reglab/statecodes huggingface dataset:
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 68 - CONTROL OF TOXIC OR DANGEROUS DRUGS › Rule 15-16-1-41.68.3

Current through June 25, 2024
The classification ordinarily thought of as toxic,
						dangerous or abuse drugs shall be narcotics sedatives, anticoagulants,
						antibiotics, oxytocic and cortisone products, antineoplastic agents and shall
						include other categories so established by federal, state or local
						laws.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 68 - CONTROL OF TOXIC OR DANGEROUS DRUGS › Rule 15-16-1-41.68.4 - Drugs to be Dispensed

Current through June 25, 2024
Therapeutic ingredients of medications dispensed shall
						be those included (or approved for inclusion) in the United States
						Pharmacopoeia, National Formulary, United State [States] Homeopathic
						Pharmacopoeia, New Drugs, or Accepted Dental Premedies [Remedies] (except for
						any drugs unfavorably evaluated therein), or those approved for use by the
						pharmacy and drug therapeutics committee. There shall be available a formulary
						or list of drugs accepted for use in the hospital which is developed and
						amended at regular intervals by the pharmacy and therapeutics committee (or
						equivalent committee) with the cooperation of the pharmacist (consulting or
						otherwise) and the administration.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 69 - REGULATION CONTROLLED SUBSTANCES IN ANESTHETIZING AREAS › Rule 15-16-1-41.69.1 - Dispensing Controlled Substances

Current through June 25, 2024
All controlled substances shall be dispensed to the
						responsible person (Supervisor, CRNA, Anesthesiologist, etc.) designated to
						handle controlled substances in the operating room by a Registered Pharmacist
						in the hospital. When the controlled substance is dispensed, the following
						information shall be recorded into the controlled substance (proof-of-use)
						record.
1. Signature of pharmacist
					 dispensing the controlled substance.
2. Signature of designated licensed person
					 receiving the controlled substance.
3. The date and time controlled substance is
					 dispensed.
4. The name, the
					 strength, and quantity of controlled substance dispensed.
5. The serial number assigned to that
					 particular record, which corresponds to same number recorded in the pharmacy's
					 dispensing record.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 69 - REGULATION CONTROLLED SUBSTANCES IN ANESTHETIZING AREAS › Rule 15-16-1-41.69.2 - Security/Storage of Controlled Substances

Current through June 25, 2024
When not in use, all controlled substances shall be
						maintained in a securely locked, substantially constructed cabinet or area. All
						controlled substance storage cabinets shall be permanently affixed. Controlled
						substances removed from the controlled substance cabinet shall not be left
						unattended.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 69 - REGULATION CONTROLLED SUBSTANCES IN ANESTHETIZING AREAS › Rule 15-16-1-41.69.3 - Controlled Substance Administration Accountability

Current through June 25, 2024
The administra tion of all controlled substances to
						patients shall be carefully recorded into the anesthesia record. The following
						information shall be transferred from the anesthesia record to the controlled
						substance record by the administering practitioner during the shift in which
						the controlled substance was administered.
1. The patient's name.
2. The name of the controlled substance and
					 the dosage administered.
3. The
					 date and time the controlled substance is administered.
4. The signature of the practitioner
					 administering the controlled substance.
5. The wastage of any controlled
					 substance.
6. The balance of
					 controlled substances remaining after the administration of any quantity of the
					 controlled substance.
7. Day-ending
					 or shift-evening verification of count of balances of controlled substances
					 remaining and controlling substances administered shall be accomplished by two
					 (2) designated licensed persons whose signatures shall be affixed to a
					 permanent record.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 69 - REGULATION CONTROLLED SUBSTANCES IN ANESTHETIZING AREAS › Rule 15-16-1-41.69.4 - Waste of Controlled Substances

