Code of Colorado Regulations
1000 - Department of Public Health and Environment
1011 - Health Facilities and Emergency Medical Services Division (1011, 1015 Series)
6 CCR 1011-1 Chapter 13 - FREESTANDING EMERGENCY DEPARTMENTS
Part 6 - GOVERNANCE AND LEADERSHIP
Universal Citation: 1000 CO Code Regs 6
Current through Register Vol. 47, No. 5, March 10, 2024
6.1 Administrator
(A) The FSED shall have an
administrator or a designated person who is principally responsible for
directing the daily operation of the FSED and acts as an administrative liaison
with the governing body and medical director.
(B) The administrator shall be responsible
for the development and implementation of:
(1) Policies and procedures for all FSED
operations. The policies and procedures shall be reviewed and updated as
needed, but no less than every three years.
(2) A written organizational plan defining
the authority, responsibility, and function of each category of
personnel.
(3) A written policy or
plan defining the scope of care and services offered, which shall include
emergency services, as required in Part 18, and optional primary care services
as defined in Part 2.10, if provided.
(4) If primary care services are offered, the
FSED administrator, in conjunction with the governing body and medical
director, shall ensure that policies, procedures, and clinical guidelines are
developed, implemented, and maintained for any primary care services included
in the scope of care.
6.2 Governing Body
(A) An FSED shall have a governing body that
is legally responsible for the conduct of the FSED.
(B) The governing body shall:
(1) Meet at least annually and maintain
accurate records of such meetings.
(2) Adopt the general bylaws by which the
governing body operates.
(3) Ensure
that patients receive care in a safe setting, including providing the
equipment, supplies, and facilities necessary for the welfare and safety of
patients.
(4) Ensure that there are
written procedures for:
(a) Lines of authority
and accountability, and
(b) The
qualifications of the personnel performing care.
(5) Ensure the approval and implementation of
written policies and procedures in cooperation with the administrator and
medical director.
(6) Ensure that
there is sufficient staff to meet the demands for services routinely provided
and coverage during periods of high demand or emergency.
(7) Ensure any disciplinary action that
results in a suspension, revocation, or limitation of the privileges of a
member of the provider, nursing, or ancillary staff is reported to the
appropriate licensing or certification authority.
(8) Ensure that the FSED meets all of the
Quality Management Program requirements of Part 8.
(9) Establish a patient transfer plan that
includes:
(a) Agreements with a hospital(s)
that include procedures for obtaining air or ground transportation, as
appropriate.
(b) Policies and
procedures for when an emergency medical condition necessitates patient
transfer. The patient shall be transferred, avoiding delay in care and with
consideration of transport time, to the closest, most appropriate acute care
hospital with the resources necessary to meet the needs of the patient, unless
either of the following dictates otherwise:
(i) The federal Emergency Medical Treatment
and Active Labor Act
(EMTALA) requirements codified at 42 U.S.C. 1395dd, or
(ii) Regional trauma triage
protocols.
(c) Transfer
protocols to include:
(i) Coordination with
the local emergency medical services system and licensed ambulance
services.
(ii) Triage and
stabilization to be initiated by on-duty staff.
(iii) Transfer of relevant patient
information with the patient.
(iv)
Compliance with all requirements as a designated or non-designated trauma
center per regulation,
6 CCR
1015-4, Chapter Three, 301.3.
6.3 Medical Director
(A) A medical director shall be a
physician, licensed under the laws of the State of Colorado, who is a member of
the FSED's staff and who is qualified by education and experience to oversee
the services provided by the FSED. The medical director shall be responsible
for the quality of medical care provided to patients in the facility.
(B) The medical director shall be responsible
for the development of policies and procedures related to the medical care
provided. The policies and procedures shall be approved by the appropriate
members of the provider staff and reviewed and updated as needed, but no less
than every three years.
(C) The
medical director shall serve as the formal clinical liaison with the governing
body.
(D) The medical director
shall ensure that services are provided in accordance with current standards of
practice and are consistent with standards established through the Quality
Management Program as defined in Part 8.
(E) The medical director shall be responsible
for the coordination of all the professional medical consultants to the FSED,
if any.
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