reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 101 - GENERAL INFORMATION › CIVIL RIGHTS › Section 101.165 - Ethnic language barriers

Current through Register Vol. 54, No. 28, July 13, 2024
When it is substantiated that the regular patient
						population of the hospital contains a foreign language speaking population for
						whom the language barrier constitutes a service disadvantage, the hospital
						should do all of the following:
(1)
					 Have a roster of bilingual personnel or volunteers, or both.
(2) Post bilingual signs and have other
					 printed materials, such as hospital handbooks, medical care instructions and
					 follow-up care, readily available.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 101 - GENERAL INFORMATION › BED COMPLEMENT › Section 101.172 - Patient limits

Current through Register Vol. 54, No. 28, July 13, 2024
The number of patients admitted to any area of the
						hospital shall not exceed the number for which the area is designed, equipped,
						and staffed except in cases of emergency, and then only in accordance with the
						emergency or disaster plan of the hospital.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 101 - GENERAL INFORMATION › LICENSE FEES › Section 101.181 - Principle

Current through Register Vol. 54, No. 28, July 13, 2024
License fees will be charged and collected in accordance
						with section 807 of the act (35 P. S. §
												448.807).
The provisions of this §
													101.181 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 101 - GENERAL INFORMATION › MISCELLANEOUS PROVISIONS › Section 101.191 - Multiple-clinical facilities

Current through Register Vol. 54, No. 28, July 13, 2024
A general or special hospital or medical center may
						operate any number of separate or distinct clinical facilities under its
						ownership and direct management. Such facilities may be structurally integrated
						or may be physically located elsewhere. The Department will rule on all
						requests for single licensing of multiple-clinical facilities according to
						pre-established criteria which are available from the Department. All such
						patient care facilities except physicians' offices shall be subject to
						appropriate onsite inspection and survey to determine whether there is
						compliance with applicable provisions of this subpart.
The provisions of this §
													101.191 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 101 - GENERAL INFORMATION › MISCELLANEOUS PROVISIONS › Section 101.192 - Owners or controlling persons

Current through Register Vol. 54, No. 28, July 13, 2024
A hospital shall provide the Department with a written
						list of the names and addresses of all persons having a 5.0% or more ownership
						or controlling interest in the hospital. As used in this section, "person"
						means any natural person, partnership, or corporate entity, including any
						public agency or religious, fraternal or philanthropic
						organization.
The provisions of this § 101.192 issued under
						  67 Pa.C.S. §§
														6101-6104 (Repealed); and Reorganization Plan
						  No. 2 of 1973 (71 P. S. §
														755-2)
						  (Renumbered).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 101 - GENERAL INFORMATION › MISCELLANEOUS PROVISIONS › Section 101.193 - Incorporated hospitals

Current through Register Vol. 54, No. 28, July 13, 2024
If a hospital is incorporated, it shall provide the
						Department, upon request, with a written list of the names and addresses of the
						hospital or parent corporation's officers, directors, and principal
						stockholders, either beneficial or of record.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 101 - GENERAL INFORMATION › MISCELLANEOUS PROVISIONS › Section 101.194 - Nonprofit corporation hospital

Current through Register Vol. 54, No. 28, July 13, 2024
Every hospital which is organized as a nonprofit
						corporation shall file with the Department a copy of its charter and articles
						of incorporation certified from the public record. It shall be the
						responsibility of the hospital to promptly submit to the Department a copy of
						any amendments or changes to the original charter.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 101 - GENERAL INFORMATION › MISCELLANEOUS PROVISIONS › Section 101.196 - Notice of closure

Current through Register Vol. 54, No. 28, July 13, 2024
A hospital shall give written notice of an intent to
						close to the Department, not later than 90 days prior to the anticipated date
						of closing.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › GENERAL PROVISIONS › Section 103.1 - Principle

Current through Register Vol. 54, No. 28, July 13, 2024
There shall be an organized governing body or
						  designated person vested with ownership who shall assume the full legal
						  authority and responsibility for the conduct of the hospital.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › GENERAL PROVISIONS › Section 103.3 - Governing body bylaws

