Current through September 17, 2024
Each hospital is to be organized, managed, and administered
by the licensee to ensure each patient receiving services at the facility
receives necessary care and treatment in a safe manner, and in accordance with
current standards of practice, the Health Care Facility Licensure Act, 175 NAC
1, and this chapter. Each hospital offsite location and mobile unit must meet
the standards except where specified otherwise.
006.01.
LICENSEE
RESPONSIBILITY. The responsibilities of the licensee include:
(A) Implementing policies and procedures to
govern the total operation and maintenance of the facility;
(B) Maintaining hospital compliance with all
applicable state and federal statutes, codes, Rules, and regulations;
(C) Ensuring the quality of all services,
care and treatment provided a patient whether those services, care or treatment
are furnished by hospital staff or through contract with an outside
entity;
(D) Designating an
administrator in writing who is responsible for the day to day management of
the hospital;
(i) Defining the duties and
responsibilities of the administrator in writing;
(ii) Notifying the Department in writing
within 5 working days if:
(1) A vacancy in the
administrator position occurs including the name of who is responsible for the
position until another administrator is appointed; and
(2) A vacancy in the administrator position
is filled including the effective date and name of person appointed to that
position;
(E)
Determining which categories of practitioners are eligible candidates for
appointment to the medical staff;
(F) Ensuring that medical staff membership or
clinical privileges in the hospital does not depend solely upon certification,
fellowship or membership in a specialty body or society although board
certification can be one permissible criterion;
(G) Appointing and reappointing medical staff
members and delineating clinical privileges, according to credential review
procedures established by the medical staff and approved by the governing
authority;
(H) Establishing
criteria for membership on the medical staff or clinical privileges, in
collaboration with the medical staff;
(i)
Making final decisions regarding medical staff recommendations for denial of
appointments and reappointments, and for the denial limitation, suspension, or
revocation of privileges, ensuring the practitioner has a right to be heard
upon request;
(J)
Ensuring the medical staff is accountable to the licensee for the quality of
medical care and treatment provided;
(K) Ensuring a medical staff committee and a
utilization review committee are formed and operated for the purpose of
reviewing care and treatment provided to provide a high standard of medical
care and promote the efficient use of the hospital;
(L) Ensuring that any person working at and
having any information or knowledge relating to the medical and hospital care
provided or the efficient use of the hospital facilities, provides all related
facts and information to the hospital medical staff committee or utilization
review committee upon request by the committee or committees;
(M) Reviewing reports and making
recommendations regarding all Quality Assurance Performance Improvement,
Medical Staff, and Utilization Review Committee activities. Ensuring these
reports are utilized to implement programs and policies to maintain and improve
the quality of patient care and treatment;
(N) Establishing and promoting effective
communication and coordination between the governing authority, the medical
staff, administration, and the hospital departments;
(O) Approving the organization, bylaws,
rules, and regulations, and policies and procedures of the medical staff and
departments in the hospital; and
(P) Establishing visitation policies which
are in the best interest of patients to ensure their health and safety, and
provide protection from communicable diseases, exposure to dangerous
substances, and hazardous equipment.
006.02
GOVERNING AUTHORITY
RECORDKEEPING. If a licensee has a governing authority, it must
hold regularly scheduled meetings and minutes of the meetings must be retained
for a minimum of 7 years.
006.03.
ADMINISTRATION. The administrator is to plan,
organize, and direct the day to day operations of the hospital. The
administrator is directly responsible to the licensee and the governing
authority, if any, in all matters related to the maintenance, operation, and
management of the facility. The administrator's responsibilities include:
(A) Being on the premises a sufficient number
of hours to ensure adequate attention to the management of the
hospital;
(B) Providing for the
protection of patients' health, safety, and well-being;
(C) Ensuring staffing in numbers and
qualifications to meet patient care and treatment, and operation
needs;
(D) Designating a substitute
in writing, to act in their absence as needed;
(E) Being available during all hours of
facility operation; and
(F)
Ensuring the completion, maintenance, and submission of reports and records as
required by federal or state statute, regulation, and the Department.
006.04
ADMINISTRATIVE
RECORDS. Accurate and complete administrative records of each
facility's operation, including an annual report that summarized the scope and
volume of services provided by the facility must be maintained and kept for a
minimum of 7 years.
006.05
PERMANENT PATIENT INDEX. A permanent patient index
must be maintained that includes:
(A) Name and
identification numbers of each patient;
(B) Dates of admission and
discharge;
(C) Name of admitting
physician or health care practitioner; and
(D) Location to which patient was
discharged.
