reglab/statecodes huggingface dataset:
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.231 - RESTRAINT AND SECLUSION ORDERS

Current through August 31, 2023
The use of restraint or seclusion must be in accordance with
				the order of a physician or other licensed independent practitioner, who has
				been granted privileges by the governing body to order restraint and seclusion.
				(3-17-22)
01.
Orders
.
			 Orders for the use of restraint or seclusion must never be written as a
			 standing order or on an as needed basis (PRN). (3-17-22)
02.
Attending Physician
.The
			 attending physician must be consulted as soon as practical if the attending
			 physician did not order the restraint or seclusion. (3-17-22)
03.
Time Limits on Orders
. Each
			 order for restraint or seclusion used for the management of violent or
			 self-destructive behavior that jeopardizes the immediate physical safety of the
			 patient, a staff member, or others may only be renewed according to the
			 following limits up to a total of twenty-four (24) hours: (3-17-22)
a. Four (4) hours for adults eighteen (18)
			 years of age or older; (3-17-22)
b.
			 Two (2) hours for children and adolescents nine (9) to seventeen (17) years of
			 age; or (3-17-22)
c. One (1) hour
			 for children under nine (9) years of age. (3-17-22)
d. The original restraint or seclusion order
			 may only be renewed within the required time limits for up to a total of
			 twenty-four (24) hours. After the original order expires, a physician or other
			 licensed independent practitioner must see and assess the patient before
			 issuing a new order. (3-17-22)
e.
			 Seclusion may only be ordered for the management of violent or self-destructive
			 behavior. (3-17-22)
f. Each order
			 for restraint used to ensure the physical safety of a non-violent or
			 non-self-destructive patient may be renewed as allowed by hospital policies.
			 (3-17-22)
g. Restraint or seclusion
			 must be discontinued at the earliest possible time when the patient no longer
			 presents an immediate risk of harm to self or others. The risk of harm must be
			 assessed by a physician or licensed independent practitioner, or a registered
			 nurse prior to releasing the patient. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.232 - RESTRAINT AND SECLUSION IMPLEMENTATION AND MONITORING

Current through August 31, 2023
The use of restraint or seclusion must be implemented in
				accordance with safe and appropriate restraint and seclusion techniques as
				determined by hospital policy. (3-17-22)
01.
Written System
. The hospital
			 must adopt a written system for the use of restraints and seclusion, including
			 techniques to identify staff and patient behaviors, events, and environmental
			 factors that may trigger circumstances that require the use of a restraint or
			 seclusion. (3-17-22)
02.
Observation of Patients Who Are Not Violent or Self-Destructive
.
			 Patients who are restrained but who are not violent or self-destructive, must
			 be observed at intervals not greater than fifteen (15) minutes.
			 (3-17-22)
03.
Management of
			 Violent or Self-Destructive Behavior
. Patients who are restrained or
			 secluded for violent or self-destructive behaviors must be continuously
			 observed by trained staff assigned to observe the patient. Staff must observe
			 the patient either directly or using both video and audio equipment. Staff
			 observing the patient must be physically close enough to protect the patient in
			 an emergency. (3-17-22)
04.
Face-to-Face by Physician or Other Licensed Independent
			 Practitioner
. Patients who are restrained or secluded for the management
			 of violent or self-destructive behavior, must be seen face-to-face within one
			 (1) hour after the initiation of the intervention by a physician or other
			 licensed independent practitioner or by a registered nurse who has been trained
			 to conduct face-to-face examinations. The face-to-face examination must
			 evaluate: (3-17-22)
a. The patient's
			 immediate situation; (3-17-22)
b.
			 The patient's reaction to the intervention; (3-17-22)
c. The patient's medical and behavioral
			 condition; and (3-17-22)
d. The
			 need to continue or terminate the restraint or seclusion. (3-17-22)
e. When the face-to-face evaluation is
			 conducted by a trained registered nurse, the trained registered nurse must
			 consult the attending physician or other licensed independent practitioner who
			 is responsible for the care of the patient, as soon as possible after the
			 completion of the one (1) hour face-to-face evaluation.
			 (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.233 - RESTRAINT AND SECLUSION DOCUMENTATION

Current through August 31, 2023
The clinical record for each patient that is restrained or
				secluded must contain comprehensive documentation of the episode.
				(3-17-22)
01.
Patient's
			 Behavior
. A description of the patient's behavior that led to the use of
			 restraint or seclusion. (3-17-22)
02.
Interventions Used Prior to
			 Restraint or Seclusion
. Alternatives or other less restrictive
			 interventions attempted prior to the use of restraint or seclusion.
			 (3-17-22)
03.
Type of
			 Intervention
. The type of interventions used, including the date and
			 time the interventions were initiated. (3-17-22)
04.
Assessments
. Initial and
			 ongoing assessments of the need for restraint or seclusion by medical and
			 nursing staff. (3-17-22)
05.
Patient's Response
. The patient's response to the use of restraint or
			 seclusion, including ongoing behaviors. (3-17-22)
06.
Monitoring Activities
.
			 Monitoring activities by staff. (3-17-22)
07.
Restraint and Seclusion Log
.
			 Each hospital must maintain a log of restraint and/or seclusion use that must
			 include: (3-17-22)
a. The name of the patient;
			 (3-17-22)
b. The type of restraints
			 and/or seclusion used; (3-17-22)
c.
			 The date and time restraints and/or seclusion were applied and discontinued;
			 and (3-17-22)
d. Any injury or
			 adverse consequence to the patient incurred during the restraint and/or
			 seclusion. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.234 - RESTRAINT AND SECLUSION TRAINING

