reglab/statecodes huggingface dataset:
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 39 - Critical Access Hospital › Section 310:667-39-3 - Admission criteria

Current through Vol. 41, No. 20, July 1, 2024
The CAH shall establish inpatient admission criteria
				  appropriate for the treatment and diagnostic services provided. The criteria
				  may be based on diagnosis and patient acuity established by the medical and
				  professional staff or the CAH may use diagnosis related groups (DRGs). The
				  criteria shall be established and revised as necessary by the medical and
				  professional staff and approved by the governing body. Stabilizing emergency
				  treatment services provided shall not be restricted by inpatient admission
				  criteria.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 17 Ok
				  Reg 692, eff 12-16-99 (emergency); Amended at 17 Ok Reg 2992, eff
				  7-13-00
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 39 - Critical Access Hospital › Section 310:667-39-4 - Basic requirements and services

Current through Vol. 41, No. 20, July 1, 2024
The CAH shall provide basic services as described in Sections
				  5 through 14 of this Subchapter and comply with Subchapters 1, 3, and 5 of this
				  Chapter. The CAH may provide additional services beyond the basic core of
				  required services if applicable sections of this Chapter are
				  met.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 17 Ok
				  Reg 692, eff 12-16-99 (emergency); Amended at 17 Ok Reg 2992, eff 7-13-00;
				  Amended at 20 Ok Reg 1664, eff 6-12-03
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 39 - Critical Access Hospital › Section 310:667-39-5 - Governing body

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
The CAH shall have an effective governing body legally
				responsible for all services and the quality of patient care provided. The
				majority of members of this body shall be residents of the incorporated
				community or service area of the CAH.
(b)
Organization.
The governing
				body may be an organized board or owner designated individual(s). The method
				for appointment, terms, officers required, meeting requirements, duties, and
				responsibilities shall be established in written bylaws which shall be
				available at the CAH. The governing body shall meet at established intervals
				and maintain minutes of meetings. Meetings may be conducted by teleconference
				if not otherwise prohibited by law.
(c)
Responsibilities.
The
				governing body's responsibilities shall include at least the following:
(1) Appointment and reappointment of members
				of the medical and professional staff by methods established in approved
				bylaws. These appointments shall be made based on recommendations received from
				the medical and professional staff and be consistent with state law.
(2) Approval of medical and professional
				staff bylaws, rules and regulations.
(3) Approval or denial of physician or
				practitioner privilege delineations recommended by the medical and professional
				staff.
(4) Consideration of reports
				received from the CAH concerning the quality of care provided. The governing
				body shall require corrective actions as necessary when inadequate patient care
				is identified.
(5) Ensure patients
				are admitted and discharged by a physician or licensed independent
				practitioner.
(6) Ensure a
				physician or licensed independent practitioner is available to communicate with
				CAH staff at all times. A physician or licensed independent practitioner shall
				be physically available as specified by CAH policy. If a physician or licensed
				independent practitioner functions as the physician or practitioner on-call for
				the CAH, the physician or licensed independent practitioner shall be physically
				available if necessary within twenty (20) minutes.
(7) Ensure the licensed independent
				practitioners and registered nurses on-call to the CAH are physically available
				if necessary within twenty (20) minutes.
(8) Designation of an administrator who shall
				be responsible for managing the facility. This person may have duties in
				addition to management responsibilities.
(9) Ensure the CAH is constructed, arranged,
				and maintained to ensure the safety of the patient, and to provide facilities
				for diagnosis and treatment appropriate to the needs of the
				community.
(10) Ensure the CAH is
				operated under an approved budget.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 39 - Critical Access Hospital › Section 310:667-39-6 - Medical and professional staff

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
The CAH shall have an organized medical and professional
				staff responsible for the quality of care provided to all patients. The staff
				shall operate under bylaws approved by the governing body.
(b)
Composition.
The CAH shall
				have a medical and professional staff composed of one (1) or more physicians
				and which may also include one (1) or more licensed independent practitioners
				with privileges at the CAH. Privileges may also be extended to other health
				care professionals who are authorized by state law to provide treatment
				services.
(1) The staff shall periodically
				reexamine credentials and conduct appraisals of its members and make
				recommendations regarding reappointments and privilege delineations to the
				governing body. The staff shall also examine credentials of candidates for
				staff membership and make recommendations regarding appointments and privileges
				extended.
(2) Temporary staff
				privileges may be extended to qualified physicians, licensed independent
				practitioners and other professional staff as specified in the medical and
				professional staff bylaws.
(3)
				Patient admission quotas or revenue generation minimums shall not be a
				condition for appointment or reappointment.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 39 - Critical Access Hospital › Section 310:667-39-7 - Quality improvement

