Louisiana Administrative Code
Title 48 - PUBLIC HEALTH-GENERAL
Part I - General Administration
Subpart 3 - Licensing and Certification
Chapter 78 - Pain Management Clinics
Subchapter C - Clinic Administration
Section I-7835 - Governing Body

1. The governing body shall consist of at least one individual who assumes full responsibility.

2. The pain management clinic shall maintain documentation on the licensed premises identifying the following information for each member of the governing body:

3. The governing body shall develop and adopt bylaws which address its duties and responsibilities.

4. The governing body shall, at minimum, meet annually and maintain minutes of such meetings documenting the discharge of its duties and responsibilities.

1. ensuring the pain management clinics continued compliance with all applicable federal, state, and local statutes, laws, rules, regulations, and ordinances, including department rules, regulations, and fees;

2. designating a person to act as the administrator and delegating sufficient authority to this person to manage the non-medical day-to-day operations of the facility;

3. designating a person to act as the medical director and delegating authority to this person to allow him/her to direct the medical staff, nursing personnel, and medical services provided to each patient consistent with all pain management rules and regulations issued by the Board;

4. evaluating the administrator and medical directors performance annually, and maintaining documentation of such in their respective personnel files;

5. ensuring that upon hire and prior to providing care to patients, and annually thereafter, each employee is provided with orientation, training, and evaluation for competency according to their respective job descriptions in accordance with the providers policies and procedures;

6. developing, implementing, enforcing, monitoring, and annually reviewing in collaboration with the administrator and medical director written policies and procedures governing the following:

7. approving all bylaws, rules, policies, and procedures formulated in accordance with all applicable state laws, rules, and regulations;

8. ensuring all bylaws, rules, policies, and procedures formulated in accordance with all applicable state laws, rules, and regulations are maintained on the licensed premises and readily accessible to all staff;

9. maintaining organization and administration of the pain management clinic;

10. acting upon recommendations from the medical director relative to appointments of persons to the medical staff;

11. ensuring that the pain management clinic is equipped and staffed to meet the needs of its patients;

12. ensuring services that are provided through a contract with an outside source, if any, are provided in a safe and effective manner;

13. ensuring that the pain management clinic develops, implements, monitors, enforces, and reviews at a minimum, quarterly, a quality assurance and performance improvement (QA) program;

14. developing, implementing, monitoring, enforcing, and annually reviewing written policies and procedures relating to communication with the administrator, medical director, and medical staff to address problems, including, but not limited to, patient care, cost containment, and improved practices;

15. ensuring that disaster plans for both internal and external occurrences are developed, implemented, monitored, enforced, and annually reviewed and that annual emergency preparedness drills are held in accordance with the disaster plan. The pain management clinic shall maintain documentation on the licensed premises indicating the date, type of drill, participants, and materials;

16. ensuring that the pain management clinic procures emergency medical equipment and medications that will be used to provide for basic life support until emergency medical services arrive and assume care;

17. ensuring that the pain management clinic orders and maintains a supply of emergency drugs for stabilizing and/or treating medical conditions on the licensed premises, subject to approval by the medical director; and

18. ensuring that the pain management clinic develops, implements, enforces, monitors, and annually reviews written policies and procedures to ensure compliance with all applicable federal, state, and local statutes, laws, ordinances, and department rules and regulations, including but not limited to, appropriate referrals when it has been determined that a patient or staff member has been diverting drugs or participating in the illegal use of drugs.