The medical record for each patient admitted to the
infirmary during the day tour of duty shall document the admission and
observation of patient acuity by a Registered Nurse. The admission shall be
performed by the Director of Nursing or the Registered Nurse on call when such
admission occurs on a weekend day;
4. Section 14, Health Information Services
and Section 15, Medical Record Requirements for Outpatient Services, Emergency
Room, Observation Services and Psychiatric Records;
5. Applicable parts of Section 19 Laboratory
and Section 20, Radiological Services. The infirmary need not comply unless the
services are offered in the infirmary. Where laboratory and/or radiology
services are not offered in the infirmary, the infirmary shall obtain a written
agreement to provide any such services, as appropriate in the scope of the
infirmary setting from a source approved by the Arkansas Department of
Health;
6. Section 17, Food and
Nutrition Services. Kitchen sanitation and food preparation areas shall meet
the requirements for public eating establishments set forth by the Arkansas
Department of Health;
7. Section
16, Pharmacy;
8. Section 83,
Physical Facilities, Infirmaries; and
9. Section 18, Infection Control.
B. Pharmacy Services. All
infirmaries shall have adequate provisions for pharmaceutical services
regarding the procurement, storage, distribution and control of all
medications. All federal and state regulations shall be followed. (See Section
16, Pharmacy.)
C. Administration of
Pharmaceutical Services.
1. The infirmary
shall provide policies and procedures for obtaining, dispensing and
administering of drugs and biologicals developed with the advice of a physician
or pharmacist.
a. Definition of Dispensing. A
function restricted to licensed pharmacists which involves the issuance of:
1) One or more doses of a medication in
containers other than the original, with such new containers being properly
labeled by the dispenser as to content and/or directions for use as directed by
the prescriber;
2) Medication in
its original container with a pharmacy prepared label that carries to the
patient the directions of the prescriber as well as other vital information;
and
3) A package carrying a label
prepared for nursing station use. The contents of the container may be for one
patient (individual prescription) or for several patients (such as a nursing
station medication container).
b. Definition of Administering. An act
restricted to nursing personnel as defined in The Nurse Practice Act, in which
a single dose of a prescribed drug or biological is given to a patient. This
activity includes the removal of the dose from a previously dispensed, properly
labeled container, verifying it with the prescriber's orders, giving the
individual dose to the proper patient and recording the time and dose
given.
2. The infirmary
shall provide for the procurement of drugs and pharmaceutical supplies as
follows:
a. If the infirmary has a pharmacy
department, a licensed pharmacist shall be employed to administer the pharmacy
in accordance with all state and federal laws and regulations regarding drugs
and drug control;
b. If the
infirmary does not have a pharmacy department, the infirmary shall provide for
prompt, convenient availability of prescribed drugs and biologicals from a
community pharmacy;
c. If the
infirmary does not have a pharmacy department but does maintain a supply of
medications, a licensed pharmacist shall be responsible for the control of all
bulk drugs and maintain records of receipt and disposition. The pharmacist
shall dispense medications from the drug supply, properly labeled and available
to appropriate nursing personnel; and d. If a physician maintains his own stock
of drugs in the infirmary, he shall dispense all drugs and maintain control as
required of a pharmacist.
D. Medication Orders.
1. All medications administered to patients
shall be ordered in writing by the physician. Verbal orders shall be given only
to a licensed nurse or a licensed pharmacist, immediately reduced in writing,
signed by the nurse or pharmacist and countersigned by the physician within 72
hours.
2. Medications are released
to patients on discharge only on the written authorization of the
physician.
E.
Administration of Medication.
1. All
medications administered by licensed personnel shall be in accordance with the
Arkansas Practice Acts.
2.
Medications prescribed for one patient shall not be administered to any other
patient.
3. Medication errors and
adverse drug reactions shall be reported to the patient's physician and the
pharmacist.
4. All medications
administered shall be recorded in the medical record.
F. Labeling.
1. Medication kept as general floor stock in
the facility shall be labeled with the trade name (or generic name with the
name of the manufacturer), strength, lot number and expiration date.
2. The label of each patient's individual
medication container shall clearly indicate the patient's full name,
physician's name, prescription number, name and strength of the medication,
date of issue, name, address and telephone number of issuing
pharmacy.
3. Medication containers
having soiled, damaged, incomplete, illegible or makeshift labels are returned
to the issuing pharmacist or pharmacy for re-labeling or disposal.
G. Storage and Security of
Medications.
1. All medications shall be
locked to limit access to licensed personnel.
2. Each patient medication shall be kept and
stored in original containers. There shall be no transferring between
containers.
3. Medication cabinets
shall be of sufficient size to permit storage of medication.
4. Refrigeration shall be provided for the
proper storage of biologicals and other medications. Medications shall be
stored in a separate compartment or area from food. Employee foods and/or
medications shall be stored in a separate refrigeration area. An internal
thermometer shall be provided and checked to assure temperatures between
36Ε- 46Ε Fahrenheit 2Ε-8Ε Centigrade. Daily
documentation of temperatures shall be maintained. Refrigerated medications may
be stored in a locked box inside the refrigerator.
5. Poisons and external medications shall be
separated from other medications.
6. Applicable medications shall be removed
from usage in the event of a drug recall or upon expiration.
H. Pharmacy Records.
1. The infirmary shall comply with all
federal and state laws and regulations relating to the procurement, storage,
dispensing, administering and disposal of medications.
2. A controlled substance record is
maintained which lists the following information on a separate sheet for each
type and strength of controlled substance: date; time administered; name of
patient; dose; prescriber's name; signature of the person administering the
dose; and remaining drug balance.
3. All controlled substances shall be counted
by two licensed personnel at the opening and closing of each staffed shift to
ensure compliance between the listed drug balances and the actual amounts in
stock.
4. All pharmacy records
shall be maintained for two years.
5. The pharmacy shall either maintain copies
of the order or a prescription for every medication dispensed.
6. Policies and procedures shall be
provided.
7. Clinically relevant
educational programs shall be conducted on a regularly scheduled basis not less
than 12 per year. There shall be documentation which includes program content,
presenter, date and time presented and signatures of attendees.
8. There shall be an ongoing QA/PI program
that is specific to the patient care administered.
I. Physical Facilities. Infirmary shall
comply with Section 83, Physical Facilities, Infirmaries.
SECTION 45:
ALCOHOL/DRUG ABUSE
INPATIENT TREATMENT CENTER
Alcohol/Drug Abuse Inpatient Treatment Center means a facility
or distinct part of a facility in which services are provided for the
diagnosis, treatment and rehabilitation of alcohol and/or drug abuse; a
facility which provides counseling only (room and board are not included in
this definition). Participating hospitals shall designate a distinct part and a
specific number of beds for the unit. The distinct part unit shall be at least
10 beds, with a maximum of ten percent (10%) of the total hospital licensed
capacity recommended. Free-standing facilities shall not be larger than 70 beds
or smaller than 35 beds. Each facility or unit shall have the capability of
providing for emergency services 24 hours per day, seven days per week.
Detoxification beds -alcohol/drug abuse treatment beds which are engaged during
that period in which the patient is being physically withdrawn from chemical
substances in order that they may be able to participate in rehabilitative
activities. Active treatment beds - alcohol/drug abuse treatment beds which are
used in providing a highly structured rehabilitative treatment program.
A. Administrative Requirements. A facility or
unit shall develop policies and procedures for the alcohol/drug program that
shall include, but be not limited to, the following:
1. Staffing. Clinical staff shall be licensed
or certified by appropriate state licensure or certification boards;
2. Admission procedures, including a
procedure for accepting emergency admissions;
3. Patient evaluation procedures, including
preliminary evaluation and establishment of an individual treatment
plan;
4. Treatment procedures and
services that are consistent with accepted standards of treatment for
alcohol/drug abuse illness;
5.
Procedures for referral and follow-up of patients' outside services;
6. Procedures for involvement of family in
counseling process;
7. Provision
for after-care plan;
8. Program
QualityAssurance/Performance Improvement;
9. Provision for an education program
acceptable to local school officials for patients of school age that would also
include suitable recreational needs of adolescents;
10. Provision for coordination of services
with community mental health centers, substance abuse treatment programs and
other appropriate facilities or programs; and
11. Clinically relevant educational programs
shall be conducted on a regularly scheduled basis not less than 12 per
year.
B. Medical
Services. A physician licensed in the State of Arkansas shall be responsible
for diagnosis and all medical care and treatment. Medical services shall be
provided directly or on call 24 hours per day, seven days per week. Upon
admission, there shall be written orders for the immediate care of the
patient.
C. Nursing Services.
Nursing services shall be under the direct supervision of a Registered Nurse
qualified by education and experience in psychiatric, mental health or chemical
dependency nursing. The number of Registered Nurses, Licensed Practical Nurses
and other personnel shall be adequate to formulate and carry out the nursing
components of the individual treatment plan for each patient. There shall be a
Registered Nurse on duty 24 hours per day, seven days per week to plan, assign,
supervise and evaluate nursing care and to provide for the delivery of nursing
care to patients.
D. Psychiatric
Services. Patients shall be provided with psychiatric services in accordance
with their needs by a psychiatrist licensed in the State of Arkansas. Services
to patients include evaluations, consultations, therapy and program
development.
E. Psychological
Services. Patients shall be provided with psychological services in accordance
with their needs by a qualified psychologist. Services to patients include
evaluations, consultation, therapy and program development. A qualified
psychologist is an individual licensed by the State Board of Psychological
Examiners with a specialty area in clinical or counseling psychology.
F. Social Services. Social work services are
under the supervision of a qualified social worker. The director of the service
or department shall be a licensed social worker in the State of Arkansas. If
the director does not have a Master's Degree from an accredited School of
Social Work or has not been certified by the Academy of Certified Social
Workers, there shall be documented monthly supervisory consultation by such a
qualified social worker.
G. Social
Work Staff. Social work staff is qualified and numerically adequate to provide
the following services:
1. Psychosocial data
for diagnosis and treatment planning;
2. Direct therapeutic services to individual
patients, patient groups or families;
3. Develop community resources; and
4. Participate in interdisciplinary
conferences and meetings concerning treatment planning, including
identification and utilization of other facilities and alternative forms of
care and treatment.
H.
Activity Services. Activity services staff shall be sufficient in number and
skills to meet the needs of patients and achieve the goals of the service. The
activity service shall be supervised by a qualified Activity Director. A
qualified Activity Director is an individual with a Bachelor's Degree who has
at least one (1) year of experience in assessing, planning and coordinating
activity services in a health care setting. In the absence of such a qualified
Activity Director, this requirement may be met with a documented monthly
supervisory consultation visit by a qualified Activity Therapist.
I. Substance Abuse counselor. There shall be
at least one Certified Substance Abuse Counselor on the treatment staff (as
certified by the Arkansas Substance Abuse Certification Board). Substance Abuse
Counselor staff is qualified and numerically adequate to provide the following
services:
1. Direct counseling services to
individual patients, patient groups and families;
2. Participate in interdisciplinary
conferences and meetings concerning treatment planning, including alternative
forms of care and treatment;
3.
Develop treatment resources; and
4.
Participate in casework processes.
J. Facility and Program Evaluation. Program
evaluation is a management tool primarily utilized by the facility's
Administrator to assess and monitor, on a priority basis, a variety of facility
services and programmatic activities which shall be a component of the
Assurance/Performance Improvement Program. The facility shall have a written
statement of goals and objectives, established as a result of a planning
process, and provided to the Governing Body for approval. There shall be
documentation that the goals and objectives of facility services and
programmatic activities are evaluated at least annually and revised as
necessary.
K. Individualized
Comprehensive Treatment Planning.
1. Intake.
Written policies and procedures governing the intake process shall specify the
following:
a. The information to be obtained
on all applicants or referrals for admission;
b. The treatment required can be
appropriately provided by the facility or program component; and
c. The statistical data to be kept on the
intake process; and
d. The
procedures to be followed when an applicant or a referral is found ineligible
for admission.
2.
Criteria for determining the eligibility of individuals for admission shall be
clearly stated in writing.
3. The
intake procedure shall include an initial assessment of the patient by
professional staff.
4. Acceptance
of a patient for treatment shall be based on an intake procedure that results
in the following conclusions:
a. The
treatment required by the patient is appropriate to the intensity and
restrictions of care provided by the facility or program component;
b. The treatment required can be
appropriately provided by the facility or program component; and
c. The alternatives for less intensive and
restricted treatment are not available.
5. The patient record shall contain the
source of any referral.
6. During
the intake process, every effort shall be made to assure that applicants
understand the following:
a. The nature and
goals of the treatment program;
b.
The treatment costs to be borne by the patient, if any; and
c. The rights and responsibilities of
patients, including the rules governing patient conduct and the types of
infractions that can result in disciplinary action or discharge from the
facility or program component.
7. Facilities shall have policies and
procedures that adequately address the following items for each patient:
a. Responsibility for medical and dental
care, including consents for medical or surgical care and treatment;
b. When appropriate, arrangements for family
participation in the treatment program;
c. Arrangements for clothing, allowances and
gifts;
d. Arrangements regarding
the patient's departure from the facility or program; and
e. Arrangements regarding the patient's
departure from the facility or program against medical advice.
8. When a patient is admitted on
court order, the rights and responsibilities of the patient and the patient's
family shall be explained to them. This explanation of the rights and
responsibilities of the patient and the patient's family shall be documented in
the patient's record.
9. Sufficient
information shall be collected during the intake process to develop a
preliminary treatment plan.
10.
Staff members who shall be working with the patient but who did not participate
in the initial assessment shall be informed about the patient prior to the
meeting.
L. Assessments.
1. Within 72 hours of admission, the staff
shall conduct a complete assessment of each patient's needs. The assessment
shall include, but shall not necessarily be limited to, physical, emotional,
behavioral, social, recreational and nutritional needs.
2. A physician shall be responsible for
assessing each patient's physical health. The health assessment shall include a
medical, alcohol and medication history; a physical examination; neurological
examination when indicated; and a laboratory workup. The physical examination
shall be completed within 48 hours after admission.
3. In facilities serving children and
adolescents, each patient's physical health assessment shall also include
evaluations of the following: Motor development and functioning; sensorimotor
functioning; speech, hearing, and language function, visual functioning; and
immunization status. Facilities serving children and adolescents shall have all
necessary diagnostic tools and personnel available to perform physical health
assessments.
4. A Registered Nurse
shall be responsible for obtaining a nursing history and assessment at the time
of admission.
5. An emotional and
behavioral assessment of each patient shall be completed and entered in the
patient's record. The assessment shall include, but not be limited to, the
following items:
a. A history of previous
emotional, behavioral, and substance abuse problem and treatment;
b. The patient's current emotional and
behavioral functioning; and
c.
When indicated, psychological assessments, including intellectual and
personality testing.
6. A
social assessment of each patient shall be completed by the qualified social
worker and entered in the patient's record. The assessment shall include
information relating to the following areas, as necessary:
a. Environment and home;
b. Religion;
c. Childhood history;
d. Military service history;
e. Financial status;
f. The social, peer group and environmental
setting from which the patient comes; and
g. The patient's family circumstances,
including the constellation of the family group, the current living situation;
and social, ethnic, cultural, emotional and health factors, including drug and
alcohol use.
7. When
appropriate, an activities assessment of each patient shall be completed by the
qualified Activity Director and shall include information relating to the
individual's current skills, talents, aptitudes and interest.
8. A nutritional assessment shall be
conducted by the food service supervisor or Registered Dietitian and shall be
documented in the patient's record.
9. An educational assessment shall be
performed by personnel approved by the Arkansas Department of
Education.
M. Treatment
Plans.
1. Each patient shall have a written
individual treatment plan that is based on assessments of their clinical
needs.
2. Overall development and
implementation of the treatment plan shall be assigned to an appropriate member
of the professional staff.
3. The
treatment plan shall be developed as soon as possible after the patient's
admission. Appropriate therapeutic efforts may begin before a fully developed
treatment plan is finalized.
4.
Upon admission, a preliminary treatment plan shall be formulated on the basis
of the intake assessment.
5. Within
72 hours following admission, a designated member of the treatment team shall
develop an initial treatment plan based on at least an assessment of the
patient's presenting problems, physical health, emotional status and behavioral
status. This initial treatment plan shall be utilized to implement immediate
treatment objectives. If a patient's stay in a facility is 10 days or less,
only a discharge summary shall be required in addition to the initial treatment
plan. If a patient's stay in a facility exceeds 10 days, the interdisciplinary
team shall develop a master treatment plan that is based on a comprehensive
assessment of the patient's needs. The master treatment plan shall contain
objectives and methods for achieving them.
6. The treatment plan shall reflect the
facility's philosophy of treatment and the participation of staff from
appropriate disciplines.
7. The
treatment plan shall specify the services necessary to meet the patient's
needs.
8. The treatment plan shall
include referrals for needed services that are not provided directly by the
facility.
9. The treatment plan
shall contain specific goals the patient shall achieve to attain, maintain,
and/or reestablish emotional and/or physical health as well as maximum growth
and adaptive capabilities. These goals shall be based on assessments of the
patient and, as appropriate, the patient's family.
10. The treatment plan shall contain specific
objectives that relate to the goals, written in measurable terms and include
expected achievement dates.
11. The
treatment plan shall describe the services, activities, and programs planned
for the patient and shall specify the staff members assigned to work with the
patient.
12. The treatment plan
shall specify the frequency of treatment procedures.
13. The treatment plan shall delineate the
specific criteria to be met for termination of treatment. Such criteria shall
be a part of the initial treatment plan.
14. When appropriate, the patient shall
participate in the development of his or her treatment plan and such
participation shall be documented in the patient's record.
15. A specific plan for involving the family
or significant others shall be included in the treatment plan when
indicated.
N. Progress
Notes.
1. Progress notes shall be recorded by
the physician, nurse, social worker and, when appropriate, others significantly
involved in treatment. The frequency of progress notes is determined by the
condition of the patient but shall be recorded at least weekly for the first
two months and at least monthly thereafter.
2. Progress notes shall be entered in the
patient's record and shall include the following:
a. Documentation of implementation of the
treatment plan;
b. Documentation of
all treatment rendered to the patient;
c. Description of change in the patient's
condition; and
d. Descriptions of
the response of the patient to treatment, the outcome of treatment and the
response of significant others to important intercurrent
events.
3. Progress notes
shall be dated and signed by the individual making the entry.
4. All entries involving subjective
interpretation of the patient's progress shall be supplemented with a
description of the actual behavioral observation.
O. Treatment Plan Review.
1. Interdisciplinary case conferences shall
be documented and the results of the review and evaluation shall be recorded in
the patient's treatment plan and his or her progress in attaining the stated
treatment goals and objectives.
2.
Interdisciplinary case conferences shall be documented and the results of the
review and evaluation shall be recorded in the patient's record. The review and
update shall be completed no later than 30 days following the first 10 days of
treatment, and at least 60 days thereafter.
P. Discharge Planning/After-care.
1. The facility shall maintain a centralized
coordinated program to ensure each patient has a planned program of continuing
care which meets his postdischarge needs.
2. Each patient shall have an individualized
discharge plan which reflects input from all disciplines involved in his/her
care. The patient, patient's family and/or significant others shall be involved
in the discharge planning process.
3. Discharge planning data shall be collected
at the time of admission or within seven days thereafter.
4. The Chief Executive Officer shall delegate
the responsibility for discharge planning, in writing, to one or more staff
members.
5. The facility shall
maintain written discharge planning policies and procedures which describe:
a. How the discharge coordinator shall
function, and his authority and relationships with the facility's
staff;
b. The time period in which
each patient's need for discharge planning is determined (within seven days
after admission);
c. The maximum
time period after which reevaluation of each patient's discharge plan is
made;
d. Local resources available
to the facility and the patient to assist in developing and implementing
individual discharge plans; and
e.
Provisions for period review and reevaluation of the facility's discharge
planning program (at least annually).
6. An interdisciplinary case conference shall
be held prior to the patient's discharge. The discharge/after-care plan shall
be reviewed with the patient, patient's family and/or significant
others.
7. The facility shall have
documentation of follow-ups to assure referrals to appropriate community
agencies.
Q. Discharge
Summary. A discharge summary shall be entered in the patient's record within 30
days following discharge. The discharge summary shall include, but not be
limited to:
1. Reason for
admission;
2. Brief summary of
treatment;
3. Reason for
discharge;
4. Assessment of
treatment plan goals and objectives; and
5. Recommendations and arrangements for
further treatment, including prescribed medications and after-care.
R. Additional Requirements. In
addition to the requirements contained in this section,
Alcohol/Drug Inpatient Treatment Centers shall comply with the
following sections of the Rules and Regulations for Hospitals and
Related Institutions in Arkansas:
1. Section 3 through Section 11.G.
2. Applicable parts of Section 14, Health
Information Services.
3. Section
19, Laboratory. (If services are not provided by the facility, an arrangement
for diagnostic services shall be made with another licensed hospital or
Medicare certified independent laboratory for such services.)
4. Section 36, Specialized Services:
Emergency Services. (If not provided, services shall be made available through
arrangement with a licensed hospital.)
5. Applicable parts of Section 18, Infection
Control.
6. Section 17, Food and
Nutrition Services.
7. Section 46,
Physical Environment.
8. Applicable
parts of Section 16, Pharmacy.
9.
Section 82, Physical Facilities, Psychiatric Hospitals and Alcohol/Drug Abuse
Inpatient Treatment Centers. A minimum of 10% of the facility's bedrooms shall
be equipped with a nurse call system. These rooms shall be located adjacent to
the nurses station, and shall be used for initial detoxification or special
treatment.
SECTION
46:
PHYSICAL ENVIRONMENT.
A. Building and Grounds.
1. The building and equipment shall be
maintained in a state of good repair at all times.
2. Facilities and their premises shall be
kept clean, neat and free of litter, rubbish.
3. Rooms for gas fired equipment shall not be
used for storage except for noncombustible materials.
4. Portable equipment shall be supervised by
the department having control of such equipment and shall be stored in areas
which are not accessible to patients, visitors or untrained
personnel.
5. Exit Access Corridors
shall be maintained clear and unobstructed of stationary and non-patient
related portable equipment. Stationary or portable non-patient care furnishings
or equipment shall not be stored in an Exit Access Corridor. Any portable
equipment such as a gurney, wheelchair, linen care, etc. that is not actively
used within a 30 minute time period is considered "Stored". The facility's fire
plan and training program shall address the relocation of these items during a
fire. Exit Access Corridors for Health Care Occupancies are those aisles,
corridors and ramps required for exit access that are located outside of a
"suite of sleeping rooms" greater than 5,000 sq. ft. or "suite of rooms"
greater than 10,000 sq. ft. (area is defined as occupiable net floor space).
Encroachments on the width of the means of egress in an Exit Access Corridor by
stationary objects or furnishings shall not be allowed. The width of the means
of egress in an Exit Access Corridor shall be defined by physical means such as
corridor walls, columns, wingwalls or other approved methods. The means of
egress may provide both visual and physical barrier design characteristics
conducive to establishing a common egress that provides for either a change in
floor texture or self-illumination in the dark.
Alternative consideration: the Means of Egress Requirements for
Health Care Occupancies of NFPA 101 (or equivalency per Section 47 of these
regulations).
6. Each
hospital shall develop a written preventive maintenance plan. This plan shall
be available to the Department for review at any time. Such plans shall provide
for maintenance as recommended by manufacturer, applicable codes or
designer.
7. The handwashing
stations in visitors' rest rooms and the handwashing stations used by staff
personnel shall be equipped with a soap dispenser, and a towel
dispenser.
8. A supply of hot water
for patient use shall be available at all times. A weekly hot water temperature
log shall be maintained.
9.
Heating, ventilating and air-conditioning (HVAC) systems shall be operated, and
maintained in a manner to provide a comfortable and safe environment for
patients, personnel and visitors. An air filter change out log shall be
maintained.
B.
Maintenance and Engineering.
1. The physical
plant and equipment maintenance programs shall be under the direction of a
person qualified by training and/or experience and licensed where
required.
2. Equipment Management
Program (EMP). There shall be a preventive maintenance program designed to
assure the electrically powered patient care equipment used to monitor,
diagnose or provide therapy, performs properly and safely. This program shall
be administered by individuals qualified through training and/or experience or
by procuring a contractual maintenance agreement. The following are minimum
program elements:
a. A current list of
electrically powered patient care equipment shall be maintained regardless of
location or ownership;
b. Each
device, or identical group of devices, shall have a procedure establishing
minimum criteria against which performance and safety are measured. The
elements of these procedures shall be based on the manufacturer's
directions;
c. Each device shall be
tested at intervals of not more than six months unless there is documented
evidence that less frequent testing is justified;
d. Historical records documenting acceptable
performance as established by the procedures shall be maintained;
e. A program to identify and repair equipment
failures shall be maintained;
f.
User or owner departments shall be notified of the status of their equipment
when it will be out of service more than 24 hours;
g. There are operator and maintenance
instructions for each device, or group of similar devices, on the electrically
powered patient care equipment list; and h. Individuals shall be trained to
operate and maintain equipment used in the performance of their duties. This
training shall be documented.
3. Utilities Management Program (UMP). There
shall be a preventive maintenance program designed to assure that the physical
plant equipment and building systems perform properly and safely. This program
shall be administered by individuals qualified through training and/or
experience or by procuring a contractual agreement. This program shall consist
of at least the following minimum elements:
a.
A list of physical plant equipment and/or building system(s) shall be
maintained regardless of location or ownership;
b. Equipment and/or building system(s), shall
have a procedure establishing minimum criteria against which performance and
safety are measured. The elements of these procedures shall be based on the
manufacturer's directions and/or the experience of the repair technician or
operator;
c. Equipment and/or
building system(s), shall be tested, serviced, or inspected at intervals of not
more than 12 months unless there is documented evidence that less frequent
service is justified;
d. Historical
records documenting acceptable performance as established by the procedures
shall be maintained;
e. A program
to identify and repair equipment failures shall be maintained;
f. User or owner departments shall be
notified of the status of their equipment or system when it will be out of
service for more than 24 hours;
g.
There shall be operator and/or maintenance instructions for each piece of
equipment or building system on the list; and h. Individuals shall be trained
to operate and maintain physical plant equipment and/or building systems. This
training shall be documented.
4. Life Safety Management Program (LSM).
There shall be a preventive maintenance program designed to assure that all
circuits of fire alarm and detection systems shall be inspected, tested and
maintained in accordance with NFPA 72. Analog detection devices that provide
automatic self-testing are exempt from the quarterly testing requirement. This
program shall be administered by individuals qualified through training and/or
experience or by procuring a contractual maintenance agreement. This program
shall consist of the following minimum elements:
a. A list of all fire protection equipment or
component groups shall be maintained;
b. Equipment and/or component groups, shall
have a procedure establishing minimum criteria against which performance and
safety are measured. The elements of these procedures shall be based on the
manufacturer's recommendations and/or the experience of the repair technician
or operator;
c. Fans or dampers in
air handling and smoke management systems shall be reliable and functional at
all times;
d. Automatic fire
extinguishing systems shall be inspected and tested annually; actual discharge
of the fire extinguishing system is not required. Records documenting
acceptable performance as established by the procedures shall be
maintained;
e. A program to
identify and repair equipment and/or component group failures shall be
maintained;
f. Systems for
transmitting fire alarms to the local fire department shall be reliable and
functional at all times;
g. There
shall be operator and maintenance instructions for each piece of equipment
and/or component group on the list;
h. Individuals shall be trained to operate
and maintain all equipment and/or component group on the list; and
i. Portable fire extinguishers shall be
clearly identified
5.
Emergency Procedures Program (EPP). There shall be written emergency procedures
or a disaster management plan for utility system disruptions or failures which
address the specific and concise procedures to follow in the event of a utility
system malfunction or failure of the water supply, hot water system, medical
gas system, sewer system, bulk waste disposal system, natural gas system,
commercial power system, communication system, boiler or steam delivery system.
These procedures shall be kept separate from all other policy and procedure
manuals as to facilitate their rapid implementation. These procedures shall
contain but are not limited to the following information:
a. A method of obtaining alternative sources
of essential utilities;
b. A method
of shutoff and location of valves for malfunctioning systems;
c. A method of notification of hospital staff
in affected areas; and
d. A method
of obtaining repair services.
6. Policies and procedures shall include job
descriptions and orientation practices for employees.
7. Policies and procedures shall have
evidence of ongoing review and/or revision. The first page of each manual shall
have the annual review date, signature of the department supervisor and/or
person(s) conducting the review.
8.
Relevant inservice educational programs shall be conducted on a regularly
scheduled basis not less than six per year. There shall be written
documentation with employee signature, program title/subject, presenter, date
and outline or narrative of presented program.
9. The department director shall ensure that
all employees annually attend mandatory inservices on the fire safety, back
safety, infection control, universal precautions, emergency procedures and
disaster preparedness or make provisions to conduct these
departmentally.
10. There shall be
sufficient supervisory and support personnel to provide maintenance services in
relation to the size and complexity of the facility and the services that are
provided.
11. An ongoing QA/PI
program with a liaison with the Infection Control and Safety
Committee.
C.
Environmental Services.
1. The environmental
services shall be under the direction of a person qualified by training and/or
experience and licensed where required.
2. There shall be written policies and
procedures which include:
a. Cleaning of the
physical plant;
b. The use, care
and cleaning of equipment;
c.
Specific cleaning methods used for:
1)
Operating rooms;
2) Delivery
rooms;
3) Nurseries/infant care
units;
4) Emergency
rooms;
5) Isolation areas;
and
6) Other units as
appropriate.
d. Job
descriptions;
e. Orientation
practices;
f. Safety
practices;
g. Infection control
measures;
h. Methods used for
evaluation of cleaning effectiveness;
i. Personal hygiene;
j. The selection of housekeeping and cleaning
supplies; and
k. The proper use of
housekeeping and cleaning supplies.
3. The policy and procedure manual shall have
evidence of ongoing review and/or revision. The first page of each manual shall
have the annual review date, signature of the department and/or person(s)
conducting the review.
4. Relevant
inservice educational programs shall be conducted on a regularly scheduled
basis not less than six per year. There shall be written documentation with
employee signatures, program title/subject, presenter, date and outline or
narrative of presented program.
5.
Expendable supplies (i.e., soap, paper products, etc.) shall be stored in a
manner that shall prevent their contamination prior to use.
6. Solutions, cleaning compounds,
disinfectants, vermin control chemicals, and all other potentially hazardous
substances that are used in connection with environmental services shall be:
a. Kept in containers which accurately
reflect at least the following:
1) Content
name;
2) Concentration of solution;
and
3) Expiration date and lot
number;
b. Stored in a
secured area. Under no circumstances shall these substances be stored in or
near food storage or food preparation areas; and
c. Selected by the director of environmental
services or other appointed qualified person. The Infection Control Committee
shall initially approve the list of chemicals used in the facility and
thereafter, any additions or deletions to the list.
7. A designee from this department shall be a
member of the Infection Control Committee.
8. The use of common towels and common
drinking utensils shall be prohibited.
9. Dry, or untreated dusting, sweeping, or
mopping, except vacuum type cleaning shall be prohibited within the
facility.
10. There shall be an
ongoing QA/PI Program with a mechanism for reporting results.
D. Linen Services.
1. Laundry services shall be under the
direction of a person qualified by training and/or experience and licensed
where required.
2. There shall be
sufficient support personnel to provide linen services in relation to the size
and complexity of the facility and the services that are provided.
3. There shall be written policies and
procedures which include:
a. Collection of
soiled, wet, and contaminated linen;
b. Transporting of soiled, wet, and
contaminated linen to the linen service or to a designated area for commercial
pick-up;
c. Storage of soiled, wet,
and contaminated linen until laundering or being picked up by the commercial
laundry;
d. Storage of clean
linen;
e. Specific laundry
requirements (type detergent, sours, bleach, time and temperatures used) for
washing:
1) New linen;
2) Diapers; and
3) Soiled, wet, and contaminated
linen.
f. Personal
hygiene;
g. Evaluation of
washing/cleaning effectiveness;
h.
Job descriptions;
i. Orientation
practices for new employees;
j.
Safety practices; and
k. Infection
control measures.
4.
Policies and procedures for linen Services shall have evidence of ongoing
review and/or revision. The first page of the manual shall have the annual
review date, signature of the department supervisor and/or person(s) conducting
the review.
5. Relevant inservice
educational programs shall be conducted on a regularly scheduled basis not less
than six per year. There shall be written documentation with employee
signature, program title/subject, presenter, date and outline or narrative of
presented program.
6. Facility
linen service:
a. Sorting of soiled laundry
shall be done in a designated area;
b. Tables or bins shall be provided for
sorting of soiled laundry;
c. Lint
traps shall be provided on dryers and shall be cleaned regularly;
d. Prerinsing shall be done in the laundry
service not in showers, bathtubs or lavatories;
e. Removal of solid soil shall be done in
soiled utility rooms or rooms that are designated for this purpose;
f. Patient clothing may be washed in the
patient area if a separate equipped laundry room is available;
g. A rinsing sink shall be provided in the
soiled linen area of the laundry;
h. Hot water supplied to laundry areas shall
be in accordance with Table 9 of the Appendix;
i. Linen contained in hot water soluble
plastic bags (identified as being contaminated) shall be placed directly into
the washing machine without being removed from the bag for sorting;
j. A lavatory equipped with wrist action
controls, a soap dispenser and a towel dispenser shall be provided in the
laundry for use by the personnel;
k. Personnel with infectious disease or open
wounds shall not be permitted in the laundry; and
l. Personnel assigned to laundry duties
shall wash their hands:
1) After handling wet
or soiled laundry;
2) Before
leaving the laundry;
3) After using
the toilet; and
4) As often as is
necessary to maintain good hygiene.
NOTE: Laundry equipment and installation requirements are set
forth in Section 68, Physical Facilities, Linen Service.
7. Soiled
linen from isolation areas, surgical cases, etc., shall be placed into
impervious bags and, if leakage occurs, bagged into a second bag with proper
identification. Suitable precautions shall be taken in transport, handling and
processing.
8. Soiled, wet and
contaminated linens shall be transported in a closed container.
9. Soiled, wet, and contaminated linens shall
be stored in closed containers or impervious bags in designated areas off the
floor. Areas for storage of soiled, wet, and contaminated linens shall have
forced ventilation to the outside of the building.
10. All new clothing, linen and diapers shall
be laundered before being used.
11.
There shall be a designated area for the storage of clean linens.
12. The linen service within the facility
shall have a capacity sufficient to process a continuous supply of clean
laundry ready for use.
13.
Temperature used in the dryer will depend on the type fabric. An employee shall
be present at all times when the dryer is in operation.
14. There shall be an ongoing QA/PI Program
with a mechanism for reporting results.
15. Linen Service shall include a written
contingency plan indicating an alternative provision that may be followed in
the event the laundry is unable to meet the production demand of the
facility.
16. Separate containers
for the disposal of infectious waste and sharps shall be located in the soiled
linen sorting area.
17. Laundry
workers handling infectious linens shall wear protective equipment, including
but not limited to waterproof, puncture-resistant gloves, protective
over-clothing and where necessary, face shields or goggles.
18. Facilities which do not have linen
services:
a. The facility shall determine that
all launderable items are processed in a commercial laundry in accordance with
standards set forth in this section and shall conduct annual onsite inspections
of the commercial laundry and shall require written verification of compliance
by the laundry.
b. Soiled, wet, and
contaminated laundry shall be stored in a designated area until pick up by the
commercial laundry.
c. A designated
clean area shall be provided for receiving clean laundry and shall be separate
from the soiled linen area.
d.
Clean linen shall be packaged and protected from contamination during
transportation and storage.
19. Refer to Section 18, Infection Control,
for additional requirements.
E. Safety Services.
1. There shall be an effective program to
enhance safety within the facility and grounds. The program shall be monitored
by a Safety Committee appointed by the Administrator. Committee members may be
selected from areas such as Administration, Nursing, Maintenance, Housekeeping,
Laboratory, Respiratory Care, Rehabilitation Services, the Medical Staff and
others as appropriate.
2. The
Safety Committee shall meet a minimum four times per year to fulfill safety
objectives. Minutes of each meeting shall be recorded and kept in the
facility.
3. The Administrator
shall designate a specific individual to carry out policies established by the
Committee and to gather data for the Committee to study safety related
incidents.
4. Safety policies and
procedures shall have evidence of ongoing review and/or revision. The first
page of each manual shall have the annual review date, signature of the
department supervisor and/or person(s) conducting the review. Safety policies
and procedures shall include:
a. Facility
wide hazard surveillance program;
b. Response to medical-device recalls and
hazard notices;
c. Safety
education;
d. Reporting of all
accidents, injuries, and safety hazards;
e. External and internal disaster
plans;
f. Fire safety; and
g. Safety devices and operational
practices.
5. The
orientation program for the facility shall include the importance of general
safety, fire safety and the responsibility of each individual to the
program.
6. The Safety Committee
shall have the following functions:
a.
Monitoring the results of the safety program and analyzing the effectiveness of
the program annually;
b. Monitor
fire drills and disaster drills;
c.
Conclusions, recommendations and actions of the committee shall be reported to
the Board at a minimum annually; and
d. Ensuring each department or service shall
have a safety policy and procedure manual within their own area that is a part
of the overall facility safety manual and establishes safety policies and
procedures specific to each area.
7. Fire extinguishers shall be provided in
adequate numbers, of the correct type, and shall be properly located and
installed. Personnel shall be trained in the proper use of fire extinguishers
and equipment. Personnel shall follow procedures in fire containment and
evacuating patients in case of fire or explosion. There shall be an annual
check of all fire extinguishers by qualified persons in accordance with the
applicable sections of the National Fire Protection Association's Standard 10
(NFPA 10). The date the check was made and the initials of the inspector shall
be recorded on the fire extinguisher or on a tag attached to the
extinguisher.
