reglab/statecodes huggingface dataset:
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.04 - Facilities Exempt from These Rules

Current through Rules and Regulations filed through June 27, 2024
The following classes of hospitals are exempt from these
				  rules:
(1)
Federally owned
				and/or operated hospitals.
Hospitals owned or operated by the federal
				government are exempt from these rules and the requirement for a Georgia
				hospital permit; and
(2)
Residential Mental Health Facilities for Children and Youth.
A
				sub-classification of specialized hospitals which are licensed to provide
				twenty-four (24) hour care and have as their primary function the diagnosing
				and treating patients to age twenty-one (21) with psychiatric disorders are
				exempt from these rules in lieu of meeting the specific regulations under
				Chapter 111-8-68.
O.C.G.A. §§
										31-2-7,
				  31-7-2 and
				  31-7-5.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.05 - Application for a Permit

Current through Rules and Regulations filed through June 27, 2024
An application for a permit to operate a hospital shall be
				  submitted on forms provided by the Department. The application submitted to the
				  Department shall be an original document. No application shall be considered by
				  the Department unless it is complete and accompanied by all required
				  attachments.
(a)
Application for
				Initial Permit.
The application for an initial permit shall be submitted
				to the Department not later than thirty (30) days prior to the anticipated date
				of the opening and initiation of operations by the hospital. The application
				shall be signed by the hospital administrator or the executive officer of the
				hospital's governing body and shall include:
1. A listing of the services
				provided:
2. Proof of hospital
				ownership. In the case of corporations, partnerships, and other entities
				authorized by law, the applicant shall provide a copy of its certificate of
				incorporation, or other acceptable proof of its legal existence together with
				the names and addresses of all persons owning five (5) percent or
				more;
3. A list of the locations of
				any services offered by the hospital on separate premises; and
4. A copy of the Certificate of Need (CON)
				from the Department.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.06 - Permit Denial and Sanctions

Current through Rules and Regulations filed through June 27, 2024
The Department may refuse to grant an initial permit, revoke
				  a current permit, or impose other sanctions as described herein and in the
				  rules for the "General Licensing and Enforcement Requirements," Chapter
				  111-8-25.
(a)
Denial of an
				Application for a Permit.
The Department may refuse to grant an initial
				permit or provisional permit without the requirement of holding a hearing prior
				to the action. Denial of an application for a change to a permit from an
				existing facility shall be subject to notice and opportunity for a hearing
				following the denial. An application may be refused or denied if:
1. The hospital has failed to demonstrate
				compliance with these rules and regulations;
2. The applicant or alter ego of the
				applicant has had a permit denied, revoked, or suspended within one (1) year of
				the date of a new application;
3.
				The applicant has transferred ownership or governing authority of a hospital
				within one (1) year of the date of the new application when such transfer was
				made in order to avert denial, suspension, or revocation of a permit;
				or
4. The applicant has knowingly
				made any verbal or written false statement(s) of material fact in connection
				with the application for the permit or on documents submitted to the Department
				as part of any inspection or investigation or in the falsification or
				alteration of facility records made or maintained by the hospital.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.07 - Hospital Inspections and Required Reports to the Department

Current through Rules and Regulations filed through June 27, 2024
(1)
Inspections by the Department.
The hospital shall be available
				during all hours of operation for observation and examination by properly
				identified representatives of the Department.
(a)
Initial Inspection.
There
				shall be an initial inspection of a hospital prior to the opening date in order
				to determine that the hospital is in substantial compliance with these rules.
				Prior to this initial inspection, the hospital shall submit to the Department:
1. A copy of the certificate of
				occupancy;
2. Verification of
				building safety and fire safety from local and state authorities; and
3. Evidence of appropriate approvals by the
				state architect.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.08 - Hospital Ownership

Current through Rules and Regulations filed through June 27, 2024
There shall be full disclosure of hospital ownership to the
				  Department at the time of the initial application and when requested. In the
				  case of corporations and partnerships, the names of all corporate officers,
				  partners, and all others owning five (5) percent or more of corporate stock or
				  ownership shall be made known to the Department.
O.C.G.A. §
										31-7-3.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.09 - Governing Body and Hospital Administration

