reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › MEDICAL STAFF BYLAWS, RULES AND REGULATIONS › Section 107.12a - Specified professional personnel-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Scope
. This section
					 applies to hospitals that use "specified professional personnel" to provide
					 direct medical care in accordance with §
											107.12(14)
					 (relating to content of bylaws, rules and regulations).
(b)
Purpose
. This section
					 clarifies the Department's regulations as they affect the use of certified
					 registered nurse practitioners (CRNPs), physician assistants (PAs) and
					 certified nurse midwives (CNMs) in hospitals.
(c)
Current regulations
.
(1) Section
					 107.12(14)
					 permits "specified professional personnel," including persons qualified to
					 render direct medical care under the supervision of a member of the medical
					 staff, to perform certain functions, including direct participation in the
					 management of patients under the supervision or direction of a member of the
					 medical staff and the writing of orders within the limits established by the
					 medical staff.
(2) Sections
					 107.61,
					 107.62 and
					 107.64 (relating to written
					 orders; oral orders; and administration of drugs) and other sections of the
					 hospital regulations limit the performance of certain functions including the
					 writing or countersigning of orders to practitioners, defined as licensed
					 physicians, dentists or podiatrists. This definition appears to render §
												107.12(14)
					 ineffective.
(3) Commonwealth
					 statutes and regulations defining CRNP, PA and CNM scope of practice permit
					 those personnel to issue written and oral medical orders, take oral orders and
					 otherwise render medical care and manage patients consistent with §
												107.12 (14).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › ORGANIZATION OF THE MEDICAL STAFF › Section 107.21 - Principle

Current through Register Vol. 54, No. 28, July 13, 2024
The medical staff shall be organized to accomplish its
						required functions. It shall provide for the election or appointment of its
						officers. The complexity of the medical staff organization shall be
						commensurate with the size of the hospital and the scope of the activities of
						the medical staff.
This section cited in 28 Pa. Code §
													107.12 (relating to content of
						  bylaws, rules and regulations).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › ORGANIZATION OF THE MEDICAL STAFF › Section 107.22 - Departments

Current through Register Vol. 54, No. 28, July 13, 2024
Departmentalization should occur when the medical staff
						duties and functions become too complex to be handled by the staff as a
						whole.
This section cited in 28 Pa. Code §
													107.12 (relating to content of
						  bylaws, rules and regulations).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › ORGANIZATION OF THE MEDICAL STAFF › Section 107.23 - Clinical department chairperson

Current through Register Vol. 54, No. 28, July 13, 2024
Each clinical department chairperson in a
						departmentalized hospital shall be responsible for departmental implementation
						of actions taken by the medical staff. He must maintain continuing surveillance
						of the professional performance of all members of the medical staff with
						privileges in his department and must report regularly thereon to the medical
						staff. A clinical department chairman should be certified by the appropriate
						Board, be eligible for Board certification, or have successfully completed an
						approved residency training program in the clinical field of which he is
						chairman.
This section cited in 28 Pa. Code §
													107.12 (relating to content of
						  bylaws, rules and regulations).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › ORGANIZATION OF THE MEDICAL STAFF › Section 107.24 - Medical staff officers

Current through Register Vol. 54, No. 28, July 13, 2024
There shall be such officers of the medical staff
						organization as will provide effective control of its affairs and ensure proper
						discharge of the responsibility for the quality of medical care delegated to
						the medical staff by the governing body.
This section cited in 28 Pa. Code §
													107.12 (relating to content of
						  bylaws, rules and regulations).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › ORGANIZATION OF THE MEDICAL STAFF › Section 107.25 - Medical staff executive committee