Current through August 31, 2023
All staff involved with the ordering, application, and
				monitoring of restraints and seclusion must be trained. (3-17-22)
01.
Training Requirements
.
			 Training must include an overview of the hospital's system for the use of
			 restraints and seclusion, including techniques to identify staff and patient
			 behaviors, events, and environmental factors that may trigger circumstances
			 that require the use of a restraint or seclusion. Training must also include:
			 (3-17-22)
a. De-escalation techniques;
			 (3-17-22)
b. Use of least
			 restrictive interventions; (3-17-22)
c. The safe application of restraints;
			 (3-17-22)
d. Monitoring patients in
			 restraint or seclusion; and (3-17-22)
e. Providing care for a patient in restraint
			 or seclusion. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.250 - MEDICAL STAFF

Current through August 31, 2023
The hospital must have an active medical staff organized under
				bylaws approved by the governing body and responsible to the governing body for
				the quality of all medical care provided the patients, and for the professional
				practices and ethical conduct of the members. (3-17-22)
01.
Medical Staff Qualifications and
			 Privileges
. All medical staff members must be qualified legally and
			 professionally for the privileges that they are granted. (3-17-22)
a. Privileges must be granted only on the
			 basis of individual training, competence, and experience. (3-17-22)
b. The medical staff, with governing body
			 approval, must develop and implement a written procedure for determining
			 qualifications for medical staff appointment, and for determining privileges.
			 (3-17-22)
c. The governing body
			 must approve medical staff privileges within the limits of the hospital's
			 capabilities for providing qualified support staff and equipment in specialized
			 areas. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.310 - NURSING SERVICE

Current through August 31, 2023
There shall be an organized nursing department with a plan that
				delineates authority, responsibility and duties of each category of nursing
				personnel, and a functional structure for cooperative planning and cooperation.
				An organizational chart shall be in the nursing service office and in all
				policy manuals. Job descriptions shall be available and in use that delineate
				responsibilities, functions or duties, and qualifications for each category of
				nursing positions. (3-17-22)
01.
Director of Nursing Services
. The nursing service shall be under
			 the overall direction of a qualified licensed registered nurse with education
			 and experience commensurate with size and complexity of the hospital whose
			 duties are as follows: (3-17-22)
a. To
			 organize, coordinate, and evaluate nursing service functions and staff; and
			 (3-17-22)
b. To be responsible for
			 development and implementation of policies and procedures as they relate to
			 care of patients; and (3-17-22)
c.
			 To select, promote, and terminate nursing staff; and (3-17-22)
d. To establish a procedure to insure staff
			 licenses are valid and current. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.320 - DIETARY SERVICE

Current through August 31, 2023
Dietetic services shall be organized and function in a manner
				to meet the nutritional needs of all patients admitted to the hospital.
				(3-17-22)
01.
Dietary
			 Supervision
. The dietary service in each hospital shall be under the
			 supervision of a person who by education or specialized training and experience
			 is knowledgeable in food service management. (3-17-22)
a. This person shall be responsible for
			 management of the food service, and represent the department in
			 interdepartmental meetings. (3-17-22)
b. The nutritional aspects of patient care
			 shall be supervised by a qualified dietitian. (3-17-22)
c. The dietitian shall correlate and
			 integrate the dietary aspects of patient care with the patient, patient's chart
			 and the patient's care plan. (3-17-22)
d. When the dietitian serves as a consultant
			 only, she shall train and instruct the food service supervisor and/or nurses to
			 take diet histories, instruct patients, and transmit dietary information to the
			 charts. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.330 - PHARMACY SERVICE

Current through August 31, 2023
The hospital shall provide an organized pharmaceutical service
				that is administered in accordance with accepted professional principles and
				appropriate federal, state, and local laws. (3-17-22)
01.
Organization and
			 Supervision
. Pharmacy services shall be under the overall direction of a
			 pharmacist who is licensed in Idaho and is responsible for developing,
			 coordinating, and supervising all pharmaceutical services in the hospital.
			 (3-17-22)
a. The director of the
			 pharmaceutical service, whether a full, part-time or a consultant member of the
			 staff, shall be responsible to the chief executive officer or his designee.
			 (3-17-22)
b. The pharmacist shall
			 be responsible for the supervision of the hospital drug storage area in which
			 drugs are stored and from which drugs are distributed. (3-17-22)
c. If trained pharmacy assistants, pharmacy
			 students, or pharmacy interns are employed, they shall work under the direct
			 supervision of a pharmacist. (3-17-22)
d. If the director of the pharmaceutical
			 service is part-time, sufficient time shall be provided by the pharmacist to
			 fulfill the responsibilities of the director of pharmaceutical services.
			 (3-17-22)
e. The director of the
			 pharmaceutical service shall be responsible for maintaining records of the
			 transactions of the pharmacy as required by law and as necessary to maintain
			 adequate control and accountability of all drugs. This includes a system of
			 control and records for the requisitioning and dispensing of drugs and supplies
			 to nursing units and to other department/services of the hospital, as well as
			 records of all prescription drugs dispensed to the patient. (3-17-22)
f. The pharmacist shall periodically check
			 drugs and drug records in all locations in the hospital where drugs are stored,
			 including but not limited to nursing stations, emergency rooms, outpatient
			 departments, operating suites. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.340 - RADIOLOGY SERVICE

