216-40-10 R.I. Code R. § 5.4

Current through August 19, 2024

Section 216-RICR-40-10-5.4 - Organization and Management

5.4.1Governing Body and Management

A. Each facility shall have an organized governing body or other legal authority, responsible for:

1. The management and control of the operation;

2. The assurance of the quality of care and services;

3. The conformity of the facility with all federal, state and local laws and regulations relating to fire, safety, sanitation, infection control; and

4. Other relevant health and safety requirements and with all the rules and regulations of this Part.

B. The governing body or other legal authority shall provide appropriate personnel, physical resources, and equipment based on the scope of services provided.

C. The governing body or other legal authority shall designate:

1. An administrator who shall be responsible for the management and operation of the facility; and

2. A medical director to ensure achievement and maintenance of quality standards of professional practice.

D. The governing body shall adopt and maintain by-laws defining responsibilities for the operation and performance of the organization, identifying purposes and means of fulfilling such, and in addition the by-laws shall include but not be limited to:

1. A statement of qualifications and responsibilities of the medical director and administrator;

2. A statement of the governing body's responsibility for the quality of care and services;

3. A statement relating to development and implementation of long and short range plans;

4. A statement of policy establishing the criteria for the selection and admission of patients;

5. A statement relating to conflict of interest on the part of the governing body, medical staff and employees;

6. A policy statement concerning the publication of an annual report, including a certified financial statement; and

7. Such other matters as may be relevant to the organization of the FASC.

E. When a majority of the members of the governing body are physicians, the governing body, either directly or by delegation, shall make initial appointments, and assignment or curtailment of surgical privileges, based on the education, training, experience and evidence of competence of the physician, dentist or podiatrist consistent with state law; or when a majority of the members of the governing body are not physicians the organization's by-laws or similar rules and regulations shall specify a procedure for establishing medical review for the purpose of making initial appointments, reappointments, and assignment or curtailment of medical privileges, based on the education, training, experience and evidence of current competence of the physician, dentist or podiatrist, and consistent with state law.

F. A health care facility shall require all persons, including students, who examine, observe, or treat a patient or resident of such facility to wear a photo identification badge which states, in a reasonably legible manner, the first name, licensure/registration status, if any, and staff position of such person.

5.4.2Administrator

A. The governing body shall appoint a qualified administrator who may be the medical director, who shall be responsible for:

1. The management and operation of the FASC;

2. The enforcement of policies, rules and regulations and statutory provisions pertaining to the health and safety of patients;

3. Serving as liaison between the governing body and the staff; and

4. The planning, organizing and directing of such other activities as may be delegated by the governing body.

5.4.3Medical Director

A. The surgical services of the FASC shall be under the direction of a physician licensed in Rhode Island, who meets the qualifications set forth by the governing body in accordance with §5.4.1 of this Part, and who shall be responsible for no less than the following.

1. The coordination, supervision and functioning of services;

2. The establishment of provisions for infection control;

3. The achievement and maintenance of quality assurance of professional practices through a mechanism of peer review; and

4. The establishment of policies and procedures for surgical and anesthesia services and other related health care services.

B. Personnel Health Requirements

1. Upon hire and prior to delivering services, a pre-employment health screening shall be required for each individual who has or may have direct contact with a patient in the freestanding ambulatory surgical center. Such health screening shall be conducted in accordance with the rules and regulations pertaining to Immunization, Testing, and Health Screening for Health Care Workers (Part 20-15-17 of this Title) promulgated by the Department of Health.

5.4.4Rights of Patients

A. Each FASC shall observe the standards enumerated in R.I. Gen. Laws § 23-17-19.1 with respect to each patient admitted on its facility.

B. Each facility shall display in a conspicuous place in the licensed FASC a copy of the "Rights of Patients."

5.4.5Disaster Preparedness

A. Each FASC shall develop and maintain a written disaster preparedness plan which shall include specific provisions and procedures for the emergency care of patients in the event of fire, natural disaster or functional failure of equipment.

1. Such a plan shall be developed and coordinated with appropriate state and local agencies and representatives concerned with emergency safety and rescue;

2. A copy of the plan shall be submitted to the licensing agency;

3. Simulated drills testing the effectiveness of the plan shall be conducted at least semi-annually. Written reports and evaluation of all drills shall be maintained by the FASC and available for review by the licensing agency;

B. Emergency steps of action shall be clearly outlined and posted in conspicuous locations throughout the facility.

5.4.6Administrative Records

A. Each FASC shall maintain such administrative records as may be deemed necessary for the business operation of the facility, in addition to the following;

1. Monthly statistical summary of numbers of surgical procedures performed, appropriately classified;

2. Narcotic register;

3. An operating room log book maintained in chronological sequence of admissions which shall include pertinent information such as patient's name, name of surgeon and anesthetist, circulating nurse, surgical procedures performed, type of anesthesia and complications (if any); and

4. A record of all transfers to a hospital for post-surgical care.

5.4.7Uniform Reporting System

A. Each FASC shall establish and maintain records and data in such a manner as to make uniform the system of periodic reporting. The manner in which the requirements of this regulation may be met shall be prescribed from time to time in directives promulgated by the Director with the advice of the Health Services Council.

B. Each FASC shall report to the licensing agency detailed financial and statistical data pertaining to its operations, services, and facility. Such reports shall be made at such intervals and by such dates as determined by the Director and shall include but not be limited to the following:

1. Utilization of FASC services;

2. Unit cost of services;

3. Charges for services;

4. Financial condition of the FASC; and

5. Quality of care.

C. The licensing agency is authorized to make the reported data available to any state agency concerned with or exercising jurisdiction over the reimbursement of the FASC.

D. The directives promulgated by the Director pursuant to these regulations shall be sent to each FASC to which they apply. Such directives shall prescribe the form and manner in which the financial and statistical data required shall be furnished to the licensing agency.

216 R.I. Code R. § 216-RICR-40-10-5.4