Current through Rules and Regulations filed through June 27, 2024
The hospital shall have an established and functioning
				  governing body that is responsible for the conduct of the hospital as an
				  institution and that provides for effective hospital governance, management,
				  and budget planning.
(a) The governing
				body shall be organized under bylaws and shall be responsible for ensuring the
				hospital functions within the classification for which it is permitted by the
				Department.
(b) The governing body
				shall appoint members of the medical staff within a reasonable period of time
				after considering the recommendations of the medical staff, if any, and shall
				ensure the following:
1. That every inpatient
				is under the care of a qualified member of the medical staff;
2. That the medical staff is organized and
				operates under medical staff bylaws and medical staff rules and regulations,
				which shall become effective when approved by the governing body; and
3. That the medical staff is responsible to
				the governing body for the quality of all medical care provided to patients in
				the hospital and for the ethical and professional practices of its members
				while exercising their hospital privileges.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.10 - Hospital-Patient Communications

Current through Rules and Regulations filed through June 27, 2024
The hospital shall develop, implement, and enforce policies
				  and procedures to ensure that each patient is:
(a) Informed about the hospital's grievance
				process, including whom to contact to file a grievance or complaint with the
				hospital and that individual's telephone number, and the name, address, and
				telephone number of the state regulatory agency;
(b) Provided an opportunity to give informed
				consent, or have the patient's legally authorized representative give informed
				consent, as required by state law, with documentation of provision of such
				opportunity in the patient's medical record;
(c) Afforded the right to refuse medical and
				surgical treatment to the extent permitted by law;
(d) Have advance directives honored in
				accordance with the law and afforded the opportunity to issue advance
				directives if admitted on inpatient status;
(e) Provided, upon request, a written summary
				of hospital charge rates, per service, sufficient and timely enough to allow
				the patient to compare charges and make cost-effective decisions in the
				purchase of hospital services;
(f)
				Provided an itemized statement of all charges for which the patient or
				third-party payer is being billed; and
(g) Provided communication of information in
				a method that is effective for the recipient, whether the recipient is the
				patient or the patient's designated representative. If the hospital cannot
				provide communications in a method that is effective for the recipient,
				attempts to provide such shall be documented in the patient's medical
				record.
O.C.G.A. §§
										10-1-393,
				  31-7-2.1,
				  31-7-11,
				  31-9-2,
				  31-9-7,
				  31-11-82,
				  31-32-1
et seq.
,
				  31-33-2,
				  31-33-3.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.11 - Medical Staff

Current through Rules and Regulations filed through June 27, 2024
Each hospital shall have an organized medical staff that
				  operates under bylaws adopted by the medical staff and approved by the
				  governing body. The bylaws may provide for the exercise of the medical staff's
				  authority through committees.
(a)
Organization of the Medical Staff.
The medical staff shall be
				organized and may operate through defined committees as appropriate.
1. Any physician, podiatrist, or dentist
				providing patient care, whether directly or by contract with the hospital,
				shall obtain clinical privileges through the hospital's medical staff
				credentialing process.
2. The
				medical staff shall be responsible for the examination of credentials of any
				candidate for medical staff membership and for any other individuals seeking
				clinical privileges and for the recommendations to the governing body
				concerning appointment of such candidates. Minimum requirements for medical
				staff appointments and clinical privileges shall include:
(i) Valid and current Georgia license to
				practice the respective profession;
(ii) Confirmed educational qualifications for
				the position of appointment;
(iii)
				References for practice and performance background;
(iv) Current health and mental status
				sufficient to perform medical and professional duties;
(v) Current Drug Enforcement Agency
				registration; if applicable;
(vi)
				Evidence of inquiry through relevant practitioner databases, such as databases
				maintained by licensing boards and the National Practitioner Data Bank;
				and
(vii) Congruity of the
				qualifications and/or training requirements with the privilege
				requested.
3. The
				medical staff shall evaluate at least biennially the credentials and
				professional performance of any individual granted clinical privileges for
				consideration for reappointment.
4.
				The medical staff shall establish a system for the approval of temporary or
				emergency staff privileges when needed.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.12 - Human Resources Management