Current through Register Vol. 54, No. 28, July 13, 2024
The governing body shall adopt bylaws in accordance
						  with all requirements contained in this subpart and in accordance with the
						  community responsibility of the hospital. As a minimum, the bylaws shall do the
						  following:
(1) State the general and
						specific goals of the hospital.
(2)
						Be reviewed annually, be revised as necessary, and be dated to indicate when
						last reviewed or revised.
(3)
						Describe the powers and duties of the governing body officers and committees
						and the responsibilities of the chief executive officer.
(4) State the qualifications for governing
						body membership, the procedures for selecting members, and the terms of service
						for members, officers, and committee chairmen.
(5) Describe the authority delegated to the
						chief executive officer and to the medical staff. No assignment, referral or
						delegation of authority by the governing body shall relieve the governing body
						of its responsibility for the conduct of the hospital. The governing body shall
						retain the right to rescind any such delegation.
(6) Require the approval of the bylaws of any
						auxiliary organizations established by the hospital.
(7) Require the governing body to review and
						approve the bylaws of the medical staff organization.
(8) Establish a procedure for processing and
						evaluating the applications for medical staff membership and for the granting
						of clinical privileges.
(9)
						Establish a procedure for implementing, disseminating, and enforcing a
						Patient's Bill of Rights in compliance with §§
												103.21-103.24 (relating to Patient's Bill
						of Rights).
(10) Require the
						governing body to institute procedures to ensure:
(i) orientation of newly elected board
						members to specific board functions and procedures;
(ii) periodic reexamination of the
						relationship of the board to the total hospital community.
(iii) an opportunity, at least annually, for
						the general public to attend a meeting of the governing body; this meeting
						shall be well publicized in advance of the meeting date and shall be held at a
						time convenient for attendance by the general public; and
(iv) the taking of minutes of all governing
						body and executive committee meetings and the dissemination of those minutes or
						summaries thereof on a regular basis to all members of the governing
						body.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › GENERAL PROVISIONS › Section 103.4 - Functions

Current through Register Vol. 54, No. 28, July 13, 2024
The governing body, with technical assistance and
						  advice from the hospital staff, shall do the following:
(1) Provide appropriate physical resources
						and personnel required to meet the needs of the patients and participate in
						planning to meet the health needs of the patients and health needs of the
						community. A quality control mechanism should be established which includes as
						an integral part thereof a risk management component and an infection control
						program.
(2) Formulate short-range
						and long-range plans for the development of the hospital.
(3) Take all reasonable steps to conform to
						all applicable Federal, State, and local laws and regulations.
(4) Provide for the control and use of the
						physical and financial resources of the hospital.
(5) Review the annual audit of the financial
						operations of the hospital.
(6)
						Utilize the advice of the medical staff in granting and defining the scope of
						clinical privileges to individuals. When the governing body does not concur in
						the medical staff recommendation regarding the clinical privileges of an
						individual, there should be a review of the recommendation by a joint committee
						of the medical staff and governing body before a final decision is reached by
						the governing body.
(7) Require
						that applicants be informed of the disposition of their application for medical
						staff membership or clinical privileges, or both, within a reasonable period of
						time after their application has been submitted.
(8) Require that the medical staff bylaws,
						rules, and regulations be approved by the governing body. Such approval shall
						not be withheld unreasonably.
(9)
						Delegate to the medical staff the authority to evaluate the professional
						competence of staff members and applicants for staff privileges and hold the
						medical staff responsible for recommending initial staff appointments,
						reappointments, and assignments or curtailments of privileges.
(10) Require that resources be made available
						to address the emotional and spiritual needs of patients either directly or
						through appropriate referral or arrangement with community agencies.
(11) Maintain effective communication with
						the medical staff. This may be established, inter alia, through:
(i) a joint conference committee;
(ii) service by the president of the medical
						staff as a member of the governing body with or without a vote; or
(iii) appointment of individual medical staff
						members to governing body committees.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › GENERAL PROVISIONS › Section 103.5 - Other functions