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
There shall be an ongoing quality improvement program,
				approved by the governing body, which shall identify problems in the facility,
				suggest solutions, and monitor results.
(b)
Quality improvement plan.
A
				written quality improvement plan shall be developed, approved, and implemented
				by the governing body with advice from the medical and professional staff. The
				plan shall include but not be limited to the following:
(1) Methods of evaluating all patient
				services to ensure quality of care, including those provided under
				contract.
(2) Methods of evaluating
				off-site health care services for appropriateness of use and the degree to
				which the services aid in the provision of quality patient care.
(3) The evaluation of nosocomial infections
				and accompanying medication therapy shall be linked to the hospital-wide
				quality improvement program through regular reporting by appropriate hospital
				committees and functions such as pharmacy and therapeutics, infection control,
				pharmaceutical services, etc.
(4)
				Evaluation of all surgical procedures if surgery is performed at the
				facility.
(5) Methods of evaluating
				licensed independent practitioner services to ensure these services are
				provided in conformance with facility policy and state law.
(6) Methods of evaluating on-call services to
				ensure staff are available as required.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 39 - Critical Access Hospital › Section 310:667-39-8 - Infection control program

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
The CAH shall establish an infection control program to
				provide a sanitary environment and avoid sources and transmission of
				infections. The program shall include written policies and procedures for
				identifying, reporting, evaluating and maintaining records of infections among
				patients and personnel. The program shall provide an ongoing review and
				evaluation of all aseptic, isolation and sanitation techniques employed in the
				hospital and coordinate training programs in infection control for all
				personnel.
(b)
Infection
				control committee.
The CAH may establish an infection control committee
				(or equivalent) or this function may be fulfilled by the medical and
				professional committee of the whole. The committee shall meet at least
				quarterly.
(c)
Policies and
				procedures review.
(1) The infection
				control committee shall evaluate, revise as necessary, and approve the type and
				scope of surveillance activities utilized at least annually.
(2) Infection control policies and procedures
				shall be reviewed periodically and revised as necessary, based on current
				scientific knowledge, accepted practice guidelines, and applicable laws and
				regulations.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 39 - Critical Access Hospital › Section 310:667-39-9 - Nursing service

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
Each CAH shall have an organized nursing service which
				provides twenty-four (24) hour nursing services for patients. The nursing
				service shall be supervised by a registered nurse.
(b)
Organization.
The nursing
				service shall be well-organized with written policies delineating
				administrative and patient care responsibilities. The director of nursing shall
				be a registered nurse who shall be responsible for the operation of the
				service, including determining the staff necessary to provide nursing care for
				all areas of the CAH. Nursing care shall be provided as specified by written
				procedures approved by the director of nursing and the governing body. All
				nursing procedures shall be consistent with state and federal law and current
				standards of practice. Procedures shall be reviewed and revised as
				necessary.
(c)
Staffing.
The nursing service shall have adequate numbers of
				licensed nurses and other nursing personnel available to provide nursing care
				to all patients as needed based on patient census and acuity. At least one (1)
				registered nurse shall be on duty on-site to furnish or supervise all nursing
				services whenever patient care is provided. If the CAH has no inpatients, the
				registered nurse may be available on an on-call basis provided he or she is
				available to return to the CAH in a period of time not to exceed twenty (20)
				minutes.
(d)
Qualifications.
(1) Individuals
				selected for the nursing staff shall be qualified by education and experience
				for the positions they are assigned. The CAH shall verify current licensure of
				licensed nurses and maintain documentation of verification.
(2) The selection and promotion of nursing
				service personnel shall be based on their qualifications and capabilities. The
				director of nursing shall have input regarding the employment, promotion,
				evaluation and termination of all nursing service personnel.
(3) The qualifications required for each
				category of nursing staff shall be in written policy and job descriptions, and
				shall be available in the CAH for reference. The functions of all nursing
				service personnel shall be clearly defined by written policy.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 39 - Critical Access Hospital › Section 310:667-39-10 - Food and nutritional services

