Current through Register Vol. 39, No. 6, September 16, 2024
A facility shall have all of the following:
(1) an organized governing body;
(2) a chief executive officer;
(3) an organized medical staff;
(4) an organized nursing staff;
(5) continuous medical services;
(6) continuous nursing services;
(7) permanent on-site facilities for the care
of patients 24 hours a day;
(8) a
hospital-wide infection control program;
(9) minimum on-site clinical provisions as
follows:
(a) appropriately equipped inpatient
care areas;
(b) nursing care
units;
(c) diagnostic and treatment
areas to include on-site laboratory and imaging facilities with the capacity to
provide immediate response to patient emergencies;
(d) pharmaceutical services in compliance
with the Pharmacy Laws of North Carolina;
(e) facilities to assure the sterilization of
equipment and supplies;
(f) medical
records services;
(g) provision for
social work services;
(h) current
reference sources to meet staff needs; and
(i) nutrition services.
(10) minimum supportive capabilities or
facilities as follows:
(a) nutrition and
dietetic services;
(b) scheduled
general and preventive maintenance services for building, services and
biomedical equipment;
(c)
capability for obtaining police and fire protection, emergency transportation,
grounds-keeping, and snow removal;
(d) personnel recruitment, training and
continuing education;
(e) business
management capability;
(f) short
and long-range planning capability;
(g) financial plan to provide continuity of
operation under both normal and emergency conditions;
(h) provision for patient, employee, and
visitor safety; and
(i) policies
for preventive and corrective maintenance including procedures to be followed
in the event of a breakdown of essential equipment.
(11) facilities must comply with construction
rules in Sections.6000 -.6200 of this Subchapter.
(12) a risk management program as follows:
(a) a specific staff member shall be assigned
responsibility for development and administration of the program;
(b) a written policy statement evidencing a
current commitment to the risk management program together with written
procedures, policies and educational programs applicable to a risk management
program which are reviewed at least every three years and updated as
necessary;
(c) established lines of
communication between the risk management program and other functions relating
to quality of patient care, safety, and professional staff performance;
and
(d) a written report of the
activities of the risk management program shall be annually submitted to the
governing body.
(13) a
quality assessment and improvement program which provides:
(a) continuous assessment and evaluation of
patient care and related services in all services and departments;
(b) a designated individual to coordinate the
quality assessment and improvement program who will assist in the establishment
of quality assessment and improvement plans and reporting methods for each
service and department;
(c) a
committee made up of representatives of the medical and nursing staff,
administration, and other services or departments as defined by the hospital to
coordinate the program, meet at least quarterly and maintain minutes of the
meetings and committee activities; and
(d) for each service and department as
defined by the hospital to be involved in the continuous assessment, monitoring
and evaluation of patient care and related services.
Authority
G.S.
131E-75;
131E-79;
Eff.
January 1, 1996;
Pursuant to
G.S.
150B-21.3A, rule is necessary without
substantive public interest Eff. July 22,
2017.
