La. Admin. Code tit. 48 § I-9317

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-9317 - Governing Body

A. The hospital shall have either an effective governing body or individual(s) who are legally responsible for the conduct of the hospital operations, including the conduct of all hospital staff, contracted, direct, or otherwise. In the absence of an organized governing body, there shall be written documentation that identifies the individual(s) who are legally responsible to carry out the functions specified in this part that pertain to the governing body. No contracts/arrangements or other agreements may limit or diminish the responsibility of the governing body.

B. The governing body shall:

1. establish hospital-wide policy;

2. adopt bylaws;

3. appoint a chief executive officer or administrator;

4. maintain quality of care;

5. determine, in accordance with state law, which categories of practitioners are eligible candidates for appointment to the medical staff; and

6. provide an overall institutional plan and budget.

C. The governing body and/or their designee(s) shall develop and approve policies and procedures which define and describe the scope of services offered. They shall be revised as necessary and reviewed at least every two years.

D. There shall be an organizational chart that delineates lines of authority and responsibility for all hospital personnel.

E. In addition to requirements stated herein, all licensed hospitals shall comply with applicable local, state, and federal laws and regulations, including but not limited to:

1. the Safe Haven Act;

2. criminal background history checks;

3. direct service worker registry checks of non-licensed personnel; and

4. preventing, responding to, reporting, and mitigating instances of healthcare workplace violence.

F. All off-site campuses operating under the license of a single provider institution (i.e., a hospital with a main facility and off-site campuses) are subject to the control and direction of one common governing body that is responsible for the operational decisions of the entire hospital enterprise.

1. The off-site campus is subject to the bylaws and operating decisions of the provider's governing body.

2. The provider has final responsibility for administrative decisions, final approval for personnel actions and final approval for medical staff appointments at the off-site campus.

3. The off-site campus functions as a department of the hospital.

4. The hospital shall submit documentation from the accrediting body that it recognizes the off-site campus as part of the hospital.

5. The off-site campus director is under the day-to-day supervision of the provider, as evidenced by:

a. patients treated at the off-site campus are considered patients of the provider and shall have full access to all appropriate provider services;

b. the off-site campus is held out to the public as part of the hospital, i.e., patients know they are entering the provider and will be billed accordingly;

c. the off-site campus director or the individual responsible for the day-to-day operations at the site is accountable to the provider's chief executive officer and reports through that individual to the provider's governing body; and

d. the administrative functions of the off-site campus, (i.e., QI, infection control, dietary, medical records, billing, laundry, housekeeping and purchasing) are integrated with those of the provider, as appropriate to that off-site campus.

6. All components of a single provider institution shall comply with applicable state licensing laws.

G. If emergency services are not provided at the hospital, the governing body shall assure that the medical staff has written policies and procedures for appraisal of emergencies, initial treatment, and transfer as appropriate. The governing body shall ensure exterior signage is present and viewable by the public stating that the hospital does not provide emergency services.

1. These policies and procedures shall address at a minimum the following:

a. needed emergency equipment and drugs to include but not be limited to, suction, oxygen, and artificial manual breathing unit (AMBU) bag;

b. training and competence of staff appropriate to the approved use of emergency equipment and drugs;

c. determining when an emergency exists;

d. rendering lifesaving first aid; and

e. making appropriate referrals to hospitals that are capable of providing needed services, inclusive of a parent surrendering an infant in accordance with the provisions of the Safe Haven Act.

La. Admin. Code tit. 48, § I-9317

Promulgated by the Department of Health and Human Resources, Office of the Secretary, LR 13:246 (April 1987), amended by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 21:177 (February 1995), LR 29:2405 (November 2003), Amended by the Department of Health, Health Standards Section, LR 501479 (10/1/2024).

AUTHORITY NOTE: Promulgated in accordance with R.S.36:254 and R.S. 40:2100-2115.