Current through Register Vol. 46, No. 39, September 25, 2024
Respiratory care services shall be provided in a manner
which assures the safe and effective operation and management of staff and
services necessary to provide respiratory care to hospital patients at all
times. The service shall have effective and current written policies and
procedures regarding staff assignments, the administration of medication,
diluents and oxygen, the maintenance of safety controls and the integration of
such services with other related services of the hospital.
(a)
Organization and direction.
The services shall be directed by a physician who shall
be responsible for the clinical aspects of organization and delivery of all
respiratory care services. The physician, or another individual qualified by
training and experience shall direct administrative aspects of the
service.
(1) Respiratory care services
shall be provided by staff who possess the necessary qualifications specified
by the medical staff, consistent with provisions of the New York State
Education Law.
(i) Each individual who
provides respiratory care services shall be competent to provide such services
as evidenced by education, training and experience and where applicable
demonstrated adherence to hospital policies and procedures.
(ii) A sufficient number of qualified
competent professional and support personnel shall be available to meet the
respiratory care needs of the patient.
(2) Written policies and procedures shall
describe mechanisms for effective management of the service, including the
nature and the amount of supervision required for personnel to carry out
specific procedures, as well as mechanisms governing interdepartmental
relationships and communications.
(3) Staff orientation and inservice training
shall be required, provided and documented in accordance with written hospital
policies and procedures.
(b)
Operation and service
delivery.
Respiratory care services shall be provided in a manner
which assures the achievement and maintenance of generally accepted standards
of professional medical practice and patient care.
(1) Respiratory care services shall only be
provided in accordance with specific hospital protocols/policies or upon the
orders of members of the medical staff. The orders for respiratory care
services shall specify the type, frequency and duration of treatment, and, as
appropriate, the type and dose of medication, the type of diluent, and the
oxygen concentration, consistent with generally accepted standards of
care.
(2) All respiratory care
services provided shall be documented in the patient's medical record,
including the type of therapy, date and time of administration, effects of
therapy, and any adverse reactions.
(3) If blood gases or other clinical
laboratory tests are performed in the respiratory care unit, the unit shall
meet the requirements for clinical laboratories with respect to management,
adequacy of facilities, proficiency testing and quality control as set forth in
section 405.16 of this Part.
(4) The service shall implement a planned and
systematic process for the monitoring and evaluation of the quality and
appropriateness of patient care and for the resolution of identified problems.
The process shall involve the reporting of findings, conclusions and
recommendations to the quality assurance committee in accordance with hospital
policies and procedures.
(5) All
equipment and services provided shall be age and size appropriate.