Current through August 31, 2023
The hospital shall provide diagnostic radiological service,
				equipment, and facilities according to the size of the hospital and the scope
				of services rendered. (3-17-22)
01.
Radiological Requests
. Radiological services shall be performed
			 only on the request of a person legally authorized to diagnose, treat and
			 prescribe. (3-17-22)
02.
Radiation Control and Safety
. All hospitals shall comply with Idaho
			 Department of Health and Welfare Rules, IDAPA 16.02.27, "Idaho Radiation
			 Control Rules." (3-17-22)
03.
Personnel
. There shall be sufficient qualified personnel to meet
			 the needs of services being offered. Minimum requirements are as follows:
			 (3-17-22)
a. A physician eligible or
			 certified by the American Board of Radiology shall have overall direction for
			 the service. In small hospitals this requirement can be accomplished by a
			 consulting physician who meets the definition found in Subsection
			 002.51 and is a member of the
			 medical staff. (3-17-22)
b. There
			 shall be sufficient radiologic technologists to meet the needs of the patients
			 and services offered, and not less than one (1) available or on call at all
			 times. If a hospital is unable to employ sufficient radiologic technologists to
			 meet its needs, that hospital may use other hospital personnel who have
			 documented, on-the-job training in radiologic technology and who are certified
			 as being able to perform safely the duties assigned within the radiology
			 services by the persons with overall direction of the radiology service under
			 Subsection 340.03.a. Such certification
			 shall be documented and updated annually. (3-17-22)
c. The physician director of the department
			 or service, or the medical staff shall determine if radiologic technologists
			 are qualified by education and experience. Such determination shall be
			 documented. (3-17-22)
d. An ongoing
			 educational program shall be developed, implemented and evaluated for personnel
			 in radiology service. (3-17-22)
e.
			 An orientation shall be given to all new employees of the radiology department.
			 (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.350 - LABORATORY SERVICE

Current through August 31, 2023
The hospital shall maintain a clinical laboratory with the
				necessary space, personnel and equipment to meet the needs of the services
				offered. Contractual services shall also meet the requirements of Subsection
				200.08. (3-17-22)
01.
Laboratory Services
. Basic
			 laboratory service necessary for routine tests shall be maintained in the
			 hospital. Clinical laboratory tests shall be performed, or arranged for, and
			 shall include the following: (3-17-22)
a.
			 Chemistry; and (3-17-22)
b.
			 Microbiology; and (3-17-22)
c.
			 Hematology; and (3-17-22)
d.
			 Serology; and (3-17-22)
e. Clinical
			 microscopy; and (3-17-22)
f.
			 Immunohematology; and (3-17-22)
g.
			 Urinalysis. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.360 - MEDICAL RECORDS SERVICE

Current through August 31, 2023
The hospital shall maintain medical records that are documented
				accurately and timely, and that are readily accessible and retrievable.
				(3-17-22)
01.
Facilities
. The hospital shall provide a medical record room, equipment,
			 and facilities for the retention of medical records. Provision shall be made
			 for the safe storage of medical records. (3-17-22)
02.
Policies and Procedures
.
			 There shall be written policies and procedures for the operation of the medical
			 records service. (3-17-22)
03.
Maintenance of Records
. A medical record shall be maintained for
			 every person who is evaluated or treated as an inpatient, outpatient, emergency
			 patient or a home care patient. (3-17-22)
04.
Access to Records
. Only
			 authorized personnel shall have access to the record. (3-17-22)
05.
Release of Medical
			 Information
. No release of medical information shall be made without
			 written consent of the patient or by official court order except to legally
			 authorized entities such as third party payors, peer review organizations,
			 licensing agency, etc. (3-17-22)
06.
Removal of Medical Records
.
			 Medical records shall only be removed from the hospital in accordance with
			 written hospital procedures. (3-17-22)
07.
Retention
. Records shall be
			 retained to conform with Section
			 39-1394, Idaho Code.
			 (3-17-22)
08.
Personnel
. The medical records service shall be under the overall
			 direction of a Registered Health Information Administrator or a Registered
			 Health Information Technician. If the person in charge of records is not so
			 trained, the facility shall retain an R.H. I.A. or R.H.I.T. on a regular
			 consulting basis. (3-17-22)
09.
Identification and Filing
. A system of identifying and filing to
			 ensure prompt retrieval of patient's records shall be maintained as follows:
			 (3-17-22)
a. Any system shall bear at least
			 the name, address, birthdate, medical record number, dates of admission and
			 discharge; and (3-17-22)
b. Each
			 record shall be maintained so that both in and outpatient records for treatment
			 are readily retrievable. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.370 - EMERGENCY SERVICE