Current through Register Vol. 54, No. 28, July 13, 2024
The governing body or its designee shall do the
						  following:
(1) Develop efficient and
						practical arrangements for the provision of extended care and of other
						long-term health care services. Such services may be provided in the hospital
						or by outside resources through an effective transfer agreement. Home care
						services should be utilized whenever feasible.
(2) Provide and implement a written plan for
						the care or for the referral, or for both, of patients who are psychiatrically
						ill or who become psychiatrically ill while in the hospital, as well as for the
						care or appropriate referral, or both, of persons who suffer the results of
						alcoholism or drug abuse.
The provisions of this §
														103.5 issued under act
							 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 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › GENERAL PROVISIONS › Section 103.8 - Conflicts of interest

Current through Register Vol. 54, No. 28, July 13, 2024
Members of the governing body shall not maintain
						  substantial personal or business interests which conflict with those of the
						  hospital. All governing body members shall execute a conflict of interest
						  statement.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › GENERAL PROVISIONS › Section 103.9 - Self-dealing prohibition

Current through Register Vol. 54, No. 28, July 13, 2024
Members of the governing body shall not engage in the
						  following forms of self-dealing:
(1)
						The sale, exchange or leasing of property or services between the hospital and
						a governing board member, his employer or an organization substantially
						controlled by him on a basis less favorable to the hospital than that on which
						such property or service is made available to the general public.
(2) Furnishing of goods, services, or
						facilities by a hospital to a governing board member, unless such furnishing is
						made on a basis not more favorable than that on which such goods, services, or
						facilities are made available to the general public or employes of the
						hospital.
(3) Any transfer to or
						use by or for the benefit of a governing board member of the income or assets
						of a hospital, except by purchase for fair market value.
This section cited in 28 Pa. Code §
														105.23 (relating to transfer
							 agreements).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › GENERAL PROVISIONS › Section 103.10 - Disclosure requirements for related organizations

Current through Register Vol. 54, No. 28, July 13, 2024
The governing body shall prohibit the lease, sale or
						  exclusive use of any hospital buildings or facilities receiving a license in
						  accordance with this subpart to any entity which provides medical or other
						  health services to the hospital's patients, unless there is full, complete,
						  and, except in the case of a sale, periodic disclosure to the governing body of
						  that entity's financial assets, liabilities, and earnings distribution with
						  regard to any single hospital facility served by that entity and for which the
						  governing body is responsible.
The provisions of this §
														103.10 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. §
															480.803).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › PATIENT'S BILL OF RIGHTS › Section 103.21 - Principle

Current through Register Vol. 54, No. 28, July 13, 2024
It is the purpose of these sections to promote the
						  interests and well-being of the patients and residents of hospitals subject to
						  this subpart even in those instances where the interests of the patients may be
						  in opposition to the interests of the hospital. It is declared to be the public
						  policy of the Department that the interests of patients be protected by a
						  Patient's Bill of Rights. Nothing in these sections is intended to serve as
						  evidence of a standard of reasonable conduct for the purpose of determining
						  civil liability between providers and consumers of health services. The
						  hospital has the right to expect the patient to fulfill patient
						  responsibilities as may be stated in the hospital rules affecting patient care
						  and conduct.
The provisions of this § 103.21 issued under
							 67
							 P. S. §§
															6101-6104; and
							 Reorganization Plan No. 2 of 1973 (71 P. S. §
															755-2).
This section cited in 28 Pa. Code §
														103.3 (relating to governing body
							 bylaws).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › PATIENT'S BILL OF RIGHTS › Section 103.23 - Procedures for distribution and display

