New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 370 - OVERSIGHT OF LICENSED HEALTHCARE FACILITIES AND COMMUNITY BASED WAIVER PROGRAMS
Part 12 - REQUIREMENTS FOR ACUTE CARE, LIMITED SERVICES AND SPECIAL HOSPITALS
Section 8.370.12.19 - POLICIES
Current through Register Vol. 35, No. 18, September 24, 2024
Every hospital shall have written policies approved by the governing board and shall include provisions for implementation, and for access by the patient, on:
A. Patient rights and responsibilities: a list of these patient rights and responsibilities shall be available in languages appropriate to the ethnic needs of the community;
B. Movement of visitors: The hospital shall develop policies regarding the movement of visitors, which provide for infection control and patient privacy, but also allow the patient appropriate freedom as to the time, nature, and location of visit.
C. Use of Volunteers:
D. Identification: The hospital shall develop a method to identify employees, patients, personnel records and patient files.
E. Cancer reporting: every hospital shall report to the tumor registry all malignant neoplasms that are diagnosed by the hospital and all malignant neoplasm's diagnosed elsewhere if the individual is subsequently admitted to the hospital; the report of each malignant neoplasm shall be made on a form prescribed or approved by the authority and shall be submitted to the UNM tumor registry within six months after the diagnosis is made or within six months after the individual's first admission to the hospital if the neoplasm is diagnosed elsewhere, as appropriate; in this paragraph, "malignant neoplasm" means an in situ or invasive tumor of the human body, but does not include a squamous cell carcinoma or basal cell carcinoma arising in the skin.
F. Post - mortem examinations:
G. Tagging of bodies: all deceased human bodies to be removed from a hospital shall be tagged by staff of the hospital; a red tag shall be used to indicate the possibility of the presence of the communicable or infectious disease or radioactive materials. If the body is in a container, a tag shall also be applied to the outside of the container.
H. Autopsy: Reports are to be distributed to the primary provider and become part of the patient's clinical record.
I. Withholding of resuscitative services from patients.
J. Anatomical gifts: A policy shall be adopted and implemented for organ and tissue donation in accordance with 370.12.42 NMAC; the policy shall include procedures to assist the medical, surgical and nursing staff in identifying, evaluating and reporting potential organ and tissue donors.
K. Reporting: A policy for compliance with all applicable state and federal reporting requirements must be adopted and updated as necessary; such federal requirements include but are not limited to the New Mexico health policy commission, the national practitioner data bank and the healthcare integrity and protection data bank.