Current through June 25, 2024
1. All partially
					 used quantities of controlled substances shall be wasted at the end of each
					 case by the practitioner, in the presence of a licensed person. The quantity,
					 expressed in milligrams, shall be recorded by the wasting practitioner into the
					 anesthesia record and into the controlled substance record followed by his or
					 her signature. The licensed person witnessing this wastage of controlled
					 substances shall co-sign the controlled substance record.
2. All unused and unopened quantities of
					 controlled substances which have been removed from the controlled substance
					 cabinet shall be returned to the cabinet by the practitioner at the end of each
					 shift.
3. Any return of controlled
					 substances to the pharmacy in the hospital must be documented by a registered
					 pharmacist responsible for controlled substance handing in the
					 hospital.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 69 - REGULATION CONTROLLED SUBSTANCES IN ANESTHETIZING AREAS › Rule 15-16-1-41.69.5 - Verification of Controlled Substances Administration

Current through June 25, 2024
The hospital shall implement procedures whereby, on a
						periodic basis, a registered pharmacist shall reconcile quantities of
						controlled substances dispensed in the hospital to the anesthetizing area
						against the controlled substance record in said area. Any discrepancies shall
						be reported to the Director of Nursing and to the Chief Executive Officer of
						the hospital. Upon completion, all controlled substance records shall be
						returned from the anesthetizing area to the hospital's pharmacy by the
						designated responsible person in the anesthetizing area.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 70 - RADIOLOGY › Rule 15-16-1-41.70.1 - Radiological Services

Current through June 25, 2024
The hospital shall maintain or have available
						radiological services according to needs of the hospital, either in the
						hospital building proper or in an adjacent clinic or medical facility that is
						readily accessible to the hospital patients, physicians, and personnel. If
						therapeutic x-ray services are also provided, they, as well as the diagnostic
						services, shall meet professionally approved standards for safety and personnel
						qualifications.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 71 - HAZARDS TO PATIENTS AND PERSONNEL › Rule 15-16-1-41.71.1

Current through June 25, 2024
The radiology department shall be free of hazards to
						patients and personnel.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 71 - HAZARDS TO PATIENTS AND PERSONNEL › Rule 15-16-1-41.71.2

Current through June 25, 2024
Proper safety precautions shall be maintained against
						fire and explosion hazards, electrical hazards, and radiation
						hazards.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 71 - HAZARDS TO PATIENTS AND PERSONNEL › Rule 15-16-1-41.71.3

Current through June 25, 2024
Periodic inspection shall be made by Department of
						Health or a radiation physicist, and hazards so identified shall be promptly
						corrected.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 71 - HAZARDS TO PATIENTS AND PERSONNEL › Rule 15-16-1-41.71.4

Current through June 25, 2024
Radiation workers shall be checked periodically for
						amount of radiation exposure by the use of exposure meters or badge
						tests.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 71 - HAZARDS TO PATIENTS AND PERSONNEL › Rule 15-16-1-41.71.5

Current through June 25, 2024
With fluoroscopes, attention shall be paid to modern
						safety design and operating procedures; records shall be maintained of the
						output of all fluoroscopes.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 71 - HAZARDS TO PATIENTS AND PERSONNEL › Rule 15-16-1-41.71.6

Current through June 25, 2024
Regulations based on medical staff recommendations shall
						be established as to the administration of the application and removal of
						radium element, its disintegration products, and other radioactive
						isotopes.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 72 - PERSONNEL › Rule 15-16-1-41.72.1

Current through June 25, 2024
Personnel adequate to supervise and conduct the services
						shall be provided, and the interpretation of radiological examinations shall be
						made by physicians competent in the field.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 72 - PERSONNEL › Rule 15-16-1-41.72.2

Current through June 25, 2024
The hospital shall have a qualified radiologist, either
						full-time or part-time, on a consulting basis, both to give direction to the
						department and to interpret films that require specialized knowledge for
						accurate reading. If the hospital is small and a radiologist cannot come to the
						hospital regularly, selected x-ray films shall be sent to a radiologist for
						interpretation.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 72 - PERSONNEL › Rule 15-16-1-41.72.3