8. Any fire or
disaster event at the facility shall be reported immediately to the Arkansas
Department of Health by telephone 501-661-2201 during regular working hours or
501-661-2136 after normal working hours, holidays and weekends. If any fire(s)
or disaster is not reported to the Department, the facility is subject to a
fine, refer to item J. of Section 4, Licensure and Codes.
9. There shall be policies and procedures
governing the routine methods of handling and storing flammable and explosive
agents, particularly in operating rooms, delivery rooms, laundries and in areas
where oxygen therapy is administered.
10. There shall be keys available to assure
prompt access to all locked areas. All doors shall be devised so they can be
opened from the inside of the locked area. Special door locking devices are
acceptable in limited areas. Usage is subject to all codes and
regulations.
11. All required exit
doors shall remain unlocked per NFPA requirements.
12. A list of Material Safety Data Sheets
(MSDS) for solutions, cleaning compounds, disinfectants, vermin control
chemicals and other potentially hazardous substances used in connection with
the facility shall be readily available to the Safety Committee, Emergency
Room, Environmental Services and as directed by facility policy and
procedures.
SECTION
47:
PHYSICAL FACILITIES.
A. General Considerations.
1. The requirements set forth herein have
been established by the Department and constitute minimum requirements for the
design, construction, renovation, and repair of facilities requiring licensure
under these regulations.
2.
Facilities shall be accessible to the public, staff, and patients with physical
disabilities. Minimum requirements shall be those set forth by the Arkansas
State Building Services, Minimum Standards and Criteria - Accessibility for the
Physically Disabled Standards.
3.
Projects involving existing facilities shall be programmed and phased to
minimize disruption of the existing functions. Access, exits and fire
protection shall be maintained for the occupant's and the facility's
safety.
4. Codes and Standards.
Nothing stated herein shall relieve the owner from compliance with building
codes, ordinances, and regulations which are enforced by city, county, or other
State jurisdictions. Where such codes, ordinances, and regulations are not in
effect, the owner shall consult the state building codes for all components of
the building type which are not specifically covered by these minimum
requirements. In location where there is a history of tornadoes, floods,
earthquakes or other regional disasters, planning and design shall consider the
need to protect the occupants and the facility.
B. Occupancy: Each licensed facility or
portion of a licensed facility shall be classified as indicated below:
1. General Hospital: A facility or portion of
a facility licensed by the Department as a General Hospital that provide for
patient care, treatment, or diagnosis on a 24 hour basis and provides treatment
or anesthesia for patients that renders the patients incapable of taking action
for self-preservation under emergency conditions without the assistance of
others.
2. Mobile, Transportable,
and Relocatable Unit: A portion of a facility licensed by the Department that
meets the definitions provided in Section 58 for mobile, transportable, and
relocatable units.
3. Freestanding
Ambulatory Surgery Center: A facility or portion of a facility licensed by the
Department as a Freestanding Ambulatory Surgery Center that provides patient
care, treatment, or diagnosis on a less than 24 hour basis and also provides
treatment or anesthesia for patients that renders the patients incapable of
taking action for self-preservation under emergency conditions without the
assistance of others.
4. Outpatient
Care Facility: A portion of a facility licensed by the Department that provides
patient care, treatment, or diagnosis on a less than 24 hour basis and does not
provide treatment or anesthesia for patients that renders the patients
incapable of taking action for self-preservation under emergency conditions
without the assistance of others. Outpatient care facilities may be utilized on
occasion by hospital inpatients provided that such use is limited to a less
than 24 hour basis.
5.
Rehabilitation Facility: A facility or portion of a facility licensed by the
Department as a Rehabilitation Facility.
6. Psychiatric Hospital: A facility or
portion of a facility licensed by the Department as a Psychiatric
Hospital.
7. Alcohol/Drug Abuse
Treatment Center: A facility or portion of a facility licensed by the
Department as an Alcohol/Drug Abuse Treatment Center.
8. Infirmary: A facility or portion of a
facility licensed by the Department as an Infirmary.
9. Non-Healthcare Occupancy: A portion of a
licensed facility that does not contain areas intended for patient care,
treatment, or diagnosis and does not contain equipment (mechanical, electrical,
plumbing, communication, fire alarm, etc.) that serves areas intended for
patient care, treatment, or diagnosis.
C. Multiple Occupancy: Facilities may contain
more than one occupancy (as described above) provided each different occupancy
is separated from all other occupancies by a 2hour fire resistive rated smoke
barrier.
D. Construction Projects:
Each construction project shall be classified as indicated below:
1. Addition: A project that increases the
floor area of a licensed facility.
2. Repair: A project that provides for the
repair or renewal of a licensed facility or portion of a licensed facility
solely for the purpose of its maintenance.
3. Simple Renovation: A project other than
repair that meets all of the criteria listed below:
a. The project does not increase the floor
area of a licensed facility.
b. The
project does not change the occupancy of a licensed facility or portion of a
licensed facility.
c. The project
does not involve more than two (2) smoke compartments.
d. The smoke compartments affected by the
project were completely protected by an automatic sprinkler system prior to the
project or the project provides for the installation of a complete automatic
sprinkler system in all smoke compartments that are affected by the
project.
4. Complex
Renovation: A project other than Addition, Repair, or Simple
Renovation.
E.
Applicable Requirements Based upon Occupancy:
1. Existing Facilities: Existing facilities
that do not comply with these regulations shall be permitted to continue in
service, provided the lack of conformity with these regulations does not
present a serious hazard to the occupants as determined by Health Facility
Services or other authorities having jurisdiction.
2. General Hospital: Facilities or portions
of facilities classified as a General Hospital occupancy shall be designed,
constructed, and renovated in accordance with the Sections of these regulations
listed below and all publications and Appendices referenced by these Sections.
a. Sections 46
b. Section 47
c. Sections 48 through 57
d. Sections 57 through 78
3. Mobile, Transportable, and
Relocatable Unit: Facilities or portions of facilities classified as a Mobile,
Transportable, and Relocatable Unit occupancy shall be designed, constructed,
and renovated in accordance with the Sections of these regulations listed below
and all publications and Appendices referenced by these Sections.
a. Sections 46
b. Section 47
c. Section 58
4. Freestanding Ambulatory Surgery Center:
Facilities or portions of facilities classified as Freestanding Ambulatory
Surgery Center occupancy shall be designed, constructed, and renovated in
accordance with the Sections of these regulations listed below and all
publications and Appendices referenced by these Sections.
a. Sections 46
b. Section 47
c. Section 79
5. Outpatient Care Facility: Facilities or
portions of facilities classified as an Outpatient Care Facility occupancy
shall be designed, constructed, and renovated in accordance with the Sections
of these regulations listed below and all publications and Appendices
referenced by these Sections.
a. Sections
46
b. Section 47
c. Section 80
6. Rehabilitation Facility: Facilities or
portions of facilities classified as an Outpatient Care Facility occupancy
shall be designed, constructed, and renovated in accordance with the Sections
of these regulations listed below and all publications and Appendices
referenced by these Sections.
a. Sections
46
b. Section 47
c. Section 81
7. Psychiatric Hospital: Facilities or
portions of facilities classified as a Psychiatric Hospital occupancy shall be
designed, constructed, and renovated in accordance with the Sections of these
regulations listed below and all publications and Appendices referenced by
these Sections.
a. Sections 46
b. Section 47
c. Section 82
8. Alcohol/Drug Abuse Treatment Center:
Facilities or portions of facilities classified as an Alcohol/Drug Abuse
Treatment Center occupancy shall be designed, constructed, and renovated in
accordance with the Sections of these regulations listed below and all
publications and Appendices referenced by these Sections.
a. Sections 46
b. Section 47
c. Section 82
9. Infirmary Occupancies: Portions of
facilities classified as an Infirmary occupancy shall be designed, constructed,
and renovated in accordance with the Sections of these regulations listed below
and all publications and Appendices referenced by these Sections.
a. Sections 46
b. Section 47
c. Section 83
10. Non-Healthcare Occupancy Facilities or
portions of facilities classified as a Non-Healthcare occupancy shall be
designed, constructed, and renovated in accordance with the Sections of these
regulations listed below and all publications and Appendices referenced by
these Sections.
a. Sections 46
b. Section 47
F. Applicable Requirements Based upon the
Type of Project:
1. General:
a. Where renovation work is done within an
existing facility, all new work, or additions, or both, shall comply, insofar
as practical with applicable sections of these regulations and appropriate
sections of National Fire Protection Association (NFPA) 101 Life Safety Code
covering new occupancies. Where major structural elements make total compliance
impractical or impossible, exceptions will be considered.
b. In renovation projects and projects
involving additions to existing facilities, only that portion of the total
facility affected by the project shall comply with applicable sections of these
regulations and with appropriate parts of NFPA 101 covering new occupancies.
Existing portions of the facility that are not included in the project but
essential to the functioning of a complete facility shall comply (at a minimum)
with the appropriate sections of NFPA 101 covering existing occupancies.
Existing portions of the facility that receive less then substantial amounts of
new work, shall also comply (at a minimum) with the appropriate sections of
NFPA 101 covering existing occupancies.
c. Facilities or portions of facilities shall
be permitted to be occupied during construction, renovation, and repair only
where required means of egress and required fire protection features are in
place and continuously maintained for the portion occupied or where alternate
life safety measures acceptable to Health Facility Services and other
authorities having jurisdiction are in place.
2. Addition, Simple Renovation, and Complex
Renovation shall be designed, constructed, and renovated in accordance with the
applicable Sections of these regulations and all Appendices and publications
referenced by these Sections.
3.
Repair projects shall be designed and constructed in a manner that does not
diminish the safety level that existed prior to the start of the
work.
G. Project Review
and Approval Process.
1. Coordination: Health
Facilities Services will coordinate the review and approval process for all
offices of the Department.
2.
Addition or Complex Renovation Projects shall be reviewed and approved by
Health Facility Services as indicated below:
a. Drawing Review and Approval Process:
1) Submission of Plan Review Fee: A plan
review fee in the amount of one percent of the total cost of construction or
$500.00, whichever is less, shall be paid for the review of plans and
specifications. The plan review fee check is to be made payable to Arkansas
Department of Health. A detailed estimate shall accompany the plans unless the
maximum fee of $500.00 is paid.
2)
Submission of Functional Program: Refer to Section 47, Paragraph H.
3) Submission of Site Location: Refer to
paragraph Section 47, Paragraph I.
4) Submission of Preliminary Plans: Refer to
Section 47, Paragraph J.
5) Review
of Functional Program, Site Location, and Preliminary Plans: Health Facility
Services shall review the Functional Program, Site Location, and Preliminary
Plans and forward a written response with comments to the Facility.
6) Submission of Final Construction
Documents: Refer to Section 47, Paragraph K.
7) Review and Approval of Final Construction
Documents: Health Facility Services shall review the Final Construction
Documents and forward a written response with comments to the Facility and the
Design Professional. Health Facility Services shall have a minimum of six (6)
weeks to review Final Construction Documents. The written response shall
indicate whether or not the Final Construction Documents are approved. If the
Final Construction Documents are not approved, the written response shall
indicate the design modifications required to secure approval.
b. Approval to Begin Construction:
Facilities may proceed with Addition and Complex Renovation projects after
receiving a letter from Health Facility Services stating that the Final
Construction Documents have been reviewed and approved and after receiving
approval from other authorities having jurisdiction.
c. Site Inspections During Construction:
Refer to Section 47, Paragraph L.
d. Final Site Inspection: Refer to Section
46, Paragraph M.
3.
Repair: Repair projects do not require Health Facility Services review and
approval.
4. Simple Renovation
Projects submitted to Health Facility Services shall be reviewed and approved
by Health Facility Services as indicated below:
a. Drawing Review and Approval Process:
1) Submission of Plan Review Fee: A plan
review fee in the amount of one percent of the total cost of construction or
$500.00, whichever is less, shall be paid for the review of plans and
specifications. The plan review fee check is to be made payable to the Arkansas
Department of Health. A detailed estimate shall accompany the plans unless the
maximum fee of $500.00 is paid.
2)
Submission of Functional Program: Refer to Section 47, Paragraph H.
3) Submission of Final Construction
Documents: Refer to Section 47, Paragraph K.
4) Review and Approval of Final Construction
Documents: Health Facility Services shall review the Final Construction
Documents and forward a written response with comments to the Facility. Health
Facility Services shall have a minimum of six (6) weeks to review Final
Construction Documents. The written response shall indicate whether or not the
Final Construction Documents are approved. If the Final Construction Documents
are not approved, the written response shall indicate the design modifications
required to secure approval.
b. Approval to Begin Construction: Facilities
may proceed with Simple Renovation projects after receiving a letter from
Health Facility Services stating that the Final Construction Documents have
been reviewed and approved and after receiving approval from other authorities
having jurisdiction.
c. Site
Inspections During Construction: Refer to Section 47, Paragraph L.
d. Final Site Inspection: Refer to Section
47, Paragraph M.
H. Functional Program.
The facility shall supply for each project (other than a repair
project) a functional program that describes the purpose of the project and
indicates the estimated cost of construction.
I. Site Location.
1. Location a. The site of any medical
facility should be easily accessible to the community and to service vehicles
such as fire protection apparatus.
b.
Facilities should be located with due regard to the accessibility by public
transportation for patients, staff, and visitors, and availability of competent
medical and surgical consultation.
c. The facility should have security measures
for patients, personnel, and the public consistent with the conditions and
risks inherent in the location of the facility. These measures shall include a
program designed to protect human and capital resources.
d. The facility should be located to provide
reliable utilities (water, natural gas, sewer and electricity).
e. The site should afford good drainage and
shall not be subject to flooding nor be located near insect breeding areas,
excessive noise, nor other nuisance producing locations, nor near airports,
railways, air pollution, penal institutions (except prison infirmaries), or a
cemetery.
2. Roads and
Parking.
a. Paved roads and walks shall be
provided within the lot lines to provide access to the main entrance and
service entrance, including loading and unloading docks for delivery trucks.
Hospitals having an organized emergency services department shall have the
emergency entrance well marked to facilitate entry from the public roads or
streets serving the site. Access to the emergency entrance shall not conflict
with other vehicular traffic or pedestrian traffic. Paved walkways shall be
provided for necessary pedestrian traffic.
b. Each facility shall have parking spaces to
satisfy the minimum needs of patients, employees, staff, and visitors. In the
absence of a formal parking study, each facility shall provide not less than
one space for each day shift staff member and employee plus one space for each
patient bed. This ratio may be reduced in an area convenient to a public
transportation system or to a public parking facility if proper justification
is given and provided that approval of any reduction is obtained from the
Department. Additional parking shall be required to accommodate outpatient and
other services when they are provided. Space shall be provided for emergency
and delivery vehicles.
3. Subsoil Investigation. Subsoil
investigation shall be made to determine the subsurface soil and water
conditions. The investigation shall include a sufficient number of test pits or
test borings to determine, in the judgment of the architect and the structural
engineer, the true subsurface conditions. Results of the investigation shall be
available in the form of a soil investigation report or a foundation
engineering report. The investigation shall be made in close cooperation with
the architect and structural engineer and shall contain detailed
recommendations for foundation design and gradings. The following is a general
outline of the suggested scope of soil investigation:
a. The borings or test pits shall extend into
stable soils well below the bottom of any proposed foundations. A field log of
the borings shall be made and the thickness, consistency, and character of each
layer recorded;
b. The amount and
elevation of groundwater encountered in each pit or boring and its probable
variation with the seasons and effect on the subsoil shall be determined. High
or low water levels of nearby bodies of water affecting the ground level shall
also be determined;
c. Laboratory
tests shall be performed to determine the safe bearing value and
compressibility characteristics of the various strata encountered in each pit
or boring;
d. Maximum depth of
frost penetration below surface of the ground shall be recorded;
e. Tests shall be made to determine whether
the soil contains alkali in sufficient quantities to affect concrete
foundations;
4.
Approval. The new building site shall be inspected and approved by the
Department before construction begins.
J. Preliminary Plans: Preliminary plans
submitted to Health Facility Services shall include as a minimum the following
information:
1. Floor plans drawn to scale
that indicate room names, room dimensions, corridor dimensions, locations of
fire resistive rated partitions, and locations of rated smoke
barriers.
2. An existing floor plan
indicating existing spaces and exits and their relationship to the new
construction (renovation projects only).
3. Building sections that establish the
proposed construction type and fire rating. Sections shall be drawn at a scale
sufficiently large to clearly present the proposed construction
system.
4. A site plan that
indicates the location of proposed roads, walks, service and entrance courts,
parking, and orientation.
5. Simple
horizontal and vertical space diagrams that indicate the relationship of
various departments and services to each other the general room arrangement in
each department.
6. A narrative
description of proposed mechanical, electrical, and fire protection
systems.
K. Final
Construction Documents.
1. Construction
Documents shall be prepared by an architect and/or professional engineer
licensed by the State of Arkansas.
2. Architectural construction documents shall
be prepared by an architect and engineering construction documents (structural,
mechanical, electrical, and civil) shall be prepared by a qualified engineer.
The documents shall be stamped with appropriate seals for each
discipline.
3. Periodic
observations of construction shall be provided and documented by each design
professional. Design professionals shall verify that the construction is in
accordance with the construction documents and that the Record Drawings are
properly maintained.
4. The
construction contract shall contain a provision to withhold progress payments
to the contractor until the Record Drawings are current.
5. Final Construction Documents shall include
drawings and specifications. Separate drawings and specifications shall be
prepared for each of the following branches of work: architectural, structural,
mechanical, electrical, life safety and fire protection.
6. The drawings shall include the following
information:
a. Architectural.
1) Approved plan showing all new topography,
newly established levels and grades, existing structures on the site (if any),
new buildings and structures, roadways, walks, and the extent of the areas to
be planted. All structures and improvements removed under the construction
contract. A print of the survey shall be included in the Contract
Documents.
2) Plan of each floor,
roof, and all intermediate levels.
3) Elevations of each exterior
wall.
4) Sections through
building.
5) Scale details as
necessary to properly indicate portions of the work.
6) Schedule of finishes.
b. Equipment.
1) Large scale drawings of typical and
special rooms indicating all fixed equipment and major items of furniture and
movable equipment.
2) The furniture
and movable equipment not included in the construction contract shall be
indicated by dotted lines.
c. Structural.
1) Plans of foundations, floors, roofs, and
all intermediate levels shall show a complete design with sizes, sections, and
the relative location of the various members and schedule of beams, girders,
and columns.
2) Dimensional floor
levels, column centers and offsets.
3) Special openings.
4) Details of all special connections,
assemblies, and expansion joints.
5) Name of the governing building code.
d. Mechanical.
1) Heating, piping, and air-conditioning
systems:
a) Steam heated equipment, such as
sterilizers, warmers, and steam tables;
b) Heating and steam mains and branches with
pipe sizes;
c) Diagram of heating
and steam risers with pipe sizes;
d) Sizes, types, and heating surfaces of
boilers and oil burners, if any;
e)
Pumps, tanks, boiler breeching and piping, and boiler room
accessories;
f) Air-conditioning
systems with required equipment, water piping, refrigerant piping, and ductwork
indicating required fire smoke/dampers;
g) Air quantities for all room supply,
return, and exhaust ventilating duct openings;
h) A ventilation schedule specifying the
following information: Room number, room name, room volume (ft3), required room
air changes, required outside air changes, required air movement relative to
adjacent area, required air filtration (% efficiency), required room total
supply air quantity (cubic feet per minute (CFM), required outside air quantity
(CFM), required room exhaust air quantity (CFM), design room total supply air
quantity (CFM), design room return air quantity (CFM), design outside air
quantity (CFM), design room exhaust air quantity (CFM), design room air
filtration (% efficiency), room design summer (ºF) dry bulb/wet bulb
(DB/WB), room design winter (ºF) DB/WB, outside air design summer
(ºF) DB/WB, and outside air design winter (ºF) DB/WB; and i) Air
filter design pressure drop (both clean and dirty).
2) Plumbing, drainage, and standpipe systems:
a) Size and elevation of street sewer, house
sewer, house drains, and street water main;
b) Locations and size of soil, waste, and
vent stacks with connections to house drains, clean outs, fixtures and
equipment;
c) Size and location of
hot and cold circulating mains, branches, and risers from the service entrance
and tanks;
d) Riser diagram to show
all plumbing stacks with vents, water risers, and fixture
connections;
e) Gas, oxygen, and
special connections;
f) Standpipe
and sprinkler systems; and
g)
Plumbing fixtures and equipment that require water and drain
connections;
3) Elevators
and dumbwaiters: Details and dimensions of shaft, pit and machine room, pit
sumps with alarms when required, sizes of car platform and doors.
4) Kitchens, laundry, refrigeration, and
laboratories detailed at a satisfactory scale (1/4 inch scale) to show the
location, size, and connection of all fixed and moveable
equipment.
e. Electrical.
1) All electrical wiring, outlets, smoke
detectors, and equipment which require electrical connections;
2) Electrical service entrance with switches,
and feeders to the public service feeders, characteristics of the light and
power current and transformers and their connections, if located in the
building;
3) Plan and diagram
showing main switchboard power panels, light panels and equipment. Diagram of
feeder and conduit sizes with a schedule of feeder breakers or
switches;
4) Light outlets,
receptacles, switches, power outlets, and circuits;
5) Telephone layout showing service entrance,
telephone switchboard, terminal boxes, and telephone outlets;
6) Nurse call systems with outlets for beds,
nurses stations, door signal lights, annunciators, and wiring
diagrams;
7) Staff paging and
doctor's in-and-out registry systems with all equipment wiring, if
provided;
8) Fire alarm and/or
security system with stations, signal devices, control board, and wiring
diagrams;
9) Emergency electrical
system with outlets, transfer switch, source of supply, feeders, and circuits;
10) Medical gas alarm systems;
and
11) All other electrically
operated systems and equipment.
f. Life Safety and Fire Protection.
1) Limits of each smoke
compartment;
2) Location of each
smoke barrier wall;
3) Dimensions
and gross areas of each smoke compartment;
4) Location of each fire rated wall or
partition, fire separation wall and horizontal exit;
5) Location of each exit sign, fire pull
station, and extinguisher cabinet and extinguisher; and
6) Travel distance(s) from the most remote
location(s) in the building to an exit as defined by NFPA 101 (i.e., horizontal
exit, exit passageway, enclosed exit stair, exterior exit door).
g. Specifications: Specifications
shall supplement the drawings to fully describe types, sizes, capacities,
workmanships, finishes, and other characteristics of all materials and
equipment and shall include the following:
1)
Cover or title sheet with architectural seal;
2) Index;
3) General conditions;
4) General requirements;
5) Sections describing material and
workmanship in detail for each class of work.
h. All construction documents and
specifications shall be approved by the Department prior to the beginning of
construction and a letter shall be issued from the licensing agency granting
approval to commence with construction. The Department shall have a minimum of
six (6) weeks to review construction documents and specifications. Health
Facility Services shall coordinate the plan review with other Divisions in the
Department. Penalties for starting construction without Department approval see
Section 4.I, Licensure and Codes.
L. Site Inspection During Construction. The
Department shall inspect the project during the construction process as
indicated below:
1. This Department is to be
notified when construction begins and a construction schedule shall be
submitted to determine inspection dates.
2. Representatives from the Department shall
have access to the construction premises and the construction project for
purposes of making whatever inspections deemed necessary throughout the course
of construction.
3. Any deviation
from the accepted construction documents shall not be permitted during
construction, until the written request for change(s) in the construction is
approved by this Department.
M. Final Site Inspection.
1. Upon completion of construction and prior
to the approval by the Department to occupy and use the facility, the owner
shall be furnished a complete set of record drawings and a complete set of
installation, operation, and maintenance manuals and parts lists for the
installed equipment.
2. A list of
final site inspection items has been provided in the Table 5 of the
Appendix.
3. No facility shall
occupy any new structure or major addition or renovation space until the
appropriate permission has been received from the local building and fire
authorities and licensing agency.
N. Referenced Publications.
1. General: These regulations include
references to other codes and standards. The most current codes and standards
adopted at the time of this publication are used. Later issues will normally be
acceptable where requirements for function and safety are not reduced; however,
editions of different dates may have portions renumbered or re-titled. Care
shall be taken to ensure that appropriate sections are used.
2. Publications adopted in whole by these
regulations are as listed below:
a. American
National Standards Institute (ANSI) Standard A17.1, "American National Standard
Safety Code for Elevators, Dumbwaiters, Escalators and Moving
Stairs."
b. American Society of
Civil Engineers, (ASCE), "Minimum Design Loads for Buildings and Other
Structures."
c. Arkansas Building
Authority, Minimum Standards and Criteria -Accessibility for the Physically
Disabled Standards.
d. National
Council on Radiation Protection (NCRP), Report No. 33, "Medical X-ray and Gamma
Ray Protection for Energies Up to 10 MeV Equipment Design and Use,
1986."
e. National Council on
Radiation Protection (NCRP), Report No. 49, "Medical X-ray and Gamma Ray
Protection for Energies up to 10 MeV Structural Shielding Design and
Evaluation, 1976."
f. National
Council on Radiation Protection (NCRP), Radiation Protection Design Guidelines
for 0.1pi29100, MeV Particle Accelerator Facilities.
g. National Fire Protection Association 101,
Life Safety Code, 2000 Edition. Note that "Mandatory References" are listed in
Chapter 2 of this document.
h.
Rules and Regulations Pertaining to the Management of Regulated Waste from
Health Care Related Facilities, Arkansas Department of Health.
3. Publications adopted in part
(only the sections specifically identified by these regulations are applicable)
by these regulations are as listed below:
a.
American Society of Heating, Refrigerating and Air Conditioning Engineers
(ASHRAE), "Handbook of Fundamentals" and "Handbook of Applications."
b. American Society of Heating, Refrigerating
and Air Conditioning Engineers (ASHRAE), Standard 52, "Method of Testing Air
Cleaning Devices Used in General Ventilation for Removing Particulate
Matter."
c. Illuminating
Engineering Society of North America, IESNA Publication CP29, "Lighting for
Health Care Facilities."
4. A partial list of other publications that
are applicable to the design and construction of healthcare facilities that are
not a part of these regulations but may be enforced by other authorities having
jurisdiction is provided below:
a. Arkansas
State Fire Prevention Code Volumes I, II, and III (based on the 2000
International Building Code).
b.
Arkansas State Mechanical Code, Arkansas Department of Health.
c. Arkansas State Plumbing Code, Arkansas
Department of Health.
d. Arkansas
Boiler Code, Arkansas Department of Labor.
5. Publications that are not a part of these
regulations but potentially helpful as reference material in the design and
construction of healthcare facilities are as listed below:
a. American Institute of Architects (AIA),
"Guidelines for Design and Construction of Hospital and Health Care Facilities
2001 Edition".
b. American Society
of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE), "HVAC
Design Manual for Hospitals and Clinics".
O. Availability of Codes and Standards.
Referenced publications can be ordered, if they are Government publications,
from the Superintendent of Documents, U.S. Government Printing Office (GPO),
Washington, DC 20402. Copies of non-government publications can be obtained at
the addresses listed below.
1. Air
Conditioning and Refrigeration Institute, 1501 Wilson Boulevard, Arlington, VA
22209.
2. American National
Standards Institute, 1430 Broadway, New York, NY 10018.
3. American Society of Civil Engineers, 345
East 47th Street, New York, NY 10017
4. American Society for Testing and
Materials, 1916 Race Street, Philadelphia, PA 19103.
5. American Society of Heating,
Refrigerating, and Air Conditioning, 1741 Tullie Circle, NE, Atlanta GA
30329.
6. Arkansas Building
Authority, 1515 West 7th Street, Suite 700, Little Rock, AR 72201.
7. Arkansas Department of Labor, 10421 West
Markham, Little Rock, AR 72205.
8.
Illuminating Engineering Society of North America (IESNA), 120 Wall Street,
17th Floor, New York, NY 10005.
9.
National Council on Radiation Protection and Measurement, 7910 Woodmont Avenue,
Suite 1016, Bethesda, MD 20814.
10.
National Fire Protection Association, 1 Batterymarch Park, Post Office Box
9101, Quincy, MA 02269-9101.
11.
International Building Code Congress International, Inc., 900 Montclair Road,
Birmingham, AL 35213.
P.
Interpretations of Requirements.
1. Memorandum
of Understanding: Conflicts between the Arkansas Fire Prevention Code and NFPA
101 Life Safety Code are to be resolved using the Memorandum of Understanding
as indicated below:
a. The Arkansas Fire
Prevention Code is the fire prevention code for the State of
Arkansas.
b. When the Arkansas
State Fire Prevention Code conflicts with the chapters of NFPA 101 Life Safety
Code governing new and existing health care and ambulatory health care
occupancies (Chapters 18, 19, 20, and 21), the provisions of the Life Safety
Code shall govern.
c. Requirements
found only in the Arkansas Fire Prevention Code (requirements not addressed by
NFPA 101) may be provided at the option of the facility (compliance with these
requirements is not mandatory).
2. Safety Improvement Plans: Nothing in these
regulations shall be construed as restrictive to a facility that chooses to do
work as a part of a long-range safety improvement plan. These regulations do
not prohibit a single phase of improvement. All hazards to life and safety all
areas of noncompliance should be corrected as soon as possible.
3. Provisions in Excess of Regulatory
Requirements: Nothing in these regulations shall be construed to prohibit a
better type of building construction, an additional means of egress, or an
otherwise safer condition than that specified by the minimum requirements of
these regulations.
4. Equivalency:
a. Insofar as practical, these minimum
standards have been established to obtain a desired performance result.
Prescriptive limitations, when given, such as exact minimum dimensions or
quantities, describe a condition that is recognized as a practical standard for
normal operation.
b. It is the
intent of these regulations to permit and promote equivalency concepts. Nothing
in these regulations shall be construed as restricting innovations that provide
an equivalent level of performance with these regulations in a manner other
than that which is prescribed by these regulations, provided that no other
safety element or system is compromised in order to establish
equivalency.
c. Health Facility
Services may approve alternate methods, procedures, design criteria, and
functional variations from these regulations, because of extraordinary
circumstances, new programs, new technology, or unusual conditions when the
facility can effectively demonstrate that the intent of the regulations is met
and that the variation does not reduce the safety or operational effectiveness
of the facility below that required by the exact language of the
regulations.
d. When contemplating
equivalency allowances, Health Facility Services may use a variety of expert
sources to make equivalency findings. Health Facility Services will document
the reasons for approval or denial of equivalency to the facility.
e. National Fire Protection Association
(NFPA) document 101A is a technical standard for evaluating equivalency to
certain Life Safety Code 101 requirements. The Fire Safety Evaluation System
(FSES) is a widely recognized method for establishing a safety level equivalent
to the Life Safety Code. The use of the FSES process may be useful for
evaluating existing facilities that will be affected by renovation.
SECTION 48:
PHYSICAL FACILITIES, PATIENT ACCOMMODATIONS (ADULT MEDICAL, SURGICAL,
COMMUNICABLE OR PULMONARY DISEASE).
NOTE: See other sections of this document for Special-Care area
units such as Postanesthesia Care Unit, Critical Care Units, Rehabilitation
Units, Pediatric Units, Postpartum Care Units and/or other specialty
units.
A. Patient Rooms. Each patient
room shall meet the following requirements.
1.
Maximum room capacity shall be two patients.
2. In new construction, patient rooms shall
have a minimum of 100 square feet of clear floor area per bed in semi-private
rooms and 120 square feet of clear floor area for single-bed rooms, exclusive
of toilet rooms, closets, lockers, wardrobes, alcoves or vestibules. The
dimensions and arrangement of rooms shall be such that there is a minimum of
three feet between the sides and foot of the bed and any wall, other fixed
obstruction or another bed. In semi-private bed rooms, a clearance of four feet
shall be available at the foot of each bed to permit the passage of equipment
and beds. Minor encroachments, including columns and lavatories, that do not
interfere with functions may be ignored when determining space requirements for
patient rooms. Where renovation work is undertaken, every effort shall be made
to meet the above minimum standards.
3. Each patient room shall have a window with
outside exposure and where the operation of windows or vents requires the use
of tools or keys, such devices shall be on the same floor and easily accessible
to staff. The windowsills shall not be higher than three feet above the floor
and shall be above the grade. Patient rooms in new construction intended for 24
hour occupancy shall have windows. If operable windows are installed, such
devices shall be permanently secured or restricted to inhibit possible escape
or suicide.
4. Nurse patient
communication station shall be provided in accordance with item G of Section
76, Physical Facilities, Electrical Standards.
5. Handwashing stations shall be provided to
serve each patient room. These handwashing stations shall be located in the
toilet room.
6. Each patient shall
have access to a toilet room without having to enter the general corridor area.
One toilet room shall serve no more than four patient beds and no more than two
patient rooms. In new construction, an additional handwashing station or
sanitizing station shall be placed in the patient room where the toilet room
serves more than one bed. The toilet room shall contain a water closet and a
handwashing station and the door shall swing outward or be double
acting.
7. Each patient shall have
within the room a separate wardrobe or closet that is suitable for hanging full
length garments and for storing personal items.
8. Visual privacy from casual observation by
other patients and visitors shall be provided for each patient in semi-private
rooms with cubicle curtains or equivalent built-in or movable dividers.
Provisions for privacy is not required within psychiatric or alcohol and drug
units. The method for providing privacy shall not obstruct passage of other
patients either to the entrance, toilet or lavatory. All curtains shall have a
flame spread of 0 to 25 and shall comply with NFPA 13 requirements for clear
space below sprinklers.
9. Each
room shall communicate directly with a corridor without passage through another
patient's room.
10. Rooms existing
partially below grade level shall not be used for patients unless they are dry,
well ventilated and are otherwise suitable for occupancy.
11. Beds shall be arranged to provide
adequate room for all patient care procedures and to prevent the transmission
of infections.
12. Individual
approved hospital type beds shall be provided. Bed rails shall be provided on
beds for children.
13. A reading
light shall be provided for each patient bed. The location and design shall be
such that the light is not annoying to other patients.
14. A bedside table with drawer shall be
provided for each bed. The lower portion of the table and/or enclosed shelves
shall be provided for individual nursing care equipment.
B. Service Areas. Each services area may be
arranged and located to serve more than one nursing unit but at least one such
service area shall be provided on each nursing floor. Some of the service areas
may be combined in a single space. The following service areas shall be located
in or readily available to each nursing unit:
1. Nursing Station. Facilities for charting,
clinical records, work counter, communication system, space for supplies and
convenient access to handwashing stations shall be provided. It may be combined
with or include centers for reception and communication.
2. Dictation area shall be provided. This
area shall be adjacent to but separate from the nurses' station;
3. Toilet room(s) for staff convenient to
nurses' station (may be unisex).
4.
Lounge facilities for staff. These facilities may be on another
floor.
5. Individual closets or
compartments for the safekeeping of coats and personal effects of nursing
personnel. These shall be located convenient to the nurses' station of
personnel or in a central location.
6. Multi-purpose room(s) for staff, patients,
patients' families for patient conferences, reports, education, training
sessions, and consultation. The rooms shall be accessible to each nursing unit.
One such room may serve several nursing units and/or departments.
7. Examination/treatment room(s). Such rooms
may be omitted if all patient rooms are single-bed rooms. It shall have a
minimum floor area of 120 square feet excluding space for vestibule, toilet,
closets, and work counters (whether fixed or movable). Centrally located
examination and treatment room(s) may serve more than one nursing unit on the
same floor. The room shall contain a lavatory or sink equipped for handwashing,
work counter, storage facilities, and a desk, counter or shelf space for
writing. The emergency treatment room may be used for this purpose if it is
conveniently located to the patient rooms.
8. Clean workroom or clean supply room. If
the room is used for preparing patient care items, it shall contain a work
counter, a handwashing fixture and storage facilities for clean and sterile
supplies. If the room is used only for storage and holding as part of a system
for distribution of clean and sterile materials, the work counter and
handwashing fixture may be omitted. Soiled and clean workrooms or holding rooms
shall be separated and have no direct connection.
9. Soiled workroom or soiled holding room.
This room shall be separate from the clean workroom. The soiled workroom shall
contain a clinical sink (or equivalent flushing-rim fixture). The room shall
contain a lavatory (or handwashing fixture). The above fixtures shall both have
a hot and cold mixing faucet. The room shall have a work counter and space for
separate covered containers for soiled linen and waste. Rooms used only for
temporary holding of soiled material may omit the clinical sink and work
counter. If the flushing-rim clinical sink is eliminated, facilities for
cleaning bedpans shall be provided elsewhere.
10. Medication Station. Provisions shall be
made for distribution of medications. This may be done from a medicine
preparation room or unit, from a self-contained medicine dispensing unit, or by
another approved system.
a. Medicine
preparation room. This room shall be designed to allow for visual supervision
by the nursing staff. It shall contain a work counter, a sink adequate for
handwashing, refrigerator, and locked storage for controlled drugs. When a
medicine preparation room is to be used to store one or more self-contained
medicine dispensing units, the room shall be designed with adequate space to
prepare medicines with the self-contained medicine dispensing unit(s)
present.
b. Self-contained medicine
dispensing unit. A self-contained medicine dispensing unit may be located at
the nurses' station, in the clean workroom or in an alcove, provided the unit
has adequate security for controlled drugs and adequate lighting to easily
identify drugs. Convenient access to handwashing stations shall be provided.
(Standard cup-sinks provided in many self-contained units are not adequate for
handwashing.)
11. Clean
Linen Storage. A separate closet or a designated area within the clean workroom
shall be provided. If a closed cart system is used, storage may be in an
alcove. Carts shall be out of the path of traffic.
12. Nourishment Station. This shall contain a
sink equipped for handwashing, equipment for serving nourishment between
scheduled and unscheduled meals, refrigerator, storage cabinets and ice maker
units to provide ice for patients' service and treatment. Ice for human
consumption shall be from self-dispensing units. Handwashing stations shall be
in or immediately accessible to the nourishment station.
