Idaho Admin. Code r. 16.03.14.200

Current through September 2, 2024

Section 16.03.14.200 - GOVERNING BODY AND ADMINISTRATION

There shall be an organized governing body, or equivalent, that has ultimate authority and responsibility for the operation of the hospital.

01.Bylaws. The governing body shall adopt bylaws in accordance with Idaho Code, community responsibility, and identify the purposes of the hospital and that specify at least the following:

a. Membership of Governing Body, that consists of:

i. Basis of selecting members, term of office, and duties; and

ii. Designation of officers, terms of office, and duties.

b. Meetings:

i. Specify frequency of meetings;

ii. Meet at regular intervals, and there is an attendance requirement;

iii. Minutes of all governing body meetings shall be maintained.

c. Committees:

i. The governing body officers shall appoint committees as appropriate for the size and scope of activities in the hospitals;

ii. Minutes of all committee meetings shall be maintained, and reflect all pertinent business.

d. Medical Staff Appointments and Reappointments:

i. A formal written procedure shall be established for appointment to the medical staff;

ii. Medical staff appointments shall include an application for privileges, signature of applicant to abide by hospital bylaws, rules, and regulations, and delineation of privileges as recommended by the medical staff. The same procedure shall apply to nonphysician practitioners who are granted clinical privileges;

iii. The procedure for appointment and reappointment to the medical staff shall involve the administrator, medical staff, and the governing body.

iv. The governing body bylaws shall approve medical staff authority to evaluate the professional competence of applicants, appointments and reappointments, curtailment of privileges, and delineation of privileges;

v. Applicants for appointment, reappointment or applicants denied to the medical staff privileges shall be notified in writing;

vi. There shall be a formal appeal and hearing mechanism adopted by the governing body for medical staff applicants who are denied privileges, or whose privileges are reduced.

e. The bylaws shall provide a mechanism for adoption, and approval of the organization bylaws, rules and regulations of the medical staff.

f. The bylaws shall specify an appropriate and regular means of communication with the medical staff.

g. The bylaws shall specify departments to be established through the medical staff, if appropriate.

h. The bylaws shall specify that every patient be under the care of a physician licensed by the Idaho State Board of Medicine.

i. The bylaws shall specify that a physician be on duty or on call at all times.

j. The bylaws shall specify to whom responsibility for operations, maintenance, and hospital practices can be delegated and how accountability is established.

k. The governing body shall appoint a chief executive officer or administrator, and shall designate in writing who will be responsible for the operation of the hospital in the absence of the administrator.

l. Bylaws shall be dated and signed by the current governing body.

m. Patients being treated by nonphysician practitioners shall be under the general care of a physician.

02.Administration. The governing body, through the administrator, shall provide appropriate physical facilities and personnel required to meet the needs of the patients and the community.

03.Chief Executive Officer or Administrator. The governing body through the chief executive officer shall establish the following policies, procedures or plans:

a. The hospital shall adopt a written personnel policy concerning qualification, responsibility, and condition of employment for each category of personnel. The policy and/or procedures shall contain the following elements:

i. Documentation of orientation of all employees to policies, procedures and objectives of the hospital.

ii. Job descriptions for all categories of personnel.

iii. Documentation of continuing education (inservice) for all patient care personnel.

b. There shall be a personnel record for each employee that shall contain at least the following:

i. Current licensure and/or certification status.

ii. The results of a Tuberculin Skin Test that shall be determined either by history of a prior positive, or by the application of a skin test prior to or within thirty (30) days of employment. If the skin test is positive, either by history or by current test, a chest X-ray shall be taken, or a report of the result of a chest X-ray taken within three (3) months preceding employment, shall be accepted. The Tuberculin Skin Test status shall be known and recorded and a chest X-ray alone is not a substitute. No subsequent annual chest X-ray or skin test is required for routine surveillance.

c. There shall be regularly scheduled departmental and interdepartmental meetings, appropriate to the needs of the hospital, and documentation of such meetings shall be available.

d. The chief executive officer shall serve as liaison between the governing body, medical staff and the nursing staff, and all other departments of the hospital.

e. Written policies and procedures shall be reviewed as needed.

04.Discharge Planning. Administration shall provide a procedure to screen each patient for discharge planning needs. If discharge planning is necessary, a qualified person shall be designated responsible for such planning. The hospital shall have a transfer agreement with a Medicare and/or Medicaid skilled nursing home. If there is a common governing board for a hospital and a skilled nursing home, a policy statement concerning transfers will be sufficient.

05.Institutional Planning. The governing body through the chief executive officer shall provide for institutional planning by means of a committee composed of members of the governing body, administration, and medical staff. The plan shall include at least these elements:

a. Annual budgeting; and

b. A protocol for coordinating the hospital services with other health care facilities and community resources.

06.Disclosure of Ownership. The governing body and administration of hospitals required to be licensed under these rules shall fully disclose to the licensing agency the names and addresses of all persons owning or controlling five percent (5%) interest in the hospital.

07.Compliance with Laws and Regulations. The governing body through the chief executive officer will be responsible for meeting all applicable laws and regulations pertaining to hospitals, and acting promptly upon reports and reviews of regulatory and inspecting agencies.

08.Use of Outside Resources. If a hospital does not employ a required professional person to render a specific service, there shall be a written agreement for such service to meet the requirements of these rules. The agreement shall specify the following:

a. Responsibilities of both parties, with the hospital retaining responsibility for services rendered.

b. All services to be performed by outside resources including reports, frequency of visits, and services rendered.

09.Substantial Change in Services. Any hospital proposing to offer a new service or a new department under these rules or proposing to implement a substantial change in an existing service or department shall provide to the licensing agency evidence of a request for a determination of reviewability if a program providing prospective review of hospitals is in effect.

10.Quality Assurance. Through administration and medical staff, the governing body shall ensure that there is an effective, hospital-wide quality assurance program to evaluate the provision of care. The hospital must take and document appropriate remedial action to address deficiencies found through the program. The hospital must document the outcome of the remedial action.

Idaho Admin. Code r. 16.03.14.200

Effective November 14, 2023 (Temporary)