Current through Register Vol. 54, No. 28, July 13, 2024
The hospital shall develop procedures to inform each
						  patient of his rights. Copies of the hospital's Patient's Bill of Rights shall
						  be made generally available through one of the following ways:
(1) Prominent displays in appropriate
						locations in addition to copies available upon request.
(2) Provision of a copy to each patient or
						responsible party upon admission or as soon after admission as is
						feasible.
The provisions of this § 103.23 issued under
							 67 Pa.C.S. §§
															6101-6104; and Reorganization Plan No. 2 of
							 1973 (71 P. S. §
															755-2).
This section cited in 28 Pa. Code §
														103.3 (relating to governing body
							 bylaws).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › PATIENT'S BILL OF RIGHTS › Section 103.24 - Investigation and enforcement procedures

Current through Register Vol. 54, No. 28, July 13, 2024
The hospital shall adopt procedures to ensure effective
						  and fair investigation of violations of patients' rights and to ensure their
						  enforcement. These procedures shall ensure that:
(1) a system is established to identify
						formal written complaints;
(2)
						formal written complaints are recorded and investigated;
(3) complaint records and case dispositions
						are kept for one year or until the next annual survey and made available to the
						Department upon request;
(4)
						investigation and resolution, when possible, of formal complaints shall be
						timely; and
(5) disciplinary and
						remedial education procedures will be developed for members of the hospital and
						medical staff who consistently cause patient relationship problems.
This section cited in 28 Pa. Code §
														103.3 (relating to governing body
							 bylaws).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › MANAGEMENT AND ADMINISTRATION OF OPERATIONS › Section 103.31 - The chief executive officer

Current through Register Vol. 54, No. 28, July 13, 2024
The governing body shall appoint a chief executive
						  officer whose qualifications, authority, responsibilities and duties shall be
						  defined in a written statement adopted by the governing body. The chief
						  executive officer shall be responsible for the application and implementation
						  of established policies in the operation of the hospital and for providing
						  liaison among the governing body, the medical staff, and the departments of the
						  hospital.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › MANAGEMENT AND ADMINISTRATION OF OPERATIONS › Section 103.32 - Qualifications of chief executive officer

Current through Register Vol. 54, No. 28, July 13, 2024
The chief executive officer shall be qualified by
						  education and experience appropriate to the proper discharge of his
						  responsibilities. It is desirable that the chief executive officer have at
						  least a baccalaureate degree and a minimum of three years' experience in a
						  responsible administration position in a hospital or in the health care field
						  or have completed formal education in an appropriate graduate
						  program.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › MANAGEMENT AND ADMINISTRATION OF OPERATIONS › Section 103.33 - Responsibilities

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The chief
						executive officer shall be the official representative of the governing
						body.
(b) The chief executive
						officer should be responsible for:
(1)
						designation of an individual to act for him in his absence;
(2) management of the hospital, commensurate
						with the authority conferred on him by the governing body and consonant with
						its expressed aims and policies;
(3) attending all meetings of the governing
						body and appropriate meetings of the medical staff;
(4) organizing the administrative functions
						of the hospital, delegating duties, and establishing formal means of
						accountability on the part of subordinates;
(5) establishing such hospital departments as
						are indicated, providing for departmental and interdepartmental meetings and
						attending or being represented at such meetings, and appointing hospital
						departmental representatives to medical staff committees where appropriate or
						when requested to do so by the medical staff;
(6) appointing the heads of administrative
						departments;
(7) reporting to the
						governing body and to the medical staff on the overall activities of the
						hospital as well as on appropriate Federal, State, and local developments that
						affect health care in the hospital;
(8) reviewing the annual audit of the
						financial operations of the hospital;
(9) fiscal planning and financial management
						of the hospital;
(10) developing,
						in cooperation with the departmental heads and other appropriate staff, an
						overall organizational plan for the hospital which will coordinate the
						functions, services, and departments of the hospital, when possible;
						and
(11) ensuring that the
						agreements with service providers-that is, such as laundry, laboratory, and
						X-ray-specifically indicate that compliance will be maintained with applicable
						State regulations as would apply to the same services if provided directly by
						the hospital.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › MANAGEMENT AND ADMINISTRATION OF OPERATIONS › Section 103.34 - Personnel policies and practices