Current through August 31, 2023
All hospitals who provide emergency medical care in a specific
				area of the facility shall have an organized plan for emergency care based upon
				current community needs and the capability of the hospital. (3-17-22)
01.
Policies and Procedures
. The
			 emergency room of every hospital shall have written policies and procedures.
			 These shall be in conformance with state and local laws. The procedures shall
			 be approved by the hospital administration, medical staff, and nursing service.
			 The policies shall be approved by the governing body. The policies and
			 procedures shall include but are not limited to, the following: (3-17-22)
a. Policies and procedures for handling
			 accident victims, rape victims, contagious disease, persons suspected of
			 criminal acts, abused children or adults, emotionally disturbed persons,
			 persons under the influence of drugs and/or alcohol, persons contaminated by
			 radioactive materials, and patients dead on arrival; and (3-17-22)
b. Medical responsibility shall be delineated
			 regarding emergency care (including levels of care relating to clinical
			 privileges and specialty areas) and shall specify a method to insure staff
			 coverage; and (3-17-22)
c.
			 Procedures that can/cannot be performed in the emergency room; and
			 (3-17-22)
d. Policies and
			 supporting procedures for referral and/or transfer to another facility; and
			 (3-17-22)
e. Policies regarding
			 instructions to be given patients requiring follow-up services; and
			 (3-17-22)
f. Policies and
			 supporting procedures for storage of equipment, medication, and supplies; and
			 (3-17-22)
g. Policy and supporting
			 procedures for care of emergency equipment; and (3-17-22)
h. Instructions for procurement of drugs,
			 equipment, and supplies; and (3-17-22)
i. Policy and supporting procedures involving
			 toxicology; and (3-17-22)
j. Policy
			 and supporting procedures devised for notification of patient's physician and
			 transmission of reports; and (3-17-22)
k. Policy involving instructions relative to
			 disclosure of patient information; and (3-17-22)
l. A policy for integration of the emergency
			 room into a disaster plan. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.374 - FREESTANDING EMERGENCY DEPARTMENT (FSED) - DEFINITION

Current through August 31, 2023
A freestanding emergency department (FSED) means a facility
				that provides emergency services twenty-four (24) hours per day, seven (7) days
				per week on an outpatient basis, is physically separate from a hospital, and
				meets the staffing and service requirements of Section
				376 of these rules. A FSED is
				located within thirty-five (35) miles of the hospital that owns or controls it.
				An FSED is owned by a hospital with a dedicated emergency department that also
				meets the staffing and service requirements found in Section
				376 of these rules.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.375 - FREESTANDING EMERGENCY DEPARTMENT (FSED): STANDARDS

Current through August 31, 2023
01.
Capability of Receiving Ground Ambulance Patients
. An FSED must be
			 capable of receiving patients transported via ground ambulance within the
			 protocols established by a licensed Emergency Medical Services (EMS) Agency
			 Medical Director. Provisions must be made to communicate any reduction or
			 increase in the capability of the FSED to receive specific levels of patients
			 to the local EMS director. (3-17-22)
02.
Transfer to Inpatient
			 Hospital
. An FSED must transfer each patient requiring inpatient
			 hospital services as soon as a bed is available. (3-17-22)
03.
Extension of the Main
			 Hospital
. An FSED as an extension of the main hospital must comply with
			 all applicable rules of IDAPA 16.03.14, "Hospitals," and Section
			 39-1307, Idaho Code
			 (3-17-22)
04.
Availability
			 of Resources and Staffing for Main Hospital and FSED
. Resources and
			 staff available at the main hospital are likewise available to individuals
			 seeking care at the FSED within the capability of the hospital.
			 (3-17-22)
05.
Prohibited
			 Transfers
. Transferring a patient to a different provider type for
			 surgery, with the intent of returning the patient to the FSED or main hospital
			 for recovery, is prohibited. (3-17-22)
06.
Written Transfer Agreements
.
			 The hospital that owns and operates the FSED must have written transfer
			 agreements with one (1) or more hospitals that provide the basis for effective
			 working arrangements in which inpatient hospital care or other hospital
			 departments are promptly available to patients when needed. (3-17-22)
07.
FSED Accreditation
. Each
			 hospital granted deemed status by the Centers for Medicare/Medicaid Services as
			 a result of accreditation must ensure the FSED is included under the same
			 accreditation. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.376 - FREESTANDING EMERGENCY DEPARTMENT (FSED): STAFFING AND SERVICES