006.06
CONSUMER SATISFACTION. A written process to measure
consumer satisfaction with the services being provided by the facility must be
established, implemented, and revised as necessary.
006.07
OFF-CAMPUS, SATELLITE
LOCATIONS AND MOBILE UNITS. All off-campus, satellite locations or
mobile units are to be approved by the Department and listed on the license
prior to patient care and treatment being provided at a location.
006.08
MOBILE UNITS.
Each mobile unit must have a designated location schedule available to the
public at all times, identifying where the unit will be located so that
unannounced inspections can occur as required in 175 NAC 1.
006.09
MEDICAL
STAFF. Each hospital is to have a medical staff that is organized
and functions in a manner consistent with the size, needs, and resources of the
facility. The medical staff responsibilities are:
(A) Participating in the Quality Assurance
Performance Improvement meetings;
(B) Abiding by hospital and medical staff
policies;
(C) Establishing a
disciplinary process for violation of a policy;
(D) Reviewing the background, experience,
training, and credentials of applicants for initial medical staff membership;
and
(E) Recommending criteria and
procedures for appointment and reappointment, and to delineate clinical
privileging to ensure the provision of quality patient care and treatment.
006.09(i)
MEDICAL STAFF
APPOINTMENT. Membership on the medical staff will be limited to
those disciplines specified in the medical staff bylaws, rules and regulations
or other similar governance document. Criteria for appointment and
reappointment must include continuing licensure or authority to practice in
Nebraska.
006.09(ii)
CLINICAL PRIVILEGES. The medical staff is to establish
a written process for the delineation of clinical privileges which includes:
(1) Each discipline and the procedures or
tasks for which medical staff in that discipline must be privileged to
perform;
(2) A process for the
review of clinical privilege requests, including a competency
component;
(3) A process for
notification of clinical privilege decisions; and
(4) A process for appealing decisions to
deny, limit, or otherwise modify privileges.
006.09(iii)
MEDICAL STAFF
BYLAWS. The medical staff must recommend and adhere to the medical
staff bylaws. Medical staff bylaws must include:
(1) A description of how the medical staff is
organized;
(2) The time frame for
medical staff meetings and the rules for conducting business;
(3) Methods for evaluating clinical practice
in the hospital;
(4) Criteria and
procedures for membership and clinical privileges;
(5) The procedure for medical staff adoption
and amendment of medical staff bylaws; and
(6) Provision for establishing a utilization
review committee.
006.10
STAFFING. A
licensee must maintain a sufficient number of staff with the required
experience, orientation, training, and competency necessary to meet the care
and treatment needs of patients and the operational needs of the hospital. Each
hospital must be staffed 24 hours per day. All staff are to wear visible
identification to identify them to patients or their designee by name and
title. A written job description is to be on file outlining the minimum
qualifications and job duties for each position. Any unlicensed staff who
assist in the provision of care and treatment provided to patients, must be
supervised by a health care professional. Staff cannot provide care or
treatment that is outside the scope of practice permitted by the credential
held by the individual.
006.11
STAFF CREDENTIALS. Staff credentials are to be
verified prior to staff assuming assigned job duties, and the licensee must
maintain evidence that such status is checked and maintained throughout the
entire time of employment.
006.12
STAFF HEALTH STATUS. A health history screening for
all staff must be completed prior to staff assuming job duties. A licensee must
make sure staff health status is maintained in a manner to prevent the
potential transmission of disease to patients, visitors, and other
staff.
006.13
CRIMINAL
BACKGROUND AND REGISTRY CHECKS. Criminal background and registry
checks must be completed on any staff members who have direct and unsupervised
access to or who provide care and treatment to patients at the facility. These
checks must be completed prior to the staff having unsupervised contact with
any patients at the facility. Documentation of such checks is to be maintained
for as long as the staff member is employed at the facility.
006.13(A)
CRIMINAL BACKGROUND
CHECKS. A criminal background check must be completed through a
governmental law enforcement agency or a private entity.
006.13(B)
REGISTRY
CHECKS. A check for adverse findings must include these Nebraska
registries and similar registries in states where the individual has resided in
the past 10 years:
(i) Nurse Aide
Registry;
(ii) Adult Protective
Services Central Registry;
(iii)
Central Register of Child Protection Cases; and
(iv) Sex Offender Registry.
