6 Colo. Code Regs. § 1011-1-15-5
Current through Register Vol. 47, No. 11, June 10, 2024
Section 6 CCR 1011-1-15-5 - ORGANIZATION AND STAFFING REQUIREMENTS5.1 Governing Board 5.1.1 A dialysis treatment clinic shall have a governing board that is formally organized with a written constitution or articles of incorporation and by-laws.5.1.2 The governing board shall meet at regularly stated intervals, and maintain records of these meetings.5.1.3 The governing board shall assume responsibility for the services provided by the clinic.5.1.4 The governing board shall provide facilities, personnel, and services necessary for the welfare and safety of patients.5.1.5 The governing board shall appoint the medical staff. Such appointments shall be made following consideration of the recommendations by the existing medical staff.5.1.6 The governing board shall appoint an administrative officer who is qualified by training and experience in hospital or clinic administration and delegate to that individual the executive authority and responsibility for the administration of the dialysis treatment clinic.5.1.7 The governing board shall adopt a national standard for infection control.5.1.8 The governing board shall establish a mechanism for the performance of medical audit and utilization review functions.5.2 Administrative Officer5.2.1 The administrative officer shall be responsible for the administration of the dialysis treatment center and shall maintain liaison between the governing board and medical staff.5.2.2 The administrative officer shall ensure that the dialysis treatment clinic is formally organized to carry out its responsibilities. The plan of organization with the authority, responsibility, and functions of each category of all personnel shall be defined clearly in writing.5.2.3 The administrative officer shall be responsible for the development of dialysis treatment clinic policies and procedures for employee and medical staff use.5.3 Medical Staff 5.3.1 All dialysis treatment clinics shall have an organized medical staff with written rules, regulations, and by-laws. The by-laws shall make provision for application, appointment, privileges, responsibilities, discipline, right of appeal, attendance at medical staff meetings, committees, and professional conduct in the clinic.5.3.2 A physician from the organized medical staff shall be appointed or elected as chief of staff.5.3.3 The medical staff shall meet regularly and maintain written records of these meetings.5.3.4 There shall be a medical audit committee to review systematically the work of the medical staff with respect to quality of medical care.5.3.5 There shall be a medical records committee that supervises and appraises the quality of medical records according to the requirements contained in Section 6.3 of this chapter.5.4 Nursing5.4.1 Each clinic shall be under the direct supervision of a registered nurse with administrative capability and experience in hemodialysis.5.4.2 The supervising nurse shall be responsible for staff assignments, policy and procedure development, records and reports, educational planning and overall patient care.5.4.3 A registered nurse qualified in hemodialysis shall be on duty during the hours of the clinic's operation.5.5 Hemodialysis Technicians5.5.1 On and after January 1, 2009, a person shall not act as, or perform the duties and functions of, a hemodialysis technician unless that person has been credentialed by a national credentialing program and is under the supervision of a physician or registered nurse experienced or trained in dialysis treatment.5.5.2 On and after January 1, 2009, a dialysis treatment clinic shall not allow any person to perform the duties and functions of a hemodialysis technician at or for the dialysis treatment clinic if the person has not been credentialed by a national credentialing program.5.5.3 Nothing in this Section 5.5 shall prohibit a person enrolled in a hemodialysis technician training program from performing the duties and functions of a hemodialysis technician if:(A) The person is under the direct supervision of a physician or a registered nurse experienced or trained in dialysis treatment, who is on the premises and available for prompt consultation or treatment; and(B) The person receives his or her credentials from a national credentialing program within 18 months after the date the person enrolled in the training program.5.6 All Clinic Personnel5.6.1 Personnel records shall be kept on each of the clinic staff. These records shall include the employment application and verification of credentials.5.6.2 On and after January 1, 2009, each dialysis treatment clinic shall confirm and maintain records for hemodialysis technician certification. Facilities shall provide a list to the department at the time of initial licensure, relicensure and upon request, with information including but not limited to the following: (A) The names of all technicians employed by the clinic,(B) The date the technician was credentialed by a national credentialing program or, if not credentialed, the date the technician enrolled in a training program as long as the technician receives his or her credentials from a national credentialing program within 18 months of enrollment, and(C) The name of the credentialing association.5.6.3 The dialysis treatment clinic shall explain its purposes and objectives to all personnel. There shall be written personnel policies and rules that govern the conditions of employment, the management of employees, the types of functions to be performed, and the quality and quantity of clinic service. Following approval by the governing board, copies of such policies and rules shall be made available to all employees.5.6.4 There shall be sufficient qualified personnel in the clinic.5.6.5 Additional personnel, including hemodialysis technicians, shall be assigned according to the needs of the patient and the clinic.5.6.6 All persons assigned to the direct care of or service to patients shall be prepared through formal education and on-the-job training in the principles, the policies, the procedures, and the techniques involved so that the welfare of patients will be safeguarded.5.6.7 There shall be an education program for all clinic personnel to keep the employees abreast of changing methods and new techniques in dialysis services.