Current through June 25, 2024
If the activities of the radiology department extend to
						radio-therapy, the physician in charge shall be appropriately
						qualified.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 72 - PERSONNEL › Rule 15-16-1-41.72.4

Current through June 25, 2024
The amount of qualified radiologist's and technologist's
						time shall be sufficient to meet the hospital's requirement. A technologist
						shall be on duty or on call at all times.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 72 - PERSONNEL › Rule 15-16-1-41.72.5

Current through June 25, 2024
The use of all x-ray apparatus shall be limited to
						personnel designated as qualified by the radiologist or by an appropriately
						constituted committee of the medical staff. The same limitation shall apply to
						personnel applying and removing radium element, its disintegration products,
						and radioactive isotopes. The use of fluoroscopes shall be limited to
						physicians or technologist under the direction of a
						physician.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 73 - SIGNED REPORTS › Rule 15-16-1-41.73.1

Current through June 25, 2024
Signed reports shall be filed with the patient's medical
						record.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 73 - SIGNED REPORTS › Rule 15-16-1-41.73.2

Current through June 25, 2024
Requests by the attending physician for x-ray
						examination shall contain a concise statement of reason for the
						examination.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 73 - SIGNED REPORTS › Rule 15-16-1-41.73.3

Current through June 25, 2024
Reports of interpretations shall be written or dictated
						and signed by the radiologist.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 73 - SIGNED REPORTS › Rule 15-16-1-41.73.4

Current through June 25, 2024
X-ray reports and roentgenographies shall be preserved or
						microfilmed according to statutes.
Miss.
						Code Ann. §
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 74 - SOCIAL WORK › Rule 15-16-1-41.74.1

Current through June 25, 2024
Hospitals without an organized Social Work Department
						may provide this service. If such department is provided, there shall be
						effective policies and procedures relating to the staff and the functions of
						the service.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 74 - SOCIAL WORK › Rule 15-16-1-41.74.2

Current through June 25, 2024
If the facility offers social services, a member of the
						staff of the facility shall be responsible for social services. If the
						designated person is not a qualified social worker, the facility has a written
						agreement with a qualified social worker, or recognized social agency for
						consultation and assistance on a regularly scheduled basis.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 74 - SOCIAL WORK › Rule 15-16-1-41.74.3

Current through June 25, 2024
A qualified social worker is an individual who is
						currently licensed by the State of Mississippi and has one (1) year of
						experience in a health care setting.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 75 - UTILIZATION REVIEW PLAN › Rule 15-16-1-41.75.1

Current through June 25, 2024
The hospital must have in effect a utilization review
						(UR) plan that provides for review of services furnished by the institution and
						by members of the medical staff to patients.
1. The UR plan must provide for review for
					 patients with respect to the medical necessity of-
a. Admissions to the institution;
b. The duration of stays; and c. Professional
					 services furnished including drugs and biologicals.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 76 - UTILIZATION REVIEW COMMITTEE › Rule 15-16-1-41.76.1

Current through June 25, 2024
A UR committee consisting of two or more practitioners
						must carry out the UR function. At least two of the members of the committee
						must be doctors of medicine or osteopathy. The other members may be any of the
						other types of practitioners.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 76 - UTILIZATION REVIEW COMMITTEE › Rule 15-16-1-41.76.2

Current through June 25, 2024
The committee must review professional services provided
						to determine medical necessity and to promote the most efficient use of
						available health facilities and services.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 77 - QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT (QAPI) PROGRAM › Rule 15-16-1-41.77.1

Current through June 25, 2024
The hospital must develop, implement, and maintain an
						effective, ongoing, hospital-wide, data-driven quality assessment and
						performance improvement program.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 77 - QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT (QAPI) PROGRAM › Rule 15-16-1-41.77.2