Current through Register Vol. 54, No. 28, July 13, 2024
The governing body, through the chief executive
						  officer, shall ensure that personnel policies and practices which adequately
						  support sound patient care are established and maintained. The policies shall
						  be reduced to writing and made available to all employes, and they shall be
						  reviewed periodically, but no less often than once every two years. The date of
						  the most recent review shall be indicated on the written policies. A procedure
						  shall be established for notifying employes of changes in the established
						  personnel policies.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › MANAGEMENT AND ADMINISTRATION OF OPERATIONS › Section 103.35 - Job descriptions

Current through Register Vol. 54, No. 28, July 13, 2024
There shall be a written job description for each type
						  of job in the hospital, including the chief executive officer and heads of
						  departments.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › MANAGEMENT AND ADMINISTRATION OF OPERATIONS › Section 103.36 - Personnel records

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Accurate and
						complete personnel records shall be maintained for each hospital employe during
						his term of employment and for 2 years thereafter. The chief executive officer
						may designate an individual to carry out this assignment.
(b) There shall be an established standard of
						content for personnel records which shall contain at least the following:
(1) Information regarding the employe's
						education, training, and experience, including, if applicable, professional
						licensure status and license number, sufficient to verify the employe's
						qualifications for the job for which he is employed. Such information shall be
						kept current. Applicants for positions requiring a licensed person should be
						hired only after obtaining verification of their licenses, records of education
						and written references.
(2) Current
						information relative to periodic work performance evaluations.
(3) Records of such pre-employment health
						examinations and of subsequent health services rendered to the employes as are
						necessary to ensure that all hospital employes are physically able to perform
						their duties.
(4) Reports verifying
						that reasonable precautions have been taken to assure the absence of detectable
						active communicable disease.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › MANAGEMENT AND ADMINISTRATION OF OPERATIONS › Section 103.38 - Education programs

Current through Register Vol. 54, No. 28, July 13, 2024
Orientation and in-service training programs should be
						  provided in order that hospital personnel may maintain their skills and learn
						  of new developments in health care.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › MANAGEMENT AND ADMINISTRATION OF OPERATIONS › Section 103.39 - Personnel health requirements

Current through Register Vol. 54, No. 28, July 13, 2024
Employes shall have preemployment medical examinations
						  and interim examinations in accordance with medically acceptable
						  criteria.
The provisions of this § 103.39 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 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › FISCAL CONTROL › Section 103.41 - Principle

Current through Register Vol. 54, No. 28, July 13, 2024
A budget shall be developed with the participation of
						  appropriate staff. There should be departmental budgets which are related to
						  the objectives of the department and to the budgetary program of the
						  hospital.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › FISCAL CONTROL › Section 103.42 - Rates

Current through Register Vol. 54, No. 28, July 13, 2024
A current written schedule of rates and charges for all
						  hospital services for which charges are assigned shall be maintained and made
						  available upon request to those who use those services.
The provisions of this § 103.42 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 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › FISCAL CONTROL › Section 103.43 - Insurance

Current through Register Vol. 54, No. 28, July 13, 2024
There should be an insurance program which provides for
						  the protection of the physical and financial resources of the hospital. There
						  should be appropriate coverage of the buildings and equipment and adequate
						  comprehensive liability insurance or an equivalent self-insurance plan covering
						  members of the governing body and appropriate medical and administrative
						  personnel.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › FISCAL CONTROL › Section 103.44 - Purchasing and inventory

Current through Register Vol. 54, No. 28, July 13, 2024
There shall be written policies governing the control
						  of inventories, including purchasing procedures, product selection and
						  evaluation, and supply distribution. Records shall be maintained from annual
						  survey to annual survey documenting compliance with these established
						  policies.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › FISCAL CONTROL › Section 103.45 - Audit of financial operations

Current through Register Vol. 54, No. 28, July 13, 2024
An audit of the financial operations of the hospital
						  should be performed by an independent public accountant at least once a
						  year.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 103 - GOVERNANCE AND MANAGEMENT › Subchapter A - GOVERNING PROCESS › FISCAL CONTROL › Section 103.46 - Equipment and supplies

