6 Colo. Code Regs. § 1011-1 Chapter 04, pt. 9
Current through Register Vol. 47, No. 17, September 10, 2024
9.1 Each department or service of the hospital shall be directed by a person qualified by appropriate education, training, competencies, and experience. (A) A physician director of a department or service shall be a member of the hospital's medical staff.(B) A physician director shall ensure that the quality of services provided by the medical staff of the department or service are monitored and evaluated.9.2 Each department shall have a sufficient number of medical staff, nursing staff, and other auxiliary personnel, qualified by education, training, competencies, and experience, in each department or service to properly operate the department or service.9.3 Hospital staff shall be licensed, certified, or registered in accordance with applicable state laws and regulations, and shall provide services within their scope of practice and, as appropriate, in accordance with credentialing. (A) Hospitals that utilize emergency medical service (EMS) providers, pursuant to Section 25-3.5-207, C.R.S., shall, in collaboration with its medical staff, establish operating policies and procedures that ensure EMS providers perform tasks and procedures, and administer medications within their scope of practice, as set forth in 6 CCR 1015-3, Chapter Two - Rules pertaining to EMS practice and medical director oversight.9.4 All persons assigned to the direct care of, or service to, patients shall be prepared through formal education, as applicable, and on-the-job training in the principles, policies, procedures, and the techniques involved to safeguard the welfare of patients. (A) Prior to delivering patient care independently, new personnel shall receive orientation regarding the patient care environment and relevant policies and procedures.9.5 The hospital shall maintain position descriptions that clearly state the qualifications and expected duties of the position for all categories of personnel.9.6 The hospital shall maintain personnel records on each member of the hospital staff, to include: (A) Employment application;(B) Verification of licensure, certification, or registration, including maintaining procedures to ensure that staff for whom state and/or federal licenses, registrations, or certificates are required have a current license, registration, or certificate; and(C) Competencies, including documentation that the training and demonstration of competency were successfully completed during orientation and on a periodic basis consistent with hospital policies. (1) The hospital shall not assign a clinical nurse staff, nurse aide, or EMS provider to a hospital unit unless, consistent with the conditions of participation adopted for federal Medicare and Medicaid programs, personnel records include such documentation.9.7 All personnel shall have a pre-employment physical examination and such interim examinations as may be required by the hospital administration or the health service physician.9.8 The hospital shall ensure access to up-to-date reference materials for the professional staff.6 CCR 1011-1 Chapter 04, pt. 9