Current through Register Vol. 50, No. 9, September 20, 2024
A. The hospital
must have either an effective governing body or individual(s) legally
responsible for the conduct of the hospital operations. No
contracts/arrangements or other agreements may limit or diminish the
responsibility of the governing body.
B. The governing body shall:
1. establish hospital-wide policy;
2. adopt bylaws;
3. appoint a chief executive officer or
administrator;
4. maintain quality
of care;
5. determine, in
accordance with state law, which categories of practitioners are eligible
candidates for appointment to the medical staff; and
6. provide an overall institutional plan and
budget.
C. The governing
body and/or their designee(s) shall develop and approve policies and procedures
which define and describe the scope of services offered. They shall be revised
as necessary and reviewed at least annually.
D. There shall be an organizational chart
that delineates lines of authority and responsibility for all hospital
personnel.
E. In addition to
requirements stated herein, all licensed hospitals shall comply with applicable
local, state, and federal laws and regulations.
F. All off-site campuses operating under the
license of a single provider institution (i.e., a hospital with a main facility
and off-site campuses) are subject to the control and direction of one common
governing body that is responsible for the operational decisions of the entire
hospital enterprise.
1. The off-site campus
is subject to the bylaws and operating decisions of the provider's governing
body.
2. The provider has final
responsibility for administrative decisions, final approval for personnel
actions and final approval for medical staff appointments at the off-site
campus.
3. The off-site campus
functions as a department of the provider.
4. The off-site campus is included under the
accreditation of the provider, if the provider is accredited by a national
accrediting body, and the accrediting body recognizes the off-site campus as
part of the provider.
5. The
off-site campus director is under the day-to-day supervision of the provider,
as evidenced by:
a. patients treated at the
off-site campus are considered patients of the provider and shall have full
access to all appropriate provider services;
b. the off-site campus is held out to the
public as part of the hospital, i.e., patients know they are entering the
provider and will be billed accordingly;
c. the off-site campus director or the
individual responsible for the day-to-day operations at the site maintains a
daily reporting relationship and is accountable to the provider's chief
executive officer and reports through that individual to the provider's
governing body; and
d. the
administrative functions of the off-site campus, (i.e., QI, infection control,
dietary, medical records, billing, laundry, housekeeping and purchasing) are
integrated with those of the provider, as appropriate to that off-site
campus.
6. All
components of a single provider institution must comply with applicable state
licensing laws.
G. If
emergency services are not provided at the hospital, the governing body shall
assure that the medical staff has written policies and procedures for appraisal
of emergencies, initial treatment and transfer as appropriate.
1. These policies and procedures shall
address at a minimum the following:
a. needed
emergency equipment and drugs to include but not limited to, suction, oxygen
and ambu bag;
b. competence of
staff appropriate to the approved use of emergency equipment and
drugs;
c. determining when an
emergency exists;
d. rendering life
saving first aid;
e. making
appropriate referrals to hospitals that are capable of providing needed
services.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
40:2100-2115.