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
The CAH shall directly provide or contract for organized
				food and nutritional services that are directed and staffed by qualified
				personnel. If the CAH has a contract with an outside food management company to
				provide services on-site or cater food to the CAH, the company shall comply
				with all requirements specified in this section.
(b)
Organization.
(1) Clinical nutritional services shall be
				under the supervision and direction of a licensed/registered dietitian on a
				full-time, part-time, or consultant basis. The dietitian shall be responsible
				for approval of menus and modified diets, review of clinical policies and
				procedures, evaluation of nutritional services and staff continuing education.
				If dietitian services are provided on a part-time or consultant basis, the
				responsibilities of the dietitian shall be clearly defined in a written job
				description and summary reports of consultant visits shall be written and on
				file. The dietitian shall be responsible for, or shall designate a person in
				writing, to carry out clinical nutritional activities. The clinical nutritional
				activities shall include but not be limited to patient and family counseling on
				modified diets as needed, any required nutritional assessments, and development
				of clinical nutritional policies and procedures. If dietitian services are
				provided on a part-time or consultant basis, a dietitian shall be available for
				telephone consultation daily and shall be able to approve menus and modified
				diets electronically.
(2) The food
				and nutritional services manager may or may not be a licensed/registered
				dietitian. If the manager is not a licensed/registered dietitian or certified
				dietary manager, the manager shall be responsible only for administrative
				management and shall not direct clinical nutritional activities.
(3) Personnel shall be adequate in number and
				training to carry out the preparation and serving of foods and other related
				functions with the proper and necessary sanitary procedures. The food service
				personnel shall complete a basic orientation program before working in the food
				service area. This orientation shall include, but not be limited to: basic
				dietary guidelines, infection control including food safety, and fire and
				safety precautions.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 39 - Critical Access Hospital › Section 310:667-39-12 - Drug distribution

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
The CAH shall provide routine and emergency drugs and
				biologicals in a safe and accurate manner to meet the needs of the patients.
				The CAH may provide all drug distribution services directly with a complete
				licensed hospital pharmacy or a drug room. The drug room may be provided
				directly by the CAH or by contract with a licensed pharmacy. The medical and
				professional staff and the CAH pharmacist shall be responsible for oversight of
				drug distribution services and shall approve policies and procedures that
				ensure compliance with state and federal laws and minimize drug errors. If
				required, the CAH shall annually register with the Oklahoma State Board of
				Pharmacy.
(b)
Personnel.
(1) The drug
				distribution service shall be directed by a pharmacist on a full-time,
				part-time, or consultant basis. The pharmacist shall be responsible for
				developing, supervising, and coordinating all activities of drug distribution
				in the CAH. The responsibility and authority of the pharmacist shall be clearly
				defined in a written job description. All compounding, packaging, labeling and
				dispensing of drugs and biologicals shall be performed or directly supervised
				by the pharmacist.
(2) If the CAH
				only maintains a drug room, drugs and biologicals shall be distributed and
				administered only to inpatients of the CAH. The pharmacist director shall be
				available at least as a consultant and a registered or licensed practical nurse
				shall be designated in writing as the drug room supervisor to ensure drugs and
				biologicals are properly distributed and stored. The drug room supervisor may
				have other job responsibilities in the CAH as long as drug distribution
				services are adequately maintained.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 39 - Critical Access Hospital › Section 310:667-39-13 - Diagnostic services

Current through Vol. 41, No. 20, July 1, 2024
(a)
Radiological services.
The CAH shall maintain or have available
				diagnostic radiological services according to the needs of the patients.
(1) Radiological services shall be free from
				hazards for patients and personnel. Proper safety precautions shall be
				maintained against fire and explosion hazards, electrical hazards, and
				radiation hazards.
(2) Diagnostic
				x-ray equipment shall have a current permit issued by the Department and shall
				be inspected at least every two (2) years by a certified health physicist or by
				Department staff. Any identified hazards shall be promptly corrected.
(3) The hospital shall identify those
				employees who are subject to significant occupational exposure to radiation
				while performing their job duties. All such workers shall be checked
				periodically for amounts of radiation exposure by the use of exposure meters or
				badge tests.
(4) The CAH shall have
				a qualified radiologist available on a full-time, part-time or consulting basis
				both to supervise services and interpret diagnostic images that require
				specialized knowledge for accurate reading. Diagnostic images may be
				electronically transmitted or delivered off-site for interpretation by the
				radiologist. The interpretation of radiological examinations shall be made by
				physicians or licensed independent practitioners competent in the field
				according to individually granted clinical privileges. Reports of
				interpretations shall be written or dictated and signed by the radiologist,
				physician, or licensed independent practitioner making the interpretation. All
				diagnostic image interpretations shall be incorporated into the patient's
				medical record with a duplicate copy kept with the image.
(5) The use of diagnostic x-ray equipment
				shall be limited to personnel designated as qualified by the radiologist or the
				medical and professional staff. Fluoroscopic procedures may be performed by
				radiology technologists only upon the written authorization of a qualified
				radiologist, and in the presence of a physician or licensed independent
				practitioner or by real time visualization through electronic means.
(6) The CAH shall maintain copies of reports
				and diagnostic images for at least five (5) years.
(7) If the CAH provides imaging services
				other than routine diagnostic x-ray, the CAH shall comply with appropriate
				sections of OAC
				310:667-23-2.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 39 - Critical Access Hospital › Section 310:667-39-14 - Emergency services