Current through August 31, 2023
The FSED must be integrated into the main hospital. This
				integration must be defined in the hospital's policies and procedures, and
				practices. Additional requirements are as follows: (3-17-22)
01.
Staffing
. An FSED must be
			 staffed twenty-four (24) hours per day, seven (7) days per week with: (3-17-22)
a. A board certified physician, or board
			 eligible emergency department physician, approved by the governing board as
			 described under Section
			 200, "Governing Body and
			 Administration," and the medical staff as described under Section
			 250, "Medical Staff," of these
			 rules; (3-17-22)
b. A qualified
			 licensed registered nurse certified in Advanced Cardiac Life Support and
			 Pediatric Advanced Life Support; and (3-17-22)
c. Additional medical, nursing, and other
			 personnel necessary to meet the needs of patients.
			 (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.377 - NOTIFICATION REQUIREMENTS TO LICENSED EMERGENCY MEDICAL SERVICES (EMS) AGENCIES

Current through August 31, 2023
01.
Required
			 Notifications to Licensed EMS Agencies
. (3-17-22)
a. On an annual basis, the FSED must send
			 written notice containing the information described in Section
			 377.01.c of this rule, to all
			 area EMS services and EMS services' medical directors, licensed by the
			 Department's EMS Bureau, that transport to the facility, (3-17-22)
b. Within three (3) business days of any
			 change in capability, the FSED must send written notice containing the
			 information described in Section
			 377.01.c of this rule, to all
			 area EMS services and EMS services' medical directors, licensed by the
			 Department's EMS Bureau, that may transport to the facility.
			 (3-17-22)
c. The written notice
			 must include the following information: (3-17-22)
i. A list of capabilities that are not
			 available at the FSED but are available at the main hospital emergency
			 department; (3-17-22)
ii. A
			 description of the preferred and alternate means by which an ambulance service
			 must make a notification to the FSED that it intends to transport to the FSED.
			 (3-17-22)
d. The EMS
			 Bureau will identify and provide, upon request from the FSED, the names and
			 mailing addresses of all EMS services and medical directors that must receive
			 notification. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.378 - FREESTANDING EMERGENCY DEPARTMENT (FSED): PLANT, EQUIPMENT AND PHYSICAL ENVIRONMENT

Current through August 31, 2023
01.
Building
			 Construction Standards
. General requirements for construction of an FSED
			 are as follows: (3-17-22)
a. All new
			 construction of an FSED must comply with any and all state and local building,
			 fire, electrical, plumbing, zoning, heating, or other applicable codes adopted
			 by the jurisdiction in which the FSED is located and that are in effect when
			 construction is begun. Where a conflict in code requirements occurs, both
			 requirements must be met, or at the discretion of the licensing agency, the
			 most restrictive will apply. (3-17-22)
b. The FSED must be structurally sound and
			 must be maintained and equipped to assure the safety of patients, employees,
			 and the public. (3-17-22)
c. On the
			 premise of an FSED where natural or man-made hazards are present, suitable
			 fences, guards, and railings must be provided to protect patients, employees,
			 and the public. (3-17-22)
d.
			 Minimum construction standards must be in accordance with the following
			 standards incorporated by reference: (3-17-22)
i. The 2006 Edition of National Fire
			 Protection Association (NFPA) 101, the Life Safety Code, Chapter 18, New Health
			 Care Occupancies, and the applicable provisions of chapters 1 through 11, as
			 published by the NFPA. The NFPA documents referenced in these regulations are
			 available from the National Fire Protection Association, 11 Tracy Drive, Avon,
			 MA 02322-9908; 1-800-344-3555; and online at
http://www.nfpa.org
; and (3-17-22)
ii. The 2006 Edition of the American
			 Institute of Architects (AIA) Guidelines for Design and Construction of Health
			 Care Facilities applicable to a Freestanding Emergency Department and General
			 Hospital. The AIA documents referenced in these regulations are available from
			 the American Institute of Architects, 1735 New York Avenue N.W., Washington,
			 D.C. 20006; 1-800-242-3837; and online at
http://www.aia.org
.
			 (3-17-22)
e. The FSED
			 must provide a Type 1 Essential Electrical System (generator and transfer
			 switch) in accordance with NFPA 99, 2005 Edition. (3-17-22)
f. The FSED must provide a Level 1 Medical
			 Gas and Vacuum System (piped gas system) in accordance with NFPA 99, 2005
			 Edition. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.380 - SURGICAL SERVICE

Current through August 31, 2023
A hospital that provides surgical service shall have equipment,
				facilities and personnel according to the needs of the type of patients served.
				(3-17-22)
01.
Location of
			 Surgical Department
. The surgical department shall be segregated from
			 the remainder of the hospital so as to prevent traffic through the area to any
			 other part of the hospital. (3-17-22)
02.
Physical Facilities
. The
			 facilities of each surgical department shall have the following: (3-17-22)
a. Scrub sinks with goose neck spout and
			 knee, elbow or foot action water control; and (3-17-22)
b. Operating rooms, that shall have floors,
			 walls and ceilings with easily cleanable surfaces; and (3-17-22)
c. A housekeeping closet shall be provided
			 for the sole use of the surgical department; and (3-17-22)
d. A utility room for the cleaning of
			 contaminated equipment and supplies; and (3-17-22)
e. Separate space for the storage of sterile
			 and non-sterile supplies. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.390 - ANESTHESIA SERVICES