Current through Register Vol. 54, No. 28, July 13, 2024
The hospital shall provide all necessary equipment and
						  supplies to meet the needs of the services it undertakes to
						  provide.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 105 - ADMISSION AND DISCHARGE › GENERAL › Section 105.1 - Principle

Current through Register Vol. 54, No. 28, July 13, 2024
The hospital shall have written policies for the
						admission, discharge, and proper referral of all patients who present
						themselves for care. Criteria should specify additional approaches to assure
						appropriate utilization of hospital resources such as preadmission testing,
						ambulatory care programs and short-term procedure units.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 105 - ADMISSION AND DISCHARGE › ADMISSION › Section 105.11 - Access

Current through Register Vol. 54, No. 28, July 13, 2024
(a) No person
					 seeking necessary medical care from the hospital shall be denied such care for
					 reasons not based on sound medical practice or the hospital's charter and,
					 particularly, no such person shall be denied such care on account of race,
					 creed, color, religion, sex or sexual preference, in accordance with the
					 provisions of the Pennsylvania Human Relations Act (43 P.S. §§
												951-963).
(b) When the hospital does not provide the
					 services required by a patient or a person seeking necessary medical care, an
					 appropriate referral shall be made. No hospital shall be required to make any
					 referral which is contrary to its stated ethical policy promulgated in
					 accordance with 16 Pa. Code §
											51.31 (relating to adoption and
					 substance of a stated ethical policy).
(c) Care shall be provided in a
					 nondiscriminatory manner.
(d) Those
					 facilities having an obligation under
					 42 U.S.C.A. §
												291 shall comply with the provisions of that
					 Act as it relates to free and low-cost care.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 105 - ADMISSION AND DISCHARGE › ADMISSION › Section 105.12 - Admission criteria

Current through Register Vol. 54, No. 28, July 13, 2024
The governing body, with the advice of and in conjunction
						with the medical staff, shall establish medical criteria for admissions to
						ensure provision of care based on medical necessity and
						appropriateness.
This section cited in 28 Pa. Code §
													141.23 (relating to medical
						  appraisal of dental patients); and 28 Pa. Code §
													143.4 (relating to medical
						  appraisal of a podiatric patient).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 105 - ADMISSION AND DISCHARGE › ADMISSION › Section 105.13 - Alternate admissions arrangements

Current through Register Vol. 54, No. 28, July 13, 2024
When, according to established criteria and the opinion
						of the attending physician, a patient requires inpatient care but, for any
						reason, cannot be admitted to the hospital, the hospital or attending
						physician, or both, should assist the patient in making arrangements for care
						in an alternate facility so as not to jeopardize the health and safety of the
						patient.
This section cited in 28 Pa. Code §
													141.23 (relating to medical
						  appraisal of dental patients); and 28 Pa. Code §
													143.4 (relating to medical
						  appraisal of a podiatric patient).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 105 - ADMISSION AND DISCHARGE › ADMISSION › Section 105.14 - Admission diagnosis

Current through Register Vol. 54, No. 28, July 13, 2024
Each patient who is admitted shall be given a provisional
						diagnosis, entered on the clinical record, at the time of
						admission.
This section cited in 28 Pa. Code §
													141.23 (relating to medical
						  appraisal of dental patients); and 28 Pa. Code §
													143.4 (relating to medical
						  appraisal of a podiatric patient).
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 105 - ADMISSION AND DISCHARGE › ADMISSION › Section 105.15 - Patient identification

Current through Register Vol. 54, No. 28, July 13, 2024
At the time of admission or as soon as possible
						thereafter, each patient shall be fitted with an identification band or other
						visible means of identification.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 105 - ADMISSION AND DISCHARGE › DISCHARGE › Section 105.22 - Discharge planning

