Ala. Admin. Code r. 420-5-7-.04

Current through Register Vol. 43, No. 1, October 31, 2024

Section 420-5-7-.04 - The Governing Authority

(1) A hospital shall have an effective governing authority that is legally responsible for the conduct of the hospital as an institution.

(2) Medical staff. The governing authority shall:

(a) Appoint members of the medical staff after considering the recommendations of the existing members of the medical staff;

(b) Assure that the medical staff has bylaws;

(c) Approve medical staff bylaws and other medical staff rules and regulations;

(d) Ensure that the medical staff is accountable to the governing body for the quality of care provided to patients;

(e) Ensure the criteria for selection are individual character, competence, training, experience, and judgment; and

(f) Ensure that under no circumstances the accordance of staff membership or professional privileges in the hospital is dependent solely upon certification, fellowship, or membership in a specialty body or society.

(3) Chief executive officer. The governing authority shall appoint a chief executive officer who is responsible for managing the hospital.

(4) Care of patients. In accordance with hospital policy, the governing authority shall ensure that the following requirements are met:

(a) Every patient is under the care of:

1. A doctor of medicine or osteopathy (this provision is not to be construed to limit the authority of a doctor of medicine or osteopathy to delegate tasks to other qualified health care personnel to the extent permitted under applicable state law);

2. A doctor of dental surgery or dental medicine who is legally authorized to practice dentistry in Alabama and who is acting within the scope of his or her license;

3. A doctor of podiatric medicine licensed in Alabama, but only with respect to functions which he or she is legally authorized to perform;

4. A doctor of optometry who is legally authorized to practice optometry in Alabama, and who is acting within the scope of his or her license;

5. A chiropractor who is licensed in Alabama, but only with respect to treatment by means of manual manipulation of the spine to correct a subluxation demonstrated by x-ray to exist;

6. A clinical psychologist licensed in Alabama, but only with respect to clinical psychologist services; and

7. These rules do not mandate that any particular individual health care practitioner be allowed medical staff membership.

(b) Patients are admitted to the hospital only on the recommendation of a licensed practitioner. If a patient is admitted by a practitioner not specified in this rule, that patient is under the care of a doctor of medicine or osteopathy.

(c) A doctor of medicine or osteopathy is on duty or on call at all times.

(d) A doctor of medicine or osteopathy is responsible for the care of each patient with respect to any medical or psychiatric problem that:

1. Is present on admission or develops during hospitalization; and

2. Is not specifically within the scope of practice of a doctor of dental surgery, dental medicine, podiatric medicine, or optometry; a chiropractor; or clinical psychologist, as that scope is:

(i) Defined by the medical staff;

(ii) Permitted by law; and

(iii) Limited, under this rule, with respect to chiropractors.

(5) Contracted services. The governing authority shall be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing authority shall ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to maintain compliance with the requirements of these rules.

(a) The governing authority shall ensure that the services performed under a contract are provided in a safe and effective manner.

(b) The hospital shall maintain a list of all contracted services, including the scope and nature of the services provided.

Ala. Admin. Code r. 420-5-7-.04

Filed September 1, 1982. Amended: Filed November 19, 1987; November 21, 1988. Repealed and New Rule: Filed November 18, 1994; effective December 23, 1994. Repealed and New Rule: Filed August 24, 2012; effective September 28, 2012.

Rule .06 was renumbered to .04 as per certification filed August 24, 2012; effective September 28, 2012.

Author: W.T. Geary, Jr., M.D., Carter Sims

Statutory Authority:Code of Ala. 1975, §§ 22-21-20, et seq.