Current through August 31, 2023
These services shall be available when the hospital provides
				surgery or obstetrical services with C-section capacity and shall be integrated
				with other services of the hospital and shall include at least the following:
				(3-17-22)
01.
Policies and
			 Procedures
. Policies and procedures shall be approved by the medical
			 staff and the administration of the hospital. These written policies and
			 procedures shall include at least the following: (3-17-22)
a. Designation of persons permitted to give
			 anesthesia, types of anesthetics, preanesthesia, and post anesthesia
			 responsibilities; and (3-17-22)
b.
			 Preanesthesia physical evaluation of a patient by an anesthetist, with the
			 recording of pertinent information prior to surgery together with the history
			 and physical and preoperative diagnosis of a physician; and (3-17-22)
c. Review of patient condition immediately
			 prior to induction; and (3-17-22)
d. Safety of the patient during anesthetic
			 period; and (3-17-22)
e. Record of
			 events during induction, maintenance, and emergence from anesthesia including:
			 (3-17-22)
i. Amount and duration of agents;
			 and (3-17-22)
ii. Drugs and IV
			 fluids; and (3-17-22)
iii. Blood
			 and blood products. (3-17-22)
f. Record of post-anesthetic visits and any
			 complications shall be made within three (3) to forty-eight (48) hours
			 following recovery; and (3-17-22)
g. There shall be a written infection control
			 procedure including aseptic techniques, and disinfection or sterilizing
			 methods. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.391 - RESPIRATORY CARE SERVICES

Current through August 31, 2023
These services shall be under the supervision of a physician,
				organized and integrated with other services of the hospital. (3-17-22)
01.
Policies and Procedures
.
			 Respiratory care policies and procedures shall include the following: (3-17-22)
a. Responsibility of the service to the
			 medical staff; and (3-17-22)
b.
			 Clear protocol as to who can perform specific procedures; and
			 (3-17-22)
c. A written procedure
			 for each type of therapeutic or diagnostic procedure; and (3-17-22)
d. A written procedure for the care of all
			 equipment; and (3-17-22)
e. Written
			 procedures for the cleaning, disinfection, or sterilizing of all equipment that
			 is not disposable; and (3-17-22)
f.
			 Written procedures for infection control; and (3-17-22)
g. A procedure for the control of all water
			 used for respiratory therapy where applicable. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.400 - MATERNITY AND NEWBORN SERVICE

Current through August 31, 2023
If a hospital offers maternity and newborn service, care shall
				be provided during pregnancy, labor, delivery, postpartum and neonatal periods
				with appropriate staff, space and equipment. (3-17-22)
01.
Area Requirements
. If the
			 hospital offers maternity and newborn service, it shall be located in such a
			 manner as to minimize traffic to and from other patient care areas.
			 (3-17-22)
02.
Delivery/Birthing Room Facilities
. The delivery/birthing room shall be
			 located in such a manner as to prevent traffic to and from other areas, and
			 meet the following: (3-17-22)
a. At least one
			 (1) delivery room shall be provided; and (3-17-22)
b. Scrub-up facilities shall be provided for
			 the delivery room. Each sink shall have a soap dispenser, elbow, knee, or foot
			 action water control, and gooseneck spout. Disposable brushes or brushes
			 capable of withstanding sterilization shall be provided; and
			 (3-17-22)
c. A separate space shall
			 be provided for the cleanup of non-sterile and contaminated material; and
			 (3-17-22)
d. Walls, ceilings and
			 floors shall be of a waterproof, washable surface; and (3-17-22)
e. Space shall be available for the storage
			 of sterile and non-sterile supplies; and (3-17-22)
f. A janitor's closet shall be provided
			 within or adjacent to the delivery suite and be used only for the delivery
			 suite; and (3-17-22)
g. There shall
			 be provided a source of oxygen with a mechanism for controlling the
			 concentration of oxygen and with a suitable device for administering oxygen to
			 both infants and adults; and (3-17-22)
h. There shall be provided a safe and
			 suitable type of suction device for both infants and adults; and
			 (3-17-22)
i. A properly heated
			 bassinet shall be provided; and (3-17-22)
j. Functional obstetrical equipment and
			 supplies shall be provided to assure safe and aseptic treatment of mothers and
			 infants; and (3-17-22)
k. There
			 shall be immediately available all cardiopulmonary resuscitation equipment for
			 both adults and infants; and (3-17-22)
l. The delivery and birthing rooms shall not
			 be used for purposes other than obstetrical care, except in a disaster or life
			 threatening emergency. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.410 - CENTRAL SERVICE

