6 Colo. Code Regs. § 1011-1 Chapter 09 Part 6

Current through Register Vol. 47, No. 11, June 10, 2024

Part 6 - GOVERNANCE AND LEADERSHIP

6.1 Applicability

(A) All community clinics shall meet the standards in this Part 6.2.

(B) All community clinics operating inpatient beds shall additionally meet the standards in this part 6.3 and 6.4.

(C) All community clinics providing emergency services shall additionally meet the standards in this Part 6.3, 6.4, and 6.5.

6.2 Administrator

(A) The clinic shall have an administrator or a designated person who is principally responsible for directing the daily operation of the clinic.

(B) The administrator shall be responsible for the development and implementation of policies and procedures for all facility operations. The policies and procedures shall be reviewed and updated as needed but no less than every three years. Policies shall include:

(1) A written organizational plan defining the authority, responsibility, and function of each category of personnel.

(2) A policy regarding the facility's hours of operation. The facility's hours of operation shall be posted on entry doors and the facility's website, if applicable.

(3) A written Emergency Evacuation Plan, including:

(a) Roles and responsibilities of employees in the event of an emergency.

(b) Training requirements for employees regarding responsibilities in the event of an emergency evacuation.

(c) The prominent posting of evacuation routes and exits.

(C) The administrator shall develop a written policy defining the scope of care and services offered. The facility shall define the scope of preventive, diagnostic, and treatment services in writing. The scope shall include a description of those services furnished directly and through agreements with or referrals to other health care service providers.

6.3 Additional Requirements for the Administrator or Governing Body for Community Clinics Operating Inpatient Beds or Community Clinics Providing Emergency Services

(A) The community clinic operating inpatient beds or providing emergency services may choose to convene a governing body. If a community clinic operating inpatient beds or providing emergency services does not convene a governing body, the clinic administrator shall have responsibility for all tasks as set forth in this Part 6.3(B).

(1) If a governing body is convened, it shall be responsible for the oversight of the organization and the providers.

(2) The governing body shall meet at least annually and maintain accurate records of such meetings.

(3) The governing body shall adopt the general bylaws by which the governing body operates.

(B) The governing body or the administrator shall:

(1) Ensure that patients receive care in a safe setting, including providing the equipment, supplies, and facilities necessary for the welfare and safety of patients.

(2) Establish the hours of operation and facilitate accessibility if the facility is closed, as specified below.

(a) The clinic shall maintain regular hours for services.

(b) The clinic shall post signage on or near the front entrance indicating: hours of operation and an emergency referral number and/or a procedure for obtaining medical services when the clinic is not open.

(3) Establish a patient transfer plan that includes:

(a) Agreements with a hospital(s) that include procedures for obtaining air or ground transportation, as appropriate.

(b) Policies and procedures for when an emergency medical condition necessitates patient transfer. The patient shall be transferred, avoiding delay in care and with consideration of transport time, to the closest, most appropriate acute care hospital with the resources necessary to meet the needs of the patient.

(c) Transfer protocols to include:

(i) Coordination with the local emergency medical services system and licensed ambulance services.

(ii) Triage and stabilization to be initiated by on-duty staff.

(iii) Transfer of relevant patient information with the patient.

(iv) Compliance with all requirements as a designated or non-designated trauma center per regulation, 6 CCR 1015-4, Chapter Three, if applicable.

(v) Compliance with regional trauma triage protocols, if applicable.

(4) Ensure that there are written procedures for:

(a) Lines of authority and accountability, and

(b) The qualifications of the personnel performing care.

(5) Ensure the approval and implementation of written policies and procedures in cooperation with the administrator and medical director.

(6) Ensure that there is sufficient staff to meet the demands for services routinely provided and coverage during periods of high demand or emergency.

(7) Ensure any disciplinary action that results in a suspension, revocation, or limitation of the privileges of a member of the provider, nursing, or ancillary staff is reported to the appropriate licensing or certification authority.

(8) Ensure that the community clinic operating inpatient beds or providing emergency services meets all of the Quality Management Program requirements of Part 8.

6.4 Medical Director (Required Only for Community Clinics Operating Inpatient Beds or Community Clinics Providing Emergency Services)

(A) The governing body of the community clinic operating inpatient beds or providing emergency services, or the clinic administrator if there is no governing body, shall appoint a medical director for the facility. Such medical director shall be a physician, licensed under the laws of the State of Colorado, who is a member of the CC's staff. The medical director shall be responsible for the quality of medical care provided to patients in the facility.

(B) The medical director shall be responsible for the development of policies and procedures related to the medical care provided. The policies and procedures shall be approved by the appropriate members of the provider staff and reviewed and updated as needed, but no less than every three years.

(C) The medical director shall serve as the formal clinical liaison with the governing body and administrator.

(D) The medical director shall ensure that services are provided in accordance with current standards of practice and are consistent with standards established through the Quality Management Program as defined in Part 8.

6.5 Hours of Operation (Required Only for Community Clinics Providing Emergency Services)

(A) Community clinics providing emergency services shall maintain operations on a 24-hour basis, every day of the year, except as authorized below.

(1) Service Interruption during a 24-hour Period: Community clinics providing emergency services in non-metropolitan areas that do not have the demand to support 24-hour services may interrupt operations for a part of the 24-hour period on a routinely scheduled basis. The governing body or administrator of a facility that conducts such service interruptions shall develop and implement a written plan that addresses:

(a) Reporting to the Department any changes in hours of operation.

(b) Access to alternative emergency services during the service interruption. The facility shall establish a process for making services available within 30 minutes or sooner if medically necessary for persons who present at a closed facility. Clear directions at the front and/or emergency entrance to the facility that can be easily understood by persons approaching the entrance(s) shall be posted in a conspicuous location with an appropriate communications device, such as a "hot phone" or "tip and ring phone" so that care can be summoned immediately and an appropriate emergency response occurs.

(c) How licensed ambulance services and other appropriate emergency response organizations will be alerted about the periods during which the facility is closed.

(2) Seasonal Closures: A community clinic providing emergency services in a non-metropolitan area that experiences seasonal population influx may choose to only operate each year during specified times. The governing body or administrator of a facility that conducts seasonal closures shall develop and implement a written plan that addresses:

(a) Reporting the seasonal closure to the Department at least 30 days prior to such closure and the resumption of services at least 30 days prior to such resumption.

(b) Compliance with 6.5(A)(1) (b) and (c) for the purpose of the seasonal closure.

6 CCR 1011-1 Chapter 09 Part 6