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
The CAH shall provide emergency stabilization and
				treatment services commensurate with emergency medical needs of the community
				and CAH service area. All services shall be provided in accordance with
				acceptable standards of practice, compliant with applicable state and federal
				laws.
(b)
Organization and
				direction.
The service shall be directed by personnel deemed qualified
				by the governing body and integrated with other services of the CAH. Although
				the service may function as a separate department, the CAH may also provide
				this service with staff from other areas who are trained in emergency services
				and who are available if needed in the emergency area.
(1) Services shall be organized under the
				direction of a qualified member of the medical and professional staff. Nursing
				functions shall be the responsibility of a registered nurse and shall be
				supervised by the director of nursing.
(2) There shall be written policies and
				procedures that establish protocols for emergency services provided. Policies
				shall also include written procedures for stabilization and transfer of
				patients whose treatment needs cannot be met at the CAH. If the CAH does not
				offer maternity services, emergency service policies shall include protocols
				for emergency deliveries.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 40 - Emergency Hospital › Section 310:667-40-1 - General

Current through Vol. 41, No. 20, July 1, 2024
An emergency hospital (EH) is a hospital that provides
				  emergency treatment and stabilization services on a twenty four (24) hour basis
				  that has the ability to admit and treat patients for short periods of time. The
				  EH shall be the sole provider of hospital services in the community and is to
				  allow the provision of emergency and stabilizing care in a community that is
				  unable to support a general medical surgical or critical access hospital. The
				  EH shall only provide emergency medical services and limited inpatient
				  stabilization or observational care. Non-emergent surgical, scheduled
				  obstetrical deliveries, and invasive diagnostic services requiring anesthesia
				  or sedation shall not be provided. The EH shall be limited to no more that ten
				  (10) inpatient stabilization and observational beds.
Added at 20 Ok Reg 1664,
				  eff 6-12-03
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 40 - Emergency Hospital › Section 310:667-40-2 - Affiliations, communications and agreements

Current through Vol. 41, No. 20, July 1, 2024
(a)
Affiliations.
The EH shall
				be affiliated with at least one (1) general medical surgical hospital to
				facilitate appropriate referrals and adequate support services. The affiliation
				shall be through a written agreement, contract for services, network
				affiliation, lease or through direct ownership by the supporting general
				medical surgical hospital.
(b)
Communications.
Direct communications shall be established between
				the EH and any facility providing support services. These communications shall
				include the electronic sharing of patient data which may include telemetry and
				diagnostic imaging if local telecommunications have this capability. As a
				minimum, the EH shall be able to send and receive patient information by
				facsimile and/or computer modem.
(c)
Agreements.
The EH shall
				have a written agreement with an emergency medical service to accept and
				receive emergency transfers. This agreement shall provide arrangements for
				emergency and non-emergency transfers to and from the EH and stipulate the
				emergency and stabilizing treatment services available at the EH. Direct
				communications shall be established between the emergency medical service and
				the EH which allow the emergency medical service to directly contact the
				on-call physician or licensed independent practitioner and the on-call or
				on-site registered nurse providing emergency services.
Added at 20 Ok Reg 1664,
				  eff 6-12-03
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 40 - Emergency Hospital › Section 310:667-40-3 - Stabilization or observational admissions