13. Equipment Storage Room. This shall be for
equipment such as I.V. stands, inhalators, air mattresses and
walkers.
14. Parking for stretchers
and wheelchairs. This shall be located out of path normal traffic.
15. Showers and bathtubs. When individual
bathing facilities are not provided in patient rooms, there shall be at least
one shower and/or bathtub for each 12 beds without such facilities. Each
bathtub or shower shall be in an individual room or enclosure that provides
privacy for bathing, drying, and dressing. Special bathing facilities,
including space for attendant, shall be provided for patients on stretchers,
carts, and wheelchairs at the ratio of one per 100 beds or a fraction thereof.
This may be on a separate floor if convenient for use.
16. Emergency Equipment Storage. Space for
emergency equipment such as a "crash cart" shall be provided and shall be under
control of the nursing staff.
17.
Environmental Services Closet. See Section 69, Physical Facilities, Cleaning
and Sanitizing Carts and Environmental Services, for detailed
requirements.
C.
Airborne Infection Isolation Room(s). Rooms for patients who are suffering from
infections shall be provided at the rate of 1 for each 30 beds or fraction
thereof. These may be located within each nursing unit or placed together in a
separate unit. See also Section 49, Physical Facilities, Critical Care Unit for
the requirements of Critical Care Units. Psychiatric and Alcohol/Drug Unit(s)
beds need not be included in the bed count ratio to establish the number of
rooms. Each isolation room shall be a single-bed room and planned as required
for a normal patient room except as follows:
1. Each airborne infection isolation room
shall have an area for handwashing, gowning, and storage of clean and soiled
materials located directly outside the entry door to the patient
room.
2. Airborne infection
isolation room perimeter walls, ceiling and floors, including penetrations,
shall be sealed tightly so that air does not infiltrate the environment from
the outside or from other spaces.
3. Airborne infection isolation room(s) shall
have self-closing devices on all room exit doors.
4. Separate toilet, bathtub (or shower) and
handwashing stations are required for each airborne infection isolation
room.
5. Airborne infection
isolation rooms may be used for noninfectious patients when not needed for
patients with airborne infectious disease.
6. Windows shall not be operable without the
use of a key or tool controlled by the nursing staff.
7. Each room shall have a permanently
installed visual mechanism to constantly monitor the pressure status of the
room when occupied by patients with an airborne infectious disease.
D. Protective Isolation Rooms. In
facilities where procedures such as organ transplants, burn therapy, and
immunosuppressive treatments are performed, special design provisions,
including special ventilation, may be necessary to meet the needs of the
functional program. Refer to Table 4 of the Appendix for air pressure and
ventilation. Each protective isolation room shall be a single-bed room and
planned as required for a normal patient room except as follows:
1. Each protective isolation room shall have
an anteroom for handwashing, gowning and storage of clean and soiled materials
located directly outside the entry door to the patient room.
2. Protective isolation room perimeter walls,
ceiling and floors, including penetrations, shall be sealed tightly so that air
does not infiltrate the environment from the outside or from other
spaces.
3. Protective isolation
room(s) shall have self-closing devices on all room exit doors.
4. Separate toilet, bathtub (or shower) and
handwashing stations are required for each protective isolation room.
5. Protective isolation rooms may be used for
nonimmunosuppressed patients, except airborne infectious patients are
prohibited.
6. Windows shall not be
operable without the use of a key or tool controlled by the nursing
staff.
E. Seclusion
Rooms. Each hospital shall provide one or more single-bed rooms for patients
needing close supervision if suitable psychiatric facilities are not available
elsewhere in the community. Such rooms shall comply with the applicable
requirements in Section 52, Physical Facilities, Psychiatric Nursing
Unit.
F. Observation Rooms.
Patients in observation status may be accommodated within the facility:
1. In private, semi-private or multi-patient
rooms. Furniture shall be arranged to provide adequate room for patient care
procedures and to prevent the transmission of infection;
2. Cubicle curtains, privacy screens or an
approved equivalent shall be provided for patient privacy in all multi-patient
rooms. The utilization of such curtains or screens shall be such that each
patient shall have privacy;
3. Each
room or cubicle shall be provided with (a) oxygen; (b) vacuum; and (c) a nurse
call button unless direct observation is afforded and maintained;
d. Hand hygiene facilities shall be available
within the area;
e. Hospital grade
furniture shall be provided. Bed rails shall be provided on beds;
f. For each area in which a patient bed is
utilized, a reading light shall be provided for each bed. The location and
design shall be such that the light is not annoying to other
patients;
g. Patient toilets shall
be provided and accessible to all patients; and
h. Adequate space shall be provided for
medical supplies.
SECTION
49:
PHYSICAL FACILITIES, CRITICAL CARE UNIT.
The Critical care units require special space and equipment
considerations for effective staff functions. In addition, space arrangement
shall include provisions for immediate access of emergency equipment from other
departments. Critical care units shall comply in size, number and type with
these standards and with the functional program. The following standards are
intended for the more common types of critical care services and shall be
appropriate to needs defined in functional programs. Where specialized services
are required, additions and/or modifications shall be made as necessary for
efficient, safe, and effective patient care.
A. Critical Care (General). The following
shall apply to all types of critical care units unless otherwise noted. Each
unit shall comply with the following provisions:
1. The location shall offer direct access by
the emergency, respiratory care, laboratory, radiology, surgery, and other
essential departments and services as defined by the functional program. It
shall be located so that the medical emergency resuscitation teams may be able
to respond promptly to emergency calls within minimum travel time. The location
shall be arranged to eliminate the need for through traffic.
2. In new construction, where elevator
transport is required for critically ill patients, the size of the cab and
mechanisms and controls shall meet the specialized needs.
3. In new construction, each patient room (or
multiple bed space for neonatal or pediatric units) shall have a minimum of 200
square feet of clear floor area with a minimum headwall width of 13 feet per
bed, exclusive of anterooms, vestibules, toilet rooms, closets, lockers,
wardrobes and/or alcoves.
In renovation of existing critical care units, every effort
shall be made to meet the above minimum standards. If it is not possible to
meet the above square foot standards, the Entity having jurisdiction may grant
approval to deviate from this requirement. In such cases, rooms shall be no
less than 130 square feet.
4. View panels to the corridor shall be
required and shall have means to provide visual privacy. Where only one door is
provided to a bed space, it shall be at least four feet wide and arranged to
minimize interference with movement of beds and large equipment. Sliding doors
shall not have floor tracks and shall have hardware that minimizes jamming
possibilities. Where sliding doors are used for access to cubicles within a
suite, a three foot wide swinging door may also be provided for personnel
communication. The sliding doors shall swing out.
5. Each patient bed area shall have space at
each bedside for visitors and provisions for visual privacy from casual
observation by other patients and visitors. For both adult and pediatric units,
there shall be a minimum of eight feet between beds.
6. Each patient bed shall have visual access,
other than skylights, to the outside environment with not less than one outside
window in each patient bed area. In renovation projects, clerestory windows
with windowsills above the heights of adjacent ceilings may be used, provided
they afford patients a view of the exterior and are equipped with appropriate
forms of glare and sun control. Distance from the patient bed to the outside
window shall not exceed 50 feet. When partitioned cubicles are used, patients'
view to outside windows may be through no more than two separate clear vision
panels.
7. Nurse/patient
communication shall be provided in accordance with item G. of Section 76,
Physical Facilities, Electrical Standards. The communication station for the
unit shall include provisions for an emergency code resuscitation alarm to
summon assistance from outside the critical care unit.
8. Handwashing fixtures shall be convenient
to nurse stations and patient bed areas. There shall be at least one
handwashing fixture for every three beds in open plan areas, and one in each
patient room. The handwashing fixture or sanitizing station shall be located
near the entrance to the patient cubicle or room, shall be sized to minimize
splashing water onto the floor, and shall be equipped with hands-free operable
controls.
9. Nurses' station shall
have space for counters and storage. It may be combined with or include centers
for reception and communication. There shall be direct or remote visual
observation between the nurses' station and all patient beds in the critical
care unit.
10. Each unit shall
contain equipment for continuous monitoring, with visual displays for each
patient at the bedside and at the nurses' station. Monitors shall be located to
permit easy viewing and access but not interfere with access to the
patient.
11. Emergency equipment
storage space that is easily accessible to the staff shall be provided for
emergency equipment such as an emergency cart.
12. Medication Station. Provisions shall be
made for distribution of medications. This may be done from a medicine
preparation room or unit, from a self-contained medicine dispensing unit, or by
another approved system:
a. Medicine
preparation room. This room shall be designed to allow for visual supervision
by the nursing staff. It shall contain a work counter, a sink adequate for
handwashing, refrigerator and locked storage for controlled drugs. When a
medicine preparation room is to be used to store one or more self-contained
medicine dispensing units, the room shall be designed with adequate space to
prepare medicines with the self-contained medicine dispensing unit(s)
present.
b. Self-contained medicine
dispensing unit. A self-contained medicine dispensing unit may be located at
the nurses' station, in the clean workroom, or in an alcove, provided the unit
has adequate security for controlled drugs and adequate lighting to easily
identify drugs. Convenient access to handwashing stations shall be provided.
(Standard cup-sinks provided in many self-contained units are not adequate for
handwashing.)
13. At
least one airborne infection isolation room shall be provided. The number of
airborne infection isolation rooms shall be determined based on an infection
control risk assessment; as per the primary catchment area by the facility.
Each room shall contain only one bed and shall comply with the requirements of
item C of Section 48, Physical Facilities, Patient Accommodations (Adult
Medical, Surgical, Communicable or Pulmonary Disease). However, the requirement
for the bathtub (or shower) may be eliminated. Compact, modular toilet/sink
combination units may replace the requirement for a "toilet room." Special
ventilation requirements are found in Table 4.
14. The following additional service spaces
shall be immediately available within each critical care area (Note: These
additional spaces may be shared by more than one critical care unit provided
that direct access is available from each unit.):
a. Securable closets or cabinet compartments
for the unit personnel; eliminated. Compact, modular toilet/sink combination
units may replace the requirement for a "toilet room." Special ventilation
requirements are found in Table 4.
b. Clean workroom or clean supply room. If
the room is used for preparing patient care items, it shall contain a work
counter, a handwashing fixture and storage facilities for clean and sterile
supplies. If the room is used only for storage and holding as part of a system
for distribution of clean and sterile supply materials, the work counter and
handwashing fixture may be omitted. Soiled and clean workrooms or holding rooms
shall be separated and have no direct connection;
c. Clean linen storage. There shall be a
designated area for clean linen storage. This may be within the clean workroom,
a separate closet or an approved distribution system on each floor. If a closed
cart system is used, storage may be in an alcove. It shall be out of the path
of normal traffic and under staff control;
d. Soiled workroom or soiled holding room.
This room shall be separate from the clean workroom. The soiled workroom shall
contain a clinical sink or equivalent flushing-rim fixture. The room shall
contain a lavatory or handwashingfixture. The above fixtures shall have a hot
and cold mixing faucet. The room shall have a work counter and space for
separate covered containers for soiled linen and a variety of waste types.
Rooms used only for temporary holding of soiled material may omit the clinical
sink and work counter. If the flushing-rim clinical sink is eliminated,
facilities for cleaning bedpans shall be provided elsewhere;
e. Nourishment Station. There shall be a
nourishment station with sink, work counter, refrigerator, storage cabinets and
equipment for hot and cold nourishments between scheduled meals. The
nourishment station shall include space for trays and dishes used for
nonscheduled meal service. Provisions and space shall be included for separate
temporary storage of unused and soiled dietary trays not picked up at mealtime.
Handwashing stations shall be in or immediately accessible from the nourishment
station;
f. Ice machine. There
shall be available equipment to provide ice for treatments and nourishment.
Ice-making equipment may be in the clean workroom or at the nourishment
station. Ice intended for human consumption shall be from self-dispensing
icemakers;
g. Equipment storage
room or alcove. Appropriate room(s) or alcove(s) shall be provided for storage
of large items of equipment necessary for patient care and as required by the
functional program. Its location shall not interfere with the flow of traffic;
and
h. X-ray viewing
equipment.
15. The
following shall be provided and may be located outside the unit if conveniently
accessible.
a. A visitors' waiting room shall
be provided with access to telephones and toilets. One waiting room may serve
several critical care units.
b.
Staff lounge(s) and toilet(s) shall be located so that staff may be recalled
quickly to the patient area in emergencies. The lounge shall have telephone or
intercom and emergency code alarm connections to the critical care unit it
serves. One lounge may serve adjacent critical care areas.
c. A special procedures room shall be
provided if required by the functional program.
d. Multipurpose room(s) for staff, patients
and patients' families for patient conferences, reports, education, training
sessions and consultation shall be provided. These rooms shall be accessible to
each nursing unit.
e. A
housekeeping room shall be provided within or immediately adjacent to the
critical care unit. It shall not be shared with other nursing units or
departments. It shall contain a service sink or floor receptor and provisions
for storage of supplies and housekeeping equipment.
f. Storage space for stretchers and
wheelchairs shall be provided in a strategic location, without restricting
normal traffic.
g. Laboratory,
radiology, respiratory care and pharmacy services shall be available. These
services may be provided from the central departments or from satellite
facilities as required by the functional program.
B. Coronary Critical Care Unit. In
addition to the standards set forth in Section 49, Physical Facilities,
Critical Care Unit, the following standards apply to the coronary critical care
unit:
1. Each coronary patient shall have a
separate room for acoustical and visual privacy.
2. Each coronary patient shall have access to
a toilet in the room. (Portable commodes may be used in lieu of individual
toilets, but provisions shall be made for their storage, servicing and odor
control.)
C. Pediatric
Critical Care. If a facility has a specific pediatric critical care unit, the
functional program shall include consideration for staffing, isolation and the
safe transportation of critically ill pediatric patients, along with life
support and environmental systems, from other areas. In addition to the
standards previously listed for critical care units, each pediatric critical
care unit shall include:
1. Space at each
bedside for family, visitors and nursing staff;
2. In new construction, each patient space
(whether separate rooms, cubicles or multiple bed space) shall have a minimum
of 200 square feet of clear floor area with a minimum headwall width of 13 feet
per bed, exclusive of anterooms, vestibules, toilet rooms, closets, lockers,
wardrobes and/or alcoves;
3.
Consultation/demonstration room within, or convenient to, the pediatric
critical care unit for private discussions;
4. Provisions for formula storage. These may
be outside the pediatric critical care unit but shall be available for use at
all times;
5. Separate storage
cabinets or closets for toys and games for use by the pediatric patients;
and
6. Examination and treatment
room(s).
D. Newborn
Intensive Care Units. Each Newborn Intensive Care Unit (NICU) shall include or
comply with the following:
1. The NICU shall
have a clearly identified entrance and reception area for families. The area
shall permit visual observation and contact with all traffic entering the unit.
A scrub area shall be provided at each public entrance to the patient care
area(s) of the NICU. All sinks shall be hands-free operable and large enough to
contain splashing;
2. At least one
door (44 inches minimum) to each room in the unit to accommodate portable X-ray
equipment;
3. There shall be
controlled access systems to the unit from the Labor and Delivery area, the
Emergency Room or other referral entry points;
4. When viewing windows are provided,
provision shall be made to control casual viewing of infants;
5. Noise control shall be a design
factor;
6. Provisions shall be made
for indirect lighting in all nurseries. Provisions shall be made for multiple
lighting levels;
7. A central area
shall serve as a nurses' station, shall have space for counters and storage,
and shall have convenient access to handwashing stations. It may be combined
with or include centers for reception and communication and patient
monitoring;
8. Each patient care
space shall contain a minimum of 120 square feet per bassinette excluding sinks
and aisles. There shall be an aisle for circulation adjacent to each patient
care space with a minimum width of three feet;
9. An airborne infection isolation room is
required in at least one level of nursery care. The room shall be enclosed and
separated from the nursery unit with provisions for observation of the infant
from adjacent nurseries or control area(s);
10. Blood gas lab facilities shall be
immediately accessible;
11. A
respiratory care work area and storage room shall be provided;
12. A consultation/demonstration/breast
feeding room shall be provided convenient to the unit;
13. Charting and dictation space for
physicians shall be provided;
14.
Medication station shall be provided;
15. Clean workroom or clean supply room shall
be provided. See Section 48 B.8, Physical Facilities, Patient Accommodations
(Adult Medical, Surgical, Communicable or Pulmonary Disease);
16. Soiled workroom or soiled holding room
shall be provided. See Section 48 B.9, Physical Facilities, Patient
Accommodations (Adult Medical, Surgical, Communicable or Pulmonary
Disease);
17. A lounge, locker room
and staff toilet within or adjacent to the unit suite for staff use shall be
provided;
18. Space shall be
provided for emergency equipment that is under direct control of the nursing
staff, such as an emergency cart. This space shall be located in an area
appropriate to the functional program, but out of normal traffic;
19. One environmental service closet shall be
provided for the unit. It shall be directly accessible from the unit and be
dedicated for the exclusive use of the neonatal critical care unit. It shall
contain a service sink or floor receptor and provisions for storage of supplies
and housekeeping equipment; and
20.
Space shall be provided for the following:
a.
A visitors' waiting room;
b.
Nurses' station; and
c.
Multipurpose room(s) for staff, patients and patients' families for patient
conferences, reports, education, training sessions and consultation. These
rooms shall be accessible to each nursing unit. They may be on other floors if
convenient for regular use. One such room may serve several nursing units
and/or departments.
SECTION 50:
PHYSICAL FACILITIES,
NURSERY UNITS.
Normal newborn infants shall be housed in nurseries that comply
with the standards below. All nurseries other than pediatric nurseries shall be
convenient to the postpartum nursing unit and obstetrical facilities. The
nurseries shall be located and arranged to preclude the need for nonrelated
pedestrian traffic. No nursery shall open directly into another nursery. There
should be one breastfeeding/pumping room readily available for mothers of NICU
babies to pump breastmilk.
A. General.
Each nursery shall contain the following:
1.
At least one lavatory, equipped with hands-free handwashing station, for each
eight infant stations;
2. Glazed
observation windows to permit the viewing of infants from public areas,
workrooms and adjacent nurseries;
3. Convenient, accessible storage for linens
and infant supplies at each nursery room;
4. A consultation/demonstration/breast
feeding or pump room shall be provided convenient to the nursery. Provision
shall be made, either within the room or conveniently located nearby, for sink,
counter, refrigeration and freezing, storage for pump and attachments and
educational materials. The area provided for the unit for these purposes, when
conveniently located, may be shared;
5. Enough space shall be provided for parents
to stay 24 hours;
6. An airborne
infection isolation room is required in or near at least one level of nursery
care. The room shall be enclosed and separated from the nursery unit with
provisions for observation of the infant from adjacent nurseries or control
area(s). All airborne infection isolation rooms shall comply with the
requirements of Section 48.C, Patient Accommodations (Adult Medical, Surgical,
Communicable or Pulmonary Disease), except for separate toilet, bathtub or
shower;
7. Workroom(s). Each
nursery room shall be served by a connecting workroom. The workroom shall
contain scrubbing and gowning facilities at the entrance for staff and
housekeeping personnel, work counter, refrigerator, storage for supplies and a
hands-free handwashing fixture. One workroom may serve more than one nursery
room provided that required services are convenient to each. The workroom
serving the full-term and continuing care nurseries may be omitted if
equivalent work and storage areas and facilities, including those for scrubbing
and gowning, are provided within that nursery. Space required for work areas
located within the nursery is in addition to the area required for infant care.
Adequate provision shall be made for storage of emergency cart(s) and equipment
out of traffic and for the sanitary storage and disposal of soiled waste.
a. When the functional program includes a
mother-baby couplet approach to nursing care, the workroom functions described
above may be incorporated in the nurse station that serves the postpartum
patient rooms.
b. Neonate
examination and treatment areas. Such areas, when required by the functional
program, shall contain a work counter, storage facilities and a hands-free
handwashing station.
c. Neonate
formula facilities. Where infant formula is prepared on-site, direct access
from the formula preparation room to any nursery room is prohibited. The room
may be located near the nursery or at other appropriate locations in the
hospital, but shall include
1) Cleanup
facilities for washing and sterilizing supplies. This area shall include a
handwashmg station, facilities for bottle washing, a work counter and
sterilization equipment.
2)
Separate room for preparing infant formula. This room shall contain warming
facilities, refrigerator, work counter, formula sterilizer, storage facilities
and a handwashing station.
3)
Refrigerated storage and warming facilities for infant formula accessible for
use by nursery personnel at all times.
8. Commercial neonate formula. If a
commercial infant formula is used, the separate cleanup and preparation rooms
may be omitted. The storage and handling may be done in the nursery workroom or
in another appropriate room in the hospital that is conveniently accessible at
all hours. The preparation area shall have a work counter, a handwashing
station and storage facilities.
9.
Housekeeping/environmental services room. A housekeeping/environmental services
room shall be provided for the exclusive use of the nursery unit. It shall be
directly accessible from the unit and shall contain a service sink or floor
receptor and provide for storage of supplies and housekeeping
equipment.
10. Charting space.
Charting facilities shall have linear surface space to ensure that staff and
physicians may chart and have simultaneous access to information and
communication systems.
B. Newborn Nursery
1. Each newborn nursery room shall contain no
more than 16 stations. The minimum floor areas shall be 24 square feet per
bassinet, exclusive of auxiliary work areas. When a rooming-in program is used,
the total number of bassinets provided in these units may be appropriately
reduced, but the newborn nursery shall not be omitted in its entirety from any
facility that includes delivery services. (When facilities use a rooming-in
program in which all infants are returned to the nursery at night, a reduction
in nursery size may not be practical.)
2 Baby holding nurseries may replace
traditional nurseries with baby holding nurseries in postpartum and
labor-delivery- recovery-postpartum (LDRP) units. The minimum floor area per
bassinet, ventilation, electrical, and medical vacuum and gases shall be the
same as that required for a full-term nursery. These holding nurseries should
be next to the nurse station on these units. The holding nursery shall be sized
to accommodate the percentage of newborns who do not remain with their mothers
during the postpartum stay.
C. Continuing Care Nursery
For hospitals that provide continuing care for infants
requiring close observation (for example, low birth-weight babies who are not
ill but require more hours of nursing than do normal neonates), the minimum
floor space-shall be 50 square feet (4.65 square meters) per bassinet,
exclusive of auxiliary work areas, with provisions for at least 4 feet (1.22
meters) between and at all sides of each bassinet.
D. Pediatric Nursery
To minimize the possibility of cross infection, each nursery
room serving pediatric patients shall contain no more than eight bassinets;
each bassinet shall have a minimum clear floor area of 40 square feet (3.72
square meters). Each room shall contain a lavatory equipped for hands-free
handwashing, a nurses emergency calling system and a glazed viewing window for
observing infants from public areas and workrooms. (Limitation on number of
patients in a nursery room does not apply to the pediatric critical care
unit.)
SECTION
51:
PHYSICAL FACILITIES, PEDIATRIC AND ADOLESCENT
UNIT.
The unit shall meet the following standards:
A. Patient Rooms. Each patient room shall
meet the following standards:
1. Maximum room
capacity shall be four patients.
2.
The space requirements for pediatric patient beds shall be the same as for
adult beds due to the size variation and the need to change from cribs to beds
and vice-versa. See Section 48, Patient Accommodations (Adult Medical,
Surgical, Communicable or Pulmonary Disease), for requirements. Additional
provisions for hygiene, toilets, sleeping, and personal belongings shall be
included where the program indicates that parents will be allowed to remain
with young children. See Sections 49, Physical Facilities, Critical Care Unit
and 50, Physical Facilities, Newborn Nursery Units for pediatric critical care
units and for newborn nurseries.
3.
Each patient room shall have a window in accordance with Section 48, Physical
Facilities, Patient Accommodations (Adult Medical, Surgical, Communicable or
Pulmonary Disease).
B.
Examination/Treatment Rooms. This room shall be provided for pediatric and
adolescent patients. A separate area for infant examination and treatment may
be provided within the pediatric nursery workroom. Examination/treatment rooms
shall have a minimum floor area of 120 square feet. The room shall contain a
handwashing fixture, storage facilities, a desk, counter or shelf space for
writing. This room is not required if all rooms are private.
1. Multipurpose or individual room(s) shall
be provided within or adjacent to areas serving pediatric and adolescent
patients for dining, education and developmentally appropriate play and
recreation, with access and equipment for patients with physical restrictions.
If the functional program requires, an individual room shall be provided to
allow for confidential parent/family comfort, consultation and teaching.
Insulation, isolation and structural provisions shall minimize the transmission
of impact noise through the floor, walls or ceiling of these multipurpose
room(s).
2. Space for preparation
and storage of infant formula shall be provided within the unit or other
convenient location. Provisions shall be made for continuation of special
formula that may have been prescribed for the infant prior to admission or
readmission.
3. Patient toilet
room(s) with handwashing station(s) in each room, in addition to those serving
bed areas, shall be conveniently located to multipurpose room(s) and to each
central bathing facility.
4.
Storage closets or cabinets for toys and educational and recreational equipment
shall be provided.
5. Storage space
shall be provided to permit exchange of cribs and adult beds.
Provisions shall also be made for storage of equipment and
supplies (including cots or recliners, extra linen, etc.) for parents who stay
with the patient overnight.
6. A least one airborne infection isolation
room shall be provided in each pediatric unit. The total number of infection
isolation rooms shall be determined by an infection control risk assessment.
Airborne infection isolation room(s) shall comply with the requirements of item
C. of Section 48, Physical Accommodations (Adult Medical, Surgical,
Communicable or Pulmonary Disease).
7. Separate clean and soiled workrooms or
holding rooms shall be provided as described in Section 48 B.8 and B.9,
Physical Accommodations (Adult Medical, Surgical, Communicable or Pulmonary
Disease).
SECTION
52:
PHYSICAL FACILITIES, PSYCHIATRIC NURSING UNIT.
When part of a general hospital, these units shall be designed
for the care of inpatients. Non-ambulatory inpatients may be treated in a
medical unit until their medical condition allows for transfer to the
psychiatric nursing unit. Provisions shall be made in the design for adapting
the area for various types of psychiatric therapies.
The environment of the unit should be characterized by a
feeling of openness with emphasis on natural light and exterior views. Various
functions should be accessible from common areas while not compromising
desirable levels of patient privacy. Interior finishes, lighting and
furnishings should suggest a residential rather than an institutional setting.
These should, however, conform with applicable fire safety codes. Security and
safety devices should not be presented in a manner to attract or challenge
tampering by patients.
Where glass fragments pose a hazard to certain patients, safety
glazing and/or other appropriate security features shall be used.
Details of such facilities should be as described in the
approved functional program. Each nursing unit shall provide the
following:
A. Patient Rooms. The
patient room requirements noted in Section 48, Physical
Accommodations (Adult Medical, Surgical, Communicable or
Pulmonary Disease), shall be applied to patient rooms in psychiatric nursing
units except as follows:
1. A nurses'
call system is not required; but if it is included, provisions shall be made
for easy removal or for covering call button outlets;
2. Bedpan-flushing devices shall be omitted
from patient room toilets;
3.
Handwashing stations are not required in patient rooms;
4. Visual privacy in multi-bed rooms (e.g.,
cubicle curtains) is not required;
5. The ceiling and the air distribution
devices, lighting fixtures, sprinkler heads, and other appurtenances shall be
of a tamper-resistant type;
6. Each
patient room shall be provided with a private toilet that meets the following
requirements:
a. The door shall not be
lockable from within;
b. The door
shall be capable of swinging outward; and
c. The ceiling shall be of tamper-resistant
construction and the air distribution devices, lighting fixtures, sprinkler
heads and other appurtenances shall be of the tamper-resistant type.
7. Patient rooms, exclusive of
toilet rooms, closets, lockers, wardrobes, alcoves, or vestibules, shall be at
least 100 square feet for single-bed rooms and 80 square feet per bed for
multiple-beds rooms. The dimensions and room arrangement criteria of Section 48
does not apply.
B.
Service Areas. The standards noted in Section 48, Physical Accommodations
(Adult Medical, Surgical, Communicable or Pulmonary Disease), shall apply to
services areas for psychiatric nursing units with the following modifications:
1. A secured storage area shall be provided
for patients' belongings that are determined to be potentially harmful (e.g.,
razors, nail files, cigarette lighters); this area shall be controlled by
staff;
2. Medication station shall
include provisions for security against unauthorized access;
3. Food service within the unit may be one,
or a combination, of the following:
a. A
nourishment station;
b. A
kitchenette designed for patient use with staff control of heating and cooking
devices; and
c. A kitchen service
within the unit including a handwashing station, storage space, refrigerator
and facilities for meal preparation.
4. Storage space for stretchers and
wheelchairs may be outside the psychiatric unit, provided that provisions are
made for convenient access as needed for disabled patients;
5. In psychiatric nursing units, a bathtub or
shower shall be provided for each six beds not otherwise served by bathing
facilities within the patient rooms. Bathing facilities shall be designed and
located for patient convenience and privacy;
6. A separate charting area shall be provided
with provisions for acoustical privacy. A viewing window to permit observation
of patient areas by the charting nurse or physician may be used if the
arrangement is such that patient files cannot be read from outside the charting
space;
7. At least two separate
social spaces, one appropriate for noisy activities and one for quiet
activities shall be provided. The combined area shall be a minimum of 40 square
feet per patient with a minimum of 120 square feet for each of the two spaces.
This space may be shared by dining activities;
8. Space for group therapy shall be provided.
This may be combined with the quiet space noted above in item 7 when the unit
accommodates not more than 12 patients, and when at least 225 square feet of
enclosed private space is available for group therapy activities;
9. Patient laundry facilities with an
automatic washer and dryer shall be provided. The following elements shall also
be provided, but may be either within the psychiatric unit or immediately
accessible to it unless otherwise dictated by the functional program;
10. Rooms (s) for examination and treatment
with a minimum floor area of 120 square feet. Examination and treatment room(s)
for medical-surgical patients may be shared by the psychiatric unit patients.
(These may be on a different floor if conveniently accessible.)
11. Separate consultation room(s)with minimum
floor space of 100 square feet each,provided at a room-to-bed ratio of one
consultation room for each 12 psychiatric beds. The room(s) shall be designed
for acoustical and visual privacy and constructed to achieve a noise reduction
of at least 45 decibels. This room is not required if all rooms are
private;
12. Psychiatric units each
containing 15 square feet of separate space per patient for patient
therapy/multipurpose use, with a minimum total area of at least 200 square
feet, whichever is greater. Space shall include provision for handwashing, work
counter(s), storage, and displays. This space may serve more than one nursing
unit. When psychiatric nursing unit(s) contain less than 12 beds, the therapy
and other functions may be performed within the noisy activities area, if at
least an additional 10 square feet per patient served is included;
and
13. A conference and treatment
planning room for use by the psychiatric unit.
C. Seclusion Treatment Room. There shall be
at least one seclusion room for up to 24 beds or a major fraction thereof. If a
facility has more than one psychiatric nursing unit, the number of seclusion
rooms shall be a function of the total number of psychiatric beds in the
facility. Seclusion rooms may be grouped together.
1. The seclusion room is intended for
short-term occupancy by a violent or suicidal patient. The room(s) shall be
located for direct nursing staff supervision. Each room shall be for only one
patient. It shall have an area of at least 60 square feet and shall be
constructed to prevent patient hiding, escape, injury or suicide. Where
restraint beds are required by the functional program, 80 square feet shall be
required.
2. Room doors shall be
designed with hardware that will permit the doors to swing out. Outside corners
shall be omitted where possible. The ceiling shall be of tamper-resistant
construction and the air distribution devices, lighting fixtures, sprinkler
heads, and other appurtenances shall be of the tamper-resistant type. The walls
shall be completely free of objects. Special fixtures and hardware for
electrical circuits shall be used. Minimum ceiling height shall be nine feet.
Doors shall be three feet eight inches wide and shall permit staff observation
of the patient while also maintaining provisions for patient privacy. Seclusion
treatment rooms shall be accessed by an anteroom or vestibule which also
provides direct access to a toilet room. The toilet room and anteroom shall
provide for safe management of the patient.
3. Where the interior of the seclusion room
is padded with combustible materials, these materials shall be of a type
acceptable to NFPA standards. The room area, including floor, walls, ceilings
and all openings shall be protected with not less than one-hour-rated
construction.
SECTION
53:
PHYSICAL FACILITIES, SURGICAL FACILITIES.
The Surgical Suite shall be located and arranged to preclude
unrelated traffic through the Suite. The Surgical Suite shall be designed in
accordance with NFPA 99 except that, within suites, mixed facilities as defined
in NFPA 99 shall not be allowed. The Suite(s) shall provide the following
elements.
A. General Operating
Room(s). At least one general operating room shall be provided for each 50 beds
or major fraction thereof up to 200 beds. Over 200 beds, additional operating
room needs shall be based on the projected surgical workload. In new
construction, each room shall have a minimum clear area of 400 square feet
exclusive of fixed or wall-mounted cabinets and built-in shelves, with a
minimum of 20 feet clear dimension between fixed cabinets and built-in shelves,
and a system for emergency communication with the surgical suite control
station. X-ray film illuminators for handling at least four films
simultaneously shall also be provided. In renovation projects, every effort
shall be made to meet the floor space requirements indicated above. In no event
shall the clear floor area be less than 360 square feet with a minimum
dimension of 18 feet.
B. Specialty
Operating Rooms for cardiovascular, orthopedic, neurological, and other
procedures that require additional personnel and/or large equipment. When
included, this room shall have, in addition to the above requirements for
general operating rooms, a minimum clear area of 600 square feet, with a
minimum of 20 feet clear dimension exclusive of fixed or wall-mounted cabinets
and built-in shelves. When open-heart surgery is performed, an additional room
in the restricted area of the surgical suite shall be designated as a pump room
where extra corporeal pump(s), supplies and accessories are stored and
serviced. When complex orthopedic and neurosurgical surgery is performed,
additional rooms shall be in the restricted area of the surgical suite which
shall be designated as equipment storage rooms for the large equipment used to
support these procedures. Appropriate plumbing, medical gases and electrical
connections shall be provided in the pump storage room. When included, a room
for orthopedic surgery shall, in addition to the above, have enclosed storage
space for splints and traction equipment. Storage outside the operating room
shall be conveniently located. If a sink is used for the disposal of casting
material, an appropriate trap shall be provided. In renovation projects, every
effort shall be made to meet the floor space requirements indicated above. In
no event shall the clear floor area be less than 400 square feet (except for
Orthopedic procedures shall be 360 square feet) with a minimum dimension of 18
feet.
C. Room(s) for Surgical
Cystoscopic and Endo-Urologic Procedures. When provided and/or required by the
written functional program, the cystoscopic and endo-urologic procedures
room(s) shall follow these requirements. A scrub sink or large lavatory shall
be provided within or adjoining the cystoscopy room. In new construction, these
rooms shall have a minimum clear area of 350 square feet, exclusive of fixed or
wall-mounted cabinets and built-in shelves with a minimum of 15 feet clear
dimension between fixed cabinets and built-in shelves. Additional clear space
may be required by the functional program to accommodate special functions in
one or more of these rooms. An emergency communications system shall connect
with the Surgical Suite control station. Facilities for the disposal of liquid
wastes shall be provided. If a floor drain is installed to provide for disposal
of liquid wastes, it shall be completely insulated from ground by means of an
insulating type floor drain and nonconductive waste connections. The drain
shall also be provided with a flushing device. X-ray viewing capability to
accommodate at least four films simultaneously shall be provided. In renovation
projects, every effort shall be made to meet the clear floor space requirements
indicted above for construction. In no event shall the clear floor space be
less than 250 square feet. D. Endoscopy
The endoscopy suite may be divided into three major functional
areas: the procedure room(s), instrument processing room(s), and patient
holding/preparation and recovery room or area.
NOTE: When invasive procedures are to be performed in this unit
on persons who are known or suspected of having airborne infectious diseases,
these procedures should not be performed in the operating suite. These
procedures shall be performed in a room meeting airborne infections isolation
ventilation requirements or in a space using local exhaust ventilation.
1. Procedures Room(s)
a. Each procedure room shall have a minimum
clear area of 200 square feet (15.58 square meters) exclusive of fixed cabinets
and built-in shelves.
b. A
freestanding handwashing fixture with handsfree controls shall be available in
the suite.
c. Refer to Table 11 for
medical gas station outlets.
d.
Floor covering shall be monolithic and joint free.
e. A system for emergency communication shall
be provided.
f. Procedure rooms
shall be designed for visual and acoustical privacy for the patient.
2. Instrument Processing Room(s)
a. Dedicated processing room(s) for cleaning
and disinfecting instrumentation shall be provided. In an optimal situation,
cleaning room(s) shall be located between two procedure rooms. However, one
processing room may serve multiple procedure rooms. Size of the cleaning
room(s) is dictated by the amount of equipment to be processed.
Cleaning rooms shall allow for flow of instrumentations from
the contaminated area to the clean area, and finally to storage. The clean
equipment rooms, including storage, should protect the equipment from
contamination.
b. The
decontamination room shall be equipped with the following:
1) Two utility sinks remote from each
other.
2) One freestanding
handwashing fixture.
3) Work
counter space(s).
4) Space and
plumbing fixtures for automatic endoscope cleaners, sonic processor, and flash
sterilizers (where required).
5)
Ventilation system. Negative pressure shall be maintained and minimum of 10 air
changes per hour shall be maintained. A hood is recommended over the work
counter. All air shall be exhausted to the outside to avoid recirculation
within the facility.
6) Outlets for
vacuum and compressed air.
7) Floor
covering shall be monolithic and joint free.