006.13(C)
USE OF
CRIMINAL BACKGROUND AND REGISTRY INFORMATION. Written policies and
procedures are to be implemented and revised as necessary related to the use of
information obtained through pre-employment criminal background and registry
checks. These are to include the following:
(i) Staff with adverse findings on the
registries regarding abuse, neglect or misappropriation must not be employed at
the facility;
(ii) How information
will be used in making hiring decisions;
(iii) Whether employment can begin prior to
receiving the results of the checks, how the safety or property of patients
will be safeguarded until the results are available; what happens if the
results have adverse findings; and
(iv) How to maintain documentation of this
information.
006.14
STAFF
TRAINING. Staff must receive initial and ongoing training and
demonstrate competency before being assigned to independently perform job
duties and assigned tasks. Training must be provided by a person qualified by
education, experience, and knowledge in the subject area provided. The facility
is to maintain the following documentation in each staff member's personnel
file:
(A) Date and time training was
provided;
(B) Summary of the
information provided to staff;
(C)
Instructor name;
(E) Staff sign in
documentation; and
(F) Results of
competency or other testing completed as a result of each training.
006.15
STAFF
ORIENTATION. An orientation program must be provided for all new
staff and for existing staff who are given new assignments. Documentation of
this training must be maintained in each staff member's personnel file. The
initial orientation program is to include the following:
(A) Job duties and
responsibilities;
(B) The facility
sanitation and infection control program;
(C) Organizational structure;
(D) Patient rights;
(E) Patient care policies and
procedures;
(F) Personnel policies
and procedures;
(G) Emergency
preparedness and disaster procedures;
(H) Disaster preparedness plan;
(I) Reporting requirements for abuse,
neglect, and exploitation in accordance with the Adult Protective Services Act,
Neb. Rev. Stat. §
28-372, or in the case of a child
in accordance with Neb. Rev. Stat. §
28-711, and with facility policies
and procedures; and
(J) The
facility hand hygiene program.
006.16
PATIENT
RIGHTS. Each patient is to be afforded the opportunity to exercise
his or her rights. Documentation that all patients or designee, when
appropriate, have been informed of their rights in a manner and format they can
understand must be kept in the medical record for each patient. Each patient
has the right to:
(A) Respectful, safe care
given by trained and competent staff;
(B) Be informed of their rights during
admission in a manner and format they can understand;
(C) Participate in the development and
implementation of a plan of care and any changes to that plan;
(D) Make informed decisions regarding care
and treatment options and be provided with information necessary to assist in
making those decisions;
(E) Be
informed of the possible consequences of refusing care and treatment, to freely
make a choice, and to be free from retaliation from the facility and staff for
choosing to refuse care and treatment options;
(F) Formulate advance directives and to have
the facility comply with the directives unless the facility notified the
patient or designee in writing they are unable to comply and the reasons the
facility is unable to comply;
(G)
Personal privacy and confidentiality of their medical records;
(H) Freedom from abuse, neglect, and
exploitation;
(I) View information
contained in their own medical record within a reasonable time when requested,
excluding limited circumstances where the attending physician determines and
documents that disclosure to the patient would be harmful;
(J) Freedom from restraints or seclusion used
for staff convenience and not utilized to treat medical conditions;
(K) Receive services without discrimination
based upon race, color, religion, gender, national origin, or payer source;
however, hospitals are not required to provide uncompensated or free care and
treatment unless otherwise required by law;
(L) Voice complaints and file grievances
without discrimination or reprisal and have those complaints and grievances
addressed within a reasonable period of time; and
(M) Receive visitors. The hospital may refuse
access to any person for any of the following reasons:
(i) The patient refuses to see the
visitor;
(ii) The presence of the
visitor may be injurious to the health and safety of the patient;
(iii) The visitor's behavior is unreasonably
disruptive to the facility and the behavior is documented by the
facility;
(iv) The presence of the
visitor threatens the security of patients, staff, or facility property;
or
(vi) The visitor is restricted
by court order, the patient's guardian or legal representative or
designee.
006.17
ABUSE, NEGLECT AND
EXPLOITATION. A licensee must address any situation where there is
reason to believe that abuse, neglect, or exploitation of a patient has
occurred by a staff member, volunteer, family member, visitor, or any other
person as provided in the Adult Protective Services Act or Child Protective
Services Act.
006.17(A)
REPORTING. Any suspected abuse, neglect or
exploitation of a patient must be reported to:
(i) The Adult and Child Abuse and Neglect
Hotline via telephone immediately; and
(ii) Local law enforcement as required by
state and federal laws.