Current through Vol. 41, No. 20, July 1, 2024
The EH shall establish inpatient stabilization and
				  observational admission criteria appropriate to treat patients that require
				  short periods of extended care that cannot be provided in an emergency room
				  setting. The criteria may be based on diagnosis and patient acuity established
				  by the medical and professional staff or the EH may use diagnosis related
				  groups (DRGs). Such admission criteria shall not in any way be based on payer
				  source. The criteria shall be established and revised as necessary by the
				  medical and professional staff and approved by the governing body. Stabilizing
				  emergency treatment services provided shall not be restricted by inpatient
				  admission criteria.
Added at 20 Ok Reg 1664,
				  eff 6-12-03
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 40 - Emergency Hospital › Section 310:667-40-4 - Basic requirements and services

Current through Vol. 41, No. 20, July 1, 2024
The EH shall provide basic services as described in Sections
				  5 through 16 of this Subchapter and comply with Subchapters 1, 3 and 5 of this
				  Chapter. The EH shall not provide additional services.
Added at 20 Ok Reg 1664,
				  eff 6-12-03
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 40 - Emergency Hospital › Section 310:667-40-5 - Governing body

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
The EH shall have an effective governing body legally
				responsible for all services and the quality of patient care
				provided.
(b)
Organization.
The governing body may be an organized board or
				owner designated individual(s). The method for appointment, terms, officers
				required, meeting requirements, duties, and responsibilities shall be
				established in written bylaws which shall be available at the EH. The governing
				body shall meet at established intervals and maintain minutes of meetings.
				Meetings may be conducted by teleconference if not otherwise prohibited by
				law.
(c)
Responsibilities.
The governing body's responsibilities shall
				include at least the following:
(1)
				Appointment and reappointment of members of the medical and professional staff
				by methods established in approved bylaws. These appointments shall be made
				based on recommendations received from the medical and professional staff and
				be consistent with state law.
(2)
				Approval of medical and professional staff bylaws, rules and
				regulations.
(3) Approval or denial
				of physician and practitioner privilege delineations recommended by the medical
				and professional staff.
(4)
				Consideration of reports received from the EH concerning the quality of care
				provided. The governing body shall require corrective actions as necessary when
				inadequate patient care is identified.
(5) Ensure patients are admitted and
				discharged for inpatient stabilization or observational care by a physician or
				licensed independent practitioner.
(6) Ensure a physician or licensed
				independent practitioner is available to communicate with EH staff at all
				times. A physician or licensed independent practitioner shall be physically
				available if necessary as specified by EH policy.
(7) Ensure adequate EH staff are physically
				available on-site to provide required emergency, stabilization, and
				observational services.
(8)
				Designation of an administrator who shall be responsible for managing the
				facility. This person may have duties in addition to management
				responsibilities.
(9) Ensure the EH
				is constructed, arranged, and maintained to ensure the safety of the patient,
				and to provide facilities for emergency, stabilization, and observational care
				provided.
(10) Ensure the EH is
				operated under an approved budget.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 40 - Emergency Hospital › Section 310:667-40-6 - Medical and professional staff

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
The EH shall have an organized medical and professional
				staff responsible for the quality of care provided to all patients. The staff
				shall operate under bylaws approved by the governing body. The medical and
				professional staff may function as a part of an affiliated hospital's organized
				staff as long as individual physician and practitioner privileges are
				independently recommended and approved by the EH governing body. If staff
				functions are combined with an affiliated hospital, EH functions required by
				the medical and professional staff bylaws shall be independently identified and
				reviewed during combined staff meetings.
(b)
Composition.
The EH shall
				have a medical and professional staff composed of one (1) or more physicians or
				licensed independent practitioners. Privileges may also be extended to other
				health care professionals who are authorized by state law to provide treatment
				services.
(1) The staff shall periodically
				reexamine credentials and conduct appraisals of its members and make
				recommendations regarding reappointments and privilege delineations to the
				governing body. The staff shall also examine credentials of candidates for
				staff membership and make recommendations regarding appointments and privileges
				extended.
(2) Temporary staff
				privileges may be extended to physicians and licensed independent practitioners
				and other professional staff as specified in the medical and professional staff
				bylaws.
(3) Patient admission
				quotas or revenue generation minimums shall not be a condition for appointment
				or reappointment.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 40 - Emergency Hospital › Section 310:667-40-7 - Quality improvement