3. Patient Holding/Prep/Recovery Area. The
following elements shall be provided in this area:
a) Each patient cubicle shall be equipped
with oxygen and suction outlets.
b)
Cubicle curtains for patient privacy.
c) Medication preparation and storage with
handwashing stations.
d) Toilet
facilities (may be accessible from patient holding or directly from procedure
room(s) or both).
e) Change areas
and storage for patients' personal effects.
f) Nurses reception and charting area with
visualization of patients.
g) Clean
utility room or area.
h)
Environmental Services closet.
E. Service Areas. Individual rooms shall be
provided when so noted; otherwise alcoves or other open spaces which shall not
interfere with traffic may be used. Services, except the soiled workroom and
the janitor's closet, may be shared with and organized as part of the
obstetrical facilities if the approved functional program reflects this sharing
concept. Service areas shall be arranged to avoid direct traffic between the
Operating and Delivery Suites. The following areas shall be provided.
1. Control station located to permit visual
surveillance of all traffic which enters the Operating Suite.
2. A supervisor's office or station. The
number of offices, stations, and teaching areas in the surgical suite shall
depend upon the functional program.
3. Sterilizing facilities conveniently
located to serve all operating rooms. The sterilizing facility shall have work
counter space and a handwashing sink. When the functional program indicates
that adequate provisions have been made for replacement of sterile instruments
during surgery, sterilization facilities in the Surgical Suite shall not be
required.
4. Medication
Distribution. Provisions shall be made for storage and distribution of
medications. This may be done from a medication preparation room or unit, from
a self-contained medication dispensing unit, or by another system approved by
the Department. If used, a medication preparation room or unit shall be under
visual control of nursing staff. It shall contain a work counter, sink,
refrigerator, and double-locked storage for controlled substances with
convenient access to handwashing stations provided. Each blood bank
refrigerator shall be on an emergency power circuit.
5. Scrub Facilities. Two scrub stations shall
be provided near the entrance to each operating room; however two scrub
stations may serve two operating rooms if the scrub stations are located
adjacent to the entrance of each operating room. Scrub facilities shall be
arranged to minimize any incidental splatter on nearby personnel or supply
carts. In new construction, view windows at scrub stations permitting
observation of room interiors shall be provided. The scrub sinks shall be
recessed into an alcove out of the main traffic areas. Equipment and supplies
for timed scrub technique shall be available at each scrub sink with manual
and/or automatic two way controls.
6. Soiled Workroom. An enclosed soiled
workroom (or soiled-holding room that is part of a system for the collection
and disposal of soiled material) for the exclusive use of the surgical suite
shall be provided. It shall be located in the restricted area. The soiled
workroom shall contain a flushing-rim clinical sink or equivalent flushing-rim
fixture, a work counter, a handwashing fixture, and space for waste
receptacles, and soiled linen receptacles. Rooms used only for temporary
holding of soiled material may omit the flushing-rim clinical sink and work
counters. However, if the flushing-rim clinical sink is omitted, other
provisions for disposal of liquid waste shall be provided. This room shall not
have direct connection with operating rooms or other sterile activity rooms.
Soiled and clean work or holding rooms shall be separated.
7. Clean Workroom or a Clean Supply Room. A
clean workroom is required when clean materials are assembled within the
surgical suite prior to use, or following the decontamination cycle. It shall
contain a work counter, a handwashing fixture, storage for clean supplies, and
space to package reusable items. The storage for sterile supplies shall be
separated from this space. If the room is used only for storage and holding as
part of a system for distribution of clean and sterile supply materials, the
work counter and handwashing fixture may be omitted. Storage space for sterile
and clean supplies shall be adequate for the functional plan. The space shall
be moisture and temperature controlled and free from cross traffic.
8. The location of sterilization for surgical
instruments and the direction of flow from the decontamination location to the
sterile location shall be addressed by the written functional program.
a. An operating room suite design with a
sterile core shall provide for no cross traffic of staff and supplies from the
decontaminated/soiled areas to the sterile/clean areas.
b. The use of facilities outside the
operating room for soiled/decontaminated processing and clean assembly and
sterile processing shall be designed to move the flow of goods and personnel
from dirty to clean/sterile without compromising standard precautions or
aseptic techniques in both departments. This room shall have no direct opening
into an operating room.
9. Anesthesia storage shall be provided in
accordance with NFPA 99.
10.
Medical gas storage facilities. Main storage of medical gases may be outside or
inside the facility in accordance with NFPA99. Provision shall be made for
additional separate storage of reserve gas cylinders necessary to complete at
least one day's procedures.
11. An
anesthesia workroom for testing and storing anesthesia equipment shall contain
a work counter, sink and racks for cylinders.
12. Equipment storage room(s) for equipment
and supplies used in the Surgical Suite. Each surgical suite shall provide
sufficient storage area to keep the exit access corridor free of equipment and
supplies, but not less than 150 square feet or 50 square feet per OR, whichever
is greater.
13. Staff Dressing
Room. Appropriate room(s) shall be provided for males and females working
within the Surgical Suite. The room(s) shall contain lockers, showers, toilets,
lavatories equipped for handwashing, and space for donning scrub suits and
boots. These room(s) shall be arranged to provide a one-way traffic pattern so
personnel entering from outside the Surgical Suite can change, shower, gown,
and move directly into the Surgical Suite.
14. Stretcher storage area out of direct line
of traffic.
15. Staff lounge and
toilet facilities. Separate or combined lounges for males and females shall be
provided. Lounge(s) shall be located to permit use without leaving the Surgical
Suite and to provide convenient access to the Recovery Room.
16. Dictation and report preparation area.
This may be accessible from the lounge area.
17. Phase II recovery. Where outpatient
surgeries are to be part of the surgical suite, and where outpatients receive
Class B or Class C sedation, a second Phase II or step-down recovery room shall
be provided. The room shall contain handwashing stations, a nurse station with
charting facilities, clinical sink, provision for bedpan cleaning, and storage
space for supplies and equipment. In addition, the design shall provide a
minimum of 50 square feet for each patient in a lounge chair with space for
additional equipment described in the functional program and for clearance of 4
feet between the sides of the lounge chairs and the foot of the lounge chairs.
Provisions shall be made for the isolation of infectious patients. Provisions
for patient privacy such as cubicle curtains shall be made. In new
construction, at least one door shall access the PACU without crossing
unrestricted corridors of the hospital. A patient toilet shall be provided with
direct access to the Phase II recovery unit for the exclusive use of patients.
A staff toilet shall be provided with direct access to the working area to
maintain staff availability to patients.
Handwashing stations with hands-free operable controls shall be
available with at least one for every four lounge chairs uniformly distributed
to provide equal access from each patient bed.
18. Change areas for outpatients and same-day
admissions. If the functional program defines outpatient surgery as part of the
surgical suite, a separate area shall be provided where outpatients may change
from street clothing into hospital gowns and be prepared for surgery. This
would include a waiting room, locker(s), toilet(s), and clothing change or
gowning area. Changing may also be accommodated in a private holding room or
cubicle
19. Provisions shall be
made for patient examination, interviews, preparation, testing, and obtaining
vital signs of patients for outpatient surgery.
20. Patient holding area. In facilities with
two or more operating rooms, an area shall be provided to accommodate stretcher
patients waiting for surgery. This holding area shall be under the visual
control of the nursing staff.
21.
Storage areas for portable X-ray equipment, stretchers, fracture tables,
warming devices, auxiliary lamps, etc. These areas shall be out of corridors
and traffic.
22. Emergency
equipment storage under direct control of the nursing staff and not obstructing
the corridor.
23. Environmental
Services closet. See Section 69, Physical Facilities, Cleaning and Sanitizing
Carts and Environmental Services, for detailed requirements.
24. Area for preparation and examination of
frozen sections. This may be part of the general laboratory if immediate
results are obtainable without unnecessary delay in the completion of
surgery.
25. Ice machine. An ice
machine shall be provided to provide ice for treatments and patient use. Ice
intended for human consumption shall be from self-dispensing ice
makers.
26. A waiting room, with
toilets, telephones, and drinking fountains conveniently located. The toilet
room shall contain handwashing stations. If outpatients, as defined by the
written functional program, are required to wait in this area, then a separate
area shall be provided. Provisions shall be made for examinations,
interviews, testing, and obtaining vital signs. A separate area
shall be provided where outpatients may change from street clothing into
hospital gowns.
27.
Ethylene Oxide Sterilization Facilities. Where ethylene oxide is used for
sterilization, provisions shall be made for complete exhaust of gases to the
exterior. When the door is opened, arrangement shall ensure that gases are
pulled away from the operator.
Provisions shall be made for appropriate aeration of supplies.
Aeration cabinets shall be vented to the outside. Where aeration cabinets are
not used in ethylene oxide processing, provision for isolated area mechanically
vented to the outside for aeration, OSHA standards shall be met.
E. Preoperative Patient
Holding Area
1. Preoperative Patient Holding
Area(s). In facilities with two or more operating rooms, areas shall be
provided to accommodate stretcher patients as well as sitting space for
ambulatory patients not requiring stretchers. These areas shall be under the
direct visual control of the nursing staff and may be part of the recovery
suite to achieve maximum flexibility in managing surgical case loads. Each
stretcher station shall be a minimum of 80 square feet and shall have a minimum
clearance of 4 feet on the sides of the stretchers and the foot of the
stretcher. Provisions shall be made for the isolation of infectious patients.
Provisions for patient privacy such as cubicle curtains shall be
made.
F. Post-anesthetic
care units (PACUs).
1. Each PACU shall
contain a medication station; handwashing stations; nurse station with charting
facilities; clinical sink; provisions for bedpan cleaning; and storage space
for stretchers, supplies, and equipment. Additionally, the design shall provide
a minimum of 80 square feet for each patient bed with a space for additional
equipment described in the functional program, and for clearance of at least 5
feet between patient beds and 4 feet between patient bedsides and adjacent
walls. Provisions shall be made for the isolation of infectious patients.
Provisions for patient privacy such as cubicle curtains shall be made. In new
construction, at least one door to the recovery room shall access directly from
the surgical suite without crossing public hospital corridors.
2. An airborne infection isolation room is
not required in a PACU. Provision for the recovery of a potentially infectious
patient with an airborne infection shall be determined by the Infection Control
Risk Assessment.
3. A staff toilet
shall be located within the working area to maintain staff availability to
patients.
4. Handwashing stations
with hands-free operable controls shall be available with at least one for
every four beds uniformly distributed to provide equal access from each patient
bed.
SECTION
54:
PHYSICAL FACILITIES, OBSTETRICAL FACILITIES.
General. The obstetrical unit shall be located and designated
to prohibit non-related traffic through the unit. When delivery and operating
rooms are in the same suite, access and service arrangements shall be such that
neither staff nor patients need to travel through one area to reach the other.
Except as permitted otherwise herein, existing facilities being renovated
shall, as far as practicable, provide all the required support services.
A. Postpartum Unit.
1. Postpartum Room.
a. A postpartum room shall have a minimum of
100 square feet of clear floor area per bed in multi-bedded rooms and 120
square feet of clear floor area in single-bedded rooms. These areas shall be
exclusive of toilet rooms, closets, alcoves, or vestibules. Where renovation
work is undertaken, every effort shall be made to meet the above minimum
standards. If it is not possible to meet the above square -foot standards, the
authorities having jurisdiction may grant approval to deviate from this
requirement. In such cases, existing postpartum patient rooms shall have no
less than 80 square feet of clear floor area per bed in multiple-bed rooms and
100 square feet in single-bed rooms.
b. In multi-bedded rooms there shall be a
minimum clear distance of four feet between the foot of the bed and the
opposite wall, three feet between the side of the bed and nearest wall, and
four feet between beds.
c. The
maximum number of beds per room shall be two.
2. Unless the functional program demonstrates
the therapeutic and social value of a multibedded arrangement, the maximum
number of beds per room should be one.
a. Each
patient room shall have a window or windows.
b. Handwashing stations shall be provided in
each patient bedroom. In multi-bedded rooms the handwashing station shall be
located outside the patients' cubical curtains so it is accessible to
staff.
c. Each patient shall have
access to a toilet room or bathroom with handwashing stations without entering
a general corridor. One such room shall serve no more than two beds and no more
than two patient rooms.
3. The following support services for this
unit shall be provided.
a. Nurses'
station.
b. Nurse office.
c. Charting facilities.
d. Toilet room for staff.
e. Staff lounge.
f. Lockable closets or cabinets for personal
articles of staff.
g.
Consultation/conference room(s).
h.
Patients' lounge. The patients' lounge may be omitted if all rooms are
single-bedded rooms.
i. Clean
workroom or clean supply room. A clean workroom is required if clean materials
are assembled within the obstetrical suite prior to use. It shall contain a
work counter, a handwashing fixture, and storage facilities for clean and
sterile supplies. If the room is used only for storage and holding as part of a
system for distribution of clean and sterile supply materials, the work counter
and handwashing fixtures may be omitted. Soiled and clean workrooms or holding
rooms shall be separated and have no direct connection.
j. Soiled workroom or soiled holding room for
the exclusive use of the obstetrical suite. This room shall be separate from
the clean workroom. The soiled workroom shall contain a clinical sink (or
equivalent flushing-rim fixture) and a handwashing fixture. The above fixtures
shall have a hot and cold mixing faucet. The room shall have work counter and
space for separate covered containers for soiled linen and waste. Rooms used
only for temporary holding of soiled material may omit the clinical sink and
work counter. If the flushing-rim clinical sink is omitted, facilities for
cleaning bedpans shall be provided elsewhere.
k. Medication station. Provision shall be
made for storage and distribution of drugs and routine medications. This may be
done from a medicine preparation room or unit, from a self-contained medicine
dispensing unit, or by another approved system. If used, a medicine preparation
room or unit shall be under visual control of nursing staff. It shall contain
work counter, sink, refrigerator, and double-locked storage for controlled
substances. Convenient access to handwashing stations shall be provided.
(Standard cup-sinks provided in many self-contained units are not adequate for
handwashing.)
l. Clean linen
storage may be part of a clean workroom or a separate closet.
When a closed cart system is used, the cart shall be stored out
of the path of normal traffic.
m. Nourishment station shall contain sink,
work counter, ice dispenser, refrigerator, cabinets, and equipment for serving
hot or cold food. Space shall be included for temporary holding of unused or
soiled dietary trays.
n. Equipment
storage room. Each unit shall provide sufficient storage area(s) located on the
patient floor to keep its required corridor width free of equipment and
supplies, but not less than 10 square feet per postpartum room and 20 square
feet per each LDR or LDRP outside of the patient room.
o. Storage space for stretchers and
wheelchairs shall be provided in a strategic location, out of corridors and
away from normal traffic.
p. When
bathing facilities are not provided in patient rooms, there shall be at least
one shower and/or bathtub for each six beds or fraction thereof.
q. A housekeeping room shall be provided for
the exclusive use of the obstetrical suite. It shall be directly accessible
from the suite and shall contain a service sink or floor receptor and
provisions for storage of supplies and housekeeping equipment.
r. Examination/treatment room and/or
multipurpose diagnostic testing room shall have a minimum clear floor area of
120 square feet. When utilized as a multi-patient diagnostic testing room, a
minimum clear floor area of 80 square feet per patient shall be provided. An
adjoining toilet room shall be provided for patient use.
s. Emergency equipment storage shall be
located in close proximity to the nurses' station.
4. Airborne infection isolation room(s). An
airborne infection isolation room is not required for the obstetrical unit.
Provisions for the care of the perinatal patient with an airborne infection
shall be determined by the Infection Control Risk Assessment.
B. Cesarean/Delivery Suite.
1. Caesarean/delivery room(s) shall have a
minimum clear floor area of 360 square feet with a minimum dimension of 16 feet
exclusive of built-in shelves or cabinets. There shall be a minimum of one such
room in every obstetrical unit.
2.
Delivery room(s)shall have minimum clear area of 300 square feet exclusive of
fixed cabinets and built-in shelves. An emergency communication system shall be
connected with the obstetrical suite control station.
3. Infant resuscitation shall be provided
within the cesarean/delivery room(s) and delivery rooms with a minimum clear
floor are of 40 square feet in addition to the required area of each room or
may be provided in a separate but immediately accessible room with a clear
floor area of 150 square feet. Six single or three duplex electrical outlets
shall be provided for the infant in addition to the facilities required for the
mother.
4. Labor room(s) (LDR or
LDRP rooms may be substituted). In renovation projects, existing labor rooms
may have a minimum clear area of 100 square feet per bed.
Where LDRs or LDRPs are not provided, a minimum of two labor
beds shall be provided for each Caesarean room and/or delivery room. In
facilities that have only one Caesarean/ delivery room, two labor rooms shall
be provided. Each room shall be designed for either one or two beds with a
minimum clear area of 120 square feet per bed. Each labor room shall contain a
handwashing fixture and have access to a private toilet room. One toilet room
may serve two labor rooms. Labor rooms shall have controlled access with doors
that are arranged for observation from a nurses' station. At least one shower
(which may be separate from the labor room if under staff control) for use of
patients in labor shall be provided. Windows in labor rooms, if provided, shall
be located, draped, or otherwise arranged to preserve patient privacy from
causal observation from outside the labor room.
5. Recovery room(s). (LDR or LDRP rooms may
be substituted). Each recovery room shall contain at least two beds and have a
nurses station with charting facilities located to permit visual control of all
beds. Each room shall include stations for handwashing and dispensing medicine.
A clinical sink with bedpan flushing device shall be available, as shall
storage for supplies and equipment. There shall be enough space for baby and
crib and a chair for the support person. There shall be the ability to maintain
visual privacy of the new family.
6. Service Areas.
a. Individual rooms shall be provided as
indicated in the following standards; otherwise, alcoves or other open spaces
that do not interfere with traffic may be used.
b. The following services shall be provided:
1) A control/nurse station located to
restrict unauthorized traffic into the suite.
2) . Soiled workroom or soiled holding room.
This room shall be separate from the clean workroom. The soiled workroom shall
contain a clinical sink (or equivalent flushing-rim fixture). The room shall
contain a handwashing fixture. The above fixtures shall have a hot and cold
mixing faucet. The room shall have a work counter and space for separate
covered containers for soiled linen and waste. Rooms used only for temporary
holding of soiled material may omit the clinical sink and work counter. If the
flushing-rim clinical sink is eliminated, facilities for cleaning bedpans shall
be provided elsewhere.
3) . Fluid
waste disposal.
c. The
following services may be shared with the surgical facilities if the functional
program reflects this concern. Where shared, areas shall be arranged to avoid
direct traffic between the delivery and operating rooms.
1) A supervisor's office or
station.
2) A waiting room, with
toilets, telephones, and drinking fountains conveniently located. The toilet
room shall contain handwashing stations.
3) Sterilizing facilities with high-speed
sterilizers convenient to all Caesarean/delivery rooms. Sterilization
facilities shall be separate from the delivery area and adjacent to clean
assembly. High-speed autoclaves shall only be used in an emergency situation
(i.e., a dropped instrument and no sterile replacement readily available).
Sterilization facilities would not be necessary if the flow of materials were
handled from a central service department based on the usage of the delivery
room (DR).
4) A drug distribution
station with handwashing stations and provisions for controlled storage,
preparation, and distribution of medication.
5) Scrub facilities for Caesarean/delivery
rooms. Two scrub stations shall be provided adjacent to entrance to each
Caesarean/delivery room. Scrub facilities should be arranged to minimize any
splatter on nearby personnel or supply carts. In new construction, provide view
windows at scrub stations to permit the observation of room
interiors.
6) Clean workroom or
clean supply room. A clean workroom shall be provided if clean materials are
assembled within the obstetrical suite prior to use. If a clean workroom is
provided it shall contain a work counter, sink equipped for handwashing and
space for storage of supplies. A clean supply room may be provided when the
narrative program defines a system for the storage and distribution of clean
and sterile supplies.
7) Medical
gas storage facilities. Main storage of medical gases may be outside or inside
the facility in accordance with NFPA99. Provision shall be made for additional
separate storage of reserve gas cylinders necessary to complete at least one
day's procedures.
8) A clean
sterile storage area readily available to the delivery room: size to be
determined on level of usage, functions provided, and supplies from the
hospital central distribution area.
9) An anesthesia workroom for cleaning,
testing, and storing anesthesia equipment. It shall contain a work counter,
sink, and provisions for separation of clean and soiled items.
10) Equipment storage room(s) for equipment
and supplies used in the obstetrical suite.
11) Staff clothing change areas. The clothing
change area shall be designed to encourage one-way traffic and cross-traffic
between clean and contaminated personnel. The area shall contain lockers,
showers, toilets, handwashing stations, and space for donning and disposing
scrub suits and booties.
12) Male
and female support persons change area (designed as described above).
13) Lounge and toilet facilities for
obstetrical staff convenient to delivery, labor, and recovery areas. The toilet
room shall contain handwashing stations.
14) An on-call room(s) for physician and/or
staff may be located elsewhere in the facility.
15) Housekeeping room with a floor receptacle
or service sink and storage space for housekeeping supplies and
equipment.
16) An area for storing
stretchers out of the path of normal traffic.
C. LDR and LDRP Facilities. When
provided by the functional program, delivery procedures in accordance with
birthing concepts may be performed in the LDR or LDRP rooms. LDR room(s) may be
located in a separate LDR suite or as part of the Caesarean/Delivery suite. The
postpartum unit may contain LDRP rooms. These rooms shall have a minimum of 250
square feet of clear floor area with a minimum dimension of 13 feet, exclusive
of toilet room, closet, alcove, or vestibules. There should be enough space for
crib and reclining chair for support person. An area within the room but
distinct from the mothers area shall be provided for infant stabilization and
resuscitation. See Table 4 of the Appendix for medical gas outlets. These
outlets shall be located in the room so that they are accessible to the
mother's delivery area and infant resuscitation area. When renovation work is
undertaken, every effort shall be made to meet the above minimum standards. If
it is not possible to meet the above square-foot standards, the authorities
having jurisdiction may grant approval to deviate from this requirement. In
such cases, existing LDR or LDRP rooms may have a minimum clear area of 200
square feet.
Each LDR or LDRP room shall be for single occupancy and have
direct access to a private toilet with shower or tub. Each room shall be
equipped with handwashing stations (handwashing stations with hands-free
operation area acceptable for scrubbing). Examination lights may be portable,
but shall be immediately accessible.
Finishes shall be selected to facilitate cleaning and with
resistance to strong detergents. Window(s) shall be provided for LDRP room(s).
Windows or doors within a normal sightline that would permit observation into
the room shall be arranged or draped as necessary for patient privacy.
Additional requirements for windows are provided above in A.2.a.
SECTION 55:
PHYSICAL FACILITIES, EMERGENCY SUITE.
A. General. The following shall be provided:
1. Grade-level well-marked, illuminated, and
covered entrance with direct access from public roads for ambulance and vehicle
traffic. Entrance and driveway shall be clearly marked. If a raised platform is
used for ambulance discharge, a ramp shall be provided for pedestrian and
wheelchair access. The emergency vehicle entry cover shall provide shelter for
both the patient and the emergency medical crew during transfer from an
emergency vehicle into the building.
2. Paved emergency access to permit discharge
of patients from automobiles and ambulances, and temporary parking convenient
to the entrance.
3. Reception,
triage, and nurses' station shall be located to permit staff observation and
control of access to treatment area, pedestrian and ambulance entrances, and
public waiting area. The triage area requires special consideration. As the
point of entry and assessment for patients with undiagnosed and untreated
airborne infections, the triage area shall be designed and ventilated to reduce
exposure of staff, patients and families to airborne infectious diseases. If
determined by the infection control risk assessment, one or more separate,
enclosed spaces designed and ventilated as airborne infection isolation rooms
shall be required
4. Wheelchair and
stretcher storage shall be provided for arriving patients. This shall be out of
traffic with convenient access from emergency entrances.
5. Public waiting area with toilet
facilities, drinking fountains, and telephones shall be provided. The hospital
shall conduct infection control risk assessment to determine if the emergency
department waiting area shall require special measures to reduce the risk of
airborne infection transmission. These measures may include enhanced general
ventilation and air disinfection similar to inpatient requirements for airborne
infection isolation rooms.
6.
Communication center shall be convenient to nurses' station and have radio,
telephone, and intercommunication systems.
7. Examination and Treatment Room(s).
Examination and treatment room(s) shall have minimum floor area of 120 square
feet. The room shall contain work counter(s); cabinets; handwashing stations;
supply storage facilities; examination lights; a desk, counter, or shelf space
for writing; and a vision panel adjacent to and/or in the door. When treatment
cubicles are in open multiple-bed areas, each cubicle shall have a minimum of
80 square feet of clear floor space and shall be separated from adjoining
cubicles by curtains. Handwashing stations shall be provided for each four
treatment cubicles or major fraction thereof in multiple-bed areas. For oxygen
and vacuum requirements, see Table 4 of the Appendix. Treatment/exam rooms used
for pelvic exams should allow for the foot of the examination table to face
away from the door.
8.
Trauma/cardiac rooms for emergency procedures, including emergency surgery,
shall have at least 250 square feet of clear floor space. Each room shall have
cabinets and emergency supply shelves, X-ray film illuminators, examination
lights, and counter space for writing. Additional space with cubicle curtains
for privacy may be provided to accommodate more than one patient at a time in
the trauma room. Provisions shall be made for monitoring the patient. There
shall be storage provided for immediate access to attire used for universal
precautions. Doorways leading from the ambulance entrance to the cardiac trauma
room shall be a minimum of five feet wide to simultaneously accommodate
stretchers, equipment, and personnel. In renovation projects, every effort
shall be made to have existing cardiac/trauma rooms meet the above minimum
standards.
9. Orthopedic and cast
work. These may be in separate room(s) or in the trauma room. They shall
include storage for splints and other orthopedic supplies, traction hooks,
X-ray film illuminators, and examination lights. If a sink is used for the
disposal of plaster of paris, a plaster trap shall be provided. The clear floor
space for this area shall depend on the functions program and the procedures
and equipment accommodated here.
10. Scrub stations located in or adjacent and
convenient to each trauma and/or orthopedic room.
11. Convenient access to radiology and
laboratory services.
12. Poison
Control Center and EMS Communications Center may be part of the work and
charting area.
13. Provisions for
disposal of solid and liquid waste. This may be a clinical sink with bedpan
flushing device within the soiled workroom.
14. Storage area out of line of traffic for
stretchers, wheelchairs and emergency equipment;
15. Housekeeping room with a floor receptacle
or service sink and storage space for housekeeping supplies and
equipment.
16. Soiled workroom for
the exclusive use of the emergency suite. This room shall be separate from the
clean workroom. The soiled workroom shall contain a clinical sink or equivalent
flushing type fixture, work counter, sink equipped for handwashing, waste
receptacle and linen receptacle. This room shall be separate from the clean
workroom and shall have separate access doors.
17. Clean workroom or clean supply room. A
clean work room is required if clean materials are assembled within the
emergency suite prior to use. It shall contain a work counter, a handwashing
fixture, and storage facilities for clean and sterile supplies. If the room is
used only for storage and holding as part of a system for distribution of clean
and sterile supply materials, the work counter and handwashing fixtures may be
omitted. Soiled and clean workrooms or holding rooms shall be separated and
have no direct connection.
18.
Nurses' Station(s). Facilities for charting, clinical records, work counter,
communication system, space for supplies and convenient access to handwashing
stations shall be provided. Visual observation of all traffic into the suite,
where feasible.
19. Securable
closets or cabinet compartments for personnel.
20. Staff Lounge. Convenient and private
access to staff toilets, lounge, and lockers shall be provided.
21. Housekeeping room. A housekeeping room
shall be directly accessible from the unit and shall contain a service sink or
floor receptor and provisions for storage of supplies and housekeeping
equipment.
22. Security station. A
security system should be located near the emergency entrances and
triage/reception area. The non-selective 24-hour accessibility of the emergency
dictates that a security system reflecting local community needs be
provided.
23. At least one airborne
infection isolation room shall be provided. The need for additional airborne
infection isolation rooms or for protective environment room shall be as
determined by the Infection Control Risk Assessment. See Section 48.C for
requirements.
24. Bereavement Room
shall be located within or adjacent to the emergency suite. A telephone shall
be provided.
25. Secured holding
room in accordance with the functional program. At least one holding/seclusion
room of 80 square feet shall be provided. This room shall allow for security,
patient and staff safety, patient observations, and soundproofing.
26. Decontamination area. A decontamination
area shall be provided. The functional program shall define the location of the
area and the types of exposure (i.e., nuclear, biological, chemical) to be
considered. The location of the area shall be permitted to be on the exterior
perimeter of the facility adjacent to the ambulance entrance or built within
the walls of the facility.
SECTION 56:
PHYSICAL FACILITIES,
IMAGING SUITE.
A. General.
1. Equipment and space shall be as required
by the functional program.
2. A
certified physicist or other qualified expert shall specify the type, location,
and amount of radiation protection to be installed in accordance with the final
approved department layout and equipment selections. Where protected alcoves
with view windows are required, a minimum of one foot six inches between the
view window and the outside partition edge shall be provided. Radiation
protection requirements shall be incorporated into the specifications and the
building plans.
3. Radiation
Control and Emergency Management shall be notified when any existing and/or new
equipment has been relocated or introduced into the facility. Radiation Control
approval for the equipment(s) and space(s) shall be obtained prior to
use.
B. Angiography.
1. Space shall be provided as required by the
functional program
2. A control
room shall be provided as necessary to meet the needs of the functional
program. A view window in the control room shall be provided to permit full
view of the patient.
3. A viewing
area shall be provided.
4. A scrub
sink located outside the staff entry to the procedure room shall be provided
for use by staff.
5. A patient
holding area shall be provided.
6.
Storage for portable equipment and supplies shall be provided
7. Provision shall be made within the
facility for extended post-procedure observation of outpatients.
C. Computerized Tomography (CT)
Scanning.
1. A control room shall be provided
which is designed to accommodate the computer and other controls for the
equipment. A view window shall be provided to permit full view of the patient.
The angle between the control and equipment centroid shall permit the control
operator to see the patient's head.
2. The control room shall be located to allow
convenient film processing.
3. A
patient toilet room shall be convenient to the procedure room, and if directly
accessible to the scan room, arranged so that a patient may leave the toilet
without having to reenter the scan room.
D. Diagnostic X-ray (e.g., Tomography,
Radiography/Fluoroscopy Rooms, Mammography). Radiology rooms shall be of a size
to accommodate the functional program. Each X-ray room shall include a shielded
control alcove. This area shall be provided with a view window designed to
provide full view of the examination table and the patient at all times,
including full view of the patient when the table is in the tilt position or
the chest X-ray is being utilized. For mammography machines with built-in
shielding for the operator, the alcove may be omitted when approved by the
certified physicist or state radiation protection agency.
E. Magnetic Resonance Imaging (MRI).
1. Space shall be provided as required by the
functional program.
2. A control
room shall be provided with full view of the MRI.
3. A computer room shall be
provided.
4. A patient holding area
should be located near the MRI unit.
5. Cryogen venting shall comply with
manufacturer's recommendations.
F. Ultrasound.
1. Space shall be provided as required by the
functional program.
2. A patient
toilet room, accessible from the procedure room and from the corridor, shall be
provided.
G. Support
Spaces. The following spaces are common to the imaging department and are
minimum requirements unless stated otherwise.
1. Patient Waiting Area. The area shall have
a seating capacity in accordance with the functional program.
2. Control Desk and Reception Area.
3. Holding Area. A convenient holding area
under staff control shall be provided to accommodate patients on stretchers or
beds.
4. Patient Toilet Rooms.
Toilet rooms shall be provided convenient to the waiting rooms and shall be
equipped with an emergency call system. Separate toilets with handwashing
stations shall be provided with direct access from each radiography/fluoroscopy
room so that a patient may leave the toilet without having to reenter the
radiography/fluoroscopy room. Rooms used only occasionally for fluoroscopy
procedures may utilize nearby patient toilets if they are located for immediate
access.
5. Patient Dressing Rooms.
Dressing rooms shall be provided convenient to the waiting areas and X-ray
rooms. Each room shall include a seat or bench, mirror, and provisions for
hanging patients' clothing.
6.
Staff Facilities. Toilets may be outside the suite but shall be convenient for
staff use. In larger suites of three or more procedure rooms, toilets internal
to the suite shall be provided.
7.
Image Storage. Provisions shall be provided by the facility for the active and
inactive image storage. A room with cabinet or shelves for filing patient image
for immediate retrieval shall be provided. A room or area for inactive image
storage shall be provided. It may be outside the imaging suite, but shall be
under imaging's administrative control and properly secured to protect films
against loss or damage.
8. Storage
for Unexposed Image. Storage facilities for unexposed images shall include
protection of film against exposure or damage and shall not be warmer than the
air of adjacent occupied spaces.
9.
Provisions for image viewing, individual consultation, clerical spaces and
charting shall be provided.
10.
Contrast Media Preparation. This area shall be provided with sink, counter, and
storage to allow for mixing of contrast media. One preparation area, if
conveniently located, may serve any number of rooms. When prepared media is
used, this area may be omitted, but storage shall be provided for the
media.
11. Image Processing Room. A
darkroom shall be provided for image processing unless the processing equipment
normally used does not require a darkroom for loading and transfer. When
daylight processing is used, the darkroom may be minimal for emergency and
special uses. Image processing shall be located convenient to the procedure
rooms and to the quality control area.
12. Quality Control Area. An area shall be
provided near the processor for viewing film immediately after it is processed.
All view boxes shall be illuminated to provide light of the same color value
and intensity for appropriate comparison of several adjacent images.
13. Cleanup Facilities. Provisions for
cleanup shall be located within the suite for convenient access and use and
shall include service sink or floor receptacle as well as storage space for
equipment and supplies. If automatic film processors are used, a receptacle of
adequate size with hot and cold water for cleaning the processor racks shall be
provided.
14. Handwashing Stations.
Handwashing stations shall be provided within each procedure room unless the
room is used only for routine screening such as chest X-rays where the patient
is not physically handled by the staff. Handwashing stations shall be provided
convenient to the MRI room, but need not be within the room.
15. Clean Storage. Provisions shall be made
for the storage of clean supplies and linens. If conveniently located, storage
may be shared with another department.
16. Soiled Holding. Provisions shall be made
for soiled holding. Separate provisions for contaminated handling and holding
shall be made. Handwashing stations shall be provided.
17. Provision shall be made for locked
storage of medications and drugs.
H. Cardiac Catheterization Lab. Note: The
number of procedure rooms and the size of the prep, holding, and recovery areas
shall be based on expected utilization.
1. The
cardiac catheterization lab is normally a separate suite, but may be within the
imaging suite when the appropriate sterile environment is provided. It may be
combined with angiography in low usage situations.
2. The procedure room shall be a minimum of
400 square feet exclusive of fixed and movable cabinets and shelves.
3. A control room or area for the efficient
functioning of the X-ray and image recording equipment. A view window
permitting full view of the patient from the control console shall be
provided.
4. An equipment room or
enclosure large enough to contain x-ray transformers, power modules, and
associated electronics and electrical gear shall be provided.
5. Scrub facilities with hands free operable
controls shall be provided adjacent to the entrance of procedure rooms, and
shall be arranged to minimize incidental splatter on nearby personnel, medical
equipment, or supplies.
6. The
following shall be available for use by the cardiac catheterization suite:
a. A viewing room;
b. A film file room.
7. Staff change area(s) shall be provided and
arranged to ensure a traffic pattern so that personnel entering from outside
the suite can enter, change their clothing, and move directly into the cardiac
catheterization suite.
8. A patient
preparation, holding, and recovery area or room shall be provided and arranged
to provide visual observation before and after the procedure.
9. A clean workroom or clean supply room
shall be provided. If the room is used for preparing patient care items, it
shall contain a work counter and handwashing sink. If the room is used only for
storage and holding of clean and sterile supply materials, the work counter and
handwashing stations may be omitted.
10. A soiled workroom shall be provided which
shall contain a handwashing and a clinical sink (or equivalent flushing rim
fixtures). When the room is used for temporary holding of soiled materials, the
clinical sink may be omitted.
11. A
housekeeping closet containing a floor receptor or service sink and provisions
for storage of supplies and housekeeping equipment shall be provided.
SECTION 57:
PHYSICAL FACILITIES, NUCLEAR MEDICINE.
A. Equipment and space shall be provided to
accommodate the functional program.
B. A certified physicist or other qualified
expert representing the owner shall specify the type, location, and amount of
radiation protection to be installed in accordance with final approved
department layout and equipment selection. These specifications shall be
incorporated into the plans.
C.
Floors and walls shall be constructed of materials that are easily
decontaminated in case of radioactive spills.
D. If radiopharmaceutical preparation is
performed onsite, an area adequate to house a radiopharmacy shall be provided
with appropriate shielding. This area should include adequate space for storage
of radionuclides, chemicals for preparation, dose calibrators, and record
keeping. Floors and walls should be constructed of easily decontaminated
materials. Vents and traps for radioactive gases should be provided if such are
used. Hoods for pharmaceutical preparation shall meet applicable standards. If
pre-prepared materials are used, storage and calculation area may be
considerable smaller than that for on-site preparation. Space shall provide
adequately for dose calibration, quality assurance, and record keeping. This
area may still require shielding from other portions of the
facilities.
E. Nuclear medicine
area when operated separately from the imaging department shall include the
following as required to accommodate the functional program:
1. Space adequate to permit entry of
stretchers, beds, and able to accommodate imaging equipment, electronic
consoles, and if present, computer terminals;
2. A darkroom onsite available for film
processing. The darkroom should contain protective storage facilities for
unexposed film that guard the film against exposure or damage;
3. When the functional program requires a
centralized computer area, it should be a separate room with access terminals
available within the imaging rooms.