Current through June 25, 2024
The hospital's governing body must ensure that the
						program reflects the complexity of the hospital's organization and services;
						involves all hospital departments and services (including those services
						furnished under contract or arrangement); and focuses on indicators related to
						improved health outcomes and the prevention and reduction of medical
						errors.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 77 - QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT (QAPI) PROGRAM › Rule 15-16-1-41.77.3

Current through June 25, 2024
The hospital must maintain and demonstrate evidence of
						its QAPI program for review by the Department.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 78 - QAPI PROGRAM SCOPE › Rule 15-16-1-41.78.1

Current through June 25, 2024
The program must include, but not be limited to, an
						ongoing program that shows measurable improvement in indicators for which there
						is evidence that it will improve health outcomes and will identify and reduce
						medical errors.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 78 - QAPI PROGRAM SCOPE › Rule 15-16-1-41.78.2

Current through June 25, 2024
The hospital must measure, analyze, and track quality
						indicators, including adverse patient events, and other aspects of performance
						that assess processes of care, hospital service and
						operations.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 79 - QAPI PROGRAM DATA › Rule 15-16-1-41.79.1 - The hospital must use the data collected to

Current through June 25, 2024
The hospital must use the data collected to:
1. Monitor the effectiveness and safety of
					 services and quality of care; and
2. to identify opportunities for improvement
					 and changes that will lead to improvement.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 79 - QAPI PROGRAM DATA › Rule 15-16-1-41.79.2

Current through June 25, 2024
The frequency and detail of data collection must be
						specified by the hospital's governing body.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 80 - QAPI PROGRAM ACTIVITIES › Rule 15-16-1-41.80.1

Current through June 25, 2024
The hospital must set priorities for its performance
						improvement activities that:
1. Focus
					 on high-risk, high-volume, or problem-prone areas;
2. Consider the incidence, prevalence, and
					 severity of problems in those areas;
3. Affect health outcomes and quality of
					 care; and
4. Affect patient
					 safety.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 80 - QAPI PROGRAM ACTIVITIES › Rule 15-16-1-41.80.2

Current through June 25, 2024
Performance improvement activities must track medical
						errors and adverse patient events, analyze their causes, and implement
						preventive actions and mechanisms that include feedback and learning throughout
						the hospital.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 80 - QAPI PROGRAM ACTIVITIES › Rule 15-16-1-41.80.3

Current through June 25, 2024
The hospital must take actions aimed at performance
						improvement and, after implementing those actions, the hospital must measure
						its success, and track performance to ensure that improvements are
						sustained.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 81 - PERFORMANCE IMPROVEMENT PROJECTS › Rule 15-16-1-41.81.1

Current through June 25, 2024
As part of its quality assessment and performance
						improvement program, the hospital must conduct performance improvement
						projects.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 81 - PERFORMANCE IMPROVEMENT PROJECTS › Rule 15-16-1-41.81.2

Current through June 25, 2024
The number and scope of distinct improvement projects
						conducted annually must be proportional to the scope and complexity of the
						hospital's services and operations.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 81 - PERFORMANCE IMPROVEMENT PROJECTS › Rule 15-16-1-41.81.3

Current through June 25, 2024
The hospital must document what quality improvement
						projects are being conducted, the reasons for conducting these projects, and
						the measurable progress achieved on these projects.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 82 - TRAUMA REGISTRY › Rule 15-16-1-41.82.1

Current through June 25, 2024
All licensed hospitals which have organized emergency
						services or departments must participate in the statewide trauma registry for
						the purpose of supporting peer review and performance improvement activities at
						the local, regional and state levels. Since this data relates to specific
						trauma patients and is used to evaluate and improve the quality of health care
						services, this data is confidential and will be governed by Miss. Code Ann.
						§
											41-59-77
						(as amended). Compliance with the above will be evidenced by:
1. Documentation of utilization of the Trauma
					 Registry data in the trauma performance improvement process and
2. Timely submission of Trauma Registry Data
					 to the Bureau of EMS at least monthly.
Miss. Code Ann.
						§
												41-9-17
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 82 - TRAUMA REGISTRY › Rule 15-16-1-41.82.2 - Data Submission Requirements