Current through Rules and Regulations filed through June 27, 2024
The hospital shall select and organize sufficient qualified
				  and competent personnel to meet patients' needs and in a manner appropriate to
				  the scope and complexity of the services offered.
(a) The hospital shall establish and
				implement human resources policies and procedures to include at least:
1. Procedures for selecting qualified
				personnel;
2. A system for
				documenting the current licensure and/or certification status for those
				personnel whose positions or functions require such licensure or
				certification;
3. A system for
				assessing competency of all personnel providing health care services, on a time
				schedule defined by hospital policy; and
4. Policies and procedures regarding the
				hospital-approved method for identification of personnel to patients, other
				staff, and visitors.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.13 - Quality Management

Current through Rules and Regulations filed through June 27, 2024
The governing body shall establish and approve a plan for a
				  hospital-wide quality management program, which includes the use of peer review
				  committees. The purpose of the quality management program is to measure,
				  evaluate, and improve the provision of patient care.
(a) The scope and organization of the quality
				management program shall be defined and shall include all patient services and
				clinical support services, contracted services, and patient care services
				provided by the medical staff.
(b)
				The hospital's quality management program shall be designed to systematically
				collect and assess performance data, prioritize data, and take appropriate
				action on important processes or outcomes related to patient care, including
				but not limited to:
1. Operative procedures
				and other invasive and non-invasive procedures that place patients at
				risk;
2. Nosocomial infection
				rates;
3. Patient
				mortality;
4. Medication
				use;
5. Patient injuries, such as,
				but not limited to, those related to falls and restraint use;
6. Errors in procedures or practices which
				could compromise patient safety ("near-miss" events);
7. Discrepancies or patterns of discrepancies
				between preoperative and postoperative diagnosis, including those identified
				during the pathologic review of specimens removed during surgical or invasive
				procedures;
8. Significant adverse
				drug reactions (as identified by the hospital);
9. Adverse events or patterns of adverse
				events during anesthesia;
10.
				Equipment malfunctions, for equipment used for patient care; and
11. Reportable patient incidents as required
				under Rule
				111-8-40-.07.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.14 - Physical Environment

Current through Rules and Regulations filed through June 27, 2024
The hospital shall be equipped and maintained to provide a
				  clean and safe environment for patients, employees, and visitors.
(a)
Safety.
The hospital shall
				develop and implement an effective hospital-wide safety program that includes
				the following components:
1. A fire safety
				program including compliance with the applicable provisions of the
Life
				Safety Code
(NFPA 101), as enforced by the state fire
				marshal;
2. An incident monitoring
				system that promptly identifies, investigates, and takes effective action
				regarding all incidents that involve injury to patients, employees, or visitors
				or that involve significant damage to property;
3. A program to inspect, monitor, and
				maintain biomedical equipment, electrical equipment, and emergency power
				generators;
4. A program for the
				monitoring and maintenance of electrical safety;
5. Security procedures for controlling access
				to sensitive areas, as defined by the hospital, for patients, employees, and
				visitors;
6. Procedures for the
				safe management of medical gases;
7. A system for patients or staff to summon
				assistance, when needed, from patient rooms, bathrooms, and treatment
				areas;
8. Policies regarding
				smoking which apply to employees, patients, and visitors; and
9. Procedures for storage and disposal of
				biohazardous medical waste in accordance with applicable laws.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.15 - Disaster Preparedness

Current through Rules and Regulations filed through June 27, 2024
The hospital shall prepare for potential emergency situations
				  that may affect patient care by the development of an effective disaster
				  preparedness plan that identifies emergency situations and outlines an
				  appropriate course of action. The plan must be reviewed and revised annually,
				  as appropriate, including any related written agreements.
(a) The disaster preparedness plan shall
				include at a minimum plans for the following emergency situations:
1. Local and widespread weather emergencies
				or natural disasters, such as tornadoes, hurricanes, earthquakes, ice or
				snowstorms, or floods;
2. Manmade
				disasters such as acts of terrorism and hazardous materials spills;
3. Unanticipated interruption of service of
				utilities, including water, gas, or electricity, either within the facility or
				within a local or widespread area;
4. Loss of heat or air
				conditioning;
5. Fire, explosion,
				or other physical damage to the hospital; and
6. Pandemics or other situations where the
				community's need for services exceeds the availability of beds and services
				regularly offered by the hospital.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.16 - Infection Control