4. Provisions for cleanup located within the
suite for convenient access and use. It shall include service sink or floor
receptacle as well as storage space for equipment and supplies;
5. Film storage with cabinets or shelves for
filing patient film for immediate retrieval;
6. Inactive film storage under the
departmental administrative control and properly secured to protect film
against loss or damage;
7. A
consultation area with view boxes illuminated to provide light of the same
color value and intensity for appropriate comparison of several adjacent
films;
8. Provisions for
physicians, assistants and clerical office space, individual consultation,
viewing, and charting of film;
9.
Waiting areas out of traffic, under staff control, with seating capacity in
accordance with the functional program. If the department is routinely used for
outpatients and inpatients at the same time, separate waiting areas with
screening or visual privacy between the waiting areas;
10. A private area for dose administration
located near the preparation area;
11. A holding area for patients on stretchers
or beds which may be provided and may be combined with the dose administration
area with visual privacy between the areas;
12. Patient dressing rooms convenient to the
waiting area and procedure rooms. Each dressing room shall include a seat or
bench, a mirror, and provisions for hanging patient's clothing;
13. Toilet rooms convenient to waiting and
procedure rooms;
14. Staff
toilet(s) convenient to the nuclear medicine laboratory;
15. Handwashing stations within each
procedure room;
16. Control desk
and reception area;
17. Storage
area for clean linen with a handwashingstation;
18. Provisions shall be made for holding
soiled material. Such provision shall include a handwashing station.
19. Separate provision shall be made for
holding contaminated material (exposed to radiation).
F. Positron Emission Tomography (PET).
1. Space should be provided as necessary to
accommodate the functional program.
2. PET scanning is generally used in
experimental settings and requires space for a scanner and for a cyclotron. The
scanner room should be a minimum of 300 square feet.
3. Where a cyclotron room is required, it
should he a minimum of 225 square feet with a 16 square foot space safe for
storage of parts, which may need to cool down for a year or more.
4. Both a hot (radioactive) lab and a cold
(nonradioactive) lab may be required, each a minimum of 250 square
feet.
5. A blood lab of a minimum
of 80 square feet should be provided.
6. A patient holding area to accommodate two
stretchers should be provided.
7. A
gas storage area large enough to accommodate bottles of gas should he provided.
Each gas will be piped individually and may go to the cyclotron or to the lab.
Ventilation adequate for the occupancy is required. Compressed air may be
required to pressurize a water circulation system.
8. Significant radiation protection may be
required since the cyclotron may generate high radiation.
9. Special ventilation systems together with
monitors, sensors, and alarm systems may be required to vent gases and
chemicals.
10. The heating,
ventilating, and air conditioning system will require particular attention;
highest pressures should be in coldest (radiation) areas and exhaust should be
in hottest (radiation) areas. Redundancy may be important.
11. The cyclotron is water cooled with
de-ionized water. A heat exchanger and connection to a compressor or connection
to chilled water may be required. A redundant plumbing system connected to a
holding tank may be required to prevent accidental leakage of contaminated
water into the regular plumbing system.
G. Radiotherapy.
1. Rooms and spaces shall be provided as
required by the functional program. Equipment manufacturers recommendations
should be sought and followed, since space requirements may vary from one
machine to another and one manufacturer to another. The radiotherapy suite may
contain one or both electron beam therapy and radiation therapy.
2. Cobalt, linear accelerators, and
simulation rooms require radiation protection. A certified physicist
representing the owner or appropriate state agency shall specify the type,
location, and amount of protection to be installed in accordance with final
approved department layout and equipment selection. The information shall be
incorporate into the floor plans.
3. Cobalt rooms and linear accelerators shall
be sized in accordance with equipment requirements and shall accommodate a
stretcher for litter-borne patients. Layouts shall provide for preventing the
escape of radioactive particles. Openings into the room, including doors,
ductwork, vents, and electrical raceways and conduits, shall be baffled to
prevent direct exposure to other areas of the facility.
4. Simulator, accelerator, and cobalt rooms
shall be sized to accommodate the equipment with patient access on a stretcher,
medical staff access to the equipment and patient, and service
access.
5. Flooring shall be
adequate to meet load requirements for equipment, patients, and personnel.
Provision for wiring raceways, ducts, or conduit should be made in floors and
ceilings. Ceiling mounted equipment should have properly designed rigid support
structures located above the finished ceiling. The ceiling height is normally
higher than 8'-0" (2.44 meters). A lay-in type of ceiling should be considered
for ease of installation, service, and remodeling.
6. Additional Support Areas for Linear
Accelerator:
a. Mold room with exhaust hood
and handwashing station.
b. Block
room with storage. The block room may be combined with the mold room.
7. Additional Support Areas for
Cobalt Room:
Hot lab.
H. General Support Areas. The following areas
shall be provided unless they are accessible from other areas such as imaging:
1. A stretcher holding area adjacent to the
treatment rooms, screened for privacy which may be combined with a seating area
for outpatients;
2. Exam rooms as
specified by the functional program. Each shall be a minimum of 120 square feet
and equipped with a handwashing station;
3. Darkroom convenient to the treatment
room(s) and the quality control area. Where daylight processing is used, the
darkroom may be minimal for emergency use. If automatic film processors are
used, a receptacle of adequate size with hot and cold water for cleaning the
processor racks shall be provided either in the darkroom or nearby;
4. Patient gowning area with provision for
safe storage of valuables and clothing. At least one space should be large
enough for staff-assisted dressing;
5. Business office and/or reception/control
area;
6. Housekeeping room equipped
with service sink or floor receptor and large enough for equipment or supplies
storage;
7. Image file area;
and
8. A storage area for
unprocessed media.
I.
Optional Support Area. The following areas may be required by the functional
program:
1. Quality control area with view
boxes illuminated to provide light of the same color value and
intensity;
2. Computer control area
normally located just outside the entry to the treatment room(s);
3. Dosimetry equipment area;
4. Hypothermia room (may be combined with an
exam room);
5. Consultation
room;
6. Oncologist's office (may
be combined with consultation room);
7. Physicist's office (may be combined with
treatment planning);
8. Treatment
planning and record room; and
9.
Work station/nutrition station.
SECTION 58:
PHYSICAL FACILITIES,
MOBILE, TRANSPORTABLE, AND RELOCATABLE UNITS.
A. General. This section applies to mobile,
transportable, and relocatable structures.
B. Definitions.
1. Mobile Unit - Any premanufactured
structure, trailer, or self-propelled unit equipped with a chassis on wheels
and intended to provide medical services on a temporary basis.
2. Transportable Unit - Any premanufactured
structure or trailer, equipped with a chassis on wheels, intended to provide
medical services on an extended basis.
3. Relocatable Unit - Any structure, not on
wheels, built to be relocated at any time and provide medical
services.
C. General
Considerations.
1. Classifications. These
facilities shall be classified as either a small outpatient facility, large
outpatient facility, ambulatory surgery center, or a hospital based upon the
definitions provided in the Rules and Regulations, the program functional and
construction type.
2. Applicable
Requirements. Facilities classified as a small outpatient clinic shall be
designed in accordance with the requirements stipulated in Section 80, Physical
Facilities, Outpatient Care Facilities. Facilities classified as a large
outpatient facility shall be designed in accordance with the requirements
stipulated in item F. of Section 80, Physical Facilities, Outpatient Care
Facilities. Facilities classified as an ambulatory surgery center shall be
designed in accordance with the requirements stipulated in Section 79, Physical
Facilities, Free-standing Ambulatory Surgery Centers. Facilities classified as
a hospital shall be designed in accordance with the requirements stipulated in
Section 47, Physical Facilities.
3.
These requirements shall be applicable to mobile, transportable, and
relocatable structures, when such structures are used to provide shared medical
services on an extended or a temporary basis.
4. When any mobile unit, transportable and
relocatable unit(s) are situated in a fixed location and rendered immobile they
shall be classified and designed as a health care facility.
D. Common Elements for Mobile,
Transportable, and Relocatable Units.
1. Site
Conditions.
a. Access for the unit to arrive
shall be taken into consideration for space planning. Turning radius of the
vehicles, slopes of the approach (six (6) percent maximum), and existing
conditions shall be addressed.
b.
Gauss fields of various strengths of magnetic resonance imaging (MRI) units
shall be considered for the environmental effect on the field homogeneity and
vice versa. Radio frequency interference shall be considered when planning the
site.
c. Sites shall be provided
with properly sized power, including emergency power, water, waste, telephone,
and fire alarm connections.
d. Site
shall have level concrete pads or piers and be designed for the structural
loads of the facility.
e. Site
utilizing MRI systems shall consider providing adequate access for
cryogen-servicing of the magnet. Storage of dewars also shall be included in
space planning.
f. It is
recommended that each site provide a covered walkway or enclosure to ensure
patient safety from the outside elements.
g. Diesel exhaust of the tractor and/or unit
generator shall be 25 feet away from the fresh air intake of the
facility.
h. Each facility shall
provide a means of preventing unit movement, either by blocking the wheels or
by providing pad anchors.
i. Sites
shall provide hazard-free patient drop-off zones and adequate
parking.
j. The facility shall
provide waiting space for patient privacy and patient and staff toilets as
close to the unit docking area as possible.
k. Each site shall provide access to the unit
for wheelchair/stretcher patients.
l. Mobile units shall be provided with
handwashing stations unless each site can provide handwashing stations within a
25 foot proximity to the unit. Transportable and relocatable units shall be
provided with handwashingstations.
E. General Standards for Details and Finishes
for Unit Construction.
1. Horizontal sliding
doors and power-operated doors shall comply with NFPA 101.
2. Units shall be permitted a single means of
egress as permitted by NFPA 101.
3.
All glazing in doors shall be safety or wire glass.
4. Units shall be equipped with fire
detection and alarm systems. In relocatable and transportable units these
systems shall be connected to the central fire alarm system.
5. Radiation protection for X-ray and gamma
ray installations shall be in accordance with Arkansas Rules and Regulations
for Control of Sources of Ionizing Radiation..
6. Interior finish materials shall be class A
as defined in NFPA 101.
7. Textile
materials having a napped, tufted, looped, woven, nonwoven, or similar surface
shall be permitted on walls and ceilings provided such materials have a class A
rating and rooms or areas are protected by an automatic extinguishment or
sprinkler system.
8. Fire retardant
coatings shall be permitted in accordance with NFPA 101.
9. Curtains and draperies shall be
noncombustible or flame retardant and shall pass both the large and small scale
tests required by NFPA 101.
F. Mechanical Standards.
1. Air conditioning, heating, ventilating,
ductwork, and related equipment shall be installed in accordance with NFPA 90A,
Standard for the Installation of Air Conditioning and Ventilation
systems.
2. Plumbing Standards.
a. Plumbing and other piping systems shall be
installed in accordance with the Arkansas State Plumbing
Code.
b. Mobile units,
requiring sinks, shall not be required to be vented through the roof.
Ventilation of waste lines shall be permitted to be vented through the
sidewalls or other acceptable locations. Transportable and relocatable units
shall be vented through the roof per model plumbing codes.
c. Backflow prevention shall be installed at
the point of water connection on the unit.
d. Medical gases and suction systems, if
installed, shall be in accordance with NFPA 99.
G. Electrical Standards
1. All electrical material and equipment,
including conductors, controls, and signaling devices, shall be installed in
compliance with applicable section of NFPA 70 and NFPA 99 and shall be listed
as complying with available standards of listing agencies or other similar
established standards where such standards are required.
2. The electrical installations, including
alarm, nurse call, and communication systems, shall be tested to demonstrate
that equipment installation and operation is appropriate and functional. A
written record of performance tests on special electrical systems and equipment
shall show compliance with applicable codes and standards.
3. Data processing and/or automated
laboratory or diagnostic equipment, if provided, may require safeguards from
power line disturbances.
4. Main
switchboards shall be located in an area separate from plumbing and mechanical
equipment and shall be accessible to authorized persons only. Switchboards
shall be convenient for use, readily accessible for maintenance, away from
traffic lanes, and located in dry, ventilated spaces free of corrosive or
explosive fumes, gases, or any flammable material. Overload protective devices
shall operate properly in ambient room temperatures.
5. Panelboards serving normal lighting and
appliance circuits shall be located on the same level as the circuits they
serve.
6. Lighting shall be
engineered to the specific application.
7. The Illuminating Engineering Society of
North America (IES) has developed recommended lighting levels for health care
facilities. The reader should refer to the IES Handbook (1993).
8. Approaches to buildings and parking lots
and all occupied spaces shall have fixtures for lighting that can be
illuminated as necessary.
9.
Consideration should be given to the special needs the elderly. Excessive
contrast in lighting levels that make effective sight adaptation difficult
should be minimized.
10. A portable
or fixed examination light shall be provided for examination, treatment, and
trauma rooms.
11. Duplex
grounded-type receptacles (convenience outlets) shall be installed in all areas
in sufficient quantities for tasks to be performed as needed. Each examination
and work table shall have access to a minimum of two duplex
receptacles.
12. At inhalation
anesthetizing locations, all electrical equipment and devices, receptacles, and
wiring shall comply with applicable sections of NFPA 99 and NFPA 70.
13. Fixed and mobile x-ray equipment
installations shall conform to articles 517 and 660 of NPFA 70.
14. Emergency lighting and power shall be
provided for in accordance with NFPA 99, NFPA 101, AND NFPA 110.
15. The fire alarm system shall be as
described in NFPA 101 AND WHERE APPLICABLE NFPA 72.
16. Terminating devices for
telecommunications and information systems wiring shall be located on the unit
that the terminating devices serve. These terminating devices shall be
accessible to authorized personnel only.
17. Special air conditioning and voltage
regulation shall be provided when recommended by the manufacturer.
SECTION 59:
PHYSICAL FACILITIES, LABORATORY SERVICES.
A. Facilities necessary for providing
laboratory services described in the functional program shall be provided. The
laboratory shall be constructed, arranged and maintained to ensure adequate
space, ventilation and utilities necessary for conducting all phases required
of testing in accordance with current CLIA regulations refer to Section
19.
B. Specimen collection
facilities shall be provided. These facilities may be located outside the
laboratory suite. The blood collection area shall have a work counter, space
for patient seating, and handwashingstations. Urine and feces collection
room(s) shall be equipped with a water closet and a lavatory.
C. Provisions shall be made for safety from
physical, chemical and biological hazards. There shall be eye flushing devices,
appropriate storage of flammable liquids, emergency spill kit(s) and fire
extinguishers as required by NFPA 99.
D. Based on the functional program, equipment
for terminal sterilization of contaminated specimens (autoclave or microwave)
shall be provided.
E. Locker and
toilet facilities for laboratory staff shall be located convenient to the
laboratory area.
SECTION
60:
PHYSICAL FACILITIES, REHABILITATION THERAPY
DEPARTMENT.
A. Common Elements. Each
rehabilitative therapy department shall include the following, which may be
shared or provided as separate units for each service:
1. Office and clerical space with provisions
for filing and retrieval of patient records.
2. Reception and control station(s) with
visual control of waiting and activities area. (This may be combined with
office and clerical space.)
3.
Patient waiting area(s) out of traffic with provision for wheelchair
patients.
4. Patient toilets with
handwashing stations accessible to wheelchair patients.
5. Space(s) for storing wheelchairs and
stretchers out of traffic while patients are using the services. These spaces
may be separate from the service area but shall be conveniently
located.
6. A conveniently
accessible housekeeping room and service sink for housekeeping use.
7. Locking closets or cabinets within the
vicinity of each work area for securing staff personal effects.
8. Convenient access to toilets and
lockers.
9. Access to a
demonstration/conference room.
10.
Lockable storage for medications.
B. Physical Therapy. If physical therapy is
part of the service, the following at least, shall be included:
1. Individual treatment area(s) with privacy
screens or curtains. Each such space shall have not less than 70 square feet of
clear floor area.
2. Handwashing
stations for staff either within or at each treatment space (one handwashing
station may serve several stations).
3. Exercise area and facilities.
4. Clean linen and towel storage.
5. Storage for equipment and
supplies.
6. Separate storage for
soiled items.
7. Patient change
area. (If required by the functional program.)
C. Occupational Therapy. If this service is
provided, at least the following shall be included:
1. Work areas and counters suitable for
wheelchair access.
2. Handwashing
stations.
3. Storage for supplies
and equipment.
4. An area for daily
living activities shall be provided. It shall contain an area for a bed,
kitchen counter with appliances and sink, bathroom, and a
table/chair.
D.
Prosthetics and Orthotics. If this service is provided, at least, the following
shall be included:
1. Work space for
technicians;
2. Space for
evaluating and fitting, with provisions for privacy;
3. Space for equipment, supplies and
storage.
E. Recreation
Therapy. NOTE: Recreation therapy assists patients in the development and
maintenance of community living skills through the use of leisure-time activity
tasks. These activities may occur in a recreation therapy department, in
specialized facilities (e.g., gymnasium), multipurpose space in other areas
(e.g., the nursing unit), or outdoors. If this service is provided, at least,
the following shall be included:
1. Activity
areas suitable for wheelchair access;
2. Handwashing stations if required by the
program;
3. Storage for supplies
and equipment;
4. Secured storage
for supplies and equipment potentially harmful;
5. Remote electrical switching for equipment
potentially harmful.
F.
Speech, Hearing, and Audio Therapy. If this service is provided, at least, the
following shall be included:
1. Space for
evaluation and treatment of patients. The space shall be protected with
acoustical treatment of walls and finishes.
2. Space for equipment storage and
supplies.
G. Respiratory
Care. If respiratory care is part of the service, the following, at least,
shall be included as a minimum:
1. Storage of
equipment and supplies.
a. Space and utilities
for cleaning and sanitizing equipment. Provide physical separation of the space
for receiving and cleaning soiled materials from the space for storage of clean
equipment and supplies. Appropriate local exhaust ventilation shall be provided
if glutaraldehyde or other noxious disinfectants are used in the cleaning
process.
b. If respiratory
services, such as testing and demonstration for outpatients are part of the
program, additional facilities and equipment shall be provided as necessary for
the appropriate function of the service, including but not limited to:
1) Patient waiting area with provision for
wheelchairs;
2) Reception and
control station;
3) Patient toilets
and handwashing stations;
4)
Room(s) for patient education and demonstration;
2. Cough-Inducing and
Aerosol-Generating Procedures. All cough-inducing procedures performed on
patients who may have suspected or active infectious Mycobacterium tuberculosis
shall be performed in rooms that meet the requirements for airborne infection
control.
SECTION
61:
PHYSICAL FACILITIES, MORGUE AND NECROPSY.
These facilities shall be directly accessible to an outside
entrance and shall be located to avoid movement of bodies through public areas.
The following elements shall be provided when autopsies are performed within
the hospital:
A. Refrigerated
facilities for body-holding;
B.
Autopsy Room. This room shall contain:
1. Work
counter with sink equipped for handwashing;
2. Storage space for supplies, equipment, and
specimens;
3. Autopsy
table;
4. A deep sink for washing
of specimens;
5. A housekeeping
service sink or receptor for cleanup and housekeeping.
NOTE: If autopsies are performed outside the facility, only a
well ventilated, temperature-controlled, body-holding room need be
provided.
SECTION
62:
PHYSICAL FACILITIES, PHARMACY.
The size and type of services to be provided in the pharmacy
can largely depend upon the type of medication distribution system used, number
of patients to be served, and extent of shared or purchased services. This
shall be described in the functional program. The pharmacy room or suite shall
be located for convenient access, staff control, and security. Facilities and
equipment shall be as necessary to accommodate the functions of the program.
See Section 16, Pharmacy, for additional requirements. (Satellite facilities,
if provided, shall include those items required by the program.) As a minimum,
the following elements shall be included:
A. Dispensing.
1 A pickup and receiving area.
2. An area for reviewing and
recording.
3. An extemporaneous
compounding area that includes a sink and sufficient counter space for
medication preparation.
4. Work
counters and space for automated and manual dispensing activities.
5. An area for temporary storage, exchange,
and restocking of carts.
6.
Security provisions for medications and personnel in the dispensing counter
area.
B. Manufacturing.
1. A bulk compounding area.
2. Provisions for packaging and
labeling.
3. A quality control
area.
C. Storage (may be
cabinets, shelves, and/or separate rooms or closets).
1. Bulk storage.
2. Active storage.
3. Refrigerated storage.
4. Volatile fluids and alcohol storage
constructed according to applicable fire safety codes for the substances
involved.
5. Double-locked storage
for controlled substances.
6.
Storage for general supplies and equipment not in use.
D. Administration.
1. An area for education and training (may be
in a multipurpose room shared with other departments).
2. An area for patient counseling and
instruction (may be in a room separate from the pharmacy).
3. A separate area for office functions.
E. Other.
1. Handwashing stations shall be provided
within each separate room where open medication is handled and readily
accessible.
2. Provide for
convenient access to toilet and locker.
3. If unit dose procedure is used, provide
additional space and equipment for supplies, packaging, labeling, and storage,
as well as for the carts.
4. If IV
solutions are prepared in the pharmacy, provide a sterile work area with a
laminar-flow work station designed for product protection. The laminar-flow
system shall include a nonhydroscopic filter (HEPA) rated at 99.97 percent, as
tested by DOP tests and have a visible pressure gauge for detection of filter
leaks or defects.
5. Hoods used for
chemotherapy shall be 100 percent exhausted to the exterior.
6. As a minimum the partitions enclosing the
pharmacy shall extend from the floor to the deck above, with gypsum board on
both sides of metal studs.
SECTION 63:
PHYSICAL FACILITIES,
DIETARY FACILITIES.
Construction, equipment, and installation shall comply with the
standards specified in FDA U.S. Public Health Service Food Code. Food service
facilities shall be designed and equipped to meet the requirements of the
functional program. These may consist of an onsite conventional food preparing
system, a convenience food service system, or an appropriate combination of the
two. The following shall be provided:
A. Receiving/Control Area. Provide an area
for the receiving and control of incoming dietary supplies. This area shall be
separated from the general receiving area and shall contain the following: a
control station, and a breakout for loading, uncrating, and weighing
supplies;
B. Storage Spaces. A
minimum of four days' supplies shall be stocked. (In remote areas, this number
may be increased to accommodate length of delivery in emergencies). All food
shall be stored clear of the floor. Lowest shelf shall not be less than 12
inches above the floor or shall be closed in and sealed tight for ease of
cleaning.
C. Cleaning supplies
storage. Provide a separate storage room for the storage of non-food items such
as cleaning supplies that might contaminate edibles.
D. Food Preparation Facilities. Conventional
food preparation systems shall have adequate space and equipment for preparing,
cooking, and baking. Convenience food preparation systems shall have adequate
space for equipment for thawing, portioning, cooking, and/or baking. These
areas shall be as close as possible to the user (i.e., tray assembly and
dining);
E. Assembly and
Distribution Areas. A patient tray assembly area shall be located within close
proximity to the food preparation and distribution areas;
F. Food Service Carts. A cart distribution
area shall provide space for storage, loading, distribution, receiving, and
sanitizing of food service carts. The cart traffic shall be designed to
eliminate any danger of cross circulation between outgoing food carts and
incoming, soiled carts, and the cleaning and sanitizing process. Cart
circulation shall not traffic through food processing areas;
G. Handwashing Stations. These shall be
operable without the use of hands and be readily accessible at locations
throughout the dietary department;
H. Dining Area. There shall be dining space
for ambulatory patients, staff, and visitors which is separate from the food
preparation and distribution areas;
I. Area for Receiving, Scraping, and Sorting
Soiled Tableware. Area shall be adjacent to ware washing and separate from food
preparation areas. A handwashing fixture shall be conveniently
available;
J. Dishwashing Space. An
area shall be located in a room separate from food preparation and serving
areas. Commercial-type dishwashing equipment shall be provided. Clean and
soiled dish areas shall be separated with an opening in the partition between
the clean and soiled dish area large enough for the dishwasher and ventilation
of the area. The clean dish area may be either a separate room or a portion of
the kitchen. A lavatory shall be conveniently available. The soiled dish area
shall be so located as to prevent soiled dishes from being carried through the
food preparation area;
K. Ware
Washing Facilities. They shall be designed to prevent contamination of clean
wares with soiled wares through cross-traffic. The clean wares should be
transferred for storage or use in the dining area without having to pass
through food preparation areas.
L.
Pot Washing Facilities including multi-compartmented sinks of adequate size for
intended use shall be provided convenient to using service. Supplemental heat
for hot water to clean pots and pans may be by booster heater or by steam
jet.
M. Waste storage room. A food
waste storage room shall be conveniently located to the food prepa-ration and
ware washing areas but not within the food preparation area. It shall have
direct access to the hospital's waste collection and disposal
facilities.
N. Storage Rooms and
Areas. A room for cans, carts, mobile tray conveyors, and cleaning and
sanitizing carts shall be provided. There shall be a separate storage room for
the storage of non-food items that might contaminate edibles (i.e., cleaning
supplies). A separate space or room for the storage of cooking wares, extra
trays, flatware, plastic and paper products, and portable equipment is
required;
O. Toilets and Locker
Spaces. Lockers, if provided in the dietary facility, shall be for the
exclusive use of the dietary staff. Toilets and lockers shall not open directly
into the food preparation areas, but shall be in close proximity to
them;
P. Office(s). Dietary service
manager/supervisor offices shall be conveniently located for visual control of
receiving area and food preparation areas;
Q. Janitor's Closet. A closet shall be
provided for the exclusive use of the dietary department to contain a floor
sink and space for mops, pails, and supplies. Where hot water or steam is used
for general cleaning, additional space within the room shall be provided for
the storage of hoses and nozzles;
R. Ice Making Equipment. Equipment shall be
convenient for service and easily cleaned. It shall be provided for both drinks
(self-dispensing equipment), and for general use (storage bin type
equipment);
S. Commissary or
Contract Services from Other Areas. If a service is used, above items may be
reduced as appropriate. The process of food delivery shall insure freshness,
retention of hot and cold, and avoidance of contamination. If delivery is from
outside sources, protection against weather shall be provided. Provisions shall
be made for thorough cleaning and sanitizing of equipment to avoid mix of
soiled and clean equipment;
T.
Equipment. Mechanical devices shall be heavy duty, suitable for intended use
and easily cleaned. Movable equipment shall have heavy duty locking casters. If
equipment is to have fixed utility connections, it shall not be equipped with
casters. Walk-in coolers, refrigerators, and freezers shall be insulated at
floor, walls and top. Coolers and refrigerators shall be capable of maintaining
a temperature down to freezing. Freezers shall be capable of maintaining a
temperature of 20º below zero Fahrenheit. Coolers, refrigerators, and
freezers shall be thermostatically controlled to maintain desired temperature
settings in increments of two degrees or less. Interior temperatures shall be
visible from the exterior. Controls may include audible and visible high and
low temperature alarm. Time of alarm shall be automatically recorded. Walk-in
units may be lockable from outside but shall have release mechanism for exit
from inside at all times. Interior shall be lighted. All shelving shall be
corrosion resistant, easily cleaned, and constructed and anchored to support a
loading of at least 100pounds per linear foot. All cooking equipment shall be
equipped with automatic shut off devices to prevent excessive heat buildup.
Under counter conduits, piping, and drains shall be arranged to not interfere
with cleaning of floor below or of the equipment;
SECTION 64:
PHYSICAL FACILITIES,
ADMINISTRATION AND PUBLIC AREAS.
The following areas shall be provided:
A. Facility entrance, at grade level,
sheltered from the weather, and able to accommodate wheelchairs;
B. Lobby, which shall include:
1. Reception and information counter or
desk;
2. Waiting
space(s);
3. Public toilet
facilities (one for each sex);
4.
Public telephone(s); and
5.
Drinking fountain(s).
C.
Interview space(s) for private interviews relating to social service, credit,
and admissions;
D. General or
individual office(s) for business transactions, medical and financial records,
and administrative and professional staffs;
E. Multipurpose room(s) with provisions for
the use of visual aids for conferences, meetings, and health education. One
multipurpose room may be shared by several services;
F. Storage for office equipment and supplies;
and
G. Staff toilet
facilities.
SECTION 65:
PHYSICAL FACILITIES, HEALTH INFORMATION UNIT.
The following rooms and areas shall be provided:
A. Health Information Director's office or
space;
B. Review and dictating
room(s) or spaces;
C. Work area for
sorting, recording, or microfilming records;
D. Medical record storage, (Refer to Section
72.A.26); and
E. Rooms for patient
medical records and archived patient medical records that remain onsite shall
be kept in a one hour fire rated enclosure or protected by a sprinkler system;
protected by a security system and a smoke detection system. Circulating
records at the nurses' station or in active working areas are excluded from
this requirement. The records shall be protected against undue destruction from
dust, vermin, water, etc.
SECTION
66:
PHYSICAL FACILITIES, CENTRAL MEDICAL AND SURGICAL
SUPPLY DEPARTMENT.
The following areas shall be provided:
A. Separate Soiled and Clean Work Areas
1. Soiled Workroom. This room shall be
physically separated from all other areas of the department. Work space shall
be provided to handle the cleaning and initial sterilization/disinfection of
all medical/surgical instruments and equipment, work tables, sinks, flush-type
devices, and washer/sterilizer decontaminators. Pass-through doors and
washer/sterilizer decontaminators shall deliver into clean processing
area/workrooms.
2. Clean
Assembly/Workroom. This workroom shall contain handwashing stations, workspace,
and equipment for terminal sterilizing of medical and surgical equipment and
supplies. Clean and soiled work areas shall be physically separated.
B. Storage Areas
Clean/Sterile Medical/Surgical Supplies. A room shall be
provided for the breakdown of clean/sterile bulk supplies. Storage for packs
etc., shall include provisions for ventilation, humidity, and temperature
control.
C.
Administrative/Changing Room
If required by the functional program, this room shall be
separate from all other areas and provide for staff to change from street
clothes into work attire. Lockers, sink, and showers shall be made available
within the immediate vicinity of the department.
D. Storage Room for Patient Care and
Distribution Carts
This area shall be adjacent, easily available to clean and
sterile storage, and close to main distribution point to keep traffic to a
minimum and to ease work flow.
SECTION 67:
PHYSICAL FACILITIES,
CENTRAL SUPPLY AND RECEIVING.
In addition to supply facilities in individual departments, a
central storage area shall also be provided. General stores may be located in a
separate building onsite with provisions for protection against inclement
weather during transfer of supplies. The following shall be provided:
A. Off-street unloading facilities;
B. Receiving area;
C. General Storage Room(s). General storage
rooms(s) with a total area of not less than 20 feet per inpatient bed shall be
provided. Storage may be in separate, concentrated areas within the institution
or in one or more individual buildings onsite. A portion of this storage may be
provided offsite; and
D. Additional
Storage Room(s). Additional storage areas for outpatient facilities shall be
provided in an amount not less than five percent of the total area of the
outpatient facilities. This may be combined with and in addition to the general
stores or be located in a central area within the outpatient department. A
portion of this storage may be provided offsite.
SECTION 68:
PHYSICAL FACILITIES, LINEN
SERVICES.
Each facility shall have provisions for storing and processing
of clean and soiled linen for appropriate patient care. Processing may be done
within the facility, in a separate building on- or off-site, or in a commercial
or shared laundry.
A. Facility
Processing. Facilities and equipment shall be as required for cost effective
operation as described in the functional program. At a minimum, the following
elements shall be included:
1. A separate room
for receiving and holding soiled linen until ready for pickup or
processing.
2. A central, clean
linen storage and issuing room(s), in addition to the linen storage required at
individual patient units.
3. Cart
storage area(s) for separate parking of clean- and soiled-linen carts out of
traffic.
4. A clean linen
inspection and mending room or area. If not provided elsewhere, a clean linen
inspection, delinting, folding, assembly and packaging area should be provided
as part of the linen services. Mending should be provided for in the linen
services department. A space for tables, shelving, and storage should be
provided
5. Handwashing stations in
each area where unbagged, soiled linen is handled.
B. If linen is processed in a laundry
facility that is not part of the licensed facility provisions shall also be
made for:
1. A service entrance, protected
from inclement weather, for loading and unloading of linen.
2. Control station for pickup and
receiving.
3. The hospital is
responsible to insure the commercial laundry does comply with Section 46,
Physical Environment.
C.
If linen is processed in a laundry facility that is part of the licensed
facility, the following shall be provided in addition to that of Section 68 A:
1. A receiving, holding, and sorting room for
control and distribution of soiled linen. Discharge from soiled linen chutes
may be received within this room or in a separate room.
2. Laundry processing room with commercial
type equipment that can process at least a seven-day supply within the regular
scheduled workweek. This may require a capacity for processing a seven-day
supply in a 40-hour week.
3.
Storage for laundry supplies.
4.
Employee handwashing stations in each room where clean or soiled linen is
processed and handled.
5.
Arrangement of equipment that will permit an orderly workflow and minimize
cross traffic that might mix clean and soiled operations.
6. Conveniently accessible staff lockers,
showers, and lounge.
SECTION 69:
PHYSICAL FACILITIES,
CLEANING AND SANITIZING CARTS, EMPLOYEE FACILITIES AND ENVIRONMENTAL
CLOSETS.
A. Facilities shall be
provided to clean and sanitize carts serving the central medical and surgical
supply department, dietary facilities, and linen services. These may be
centralized or departmentalized or offsite as required by the written
functional program.
B. Lockers,
lounges, toilets, etc. should be provided for employees and volunteers. These
should be in addition to, and separate from, those required for medical staff
and public.
C. Each environmental
services closet shall contain a floor receptor and/or services sink and storage
space for environmental services equipment (cart, bucket, etc.) and supplies.
There shall be at least one environmental services closet for each
floor.
SECTION 70:
PHYSICAL FACILITIES, ENGINEERING SERVICE AND EQUIPMENT AREAS.
Space shall be included in all mechanical and electrical
equipment rooms for proper maintenance of equipment. Provisions shall also be
made to provide for equipment removal and replacement. The following shall be
provided:
A. Boilers, mechanical
equipment, and electrical equipment shall be located in ventilated rooms or
buildings except as noted below:
1. Rooftop
air conditioning and ventilation equipment installed in weatherproof
housings;
2. Standby generators
where the engine and appropriate accessories (i.e., batteries) are properly
heated and enclosed in a weatherproof housing as recommended by the
manufacturer;
3. Cooling towers and
other heat rejection equipment;
4.
Electrical transformers and switchgear where required to serve the facility and
where installed in a weatherproof housing;
5. Medical gas parks and equipment;
6. Air cooled chillers where installed in a
weatherproof housing;
7. Waste
processing equipment. Site lighting, post indicator valves, and other equipment
normally installed on the exterior of the building;
8. Site lighting, post indicator valves, and
other equipment normally installed on the exterior of the building;
and
9. Exhaust fans.
B. Engineer's office with file
space and provisions for secured storage of facility drawings, records,
manuals, etc. The engineer's office shall be a separate and distinct space
dedicated for the purpose
C.
General maintenance shop(s) for repair and maintenance as required by the
functional program;
D. Storage room
for building maintenance supplies. Storage for solvents and flammable liquids
shall comply with applicable NFPA codes;
E. Yard equipment and supply storage shall be
located so equipment may be moved directly to exterior without interfering with
other work;
F. Separate area or
room specifically for storage, repair, and testing of electronic and other
medical equipment. The amount of space and type of utilities will vary with the
type of equipment involved and types of outside contracts used.
SECTION 71:
PHYSICAL
FACILITIES, WASTE PROCESSING SERVICES.
A. Hazardous Waste and Antineoplastic Agent
Disposal. The facility shall have policies and procedures for the
identification, segregation, labeling, storage, transport and disposal of
hazardous waste. The policies and procedures shall conform with the latest
edition of Hazardous Waste Management Regulation 23, Arkansas
Department of Environmental Quality, Little Rock, Arkansas.
Within the facility, hazardous waste, especially antineoplastic
agents, shall be labeled in a manner that it shall be easily recognized from
all other waste. The facility shall compile a list of all antineoplastic agents
used in the facility. The facility shall have policies and procedures for the
clean up of spills, decontamination and treatment of personnel exposed to
hazardous waste and antineoplastic agents.
B. Radioactive Waste Disposal. The facility
shall have policies and procedures for the identification, segregation,
labeling, storage, transport and disposal of radioactive waste and materials.
The policies and procedures shall conform to the most current Rules
and Regulations for Control of Sources of Ionizing Radiation, Arkansas
Department of Health, Little Rock, Arkansas. The facility shall
maintain records of all radioactive waste and materials which have been
disposed.
C. Regulated Medical
Waste (Infectious Waste) Disposal. The facility shall have policies and
procedures for the identification, segregation, labeling, storage, transport
and disposal of regulated medical waste. All policies and procedures shall
conform to the latest edition of the Rules and Regulations
Pertaining to the Management of Medical Waste from Generators and Health Care
Related Facilities, Arkansas Department of Health, Little Rock, Arkansas.
The facility shall have policies and procedures for the clean up
of spills, and for decontamination and treatment of personnel exposed to
regulated medical waste.
D. Solid
Waste Disposal (Non-Infectious Waste). The facility shall have policies and
procedures for the identification, segregation, labeling, storage, transport
and disposal of solid waste. Policies and procedures shall conform with the
latest edition of the Solid Waste Management Regulation 22,
Arkansas Department of Environmental Quality, Little Rock,
Arkansas.
E. Nuclear
Waste Disposal: The facility shall have policies and procedures for the
identification, segregation, labeling, storage, transport and disposal of
nuclear waste. All policies and procedures shall conform to the Code of Federal
Regulations; title X, parts 20 and 35, concerning the handling and disposal of
nuclear materials in health care facilities.
F. Containers of hazardous and antineoplastic
agent waste, radioactive waste, and regulated medical waste shall be closed
except when receiving waste. Containers have swinging lids or lids that are
easily contaminated are prohibited. Open containers shall be emptied between
patients and the container disinfected. Containers shall be kept closed except
when receiving waste.
G. Other
Waste. The facility shall have policies and procedures for the identification,
segregation, labeling, storage, transport, and disposal of any waste not
specifically mentioned in this section.