Current through June 25, 2024
Patients to be included in the trauma registry are
						defined in "Mississippi Trauma Care System: Rules and Regulations (as
						amended)."
Miss. Code Ann.
						§
												41-9-1
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 83 - FREESTANDING EMERGENCY DEPARTMENTS › Rule 15-16-1-41.83.1 - Adoption of Regulations and Minimum Standards

Current through June 25, 2024
By virtue of authority vested in it by the Mississippi
						Code Annotated Sections
						41-75-1
						through
						41-75-13,
						or as otherwise amended, the Mississippi Department of Health does hereby adopt
						and promulgate the following regulations and standards for Freestanding
						Emergency Departments (FED).
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 83 - FREESTANDING EMERGENCY DEPARTMENTS › Rule 15-16-1-41.83.2 - Compliance with Rules, Regulations and Standards

Current through June 25, 2024
The FED shall:
1. Comply with all applicable Medicare
					 provider-based regulations. The FED shall comply with all regulations that
					 apply to clinical services and staffing for emergency departments, as set forth
					 in the MSDH Minimum Standards of Operation for Mississippi Hospitals.
2. Provide data to their Trauma Region and
					 the department's Trauma Registry through participation in the Mississippi
					 Trauma Care System (MTS).
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 83 - FREESTANDING EMERGENCY DEPARTMENTS › Rule 15-16-1-41.83.3 - Definitions

Current through June 25, 2024
The definitions specific to the FED are:
1.
Freestanding Emergency
					 Room.
"Freestanding Emergency Room" is a facility open twenty-four hours
					 a day for the treatment of urgent and emergent medical conditions which is not
					 located on a hospital campus. In order to e eligible for licensure under this
					 chapter, the freestanding emergency room shall be located at least fifteen (15)
					 miles from the nearest hospital-based emergency room in any rural community
					 where the federal Centers for Medicaid & Medicare Services (CMS) had
					 previously designated a rural hospital as a critical access hospital and that
					 designation has been revoked.
2.
Licensing Agency.
"Licensing agency" means the Mississippi State
					 Department of Health.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 83 - FREESTANDING EMERGENCY DEPARTMENTS › Rule 15-16-1-41.83.4 - License

Current through June 25, 2024
No person or governmental unit shall establish, conduct,
						or maintain a Freestanding Emergency Department in this state without a
						license.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 83 - FREESTANDING EMERGENCY DEPARTMENTS › Rule 15-16-1-41.83.5 - Application for License

Current through June 25, 2024
An application for a license shall be made to the
						licensing agency upon forms provided by the licensing agency, and shall contain
						such information as the licensing agency reasonably requires.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 83 - FREESTANDING EMERGENCY DEPARTMENTS › Rule 15-16-1-41.83.6 - Licensure and User Fees

Current through June 25, 2024
Such fees shall be paid to the licensing agency by
						electronic payment, business check, certified check or money order. A license
						shall not be issued to any FED until such fee is received by the licensing
						agency.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 83 - FREESTANDING EMERGENCY DEPARTMENTS › Rule 15-16-1-41.83.7 - User Fee

Current through June 25, 2024
A "user fee" shall be assessed by the licensing agency
						for the purpose of the required reviewing and inspections of the proposal of
						any FED in which there are additions, renovations, modernizations, expansion,
						alterations, conversions, modifications or replacement of the entire facility
						involved in the proposal. This fee includes the reviewing of architectural
						plans in all required steps.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 83 - FREESTANDING EMERGENCY DEPARTMENTS › Rule 15-16-1-41.83.8 - Renewal of License

Current through June 25, 2024
A license, unless suspended or revoked, shall be
						renewable annually by submitting an application, paying an annual fee and
						submitting such reports as required by the licensing agency, including annual
						information reports.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 83 - FREESTANDING EMERGENCY DEPARTMENTS › Rule 15-16-1-41.83.9 - Issuance of License