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 In a departmentalized hospital, there shall be an executive committee, or its
					 equivalent, which represents the medical staff, which has responsibility for
					 the effectiveness of all medical activities of the staff, and which acts for
					 the medical staff.
(b) The
					 executive committee, or its equivalent, shall:
(1) receive and act upon the reports of other
					 medical staff committees;
(2)
					 consider and recommend action to the chief executive officer on all matters of
					 a medical administrative nature;
(3) implement the policies of the medical
					 staff;
(4) make recommendations to
					 the governing body and chief executive officer concerning hospital operations,
					 problems, and procedures.
(5) take
					 reasonable steps to ensure ethical professional conduct on the part of all
					 members of the medical staff, and initiate such prescribed disciplinary
					 measures as are indicated;
(6) be
					 held accountable to the governing body, as representative of the medical staff,
					 for the medical care rendered to the patients of the hospital;
(7) ensure that the medical staff is kept
					 abreast of the approved accreditation program and informed of the accreditation
					 status of the hospital;
(8) meet as
					 necessary, but at least ten times a year, and maintain a permanent record of
					 each meeting and of any actions taken. The record of each executive committee
					 meeting shall be submitted in full or in summary form to the governing body
					 prior to the next meeting of the governing body; and
(9) fulfill such other responsibilities as
					 are assigned to it by the medical staff bylaws.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › ORGANIZATION OF THE MEDICAL STAFF › Section 107.26 - Additional committees

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 There shall be such additional committees as are necessary to organize and
					 conduct the operations of the medical staff. All rules and proceedings of any
					 additional committees shall be permanently recorded and kept available for
					 inspections by members of the medical staff and the governing body.
(b) The following additional committees are
					 mandatory:
(1) A credentials committee which
					 shall make recommendations for staff appointments and reappointments,
					 promotions, demotions, and clinical privileges. The credentials committee shall
					 be advisory and investigative and shall report to the executive committee of
					 the medical staff.
(2) A tissue
					 committee, which shall review and evaluate surgery performed in the hospital
					 when there is a disagreement among the preoperative, post-operative, and
					 pathological diagnoses, or where a question of the acceptability of the
					 procedure undertaken has been raised. The tissue committee shall meet at least
					 once monthly, and its reports should be made available to the medical care
					 evaluation committee.
(3) A medical
					 records committee or its equivalent, which shall supervise the maintenance of
					 medical records at the required standard of completeness. The medical records
					 committee shall recommend for discipline any member of the medical staff whose
					 medical records practices fail to conform with necessary record keeping
					 requirements. The medical records committee shall have at least four meetings
					 annually.
(4) A medical care
					 evaluation committee.
(5) A
					 pharmacy-therapeutics committee in accordance with §
												113.5 (relating to pharmacy and
					 therapeutics committee).
(6) A
					 radiation safety committee.
(7) A
					 bylaws committee.
(8) Such other
					 committees as the medical staff deems appropriate.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › MEDICAL STAFF MEETINGS › Section 107.31 - Medical staff meetings

Current through Register Vol. 54, No. 28, July 13, 2024
There shall be regular medical staff and departmental
						meetings for the purpose of reviewing the performance of the medical staff,
						departments/services and reports and recommendations of medical staff and
						multi-disciplinary committees.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › MEDICAL STAFF MEETINGS › Section 107.32 - Meetings and attendance

Current through Register Vol. 54, No. 28, July 13, 2024
Where the medical staff is departmentalized, the
						frequency of general staff meetings shall be determined by the medical staff
						and clearly stated in the medical staff bylaws and rules and regulations.
						Departmental meetings should be held monthly. When the medical staff is not
						departmentalized, medical staff meetings shall be conducted at least ten times
						annually, at monthly intervals. There shall be at least an annual meeting of
						the medical staff at which officers and committee chairmen make such reports as
						may be desirable and at which officers are elected for the ensuing
						year.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › MEDICAL STAFF MEETINGS › Section 107.33 - Minutes

Current through Register Vol. 54, No. 28, July 13, 2024
Minutes shall be taken at each meeting and retained in
						accordance with the policy of the hospital. These minutes shall adequately
						reflect the transactions, conclusions and recommendations of the
						meetings.
The provisions of this § 107.33 issued under
						  67 Pa.C.S. §§
														6101-6104; and Reorganization Plan No. 2 of
						  1973 (71 P. S. §
														755-2).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › MEDICAL STAFF EDUCATION PROGRAMS › Section 107.41 - Continuing education

Current through Register Vol. 54, No. 28, July 13, 2024
The medical staff shall require a continuing program of
						professional education for medical staff members, or require its members to
						give evidence of participation in such a program.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › MEDICAL CARE REVIEW › Section 107.51 - Medical staff responsibilities