SECTION 72:
PHYSICAL FACILITIES,
DETAILS AND FINISHES.
All details for alteration or expansion projects as well as for
new construction shall comply with the following.
A. Details.
1. Compartmentation, exits, automatic
extinguishing systems, and other details relating to fire prevention and fire
protection shall comply with requirements listed in the NFPA referenced codes
and be shown on the Fire Protection Plan. The Fire Safety Evaluation System
(FSES) is an acceptable means of determining Life Safety Code
compliance.
2. Minimum corridor
width shall be eight feet clear without projections. Increased width shall be
provided at elevator lobbies and other places where conditions may demand more
clearance. All service or administrative corridors shall not be less than 44
inches in width. Doors to patient rooms shall be a minimum door size of three
feet eight inches wide and seven feet high to provide clearance for movement of
beds and other equipment. Alternatively NFPA 101 shall be deemed to meet
requirements.
3. Items such as
drinking fountains, telephone booths, and vending machines, shall be located so
as not to project into exit access corridors. Incidental items shall be
determined by the licensing agency.
4. Rooms containing bathtubs, sitz baths,
showers, and water closets, subject to occupancy by patients, shall be equipped
with doors and hardware which shall permit access from the outside in any
emergency.
5. All doors between
corridors, rooms, or spaces subject to occupancy, except elevator doors, shall
be of the swing type. Openings to showers, baths, patient toilets, ICU patient
compartments with the break away feature, and other such areas not leading to
fire exits shall be exempt from this standard.
6. All patient room doors located on exit
access corridors shall have positive latching hardware.
7. Doors to patients' toilet rooms and other
rooms needing access for wheelchairs shall have a minimum width of 36 inches
for new facilities. Alcoves and similar spaces which generally do not require
doors are excluded from this requirement.
8. Windows shall be designed so that persons
cannot accidentally fall out of them when they are open or shall be provided
with security screens. Operation of windows shall be restricted to inhibit
possible escape or suicide. Where the operation of windows or vents require the
use of tools or keys, tools or keys shall be on the same floor and easily
accessible to staff.
9. Glass
doors, lights, sidelights, borrowed lights, and windows located within 12
inches of a door jamb (with a bottom frame height of less than 60 inches above
the finished floor) shall be constructed of safety glass, wired glass, or
plastic,
break resistant material that creates no dangerous cutting
edges when broken. Similar materials shall be used for wall openings in active
areas such as recreation rooms and exercise rooms, unless otherwise required
for fire safety. Safety glass-tempered or plastic glazing materials shall be
used for shower doors and bath enclosures. Plastic and similar materials used
for glazing shall comply with the flame-spread ratings of NFPA 101. Safety
glass or plastic glazing materials, as noted above, shall also be used for
interior windows and doors, including those in pediatric and psychiatric unit
corridors. In renovation projects, only glazing within 18 inches of the floor
shall be changed to safety glass, wire glass, or plastic, break-resistant
material. NFPA 101 contains additional requirements for glazing in exit
corridors, etc., especially in buildings without sprinkler systems.
10. Where labeled fire doors are
required, these shall be certified by an independent test laboratory as meeting
the construction requirements equal to those for fire in NFPA Standard 80.
Reference to a labeled door shall be construed to include labeled frame and
hardware.
11. Trash chutes shall be
in accordance with NFPA standard 82. In addition, linen and refuse chutes shall
meet or exceed the following requirements:
a.
Service openings to chutes shall not be located in corridors or passageways but
shall be located in a room which complies with NFPA 101;
b. Service openings to chutes shall have
approved self-closing Class B one and one-half hour labeled fire
doors;
c. Minimum cross-sectional
dimensions of gravity chutes shall not be less than two feet;
d. Chutes shall discharge directly into
collection rooms separate from incinerator, laundry, or other services.
Separate collection rooms shall be provided for trash and for linen. Chute
discharge into collection rooms shall comply with NFPA 101;
e. Gravity chutes shall extend through the
roof with provisions for continuous ventilation as well as for fire and smoke
ventilation. Openings for fire and smoke ventilation shall have an effective
area of not less than that of the chute cross-section and shall be not less
than four feet above the roof and not less than six feet clear of other
vertical surfaces. Fire and smoke ventilating openings may be covered with
single strength sheet glass.
12. Dumbwaiters, conveyors, and material
handling systems shall comply with NFPA 101.
13. Thresholds and expansion joint covers
shall be installed flush with the floor surface to facilitate use of
wheelchairs and carts. Expansion and seismic joints shall be constructed to
restrict the passage of smoke.
14.
Grab bars shall be provided in all patients' toilets, showers, tubs, and sitz
baths. The bars shall have one and one-half inch clearance to walls and shall
have sufficient strength and anchorage to sustain a concentrated load of 250
pounds.
15. Soap dishes, soap
dispensers and/or other devices shall be provided at showers, bath tubs, and
all handwashing stations except scrub sinks.
16. Location and arrangement of handwashing
stations shall permit proper use and operation. All sinks, except public
toilets, janitor closets, and sinks used by patients only, shall have foot,
knee, or wrist blade faucets. Particular care shall be given to the clearances
required for blade-type operating handles.
17. Mirrors shall not be installed at
handwashing fixtures in food preparation areas, nurseries, clean and sterile
supply areas, scrub sinks, or other areas where asepsis is essential.
Provisions for hand drying shall be included at all handwashing stations except
scrub sinks. Paper units shall be enclosed to protect against dust or soil and
to insure single unit dispensing.
18. Lavatories and handwashing stations shall
be securely anchored to withstand an applied downward vertical load of not less
than 250 pounds on the front of the fixture.
19. Radiation protection requirements of
X-ray and gamma ray installations shall conform with Rules and
Regulations for Control of Sources of Ionizing Radiation, Arkansas Department
of Health.
20. The
minimum ceiling height shall be seven feet ten inches with the following
exceptions:
a. Boiler rooms shall have
ceiling clearances not less than two feet six inches above the main boiler
header and connecting piping.
b.
Ceilings in radiographic, operating and delivery rooms, and other rooms
containing ceiling-mounted equipment or ceiling-mounted surgical light fixtures
shall be of sufficient height to accommodate the equipment or fixtures and
their normal movement.
c. Ceilings
in corridors, storage rooms, and toilet rooms shall be not less then seven feet
eight inches in height. Ceiling heights in small, normally unoccupied spaces
may be reduced.
d. Suspended
tracks, rails, and pipes located in the traffic path for patients in beds
and/or on stretchers, including those in inpatient service areas, shall be not
less than seven feet above the floor. Clearances in other areas may be six feet
eight inches.
e. Where existing
structures make the above ceiling clearance impractical, clearances shall be as
required to avoid injury to individuals up to six feet four inches
tall.
f. Seclusion treatment rooms
shall have a minimum ceiling height of nine feet.
21. Recreation rooms, exercise rooms, and
similar spaces where impact noises may be generated shall not be located
directly over patient bed area, delivery or operating suites, unless special
provisions are made to minimize such noise.
22. Rooms containing heat-producing equipment
(such as boiler or heater rooms and laundries) shall be insulated and
ventilated to prevent any floor or partition surface from exceeding a
temperature of ten degrees Fahrenheit above ambient room temperature.
23. Noise reduction criteria shown in Table 2
of the Appendix shall apply to partition, floor, and ceiling construction in
patient areas. (Careful attention shall be given to penetrations.)
24. Approved fire extinguishers shall be
provided in locations throughout the building in accordance with NFPA Standard
No. 10. Extinguishers located in exit corridors shall be recessed.
25. Offsite buildings or freestanding
buildings used for storage of archived patient medical records shall be built
of noncombustible materials and provide security and smoke detection systems
for the records. Records shall be arranged in an accessible manner and stored
at least six inches above the floor. Records shall be protected against undue
destruction from dust, vermin, water, etc. X-ray film storage are not required
to meet the above requirements.
26.
Light fixtures shall be provided with protective covers in food preparation,
serving areas, and patient care and treatment spaces. Protective light fixture
covers are not required in corridors.
27. Minimum distance between patient room
windows and adjacent structures shall be 30 feet (new construction
only).
28. A panic bar releasing
device shall be provided for all required exit doors subject to patient traffic
(new construction only).
29. Doors
in smoke barrier partitions shall comply with NFPA 101.
30. Fire rated roof-ceiling assemblies shall
be listed with a nationally recognized laboratory.
31. Mechanical smoke door coordinators shall
not be used. Adjustable hydraulic closures or the full length header type shall
be used.
32. Corridor partitions,
smokestop partitions, horizontal exit partitions, exit enclosures, and fire
rated walls required to have protected openings shall be effectively and
permanently identified with signs or stenciling in a manner acceptable to the
Health Facility Services. Such identification shall be above any decorative
ceiling and in concealed spaces.
B. Finishes.
1. Cubicle curtains and draperies shall be
noncombustible or rendered flame retardant and shall pass both the large and
small scale tests of NFPA Standard 701 and the requirements of NFPA 13 when
applicable.
2. Flame spread, fuel
contributed, smoke density, and critical radiant flux of finishes shall comply
with NFPA 101.
3. Floors in areas
and rooms in which anesthetic agents are stored or administered to patients
shall comply with NFPA Standard 99. Conductive flooring may be omitted in
anesthetizing areas where a written resolution is signed by the hospital board
stating that no flammable anesthetic agents shall be used and appropriate
notices are permanently and conspicuously affixed to the wall in each such area
and room.
4. Floor materials shall
be easily cleanable and have wear resistance appropriate for the location
involved. Floors in areas used for food preparation or food assembly shall be
water resistant and grease-proof. Joints in tile and similar material in such
areas shall be resistant to food acids. In all areas frequently subject to wet
cleaning methods, floor-materials shall not be physically affected by
germicidal and cleaning solutions. Floors that are subject to traffic while wet
(such as shower and bath areas, kitchens, and similar work areas) shall have a
non-slip surface. Any facility designed to install carpet shall have prior
approval from the Arkansas Department of Health. The prior approval in part
shall be contingent upon submission of a laboratory test report from an
approved independent laboratory indicating that the proposed carpet meets or
exceeds the requirements listed in NFPA 101 and agreement by the Department as
to the specific areas in which carpet is to be used. In all carpet
installations no rubber backings or rubber padding shall be permitted except in
cases where the carpet and backing are tested as an integral component and the
integral component meets the requirements listed in NFPA 101. Carpet shall not
be allowed in the following areas or rooms: operating rooms, delivery rooms,
emergency rooms, intensive care units, nursery, recovery, kitchens,
laboratories, LDR and LDRP rooms, clean and soiled holding/workrooms, and
isolation rooms. Operating rooms shall have a seamless floor.
5. Wall bases in kitchens, operating rooms,
soiled workrooms, and other areas which are frequently subject to wet cleaning
methods shall be made integral and coved with the floor, tightly sealed within
the wall, and constructed without voids that can harbor insects.
6. Wall finishes shall be washable. In the
vicinity of plumbing fixtures, shall be smooth and water resistant.
7. Floors and walls penetrated by pipes,
ducts, and conduits shall be tightly sealed to minimize entry of rodents and
insects.
8. Ceilings in
food-preparation and storage areas, shall be cleanable with routine
housekeeping equipment.
9.
Operating rooms, trauma rooms, delivery rooms for Caesarean sections, and
protective isolation rooms shall have ceilings with a smooth finish plaster or
gypsum board surface with a minimum of fissures equipped with access panels
where needed.
10. In psychiatric
patient rooms, toilets, and seclusion rooms, ceiling construction shall be
smooth finish plaster or gypsum board surface with a minimum of fissures.
Ceiling-mounted air and lighting devices shall be security type.
Ceiling-mounted sprinkler heads shall be of the concealed type.
11. Ceilings shall be cleanable and in the
following areas shall be washable, waterproof, smooth finish plaster or gypsum
board or vinyl faced acoustic panels: cardiac cath labs, surgical suite
corridors, delivery suite corridors, central sterilization suite, autopsy
rooms, bacteriology, mycology, media preparation rooms, glass washing rooms
located in the labs, soiled holding rooms, soiled and clean utility rooms,
emergency suite-treatment rooms and trauma rooms.
12. Finished ceilings may be omitted in
mechanical, electrical, equipment spaces and shops.
13. Finished ceilings shall be provided for
corridors in patient areas.
14.
Sound sensitive areas such as neonatal intensive care may have special floor
and ceiling treatments.
SECTION 73:
PHYSICAL FACILITIES,
CONSTRUCTION, INCLUDING FIRE RESISTIVE REQUIREMENTS.
A Design. Every building and every portion
thereof shall be designed and constructed to sustain all dead and live loads in
accordance with American Society of Civil Engineers, (ASCE), "Minimum Design
Loads for Buildings and Other Structures."
B. Foundations. Foundations shall rest on
natural solid bearing if a satisfactory bearing is available at reasonable
depths. Proper soil-bearing values shall be established in accordance with
recognized standards. If solid bearing is not encountered at practical depths,
the structure shall be supported on drive piles or drilled piers designed to
support the intended load without detrimental settlement, except that one story
buildings may rest on a fill designed by a soils engineer. When engineered fill
is used, site preparation and placement of fill shall be performed under the
direct full-time supervision of the soils engineer. The soils engineer shall
issue a final report on the compacted fill operation and certification of
compliance with the job specifications. All footings shall extend to a depth
not less than one foot below the estimated maximum frost line.
C. Construction.
1. Construction shall comply with the
applicable requirements of NFPA 101, and the Arkansas Fire Protection Code
Volumes I and II and Arkansas State Building Services, Minimum Standards and
Criteria - Accessibility for the Physically Disabled Standards.
NOTE: NFPA 101 generally covers fire/safety requirements only,
whereas most model codes also apply to structural elements. The fire/safety
items of NFPA 101 would take precedence over other codes in case of conflict.
In the event NFPA 101 does not specifically address a life safety requirement
found only in the Arkansas Fire Prevention Code, compliance with the
requirement is not mandatory. Appropriate application of each would minimize
problems. For example, some model codes require closers on all patient doors.
NFPA 101 recognizes the potential fire/safety problems of this requirement and
stipulates that if closers are used for patient room doors, smoke detectors
shall also be provided within each affected patient room.
2. For renovation projects, the extent of new
construction shall be determined by the licensing agency. Construction shall
comply with applicable requirements of NFPA 101.
D. Free-standing Buildings (For Patient Use).
Buildings of this element category are considered to be greater than 30 feet
from the hospital or separated from the hospital by two hour fire resistance
rated construction. Buildings housing non-sleeping patient areas shall comply
with NFPA 101.
E. Free-standing
Buildings. Separate free-standing buildings over 30 feet from an inpatient
facility housing the boiler plant, laundry, shops, or general storage shall be
built in accordance with applicable building codes for such
occupancy.
F. Interior Finishes.
Interior finish materials shall comply with the limitations as indicated in
NFPA 101. If a separate underlayment is used with any floor
finish materials, the underlayment and the finish material shall be tested as a
unit. Tests shall be performed by an approved independent testing
laboratory.
G. Insulation
Materials. Building insulation materials, unless sealed on all sides and edges,
shall have a flame spread rating of 25 or less and a smoke developed rating of
150 or less when tested in accordance with NFPA 255.
H. Flood Protection. Executive Order No 11296
was issued to minimize financial loss from flood damage to facilities
constructed with federal assistance. In accordance with that order, possible
flood effects shall be considered when selecting and developing the site.
Insofar as possible, new facilities shall not be located on designated flood
plains. Where this is unavoidable, consult with the Corps of Engineers regional
office for the latest applicable regulations pertaining to flood insurance and
protection measures that may be required.
I. Elevators. All hospitals having patient
facilities (such as bedrooms, dining rooms, or recreation areas) or critical
services (such as operating, delivery, diagnostic, or therapeutic) located on
other than the grade-level entrance floor shall have electric or hydraulic
elevators. Installation and testing of elevators shall comply with ANSI/ASME
A17.1 for new construction and ANSI/ASME A17.3 for existing facilities. (See
ASCE 7-93 for seismic design and control systems requirements for elevators.)
1. In the absence of an engineered traffic
study the following guidelines for number of elevators shall apply:
a. At least one hospital-type elevator shall
be installed when one to 59 patient beds are located on any floor other than
the main entrance floor.
b. At
least two hospital-type elevators shall be installed when 60 to 200 patient
beds are located on floors other than the main entrance floor, or where the
major inpatient serves are located on a floor other than those containing
patient beds. (Elevator service may be reduced for those floors providing only
partial inpatient services.)
c. At
least three hospital-type elevators shall be installed where 201 to 350 patent
beds are located on floors other than the main entrance floor, or where the
major inpatient services are located on a floor other than those containing
patient beds. (Elevator service may be reduced for those floors which provide
only partial inpatient services.)
d. For hospitals with more than 350 beds, the
number of elevators shall be determined from a study of the hospital plan and
the expected vertical transportation requirements.
2. Hospital-type elevator cars shall have
inside dimensions that accommodate a patient bed with attendants. Cars shall be
at least five feet eight inches wide by nine feet deep. Car doors shall have a
clear opening of not less than four feet wide and seven feet high. In
renovations, existing elevators that can accommodate patient beds used in the
facility will not be required to be increased in size.
NOTE: Additional elevators installed for visitors and material
handling may be smaller than noted above, within restrictions set by standards
for disabled access.
3.
Elevators shall be equipped with a two way automatic level-maintaining device
with an accuracy of ± one-fourth inch.
4. Each elevator, except those for material
handling, shall be equipped with an independent keyed switch for staff use for
bypassing all landing button calls and responding to car button calls
only.
5. Elevator call buttons and
controls shall not be activated by heat or smoke. Light beams, if used for
operating door reopening devices without touch, shall be used in combination
with door-edge safety devices and shall be interconnected with a system of
smoke detectors. This is so the light control feature will be overridden or
disengaged should it encounter smoke at any landing.
6. Field inspections and tests shall be made
and the owner shall be furnished with written certification stating the
installation meets the requirements set forth in this section as well as all
applicable safety regulations and codes.
SECTION 74:
PHYSICAL FACILITIES,
MECHANICAL REQUIREMENTS.
A. General.
1. Prior to acceptance of the facility, all
mechanical systems shall be tested and operated to demonstrate to the owner or
his designated representative that the installation and performance of these
systems conform to design intent. Test results shall be documented for
maintenance files.
2. Upon
completion of the special systems equipment installation contract, the owner
shall be furnished with a complete set of manufacturers; operating,
maintenance, and preventive instructions, parts list, and complete procurement
information including equipment numbers and descriptions. Operating staff shall
be provided with instructions for proper operation of systems and
equipment
3. Rotating mechanical
equipment, shall be mounted on vibration isolators as required to prevent
unacceptable structure-borne vibration.
4. Supply and return mains and risers for
cooling, heating, and steam systems shall be equipped with valves to isolate
the various sections of each system and each piece of equipment.
B. Thermal and Acoustical
Insulation.
1. Insulation within the building
shall be provided to conserve energy, protect personnel, prevent vapor
condensation, and reduce noise.
2.
Insulation on cold surfaces shall include an exterior vapor barrier. Material
that will not absorb or transmit moisture will not require a separate vapor
barrier.
3. Insulation, including
finishes and adhesives on the exterior surfaces of ducts, piping, and
equipment, shall have a flame-spread rating of 25 or less and a smoke-developed
rating of 50 or less as determined by an independent testing laboratory in
accordance with NFPA 255.
4.
Interior duct linings shall not be used. This requirement shall not apply to
air terminals and sound attenuation devices that have special coverings over
such linings.
5. Existing
accessible insulation within areas that are renovated shall be inspected and
addressed as appropriate.
C. Steam and Hot Water Systems and Pressure
Vessels.
1. All pressure vessels shall meet
the requirements of the Arkansas Boiler Inspector, Arkansas Department of
Labor.
2. Boilers shall have the
capacity, based upon the net ratings published by the Hydronics Institute or
another acceptable national standard, to supply the normal heating, hot water
and steam requirements of all systems and equipment. Their number and
arrangement shall accommodate facility needs despite the break down or routine
maintenance for any one boiler. The capacity of the remaining boiler(s) shall
be sufficient to provide hot water service for clinical, dietary, and patient
use; steam for sterilization and dietary purposes; and heating for operating,
delivery, birthing, labor, recovery, intensive care, nursery, and general
patient rooms. Boilers shall be designed for a standby fuel and onsite standby
fuel shall be provided with a minimum 48 hour capacity.
3. Boiler Accessories. Boiler feed pumps,
heating circulating pumps, condensate return pumps, and fuel oil pumps shall be
connected and installed to provide normal and standby service.
D. Air Conditioning, Heating and
Ventilating Systems.
1. The systems shall be
designed to provide the dry bulb temperatures noted in Table 3 of the appendix.
The systems shall be designed and operated to provide the relative humidity
noted in Table 3 of the appendix.
2. All rooms and areas in the facility used
for patient care shall have provisions for ventilation. The ventilation rates
shown in Table 4 shall be used only as minimum standards; they do not preclude
the use of higher, more appropriate rates. Fans serving exhaust systems shall
be located at the discharge end and shall be readily serviceable. Air supply
and exhaust in rooms for which no minimum total air change rate is noted may
vary down to zero in response to room load. For rooms listed in Table 4 where
VAV systems are used, minimum total air change shall be within limits noted.
Temperature control shall also comply with these standards. To maintain asepsis
control, airflow supply and exhaust should generally be controlled to ensure
movement of air from "clean" to "less clean" areas, especially in critical
areas. The ventilation systems shall be designed and balanced according to the
requirements shown in Table 4 and in the applicable notes.
3. Exhaust systems may be combined to enhance
the efficiency of recovery devices required for energy conservation. Local
exhaust systems shall be used whenever possible in place of dilution
ventilation to reduce exposure to hazardous gases, vapors, fumes, or mists.
Airborne infection isolation rooms shall not be served by exhaust systems
incorporating energy recovery devices that permit
cross-contamination.
4. Fresh air
intakes shall be located at least 25 feet from exhaust outlets of ventilating
systems, combustion equipment stacks, medical-surgical vacuum systems, plumbing
vents, or areas that may collect vehicular exhaust or other noxious fumes.
(Prevailing winds and/or proximity to other structures may require greater
clearances.) Plumbing and vacuum vents that terminate at a level above the top
of the air intake may be located as close as 10 feet. The bottom of outdoor air
intakes serving central systems shall be as high as practical, but at least six
feet above ground level, or, if installed above the roof, three feet above roof
level. Exhaust outlets from areas that may be contaminated shall be above roof
level and arranged to minimize recirculation of exhaust air into the
building.
5. In new construction
and major renovation work, air supply for operating and delivery rooms
(excluding LDR/LDRP rooms) shall be from ceiling outlets near the center of the
work area. Return air shall be near the floor level. Each operating and
delivery room shall have at least two return-air inlets located as remotely
from each other as practical. (Design should consider turbulence and other
factors of air movement to minimize fall of particulates onto sterile
surfaces.) Where extraordinary procedures, such as organ transplants, justify
special designs, installation shall properly meet performance needs as
determined by applicable standards. These special designs should be reviewed on
a case-by-case basis. Temperature shall be individually controlled for each
operating and cesarean section room.
6. The operating and delivery room (excluding
LDR/LDRP rooms) room ventilation systems should operate at all times to
maintain the "air movement relationship to adjacent areas." The cleanliness of
the spaces is compromised when the ventilation system is shut down, e.g.,
airflow from a less clean space such as the corridor can occur, and standing
water can accumulate in the ventilation system (near humidifiers or cooling
coils).
7. In new construction and
major renovation work, air supply for rooms used for invasive procedures such
as autopsy rooms, cardiac cath labs, cystoscopic rooms, trauma rooms, endoscopy
rooms, bronchoscopy rooms, and/or rooms where anesthesia gases are used shall
be from ceiling outlets near the center of the room and/or work area. Return or
exhaust air inlets shall be near the floor level. Exhaust inlets for anesthesia
evacuation and other special applications shall be permitted to be installed in
the ceiling.
8. Each space
routinely used for administering inhalation anesthesia and inhalation analgesia
shall be served by a scavenging system to vent waste gases. If a vacuum system
is used, the gas-collecting system shall be arranged so that it does not
disturb patient respiratory systems. Gases from the scavenging system shall be
exhausted directly to the outside. The anesthesia evacuation system may be
combined with the room exhaust system, provided the part used for anesthesia
gas scavenging exhausts directly to the outside and is not part of the
recirculation system. Scavenging systems are not required for areas where gases
are used only occasionally, such as the emergency room, offices for routine
dental work, etc.
9. The bottoms of
ventilation openings shall be at least three inches above the floor.
10. The space above ceilings in new
construction shall not be used as plenum space to supply to, return air from,
or to exhaust air from any patient room, operating room, trauma room, critical
care room, delivery room, endoscopy room, cardiac cath lab, bronchoscopy room,
autopsy room, exam room, treatment room, airborne infection isolation room,
protective environment room, radiology suite, laboratory suite, soiled
workroom, soiled holding, physical therapy and hydrotherapy, ETO-sterilizer
room, sterilizer equipment room, and central medical and surgical supply areas
or rooms. Plenum return air space conforming to NFPA 90A requirements shall be
acceptable in areas where it is not listed above.
11. All central ventilation or air
conditioning systems shall be equipped with filters with efficiencies equal to,
or greater than, those specified in Table 1 of the Appendix. Where two filter
beds are required, filter bed number one shall be located upstream of the air
conditioning equipment and filter bed number two shall be downstream of any fan
or blowers. Filter efficiencies, tested in accordance with ASHRAE 52-92, shall
be average. Filter frames shall be durable and proportioned to provide an
airtight fit with the enclosing ductwork. All joints between filter segments
and enclosing ductwork shall have gaskets or seals to provide a positive seal
against air leakage. A manometer or equal equivalent method of monitoring high
and low pressure drop shall be installed across each filter bed having a
required efficiency of 75 percent or more including hoods requiring HEPA
filters.
12. If duct humidifiers
are located upstream of the final filters, they shall be located in a manner to
prevent condensation on the surface of the filters. Ductwork with duct-mounted
humidifiers shall have a means of water removal. An adjustable high-limit
humidistat shall be located downstream of the humidifier to reduce the
potential of condensation inside the duct. All duct take-offs should be
sufficiently downstream of the humidifier to ensure complete moisture
absorption. Steam humidifiers shall be used. Reservoir-type water spray or
evaporative pan humidifiers shall not be used.
13. Air-handling duct systems shall be
designed with accessibility for duct cleaning, and shall meet the requirements
of NFPA 90A.
14. Ducts that
penetrate construction intended to protect against X-ray, magnetic, RFI, or
other radiation shall not impair the effectiveness of the protection.
15. Fire and smoke dampers shall be
constructed, located, and installed in accordance with the requirements of NFPA
101, 90A, and the specific damper's listing requirements. Fans, dampers, and
detectors shall be interconnected so that damper activation will not damage
ducts. Maintenance access shall be provided at all dampers. All damper
locations shall be indicatedon design drawings. Dampers should be activated by
fire or smoke sensors, not by fan cutoff alone. Switching systems for
restarting fans may be installed for fire department use in venting smoke after
a fire has been controlled. However, provisions should be made to avoid
possible damage to the system due to closed dampers. When smoke partitions are
required, heating, ventilation, and air conditioning zones shall be coordinated
with compartmentation insofar as practical to minimize need to penetrate fire
and smoke partitions.
16. Hoods and
safety cabinets may be used for normal exhaust of a space provided that minimum
air change rates are maintained. If air change standards in Table 4 of the
Appendix do not provide sufficient air for proper operation of exhaust hoods
and safety cabinets (when in use), supplementary makeup air (filtered and
preheated) shall be provided around these units to maintain the required
airflow direction and exhaust velocity. Use of makeup air will avoid dependence
upon infiltration from outdoor and/or from contaminated areas. Makeup systems
for hoods shall be arranged to minimize "short circuiting" of air and to avoid
reduction in air velocity at the point of contaminant capture.
17. Laboratory hoods shall meet the following
general standards:
a. Have an average face
velocity of at least 75 feet per minute.
b. Have an exhaust fan located at the
discharge end of the system.
c.
Have an exhaust duct system of noncombustible corrosion-resistant material as
needed to meet the planned usage of the hood.
18. Laboratory exhaust and ventilation
systems shall comply with NFPA 45.
19. Laboratory hoods shall meet the following
special standards:
a. Fume hoods, and their
associated equipment in the air stream, intended for use with perchloric acid
and other strong oxidants, shall be constructed of stainless steel or other
material consistent with special exposures, and be provided with a water wash
and drain system to permit periodic flushing of duct and hood. Electrical
equipment intended for installation within such ducts shall be designed and
constructed to resist penetration by water. Lubricants and seals shall not
contain organic materials. When perchloric acid or other strong oxidants are
only transferred from one container to another, standard laboratory fume hoods
and the associated equipment may be used in lieu of stainless steel
construction.
b. In new
construction and major renovation work, each hood used to process infectious or
radioactive materials shall have a minimum face velocity of 90 feet per minute
with suitable pressure-independent air modulating devices and alarms to alert
staff of fan shutdown or loss of airflow. Each shall also have filters with
99.97 percent efficiency (based on dioctyl-phthalate (DOP) test method) in the
exhaust stream, and be designed and equipped to permit the safe removal,
disposal, and replacement of contaminated filters. Filters shall be as close to
the hood as practical to minimize duct contamination. Fume hoods intended for
use with radioactive isotopes shall be constructed of stainless steel or other
material suitable for the particular exposure and shall comply with NFPA 801,
Facilities for Handling Radioactive Materials. Radioactive isotopes used for
injections, etc. without probability of airborne particulates or gases may be
processed in a clean-workbench-type hood where acceptable to the Nuclear
Regulatory Commission.
20. Exhaust hoods handling grease-laden
vapors in food preparation enters shall comply with NFPA 96. All hoods over
cooking ranges shall be equipped with grease filters, fire extinguishing
systems, and heat-actuated fan controls. Cleanout openings shall be provided
every 20 feet and at changes in direction in the horizontal exhaust duct
systems serving these hoods. (Horizontal runs of ducts serving range hoods
should be kept to a minimum.
21.
The ventilation system for anesthesia storage rooms shall conform to the
requirements of NFPA 99.
22. The
ventilation system for the space that houses ethylene oxide (ETO) sterilizers
should be designed to:
a. Provide a dedicated
(not connected to a return air or other exhaust system) exhaust system. Refer
to 29 CFR Part 1910.1047.
b. All
source areas shall be exhausted, including the sterilizer equipment room,
service/aeration areas, over the sterilizer door, and the aerator. If the ETO
cylinders are not located in a well-ventilated, unoccupied equipment space, an
exhaust hood shall be provided over the cylinders. The relief valve shall be
terminated in a well-ventilated, unoccupied equipment space, or outside the
building. If the floor drain which the sterilizer(s) discharges to is not
located in a well-ventilated, unoccupied equipment space, an exhaust drain cap
shall be provided (coordinate with local codes).
c. Ensure that general airflow is away from
sterilizer operator(s).
d. Provide
a dedicated exhaust duct system for ETO. The exhaust outlet to the atmosphere
should be at least 25 feet away from any air intake.
23. An audible and visual alarm shall
activate in the sterilizer work area, and a 24 hour staffed location, upon loss
of airflow in the exhaust system.
24. Rooms with fuel-fired equipment shall be
provided with sufficient outdoor air to maintain equipment combustion
rates.
25. Gravity exhaust may be
used, where conditions permit, for nonpatient areas such as boiler rooms,
central storage, etc.
26. The
energy-saving potential of variable air volume systems is recognized and these
standard herein are intended to maximize appropriate use of that system. Any
system utilized for occupied areas shall include provisions to avoid air
stagnation in interior spaces where thermostat demands are met by temperatures
of surrounding areas.
27. Special
consideration shall be given to the type of heating and cooling units,
ventilation outlets, and appurtenances installed in patient-occupied areas of
psychiatric units. The following shall apply:
a. All air grilles and diffusers shall be of
a type that prohibits the insertion of foreign objects. All exposed fasteners
shall be tamper-resistant.
b. All
convector or HVAC enclosures exposed in the room shall be constructed with
round corners and shall have enclosures fastened with tamper-resistant
screws.
c. HVAC equipment shall be
of a type that minimizes the need for maintenance with the room.
28. Rooms or booths used for
sputum induction, aerosolized pentamidine treatments, and other high-risk
cough-inducing procedures shall be provided with local exhaust ventilation. See
Table 4 of the Appendix for ventilation requirements.
29. Non-central air handling systems, i.e.,
individual room units that are used for heating and cooling purposes (fan-coil
units, heat pump units, etc.) in areas permitted by Table 4 to utilize air
recirculated by means of a room unit shall be equipped with permanent
(cleanable) or replaceable filters. The filters shall have a minimum efficiency
of 68 percent weight arrestance. These units may be used as recirculating units
only. All outdoor air requirements shall be met by a separate central air
handling system with the proper filtration, as noted in Table 1 of the
Appendix.
30. For special needs
pharmacy work area and equipment requirements refer to Laws and
Regulations - Arkansas State Board of Pharmacy.
SECTION 75:
PHYSICAL FACILITIES, PLUMBING AND OTHER PIPING SYSTEMs.
All plumbing systems shall be designed and installed in
accordance with the requirements of the latest edition of the Arkansas State
Plumbing Code and the latest edition of the Laws, Rules, and Regulations
Governing Boiler Inspection, Arkansas Department of Labor.
A. Plumbing Fixtures.
1. The material used for plumbing fixtures
shall be nonabsorbent acid-resistant material.
2. The water supply spout for lavatories and
sinks required in patient care areas (except patient rooms) shall be mounted so
that the discharge point is a minimum distance of five inches above the rim of
the fixture.
3. All fixtures used
by medical and nursing staff and all lavatories used by patients and food
handlers shall be trimmed with valves which can be operated without the use of
hands. Where blade handles are used for this purpose, they shall not exceed
four and one-half inches in length, except that handles on clinical sinks shall
be not less than six inches long. (Automatic controls are acceptable.) Scrub
sinks shall be trimmed with foot, knee or ultrasonic controls.
4. Clinical sinks shall have an integral trap
in which the upper portion of the water trap provides a visible seal.
5. Shower bases and tubs shall provide
non-slip walking surfaces.
B. Potable Water Supply Systems.
1. Systems shall be designed to supply water
at sufficient pressure to operate all fixtures and equipment during maximum
demand periods.
2. Each water
service main, branch main, riser, and branch to a group of fixtures shall be
valved. Stop valves shall be provided at each fixture. Appropriate panels for
access shall be provided at all valves where required.
3. Backflow preventers (vacuum breakers)
shall be installed on hose bibs, laboratory sinks, janitors' sinks, bedpan
flushing attachments, autopsy tables, and on all other fixtures to which hoses
or tubing can be attached.
4.
Bedpan flushing devices shall be provided in each inpatient toilet room.
Installation is optional in psychiatric and alcohol-abuse units where patients
are ambulatory.
5. The following
standards shall apply to hot water systems:
a.
The water-heating system shall have sufficient supply capacity at the
temperatures and amounts indicated in Table 9 of the Appendix. Water
temperature is measured at the point of use or inlet to the
equipment.
b. Hot-water
distribution systems serving patient care areas shall be under constant
recirculation to provide continuous hot water at each hot water outlet. The
temperature of hot water for showers and bathing shall be appropriate for safe
and comfortable use. (See table 9 of the Appendix)
6. Water distribution systems shall be
arranged to provide hot water at each hot water outlet at all times. (See table
9 of the Appendix)
C.
Drainage Systems. The following standards shall apply to drainage systems:
1. Drain lines used for acid waste disposal
shall be made of acid-resistant material.
2. Drain lines serving some types of
automatic blood-cell counters shall be of carefully selected material that will
eliminate potential for undesirable chemical reactions (and/or explosions)
between sodium oxide wastes and copper, lead, brass, and solder, etc.
3. Drainage piping should not be installed
within the ceiling or exposed in operating and delivery rooms, nurseries, food
preparation centers, food serving facilities, food storage areas, central
services, electronic data processing areas, electric closets, and other
sensitive areas. Where exposed overhead drain piping in these areas is
unavoidable, special provisions shall be made to protect the space below from
leakage, condensation, or dust particles.
4. Floor drains shall not be installed in
operating and delivery rooms.
5. If
a floor drain is installed in cystoscopy, it shall contain a nonsplash,
horizontal-flow flushing bowl beneath the drain plate. Note: Floor drains in
cystoscopy operating rooms have been shown to disseminate heavily contaminated
spray during flushing. Unless regularly with large amounts of fluid, the trap
tends to dry out and permit passage of gases, vapors, odors, insects and vermin
directly into the operating room. For new construction, if a floor drain is
insisted upon by the users, the drain plate should be located away from the
operative preferably with a closed system of drainage. Alternative methods
include (a) an aspirator/trap installed in a wall connected to the collecting
trough of the operating table by a closed, disposable tube system, or (b) a
closed system using portable collecting vessels. (See NFPA 99.)
6. Drain systems for autopsy tables shall be
designed to positively avoid splatter or overflow onto floors or back siphonage
and for easy cleaning and trap flushing.
7. Building sewers shall discharge into
community sewage. Where such a system is not available, the facility shall
treat sewage in accordance with local and state regulations.
8. Kitchen grease traps shall be located and
arranged to permit easy access without the need to enter food preparation or
storage areas. Grease traps shall be of capacity required and shall be
accessible from outside of the building without need to interrupt any
services.
9. Where plaster traps
are used, provisions shall be made for appropriate access and
cleaning.
10. In dietary areas,
floor drains and/or floor sinks shall be of a type that can be easily cleaned
by removal of cover. Provide floor drains or floor sinks at all "wet equipment"
(i.e., ice machines) and as required for wet cleaning of floors. Provide
removable stainless steel mesh in addition to grilled drain cover to prevent
entry of large particles of waste which might cause stoppages. Location of
floor drains and floor sinks shall be coordinated to avoid conditions where
locations of equipment make removal of covers for cleaning difficult.
