California Code of Regulations
Title 22 - Social Security
Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies
Chapter 1 - General Acute Care Hospitals
Article 7 - Administration
Section 70701 - Governing Body
Universal Citation: 22 CA Code of Regs 70701
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) The governing body shall:
(1) Adopt written bylaws in accordance with legal requirements and its community responsibility which shall include but not be limited to provision for:
(A) Identification of the purposes of the hospital and the means of fulfilling them.
(B) Appointment and reappointment of members of the medical staff.
(C) Appointment and reappointment of one or more dentists, podiatrists, and/or clinical psychologists to the medical staff respectively, when dental, podiatric, and/or clinical psychological services are provided.
(D) Formal organization of the medical staff with appropriate officers and bylaws.
(E) Membership on the medical staff which shall be restricted to physicians, dentists, podiatrists, and clinical psychologists competent in their respective fields, worthy in character and in professional ethics. No hospital shall discriminate with respect to employment, staff privileges or the provision of professional services against a licensed clinical psychologist within the scope of his/her licensure, or against a licensed physician and surgeon or podiatrist on the basis of whether the physician and surgeon or podiatrist holds an M.D., D.O. or D.P.M. degree. Wherever staffing requirements for a service mandate that the physician responsible for the service be certified or eligible for certification by an appropriate American medical board, such position may be filled by an osteopathic physician who is certified or eligible for certification by the equivalent appropriate American Osteopathic Board.
(F) Self-government by the medical staff with respect to the professional work performed in the hospital, periodic meetings of the medical staff to review and analyze at regular intervals their clinical experience and requirement that the medical records of the patients shall be the basis for such review and analysis.
(G) Preparation and maintenance of a complete and accurate medical record for each patient.
(2) Appoint an administrator whose qualifications, authority and duties shall be defined in a written statement adopted by the governing body.
(3) The Department shall be notified in writing whenever a change of administrator occurs.
(4) Provide appropriate physical resources and personnel required to meet the needs of the patients and shall participate in planning to meet the health needs of the community.
(5) Take all reasonable steps to conform to all applicable federal, state and local laws and regulations, including those relating to licensure, fire inspection and other safety measures.
(6) Provide for the control and use of the physical and financial resources of the hospital.
(7) Require that the medical staff establish controls that are designed to ensure the achievement and maintenance of high standards of professional ethical practices including provision that all members of the medical staff be required to demonstrate their ability to perform surgical and/or other procedures competently and to the satisfaction of an appropriate committee or committees of the staff, at the time of original application for appointment to the staff and at least every two years thereafter.
(8) Assure that medical staff by-laws, rules and regulations are subject to governing body approval, which approval shall not be withheld unreasonably.
(9) These by-laws shall include an effective formal means for the medical staff, as a liaison, to participate in the development of all hospital policy.
1. Amendment filed 2-8-83; designated effective 3-2-83 (Register 83, No. 7).
2. Editorial correction of subsection (a)(7) filed 8-31-83; effective thirtieth day thereafter (Register 83, No. 36).
Note: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference: Sections 1276, 1315, 1316 and 1316.5, Health and Safety Code.
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