Current through Register Vol. 48, No. 9, September 27, 2024
(1) General: Every facility shall be
organized, equipped, manned and administered to provide adequate care for each
person admitted.
(2) Governing
Authority: The governing authority shall be the supreme authority responsible
for the management control of the facility and shall develop a written set of
bylaws or other appropriate policies and procedures for operation of the
facility. These shall: (II)
(a) State the
purpose of the facility;
(b)
Specify by name the person to whom responsibility for operation and maintenance
of the facility is delegated and methods established by the governing authority
for holding such individual responsible;
(c) Provide for at least annual meetings of
the governing authority;
(d)
Provide for a policies and procedures manual which is designed to ensure
professional and safe care for the patients to include but not limited to:
(1) admission criteria;
(2) extent of physician participation in the
services offered;
(3) rights and
responsibilities of patients;
(4)
patient grievance procedures;
(5)
infection control procedures;
(6)
personnel training requirements;
(7) transfer of mothers who, during the
course of pregnancy, labor, delivery or recovery, are determined to be
ineligible for continued care;
(8)
the use of IV's, food, fluids, analgesia/anesthesia, oxytocin, episiotomies,
positions for delivery;
(9)
provisions for the education of mother, family and others, as appropriate in
birthing, newborn care, and maternal postpartum care.
(10) plans for follow-up of mother and infant
after discharge from the center;
(11) plans for tests/treatments including,
but not limited to, PKU, bilirubin, Rh factor, ophthalmic prophylaxis, and
prophylaxis for neonatal hemorrhagic disease;
(12) plan for circumcision.
(e) Provide for annual reviews and
evaluations of the facility's policies, procedures, management and
operation.
(f) Provide for a
facility-wide quality assurance program to evaluate the provision of patient
care. The program shall be ongoing and have a written plan of
implementation.
(3)
Administrator: The chief administrative officer shall be selected by the
governing authority and shall have charge of and be responsible for the
management and administration of the facility in all its branches and
departments and shall see that the bylaws and amendments thereto are complied
with. Any change in the position of the chief administrative officer shall be
reported immediately by the governing authority to the Department in writing.
An individual shall be appointed to act in the absence of the administrator.
(II)
(4) Administrative Records:
The following essential documents and references shall be on file in the
administrative office of the facility:
(a)
appropriate documents showing control and ownership;
(b) bylaws, policies and procedures of the
governing authority;
(c) minutes of
the governing authority meetings if applicable;
(d) minutes of the facility's professional
and administrative staff meetings;
(e) a current copy of these
regulations;
(f) reports of
inspections, reviews, and corrective actions taken related to
licensure;
(g) contracts and
agreements to which the facility is a party;
(h) a record of each accident or incident
occurring in the facility.
(5) Personnel: Qualified personnel shall be
employed in sufficient numbers to carry out the functions of the facility. The
licensee shall obtain written applications for employment from all employees.
Such applications shall contain accurate information as to education, training,
experience, health and personal background of each employee. All applications
for licensed personnel shall contain the South Carolina license number and/or
current renewal number, if applicable. (II)
(a) All new employees who have contact with
patients shall have a physical examination prior to employment, which shall
include a tuberculin skin test, unless a previously positive reaction can be
documented. The intradermal (Mantoux) method, using five tuberculin units of
stabilized purified protein derivative (PPD) is recommended. (II)
(1) Employees with positive reactions to the
pre-employment tuberculin test and those who are documented with previously
positive reactions shall be given a chest x-ray to determine whether tuberculin
disease is present. If tuberculosis is diagnosed, appropriate treatment should
be given.
(2) Employees who
complete treatment, either for disease or infection, may be exempt from further
screening unless they have symptoms of tuberculosis.
(3) Positive reactors who are unable or
unwilling to take preventive treatment need not receive an annual chest x-ray.
These individuals shall be informed of their lifelong risk of developing and
transmitting tuberculosis to individuals in the agency and in the community.
They shall be informed of symptoms which may suggest the onset of tuberculosis,
and of the procedure to follow in reporting suspect symptoms to a designated
member of the agency staff.
(4)
Employees with negative tuberculin skin tests shall have an annual tuberculin
skin test.
(b) Personnel
Records: A personnel record folder shall be maintained for each employee. The
folder shall contain history and physicals, laboratory test results, resumes of
training and experience, current job description that reflects the employee's
responsibilities and work assignments, orientation and periodic evaluations.
(II)
(c) Job Descriptions:
(1) Written job descriptions which adequately
describe the duties of every position shall be maintained.
(2) Each job description shall include:
position title, authority, specific responsibilities and minimum
qualifications.
(3) Job
descriptions shall be reviewed at least annually, kept current and given to
each employee when assigned to the position and when revised.
(d) Orientation shall be provided
to familiarize each new employee with the facility, its policies, and job
responsibility.
(e) Continuing
education must be provided to all non-clerical employees at least once a year.
Inservice training may be provided by qualified facility staff.
(f) All professional personnel and clinical
staff shall be certified in adult and neonatal American Red Cross CPR
training.
(6) Emergency:
(a) All practicing and/or consulting
physicians shall have admitting privileges at one or more hospitals with
appropriate obstetrical services, or other arrangements approved by the
Department for the transfer of emergency cases when hospitalization becomes
necessary. (I)
(b) Equipment and
services shall be provided to render emergency resuscitative and life-support
procedures pending transfer to a hospital for both mother and infant.
(I)
(c) The center shall enter into
a signed written agreement with an ambulance service licensed in this state to
ensure the immediate transfer of mothers and/or newborns in emergencies, where
appropriate. (I)
(7)
Client's Rights:
(a) The birthing center
shall have written policies and procedures to assure the individual client the
right to dignity, privacy, and safety. The policies and procedures shall be
developed by the Director of Midwifery Services and the Director of Medical
Affairs, if appropriate, and approved by the governing body.
(b) Each center shall display in a
conspicuous place on the premises, a copy of the "Rights of
Patients."