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
There shall be an ongoing quality improvement program,
				approved by the governing body, which shall identify problems in the facility,
				suggest solutions, and monitor resolutions.
(b)
Quality improvement plan.
A
				written quality improvement plan shall be developed, approved, and implemented
				by the governing body with advice from the medical and professional staff. The
				plan shall include but not be limited to the following:
(1) Methods of evaluating all patient
				services to ensure quality of care, including those provided under
				contract.
(2) Methods of evaluating
				off-site health care services for appropriateness of use and the degree to
				which the services aid in the provision of quality patient care.
(3) The evaluation of nosocomial infections
				and accompanying medication therapy shall be linked to the hospital-wide
				quality improvement program through regular reporting to the medical and
				professional staff committee of the whole.
(4) Methods of evaluating physician and
				practitioner services to ensure these services are provided in conformance with
				facility policy and state law.
(5)
				Methods of evaluating on-call services to ensure staff are available as
				required.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 40 - Emergency Hospital › Section 310:667-40-8 - Infection control program

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
The EH shall establish an infection control program to
				provide a sanitary environment and avoid sources and transmission of
				infections. The program shall include written policies and procedures for
				identifying, reporting, evaluating and maintaining records of infections among
				patients and personnel. The program shall provide an ongoing review and
				evaluation of all aseptic, isolation and sanitation techniques employed in the
				hospital and coordinate training programs in infection control for all
				personnel.
(b)
Infection
				control committee.
The EH may establish an infection control committee
				(or equivalent) or this function may be fulfilled by the medical and
				professional committee of the whole. The committee shall meet at least
				quarterly.
(c)
Policies and
				procedures review.
(1) The infection
				control committee shall evaluate, revise as necessary, and approve the type and
				scope of surveillance activities utilized at least annually.
(2) Infection control policies and procedures
				shall be reviewed periodically and revised as necessary, based on current
				scientific knowledge, accepted practice guidelines, and applicable laws and
				regulations.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 40 - Emergency Hospital › Section 310:667-40-9 - Nursing service

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
Each EH shall have an organized nursing service which
				provides twenty-four (24) hour nursing services for patients. The nursing
				service shall be supervised by a registered nurse.
(b)
Organization.
The nursing
				service shall be well-organized with written policies delineating
				administrative and patient care responsibilities. The director of nursing shall
				be a registered nurse who shall be responsible for the operation of the
				service, including determining the staff necessary to provide nursing care for
				the EH. Nursing care shall be provided as specified by written procedures
				approved by the director of nursing and the governing body. All nursing
				procedures shall be consistent with state and federal law and current standards
				of practice. Procedures shall be reviewed and revised as necessary.
(c)
Staffing.
The nursing
				service shall have adequate numbers of licensed nurses and other nursing
				personnel available to provide nursing care to all patients as needed based on
				patient census and acuity. At least one (1) registered nurse shall be on duty
				on-site to furnish or supervise all nursing services whenever patient care is
				provided. If the EH has no inpatients, the registered nurse may be available on
				an on-call basis provided he or she is available to return to the EH in a
				period of time not to exceed twenty (20) minutes.
(d)
Qualifications.
(1) Individuals selected for the nursing
				staff shall be qualified by education and experience for the positions they are
				assigned. The EH shall verify current licensure of licensed nurses and maintain
				documentation of verification.
(2)
				The selection and promotion of nursing service personnel shall be based on
				their qualifications and capabilities. The director of nursing shall have input
				regarding the employment, promotion, evaluation and termination of all nursing
				service personnel.
(3) The
				qualifications required for each category of nursing staff shall be in written
				policy and job descriptions, and shall be available in the EH for reference.
				The functions of all nursing service personnel shall be clearly defined by
				written policy.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 40 - Emergency Hospital › Section 310:667-40-10 - Food and nutritional services

