North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter B - LICENSING OF HOSPITALS › Section .3500 - GOVERNANCE AND MANAGEMENT › Section 13B .3503 - FUNCTIONS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The governing
				  body shall:
(1) provide management, physical
				  resources, and personnel determined by the governing body to be required to
				  meet the needs of patients for treatment as authorized by the facility's
				  license;
(2) require facility
				  administration to establish a quality control mechanism that includes a risk
				  management component and an infection control program;
(3) formulate short-range and long-range
				  plans as defined in the facility bylaws, policies, rules, and
				  regulations;
(4) conform to all
				  applicable State and federal laws, rules, and regulations, and applicable local
				  ordinances;
(5) provide for the
				  control and use of the physical and financial resources of the
				  facility;
(6) review the annual
				  audit, budget, and periodic reports of the financial operations of the
				  facility;
(7) consider the
				  recommendation of the medical staff in granting and defining the scope of
				  clinical privileges to individuals in accordance with medical staff bylaws
				  requirements for making such recommendations and the facility bylaws
				  established by the governing body for the review and final determination of
				  such recommendations;
(8) require
				  that applicants be informed of the disposition of their application for medical
				  staff membership or clinical privileges in accordance with the facility bylaws
				  established by the governing body, after an application has been
				  submitted;
(9) review and approve
				  the medical staff bylaws, rules, and regulations;
(10) delegate to the medical staff the
				  authority to:
(A) evaluate the professional
				  competence of medical staff members and applicants for medical staff membership
				  and clinical privileges; and
(B)
				  recommend to the governing body initial medical staff appointments,
				  reappointments, and assignments or curtailments of privileges;
(11) require that resources be
				  made available to address the emotional and spiritual needs of patients either
				  directly or through referral or arrangement with community agencies;
(12) maintain communication with the medical
				  staff which may be established through:
(A)
				  meetings with the executive committee of the medical staff;
(B) service by the president of the medical
				  staff as a member of the governing body with or without a vote;
(C) appointment of individual medical staff
				  members to the medical review committee; or
(D) a joint conference committee that will be
				  a committee of the governing body and the medical staff composed of equal
				  representatives of each of the governing body, the chairman of the board or
				  designee, the medical staff, and the chief of the medical staff or designee,
				  respectively;
(13)
				  require the medical staff to establish controls that are designed to provide
				  that standards of ethical professional practices are met;
(14) provide administrative staff support to
				  facilitate utilization review and infection control within the facility, to
				  support quality control and any other medical staff functions required by this
				  Subchapter or by the facility bylaws;
(15) meet the following disclosure
				  requirements:
(A) provide data required by
				  the Division;
(B) disclose the
				  facility's average daily inpatient charge upon request of the Division;
				  and
(C) disclose the identity of
				  persons owning five percent or more of the facility as well as the facility's
				  officers and members of the governing body upon request;
(16) establish a procedure for reporting the
				  occurrence and disposition of allegations of abuse or neglect of patients and
				  incidents involving quality of care or physical environment at the facility.
				  These procedures shall require that:
(A)
				  incident reports are analyzed and summarized by a designated party;
				  and
(B) corrective action is taken
				  based upon the analysis of incident reports;
(17) in a facility with one or more units, or
				  portions of units, however described, utilized for psychiatric or substance
				  abuse treatment, adopt policies implementing the provisions of G.S. 122C,
				  Article 3, and Article 5, Parts, 2, 3, 4, 5, 7, and 8;
(18) develop arrangements for the provision
				  of extended care and other long-term healthcare services. Such services shall
				  be provided in the facility or by outside resources through a transfer
				  agreement or referrals;
(19)
				  provide and implement a written plan for the care or for the referral, or both,
				  of patients who require mental health or substance abuse services while in the
				  facility;
(20) develop a conflict
				  of interest policy which shall apply to all governing body members and facility
				  administration. All governing body members shall execute a conflict of interest
				  statement; and
(21) conduct direct
				  consultations with the medical staff at least twice during the year.