Current through Rules and Regulations filed through June 27, 2024
The hospital shall have an effective infection control system
				  to reduce the risks of nosocomial infections in patients, health care workers,
				  volunteers, and visitors.
(a) The
				hospital shall designate qualified infection control staff to coordinate the
				infection control program.
(b) The
				administrative and medical staff of the hospital, as well as staff from
				appropriate organized services, shall participate in the infection control
				program.
(c) The infection control
				program shall function from a well-designed surveillance plan that is based on
				accepted epidemiological principles, is tailored to meet the needs of the
				hospital, and includes both outcome and process surveillance
				methodologies.
(d) The surveillance
				plan shall require collection of sufficient baseline data on the incidence of
				nosocomial infections in order that outbreaks can be identified.
(e) The infection control methodologies for
				effective investigation and control of outbreaks, once identified, shall
				include at least:
1. The availability of
				microbiology laboratory capacity to detect and investigate outbreaks;
2. A system for obtaining appropriate
				clinical specimens for culture;
3.
				Access to necessary information in order to investigate infectious outbreaks;
				and
4. Administrative, physician,
				and nursing support to direct hospital changes to achieve immediate control of
				outbreaks and for implementation of corrective actions.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.17 - Sterile Processing Services

Current through Rules and Regulations filed through June 27, 2024
Each hospital shall designate a sterile processing service
				  area designated for the decontamination, cleaning, sterilizing of reusable
				  equipment, instruments, and supplies.
(a) With the collaboration of the infection
				control program, the staff providing sterile processing services shall develop
				and implement standardized policies and procedures that conform to generally
				accepted standards of practice for:
1.
				Decontamination and cleaning of instruments and other items and description of
				reprocessing protocols for contaminated patient equipment;
2. Disinfecting and/or sterilizing equipment
				and other items;
3. Monitoring of
				the systems used for sterilization;
4. Procedures for ensuring the sterility of
				packaged instruments and supplies;
5. Recall of items; and
6. Mechanisms for protection of workers from
				exposure to blood and other potentially infectious materials and environmental
				hazards.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.19 - Patient Assessment and Treatment

Current through Rules and Regulations filed through June 27, 2024
All patient care services provided by the hospital shall be
				  under the direction of a member of the medical staff or a licensed physician,
				  dentist, osteopath, or podiatrist who has been granted hospital
				  privileges.
(a)
Patient
				Assessment/Screening on Admission.
The hospital shall provide each
				inpatient with an appropriate assessment of the patient's condition and needs
				at the time of admission. Such assessments shall be provided by personnel
				authorized by hospital policy or the medical staff bylaws and/or rules and
				regulations and shall be designed to trigger referral for further assessment
				needs.
1. A history and physical examination
				shall be completed within the first twenty-four (24) hours after admission. A
				history and physical examination completed by either the patient's physician or
				the appropriate practitioner operating under the direction of the physician as
				authorized by law no more than thirty (30) days prior to the admission may be
				accepted but must be updated to reflect the patient's condition at the time of
				admission. Where the patient is admitted solely for oromaxillofacial surgery,
				such history and physical may be completed by the oromaxillofacial
				surgeon.
2. A basic nursing
				assessment to include at least evaluation of physical and psychological status
				sufficient to develop an initial plan of care shall be completed within the
				first twelve (12) hours after admission. Within twenty-four (24) hours after
				admission, a comprehensive nursing assessment will be completed to include at
				least:
(i) Screening and referral for further
				assessment of patient needs related to social, nutritional, and functional
				status; and
(ii) Screening of
				educational and potential post-hospitalization needs.
3. Inquiry as to the status of any advance
				directives for the patient shall be made at the time of admission.
(i) If a patient has an advance directive in
				place that the patient wishes to invoke, but the written directive is not
				available at the time of admission, there shall be a mechanism in place to
				trigger a recheck by hospital personnel for the document within a reasonable
				period of time.
(ii) If the patient
				does not have an advance directive in place, admissions procedures shall
				require that designated hospital personnel will offer information regarding
				advance directives according to hospital policy and timelines.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.20 - Discharge Planning and Transfers for Inpatients

