410 Ind. Admin. Code 27-4-1

Current through November 6, 2024

Section 410 IAC 27-4-1 - Powers and duties

Authority: IC 16-21-1-7; IC 16-21-2-2.5

Affected: IC 16-21-1; IC 25-22.5

Sec. 1.

(a) The governing body:

(1) shall function as the ultimate authority of the birthing center; and

(2) is responsible for the conduct and management of the center.

(b) If the governing body is an individual who has sole authority and responsibility for the center, that individual may also serve as the center administrator or staffing physician, or both, if qualified. A center administrator appointed by the governing body may also serve as the staffing physician if qualified.

(c) The governing body shall do the following:

(1) Assume responsibility for:

(A) determining;

(B) implementing; and

(C) monitoring;

policies governing the center's operation.

(2) Ensure that:

(A) center policies are followed so as to provide quality health care in a safe environment; and

(B) the center complies with:

(i) this article; and

(ii) IC 16-21.

(3) Review, at least quarterly, reports of management operations, including, but not limited to, the following:

(A) Quality assessment and improvement program.

(B) Patient services provided.

(C) Results attained.

(D) Recommendations made.

(E) Actions taken.

(F) Follow-up.

(4) Maintain documents, registers, and reports that show the following:

(A) Ownership.

(B) Compliance with local, state, and federal laws and regulations.

(C) Adherence to center bylaws (if applicable) and center policies.

(5) Approve all appointments to or contracts with medical staff.

(6) Ensure the following:

(A) Maintenance of the physical plant.

(B) That the center is:

(i) equipped; and

(ii) staffed;

to meet the needs of the patients.

(7) Require for all services policies and procedures that are:

(A) updated as needed; and

(B) reviewed at least triennially.

(8) Establish a policy and procedure for communication with physicians concerning a patient emergency.

(9) Review and analyze each medical staff's services at specified intervals at regular meetings, including, but not limited to, the following:

(A) Appropriateness of diagnoses and treatments rendered related to a standard of care and anticipated or expected results.

(B) Performance evaluation based on clinical performance indicated in part by the results or outcome of surgical intervention.

(C) Scope and frequency of procedures.

(10) Establish a process for the following:

(A) Reporting physicians who fail to comply with state professional licensing law requirements as found in IC 25-22.5.

(B) Documenting actions against physicians who fail to comply with the center policies and procedures.

(11) Ensure physician coverage of emergency care that at least:

(A) provides a definition; and

(B) addresses a timely response.

(d) If the governing body is not an individual responsible for the governing of the center, the governing body must do the following:

(1) Adopt bylaws and operate in compliance with the bylaws.

(2) Review the bylaws at least triennially.

(e) If the governing body is not an individual who is also serving as the staffing physician, the governing body shall do the following:

(1) Designate a staffing physician who has the responsibility for the direction of:

(A) medical;

(B) nursing; and

(C) health-related;

services to patients.

(2) Maintain a liaison with the staffing physician.

(f) If the governing body is not an individual who is also serving as the center administrator, the governing body shall do the following:

(1) Designate a center administrator who has the responsibility and authority to carry out the day-to-day operation of the center.

(2) Develop criteria, which include, but are not limited to, defining educational and experience requirements for the center administrator.

(3) Delineate in writing the responsibility and authority of the center administrator.

(4) Require the following:

(A) That the center administrator or a designee:

(i) attend meetings of the governing body and its committees; and

(ii) act as its representative at medical staff meetings.

(B) That the center administrator:

(i) designate in writing an administrative officer to serve during his or her absence; and

(ii) develop and implement appropriate policies and programs.

410 IAC 27-4-1

Indiana State Department of Health; 410 IAC 27-4-1; filed Feb 3, 2006, 2:00 p.m.: 29 IR 1909; readopted filed Jul 12, 2012, 12:09 p.m.: 20120808-IR-410120265RFA

Readopted filed 9/26/2018, 2:48 p.m.: 20181024-IR-410180328RFA