Current through August 31, 2023
The hospital shall provide an area for the cleaning,
				disinfection, packaging, sterilization, storing and distribution of
				medical/surgical patient care supplies. (3-17-22)
01.
Service Areas
. The service
			 shall be separated into the following areas: (3-17-22)
a. Receiving and cleaning of contaminated
			 supplies; and (3-17-22)
b. Assembly
			 area (packaging); and (3-17-22)
c.
			 Sterilization area; and (3-17-22)
d. Sterile and nonsterile storage area.
			 (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.420 - CRITICAL CARE UNITS

Current through August 31, 2023
If appropriate for the hospital, these units may be established
				for patients requiring extraordinary care. (3-17-22)
01.
Policies and Procedures
. If
			 the hospital has critical care units then written policies and procedures shall
			 be developed and implemented by the medical staff, appropriate nursing staff,
			 and administration. The physician or committee responsible for the overall
			 medical direction of the unit, shall also participate in the development of the
			 written policies and procedures and approve them. Policies and procedures shall
			 include at least the following: (3-17-22)
a. A
			 policy statement regarding the responsibility of the units to the medical staff
			 including the working relationship between the unit director and the patient's
			 physician; and (3-17-22)
b.
			 Admission criteria, priorities, discharge and transfer policies and procedures;
			 and (3-17-22)
c. Staffing
			 requirements including training and experience; and (3-17-22)
d. Emergency procedures; and
			 (3-17-22)
e. Infection control
			 procedure including isolation procedures; and (3-17-22)
f. Policies and procedures including standing
			 orders for medical emergencies when a physician is not present. These shall
			 include the procedure for the use of drugs and equipment, and specify who can
			 do the procedure. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.430 - NUCLEAR MEDICINE SERVICES

Current through August 31, 2023
If appropriate for the hospital the use of internal
				radionuclides for diagnosis and treatment of patients may be established.
				(3-17-22)
01.
Nuclear Medicine
			 Staffing
. If the hospital has nuclear medical service, medical care
			 shall be under the overall direction of a qualified nuclear medicine physician.
			 The physician shall provide direction for: (3-17-22)
a. Determination of qualifications of all
			 other personnel in the service; and (3-17-22)
b. Organizational structure and personnel
			 needed; and (3-17-22)
c.
			 Establishing a procedure for assuring physician coverage; and
			 (3-17-22)
d. Continuing education
			 for all staff. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.440 - REHABILITATION SERVICES FOR HOSPITALS

Current through August 31, 2023
If this service is offered the ill or injured patient shall be
				rehabilitated to the highest level of self-sufficiency possible.
				(3-17-22)
01.
Rehabilitation
			 Service
. If the hospital offers rehabilitation services, they shall be
			 provided in accordance with orders of practitioners who are authorized by the
			 medical staff to order the services and shall be given by qualified therapists
			 and shall include at least the following services for inpatients and
			 outpatients: (3-17-22)
a. Physical therapy;
			 and (3-17-22)
b. Occupational
			 therapy; and (3-17-22)
c. Speech
			 pathology and audiology. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.450 - SOCIAL SERVICES

Current through August 31, 2023
If the hospital offers this service, the patient and his family
				shall be assisted to understand and cope with social problems that affect
				health. (3-17-22)
01.
Provision
			 of Social Services
. If the hospital provides these services, it can be
			 provided by the following methods: (3-17-22)
a. An organized service within the hospital
			 under the overall direction of a social worker; or (3-17-22)
b. A social worker employed part time; or
			 (3-17-22)
c. Consultation from a
			 social worker from an outside resource. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.460 - OUTPATIENT SERVICE

Current through August 31, 2023
If the hospital has such service it shall meet the nonemergency
				health needs of patients who remain in the hospital less than twenty-four (24)
				hours. (3-17-22)
01.
Staffing
. When a hospital maintains a formally organized clinic service
			 distinct from the emergency service, the outpatient service shall be under the
			 overall medical direction of a physician whose authority and responsibilities
			 are defined in writing and approved by the governing body. There shall be
			 adequate personnel to meet the needs of the patients, and a licensed registered
			 nurse shall be on duty at all times. All practitioners shall be members of the
			 active medical staff. (3-17-22)
02.
Outpatient Surgery
. If outpatient surgery is performed, the
			 requirements found in Section
			 380 shall be met.
			 (3-17-22)
03.
Policies and
			 Procedures
. There shall be written policies and procedures for at least
			 the following: (3-17-22)
a. Services offered,
			 including types of surgeries performed; and (3-17-22)
b. Procedure for evaluation, treatment and
			 referral of patients; and (3-17-22)
c. Responsibility and accountability to other
			 hospital services or departments, and to the medical staff and administration.
			 (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.470 - PSYCHIATRIC SERVICE

Current through August 31, 2023
If the hospital offers psychiatric service it must be
				organized, staffed and equipped to provide inpatient and outpatient treatment
				to the mentally ill. (3-17-22)
01.
Staffing
. If the hospital offers psychiatric service, it must be
			 directed and evaluated by a psychiatrist and staffed by adequate numbers of
			 qualified personnel to meet patient needs. (3-17-22)
a. A licensed registered nurse qualified by
			 training or experience in psychiatric nursing must supervise the nursing care
			 rendered in the psychiatric service. (3-17-22)
b. Psychiatric service staff must collaborate
			 with medical, nursing, and other professional personnel in patient care
			 planning, and provide consultation to staff of other services regarding the
			 psychiatric problems of patients. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.510 - FIRE AND LIFE SAFETY STANDARDS