Current through Rules and Regulations filed through June 27, 2024
The hospital shall utilize an effective and on-going
				  discharge planning process that identifies post-hospital needs of inpatients
				  and arranges for appropriate resource referral and follow-up care.
(a) On admission, the nursing assessment
				shall identify patients who are likely to suffer adverse consequences upon
				discharge in the absence of adequate discharge planning.
(b) For those patients identified as needing
				a discharge plan, designated qualified staff shall complete an evaluation of
				post-hospital needs and shall develop a plan for meeting those needs. The
				discharge plan shall be revised as needed with changes in the patient's
				condition.
(c) The hospital shall
				provide education to patients, and their family members or interested persons
				as necessary or as requested by the patient, to prepare them for the patient's
				post-hospital care.
(d) The
				hospital shall arrange for the initial implementation of any discharge plan,
				including, as applicable, any transfer or referral of the patient to
				appropriate facilities, agencies, or outpatient services for follow-up or
				ancillary care. The hospital shall be responsible for the transfer of any
				necessary medical information to other facilities for the purpose of
				post-hospital care.
(e) The
				hospital shall regularly reassess the discharge planning process to ensure that
				it is responsive to patients' discharge needs.
(f) The hospital shall adopt and enforce a
				policy requiring annually during influenza season (inclusive of at least
				October 1st through March 1st) and prior to discharge, any inpatient 65 years
				of age or older shall be offered vaccinations for the influenza virus and
				pneumococcal disease unless contraindicated and contingent on availability.
1. The hospital policy may authorize such
				vaccinations to be administered per hospital medical staff approved standing
				order and protocol following an assessment for contraindications.
2. The hospital policy must also require the
				inpatient's medical record, where such vaccination is administered, to contain
				an assessment for contraindications, the date of such administration and
				patient response.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.21 - Nursing Services

Current through Rules and Regulations filed through June 27, 2024
The hospital shall have an organized nursing service that
				  provides twenty-four (24) hour nursing care to meet the needs of patients.
				  Critical access hospitals are exempted from providing on-site twenty-four (24)
				  hour nursing care when there are no hospitalized patients.
(a)
Organization of Nursing Services.
The hospital's nursing services shall be directed by a licensed
				registered nurse who shall be responsible for implementing a system for
				supervision and evaluation of nursing clinical activities.
1. The chief nurse executive shall establish
				and implement policies and procedures for nursing services based on generally
				accepted standards of practice including the evaluation of the effectiveness of
				the services in coordination with the hospital's quality management
				program.
2. The chief nurse
				executive shall be responsible for ensuring that nursing personnel are oriented
				to nursing policies and procedures.
3. Nursing services shall have and follow a
				written plan for organization, administrative authority, delineation of
				responsibilities for patient care, and staff qualifications and competencies.
(i) The nursing service plan shall include
				the types and numbers of nursing personnel necessary to provide appropriate
				nursing care for each patient in the hospital.
(ii) Specialty areas shall specify nursing
				requirements for their areas that also define any special nursing competency
				requirements, staffing patterns based on patient acuity, and the required ratio
				of nurses to technical staff.
(iii)
				A system of patient assignment shall be defined which reflects a consideration
				of patient needs and nursing staff qualifications and competencies.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.22 - Pharmaceutical Services

Current through Rules and Regulations filed through June 27, 2024
The hospital shall provide or have access to effective
				  pharmaceutical services to meet the needs of its patients in accordance with
				  generally accepted standards of practice and applicable laws and
				  regulations.
(a)
Pharmacy
				Director.
All pharmaceutical services in the hospital shall be under the
				direction of a pharmacist licensed in Georgia. The responsibilities of the
				director of pharmaceutical services shall include:
1. Developing, supervising, and coordinating
				all activities of the pharmaceutical service to be in compliance with state
				rules and regulations for hospital pharmacies including the evaluation of the
				effectiveness of the services in coordination with the hospital's quality
				management program; and
2.
				Developing and implementing an effective system that does the following:
(i) Minimizes drug errors and identifies
				potential drug interactions and adverse drug reactions;
(ii) Controls the availability and storage of
				drugs throughout the hospital;
(iii) Distributes and administers the drugs
				in compliance with generally accepted standards of practice;
(iv) Tracks the receipt and disposition of
				all scheduled drugs;
(v) Staffs
				pharmaceutical services to provide sufficient qualified personnel to respond to
				the pharmaceutical needs of the patient population being served, including
				twenty-four (24) hours per day, seven (7) days per week emergency
				coverage;
(vi) Labels and dispenses
				drugs, including a requirement that only licensed pharmacists or properly
				supervised licensed pharmacy interns are permitted to compound, label, and
				dispense drugs or biologicals;
(vii) Manages drug recalls;
(viii) Addresses the removal of drugs when a
				pharmacist is not available;
(ix)
				Compiles and reports data related to drug ordering; dispensing and
				administration errors, and possible adverse drug reaction to the hospital's
				quality management program; and
(x)
				Reviews all activities and functions of the hospital's pharmaceutical
				services.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.23 - Food and Dietary Services