D. The installation, testing, and
certification of nonflammable medical gas and air systems shall comply with the
requirements of NFPA 99. (See Table 11 of the Appendix for rooms that require
station outlets.)
E. Clinical
vacuum system installations shall be in accordance with NFPA 99. (See Table 11
of the Appendix for rooms that require station outlets.)
F. All piping, except control-line tubing,
shall be identified. All valves shall be tagged, and a valve schedule shall be
provided to the facility owner for permanent record and reference.
G. When the functional program includes
hemodialysis, continuously circulated filtered cold water shall be
provided.
H. Provide condensate
drains for cooling coils of a type that may be cleaned as needed without
disassembly. Provide air gap where condensate drains empty into floor drains.
Provide heater elements for condensate lines in freezer or other areas where
freezing may be a problem.
I. No
plumbing lines may be exposed overhead or on walls where possible accumulation
of dust or soil may create a cleaning problem or where leaks would create a
potential for food contamination.
SECTION 76:
PHYSICAL ENVIRONMENT,
ELECTRICAL STANDARDS.
A. General.
1. All electrical material and equipment,
including conductors, controls, and signaling devices, shall be installed in
compliance with and maintained per applicable sections of NFPA 70 and NFPA 99
and shall be listed as complying with available standards of listing agencies,
or other similar established standards where such standards are required.
Maintenance and testing of receptacles in patient care areas shall be performed
at initial installation, replacement or servicing of devices. Records shall be
maintained of all tests, rooms or areas tested, with itemized pass/fail
indicators.
2. The electrical
installations, including alarm, nurse call, and communication systems, shall be
tested to demonstrate that equipment installation and operation is appropriate
and functional. A written record of performance tests on special electrical
systems and equipment shall demonstrate compliance with applicable codes and
standards.
3. Shielded isolation
transformers, voltage regulators, filters, surge suppressors, and other
safeguards shall be provided as required where power line disturbances are
likely to affect data processing and/or automated laboratory or diagnostic
equipment.
B. Main
switchboards shall be located in an area separate from plumbing and mechanical
equipment and shall be accessible to authorized persons only. Switchboards
shall be convenient for use, readily accessible for maintenance, away from
traffic lanes, and located in dry, ventilated spaces free of corrosive or
explosive fumes, gases, or any flammable material. Overload protective devices
shall operate properly in ambient room temperatures.
C. Lighting.
1. The Illuminating Engineering Society of
North America (IES) has developed recommended lighting levels for health care
facilities. The reader should refer to the IES
Handbook.
2.
Approaches to buildings and parking lots, and all occupied spaces within
buildings shall have fixtures that can be illuminated as necessary.
3. Patient rooms shall have general lighting
and night lighting. A reading light shall be provided for each patient. Reading
light controls shall be readily accessible to the patient(s). Incandescent and
halogen light sources which produce heat shall be avoided to prevent burns to
the patient and/or bed linen. The light source should be covered by a diffuser
or lens. Flexible light arms, if used, shall be mechanically controlled to
prevent the lamp from contacting the bed linen. At least one night light
fixture in each patient room shall be controlled at the room entrance. Lighting
for coronary and intensive care bed areas shall permit staff observation of the
patient while minimizing glare.
4.
Operating and delivery rooms shall have general lighting in addition to special
lighting units provided at surgical and obstetrical tables. General lighting
and special lighting shall be on separate circuits.
5. Nursing unit corridors shall have general
illumination with provisions for reducing light levels at night.
6. Light intensity for staff and patient
needs should generally comply with health care guidelines set forth in the IES
publication. Consideration should be given to controlling intensity and/or
wavelength to prevent harm to the patient's eyes (i.e., retina damage to
premature infants and cataracts due to ultraviolet light). Many procedures are
available to satisfy lighting requirements, but the design should consider
light quality as well as quantity for effectiveness and efficiency.
7. An examination light shall be provided for
examination, treatment, and trauma rooms.
8. Light intensity of required emergency
lighting shall follow IES guidelines. Egress and exit lighting shall comply
with NFPA 101.
D.
Receptacles.
1. Each operating and delivery
room shall have at least six receptacles convenient to the head of the
procedure table. Each operating room shall have at least 16 simplex or eight
duplex receptacles. Where mobile X-ray, laser, or other equipment requiring
special electrical configurations is used, additional receptacles distinctively
marked for X-ray or laser use shall be provided.
2. Each patient room shall have
duplex-grounded receptacles. There shall be one at each side of the head of
each bed; one for television, if used; and one on every other wall. Receptacles
may be omitted from exterior walls where construction or room configuration
makes installation impractical. Nurseries shall have at least two
duplex-grounded receptacles for each bassinet. Outlets for general care areas
and critical care areas shall be provided for as defined by NFPA 99 and NFPA
70.
3. Duplex-grounded receptacles
for general use shall be installed approximately 50 feet apart in all corridors
and within 25 feet of corridor ends. Receptacles in pediatric and psychiatric
unit corridors shall be of the tamper resistant type. Special receptacles
marked for X-ray use shall be installed in corridors of patient areas so that
mobile equipment may be used anywhere within a patient room using a cord length
of 50 feet or less. If the same mobile X-ray unit is used in operating rooms
and in nursing areas, receptacles for X-ray use shall permit the use of one
plug in all locations. Where capacitive discharge or battery-powered X-ray
units are used, special X-ray receptacles are not required.
4. Electrical receptacle cover plates or
electrical receptacles supplied from the emergency systems shall be
distinctively colored or marked for identification. If color is used for
identification purposes, the same color shall be used throughout the
facility.
5. For renal dialysis
units, two duplex receptacles shall be on each side of a patient bed or lounge
chair. One duplex receptacle on each side of the bed shall be connected to
emergency power.
E.
Equipment.
1. At inhalation anesthetizing
locations, all electrical equipment and devices, receptacles, and wiring shall
comply with applicable sections of NFPA 99 and NFPA 70.
2. Fixed and mobile X-ray equipment
installations shall conform to articles 517 and 660 of NFPA 70.
3. The X-ray film illuminator unit or units
for displaying at least two films simultaneously shall be installed in each
operating room, specified emergency treatment rooms, and X-ray viewing room of
the radiology department. All illuminator units within one space or room shall
have lighting of uniform intensity and color value.
4. Ground-fault circuit interrupters (GFCI)
shall comply with NFPA 70. When ground-fault circuit interrupters are used in
critical areas, provisions shall be made to ensure the other essential
equipment is not affected by activation of one interrupter.
5. In areas such as critical care units and
special nurseries where a patient may be treated with an internal probe or
catheter connected to the heart, the ground system shall comply with applicable
sections of NFPA 99 and NFPA 70.
F. Nurse/Patient Communication Station.
1. In patient areas, each patient room shall
be served by at least one nurse/patient communication station for two way voice
communication. All primary nurse call systems shall be of the
electrical/electronic nature. The signal shall activate an annunciator panel at
the nurse station, a visible signal in the corridor at the patient's door, and
at other areas defined by the functional program. Each bed shall be provided
with a call device. Two call devices serving adjacent beds may be served on one
calling station. Calls shall activate a visible signal in the corridor at the
patient's door, in the clean workroom, in the soiled workroom, medication,
charting, nourishment, and examination/treatment room(s) and at the nurses'
station. In multi-corridor nursing units, additional visible signals shall be
installed at corridor intersections. In rooms containing two or more
nurse/patient communication stations, indicating lights shall be provided at
each station. Nurse/patient communication stations at each calling station
shall be equipped with an indicating light which remains lighted as long as the
voice circuit is operating.
2. An
emergency call system shall be provided at each inpatient toilet, bath and
shower room. An emergency call shall be accessible to a collapsed patient on
the floor. Inclusion of a pull cord within four to six inches from the floor
will satisfy this standard. The emergency call shall be designed so that a
signal activated at a patient's calling station will initiate a visible and
audible signal distinct from the regular nurse/patient communication station
that can be turned off only at the patient calling station.
The signal shall activate an annunciator panel at the nurse
station, a visible signal in the corridor at the patient's door, and at other
areas defined by the functional program. Provisions for emergency calls will
also be provided in outpatient and treatment areas where patients are subject
to incapacitation.
3. In
areas such as critical care, recovery and pre-op, where patients are under
constant visual surveillance, the nurse/patient communication call may be
limited to a bedside button or station that activates a signal readily seen at
the control station.
4. A staff
emergency assistance system for staff to summon additional assistance shall be
provided in each operating, delivery, recovery, emergency examination and/or
treatment area, and in critical care units, nurseries, special procedure rooms,
cardiac catheterization rooms, stress-test areas, triage, outpatient surgery
admission and discharge areas, and areas for psychiatric patients including
seclusion and security rooms, anterooms and toilet rooms serving them, communal
toilet and bathing facility rooms, and dining, activity, therapy, exam and
treatment rooms. This system shall annunciate audibly or visually in the clean
work room, in the soiled work room, medication, charting, nourishment, and
examination/treatment room(s) if provided and at the administrative center of
the nursing unit with back up to another staffed area from which assistance can
be summoned.
5. A nurse/patient
communication station is not required in psychiatric nursing units, but if it
is included, provisions shall be made for easy removal, or for covering call
button outlets. In psychiatric nursing units all hardware shall have
tamper-resistant fasteners.
G. Emergency power shall be provided in
accordance with NFPA 99, NFPA 101, and NFPA 110.
H. Emergency electrical generators shall have
a minimum 48 hours of on-site fuel.
I. All health care occupancies shall be
provided with a fire alarm system in accordance with
NFPA 101 and NFPA 72.
J. Telecommunications and Information
Systems.
1. Locations for terminating
telecommunications and information system devices shall be provided.
2. A room shall be provided for
telecommunications and information systems. Special air conditioning and
voltage regulations shall be provided when recommended by the
manufacturer.
3. All patient
care-related telecommunications and information systems shall be powered from
the essential electrical system.
K. Annuciator alarm panels for Emergency
Systems including but not limited to such as the fire alarms, medical gas and
emergency generators shall be located according to the functional program and
shall be located in prominent locations easily observed and accessible by staff
at all times.
SECTION
77:
HYPERBARIC SUITE
A. General
1. The number of treatment stations should be
based upon the expected workload and may include several work shifts per
day.
2. The location should offer
convenient access for outpatients. Accessibility to the unit from parking and
public transportation should be a consideration.
B. Treatment Areas
1. Hyperbaric chambers for multiple occupancy
(Class A) should be installed in accordance with NFPA 99.
2. Hyperbaric chambers for individual
patients (Class B) should be installed in accordance with NFPA 99 in a room or
suite adequately sized to provide the following clearances: chamber and side
wall, 5 feet; between chambers, 6 feet; and between the chamber head-board and
the wall, 3 feet. A minimum passage space of 4 feet shall be provided at the
foot of each chamber in addition to the required clearances for sliding
patients' platforms in end-loading chambers.
C. Functional Elements. The following support
spaces should be provided and may be shared with adjacent departments.
1. Patient waiting area. The area should be
out of traffic, under staff control, and should have seating capacity in
accordance with the functional program. When the hyperbaric suite is routinely
used for outpatients and inpatients at the same lime, separate waiting areas
should be provided with screening for visual privacy between the waiting
areas.
2. A control desk and
reception area should be provided.
3. A holding area under staff control should
accommodate inpatients on stretchers or beds. Stretcher patients should be out
of the direct line of normal traffic. The patient holding area may be omitted
for two or fewer individual hyperbaric chamber units.
4. Toilet rooms for the use of patients
should be provided with direct access from the hyperbaric suite.
5. Dressing rooms for outpatients should be
provided and should include a seat or bench, mirror, and provisions for hanging
patients' clothing and for securing valuables. At least one dressing room
should be provided to accommodate wheelchair patients.
6. An appropriate room for individual and
family consultation with referring physicians should be provided for
outpatients.
7. A clean storage
space should be provided for clean supplies and linens. Handwashing stations
should be provided with hands-free operable controls. When a separate storage
room is provided, it may be shared with another department when conveniently
located.
8. A soiled holding room
should be provided with waste receptacles and soiled linen receptacles Storage
for patients' belongings should be provided.
9. A housekeeping room should be provided and
should contain a floor receptor or service sink and storage space for
housekeeping supplies and equipment; it should be located nearby.
10. Appropriate areas should be available for
male and female personnel for staff clothing change area and lounge. The areas
should contain lockers, shower, toilet, and handwashing stations.
11. A waiting room, toilet with handwashing
stations, drinking fountain, public telephone, and seating accommodations for
waiting periods should be available or accessible to the unit.
D. Electrical Requirements
1. Grounding of hyperbaric chambers should be
connected only to the equipment ground in accordance with NFPA 99 and NFPA
70.
2. Additional grounds such as
earth or driven grounds should not be permitted.
SECTION 78:
PHYSICAL
FACILITIES, HELICOPTER LANDING AREA.
Helicopter landing area (if provided) shall be
documented.
A. Safe planning for the
helicopter service shall include the following:
1. Plot plan showing the heliport for
Department of Health files and inspection; and
2. More than one approach/departure
route.
B. Service shall
be as close to the emergency service at the hospital as can be accomplished
safely. The Department of Health will consider that a helicopter landing area
does exist upon repeated or regular use of a location.
C. See NFPA 418 for roof top heliports.
NOTE: If there are wire obstacles, wire markers are available
at no charge. They shall be picked up at the Arkansas Department of
Aeronautics.
SECTION
79:
PHYSICAL FACILITIES, FREESTANDING AMBULATORY SURGERY
CENTERS.
A. General Construction
Considerations. See Section 47.B, Physical Facilities.
B. Site Location, Inspection, Approval, and
Subsoil Investigation. See Section 47.C-G, I and J, Physical
Facilities.
C. Construction
Documents. See Section 47.H, Physical Facilities.
D. Codes and Standards. See Section 47.B and
K, Physical Facilities.
E. General.
Outpatient surgery is performed without anticipation of overnight patient stay.
The functional program shall describe in detail staffing, patient types, hours
of operation, function and space relationships, transfer provisions, and
availability of offsite services.
Visual and audible privacy shall be provided by design and
include the registration, preparation, examination, treatment, and recovery
areas.
F. If the ambulatory
surgery center is part of an acute care hospital or other medical facility,
service may be shared to minimize duplication as appropriate. Where outpatient
surgical services are provided within the same area or suite as inpatient
surgery.
G. Size. The extent
(number and types) of the diagnostic, clinical, and administrative facilities
to be provided will be determined by the services contemplated and the
estimated patient load as described in the functional program. Provisions shall
be made for patient examination, interview, preparation testing, and obtaining
vital signs of patient.
H. Parking.
Four spaces for each room routinely used for surgical procedures plus one space
for each staff member should be provided. Additional parking spaces convenient
to the entrance for pickup of patients after recovery should be
provided.
I. Administration and
Public Areas. The following shall be provided:
1. A covered entrance for pickup of patients
after surgery.
2. A lobby area
including a waiting area, conveniently accessible wheelchair storage, a
reception/information desk, accessible public toilets, public telephone(s),
drinking fountain(s).
3. Interview
space(s) for private interviews relating to admission, credit, and demographic
information gathering.
4. General
and individual office(s) for business transactions, records, and administrative
and professional staff. These shall be separate from public and patient areas
with provisions for confidentiality of records. Enclosed office spaces for
administration and consultation shall be provided.
5. Multipurpose or consultation
room(s).
6. A medical records room
equipped for dictating, recording and retrieval.
7. Special storage, including locking drawers
and/or cabinets, for staff personnel effects.
8. General storage facilities (50 square feet
per operating room).
J.
Sterilizing Facilities. A system for sterilizing equipment and supplies shall
be provided.
When sterilization is provided off site, adequate sterile
supplies shall be provided. If onsite processing facilities are provided, they
shall include the following:
1. Soiled
Workroom. This room shall be physically separated from all other areas of the
department. Work space shall be provided to handle the cleaning and terminal
sterilization/disinfection of all medical/surgical instruments and equipment.
The soiled workroom shall contain work tables, sinks, flush-type devices, and
washer/sterilizer decontaminators or other decontamination equipment.
Pass-through doors and washer/sterilizer decontaminators shall deliver into
clean assembling areas/workrooms.
2. Clean Assembly/Workroom. This room shall
contain sterilization equipment. This workroom shall contain handwashing
stations, work space, and equipment for terminal sterilizing of medical and
surgical equipment and supplies. Access to sterilization room shall be
restricted.
This room is exclusively for the inspection, assembly, and
packaging of medical/surgical supplies and equipment for sterilization and
shall contain work tables, counters, ultrasonic cleaning facilities for backup
supplies and instrumentation or equipment. The room shall be designed to hold
sterilizer carts for loading or prepared supplies for sterilization.
3. Clean/Sterile Storage. Storage
for packs, etc., shall include provisions for ventilation, humidity, and
temperature control.
K.
Clinical Facilities. Provisions shall be made to separate pediatric from adult
patients. This shall include pre- and post-operative care areas and shall allow
for parental presence.
1. At least one room
shall be provided for examination and testing of patients prior to surgery,
assuring both visual and audible privacy. This may be an examination room or
treatment room, as required by the written functional program. Each room shall
have a minimum floor area of 80 square feet, excluding vestibules, toilets, and
closets. Room arrangement shall permit at least two feet eight inches clearance
at each side and at the foot of the examination table. A handwashing fixture
and a counter or shelf space for writing shall be provided.
2. Treatment room(s) for minor surgical and
cast procedures shall have a minimum floor area of 120 square feet excluding
vestibules, toilets, and closets. The minimum room dimension shall be ten
feet.
3. Each operating room shall
have a minimum clear area of 360 square feet, exclusive of cabinets and
shelves, but may be larger to accommodate the functional plan which requires
additional staff and/or equipment. An emergency communication system connected
with the surgical suite control station shall be provided. There shall be at
least one X-ray film illuminator in each room.
4. Room(s) for post-anesthesia recovery shall
be provided as required by volume and procedure type (two per operating room is
the minimum). At least three feet shall be provided at each side and at the
foot of each bed as needed for work and/or circulation. If pediatric surgery is
part of the program, separation from the adult section and space for parents
shall be provided. Soundproofing of the area and the ability to view the
patient from the nursing station shall be considered. Bedpans shall be supplied
in this area.
5. A supervised
post-recovery area shall be provided for patients who do not require
post-anesthesia recovery but need recovery time prior to leaving the
facility.
6. The following services
shall be provided in surgical service areas:
a. A control station located to permit visual
surveillance of all traffic entering the operating suite.
b. A drug distribution station for the
storage and preparation of medications to be administered to patients. The
station shall include refrigeration for medications, double-locked security for
controlled substances and convenient access to handwashing stations.
c. Scrub facilities shall be located near the
entrance to each operating room. Stations may serve two operating rooms if
needed, but shall be arranged to minimize incidental splatter on nearby
personnel or supply carts.
d. A
soiled workroom which includes a clinical sink or equivalent flushing-type
fixture, a work counter, a sink for handwashing, and waste
receptacle(s).
e. Fluid waste
disposal facilities convenient to the general operating rooms. Note: A clinical
sink or equivalent equipment in a soiled workroom shall meet this
requirement.
f. Anesthesia storage
facilities in accordance with NFPA 99.
g. Medical gas supply and storage to include
space for reserve nitrous oxide and oxygen cylinders.
h. Storage room(s) for equipment and supplies
used in the surgical suite.
i.
Appropriate change areas for staff working within the surgical suite. The areas
shall include lockers, showers, toilets, lavatories for handwashing, and space
for donning scrub attire.
j. A
separate patient change area which includes waiting room(s), lockers,
toilets, clothing change or gowning area(s), and space for
medication administration. The functional program shall include provisions for
securing patients' personal effects.
k. A convenient stretcher storage area out of
the direct line of traffic.
l. A
housekeeping room which includes a floor receptor or service sink and space for
housekeeping supplies and equipment. This room shall be for the exclusive use
of the surgical suite.
m. Space for
temporary storage of wheelchairs.
n. Convenient access to and use of emergency
crash carts for both the surgical and recovery areas.
o. An area for the storage and processing of
clean and soiled linen.
Laundry Services shall conform to Section 68, Physical
Facilities, Linen Service.
L. Diagnostic Facilities. Diagnostic services
shall be provided on or offsite for preadmission tests as required by the
functional program.
M. Details and
Finishes. All details and finishes shall meet the standards in Section 72,
Physical Facilities, Details and Finishes, with the following exceptions:
1. Details shall conform to the following
guidelines:
a. Minimum patient corridor width
shall be five feet, except that corridors in the operating room section, where
patients are transported on stretchers or beds, shall be eight feet wide.
Passages and corridors used exclusively for staff access may be forty-four
inches in clear width.
b. Patient
toilet rooms shall be equipped with doors and hardware that permit access from
the outside in emergencies.
c.
Flammable anesthetics shall not be used.
N. Finishes. Finishes shall conform to
Section 72, Physical Facilities, Details and Finishes.
O. Plumbing. Plumbing shall conform to
Section 75, Physical Facilities, Plumbing and Other Piping Systems.
P. Electrical. Electrical installations shall
conform to Section 76, Physical Environment,
Electrical Standards, with the following exceptions:
1. Eight hours of on-site fuel for the
emergency generator.
2. Emergency
call system is required in all patient toilet rooms.
Q. Fire Alarm System. A manually operated,
electrically supervised fire alarm system shall be installed in each facility
as described in NFPA 101.
R.
Mechanical. Mechanical systems shall conform to Section 74, Physical
Facilities,
Mechanical Requirements, with the exception that stand-by fuel
requirements shall be eight hours.
S. Extended Recovery Time. See Section
39.M.
SECTION 80:
PHYSICAL FACILITIES, OUTPATIENT CARE FACILITIES.
A. General Considerations. See Section 47.A,
Physical Facilities .
1. This section applies
to the outpatient care unit licensed under the facility as a department and
under the rule of the Governing Body. An outpatient care unit can be a part of
the facility or a separate freestanding facility. An outpatient unit within the
main facility building shall be located so outpatients do not traverse
inpatient areas.
2. The general
standards set forth in the following sections shall apply to each of the items
below.
a. Outpatient psychiatric
centers;
b. Primary care outpatient
centers; and
c. Diagnosis and/or
treatment centers.
3.
Each element provided in the outpatient care facility shall be described in the
written functional program and meet the requirements outlined herein as a
minimum.
B. General
Construction Considerations. See Section 47.A, Physical Facilities.
C. Site Location, Inspection, Approval and
Subsoil Investigation. See Section 47.D-M, Physical Facilities.
D. Construction Documents. See Section 47.K,
Physical Facilities.
E. Codes and
Standards. New/existing Outpatient Care Facilities which do not meet the
criteria established by NFPA, Life Safety Code Volume 101for healthcare and/or
ambulatory healthcare occupancies may be classified as a Business Occupancy as
defined in LSC 101, Chapter 38 (new)/39 (existing) with exceptions noted within
these regulations.
F. General
Requirements for Outpatient Care Facilities. As needed the following elements
shall be provided to satisfy the functional program:
1. Functional Program. See Section 47,
Physical Facilities.
2. Parking.
Each facility should provide adequate parking for staff and patients.
3. Patient Privacy. Each facility design
shall ensure patient audible and visual privacy during interview, examination,
treatment and recovery.
4.
Administration and Public Areas. The following shall apply to each outpatient
care facility described herein with additions and/or modification as noted for
each specific type.
a. Entrance. Located at
grade level and able to accommodate wheelchairs.
b. Public services shall include:
1) Conveniently accessible wheelchair
storage;
2) A reception and
information counter or desk;
3)
Waiting space(s). Where an organized pediatric service is part of the
outpatient care facility, provisions shall be made for separating pediatric and
adult patients;
4) Public
toilets;
5) Drinking fountain;
and
6) Public telephones.
c. Interview space(s). Private
interviews related to social services, credit, etc. shall be
provided.
d. General or individual
offices for business transactions, records, administrative and professional
staffs shall be provided.
e.
Clerical space or rooms for typing, clerical work, and filing, separated from
public areas for confidentiality, shall be provided.
f. Multipurpose room(s) equipped for visual
aids shall be provided for conferences, meetings and health education
purposes.
g. Special storage for
staff personal effects with locking drawers or cabinets (may be individual
desks or cabinets) shall be provided. Such storage shall be near individual
work stations and staff controlled.
h. General storage facilities for supplies
and equipment shall be provided as needed for continuing operation.
i. In new construction and renovation where
hemodialysis or hemoperfusion are routinely performed, there shall be a
separate water supply and a drainage facility that do not interfere with
handwashing.
5. General
purpose examination rooms. For medical, and similar examinations, rooms shall
have a minimum floor area of 80 square feet, excluding vestibules, toilets, and
closets. Room arrangement shall permit at least two feet eight inches clearance
at each side and at the foot of the examination table. A handwashing fixture
and a counter or shelf space for writing shall be provided.
6. Special- purpose examination rooms. Rooms
for special clinics such as eye, ear, nose, and throat examinations, if
provided, shall be designed and outfitted to accommodate procedures and
equipment used. A handwashing stations and a counter or shelf space for writing
shall be provided.
7. Treatment
Room(s). Rooms for diagnosis and/or treatment if provided, shall have a minimum
floor area of 120 square feet, excluding vestibule, toilet, and closets. The
minimum room dimension shall be ten feet. A handwashing fixture and counter or
shelf for writing shall be provided.
8. Observation room(s). Observation rooms for
the isolation of suspect or disturbed patients shall have a minimum floor area
of 80 square feet and shall be convenient to a nurse or control station. This
is to permit close observation of patients and to minimize possibilities of
patients' hiding, escape, injury, or suicide. An examination room may be
modified to accommodate this function. A toilet room with lavatory should be
immediately accessible.
9. Control
Station. A work counter, communication system, space for supplies, and
provisions for charting shall be provided.
10. Medication Distribution Station. This may
be a part of the control station and shall include a work counter, sink,
refrigerator, and locked storage for biologicals and medications.
11. Clean Holding. A separate room or closet
for storing clean and sterile supplies shall be provided. This storage shall be
in addition to that of cabinets and shelves.
12. Soiled Holding. Provisions shall be made
for separate collection, storage, and disposal of soiled materials
.
13.
Sterilizing Facilities. A system for sterilizing equipment and supplies shall
be provided, if required by the functional program.
14. Wheelchair Storage Space. Such storage
shall be out of the direct line of traffic.
15. The need for and number of required
airborne infection isolation rooms shall be determined by an infection control
risk assessment. When required, the airborne infection isolation room(s) shall
comply with the general requirements of Section 48.C.
16. Imaging Suite. See Section 56, Physical
Facilities, Imaging Suite.
17.
Laboratory. See Section 59, Physical Facilities, Laboratory Services.
18. Rehabilitation Services. See Section 81,
Physical Facilities, Rehabilitation Facilities.
19. Environmental Services, Safety Services,
Physical Environment. See Sections 46, Physical Facilities.
20. Staff Facilities. See Section 70,
Physical Facilities, Engineering Service and Equipment Areas.
21. Waste Processing Services. See Section
71, Physical Facilities, Waste Processing Services.
22. Social Spaces/Group Therapy. See Section
82, Physical Facilities for Psychiatric Hospitals -F.3 Service Areas
23. Details shall comply with the following
standards:
a. Minimum patient corridor width
shall be five feet. Staff only corridors may be 44 inches wide.
b. Each building shall have two exits that
are remote from each other. Other details relating to exits and fire safety
shall comply with NFPA 101 and the standards outlined herein.
c. Items such as drinking fountains,
telephone booths, vending machines, etc., shall not restrict corridor traffic
or reduce corridor width below the minimum. Out of traffic storage space for
portable equipment shall be provided.
d. The minimum nominal door width for patient
use shall be three feet. If the outpatient facility services hospital
inpatients, the minimum nominal width of doors to rooms used by hospital
inpatients transported in beds shall be three feet eight inches.
e. Doors, sidelights, borrowed lights, and
windows glazed to within 18 inches of the floor shall be constructed with
safety glass, wired glass, or similar materials. Glazing materials used for
shower doors and bath enclosures shall be safety glass or plastic.
f. Threshold and expansion joints covers
shall be flush with the floor surface.
g. Handwashing stations shall be located and
arranged to permit proper use and operation.
h. Provisions for hand drying shall be
included at all handwashingstations.
i. Radiation protection for X-ray and gamma
ray installations shall be in accordance with the rules and regulations of the
Arkansas Department of Health.
j.
The minimum ceiling height shall be seven feet eight inches.
24. Finishes shall comply with the
following:
a. Cubicle curtains and draperies
shall be noncombustible or flame-
retardant and shall pass both the large- and small-scale tests
required by NFPA 701.
b.
The flame spread and smoke development ratings of finishes shall comply with
NFPA 101, Chapter 38.
c. Floor
materials shall be readily cleanable and appropriately wear-resistant. In all
areas subject to wet cleaning, floor materials shall not be physically affected
by liquid germicidal and cleaning solutions. Floors subject to traffic while
wet, including showers and bath areas, shall have a nonslip surface.
d. Wall finishes shall be washable, and in
the proximity of plumbing fixtures, shall be smooth and water
resistant.
e. Wall bases in areas
frequently subject to wet cleaning methods shall be monolithic and coved with
the floor, tightly sealed to the wall, and constructed without voids.
f. Floor and wall areas penetrated by pipes,
ducts, and conduits shall be tightly sealed to minimize entry of rodents and
insects. Joints of structural elements shall be similarly sealed.
25. Provision for Disasters. See
Section 46, Physical Environment.
26. Mechanical, Plumbing and Electrical.
a. Small Outpatient Clinics that provide
space and equipment serving four or fewer direct patient care workers at one
time shall comply with the following minimum requirements:
1) Emergency lighting shall be connected to
rechargeable back-up batteries as a means of emergency illumination.
2) A protected premises fire alarm system as
defined in Chapter 3, NFPA 72 is required.
b. Large Outpatient Facilities that provide
space and equipment for more than four direct patient care workers at one time
shall comply with the following minimum requirements:
1) Emergency lighting and power shall be
provided in accordance with NFPA 99, NFPA 101, and NFPA 110.
2) Any fire alarm system shall be as required
by NFPA 101 and installed per NFPA 72.
3) The installation, testing, and
certification of nonflammable medical gas and air systems shall comply with the
requirements of NFPA 99.
4)
Clinical vacuum system installed shall be in accordance with NFPA 99.
5) All electrical material and equipment
shall be installed, tested and certificated in accordance with NFPA 70 and NFPA
99.
6) The mechanical system shall
comply with Section 74, Physical Facilities, Mechanical Requirements, with the
following exceptions:
a) Redundant space
heating and water heating capability are not required, unless required by the
written functional program;
b)
Ducted return air systems are not required, unless required by the written
functional program; and
c)
Stand-by fuel for space and water heating is not required.
7) A nurses emergency call system shall be
provided for all patient use at each patient toilet, bath, sitz bath and shower
room. This system shall be accessible to a patient lying on the floor.
Inclusion of a pull cord shall satisfy this standard.
8) Fire extinguisher(s) shall be provided and
be easily accessible per NFPA requirements.
G. Endoscopy refer to Section
53.D
SECTION 81:
PHYSICAL FACILITIES, REHABILITATION FACILITIES.
A. General Considerations. Rehabilitation
facilities may be organized under hospitals (organized departments of
rehabilitation), outpatient clinics, rehabilitation centers, and other
facilities designed to serve either single- or multiple-disability categories
including but not limited to: cerebrovascular, head trauma, spinal cord injury,
amputees, complicated fractures, arthritis, neurological degeneration, genetic,
and cardiac. In general, rehabilitation hospitals shall have larger space
requirements than general hospitals, have longer lengths of stay and have less
institutional and more residential environments.
B. General Construction Considerations. See
Section 47.A, Physical Facilities.
C. Site Location, Inspection, Approval and
Subsoil Investigation. See Section 47.D-M, Physical Facilities.
D. Construction Documents. See Section 47.K,
Physical Facilities.
E. Codes and
Standards. See Section 47.A and O, Physical Facilities.
F. Functional Units and Service Areas.
1. Required units. Each rehabilitation
facility shall contain a medical evaluation unit and shall provide the
following service areas, if the services are not otherwise conveniently
accessible to the facility and appropriate to program functions:
a. Psychological services;
b. Social services;
c. Vocational services;
d. Patient dining, recreation and day
spaces;
e. Dietary;
f. Personal care facilities;
g. Space for teaching activities of daily
living;
h. Administration
Department;
i. Medical
Records;
j. Engineering service and
equipment areas;
k. Laundry
Services;
l. Housekeeping
Rooms;
m. Employees'
facilities;
n. Nursing
unit;
o. Physical
therapy;
p. Occupational therapy;
and
q. Speech and
hearing.
2. Optional
Units. The following special services areas, if required by the functional
program, shall be provided as outlined in these sections. The sizes of the
various departments will depend upon the services to be provided:
a. Sterilizing facilities;
b. Prosthetics and orthotics;
c. Dental;
d. Radiology;
e. Pharmacy;
f. Laboratory;
g. Home health;
h. Outpatient services; and
i. Therapeutic pool.
G. Evaluation Unit.
1. Office(s) for Personnel.
2. Examination Rooms. The rooms shall have a
minimum floor area of 140 square feet excluding such spaces as the vestibule,
toilet, closet, and work counter (whether fixed or movable). The minimum room
dimension shall be ten feet. The room shall contain a lavatory or sink equipped
for handwashing, a work counter and storage facilities, and a desk, counter, or
shelf space for writing.
3.
Evaluation Rooms. The room areas shall be arranged to permit appropriate
evaluation of patient needs and progress and to determine specific programs of
rehabilitation. Rooms shall include a desk and work area for the evaluators,
writing and work space for patients, and storage for supplies. Where the
facility is small and workload light, evaluation may be done in the examination
room.
4. Laboratory Facilities.
Facilities shall be provided within the rehabilitation department or through
contract arrangement with a nearby hospital or laboratory service for
hematology, clinical chemistry, urinalysis, cytology, pathology, and
bacteriology. If these facilities are provided through contract, the following
minimum laboratory services shall be provided in the rehabilitation facility:
a. Laboratory work counter(s) with a sink,
and gas and electric service;
b.
Handwashingstations;
c. Storage
cabinet(s) or closet(s); and
d.
Specimen collection facilities. Urine collection rooms shall be equipped with a
water closet and lavatory. Blood collection facilities shall have space for a
chair and work counter.
5. Imaging Facilities. Imaging facilities, if
required by the functional program, shall be in accordance with Section 56,
Physical Facilities, Imaging Suite.
H. Psychological Service. Office(s) and work
space for testing, evaluation, and counseling shall be provided.
I. Social Service. Office space(s) for
private interviewing and counseling shall be provided.
J. Vocational Services. Office(s) and work
space for vocational training, counseling, and placement shall be
provided.
K. Dining, Recreation,
and Day Spaces.
The following standards shall be met for patient dining,
recreation, and day spaces (areas may be in separate or adjoining
spaces):
1. Inpatient and residents
shall have a total of 55 square feet per bed.
2. Outpatients, if dining is part of the day
care program, a total of 55 square feet per person shall be provided. If dining
is not part of the program, at least 35 square feet per person shall be
provided for recreation and day spaces.
3. Storage spaces shall be provided for
recreation equipment and supplies.
L. Dietary Department. See Section 63,
Physical Facilities, Dietary Facilities.
M. Personal Care Unit for Inpatients. A
separate room with appropriate fixtures and utilities shall be provided for
patient grooming. The activities for daily living unit may serve this
purpose.
N. Activities for Daily
Living Unit. An area for teaching daily living activities shall be provided. It
shall include a bedroom, bath, kitchen, and space for training stairs.
Equipment shall be functional. The bathroom shall be in addition to other
toilet and bathing requirements. The daily living area shall be similar to a
residential environment for the purpose of facilitating the patient's skill for
daily living.
O. Administration
Department and Medical Records. See Sections 64, Physical Facilities,
Administration and Public Areas.
P.
Engineering Service and Equipment Areas. See Section 70, Physical Facilities,
Engineering Service and Equipment Areas.
Q. Laundry Services. See Section 68, Physical
Facilities, Linen Service.
R.
Housekeeping Rooms. See Section 69, Physical Facilities, Cleaning and
Sanitizing Carts and Environmental Services.
S. Employee Facilities. See Section 70,
Physical Facilities, Engineering Service and Equipment Areas.
T. Nursing.
1. The nursing units for rehabilitation
facilities shall follow the standards as described in Section 48, Physical
Facilities, Patient Accommodations (Adult Medical, Surgical, Communicable or
Pulmonary Disease), with the following exceptions:
a. Patient Rooms. Minimum areas exclusive of
toilet rooms, closets, lockers, wardrobes, alcoves, or vestibules shall be 140
square feet in single-bed rooms and 125 square feet per bed in semi-private
rooms.
b. Each patient shall have
access to a toilet room without having to enter the general corridor area. One
toilet room shall serve no more than four beds and no more than two patient
rooms. The toilet room shall contain a water closet, a handwashing fixture and
a tub and/or shower. The handwashing fixture may be omitted from a toilet room
that serves single-bed and two bed rooms if each such patient's room contains a
handwashing fixture. Each toilet room shall be of sufficient size to ensure
that wheelchair users and staff shall have access.
c. Each patient shall have access to a
wardrobe, closet, or locker with minimum clearance of one foot ten inches by
one foot eight inches. A clothes rod and adjustable shelf shall be
provided.
