Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 175 - HEALTH CARE FACILITIES AND SERVICES LICENSURE › Chapter 9 - HOSPITALS › Section 175-9-006 - STANDARDS OF OPERATION, CARE AND TREATMENT

Current through June 17, 2024
Each hospital is to be organized, managed, and administered
				  by the licensee to ensure each patient receiving services at the facility
				  receives necessary care and treatment in a safe manner, and in accordance with
				  current standards of practice, the Health Care Facility Licensure Act, 175 NAC
				  1, and this chapter. Each hospital offsite location and mobile unit must meet
				  the standards except where specified otherwise.
006.01.
LICENSEE
				RESPONSIBILITY.
The responsibilities of the licensee include:
(A) Implementing policies and procedures to
				govern the total operation and maintenance of the facility;
(B) Maintaining hospital compliance with all
				applicable state and federal statutes, codes, Rules, and regulations;
(C) Ensuring the quality of all services,
				care and treatment provided a patient whether those services, care or treatment
				are furnished by hospital staff or through contract with an outside
				entity;
(D) Designating an
				administrator in writing who is responsible for the day to day management of
				the hospital;
(i) Defining the duties and
				responsibilities of the administrator in writing;
(ii) Notifying the Department in writing
				within 5 working days if:
(1) A vacancy in the
				administrator position occurs including the name of who is responsible for the
				position until another administrator is appointed; and
(2) A vacancy in the administrator position
				is filled including the effective date and name of person appointed to that
				position;
(E)
				Determining which categories of practitioners are eligible candidates for
				appointment to the medical staff;
(F) Ensuring that medical staff membership or
				clinical privileges in the hospital does not depend solely upon certification,
				fellowship or membership in a specialty body or society although board
				certification can be one permissible criterion;
(G) Appointing and reappointing medical staff
				members and delineating clinical privileges, according to credential review
				procedures established by the medical staff and approved by the governing
				authority;
(H) Establishing
				criteria for membership on the medical staff or clinical privileges, in
				collaboration with the medical staff;
(i)
				Making final decisions regarding medical staff recommendations for denial of
				appointments and reappointments, and for the denial limitation, suspension, or
				revocation of privileges, ensuring the practitioner has a right to be heard
				upon request;
(J)
				Ensuring the medical staff is accountable to the licensee for the quality of
				medical care and treatment provided;
(K) Ensuring a medical staff committee and a
				utilization review committee are formed and operated for the purpose of
				reviewing care and treatment provided to provide a high standard of medical
				care and promote the efficient use of the hospital;
(L) Ensuring that any person working at and
				having any information or knowledge relating to the medical and hospital care
				provided or the efficient use of the hospital facilities, provides all related
				facts and information to the hospital medical staff committee or utilization
				review committee upon request by the committee or committees;
(M) Reviewing reports and making
				recommendations regarding all Quality Assurance Performance Improvement,
				Medical Staff, and Utilization Review Committee activities. Ensuring these
				reports are utilized to implement programs and policies to maintain and improve
				the quality of patient care and treatment;
(N) Establishing and promoting effective
				communication and coordination between the governing authority, the medical
				staff, administration, and the hospital departments;
(O) Approving the organization, bylaws,
				rules, and regulations, and policies and procedures of the medical staff and
				departments in the hospital; and
(P) Establishing visitation policies which
				are in the best interest of patients to ensure their health and safety, and
				provide protection from communicable diseases, exposure to dangerous
				substances, and hazardous equipment.