16 Del. Admin. Code § 3340-5.0

Current through Register Vol. 28, No. 3, September 1, 2024

Section 3340-5.0 - Governing Body

5.1 Each FSED shall have an identified, organized governing body (governing authority, owner or person or persons designated by the owner) fully responsible for the organization, management, control, and operation of the facility.

5.2 The governing body responsibilities include:

5.2.1 Appointing a qualified director in writing;

5.2.2 Appointing members of the medical and clinical staff, ensuring their competence and delineating their job responsibilities;

5.2.3 Adopting, implementing, and enforcing written policies and procedures for the total operation and all services provided by the facility;

5.2.4 Documentation of annual review and evaluation of the FSED policies and services;

5.2.5 All services furnished by the facility, whether furnished directly or under contract are provided in a safe and effective manner that permits the facility to comply with all applicable rules and standards;

5.2.6 Conducting meetings, when the governing body is more than one person, at least annually and maintaining written minutes of the meetings;

5.2.7 Adopting governing body and medical staff bylaws for the orderly development and management of the FSED.

5.2.7.1 Bylaws shall be reviewed annually by the governing body and so dated. Revisions shall be completed as necessary.

5.2.8 Determining the mission, goals, and objectives of the facility;

5.2.9 Ensuring that the physical environment protects the health and safety of patients, personnel, and the public;

5.2.10 Establishing an organizational structure and specifying functional relationships among various components of the facility;

5.2.11 Reviewing and approving the facility's training program for staff;

5.2.12 Ensuring that all equipment utilized by facility staff or by patients is properly used and maintained per manufacturer's recommendations;

5.2.13 Adopting, implementing and enforcing policies and procedures related to emergency planning and disaster preparedness. The governing body shall review the facility's disaster preparedness plan at least annually;

5.2.14 Ensuring there is a quality assessment and performance improvement (QAPI) program to evaluate the provision of patient care. The governing body shall review and monitor QAPI activities quarterly;

5.2.15 Reviewing legal and ethical matters concerning the facility and its staff when necessary and responding accordingly;

5.2.16 Maintaining effective communication throughout the facility;

5.2.17 Approving all contracts or arrangements affecting the medical care provided under its auspices;

5.3 There shall be a description of each type of service offered.

5.4 The governing body shall provide for full disclosure of ownership to the Department.

16 Del. Admin. Code § 3340-5.0

24 DE Reg. 692( 1/1/2021) (final)