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
The EH shall directly provide or contract for organized
				food and nutritional services that are directed and staffed by qualified
				personnel. If the EH has a contract with an outside food management company to
				provide services on-site or cater food to the EH, the company shall comply with
				all requirements specified in this section.
(b)
Organization.
(1) Clinical nutritional services shall be
				under the supervision and direction of a licensed/registered dietitian on a
				full-time, part-time, or consultant basis. The dietitian shall be responsible
				for approval of menus and modified diets, review of clinical policies and
				procedures, evaluation of nutritional services and staff continuing education.
				If dietitian services are provided on a part-time or consultant basis, the
				responsibilities of the dietitian shall be clearly defined in a written job
				description and summary reports of consultant visits shall be written and on
				file. The dietitian shall be responsible for, or shall designate a person in
				writing, to carry out clinical nutritional activities. The clinical nutritional
				activities shall include but not be limited to patient and family counseling on
				modified diets as needed, any required nutritional assessments, and development
				of clinical nutritional policies and procedures. If dietitian services are
				provided on a part-time or consultant basis, a dietitian shall be available for
				telephone consultation daily and shall be able to approve menus and modified
				diets electronically.
(2) The food
				and nutritional services manager may or may not be a licensed/registered
				dietitian. If the manager is not a licensed/registered dietitian or certified
				dietary manager, the manager shall be responsible only for administrative
				management and shall not direct clinical nutritional activities.
(3) Personnel shall be adequate in number and
				training to carry out the preparation and serving of foods and other related
				functions with the proper and necessary sanitary procedures. The food service
				personnel shall complete a basic orientation program before working in the food
				service area. This orientation shall include, but not be limited to: basic
				dietary guidelines, infection control including food safety, and fire and
				safety precautions.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 40 - Emergency Hospital › Section 310:667-40-12 - Drug distribution

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
The EH shall provide routine and emergency drugs and
				biologicals in a safe and accurate manner to meet the needs of the patients.
				The EH may provide all drug distribution services directly with a complete
				licensed hospital pharmacy or drug room, or services may be provided by
				contract with a licensed pharmacy. The medical and professional staff and the
				EH pharmacist shall be responsible for oversight of drug distribution services
				and shall approve policies and procedures that ensure compliance with state and
				federal laws and minimize drug errors. If required, the EH shall annually
				register with the Oklahoma State Board of Pharmacy.
(b)
Personnel.
(1) The drug distribution service shall be
				directed by a pharmacist on a full-time, part-time, or consultant basis. The
				pharmacist shall be responsible for developing, supervising, and coordinating
				all activities of drug distribution in the EH. The responsibility and authority
				of the pharmacist shall be clearly defined in a written job description. All
				compounding, packaging, labeling and dispensing of drugs and biologicals shall
				be performed or directly supervised by the pharmacist.
(2) If the EH only maintains a drug room,
				drugs and biologicals shall be distributed and administered only to patients of
				the EH. The pharmacist director shall be available at least as a consultant and
				a registered or licensed practical nurse shall be designated in writing as the
				drug room supervisor to ensure drugs and biologicals are properly distributed
				and stored. The drug room supervisor may have other job responsibilities in the
				EH as long as drug distribution services are adequately maintained.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 40 - Emergency Hospital › Section 310:667-40-13 - Diagnostic services

Current through Vol. 41, No. 20, July 1, 2024
(a)
Radiological services.
The EH shall maintain or have available
				diagnostic radiological services according to the needs of the patients.
(1) Radiological services shall be free from
				hazards for patients and personnel. Proper safety precautions shall be
				maintained against fire and explosion hazards, electrical hazards, and
				radiation hazards.
(2) Diagnostic
				x-ray equipment shall have a current permit issued by the Department and shall
				be inspected at least every two (2) years by a certified health physicist or by
				Department staff. Any identified hazards shall be promptly corrected.
(3) The hospital shall identify those
				employees who are subject to significant occupational exposure to radiation
				while performing their job duties. All such workers shall be checked
				periodically for amounts of radiation exposure by the use of exposure meters or
				badge tests.
(4) The EH shall have
				a qualified radiologist available on a full-time, part-time or consulting basis
				both to supervise services and interpret diagnostic images that require
				specialized knowledge for accurate reading. Diagnostic images may be
				electronically transmitted or delivered off-site for interpretation by the
				radiologist. The interpretation of radiological examinations shall be made by
				physicians or licensed independent practitioners competent in the field
				according to individually granted clinical privileges. Reports of
				interpretations shall be written or dictated and signed by the radiologist,
				physician, or licensed independent practitioner making the interpretation. All
				diagnostic image interpretations shall be incorporated into the patient's
				medical record with a duplicate copy kept with the image.
(5) The use of diagnostic x-ray equipment
				shall be limited to personnel designated as qualified by the radiologist and
				the medical and professional staff. Fluoroscopic procedures may be performed by
				radiology technologists only upon the written authorization of a qualified
				radiologist, and in the presence of a physician or licensed independent
				practitioner or by real time visualization through electronic means.
(6) The EH shall maintain copies of reports
				and diagnostic images for at least five (5) years.
(7) If the EH provides imaging services other
				than routine diagnostic x-ray, the EH shall comply with appropriate sections of
				OAC
				310:667-23-2.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 40 - Emergency Hospital › Section 310:667-40-14 - Emergency services

