410 Ind. Admin. Code 15-1.4-1

Current through November 6, 2024

Section 410 IAC 15-1.4-1 - Governing board

Authority: IC 16-21-1-7

Affected: IC 16-21-1

Sec. 1.

(a) The governing board is legally responsible for the conduct of the hospital as an institution. The governing board shall do the following:

(1) Function as the supreme authority of the hospital.

(2) Ensure that the hospital:

(A) meets all rules and regulations for licensure and certification, if applicable; and

(B) makes available to the commissioner upon request all reports, records, minutes, documentation, information, and files required for licensure.

(3) Adopt bylaws and function accordingly.

(4) Review the bylaws at least triennially.

(5) Maintain a liaison with the medical staff.

(6) Review, at least quarterly, reports of management operations, medical staff actions, and quality monitoring, including patient services provided, results attained, recommendations made, actions taken, and follow-up.

(7) Ensure that there is a hospital-wide, quality assessment and improvement program to evaluate the provision of patient care.

(b) The governing board is responsible for the conduct of the medical staff. The governing board shall do the following:

(1) Determine, with the advice and recommendation of the medical staff, and in accordance with state law, which categories of practitioners are eligible candidates for appointment to the medical staff.

(2) Ensure that:

(A) the requests of practitioners, for appointment or reappointment to practice in the hospital, are acted upon, with the advice and recommendation of the medical staff;

(B) reappointments are acted upon at least biennially;

(C) practitioners are granted privileges consistent with their individual training, experience, and other qualifications; and

(D) this process occurs within a reasonable period of time, as specified by the medical staff bylaws.

(3) Ensure that the medical staff has approved bylaws and rules and that the bylaws and rules are reviewed and approved at least triennially. Governing board approval of medical staff bylaws and rules shall not be unreasonably withheld.

(4) Ensure that the medical staff is accountable and responsible to the governing board for the quality of care provided to patients.

(5) Ensure that criteria for selection for medical staff membership are individual character, competence, education, training, experience, and judgment.

(6) Ensure that the granting of medical staff membership or professional privileges in the hospital is not solely dependent upon certification, fellowship, or membership in a specialty body or society.

(c) The governing board is responsible for managing the hospital. The governing board shall do the following:

(1) Develop criteria, which include, but are not limited to, defining educational and experience requirements for the chief executive officer. These criteria would apply to all chief executive officers appointed after the effective date of this article.

(2) Appoint a qualified chief executive officer who is delegated the authority and responsibility for managing the hospital and report to the division the name of the chief executive officer within ten (10) days after the appointment.

(3) Delineate in writing the responsibility and authority of the chief executive officer.

(4) Require that the chief executive officer or designee attends meetings of the governing board and its committees and act as its representative at medical staff meetings.

(5) Require that the chief executive officer has designated in writing an administrative officer to serve during his or her absence.

(6) Require that the chief executive officer develops policies and programs for the following:

(A) Ensuring the employment of personnel, in accordance with state and federal rules, whose qualifications are commensurate with anticipated job responsibilities.

(B) Orientation of all new employees, including contract and agency personnel, to applicable hospital, department, service, and personnel policies.

(C) Ensuring that all health care workers, including contract and agency personnel, for whom a license, registration, or certification is required, maintain current license, registration, or certification and keep documentation of same so that it can be made available within a reasonable period of time.

(D) Annual performance evaluations, based on a job description, for each employee providing direct patient care or support services, including contract and agency personnel, who are not subject to a clinical privileging process.

(E) Establishing criteria for each service manager, department director, or supervisor that includes, but is not limited to, the following:

(i) Definition of educational requirements.

(ii) Experience requirements.

(iii) Professional certification, licensing, or registration, where appropriate.

(F) Ensuring cardiopulmonary resuscitation (CPR) competence in accordance with current standards of practice and hospital policy for all health care workers, including contract and agency personnel, who provide direct patient care.

(G) Providing employee health services and a post offer physical examination in consultation with the infection control committee.

(H) Requiring all services to have written policies and procedures that are updated as needed and reviewed at least triennially.

(I) Establishing a policy and procedure for communicating with physicians concerning an inpatient emergency in accordance with 410 IAC 15-1.5-5(b)(3)(L).

(J) Maintaining a current roster of members of the medical staff and their service categories.

(K) Maintaining personnel records for each employee of the hospital which include personal data, education and experience, evidence of participation in job related educational activities, and records of employees which relate to post offer and subsequent physical examinations, immunizations, and tuberculin test or chest x-ray, as applicable.

(L) Demonstrating and documenting personnel competency in fulfilling assigned responsibilities and verifying in-servicing in special procedures.