Current through Rules and Regulations filed through June 27, 2024
The hospital shall have an organized food and dietary service
				  that is directed and staffed by an adequate number of qualified personnel to
				  meet the nutritional needs of hospital patients. All hospital food service
				  areas and operations shall comply with current federal and state laws and rules
				  concerning food service.
(a)
Organization of Food and Dietary Services.
1.
Food Service Manager.
The
				hospital shall have a manager of food and dietary services who has training and
				experience in management of a food service system in a health care setting and
				receives on-going training. The responsibilities of the manager shall include:
(i) Overall coordination and integration of
				the therapeutic and administrative aspects of the service;
(ii) Development and implementation of
				policies and procedures concerning the scope and conduct of dietary services,
				including food preparation and delivery systems;
(iii) Orientation and training programs for
				dietary service personnel and other hospital personnel involved in food
				delivery on all applicable dietary services policies and procedures, including
				personal hygiene, safety, infection control requirements, and proper methods of
				waste disposal;
(iv) The
				implementation of a system to ensure that prescribed diets are delivered to the
				correct inpatients;
(v) Maintenance
				of a staff of sufficient numbers of administrative and technical personnel
				competent in their assigned duties to carry out the dietary service
				program;
(vi) Procurement of food,
				paper, chemical, and other supplies sufficient to meet the anticipated food
				service needs of the hospital; and
(vii) Implementation of procedures to rotate
				all food items to ensure use in a timely manner.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.24 - Imaging and Therapeutic Radiology Services

Current through Rules and Regulations filed through June 27, 2024
(1)
Imaging Services.
The
				hospital shall maintain or arrange for effective imaging services to meet the
				needs of patients. The radiological imaging services shall be provided by the
				hospital in accordance with the rules under Chapter 290-5-22 Rules and
				Regulations for X-rays, where applicable.
(a)
Organization and Staffing for Imaging Services
. The hospital shall
				have an organizational plan for imaging services that identifies the scope of
				the services provided and the qualifications of the individuals necessary for
				the performance of various aspects of imaging services and delineates the lines
				of authority and accountability.
1. There
				shall be a qualified director of imaging services who is a member of the
				medical staff and a licensed doctor of medicine or osteopathy with knowledge
				andexperience in imaging services to supervise the provision of imaging
				services on a full-time or part-time basis.
2. The director shall be responsible for all
				clinical aspects of the organization and delivery of imaging services,
				including the evaluation of the effectiveness of the services in coordination
				with the hospital's quality management program.
3. Basicradiological imaging services shall
				be available at all times, or there shall be an on-call procedure to provide
				access to qualified x-ray personnel within thirty (30) minutes.
4. The hospital shall have qualified staff
				performing imaging services.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.25 - Laboratory Services

Current through Rules and Regulations filed through June 27, 2024
The hospital shall maintain or arrange for clinical
				  laboratory services to meet the needs of hospital patients.
(a)
Organization and Staffing for
				Clinical Laboratory Services.
The administration, performance, and
				operation of all laboratories used by the hospital, as well as any laboratory
				functions performed by the hospital, shall conform to the Rules and Regulations
				for Licensure of Clinical Laboratories, Chapter 111-8-10.
1. The hospital shall have an organizational
				plan for laboratory services that identifies the scope of the services provided
				and the qualifications of the individuals necessary for the performance of
				various aspects of clinical laboratory services and delineates the lines of
				authority and accountability.
2.
				There shall be a qualified director of clinical laboratory services who is a
				member of the medical staff and meets the requirements for a director set forth
				in the Rules and Regulations for Clinical Laboratories, Chapter
				111-8-10.
3. The director shall be
				responsible for the administration of clinical laboratory services, including
				the evaluation of the effectiveness of the services in coordination with the
				hospital's quality management program.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.26 - Respiratory/Pulmonary Services

