Current through Reg. 49, No. 52; December 27, 2024
(a) A limited
services rural hospital (LSRH) shall have an organized medical staff that
operates under bylaws approved by the LSRH's governing body, and which is
responsible for the quality of medical care provided to patients by the
LSRH.
(b) The medical staff shall
be composed of physicians and may also include podiatrists, dentists, and other
practitioners appointed by the LSRH's governing body.
(c) The medical staff shall be
well-organized, in a manner approved by the LSRH's governing body, and
accountable to the governing body for the quality of the medical care provided
to patients.
(d) The responsibility
for organization and conduct of the medical staff must be assigned to a
physician.
(e) When an LSRH is part
of a system consisting of multiple separately certified hospitals, critical
access hospitals, or LSRHs, and the system elects to have a unified and
integrated medical staff, each separately certified LSRH must demonstrate:
(1) the decision to have a unified and
integrated medical staff is in accordance with all applicable state and local
laws;
(2) the medical staff members
of each separately certified LSRH in the system (that is, all medical staff
members who hold specific privileges to practice at that LSRH) have voted by
majority, in accordance with medical staff bylaws, either to accept a unified
and integrated medical staff structure or to opt out of such a structure and to
maintain a separate and distinct medical staff for their respective
LSRH;
(3) the unified and
integrated medical staff has bylaws, rules, and requirements describing:
(A) its processes for self-governance,
appointment, credentialing, privileging, and oversight;
(B) its peer review policies and due process
rights guarantees; and
(C) a
process to advise the members of the medical staff of each separately certified
LSRH (that is, all medical staff members who hold specific privileges to
practice at that LSRH) of their right to opt out of the unified and integrated
medical staff structure in accordance with paragraph (2) of this
subsection;
(4) the
unified and integrated medical staff is established in a manner that considers
each member LSRH's unique circumstances and any significant differences in
patient populations and services offered in each hospital, critical access
hospital (CAH), and LSRH;
(5) the
unified and integrated medical staff establishes and implements policies and
procedures to ensure that the needs and concerns expressed by members of the
medical staff, at each of its separately certified hospitals, CAHs, and LSRHs,
regardless of practice or location, are given due consideration; and
(6) the unified and integrated medical staff
has mechanisms in place to ensure that issues localized to particular
hospitals, CAHs, and LSRHs are duly considered and addressed.
(f) The medical staff shall
periodically conduct appraisals of its members according to medical staff
bylaws.
(g) The medical staff shall
examine credentials of a candidate for medical staff membership and make a
recommendation to the LSRH's governing body on the candidate's
appointment.
(h) When the medical
staff has an executive committee, a majority of the members of the committee
must be doctors of medicine or osteopathy.
(i) An LSRH shall maintain records of medical
staff meetings.
(j) The medical
staff shall adopt, implement, and enforce written bylaws, rules, and
regulations to carry out its responsibilities. The bylaws shall:
(1) be approved by the governing
body;
(2) include a statement of
the duties and privileges of each category of medical staff (for example,
active, courtesy, etc.);
(3)
describe the organization of the medical staff;
(4) describe the candidate qualifications
needed for the medical staff to recommend the candidate's appointment by the
governing body; and
(5) include
criteria for granting privileges to individual practitioners and a procedure
for applying the criteria to individuals requesting privileges. For
distant-site physicians and practitioners requesting privileges to provide
telemedicine services under an agreement with the LSRH, the criteria for
determining privileges and the procedure for applying the criteria are also
subject to the requirements in the Code of Federal Regulations Title 42 (42
CFR) §485.510(a)(8) and §485.512(a)(9).
(k) To be privileged as an emergency room
physician, the physician shall:
(1) be
currently board certified in emergency medicine; or
(2) have a minimum of one year experience in
emergency services and current certification in advanced cardiac life support,
pediatric advanced life support, and advanced trauma life support.
(l) The LSRH shall comply with
applicable telemedicine requirements in
42 CFR §
485.512.
