W. Va. Code R. § 64-12-4

Current through Register Vol. XLI, No. 36, September 6, 2024

Section 64-12-4 - Administration of the Hospital

4.1. Governing Authority.

4.1.1. The governing authority or owner is the highest authority responsible for the management and control of the hospital including employment of a hospital administrator, a licensed nursing home administrator when applicable and appointment of medical staff. The administrator is responsible for the direction and control of the hospital operation in accordance with policies established by the governing authority. The medical staff is responsible for the quality of medical care provided and for submitting reports on the quality of this care to the governing body of the hospital at defined intervals.

4.1.2. The governing authority is legally responsible for the management and control of the hospital. In the discharge of its duties, the governing authority exercises its responsibility for the care of patients through the medical staff. The governing authority is responsible for the establishment of policies and compliance with the requirements of this rule.

4.1.3. The governing authority shall adopt bylaws, subject to amendment, which require it to:

4.1.3.a. Appoint members to the medical staff;

4.1.3.b. Approve the bylaws and regulations of the medical staff;

4.1.3.c. Define the committees of the governing authority and their functions and responsibilities;

4.1.3.d. Develop and maintain a formal liaison with the medical staff;

4.1.3.e. Appoint a full-time administrator and delegate to him or her executive authority and responsibility;

4.1.3.f. Maintain an up-to-date file of all medical and ancillary staff licensed, registered, or certified by the appropriate agency of the state;

4.1.3.g. Provide for the proper control of all assets and funds, including requiring annual audits;

4.1.3.h. Provide for an assessment of all hospital clinical departments and functions provided directly or under contract through review and approval of the hospital's quality improvement reports at intervals defined by the governing body, but at least yearly;

4.1.3.i. Determine the scope of services to be offered by the hospital; and

4.1.3.j. Ensure the hospital is meeting all state requirements, inclusive of certificate of need, for the addition or termination of services, and notification of the Department of Health, Office of Health Facility Licensure and Certification of the addition or termination of services.

4.1.4. The governing authority shall record, sign, and retain in the hospital as a permanent record minutes of all of its meetings and the meetings of all of its committees, including a record of attendance for a minimum of five years.

4.1.5. The governing authority shall ensure for the provisions of a safe physical plant, equipped, and staffed to maintain adequate facilities and services for hospital patients.

4.1.6. The governing authority shall ensure there is a system in place to prevent, control, investigate, and resolve, through appropriate actions, infections, and communicable diseases within the hospital.

4.1.7. The governing authority is responsible for the effective operation of the patient grievance process.

4.2. Hospital Administrator.

4.2.1. The governing authority shall appoint a hospital administrator qualified by education and experience, who is responsible for:

4.2.1.a. Directing, coordinating, and supervising the administration of the hospital;

4.2.1.b. Carrying out the policies of the governing authority; and

4.2.1.c. Ensuring compliance with the rules of the medical staff as established in subsection 11.2. of this rule.

4.2.2. The administrator shall serve as liaison to the governing body, medical staff and other professional and supervisory staff.

4.3. Patient Rights.

4.3.1. The administrator shall ensure that the hospital informs each patient, family members, or interested persons of:

4.3.1.a. The patient's rights in advance of furnishing care; and

4.3.1.b. The process for submission of a patient grievance. This process should include informing the interested parties of the name of the hospital contact person and the address and telephone number of the Office of Health Facility Licensure and Certification.

4.3.2. The hospital shall develop and implement a written policy and procedure designating how each patient shall be informed of his or her rights in accordance with the hospital's specific manner of operation.

4.3.3. Patient rights include but are not limited to the following:

4.3.3.a. The right to be informed of his or her rights, to participate in the development and implementation of his or her plan of care and to make decisions regarding that care;

4.3.3.b. The facilitation and the communication of information to the patient, family, other legally responsible party, or a combination of the foregoing regarding understanding and participating in the plan of care;

4.3.3.c. The right to formulate advance directives and to have those directives followed;

4.3.3.d. The right to privacy and to receive care in a safe setting;

4.3.3.e. The right to be free from all forms of abuse or harassment;

4.3.3.f. The right to be free from the use of seclusion and restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff;

4.3.3.g. The right to confidentiality of his or her medical records as described in subsection 7.2. of this rule; and

4.3.3.h. The right to access information contained in his or her clinical records within a reasonable time, as defined by hospital policy.

4.3.4. The corporation shall provide, in a timely manner, skilled interpreters and personnel skilled in communicating with vision and hearing-impaired individuals either by direct employment with the corporation or by employment under a contract with the corporation.

4.3.5. The hospital shall establish a process for prompt resolution of patient grievances and shall inform each patient of the person to contact to file a grievance.

4.3.5.a. The grievance process shall specify time frames for review of the grievance and the provision of a response.

4.3.5.b. In its resolution of the grievance, the hospital shall provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion of the investigation.

4.3.6. A licensed hospital shall permit patient visitation privileges for non-relatives unless otherwise requested by the patient or legal designee. For the purposes of this section, the term "legal designee" means and includes those persons eighteen years of age or older, appointed by the patient to make health care decisions for the patient.

4.3.7. A hospital shall post signage in every patient room, patient care area or department, and staff rest area information outlining the process for reporting patient safety concerns via the facility's designated internal reporting mechanism and the process for reporting unresolved patient safety concerns or complaints to the Office of Health Facility Licensure and Certification. The posting shall include the address and telephone number for the Office of Health Facility Licensure and Certification. Signage color and text shall conform to the Office of Safety and Health Administration regulations for safety instruction signs as provided in standard §1910.145. Nothing in this subdivision precludes any patient, patient representative, or health care provider from making a good faith report pertaining to patient safety concerns and/or alleged wrongdoing or waste to any other appropriate authorities as provided in W. Va. Code §16-39-3.

W. Va. Code R. § 64-12-4