Current through Register Vol. 54, No. 28, July 13, 2024
(a) In
					 order for the medical staff to take reasonable steps to ensure clinical
					 practice of the highest quality, each staff member should endeavor to:
(1) Provide his patients with the best
					 quality of care consistent with the circumstances of each case.
(2) Conduct his professional activities in
					 accordance with the bylaws, rules and regulations of the medical
					 staff.
(3) Assist in the promotion
					 and maintenance of high quality care through the analysis, review, and
					 evaluation of the clinical practice which exists within the hospital.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › MEDICAL CARE REVIEW › Section 107.53 - Utilization review

Current through Register Vol. 54, No. 28, July 13, 2024
The hospital shall have a written plan for utilization
						review approved by the medical staff, administration, and governing body which
						generates reports adequate enough to permit identification of patient care
						problems. The plan shall establish a system to use this data to document
						appropriate utilization which shall include at least the following:
(1) A description of the method for
					 evaluating the appropriateness and medical necessity of admissions, continued
					 stays, and supportive services as well as delays in the provision of supportive
					 services.
(2) The procedures for
					 conducting concurrent review, including the time period within which the review
					 is to be initiated following admission and the length of stay norms and
					 percentiles to be used in assigning continued stay review dates. Records of the
					 findings shall be maintained and reported, according to established mechanisms,
					 to the executive committee of the medical staff and to the governing
					 body.
The provisions of this § 107.53 issued under
						  67 Pa.C.S. §§
														6101-6104; and Reorganization Plan No. 2 of
						  1973 (71 P. S. §
														755-2).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › MEDICAL CARE REVIEW › Section 107.54 - Medical audit

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Medical audit
					 shall include periodic review, on a sample or other basis, of the care rendered
					 to patients in every medical department of the hospital. The audit shall cover
					 admission, length of stay and professional services furnished.
(b) The medical audit process should include
					 both practitioners and allied health professionals from the hospital staff and
					 should be interdisciplinary in nature.
(c) Minutes shall be taken at all medical
					 audit committee meetings, and these minutes made available to the medical staff
					 on a regular basis in accordance with established policy. These minutes shall
					 be retained on file for no less than two years.
The provisions of this § 107.54 issued under
						  67 Pa.C.S. §§
														6101-6104; and Reorganization Plan No. 2 of
						  1973 (71 P. S. §
														755-2).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › MEDICAL ORDERS › Section 107.61 - Written orders

Current through Register Vol. 54, No. 28, July 13, 2024
Medication or treatment shall be administered only upon
						written and signed orders of a practitioner acting within the scope of his
						license and qualified according to medical staff bylaws and §
											107.12(k) 
						(relating to content of bylaws, rules and regulations) except as provided in
						§§
											107.62,
						107.64 and
						107.65 (relating to oral orders;
						administration of drugs; and automatic stop drug orders). The date that the
						order was written shall be included on all written orders.
The provisions of this §
													107.61 issued under section
						  2102(g) of The Administrative Code of 1929 (71 P. S. §
														532(g)); and section 803 of
						  the Health Care Facilities Act (35 P. S. §
														448.803).
This section cited in 28 Pa. Code §
													107.12a (relating to specified
						  professional personnel-statement of policy); 28 Pa. Code §
													109.23 (relating to written
						  nursing care policies and procedures); 28 Pa. Code §
													109.61 (relating to medication or
						  treatment); and 28 Pa. Code §
													115.33 (relating to
						  entries).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › MEDICAL ORDERS › Section 107.62 - Oral orders

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Oral orders
					 for medication or treatment shall be accepted only under urgent circumstances
					 when it is impractical for the orders to be given in written manner by the
					 responsible practitioner. Oral orders shall be taken only by personnel
					 qualified according to medical staff bylaws who shall transcribe the orders in
					 the proper place in the medical record of the patient. The order shall include
					 the date, time, and full signature of the person taking the order and shall be
					 countersigned by a practitioner within 24 hours. If the practitioner is not the
					 attending physician, he must be authorized by the attending physician and must
					 be knowledgeable about the patient's condition.
(b) The medical staff bylaws shall specify
					 personnel who are qualified to accept oral orders and shall specify that
					 acceptance of orders is limited to personnel listed in this subsection, with
					 restrictions as noted:
(1) A
					 practitioner.
(2) A professional
					 nurse.
(3) A licensed practical
					 nurse.
(4) A pharmacist who may
					 transcribe oral orders pertaining to drugs.
(5) A physical therapist who may transcribe
					 oral orders pertaining to physical therapy regimens.
(6) A respiratory therapist who may
					 transcribe oral orders pertaining to respiratory therapy treatments.
(7) A paramedic practicing under §
												117.30 (relating to emergency
					 paramedic services).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › MEDICAL ORDERS › Section 107.64 - Administration of drugs

