Florida Administrative Code
59 - AGENCY FOR HEALTH CARE ADMINISTRATION
59A - Health Facility and Agency Licensing
Chapter 59A-3 - HOSPITAL LICENSURE
Section 59A-3.273 - Management and Administration
Universal Citation: FL Admin Code R 59A-3.273
Current through Reg. 50, No. 187; September 24, 2024
(1) Each hospital shall be under the direction of a chief executive officer appointed by the governing board, who is responsible for the operation of the hospital in a manner commensurate with the authority conferred by the governing board.
(2) The chief executive officer shall take all reasonable steps to provide for:
(a) Compliance with applicable laws and
regulations; and,
(b) The review of
and prompt action on reports and recommendations of authorized planning,
regulatory, and inspecting agencies.
(3) The chief executive officer shall provide for the following:
(a) Establishment and
implementation of organized management and administrative functions, including:
1. Clear lines of responsibility and
accountability within and between department heads and administrative
staff;
2. Effective communication
mechanisms among departments, medical staff, the administration and the
governing board;
3. Internal
controls;
4. Coordination of
services with the identified needs of the patient population;
5. A policy on patient rights and
responsibilities;
6. A mechanism
for receiving and responding to complaints concerning patient care;
7. A policy on withholding resuscitative
services;
8. Policies and
procedures on identification and referral of organ and tissue donors including
notification of organ and tissue procurement agencies when organs and tissues
become available as specified under rule
59A-3.274, F.A.C.;
9. Policies and procedures for meeting the
communication needs of multicultural populations and persons with impaired
hearing or speaking skills;
10.
Policies and procedures on discharge planning;
11. A policy to assist in accessing
educational services for children or adolescents when treatment requires a
significant absence from school;
12. Policies and procedures to assure that
the treatment, education and developmental needs of neonates, children and
adolescents transferred from one setting to another are assessed;
13. Dissemination and enforcement of a policy
prohibiting the use of smoking materials in hospital buildings and procedures
for exceptions authorized for patients by a PA, APRN or physician's written
authorization;
14. A policy
regarding the use of restraints and seclusion; and,
15. A comprehensive emergency management plan
which meets the requirements of paragraph
395.1055(1)(c),
F.S., and rule 59A-3.078,
F.A.C.
(b) Personnel
policies and practices which address:
1.
Non-discriminatory employment practices;
2. Verification of credentials including
current licensure and certification;
3. Periodic performance evaluations; and,
4. Provision of employee health
services.
(c) Financial
policies and procedures;
(d) An
internal risk management program which meets the requirements of section
395.0197, F.S., and chapter
59A-10, F.A.C., and,
(e) Assurance
of compliance with educational requirements on human immunodeficiency virus and
acquired immune deficiency syndrome pursuant to sections
381.0034 and
381.0035, F.S., and chapter
64D-2, F.A.C.
Rulemaking Authority 395.1055 FS. Law Implemented 395.0197, 395.1055 FS.
New 9-4-95, Formerly 59A-3.218, Amended 10-16-14.
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