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
The EH shall provide emergency stabilization and
				treatment services commensurate with emergency medical needs of the community
				and EH service area. All services shall be provided in accordance with
				acceptable standards of practice, compliant with applicable state and federal
				laws.
(b)
Organization and
				direction.
The service shall be directed by personnel deemed qualified
				by the governing body and integrated with the nursing stabilization and
				observation unit of the EH.
(1) Services
				shall be organized under the direction of a qualified member of the medical and
				professional staff. Nursing functions shall be the responsibility of a
				registered nurse and shall be supervised by the director of nursing.
(2) There shall be written policies and
				procedures that establish protocols for emergency services provided. Policies
				shall also include written procedures for stabilization and transfer of
				patients whose treatment needs cannot be met at the EH. EH emergency service
				policies shall include protocols for emergency deliveries if the patient cannot
				be safely transferred.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 40 - Emergency Hospital › Section 310:667-40-15 - Outpatient services

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
The EH may provide limited outpatient services consistent
				with the diagnostic and treatment capabilities of the facility. These services
				may be provided in the emergency services area or in a separate examination or
				treatment room.
(b)
Personnel.
The EH may provide limited outpatient services
				consistent with the diagnostic and treatment capabilities of the facility.
				These services may be provided in the emergency services area or in a separate
				examination or treatment room.
(1) A
				physician or licensed independent practitioner shall be responsible for the
				services provided to each patient.
(2) The director of nursing shall be
				responsible for all nursing services provided.
(3) Additional EH staff shall be available as
				necessary to provide required diagnostic and treatment services.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 40 - Emergency Hospital › Section 310:667-40-16 - Therapy services

Current through Vol. 41, No. 20, July 1, 2024
(a)
Respiratory therapy.
If the EH provides respiratory therapy either
				directly or by contract, the services shall meet the requirements specified at
				OAC
				310:667-23-5.
(b)
Physical and occupational
				therapy.
If the EH provides physical and/or occupational therapy either
				directly or by contract, the services shall meet the requirements specified at
				OAC
				310:667-23-6.
Added at 20 Ok Reg 1664,
				  eff 6-12-03
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 41 - General Construction Provisions › Section 310:667-41-1 - General

Current through Vol. 41, No. 20, July 1, 2024
(a) The following national standards are
				incorporated by reference:
(1) Facility
				Guidelines Institute (FGI): Guidelines for Design and Construction of Hospitals
				2018 Edition; and
(2) National Fire
				Protection Association (NFPA)101: Life Safety Code (LSC), 2012 Edition and 2012
				LSC Tentative Interim Amendments (TIA) 12-1, 12-2, 12-3, and 12-4; and NFPA99
				Health Care Facilities Code (HCFC), 2012 Edition, excluding Chapters 7,8, 12
				and 13, and 2012 HCFC TIA 12-2, 12-3, 12-4, 12-5 and 12-6 adopted in 81 Federal
				Register 26871 by the Centers for Medicare& Medicaid Services on July 5,
				2016.
Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 41 - General Construction Provisions › Section 310:667-41-3 - Design standards for the disabled

Current through Vol. 41, No. 20, July 1, 2024
(a) The Americans with Disabilities Act (ADA)
				extends comprehensive civil rights protection to individuals with disabilities.
				Under Titles II and III of the ADA, public, private, public service hospitals
				and other health care facilities shall comply with the "Accessibility
				Guidelines for Buildings and Facilities" (ADAAG) for alterations and new
				construction. The "Uniform Federal Accessibility Standards" (UFAS) also
				provides criteria for the disabled. United States government facilities shall
				comply with a combination of UFAS and ADAAG using the most stringent criteria.
				Also available for use in providing quality design for the disabled is the
				American National Standards Institute (ANSI) A117.1 "American National Standard
				for Accessible and Usable Buildings and Facilities."
(b) State and local standards for
				accessibility and usability may be more stringent than ADA, UFAS, or ANSI A
				117.1. Designers and owners, therefore, shall assume responsibility for
				verification of all applicable requirements and comply with the most stringent
				standards.
Added at 12 Ok Reg 1555,
				  eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok
				  Reg 1664, eff 6-12-03