Current through Register Vol. 54, No. 28, July 13, 2024
Drugs shall be administered only upon the proper order of
						a practitioner acting within the scope of his license and authorized according
						to medical staff bylaws, rules and regulations. Drugs shall be administered
						directly by a practitioner qualified according to medical staff bylaws, rules
						and regulations or by a professional nurse or by a licensed practical nurse
						with pharmacy training. Graduate practical nurses, graduate nurses, and
						students in approved schools of nursing may be authorized to administer drugs,
						but only under the supervision of a registered professional nurse or a
						physician under 49 Pa. Code §
											21.14 (relating to administration
						of drugs). A paramedic may be permitted to administer drugs only under §
											117.30 (relating to emergency
						paramedic services) and Chapter 2, Subchapter A (relating to emergency medical
						technicians). Further policies on the administration of drugs shall be
						established by the medical staff in conjunction with the pharmacy
						committee.
The provisions of this §
													107.64 issued under section
						  2102(g) of The Administrative Code of 1929 (71 P. S. §
														532(g)); and section 803 of
						  the Health Care Facilities Act (35 P. S. §
														448.803).
This section cited in 28 Pa. Code §
													107.12a (relating to specified
						  professional personnel-statement of policy); 28 Pa. Code §
													107.61 (relating to written
						  orders); 28 Pa. Code §
													109.23 (relating to written
						  nursing care policies and procedures); 28 Pa. Code §
													109.61 (relating to medication or
						  treatment); and 28 Pa. Code §
													115.33 (relating to
						  entries).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › MEDICAL ORDERS › Section 107.65 - Automatic stop drug orders

Current through Register Vol. 54, No. 28, July 13, 2024
The medical staff shall establish a written policy
						pursuant to §
											113.26 (relating to administration
						of drugs) for all dangerous medications not specifically prescribed as to time
						or number of doses to be automatically stopped after a reasonable time limit.
						The prescriber shall be notified according to hospital policies and procedures
						within 48 hours before an order is automatically stopped.
This section cited in 28 Pa. Code §
													107.61 (relating to written
						  orders); 28 Pa. Code §
													109.23 (relating to written
						  nursing care policies and procedures); 28 Pa. Code §
													109.61 (relating to medication or
						  treatment); 28 Pa. Code §
													113.26 (relating to administration
						  of drugs); and 28 Pa. Code §
													115.33 (relating to
						  entries).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › GENERAL PROVISIONS › Section 109.1 - Principle

Current through Register Vol. 54, No. 28, July 13, 2024
The hospital shall maintain a nursing staff to provide
						nursing care for the needs of the patients and a nursing staff organization to
						be responsible to the chief executive officer or chief operating officer of the
						hospital for the performance of its members.
The provisions of this § 109.1 issued under
						  67 Pa.C.S. §§
														6101-6104; and Reorganization Plan No. 2 of
						  1973 (71 P.S. §
														755-2).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › GENERAL PROVISIONS › Section 109.2 - Director of nursing services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
					 nursing service shall be under the direction of a registered professional nurse
					 who should be qualified in the field of administration and who has the ability
					 to organize, coordinate and evaluate the service.
(b) The director of nursing services shall be
					 employed on a full-time basis and shall be responsible to the chief executive
					 officer or his designee for developing and implementing policies and procedures
					 of the service.
(c) The director
					 shall make the recommendations on the selection and promotion of nursing
					 personnel based on established job descriptions and individual qualifications
					 and capabilities.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › GENERAL PROVISIONS › Section 109.3 - Assistants to director of nursing services

