216-40-10 R.I. Code R. § 9.5

Current through June 12, 2024

Section 216-RICR-40-10-9.5 - Organization and Management

9.5.1Governing Body and Management

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

1. The management and control of the operation;

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

3. The compliance with all federal, state and local laws and regulations; and

4. Other relevant health and safety requirements including the rules and regulations herein.

B. The governing body or equivalent legal authority shall provide appropriate personnel, physical resources, and equipment for the delivery of safe and effective emergency medical care.

C. The governing body or equivalent 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 or equivalent legal authority shall adopt and maintain by-laws defining responsibilities for the operation and performance of the organization, identifying purposes and means of fulfilling each. In addition, the governing body shall establish administrative policies pertaining to no less than the following:

1. Qualifications and responsibilities of the medical director and administrator;

2. The plan of the governing body for the implementation of long- and short-range plans as prescribed by the Director in accordance with R.I. Gen. Laws Chapter 23-17; and

3. Such other matters as may be relevant to the organization and operation of the FECF.

E. The governing body or other legal authority shall be responsible through the organization's by-laws, policies, or other mechanism to determine the qualifications of physicians and other professionals as required herein, considering such factors as education, training, experience, board certification, eligibility to sit for examination of specialty board, evidence of current professional practice and licensure as may be required by law or regulation, the relevant qualifications required in §9.5.4 of this Part and such other relevant factors as may be deemed necessary.

9.5.2Administrator

A. The governing body or equivalent legal authority shall appoint an administrator (who may also be the medical director), who shall be operationally responsible for:

1. The management and operation of the FECF;

2. The compliance with 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.

9.5.3Medical Director

A. The FECF shall have a physician licensed in this state, who shall serve as Medical Director and be responsible for no less than the following:

1. Coordination and supervision of emergency medical care services;

2. The achievement and maintenance of quality assurances of professional practice through a mechanism of peer review; and

3. The establishment of policies and procedures for emergency medical care services and other related emergency health care services.

9.5.4Personnel

A. Each FECF shall be staffed by a licensed physician(s) who has certification, as defined in §9.5.4(B) of this Part, and full licensure and who shall be present within the facility during the hours of operation.

B. At least one physician on duty during the hours of operation shall be:

1. Certified or Board Eligible by the American Board of Emergency Medicine or the American Board of Osteopathic Emergency Medicine; OR

2. Certified or Board Eligible to sit for the examination of one of the following boards: Internal Medicine, Family Practice, or Surgery; AND must hold a certificate from the following approved programs: Advanced Coronary Life Support; Advanced Trauma Life Support; Pediatric Advanced Life Support.

C. No less than one licensed registered nurse who has training and experience in emergency care shall be on duty during the hours of operation.

D. Every freestanding emergency care facility shall have a person qualified by training and experience on the premises during the hours of operation who shall determine the nature, level and urgency of care required of all persons seeking treatment and to categorize them accordingly, assuring that serious cases are accorded priority treatment. If such person is a non-physician, he or she shall serve under the supervision of the physician-in-charge and in accordance with policies and procedures acceptable to the governing body or other legal authority.

E. Each FECF shall establish a protocol to govern the interpretation by a radiologist, of diagnostic images produced by x-ray or other modalities, including a procedure for the prompt communication of the radiologist's interpretation to the facility.

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.

G. Health Screening

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 emergency care facility. Such health screening shall be conducted in accordance with the Rules and Regulations Pertaining to Immunization, Testing, and Health Screening for Health Care Workers promulgated by the Department of Health.

9.5.5Rights of Patients

A. Each FECF shall observe the standards of R.I. Gen. Laws § 23-17-19.1 with respect to each patient.

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

9.5.6Disaster Preparedness

A. Each FECF shall develop and maintain a written disaster preparedness plan which shall include specific provisions and procedures for the emergency medical care of patients in the event of an external disaster or internal functional failure of equipment.

1. Such plan shall be developed in cooperation with appropriate state and local agencies.

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

9.5.7Administrative Records

A. Each FECF shall maintain such administrative records as may be deemed necessary by the licensing agency. These records shall include but not be limited to:

1. Monthly statistical summary of numbers of patients seen appropriately classified as to the nature of the conditions;

2. A copy of the long and short range plans;

3. An administrative record of log book containing pertinent data such as patient's name, record number, age, sex, date and time of arrival and discharge, type of care, diagnosis and disposition, and provider of service; and

4. A record of all transfers to other health facilities.

9.5.8Uniform Reporting System

A. Each FECF 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.

B. Each FECF shall make available for review upon request of the licensing agency detailed statistical data pertaining to its operations, services, and facility. Such reports and data shall be made at such intervals and by such dates as determined by the Director.

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

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

216 R.I. Code R. § 216-RICR-40-10-9.5