(M) Coordinating with local, regional, and state health planning groups and other hospital services providers so that effective disaster preparedness, emergency service communication, and transportation systems are established and maintained.

(N) Annual implementation of internal and external disaster preparedness plans with documentation of outcome.

(O) Development, implementation, and monitoring of a safety management program under the direction of a safety officer, qualified by experience or education.

(P) Safe, appropriate, and adequate transport of patients.

(d) The governing board is responsible for assuring that quality patient care is provided. In accordance with hospital policy, the governing board shall do the following:

(1) Ensure all patients are admitted to the hospital only by a licensed practitioner who has been granted admitting privileges in accordance with the credentialing process of the hospital.

(2) Ensure a qualified licensed physician member of the medical staff is responsible for the care and treatment of each patient with respect to any medical or psychiatric problem that is present on admission or develops during hospitalization that does not specifically fall within the scope of practice or the medical staff privileges of the admitting practitioner.

(3) Provide the following for any patients requiring emergency care:

(A) In hospitals with at least one hundred (100) acute care staffed beds, a licensed physician on the premises at all times who has the responsibility to respond to patients requiring emergency care as defined in 410 IAC 15-1.5-5(b)(3)(L)(i).

(B) In hospitals of less than one hundred (100) acute care staffed beds:

(i) a licensed physician on the premises as in clause (A); or

(ii) a licensed physician who has the responsibility to respond to patients requiring emergency care as defined in 410 IAC 15-1.5-5(b)(3)(L)(i) and who is on call at all times and immediately available by phone and then available on the premises within thirty (30) minutes, if necessary, and in accordance with hospital and medical staff policies.

(4) Ensure either of the following:

(A) If the hospital does provide community emergency services to the public, it shall provide that service in compliance with 410 IAC 15-1.6-2.

(B) If the hospital does not provide community emergency services to the public, it shall do the following:

(i) Have written medical staff policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate.

(ii) Provide immediate lifesaving measures within the scope of services available to all persons who appear for emergency care which includes, but is not limited to, the following:

(AA) Timely assessment.

(BB) Stabilization.

(CC) Treatment prior to transfer.

(iii) Arrange for transfer of the patient, with copies of records of treatments provided, to another hospital which does provide appropriate clinical services.

(5) Ensure policies are established to cover physician limited practice problems that may include, but are not necessarily limited to, the following:

(A) Impaired physicians.

(B) Criminal checks.

(C) Disciplinary action.

(6) Ensure that the hospital does the following:

(A) Establish written protocols to identify potential organ and tissue donors.

(B) Has written policies and procedures for the facilitation of organ and tissue donations, including procurement.

(C) Inform families or authorized persons of potential organ and tissue donors of the option of donation on admission or at the time of death of a potential donor.

(D) Use discretion and sensitivity in contacts with potential organ donor families.

(E) Notify the appropriate procurement organization of potential organ donors.

(F) Establish membership in the organ procurement and transplantation network if the hospital performs transplants.

(e) The governing board is responsible for the overall institutional plan as follows:

(1) The institutional plan shall:

(A) be reviewed and updated annually; and

(B) be prepared, under the direction of the governing board, by a committee with representatives from:

(i) the governing board;

(ii) the administration, which includes, but is not limited to:

(AA) nursing;

(BB) finance; and

(CC) medical staff of the hospital.

(2) The plan shall include, but not be limited to, the programs and services provided and an annual operating budget prepared according to generally accepted accounting principles.

(f) The governing board is responsible for services delivered in the hospital whether or not they are delivered under contracts. The governing board shall ensure the following:

(1) That a contractor of any service furnishes those services in such a manner as to permit the hospital to comply with all applicable statutes and rules.

(2) That the services performed under a contract are provided in a safe and effective manner and are included in the hospital's quality assessment and improvement program.

(3) That the hospital maintains a list of all contracted services, including the scope and nature of the services provided.

410 IAC 15-1.4-1

Indiana State Department of Health; 410 IAC 15-1.4-1; filed Dec 21, 1994, 9:40 a.m.: 18 IR 1264; readopted filed Jul 11, 2001, 2:23 p.m.: 24 IR 4234; readopted filed May 22, 2007, 1:44 p.m.: 20070613-IR-410070141RFA; readopted filed Jul 14, 2011, 11:42 a.m.: 20110810-IR-410110253RFA

Readopted filed 9/13/2017, 4:08 p.m.: 20171011-IR-410170339RFA

Readopted filed 11/28/2023, 12:13 p.m.: 20231227-IR-410230639RFA