Current through Register Vol. 54, No. 28, July 13, 2024
There shall be assistants to the director for evening and
						night services and, when necessary, for day services, which assistants are
						registered professional nurses and are qualified, by experience and otherwise,
						for the responsibilities delegated to them.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › GENERAL PROVISIONS › Section 109.4 - Professional nursing staff

Current through Register Vol. 54, No. 28, July 13, 2024
A sufficient number of registered professional nurses
						shall be on duty at all times to plan, assign, supervise, and evaluate nursing
						care as well as to give patients such nursing care as requires the judgment and
						specialized skills of a registered nurse. A graduate nurse, or graduate
						practical nurse, providing care shall be under the supervision of a registered
						nurse.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › GENERAL PROVISIONS › Section 109.5 - Auxiliary nursing staff

Current through Register Vol. 54, No. 28, July 13, 2024
Licensed practical nurses and other nursing personnel
						shall be qualified by training, education, experience, and demonstrated
						abilities to give nursing care that does not require the skill and judgment of
						a registered or professional nurse. Auxiliary nursing personnel shall be
						supervised by a professional nurse.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › GENERAL PROVISIONS › Section 109.6 - Staffing schedules

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 There shall be staffing schedules reflecting actual nursing personnel required
					 for the hospital and for each patient unit, including but not limited to the
					 surgical and obstetrical suites, the outpatient unit, special care units, and
					 the emergency service unit. Staffing patterns should reflect consideration of
					 nursing goals, standards of nursing practice, and the needs of the
					 patients.
(b) Staffing schedules
					 shall accomplish the following:
(1) Staffing
					 patterns which reflect the quality and quantity of various categories of
					 nursing personnel necessary to carry out the nursing care program.
(2) Assignment of personnel in a manner which
					 minimizes the risk or cross-infections.
(3) The patient care assignment is
					 commensurate with the qualifications of each nursing staff member, the
					 identified nursing needs of the patient, and the prescribed medical
					 regimen.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › GENERAL PROVISIONS › Section 109.7 - Nursing staff qualifications

Current through Register Vol. 54, No. 28, July 13, 2024
Persons employed and classified as registered
						professional nurses or licensed practical nurses shall be licensed to practice
						in this Commonwealth. There shall be a procedure to verify the licensure status
						of all such nurses. A licensed practical nurse in charge of a patient unit must
						have satisfactorily completed a course in practical nursing which meets the
						curricula standards prescribed and approved by the State Board of Nurse
						Examiners.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › ORGANIZATIONAL PLAN › Section 109.11 - Contents and function

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A written
					 organizational plan of nursing services shall be an integral part of the
					 overall hospital organizational plan and shall be available to all nursing
					 personnel.
(b) The nursing service
					 organizational plan shall:
(1) indicate the
					 lines of communication within and between nursing services and other
					 departments;
(2) define the
					 relationship of nursing services to other services and departments of the
					 hospital, both administrative and professional; and
(3) include a written statement which defines
					 the role and responsibility of both the nursing service and the education
					 program if the hospital provides clinical facilities for the education and
					 training of nursing students.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › ORGANIZATIONAL PLAN › Section 109.12 - Role in hospital planning

Current through Register Vol. 54, No. 28, July 13, 2024
Any planning, decision making, and formulation of
						policies that affects the operation of the nursing service, the nursing care of
						patients, or the environment of patients should include nursing service
						representatives, and their recommendations should be
						considered.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › ORGANIZATIONAL PLAN › Section 109.13 - Job descriptions

Current through Register Vol. 54, No. 28, July 13, 2024
Job descriptions shall be written for each position
						classification in nursing services and shall delineate the functions,
						responsibilities, and desired qualification of each classification. Copies of
						job descriptions shall be available to nursing personnel.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › ORGANIZATIONAL PLAN › Section 109.14 - Nursing committees

Current through Register Vol. 54, No. 28, July 13, 2024
Nursing committees should be formally organized within
						the nursing department to facilitate the establishment and attainment of the
						goals and objectives of the nursing service. The purpose and function of each
						standing committee shall be defined in the nursing service organizational
						plan.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › POLICIES › Section 109.21 - Principle

Current through Register Vol. 54, No. 28, July 13, 2024
Written nursing care and administrative policies and
						procedures shall be developed to provide the nursing staff with methods of
						meeting its responsibilities and achieving goals.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › POLICIES › Section 109.23 - Written nursing care policies and procedures

