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 22 - BIRTH CENTERS
Section 6 CCR 1011-1-22-4 - GOVERNING BODY

(A) adopt administrative and operational by-laws in accordance with legal requirements that include the facility's organizational structure with lines of authority and responsibility.

(B) meet at least annually and maintain accurate records of such meetings.

(C) define the scope of the services provided by the facility.

(D) ensure that the facility is available for occupancy 24 hours per day.

(E) appoint, in writing, a full-time administrator.

(F) appoint and delineate, in writing, clinical privileges of practitioners based upon recommendations by the clinical staff and commensurate with the practitioner's qualifications, experience, and present capabilities. An up-to-date roster of practitioners credentialed by the facility that specifies the approved procedural privileges of each practitioner shall be available to the staff at all times.

(G) approve written policies and procedures for the operation of the facility. Policies and procedures shall be consistent with current professional standards, reviewed annually and revised as necessary.

(H) ensure that contracted services are delivered in accordance with the facility's policies and procedures. Contracts, including service contracts, shall be reviewed annually and revised as necessary.

(I) develop job descriptions for all employee positions that delineate functional responsibilities and authority.

(J) maintain an effective quality management program in accordance with 6 CCR 1011-1, Chapter 2, Part 4.

(K) adopt a national standard for infection control and ensure the adequate investigation, control and prevention of infections.

(L) establish a written plan for emergent and non-emergent transport of clients to a hospital with specific examples that denote emergent and non-emergent conditions. The effectiveness of the plan shall be evaluated annually. Clients with an emergent condition shall be transported by emergency medical services to the nearest hospital capable of providing care.

(M) develop and maintain a written emergency preparedness plan for the emergency care or relocation of clients in the event of fire or other physical damage to the facility, weather emergencies endemic to the region, loss of utilities or equipment malfunction. The plan shall be current. Emergency evacuation drills shall be conducted at least semiannually.

(N) ensure that staff perform medical emergency drills at least quarterly.