Current through Register Vol. 50, No. 12, December 20, 2024
A. The hospital
shall have either an effective governing body or individual(s) who are legally
responsible for the conduct of the hospital operations, including the conduct
of all hospital staff, contracted, direct, or otherwise. In the absence of an
organized governing body, there shall be written documentation that identifies
the individual(s) who are legally responsible to carry out the functions
specified in this part that pertain to the governing body. 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;
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 every two years.
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, including but not limited to:
2. criminal background history
checks;
3. direct service worker
registry checks of non-licensed personnel; and
4. preventing, responding to, reporting, and
mitigating instances of healthcare workplace violence.
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 hospital.
4. The hospital shall submit documentation
from the accrediting body that it recognizes the off-site campus as part of the
hospital.
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 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 shall 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. The governing body shall ensure
exterior signage is present and viewable by the public stating that the
hospital does not provide emergency services.
1. These policies and procedures shall
address at a minimum the following:
a. needed
emergency equipment and drugs to include but not be limited to, suction,
oxygen, and artificial manual breathing unit (AMBU) bag;
b. training and competence of staff
appropriate to the approved use of emergency equipment and drugs;
c. determining when an emergency
exists;
d. rendering lifesaving
first aid; and
e. making
appropriate referrals to hospitals that are capable of providing needed
services, inclusive of a parent surrendering an infant in accordance with the
provisions of the Safe Haven Act.
AUTHORITY
NOTE: Promulgated in accordance with
R.S.36:254 and
R.S.
40:2100-2115.