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Written administrative and nursing care
					 policies shall be reviewed at least annually and revised as necessary. They
					 shall be dated to indicate the time of the most recent review.
(b) Nursing care policies and procedures
					 shall be consistent with professionally recognized standards of nursing
					 practice and shall be in accordance with The Professional Nursing Law
					 (63
					 P. S. §§
												211-225) and regulations
					 promulgated by the State Board of Nurse Examiners. These policies shall include
					 procedures for the following:
(1) Noting
					 diagnostic and therapeutic orders.
(2) Assigning the nursing care of
					 patients.
(3) Infection
					 control.
(4) Patient
					 safety.
(5) Implementing orders for
					 medication or treatment, consistent with §§
												107.61-107.65 (relating to medical
					 orders).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › POLICIES › Section 109.24 - Specialized nursing services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If
					 specialized nursing services are provided for separate medical departments,
					 those services shall be subject to the policies and procedures established
					 pursuant to this chapter.
(b) Some
					 of the departments which may utilize special nursing services are the
					 following:
Department
Chapter
emergency
117
outpatient
119
anesthesia
123
rehabilitation services
131
special care units
133
surgery
135
obstetrics
137
newborn
139
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › NURSING CARE PLANS › Section 109.31 - Principle

Current through Register Vol. 54, No. 28, July 13, 2024
There shall be evidence that the nursing service provides
						safe, efficient, and therapeutically effective nursing care through the
						planning of the care of each inpatient and the effective implementation of
						nursing care plans. In any case where it is determined that a nursing care plan
						is not necessary, that decision shall be documented in the medical
						record.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › NURSING CARE PLANS › Section 109.33 - Contents

Current through Register Vol. 54, No. 28, July 13, 2024
Each nursing care plan should, at minimum,
						indicate:
(1) what nursing care is
					 needed;
(2) how it can best be
					 accomplished;
(3) what methods and
					 approaches are believed likely to be most successful; and
(4) what modifications are necessary to
					 ensure the best results.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › NURSING CARE PLANS › Section 109.34 - Administration

Current through Register Vol. 54, No. 28, July 13, 2024
Each nursing care plan shall be initiated upon the
						admission of the patient to the hospital and should include a discharge
						plan.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › NURSING CARE PLANS › Section 109.35 - Distribution

Current through Register Vol. 54, No. 28, July 13, 2024
The nursing care plans should be available to all nursing
						personnel and should be reviewed and revised as necessary.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › NURSING CARE PLANS › Section 109.36 - Nursing notes

Current through Register Vol. 54, No. 28, July 13, 2024
Nursing records and reports which reflect the progress of
						each patient and the nursing care planned shall be maintained. They shall be
						pertinent, accurate, and concise so that they contribute to the continuity of
						patient care. Nursing records and reports shall become part of each patient's
						medical record.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › NURSING CARE PLANS › Section 109.37 - Unusual incidents

Current through Register Vol. 54, No. 28, July 13, 2024
A procedure shall be established to investigate any
						unusual incidents which occur at any time during any nursing shift. The
						procedure shall include the making and disposition of incident reports.
						Notation of incidents having a direct medical effect on a specific patient
						shall be entered in the medical record of that patient. Each report shall be
						analyzed and summarized, and corrective action shall be taken if necessary.
						Summarized reports shall be available to the Department.
This section cited in 28 Pa. Code §
													115.33 (relating to
						  entries).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › MEETINGS › Section 109.41 - Principle

Current through Register Vol. 54, No. 28, July 13, 2024
Meetings of the nursing staff shall be held at least six
						times per year in order to discuss ways of improving nursing care and nursing
						service problems and policies. Meetings may be organized by clinical department
						or service, by categories of nursing staff, or by the staff as a whole,
						consistent with the organizational plan of nursing staff.
The provisions of this § 109.41 issued under
						  67 Pa.C.S. §§
														6101-6104; and Reorganization Plan No. 2 of
						  1973 (71 P. S. §
														755-2).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › EDUCATION PROGRAM › Section 109.52 - Orientation and continuing education