Current through Rules and Regulations filed through June 27, 2024
The hospital shall provide or arrange for effective services
				  to meet the respiratory/ pulmonary needs of patients and shall define in
				  writing the scope and complexity of the respiratory/pulmonary services offered
				  by the facility.
(a)
Organization and Staffing of Respiratory/Pulmonary Services.
1. The hospital shall have an organizational
				plan for respiratory/ pulmonary services that clearly defines the necessary
				staff for the services and the lines of authority and accountability.
2.
Director.
There shall be a
				qualified director of respiratory/pulmonary services who is a member of the
				medical staff and a licensed doctor of medicine or osteopathy with knowledge,
				experience, and capability to supervise the services on a full-time or
				part-time basis including the evaluation of the effectiveness of the services
				in coordination with the hospital's quality management program.
(i) The director shall be responsible for all
				clinical aspects of the organization and delivery of clinical respiratory care
				services, including the evaluation of the effectiveness of the services in
				coordination with the hospital's quality management program.
(ii) The director shall be responsible for
				the development, implementation, and periodic review of policies, procedures,
				and protocols for respiratory/pulmonary care, which shall reflect the scope of
				services offered, including at least:
(I)
				Routine inspection, cleaning, and maintenance procedures for respiratory
				equipment, as well as protocols for their assembly and operation;
(II) Adverse reaction protocols;
(III) Safety practices and
				interventions;
(IV) Staff
				participation in emergency situations at the facility;
(V) Infection control procedures;
(VI) Procedures for handling, storage, and
				dispensing of therapeutic gases;
(VII) Procedures for obtaining blood samples
				and analysis of samples, as applicable;
(VIII) Procedures for testing of pulmonary
				function, as applicable;
(IX)
				Procedures for therapeutic percussion and vibration and for broncho-pulmonary
				drainage, as applicable;
(X)
				Procedures for mechanical ventilation and oxygenation support and for
				administration of aerosol, humidification, and therapeutic gases, as
				applicable;
(XI) Policies for
				administration of medications;
(XII) A system for the reissuing and
				discontinuing of respiratory therapy orders; and
(XIII) Procedures for verbal/telephone orders
				taken by state-certified respiratory care professionals.
3. There shall be a sufficient
				number of qualified competent professionals and support personnel to respond to
				and meet the respiratory/ pulmonary care needs of the patients.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.27 - Organ, Tissue, and Eye Procurement and Transplantation

Current through Rules and Regulations filed through June 27, 2024
The hospital shall participate, as appropriate, in the
				  procurement of anatomical gifts.
(a)
Receipt of Donations.
The hospital shall receive donations of
				organs or tissues for the purposes of medical and dental education, research,
				advancement of medical or dental science, therapy, or transplantation only in
				accordance with the provisions of the "Georgia Anatomical Gift Act," O.C.G.A.
				Section 44-5-140, and the applicable rules
				of Chapter 111-8-5.
(b)
Voluntary Expression of Intent to Donate.
The hospital shall
				establish and implement policies and procedures for documenting requests by
				patients regarding their intentions for disposition of their bodies or organs
				and for seeing that these expressed intentions are honored upon death when
				possible.
(c)
Hospital
				Requests for Anatomical Gifts.
The hospital shall establish and
				implement policies and procedures for requesting anatomical gifts on or before
				the occurrence of death in the absence of a patient's expressed intentions.
1. Policies and procedures shall provide for
				a written agreement(s) with an organ bank or storage facility with the
				provisions specified in Rules for Anatomical Gifts, Chapter
				111-8-5-.07, and provisions for the
				training of staff authorized to request the gifts, when applicable.
2. Where the hospital does not have the Organ
				Procurement Organization handle requests for anatomical gifts, the hospital
				shall designate staff authorized to make requests for anatomical gifts, and
				such staff shall be appropriately trained in the following areas:
(i) Psychological and emotional
				considerations when dealing with bereaved families;
(ii) Social, cultural, ethical, and religious
				factors affecting attitudes toward donations;
(iii) General medical concepts and issues in
				organ, tissue, and eye donations;
(iv) Procedures for declaring death and
				collecting and preserving organs, tissues, and/or other body parts and for how
				these procedures are to be explained to decedents' families;
(v) Procedures for notifying and involving
				banks or storage facilities; and
(vi) procedures for recording the outcomes of
				requests.
3. If the
				hospital engages in harvesting tissue and/or transplanting organs and tissues
				from living donors, the hospital shall develop a living donor organ/transplants
				policy that addresses the issues related to such donations.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.29 - Anesthesia Services