006.17(B)
INVESTIGATION. Any incident of suspected abuse,
neglect, or exploitation of a patient must be thoroughly investigated and a
written report of the investigation must be submitted to the Department within
5 working days of the occurrence.
006.17(C)
PROTECTION. All patients must be protected throughout
the investigation of any suspected abuse, neglect, or exploitation. Actions
must be implemented as a result of the investigation to ensure patient safety
and to prevent the potential for recurrence.
006.18
ADVANCED
DIRECTIVES. Each licensee must comply with the requirements of the
Health Care Power of Attorney Act and the Rights of the Terminally Ill Act.
Patients or designees must be informed in a manner and format they can
understand upon admission of the facility policies and procedures, and at the
time of any change to the policies and procedures.
006.19
PATIENT EDUCATION RECORD
KEEPING REQUIREMENTS. Documentation of all education provided to a
patient or their designee is to be retained in each patient's medical record.
This information needs to include:
(A) The
name of the persons who were provided education and their relationship to the
patient;
(B) Information provided;
and
(C) The date the education was
provided, along with the name and title of the person providing the
education.
006.20
DISCHARGE PLANNING. Discharge planning must be
provided for all patients and his or her designee which is to include:
(A) Development of a discharge plan which
includes input from the patient or designee;
(B) Identification of the staff responsible
for the discharge planning program;
(C) Education regarding identified diagnoses,
treatment provided, medications, and follow up needed in a manner and format
the patient or designee can understand;
(D) A complete and accurate list of
community-based services, resources, and facilities for the patient or designee
to choose from to meet their post-hospital care needs; and
(E) Any transfer of necessary medical
information to facilitate continuity of care upon discharge.
006.20(i)
DISCHARGE PLANNING
RECORD KEEPING REQUIREMENTS. Documentation of all discharge
planning and education provided to a patient or his or her designee must be
retained in each patient's medical record. This needs to include:
(1) The name of the persons who were involved
in the discharge planning process and their relationship to the
patient;
(2) Information
provided;
(3) Date and time the
discharge information was provided to the patient or designee along with the
name and title of the person providing the education.
006.21
PERSONAL POSSESSIONS. Patient personal possessions or
belongings brought into the facility at the time of admission must be
safeguarded. The facility must maintain documentation of patient personal items
upon admission and must reconcile them with the patient and or designee upon
discharge from the facility.
006.22
PLAN OF CARE. A plan of care is to be established
according to each patient's individual needs which must be kept current
throughout the hospital stay. The plan of care must include a communication
component which encompasses methods and interventions outlining how facility
staff need to communicate with the patient and their designee in a manner and
method the patient and designee can comprehend. The plan of care may be
interdisciplinary when appropriate to meet a patient's needs.
006.23
LABORATORY
SERVICES. A licensee must provide clinical laboratory services
either directly or through agreement, or contract, which comply with the
federal Clinical Laboratory Improvement Amendments of 1988 as amended.
Laboratory services are to include:
(A)
Identification of a physician who meets the qualifications for laboratory
director, preferably a pathologist;
(B) Necessary laboratory services and testing
as determined by the medical staff;
(C) Emergency laboratory services, including
urinalysis, complete blood counts, blood typing and cross matching, and other
necessary emergency laboratory services and tests as determined by the medical
staff;
(D) Receipt and reporting of
tissue specimens; and
(E) Which
tissue specimens require macroscopic examination and which tissue specimens
require both macroscopic and microscopic examination as determined by the
medical staff.
006.23(i)
LABORATORY SERVICES RECORD KEEPING. All laboratory
testing reports and results must be maintained in the individual patient
records to whom they apply.
006.23(ii)
LABORATORY SERVICES
PHYSICAL PLANT REQUIREMENTS. A licensee is to have dedicated
laboratory areas for sample collection, protection, analyzing, testing and
storage.
006.24
NUTRITIONAL SERVICES. Nutritional services must
include:
(A) Assessment of a patient's
nutritional status by a licensed medical nutrition therapist;
(B) A therapeutic diet order for a patient
may be written by the following professions, if approved by the medical staff
and credentialed by the licensed hospital, in accordance with state and federal
law:
(i) Medical Practitioner; or
(ii) Licensed Medical Nutritional Therapist
in accordance with Neb. Rev. Stat. §
38-1813;
(C) Education on diet and nutrition in a
language and format the patient or designee can understand;
(D) A sufficient number of qualified and
competent dietary and nutritional staff as determined by each individual
hospital needs on duty;
(E) Menus
to be planned, written, and followed;
(F) Meals are to be served to patients at
appropriate times and intervals; and
(G) The Nebraska Food Code must be met at all
times.