Current through June 25, 2024
Each license shall be issued only for the premises and
						persons or governmental units names in the application and shall not be
						transferable or assignable except with the written approval of the licensing
						agency.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 83 - FREESTANDING EMERGENCY DEPARTMENTS › Rule 15-16-1-41.83.10 - Denial or Revocation of a License

Current through June 25, 2024
The licensing agency, after notice and opportunity for
						hearing to the applicant or licensee, is authorized to deny, suspend or revoke
						a license in any case in which it finds that there has been a substantial
						failure to comply with the requirements established in these regulations and
						standards.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 83 - FREESTANDING EMERGENCY DEPARTMENTS › Rule 15-16-1-41.83.11 - Ownership

Current through June 25, 2024
There shall be full disclosure of FED ownership and
						control. Annually, in its application for renewal of an FED License, the
						facility shall report the name and address of the owner and the name and
						address of the individual(s) responsible for operation of the FED.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 83 - FREESTANDING EMERGENCY DEPARTMENTS › Rule 15-16-1-41.83.12 - Change of Ownership

Current through June 25, 2024
When change of ownership of a FED is contemplated, the
						FED shall notify the licensing agency, in writing, at least 30 days prior to
						the proposed date of change of ownership, giving the name and address of the
						proposed new owner and all other documents as required by the licensing agency.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 83 - FREESTANDING EMERGENCY DEPARTMENTS › Rule 15-16-1-41.83.13 - Governing Authority

Current through June 25, 2024
The FED shall have an organized governing body, or
						designated person(s):
1. That has
					 overall responsibility for the conduct of the FED in a manner consistent with
					 the objective of making available high quality patient care.
2. That shall be the authority in the FED,
					 responsible for the management of the FED and appointment of the medical staff.
3. That shall adopt bylaws in
					 accordance with legal requirements and with its community responsibility,
					 identifying the purposes of the FED and the means of fulfilling them,
4. That shall take all reasonable
					 steps to comply with all applicable federal, state and local laws and
					 regulations.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 83 - FREESTANDING EMERGENCY DEPARTMENTS › Rule 15-16-1-41.83.14 - Staffing and Treatment

Current through June 25, 2024
The FED must possess the staff and resources necessary
						to evaluate all individuals presenting to the emergency department. The FED
						must follow all requirements of EMTALA in regard to assuring the medical
						evaluation, stabilization and transfer of a patient found to have an emergency
						condition. Because of the unscheduled and episodic nature of health emergencies
						and acute illness, the FED must be staffed with experienced American Board of
						Medical Specialties (ABMS) or American Osteopathic Association (AOA) board
						certified or board eligible physicians, nursing and ancillary personnel who
						must be available 24 hours a day. The FED will also provide treatment for
						individuals whose health needs are not of an emergent nature, but for whom the
						FED may be the only accessible or timely entry point into the broader health
						care system.
1. Each FED shall have
					 patient transfer agreements with an EMS service and with an acute care or
					 trauma hospital with the capability of handling such emergencies and to assure
					 provisions for patient admissions, continued emergency and diagnostic services
					 beyond the capability of the FED, and the safe emergency transport of the
					 patient, when needed.
2. As stated
					 by the American College of Emergency Physicians (ACEP):
a. Emergency medical care must be available
					 to all members of the public.
b.
					 Access to appropriate emergency medical and nursing care must be unrestricted.
c. A smooth continuum should exist
					 among pre-hospital providers, emergency department (ED) providers, and
					 providers of definitive follow-up care.
d. Evaluation, management, and treatment of
					 patient must be appropriate and expedient.
e. Resources should exist in the ED to
					 accommodate each patient from the time of arrival through evaluation, medical
					 decision making, treatment and disposition.
f. FEDs should have policies and plans to
					 provide effective administration, staffing, facility design, equipment,
					 medication and ancillary services.
g. The emergency physician, emergency nurse,
					 and additional medical team members must establish effective working
					 relationships with other health care providers and entities with whom they must
					 interact. These include emergency medical services (EMS) providers, ancillary
					 hospital personnel, other physicians, and other health care and social services
					 resources.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 83 - FREESTANDING EMERGENCY DEPARTMENTS › Rule 15-16-1-41.83.15 - Required Policies