2. Nursing
Unit Service Areas shall follow the standards described in Section 48, Physical
Facilities, Patient Accommodations (Adult Medical, Surgical, Communicable or
Pulmonary Disease), with the following exceptions:
a. Patient Bathing Facilities. At least one
island-type bathtub and/or gurney shower shall be provided in each nursing
unit. Each tub and/or shower shall be in an individual room or privacy
enclosure that provides space for the private use of bathing fixtures, for
drying and dressing, and for a wheelchair and an assistant. Showers in central
bathing facilities shall be at least four feet square, curb-free and designed
for use by a wheelchair patient;
b.
At least one room on each floor containing a nursing unit shall be provided for
toilet training. It shall be accessible from the nursing corridor. A minimum
clearance of three feet shall be provided at the front and at each side of the
water closet. The room shall also contain a lavatory; and c. Handrails shall be
provided on both sides of corridors used by patients. A clear distance of one
and one-half inches shall be provided between the handrail and the wall, and
the top of the rail shall be 34 inches minimum and 36 inches maximum above the
floor. Exceptions for height shall be for special care areas such as those
serving children.
U. Sterilizing Facilities. See Section 69,
Physical Facilities, Cleaning and Sanitizing Carts and Environmental
Services.
V. Rehabilitation
Therapy. See Section 60, Physical Facilities, Rehabilitation Therapy
Department.
W. Pharmacy Unit. See
Section 62, Physical Facilities, Pharmacy.
X. Details and Finishes. See Section 72,
Physical Facilities, Details and Finishes.
Y. Design and Construction, Including
Fire-Resistant Standards. See Section 73, Physical Facilities, Construction,
Including Fire Resistive Requirements.
Z. Waste Processing Services. See Section 71,
Physical Facilities, Waste Processing Services.
AA. Elevators. See Section 76, Physical
Facilities, Electrical Standards.
BB. Mechanical, Plumbing and Electrical
Standards. See Sections 74, 75 and 76.
SECTION 82:
PHYSICAL FACILITIES,
PSYCHIATRIC HOSPITALS AND ALCOHOL/DRUG ABUSE INPATIENT TREATMENT
CENTERS.
A. General Considerations. See
Section 47.A, Physical Facilities.
B. General Construction Consideration. See
Section 47.A, Physical Facilities.
1. The
facility shall provide a therapeutic environment appropriate for the planned
treatment programs. Security appropriate for the planned treatment programs
shall be provided. The area shall be characterized by a feeling of openness,
with emphasis on natural light and exterior view. Interior finishes, lighting,
and furnishings shall suggest a residential rather than an institutional
setting. These shall, however, conform with applicable fire safety codes.
Security and safety devices shall not be presented in a manner to attract or
challenge tampering by patients. Design, finishes, and furnishings shall be
such as to minimize the opportunity for residents to cause injury to themselves
or others. Special design considerations for injury and suicide prevention
shall be given to the following elements:
a.
Visual control of nursing units and passive activity areas such as day rooms
and outdoor areas;
b. Hidden
alcoves or enclosed spaces;
c.
Areas secured from patients access such as staff areas and mechanical
space;
d. Door closers, latch
handles and hinges;
e. Door swings
to private patient bathrooms;
f.
Shower, bath, toilet, and sink plumbing fixtures, hardware and accessories
including grab bars and toilet paper holders;
g. Windows including interior and exterior
glazing;
h. Light fixtures,
electrical outlets, electrical appliances, nurse call systems, and staff
emergency assistance systems;
i.
Ceilings, ventilation grilles, and access panels in patient bedrooms and
bathrooms;
j. Sprinkler heads and
other protrusions; and
k. Fire
extinguisher cabinets and fire alarm pull stations.
C. Site Location, Inspection,
Approval and Subsoil Investigation. See Section 47.D-M, Physical
Facilities.
D. Construction
Documents. See Section 47.K, Physical Facilities.
E. Codes and Standards. See Section 47.A and
O, Physical Facilities.
F. General
Requirements for Psychiatric Hospitals and Alcohol/Drug Abuse Inpatient
Treatment Centers.
1. Nursing Unit. See
Section 52, Physical Facilities, Psychiatric Nursing Unit. (Seclusion Room is
not required in the Alcohol/Drug Unit.)
2. Patient Rooms. See Section 52, Physical
Facilities, Psychiatric Nursing Unit.
3. Service Areas. The service areas shall
follow the standards described in Section 52, Physical Facilities, Psychiatric
Nursing Unit, with the following exceptions:
a. At least two separate social spaces, one
appropriate for noisy activities and one for quiet activities, shall be
provided. The combined area shall be a minimum of 30 square feet per patient
with a minimum of 120 square feet for each of the two spaces. This space may be
shared by dining activities if an additional 15 square feet per patient is
added; otherwise provide 20 square feet per patient for dining. Dining
facilities may be located off the nursing unit in a central area;
b. Space for group therapy shall be provided.
This may be combined with the quiet space noted above when the unit
accommodates not more than 12 patients and when at least 225 square feet of
enclosed private space is available for group therapy activities;
c. Patient laundry facilities with an
automatic washer and dryer shall be provided;
d. Examination and treatment room(s). The
examination and treatment room(s) may serve several nursing units and shall be
on the same floor and conveniently located for routine use. Examination rooms
shall have a minimum floor area of 120 square feet excluding space for
vestibule, toilets, and closets. The room shall contain a lavatory or sink
equipped for handwashing, storage facilities, and desk, counter, or shelf space
for writing;
4.
Outpatient Clinic Services. See Section 80, Physical Facilities, Outpatient
Care Facilities.
5. Imaging Suite.
See Section 56, Physical Facilities, Imaging Suite.
6. Laboratory Suite. See Section 59, Physical
Facilities, Laboratory Services.
7.
Physical Therapy Suite. See Section 60, Physical Facilities, Rehabilitation
Therapy Department.
8. Occupational
Therapy Suite. See Section 60, Physical Facilities, Rehabilitation Therapy
Department.
9. Pharmacy Suite. See
Section 62, Physical Facilities, Pharmacy.
10. Dietary Facilities. See Section 63,
Physical Facilities, Dietary Facilities.
11. Administration and Public Areas. See
Section 64, Physical Facilities, Administration and Public Areas.
12. Medical Record Unit. See Section 65,
Physical Facilities, Health Information Unit.
13. Central Storage. See Section 67, Physical
Facilities, Central Supply and Receiving.
14. Laundry Services. See Section 68,
Physical Facilities, Linen Service.
15. Facilities for Cleaning and Sanitizing
Carts and Environmental Services. See Section 69, Physical Facilities, Cleaning
and Sanitizing Carats and Environmental Services.
16. Employee Facilities. See Section 70,
Physical Facilities, Engineering Service and Equipment.
17. Engineering Services and Equipment Areas.
See Section 70, Physical Facilities, Engineering Service and
Equipment.
18. Waste Processing
Services. See Section 71, Physical Facilities, Waste Processing
Services.
19. Details and Finishes.
See Section 72, Physical Facilities, Details and Finishes.
20. Construction, Including Fire
Requirements. See Section 73, Construction, Including Fire Resistive
Requirements.
21. Elevator. See
Section 76, Physical Facilities, Electrical Standards.
22. Mechanical, Plumbing and Electrical
Requirements. See Sections 74, 75 and 76.
SECTION 83:
PHYSICAL FACILITIES,
INFIRMARIES.
A. General
Considerations. See Section 47.A, Physical Facilities.
B. General Construction Considerations. See
Section 47.A, Physical Facilities.
C. Site Location, Inspection, Approval and
Subsoil Investigation. See Section 47.D-M, Physical Facilities.
D. Construction Documents. See Section 47.K,
Physical Facilities.
E. Codes and
Standards. See Section 47.A and O, Physical Facilities.
F. General Requirements for Infirmaries.
1. General Consideration (New Construction
Only). See Section 47.A, Physical Facilities.
2. Nursing Unit (Medical). NOTE: The
infirmaries shall only provide medical services as stated in Section 48,
Patient Accommodations (Adult Medical, Surgical, Communicable or Pulmonary
Disease).
a. Patient Rooms. See Section 48,
Patient Accommodations (Adult Medical, Surgical, Communicable or Pulmonary
Disease).
b. Service Areas. See
Section 48, Patient Accommodations (Adult Medical, Surgical, Communicable or
Pulmonary Disease).
c. Isolation
Rooms. See Section 48, Patient Accommodations (Adult Medical, Surgical,
Communicable or Pulmonary Disease).
G. Outpatient Clinic.
1. General. NOTE: The outpatient facilities,
if provided shall be contained within the infirmary only. See Section 80,
Physical Facilities, Outpatient Care Facilities.
2. Outpatient Clinical Services. See Section
80, Physical Facilities, Outpatient Care Facilities.
3. Administration and Public Areas. See
Section 80, Physical Facilities, Outpatient Care Facilities.
4. Clinical Facilities. See Section 80,
Physical Facilities, Outpatient Care Facilities.
H. Radiology Suite, if provided. See Section
56, Physical Facilities, Imaging Suite. NOTE: Mobile CT, MRI and Litho Units
shall not be provided at infirmaries.
I. Laboratory Suite. See Section 59, Physical
Facilities, Laboratory Services.
J.
Physical Therapy and Respiratory Care Suite. See Section 60, Physical
Facilities, Rehabilitation Therapy Department.
K. Occupational Therapy, Recreational
Therapy, Speech/Hearing/Audio Unit Suite, if provided. See Section 60, Physical
Facilities, Rehabilitation Therapy Department.
L. Pharmacy Suite. See Section 62, Physical
Facilities, Pharmacy.
M. Dietary
Facilities. See Section 63, Physical Facilities, Dietary Facilities.
N. Administration and Public Areas. See
Section 64, Physical Facilities, Administration and Public Areas.
O. Medical Record Unit. See Section 65,
Physical Facilities, Health Information Unit.
P. Central Medical Supply Department. See
Section 67, Physical Facilities, Central Supply and Receiving.
Q. Central Supplies and Receiving. See
Section 67, Physical Facilities, Central Supply and Receiving.
R. Laundry Services. See Section 68, Physical
Facilities, Linen Service.
S.
Facilities for Cleaning and Sanitizing Carts and Environmental Services. See
Section 69,
Physical Facilities, Cleaning and Sanitizing Carts and
Environmental Services.
T.
Employee Facilities. See Section 70, Engineering Service and Equipment
Areas.
U. Engineering Services and
Equipment Areas. See Section 70, Physical Facilities, Engineering Service and
Equipment.
V. Waste Processing
Services. See Section 71, Physical Facilities, Waste Processing
Services.
W. Details and Finishes.
See Section 72, Physical Facilities, Details and Finishes.
X. Construction. See Section 73, Physical
Facilities, Construction, Including Fire Resistive Requirements.
Y. Elevators. See Section 76, Physical
Facilities, Electrical Standards.
Z. Mechanical Requirements. See Section 74,
Physical Facilities, Mechanical Requirements.
TABLE 1
Area Designation |
No. Filter Beds |
Filter Bed No.1 (%) |
1
Filter Bed No.2 (%) |
All areas for patient care, treatment, and diagnosis,
and those areas providing direct service or clean supplies such as sterile and
clean processing. |
2 |
30 |
90 |
Protective Environment Room 2 |
2 |
30 |
99.97 |
Laboratories |
1 |
80 |
- |
Administrative, Bulk Storage, Soiled Holding Areas,
Food Preparation Areas, and Laundries |
1 |
30 |
- |
¹These requirements do not
apply to small outpatient clinics or outpatient clinics that do not perform
invasive applications or procedures.
Notes: The filtration efficiency ratings are based on average
dust spot efficiency per ASHRAE 52.1 -1992.
Additional roughing or prefilters should be considered to
reduce maintenance required for filters with efficiencies higher than 75
percent.
TABLE 2
Sound Transmission Limitations in Health Care
Facilities |
|
Airborne Sound
1
Transmission Class (STC) |
|
Partitions |
Floors |
2
NEW CONSTRUCTION |
Patients= Room to Patients= Room |
45 |
40 |
3
Public Space to Patients= Room |
55 |
40 |
4
Service Areas to Patients= Room |
65 |
45 |
5
Patient room access corridor |
45 |
45 |
Exam room to exam room |
45 |
|
Exam room to public space |
45 |
|
Toilet room to public space |
45 |
|
Consultation rooms/ conference rooms to public
space |
45 |
____ |
Consultation rooms/ Conference rooms to patient
rooms |
45 |
____ |
Staff lounges to patient rooms |
45 |
|
2
Existing Construction |
|
|
Patient room to patient room |
35 |
40 |
3
Public space to patient room |
40 |
40 |
4
Service areas to patient room |
45 |
45 |
1. Sound transmission class (STC)
shall be determined by tests in accordance with methods set forth in ASTM
Standard E90 and ASTM E413. Where partitions do not extend to the structure
above, sound transmission through ceilings and composite STC performance shall
be considered.
2. Treatment rooms shall be treated
the same as patient rooms
3. Public space includes corridors
(except patient room access corridors), lobbies, dining rooms, recreation
rooms, treatment rooms, and similar spaces.
4. Service areas include kitchens,
elevators, elevator machine rooms, laundries, garages, maintenance rooms,
boiler and mechanical equipment rooms, and similar spaces of high noise.
Mechanical equipment located on the same floor or above patient rooms, offices,
nurses stations, and similar occupied space shall be effectively isolated from
the floor.
5. Patient room access corridors
contain composite walls with doors/windows and have direct access to patient
rooms.
TABLE 3
Temperature and Relative Humidity
Requirements |
Area Designation |
Dry Bulb Temperatures
ºF¹ |
Relative Humidity (%) Minimum-Maximum² |
Operating Rooms, Delivery Rooms, Endoscopy, and
Bronchoscopy |
68-73 |
30-60 |
Newborn Intensive Care and Newborn Nursery
Suite |
72-78 |
30-60 |
Recovery, Intensive Care, Trauma Rooms, Procedure
Rooms, and Radiological X-ray (Surgical/Critical Care and
Catheterization) |
71-75 |
30-60 |
Clean Work Room and ETO Sterilizer Room |
75 |
30-60 |
Sterile Storage |
75 |
70 (max) |
¹Where temperature ranges are
indicated, the systems shall be capable of maintaining the rooms at any point
within the range. A single figure indicates a heating or cooling capacity of at
least the indicated temperature. This is usually applicable when patients may
be undressed and require a warmer environment. Nothing in these guidelines
shall be construed as precluding the use of temperatures lower than those noted
when the patients= comfort and medical conditions make lower temperatures
desirable. Unoccupied areas such as storage rooms shall have temperatures
appropriate for the function intended.
2Humidification systems serving anesthetizing locations shall
be designed in accordance with NFPA 99 paragraph 5-4.1.1.
TABLE 4
Ventilation, Medical Gas, and Air Flow Requirements in
Health Care Facilities1
Area Designation |
Air Movement Relationship To Adjacent Area |
Minimum Air
Changes Outside Air
Per Hour3 |
Minimum Total Air Changes Per
Hour4,5 |
Air
Recirculated By
Means of Room
Unit7 |
All Air Exhausted Directly
Outdoor6 |
SURGERY AND CRITICAL CARE
AREAS |
Operating/Surgical Cystoscopic Rooms
8,9 |
Out |
3 |
15 |
No |
Optional |
Delivery Room
8 |
Out |
3 |
15 |
No |
Optional |
Recovery Room8 |
- |
2 |
6 |
No |
Optional |
Critical Care and Intensive Care |
- |
2 |
6 |
No |
Optional |
Newborn intensive care |
- |
2 |
6 |
No |
Optional |
Treatment Room 10 |
- |
- |
6 |
Optional |
Optional |
Trauma Room10 |
Out |
3 |
15 |
No |
Optional |
Anesthesia gas storage |
In |
- |
8 |
Optional |
Yes |
Endoscopy |
In |
2 |
6 |
No |
Optional |
Bronchoscopy
9 |
In |
2 |
12 |
No |
Yes |
ER Waiting Room |
In |
2 |
12 |
No |
Yes 11,12 |
Triage |
In |
- |
12 |
No |
11
Yes |
Radiology waiting rooms |
In |
2 |
12 |
Optional |
11, 12
Yes |
Procedure room |
Out |
3 |
15 |
No |
Optional |
NURSING AREAS |
Patient Room |
- |
2 |
13
6 |
Optional |
Optional |
Toilet Room |
In |
- |
10 |
Optional |
Yes |
Newborn Nursery Suite |
- |
2 |
6 |
No |
Optional |
Protective environment room 9,14 |
Out |
2 |
12 |
No |
Optional |
Airborne Infectious Isolation, Bronchoscopy
9, 15
Room |
In |
2 |
12 |
No |
Yes |
14,15
Isolation alcove or anteroom |
In/Out |
- |
10 |
No |
Yes |
Labor/Delivery/Recovery (LDR) |
- |
2 |
13
6 |
Optional |
Optional |
Labor/Delivery/ Recovery/ Post Partum (LDRP)
- |
- |
2 |
613 |
Optional |
Optional |
Patient Corridor |
- |
- |
2 |
Optional |
Optional |
ANCILLARY AREAS |
Radiology X-ray (Surgical/Critical Care &
16
Catheterization) |
Out |
3 |
15 |
No |
Optional |
Radiology X-ray (Diagnostic &
Treatment)16 |
- |
- |
6 |
Optional |
Optional |
Radiology Darkroom |
In |
- |
10 |
No |
Yes |
l6
Lab General |
- |
- |
6 |
Optional |
Optional |
16
Lab Biochemistry |
Out |
- |
6 |
No |
Optional |
Lab Cytology |
In |
- |
6 |
No |
Yes |
Lab Glass Washing |
In |
- |
10 |
Optional |
Yes |
Lab Histology |
In |
- |
6 |
No |
Yes |
Lab Microbiology
16 |
In |
- |
6 |
No |
Yes |
Lab Nuclear Med |
In |
- |
6 |
No |
Yes |
Lab Pathology |
In |
- |
6 |
No |
Yes |
Lab Serology |
Out |
- |
6 |
No |
Optional |
Lab Sterilizing |
In |
- |
10 |
Optional |
Yes |
Autopsy9 |
In |
- |
1712 |
No |
Yes |
Nonrefrigerated body holding room |
In |
- |
10 |
Optional |
Yes |
Pharmacy |
Out |
- |
4 |
Optional |
Optional |
DIAGNOSTIC AND TREATMENT AREAS |
Examination Room |
- |
- |
6 |
Optional |
Optional |
Medication Room |
Out |
- |
4 |
Optional |
Optional |
Treatment Room |
- |
- |
6 |
Optional |
Optional |
Physical Therapy and Hydrotherapy |
In |
- |
6 |
Optional |
Optional |
Soiled Workroom or Soiled Holding |
In |
- |
10 |
No |
Yes |
Clean Workroom or Clean Holding |
Out |
- |
4 |
Optional |
Optional |
STERILIZING AND SUPPLY AREAS |
ETO Sterilizer Room |
In |
- |
10 |
No |
Yes |
Sterilizer Equipment Room |
In |
- |
10 |
Optional |
Yes |
Central Supply Soiled or Decontamination
Room |
In |
- |
6 |
No |
Yes |
Central Supply Clean
Workroom17 |
Out |
- |
4 |
No |
Optional |
Sterile Storage |
Out |
- |
4 |
Optional |
Optional |
SERVICE AREAS |
Food Preparation
Centers17 |
- |
- |
10 |
No |
Optional |
Warewashing |
In |
- |
10 |
No |
Yes |
Dietary Day Storage |
In |
- |
2 |
Optional |
Optional |
Laundry, General |
- |
- |
10 |
Optional |
Yes |
Soiled Linen Sorting and Storage |
In |
- |
10 |
No |
Yes |
Clean Linen Storage |
Out |
- |
2 |
Optional |
Optional |
Soiled Linen and Trash Chute Room |
In |
- |
10 |
No |
Yes |
Bedpan Room |
In |
- |
10 |
Optional |
Yes |
Bathroom |
In |
- |
10 |
Optional |
Optional |
Janitor's Closet |
In |
- |
10 |
No |
Yes |
Notes for Table 4
1. The ventilation rates in this
table cover ventilation for comfort, as well as for asepsis and odor control in
areas of acute care hospitals that directly affect patient care and are
determined based on healthcare facilities being predominantly "No Smoking"
facilities. Where smoking may be allowed, ventilation rates will need
adjustment. Areas where specific ventilation rates are not given in the table
shall be ventilated in accordance with ASHRAE Standard 62, Ventilation for
Acceptable Indoor Air Quality; and ASHRAE Handbook-HVAC Applications.
Specialized patient care areas, including organ transplant units, burn units,
specialty procedure rooms, etc., shall have additional ventilation provisions
for air quality control as may be appropriate. OSHA standards and/or NI0SH
criteria require special ventilation requirements for employee health and
safety within healthcare facilities.
2. Design of the ventilation system
shall provide air movement which is generally from clean to less clean areas.
If any form of variable air volume or load shedding system is used for energy
conservation, it shall not compromise the corridor-to-room pressure balancing
relationships or the minimum air changes required by the table. Where the air
movement relationship is "In " (negative) or "Out" (positive), the air movement
relationship shall not be reversible. Rooms with reversible airflow provision
for the purpose of switching between "In" and "Out" are not acceptable.
3. To satisfy exhaust needs,
replacement air from the outside is necessary. Table 4 does not attempt to
describe specific amounts of outside air to be supplied to individual spaces
except for certain areas such as those listed. Distribution of the outside air,
added to the system to balance required exhaust, shall be as required by good
engineering practice. Minimum outside air quantities shall remain constant
while the system is in operation.
4. Number of air changes may be
reduced when the room is unoccupied if provisions are made to ensure that the
number of air changes indicated is reestablished any time the space is being
utilized. Adjustments shall include provisions so that the direction of air
movement shall remain the same when the number of air changes is reduced. Areas
not indicated as having continuous directional control may have ventilation
systems shut down when space Is unoccupied and ventilation is not otherwise
needed, if the maximum infiltration or exfiltration permitted in Note 2 is not
exceeded and if adjacent pressure balancing relationships arc not compromised.
Air quantity calculations shall account for filter loading such that the
indicated air change rates are provided up until the time of filter
change-out.
5. Air change requirements indicated
are minimum values. Higher values should be used when required to maintain
indicated room conditions (temperature and humidity), based on the cooling load
of the space (lights, equipment, people, exterior walls and windows,
etc.).
6. Air from areas with contamination
and/or odor problems shall be exhausted to the outside and not recirculated to
other areas. Note that individual circumstances may require special
consideration for air exhaust to the outside, e.g., in intensive care units in
which patients with pulmonary infection are treated, and rooms for burn
patients.
7. Recirculating room HVAC units
refers to those local units that are used primarily for heating and cooling of
air, and not disinfection of air. Because of cleaning difficulty and potential
for buildup of contamination, recirculating room units shall not be used in
areas marked "No." However, for airborne infection control, air may be
recirculated within Individual isolation rooms if HEPA filters are used.
Isolation and intensive care unit rooms may be ventilated by reheat induction
units in which only the primary air supplied from a central system passes
through the reheat unit. Gravity-type heating or cooling units such as
radiators or convectors shall not be used m operating rooms and other special
care areas. See Appendix A for a description of recirculation units to be used
in isolation rooms.
8. National Institute for
Occupational Safety and Health (NIOSH) Criteria Documents regarding
Occupational Exposure to Waste Anesthetic Gases and Vapors, and Control of
Occupational Exposure to Nitrous Oxide indicate a need for both local exhaust
(scavenging) systems and general ventilation of the areas in which the
respective gases are utilized.
9. Differential pressure shall be a
minimum of 0.01" water gauge (2.5 Pa). If alarms are installed, allowances
shall be made to prevent nuisance alarms of monitoring devices.
10. The term trauma room as used
here is the operating room space in the emergency department or other trauma
reception area that is used for emergency surgery. The first aid room and/or
"emergency room" used for initial treatment of accident victims may be
ventilated as noted for the "treatment room." Treatment rooms used for
Bronchoscopy shall be treated as Bronchoscopy rooms. Treatment rooms used for
cryosurgcry procedures with nitrous oxide shall contain provisions for
exhausting waste gases.
11. In a ventilation system that
recirculates air, HEPA filters can be used in lieu of exhausting the air from
these spaces to the outside. In this application, the return air shall be
passed through the HEPA filters before it is introduced into any other
spaces.
12. If it is not practical to
exhaust the air from the airborne infection isolation room to the outside, the
air may be returned through HEPA filters to the air-handling system exclusively
serving the isolation room.
13. Total air changes per room for
patient rooms, labor/delivery/recovery rooms, and
labor/delivery/recovery/postpartum rooms may be reduced to 4 when supplemental
heating and/or cooling systems (radiant heating and cooling, baseboard heating,
etc.) are used.
14. The protective environment
airflow design specifications protect the patient from common environmental
airborne infectious microbes (i.e., Aspergillus spores). These special
ventilation areas shall be designed to provide directed airflow from the
cleanest patient care area to less clean areas. These rooms shall be protected
with HEPA filters at 99.97 percent efficiency for a 0.3 micron sized particle
in the supply airstream. These Interrupting filters protect patient rooms from
maintenance-derived release of environmental microbes from the ventilation
system components. Recirculation HEPA filters can be used to increase the
equivalent room air exchanges. Constant volume airflow is required for
consistent ventilation for the protected environment. It the facility
determines that airborne infection isolation is necessary for protective
environment patients, an anteroom shall be provided. Rooms with reversible
airflow provisions for the purpose of switching between protective environment
and airborne infection isolation functions are not acceptable.
15. The infectious disease isolation
room described in these guidelines is to be used for isolating the airborne
spread of infectious diseases, such as measles, varicella, or tuberculosis. The
design of airborne infection isolation (All) rooms should include the provision
for normal patient care during periods not requiring Isolation precautions.
Supplemental recirculating devices may be used in the patient room, to increase
the equivalent room air exchanges; however, such recirculating devices do not
provide the outside air requirements. Air may be recirculated within individual
isolation rooms if HEPA filters are used. Rooms with reversible airflow
provisions for the purpose of switching between protective environment and All
functions are not acceptable.
16. When required, appropriate hoods
and exhaust devices for the removal of noxious gases or chemical vapors shall
be provided per NFPA 99.
17. Food preparation centers shall
have ventilation systems whose air supply mechanisms arc interfaced
appropriately with exhaust hood controls or relief vents so that exfiltration
or infiltration to or from exit corridors does not compromise the exit corridor
restrictions of NFPA 90A, the pressure requirements of NFPA 96, or the maximum
defined in the table. The number of air changes may be reduced or varied to any
extent required for odor control when the space is not in use.
TABLE 5
Final Occupancy Inspection Check List
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TABLE 6
Behavioral Screening Exam
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TABLE 7
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TABLE 8
RECORD RETENTION TIME FRAMES
DEPARTMENT |
DOCUMENT |
RETENTION TIME |
Administrative |
Governing Body |
Permanent |
Medical Staff |
Permanent |
Executive Committees |
Permanent |
Other Hospital Committees |
2 years |
Medical Records |
Original/Microfilm
Adult/Inpatient/Outpatient
Electrocardiogram Strips/
Interpretations
Electroencephalogram/
Interpretations |
10 years after last discharge.
Facility shall maintain information in the master
patient index. |
|
Original/Microfilm
Minor/Inpatient/Outpatient
Fetal Monitor Strips
Electroencephalogram/
Interpretations
Electroencephalogram/
Interpretations |
10 years after last discharge plus 2 years past
majority. Facility shall maintain information in the master patient
index. |
Radiology |
Films |
5 years |
Nuclear Medicine |
Films |
5 years |
Laboratory |
Blood Gas Reports |
2 years |
Patient Specimens |
2 years |
Control Documentation |
2 years |
Immunohematology |
5 years |
Immunohematology Quality Control Records |
5 years |
Cytology: Histopathology Quality Control
Records |
10 years |
Transfusions |
5 years |
Blood Donor Samples |
7 days post transfusion |
Quality Assurance |
2 years |
Pathology Lab |
Pathology Reports |
10 years |
Reference Pathology |
2 years |
Preliminary/Corrected |
Exact duplicate |
Histopathology |
Stained Slides |
10 years |
Specimen Blocks |
2 years |
Pharmacy |
All drug records to include: Purchase invoices Official
records Prescription records Inventory records, etc |
2 years |
TABLE 9
REQUIRED TEMPERATURES
MEDICATIONS |
Refrigerators |
36-46 ºF |
Medication Storage Room |
59-86 ºF |
1
DIETARY |
Temperature of Food at Bedside |
Hot Foods =[GREATER THAN]140ºF |
|
Cold Foods =[LESS THAN]40ºF |
Temperature of Heated Food Prior to Hot
Holding |
[GREATER THAN]160 ºF |
Temperature of Heated Leftovers Prior to Hot
Holding |
[GREATER THAN]165ºF |
Temperature for Thawing Potentially Hazardous
Food |
Tempering Units = 45ºF or less |
|
Refrigerator = 40ºF or less |
Refrigerators |
[LESS THAN]40ºF |
Freezers |
[LESS THAN]0ºF |
Single Tank Stationary Rack Dual Temperature
Machine |
Wash Temperature = 150ºF Final Rinse Temperature =
180ºF |
Single Tank Conveyor Machine |
Wash Temperature = 180ºF |
|
Final Rinse Temperature = 180ºF |
Multi-tank Conveyor Machine |
Wash Temperature = 150ºF |
|
Final Rinse Temperature = 180ºF |
|
Pumped Rinse Temperature = 160ºF |
Single Tank Pot, Pan & |
Wash Temperature = 140ºF |
Utensil Washer |
Final Rinse Temperature = 180ºF |
Manual Warewashing |
Wash Temperature = 110ºF |
|
Rinse Temperature = 120ºG - 140ºF |
Chemical Sanitation (Manual or Mechanical) |
Sanitation Temperature = *171ºF or Immersion in
75ºF water and 50 ppm of hypochlorite for at least 1 minute or other
method approved by Arkansas Department of Health |
All Cutting Board Surfaces |
Immersion in clean, hot water of * 180ºF for at
least 30 seconds or any other method approved. |
LAUNDRY2 |
Water |
Nothing under 120ºF |
Water with Chlorine Bleach |
150 parts per million ppm (parts per
million) |
CLINICAL |
Gallons per hour per
bed2 |
105ºF - 120ºF |
Notes for Table 9:
1. Provisions shall be made to
provide 180°F rinse water at warewasher. (may be by a separate
booster.)
2. Provisions shall be made to
provide 160°F hot water at the laundry equipment when needed. (This may be
a steam jet or separate booster heater.) However, this does not imply that all
water used would be at this temperature. Water temperatures required for
acceptable laundry results will vary. Lower temperatures may be adequate for
most procedures in many facilities but the higher 160°F should be available
when needed for special conditions.
TABLE 10
Newborn Screening Requirements
All Newborns shall be tested for: |
1. Newborn Hearing Screening |
2. Newborn Genetic Screening: |
PKU Phenylketonuria |
CH Congenital Hypothyroidism |
Galactosemia |
Sickle Cell Anemia* |
For further Information Arkansas Department of Health,
Child & Adolescent Health Team |
Contacts: Newborn Lab Screening:
501-661-2592 |
Newborn Hearing Screening: 501-661-2459 |
Note: Lab specimens should be mailed promptly to prevent
degradation of the specimen and increase the quality of results.
Reference: Ark. Code Ann.
20-15-302,304 Ark. Code Ann.
20-15-1104 Ark. Code Ann.
20-15-1504
*Non-Caucasians
TABLE 11
Central6 Station Outlets for
Oxygen, Vacuum (Suction), and Medical Air Systems in
Hospitals1
Patient Rooms (medical & surgical) |
1/bed |
1/bed |
- |
Examination/Treatment
(medical, surgical, endoscopy & postpartum
care) |
1/room |
1/room |
- |
Isolation -Infectious and protective medical &
surgical) |
1/bed |
1/bed |
- |
Security Room (medical, surgical, &
postpartum) |
1/bed |
1/bed |
- |
Critical Care (general) |
3/bed |
3/bed |
1/bed |
Isolation (critical) |
3/bed |
3/bed |
1/bed |
Coronary Critical Care |
3/bed |
2/bed |
1/bed |
Pediatric Critical Care |
3/bed |
3/bed |
1/bed |
Newborn Intensive Care |
3/bassinet |
3/bassinet |
3/bassinet |
Newborn Nursery (full-term) |
1 / 4 bassinets2 |
1 / 4 bassinets2 |
1 / 4 bassinets2 |
Pediatric and Adolescent |
1/bed |
1/bed |
1/bed |
Pediatric Nursery |
1/bassinet |
1/bassinet |
1/bassinet |
Psychiatric Patient Rooms |
- |
- |
- |
Seclusion Treatment Room |
- |
- |
- |
General Operating Room |
2/room |
3/room |
- |
Cardio, Ortho, Neurological |
2/room |
3/room |
- |
Orthopedic Surgery |
2/room |
3/room |
- |
Surgical Cysto & Endo |
1/room |
3/room |
- |
Post-anesthesia Care Unit |
1/bed |
3/bed |
1/bed |
Anesthesia Workroom |
1 per workstation |
- |
1 per workstation |
3
Phase II Recovery |
1/bed |
3/bed |
- |
Postpartum Bedroom |
1/bed |
1/bed |
- |
Cesarean/Delivery Room |
2/room |
3/room |
1/room |
4
Infant Resuscitation Station |
1/bassinet |
1/bassinet |
1/bassinet |
Labor Room |
1/room |
1/room |
1/room |
OB Recovery Room |
1/bed |
3/bed |
1/room |
5
Labor/Delivery/Recovery (LDR) |
2/bed |
2/bed |
- |
5
Labor/Delivery/Recovery (LDRP) |
2/bed |
2/bed |
- |
Initial Emergency Management |
1/bed |
1/bed |
- |
Triage Area (definitive emergency care) |
1/station |
1/station |
- |
Definitive Emergency Care Exam/Treatment
Rooms |
1/bed |
1/bed |
1/bed |
Definitive Emergency Care Holding Area |
1/bed |
1/bed |
- |
Trauma/Cardiac Room(s) |
2/bed |
3/bed |
1/bed |
Orthopedic & Cast Room |
1/room |
1/room |
- |
Cardiac Catheterization Lab |
2/bed |
2/bed |
2/bed |
Autopsy Room |
- |
1 per workstation |
1 per workstation |
Notes for Table 11
1. For any area or room not
described above, the facility clinical staff shall determine outlet
requirements after consultation with the authority having jurisdiction.
2. Four bassinets may share one
outlet that is accessible to each bassinet.
3. If Phase II recovery area is a
separate area from the PACU, only one vacuum per bed or station shall be
required.
4. When infant resuscitation takes
place in a room such as cesarean section/delivery or LDRP, then the infant
resuscitation services shall be provided in that room in addition to the
minimum service required for the mother.
5. Two outlets for mother and two
for one bassinet.
6. Facilities with medical gas
requirements in more than one area shall be equipped with central
systems.
TABLE 12 VERBAL ORDER
Basic Premise: |
Verbal orders may be used when there is no reasonable
alternative to obtaining a written order. |
State Health Rules: |
Permit licensed nurses and pharmacist (for drugs only)
to take verbal orders and no one else. Section 12, Medications and Section 14,
Health Information Services. |
Practical Application: |
Health professionals other than nurses may take verbal
orders pertaining directly to their profession under specified
circumstances. |
Situation to Address: |
1. Doctor in the department away from nurses
station.
2. Doctor calls the department. |
Policy Statement Parts: |
1. Who are the authorized receivers?
2. Repeat order back for accuracy.
3. Identify ordering doctor.
4. Identify receiver by name and title.
5. The receiver of the order shall enter the order on
the medical record, and then sign first initial, last name and
title. |
Hospital Administration Responsibility: |
1. Policy shall be in writing, and approved by the
Medical Staff and Governing Body (including identification of
receivers).
2. Policy shall be made a part of applicable department
manuals.
3. Inservice training provided for all personnel
involved.
4. Establish an effective monitoring
system. |
Outpatient Department (Emergency Services is not
outpatient): |
1. The therapist or other authorized receivers may take
a verbal or telephone order from the doctor.
2. Shall document on outpatient medical record.
3. Doctor shall authenticate the order on his next
visit. |
RATIONALE
Health Facility Services has received numerous requests for a
variance in the regulations relating to who may receive doctors orders for
hospital inpatients and outpatients. This office realizes the communication
problems involved between every expanding service departments of hospitals and
the multiplicity of diagnostic treatment, therapy, and therapeutic duties
necessary for coordinating of patient care. Other certification and accrediting
organizations have also realized the communication difficulty.
The reason and intent of the regulation was, and still is, to
coordinate all inpatient care through nursing service. The patient's medical
record shall be maintained at the nurses station to coordinate and implement
physician orders for patient care and services.
It is the intent of this policy to have
both communication between departments and also assure
all physician orders and services rendered to patients are promptly documented
on the patient's chart. In order to maintain continuity of care on an inpatient
basis, it is necessary that all aspects of the patients' treatment be
coordinated through the nursing service of the facility.
TABLE 13 REUSE
THIRD PARTY REPROCESSING OF SINGLE USE
ITEMS
The Office of Compliance Center of Devices and Radiological
Health of the Food and Drug Administration (FDA) provides guidelines for third
party reprocessing of devices labeled for single use provided the reprocessing
firm complies fully with all FDA regulatory requirements.
The Arkansas Department of Health will recognize FDA
guidelines.
CERTIFICATION
This will certify that the foregoing revisions to the Rules and
Regulations for Hospitals and Related Institutions in Arkansas were adopted by
the State Board of Health of Arkansas at a regular session of said Board held
in Little Rock, Arkansas, on the 26th day of July,
2007.
____________________________________
Paul Halverson, DrPH. Date
Executive Officer, Arkansas State Board of Health, State Health
Officer
The forgoing Rules and Regulation, copy having been filed in my
office, are hereby approved.
____________________________________
Mike Beebe Date
Governor