Section 11-93-14 - Governing body and management(a) Each hospital shall have an organized governing body or designated persons with overall responsibility for the conduct of all activities.(b) The governing body or designated persons shall adopt by-laws in accordance with legal requirements and with the community responsibility of the hospital, and shall identify through its by-laws the purposes of the hospital and the means of fulfilling them.(c) The governing body shall: (1) Provide for the election of officers and for the appointment of committees as necessary to discharge its responsibilities. In addition, it shall adopt a schedule of meetings, attendance requirements, and methods of recording minutes of proceedings.(2) Provide an administrator whose qualifications, authority, and duties shall be defined in a written statement.(3) Designate in writing a suitable employee to act on the administrator's behalf in the administrator's absence.(4) Approve, deny, revoke, and suspend staff privileges.(5) Delegate to the medical staff authority to evaluate the professional competence of staff members and applicants for staff privileges.(6) Delegate to the medical staff responsibility for making recommendations concerning staff appointments, reappointments, and the assignment or curtailment of privileges.(7) Approve medical staff by-laws.(8) Require the medical staff to establish controls to ensure the achievement and maintenance of high standards of professional practices.(9) Require and establish an ongoing quality assurance program that includes effective mechanisms for reviewing and evaluating patient care, as well as an appropriate response to findings.(10) Not enter into any contract or agreement with a person or persons limiting the governing body's responsibility.(d) The facility shall maintain methods of administrative management which assure that: (1) Staff sufficient in number and qualifications to carry out the policies, responsibilities, and program of the facility shall be on duty at all hours of the day.(2) The number of patients and their particular needs shall determine the numbers and categories of personnel.(e) Personnel policies. (1) There shall be written job descriptions available for all positions.(2) Licensure, certification, or standards such as are required in community practice shall be required for all comparable positions in the facility.(3) The facility's personnel policies and practices shall be in writing and shall be available to all employees.(4) Written policy shall prohibit neglect or abuse of patients. (A) Suspected incidences of neglect or abuse shall be reported immediately to the administrator, or his representatives, to the department of health, State of Hawaii and to appropriate government agencies as required by law; and(B) All alleged incidences of abuse or neglect shall be thoroughly investigated by the administrator, or his representative, and documented.(5) There shall be an organization chart showing major operating programs of the facility, staff divisions, administrative personnel in charge of programs and divisions, and line of authority, responsibility, and communication.(6) There shall be documented evidence that every employee has a pre-placement health assessment which will certify that the employee is free of any infectious disease which is liable to jeopardize the health of a patient. Periodic health evaluations may be ordered by the director to insure that employees are free from infectious disease. (A) A health assessment shall include a clearance for tuberculosis for all employees. Those employees who have patient contact in an outpatient obstetrical clinic or planned parenthood clinic shall have a rubella antibody test. Counseling shall be available to employees with a negative test for rubella antibodies, including education or vaccine side effects.(B) If the tuberculin skin test result is significant, as defined by the tuberculosis branch of the department, appropriate medical follow-up must be obtained. In addition, a yearly chest x-ray for three successive years thereafter shall be required, unless the individual has documentation that the individual has received antimicrobial therapy for tuberculosis. Additional chest x-rays may be required at the discretion of the director.(C) If the tuberculin skin test result is not significant, a second tuberculin skin test shall be done after one week but not later than three weeks after the first test. The results of the second test shall be considered the baseline test and be used to determine appropriate treatment and follow-up. If the second test is not significant, a single test is required yearly thereafter until it becomes significant.(D) Any employee who develops evidence of an infection shall be immediately excluded from any duties relating to food handling and direct patient contact and remain excluded until such time as a physician or a licensed nurse, under the physician's supervision, certifies it is safe for the employee to resume such duties. The appearance of diarrhea, temperature elevation, skin pathology, and respiratory symptoms shall be considered presumptive evidence of infection.
[Eff. 3/3/86; am AUG 3, 1992] (Auth: HRS §§ 321-9, 321-11) (Imp: HRS §§ 321-9, 321-11)