Current through June 25, 2024
The FED Emergency Department Policy Sections shall
						include:
1. Resources and Planning
a. Necessary Elements
i. Administration
ii. Staffing
iii. Facility
iv. Equipment and Supplies
v. Pharmacologic/Therapeutic Drugs and Agents
vi. Safety
vii. Ancillary Services
viii. Transfer policies and procedures for
					 critical patients
ix. Electronic
					 Medical Record
x. Relationships
					 and Responsibilities
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 83 - FREESTANDING EMERGENCY DEPARTMENTS › Rule 15-16-1-41.83.16 - FED Equipment, Instruments, and Supplies

Current through June 25, 2024
The equipment, instruments, and supplies listed below are
						required in the FED and each of the items should be located in or immediately
						available to the area noted. This list does not include routine
						medical/surgical supplies such as adhesive bandages, gauze pads, and suture
						material, nor does it include routine office items such as paper, desks, paper
						clips, and chairs.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 41 - MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS › Subchapter 83 - FREESTANDING EMERGENCY DEPARTMENTS › Rule 15-16-1-41.83.17 - Entire FED Department shall include

Current through June 25, 2024
1. Central
					 station monitoring capability
2.
					 Physiological monitors
3. Blood
					 flow detectors
4. Defibrillator
					 with monitor and battery
5.
					 Thermometers
6. Pulse oximetry
7. Nurse-call system for patient
					 use
8. Portable suction regulator
9. Infusion pumps to include blood
					 pumps
10. IV poles
11. Bag-valve-mask respiratory and adult and
					 pediatric size mask
12. Portable
					 oxygen tanks
13. Blood/fluid
					 warmer and tubing
14. Nasogastric
					 suction supplies
15. Nebulizer
16. Gastric lavage supplies,
					 including large-lumen tubes and bite blocks
17. Urinary catheters, including straight
					 catheters, Foley catheters, Coude catheters, filiforms and followers, and
					 appropriate collection equipment
18. Intraosseous needles
19. Lumbar puncture sets (adult and
					 pediatric)
20. Blanket warmer
21. Tonometer
22. Slit lamp
23. Wheel chairs
24. Medication dispensing system with locking
					 capabilities
25. Separately
					 wrapped instruments (specifics will vary by department)
26. Availability of light microscopy for
					 emergency procedures
27. Weight
					 scales (adult and infant)
28. Tape
					 measure
29. Ear irrigation and
					 cerumen removal equipment
30.
					 Vascular Doppler
31. Anoscope
32. Adult and Pediatric "code"
					 cart
33. Suture or minor surgical
					 procedure sets (generic)
34.
					 Portable sonogram equipment
35.
					 EKG machine
36. Point of care
					 testing
37. X-ray view box and hot
					 light
38. Film boxes for holding
					 x-rays
39. Chart Rack
40. Computer system
41. Internet capabilities
42. Patient tracking system
43. Radio or other device for communication
					 with ambulances
44. Patient
					 discharge instruction system
45.
					 Patient registration system/ Information services
46. Intradepartmental staff communication
					 system- pagers, mobile phones
47.
					 ED charting system for physician, nursing, and attending physician
					 documentation equipment
48.
					 Reference materials including toxicology resource information
49. Personal protective equipment- gloves,
					 eye goggles, face mask, gowns, head
50. and foot covers
51. Linen (pillows, towels, wash cloths,
					 gowns, blankets)
52. Patient
					 belongings or clothing bag
53.
					 Security needs -including restraints and wand-type or free standing metal
54. detectors as indicated
55. Equipment for adequate
					 housekeeping
Miss. Code Ann.
						§
												41-75-13