Current through August 31, 2023
Buildings on the premises used as a hospital shall meet all the
				requirements of local, state, and national codes concerning fire and life
				safety that are applicable to hospitals. (3-17-22)
01.
General Requirements
.
			 General requirements for the fire and life safety standards for a hospital are
			 that: (3-17-22)
a. The hospital shall be
			 structurally sound and shall be maintained and equipped to assure the safety of
			 patients, employees, and the public. (3-17-22)
b. On the premises of all hospitals where
			 natural or man-made hazards are present, suitable fences, guards, and railings
			 shall be provided to protect patients, employees, and the public.
			 (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.520 - DISASTER PLANS

Current through August 31, 2023
The hospital shall have written plans for the care of
				casualties from both external and internal disasters. The plans shall be
				developed with the assistance of all appropriate community resources. The plan
				shall be reviewed and/or revised at least annually. (3-17-22)
01.
External Disaster Plan
. The
			 hospital shall develop a plan for external disasters for the area served and
			 within the capability of the facility. The plan shall contain the following
			 elements: (3-17-22)
a. Availability of basic
			 utilities, including food, water, and essential medical supplies; and
			 (3-17-22)
b. A procedure for
			 notifying and assigning personnel; and (3-17-22)
c. Unified medical command; and
			 (3-17-22)
d. Space and procedure
			 for triage; and (3-17-22)
e.
			 Procedure for casualty transfer to appropriate facility; and
			 (3-17-22)
f. Agreement with other
			 agencies for communications; and (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.530 - MAINTENANCE AND SAFETY

Current through August 31, 2023
The hospital shall be equipped and maintained to protect the
				health and safety of the patient, personnel, and visitors. (3-17-22)
01.
Maintenance
. The hospital
			 shall have a written preventive maintenance program to include at least the
			 following elements: (3-17-22)
a. Designation
			 of person responsible for maintaining the hospital; and (3-17-22)
b. Written preventive maintenance procedure
			 and appropriate inspection interval shall be made for at least the following:
			 (3-17-22)
i. Heating systems; and
			 (3-17-22)
ii. Air
			 conditioning/mechanical systems; and (3-17-22)
iii. Electrical systems; and
			 (3-17-22)
iv. Vacuum systems and
			 gas systems; and (3-17-22)
v. All
			 air filters in heating, air conditioning and ventilating systems; and
			 (3-17-22)
vi. Equipment related
			 directly and indirectly to patient care, and any other equipment.
			 (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.531 - GENERAL PATIENT ACCOMMODATIONS

Current through August 31, 2023
Hospitals licensed prior to the effective date of these rules
				shall provide for the comfort and safety of all patients as follows:
				(3-17-22)
01.
General
			 Requirements
. The hospital shall comply with the following minimums:
			 (3-17-22)
a. Minimum floor area exclusive of
			 toilet rooms, closets, lockers, wardrobes, alcoves, and/or vestibules shall be
			 one hundred (100) square feet in single-bed rooms and eighty (80) square feet
			 per bed in multi-bed rooms. (3-17-22)
b. A minimum distance of three (3) feet shall
			 be provided between beds in multi-bed rooms. (3-17-22)
c. Adequate storage space shall be provided
			 for clothing, toilet articles, and other personal belongings of each patient.
			 (3-17-22)
d. Cubicle curtains or
			 drapes shall be provided in multi-bed rooms for patient privacy.
			 (3-17-22)
e. A staff calling system
			 shall be provided at each patient bed and in each patient toilet, bath, and/or
			 tub room. All calls shall register at the staff station and must activate a
			 visual signal in the corridor at the patient room door. (3-17-22)
f. Tubs (or showers), toilets, and lavatories
			 shall be provided at the rate of one (1) each for every ten (10) licensed beds.
			 (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.540 - INFECTION CONTROL

Current through August 31, 2023
The hospital shall develop a plan for the prevention and
				control of infection with special emphasis on hospital acquired infection.
				(3-17-22)
01.
Infection Control
			 Committee
. The hospital shall establish an infection control committee
			 composed of representatives of the medical staff, administration, nursing
			 service, pharmacy services and laboratory. Other appropriate department heads
			 shall be members as needed. (3-17-22)
02.
Infection Control Program
.
			 The program shall include at least the following elements: (3-17-22)
a. Definition of nosocomial infection, as
			 opposed to community acquired infections; and (3-17-22)
b. A procedure for hospital surveillance of
			 and for nosocomial infections; and (3-17-22)
c. A procedure for reporting and evaluating
			 nosocomial infections. The procedure must enable the hospital to establish the
			 following on at least a quarterly basis: (3-17-22)
i. Level or rate of nosocomial infections;
			 and (3-17-22)
ii. Site of
			 infection; and (3-17-22)
iii.
			 Microorganism involved. (3-17-22)