Current through Rules and Regulations filed through June 27, 2024
Any hospital offering surgical or obstetrical services shall
				  have an organized anesthesia service which shall be responsible for all
				  anesthesia delivered at the hospital. The anesthesia services will be provided
				  in a manner which protects the health and safety of patients in accordance with
				  generally accepted standards of practice.
(a)
Organization of Anesthesia
				Services.
1. Anesthesia services shall
				be directed by a qualified physician member of the medical staff who is
				responsible for organizing the delivery of anesthesia services provided by the
				hospital in accordance with generally accepted standards of practice.
2. The anesthesia director shall be
				responsible for monitoring the quality and appropriateness of anesthesia
				services and for ensuring that identified problems are addressed through the
				quality management program.
3. The
				anesthesia director shall be responsible for establishing an orientation and
				continuing education program for anesthesia services staff that include, at a
				minimum, instruction in safety precautions, emergency patient management,
				equipment use and inspections, and infection control procedures in the surgical
				suite.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.30 - Nuclear Medicine Services

Current through Rules and Regulations filed through June 27, 2024
If the hospital provides nuclear medicine services, those
				  services shall be organized and effective. The nuclear medicine services shall
				  be provided in a manner consistent with applicable state laws and regulations
				  and generally accepted standards of practice.
(a) Radioactive materials used in the
				provision of nuclear medicine services shall be prepared by personnel
				authorized as defined by state law to prepare radiopharmaceuticals and shall be
				labeled, used, transported, stored, and disposed of in a manner consistent with
				the "Georgia Radiation Control Act," O.C.G.A. Chapter 31-13
et
				seq.
, and applicable rules.
(b) If a clinical laboratory is utilized in
				the provision of nuclear medicine services, the laboratory shall be licensed to
				perform these services as required by the Rules and Regulations for Clinical
				Laboratories, Chapter 111-8-10.
(c)
				Nuclear medicine services shall be directed by a doctor of medicine or
				osteopathy who is a member of the medical staff qualified to perform and
				supervise those services. The director shall be responsible for the
				administration of nuclear medical services, including the evaluation of the
				effectiveness of the services in coordination with the hospital's quality
				management program.
(d) Nuclear
				medicine procedures shall be administered and/or supervised by licensed doctors
				of medicine or osteopathy as authorized by state law.
O.C.G.A. §§
										31-7-2.1,
				  31-13-1
et seq.
and 31-22-1
et seq.
Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.31 - Emergency Services

Current through Rules and Regulations filed through June 27, 2024
The hospital shall provide, within its capabilities, services
				  to persons in need of emergency care.
(a)
Full-time Emergency Services.
If the hospital offers emergency care as an organized service and/or
				holds itself out to the public as offering emergency services, the service
				shall be included in the scope of services submitted with the application for
				the hospital permit and shall be offered twenty-four (24) hours per day.
1.
Organization.
Supervision and
				organization of emergency services shall be under the direction of a qualified
				member of the medical staff.
(i) The director
				shall be responsible for the development of policies and procedures related to
				emergency services and the review and update of policies as necessary. The
				policies and procedures shall be approved by appropriate members of the medical
				staff.
(ii) The director shall
				implement systems to assess the effectiveness of the emergency service and to
				address improvement issues through the hospital's quality management
				program.
(iii) Staffing assignments
				shall provide for sufficient nursing, medical, and technical staff to meet the
				anticipated needs of emergency patient care. There shall be available to
				emergency room staff procedures for accessing additional staff on an as-needed
				basis to meet unanticipated needs.
(iv) Patient care responsibilities for
				emergency services staff shall be specified by written policies and procedures,
				which shall include training and experience requirements appropriate to the
				assigned responsibilities and clearly defined lines of authority.