Compilation of Rules and Regulations of the State of Georgia
Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH
Chapter 111-8 - HEALTHCARE FACILITY REGULATION
Subject 111-8-22 - END STAGE RENAL DISEASE FACILITIES
Rule 111-8-22-.06 - Facility Organization and Administration
Universal Citation: GA Rules and Regs r 111-8-22-.06
Current through Rules and Regulations filed through September 23, 2024
(1) Governing Body. The facility shall function under the control of an identifiable governing body, which has full legal authority for the governance and operation of the facility.
(a) The governing body shall specify in writing the operational objectives of the facility, including which services are to be offered.
(b) The governing body shall be responsible for the establishment, adoption, and annual review of administrative rules and regulations and facility policies and procedures, and for ensuring that they are in accordance with accepted standards of practice and safeguard the health and safety of patients.
(c) The governing body shall be responsible for ensuring that the facility's design and operation are in compliance with all relevant federal, state, and local legal requirements.
(d) The governing body shall adopt for the facility admission criteria that ensure equitable access to services for individuals needing care for end stage renal disease.
(e) The governing body shall designate sufficient staff and allocate sufficient staff time to implement the facility's quality management program and shall provide for leadership support of the program.
(f) The governing body shall establish and implement written policies regarding the determination, selection, or privileging of medical staff for the facility.
(g) The governing body shall appoint a facility administrator to be responsible for the administrative management of the facility and the enforcement of adopted rules and regulations.
1. The governing body shall delineate the responsibilities of the facility administrator in writing and shall ensure that the administrator is sufficiently free of other duties to provide effective management of the facility.
2. The governing body of the facility shall notify the Department of a change in the administrator of the facility and shall at that time provide the name and contact numbers of the new administrator.
(2) Facility Administrator.
(a) The facility administrator may serve on a full-time or part-time basis, but shall serve sufficient time to plan, organize, and direct the overall function of the facility, and to carry out those responsibilities as assigned by the governing body. The facility administrator shall meet one of the following qualifications:
1. Holds at least a baccalaureate degree and has at least one (1) year experience in an end stage renal disease facility; or
2. Meets the qualifications for a physician director or a nurse responsible for nursing services for an end stage renal disease facility as described in these rules; or
3. As of the first effective date of these rules, has been acting for at least two years as a facility administrator for an end stage renal disease facility which has been certified for a federal Medicare program.
(b) The facility administrator shall be responsible for:
1. Management of the facility's fiscal affairs, including maintenance of financial records and generating regular reports of expenses and revenues for review by the governing body;
2. Implementing the policies and procedures of the facility as approved by the governing body, and ensuring that all personnel at the facility are familiar with applicable policies as well as applicable state and federal regulations;
3. Coordinating the provision of services at the facility, including establishing clear lines of authority and accountability for those involved in patient care;
4. Ensuring that the facility employs sufficient qualified staff to provide patient care services, and adequately orients staff to their work responsibilities while meeting the following minimum staffing ratios:
(i) There must be one (1) licensed and qualified nurse for every twelve (12) patients receiving dialysis care and one qualified dialysis care giver for each four (4) patients present in the immediate clinical care area. At least one licensed and qualified registered nurse shall be available in the immediate clinical care area to provide nursing care whenever patients are being dialyzed.
(ii) Trainees may not be counted in the staff:patient ratios.
5. Maintaining facility records, including a chronological record of patient care services provided, and submitting reports on facility functions and operations as required by the governing body or the Department.
(c) The facility administrator shall serve as the liaison between the governing body and the medical staff and other healthcare workers at the facility.
(d) The facility administrator shall designate in writing a qualified individual to act on his/her behalf in the event of his/her absence.
(e) The facility administrator shall be responsible for ensuring that the care of dialysis patients of the facility is coordinated appropriately when a patient is being transferred to a hospital or another dialysis provider or being received back by the facility.
O.C.G.A. §§ 31-2-5, 31-2-7, 31-44-3.
Disclaimer: These regulations may not be the most recent version. Georgia may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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