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The director of nursing services or his
					 designee shall design and implement an education program to orient new employes
					 and to keep the nursing staff up-to-date on new and expanding programs,
					 techniques, equipment, and concepts of care. The program shall be planned,
					 scheduled, documented by a written outline of its contents, and evaluated at
					 least annually.
(b) The scope and
					 duration of the education program shall be such as to effectively train new and
					 existing personnel. An orientation program shall be provided for each new
					 nursing service employe.
(c) The
					 education program may be conducted using resources internal or external to the
					 hospital. Teaching material and suitable reference shall be supplied as needed
					 for each nursing unit and special care area.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › DRUG ADMINISTRATION PROCEDURES › Section 109.61 - Medication or treatment

Current through Register Vol. 54, No. 28, July 13, 2024
Medication or treatment shall be administered only upon
						written and signed orders of a practitioner and in accordance with the
						provisions of §§
											107.61-107.65 (relating to medical
						orders).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › DRUG ADMINISTRATION PROCEDURES › Section 109.62 - Administration of drugs

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
					 individual preparing a dose of medication for administration shall also
					 administer it, except as provided by subsections (b) and (c).
(b) A pharmacist may prepare intravenous
					 solutions with additives, dilute dried or concentrated injectables, or prepare
					 unit dose medications for administration by an appropriately licensed
					 individual.
(c) A physician may
					 order another individual to prepare for him injectable medicines, which he will
					 administer.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › DRUG ADMINISTRATION PROCEDURES › Section 109.63 - Self-administered drugs

Current through Register Vol. 54, No. 28, July 13, 2024
Self-administration of drugs by patients may be permitted
						as prescribed in writing by the attending practitioner.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › DRUG ADMINISTRATION PROCEDURES › Section 109.64 - Patients' own drugs

Current through Register Vol. 54, No. 28, July 13, 2024
If patients bring their own drugs to the hospital, these
						drugs shall not be administered unless the attending practitioner has written
						an order for their administration. If the drugs are not to be used, they shall
						be packaged, sealed, and returned to the patient for removal from the hospital.
						If such removal is not feasible, the drugs shall be stored and returned to the
						patient at the time of discharge. The patient shall be cautioned concerning
						outdated or distressed drugs. Controlled substances as listed in the schedule
						of controlled substances pursuant to section 4 of the act of April 14, 1972 (P.
						L. 233, No. 64) (35 P. S. §
												780-104)
						known as The Controlled Substances, Drug Device and Cosmetic Act shall not be
						returned to the patient without approval of the attending
						practitioner.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › DRUG ADMINISTRATION PROCEDURES › Section 109.65 - Recording of drugs administered

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 Each dose of drug shall be recorded in the medical record of the patient and
					 properly signed after the drugs have been administered.
(b) Any medication error or apparent drug
					 reaction shall be reported immediately to the practitioner who ordered the
					 drug. Any entry of the medication given in error or the apparent drug reaction,
					 or both, shall be properly recorded in the medical record of the patient. Any
					 adverse drug reaction shall be immediately noted on the medical record of the
					 patient in the most conspicuous manner possible, in order to notify everyone
					 treating the patient throughout the duration of his hospitalization of his drug
					 sensitivity and thereby prevent a recurrence of adverse reaction. Notification
					 of all drug sensitivities, including any apparent adverse reaction, shall be
					 sent to the physician and to the director of pharmaceutical services. Records
					 of drug sensitivities shall be retained in accordance with §
											113.23(e) 
					 (relating to records).
This section cited in 28 Pa. Code §
													113.23 (relating to
						  records).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › DRUG ADMINISTRATION PROCEDURES › Section 109.66 - Blood transfusions and intravenous medications

Current through Register Vol. 54, No. 28, July 13, 2024
When blood transfusions and intravenous medications are
						administered by nurses, they shall be administered only by professional nurses
						who have been specially trained for this duty under the Professional Nursing
						Law (63 P. S. §§
												211-225) and 49 Pa. Code Chapter 21 (relating
						to State Board of Nursing). Paramedics may be authorized to administer
						intravenous medications only under §
											117.30 (relating to emergency
						paramedic services) and Chapter 2, Subchapter A (relating to emergency medical
						technicians).
The provisions of this §
													109.66 issued under section
						  2102(g) of The Administrative Code of 1929 (71 P. S. §
														532(g)); and section 803 of
						  the Health Care Facilities Act (35 P. S. §
														448.803).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › DRUG ADMINISTRATION PROCEDURES › Section 109.67 - Disposable syringes and needles