006.24(i)
NUTRITIONAL SERVICES PHYSICAL PLANT REQUIREMENTS. If
food preparation is provided onsite, a licensee is to have dedicated space and
equipment for the preparation, storage, and processing of meals. Food service
physical environment must comply with the Nebraska Food Code, except when used
exclusively for activities or training purposes.
006.24(ii)
DINING
AREAS. If provided, dining areas for patients must have an outside
wall with windows for natural light and ventilation and must not be in spaces
used for sleeping, offices, or corridors. Each dining area needs to:
(1) Be furnished with tables and chairs that
accommodate or conform to patient needs;
(2) Have a floor area of 15 square feet per
patient in existing facilities; and
(3) Allow for group dining at the same time
in either separate dining areas, or a single dining area, dining in 2 shifts or
dining during open dining hours.
006.25
PHARMACY
SERVICES. Medications, devices, and any biologicals must be under
the supervision of a licensed Nebraska pharmacist or licensed Nebraska
physician. The storage, control, handling, compounding, and dispensing of
drugs, devices, and biologicals must be in accordance with state and federal
law. Any licensee that has a pharmacy or engages in the practice of pharmacy
must do so in accordance with the Pharmacy Practice Act. Each licensee must
identify a qualified, competent Nebraska licensed pharmacist designated as the
pharmacist-in-charge.
006.25(A)
HOSPITAL PHARMACY QUALITY ASSURANCE REPORT. All
hospital pharmacies must complete and submit a Hospital Pharmacy Quality
Assurance Report form and annual inventory of controlled substances to the
Division of Public Health for review.
006.25(A)(i)
DUE
DATE. The Hospital Pharmacy Quality Assurance Report and inventory
must be submitted no later than May 1 annually.
006.25(A)(ii)
PLAN OF
CORRECTION. If deficiencies are found in either the Hospital
Pharmacy Quality Assurance Report or the inventory the licensee must submit a
plan of correction.
006.26
MEDICATIONS, BIOLOGICALS
AND DEVICES. Medications, biologicals, and devices may only be
provided to patients as legally prescribed by a medical practitioner and
administered by a health care professional who has medication administration
included in their scope of practice and may only be dispensed by a Nebraska
licensed pharmacist or a Nebraska licensed physician with a dispensing permit.
Pharmacy services are to include:
(A) A
current policy and procedure manual regarding the administration and handling
of all medications and biologicals in the facility available to all staff at
all times;
(B) A documented count
of all controlled substances completed every shift;
(C) Authorized personnel permitted access to
medications and biologicals;
(D)
Written procedures for the self-administration of medication, if
applicable;
(E) Medication error
and adverse reaction reporting and documentation;
(F) Information related to interactions,
contraindications, side effects, toxicology, dosage, indications for use, and
routes of administration available to staff at all times;
(G) Emergency medications and
biologicals;
(H) Checking for
expired, mislabeled or otherwise unusable medications, devices or biologicals
on a regular basis, and method of keeping them from being used for
patients;
(I) Dispensing of
medications and biologicals;
(J) If
performed, compounding of medication must be done by personnel trained to
compound, in compliance with written procedures for the process of compounding
and in accordance with state and federal law;
(K) The use, storage of, and provision of
sample medications and biologicals;
(L) Recording, reporting, and investigating
the abuse or loss of any drugs and biologicals;
(M) Storage of all drugs, devices, and
biologicals in secured areas, and in accordance with the manufacturer's,
distributor's, packager's, or dispensing pharmacist's instructions regarding
temperature, light, humidity, and other storage instructions;
(N) Information regarding all drugs, devices,
and biologicals administered, provided, or dispensed to a patient must be
recorded and maintained in the patient's medical record. The record must
contain the date of administration or provision; the identification of the
person who administered or provided the medication, device or biological to the
patient; the patient's medication allergies and sensitivities; any refusal of
medication by the patient or the patient's designee; and any time a drug,
device, or biological ordered by a medical practitioner has not been provided
to the patient in accordance with the medical practitioner's order;
(O) A complete and accurate record of all
medications, devices, and biologicals received, stored, administered, provided,
dispensed, or disposed of by the hospital must be kept and maintained for a
minimum of 7 years; and
(P) Drugs,
devices, and biologicals used as part of a clinical investigation must be
maintained in a locked and separate area from all other drugs, devices, and
biologicals, and must only be administered in accordance with the clinical
study protocol.