Current through Register Vol. 54, No. 28, July 13, 2024
Disposable syringes and needles shall be maintained in
						hospital-approved locations which provide adequate security, and access shall
						be available only to authorized personnel. Provision shall be made for
						disposable syringes and needles to be destroyed or otherwise rendered unusable
						and inaccessible immediately following their use.
The provisions of this § 109.67 issued under
						  67 Pa.C.S. §§
														6101-6104; and Reorganization Plan No. 2 of
						  1973 (71 P. S. §
														755-2).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 109 - NURSING SERVICES › DRUG ADMINISTRATION PROCEDURES › Section 109.68 - Emergency drug cart or kit

Current through Register Vol. 54, No. 28, July 13, 2024
An emergency drug cart or kit shall be available,
						maintained, and used in accordance with §
											113.27 (relating to emergency
						pharmaceutical services).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 111 - DIETETIC SERVICES › GENERAL PROVISIONS › Section 111.1 - Principle

Current through Register Vol. 54, No. 28, July 13, 2024
There shall be an organized dietetic service which shall
						effectively apply the principles of the science of nutrition to the nutritional
						care of patients and the preparation of palatable and appropriate
						food.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 111 - DIETETIC SERVICES › GENERAL PROVISIONS › Section 111.2 - Organization and staffing

Current through Register Vol. 54, No. 28, July 13, 2024
The service shall be under the full-time direction of a
						person who is trained and experienced in food services administration and
						dietary management. If the director of the services is not the qualified
						dietitian, there should be an effective method of communication and a close
						working relationship between the director and dietitian.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 111 - DIETETIC SERVICES › GENERAL PROVISIONS › Section 111.3 - Dietitian

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The dietary
					 services shall have at least one qualified dietitian, either full-time,
					 part-time, or as consultant. The resume of the dietitian shall be included in
					 the personnel files. The dietitian shall have training and experience in
					 nutrition, therapeutic diets, and nutritional food service
					 management.
(b) If a consultant
					 dietitian is used, there shall be a written contract which shall clearly define
					 the responsibilities and frequency of visits of the consultant dietitian. This
					 contract, together with the dietitian's regular reports or running log of
					 services performed, shall be available for review by the surveyors of the
					 Department. The consultant dietician shall provide a minimum of four hours
					 service per week.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 111 - DIETETIC SERVICES › GENERAL PROVISIONS › Section 111.4 - Staffing pattern

Current through Register Vol. 54, No. 28, July 13, 2024
The number of personnel assigned to the dietary
						department shall be adequate to perform effectively all functions related to
						food service to meet the needs of patients. Supervisors of appropriate ability
						shall be assigned in such numbers as to provide a satisfactory span of control
						as well as to provide coverage for all hours of department
						operation.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 111 - DIETETIC SERVICES › GENERAL PROVISIONS › Section 111.5 - Patient nutritional care

Current through Register Vol. 54, No. 28, July 13, 2024
The administration of the nutritional aspects of patient
						care shall be directed by a qualified dietitian or by other appropriate persons
						such as dietetic technicians or dietetic assistants who are supervised by the
						dietitian. Observations and information pertinent to special dietetic treatment
						shall be recorded in the medical record of the patient and discussed with the
						patient and his physician, if appropriate.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 111 - DIETETIC SERVICES › GENERAL PROVISIONS › Section 111.6 - Menus

Current through Register Vol. 54, No. 28, July 13, 2024
All master menus shall be approved, dated and signed by
						the dietitian.
The provisions of this § 111.6 issued under
						  67 Pa.C.S. §§
														6101-6104; and Reorganization Plan No. 2 of
						  1973 (71 P.S. §
														755-2).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 111 - DIETETIC SERVICES › GENERAL PROVISIONS › Section 111.7 - Commercial food service

Current through Register Vol. 54, No. 28, July 13, 2024
A hospital which has a contract with an outside food
						management service shall require as a part of the contract that the company
						maintain at least the standards outlined in this chapter for the service. The
						contract shall be available for review by the surveyors.