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Discharge
					 planning shall be an integral part of the hospitalization of each patient and
					 shall commence as soon as possible after admission. When the hospital
					 determines no discharge planning is necessary in a particular case, that
					 conclusion shall be noted on the medical record of the patient.
(b) The hospital shall have written policies
					 governing discharge planning. These shall include but need not be limited to
					 the following:
(1) Appropriate referral and
					 transfer plans.
(2) Methods to
					 facilitate the provision of follow-up care.
(3) Information to be given to the patient or
					 his family or other persons involved in caring for the patient on matters such
					 as the patient's condition; his health care needs; the amount of activity he
					 should engage in; any necessary medical regimens including drugs, diet, or
					 other forms of therapy; sources of additional help from other agencies; and
					 procedures to follow in case of complications. This information should be
					 provided by the attending physician.
(4) Procedures for assisting the patient and
					 his family in gaining information regarding financial assistance in paying
					 bills incurred as a result of the hospitalization. The procedures shall specify
					 how the patient is to be informed where relevant information can be obtained,
					 how relevant hospital information is to be made available in a timely and
					 useful manner, and how the hospital will affirmatively inquire into the
					 eligibility of the patient for assistance from the various Federal and State
					 government programs, for example, Medicare, Medicaid, Hill-Burton.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 105 - ADMISSION AND DISCHARGE › DISCHARGE › Section 105.23 - Transfer agreements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Any
					 hospital which does not provide extended care, subacute care, long-term care,
					 or intermediate care shall maintain, to the extent possible, written agreements
					 with institutions offering these kinds of care. Such agreements shall provide
					 for the prompt transfer and admission of patients who no longer require the
					 services of the hospital but do require one of the aforementioned kinds of
					 institutional care.
(b) The
					 hospital shall have written policies, adopted by the governing body,
					 prohibiting transfer agreements which violate the provisions of §
											103.9 (relating to conflicts of
					 interest) or which could jeopardize the health of patients.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 105 - ADMISSION AND DISCHARGE › DISCHARGE › Section 105.24 - Discharge by transfer

Current through Register Vol. 54, No. 28, July 13, 2024
A patient shall not be transferred to another medical
						care facility unless prior arrangements for admission have been made. Clinical
						records of sufficient content to insure continuity of care shall accompany the
						patient.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 105 - ADMISSION AND DISCHARGE › DISCHARGE › Section 105.25 - Discharge of minor or incompetent patient

Current through Register Vol. 54, No. 28, July 13, 2024
Any individual who cannot legally consent to his own care
						shall be discharged only to the custody of parents, legal guardian, person
						standing
in loco parentis,
or another responsible party unless
						otherwise directed by the parent or guardian or court of competent
						jurisdiction. If the parent or guardian directs that discharge be made
						otherwise, he shall so state in writing, and the statement shall become a part
						of the permanent medical record of the patient.
The provisions of this § 105.25 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 › GENERAL PROVISIONS › Section 107.1 - Principle

Current through Register Vol. 54, No. 28, July 13, 2024
There shall be an organized medical staff which is
						accountable to the governing body and which has responsibility for the quality
						of all medical care provided to patients and for the ethical conduct and
						professional practice of its members.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › GENERAL PROVISIONS › Section 107.2 - Medical staff membership

Current through Register Vol. 54, No. 28, July 13, 2024
The medical staff shall be limited to physicians and
						dentists who have made application in accordance with the bylaws, rules, and
						regulations of the medical staff and with the bylaws of the hospital. Each
						member of the medical staff shall be qualified for membership and the exercise
						of clinical privileges granted to him. The medical staff must define in bylaws
						the requirements for admission to staff membership and for the delineation and
						retention of clinical privileges. The governing body of the hospital, after
						considering the recommendations of the medical staff, may grant clinical
						privileges to other qualified, licensed practitioners in accordance with their
						training, experience, and demonstrated competence and judgment. Members of the
						medical staff and those granted clinical privileges shall currently hold
						licenses to practice in this Commonwealth.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › GENERAL PROVISIONS › Section 107.3 - Requirements for membership and privileges

Current through Register Vol. 54, No. 28, July 13, 2024
(a) In order to receive favorable
					 recommendation for appointment or reappointment, members of the medical staff
					 must always act in a manner consistent with the highest ethical standards and
					 levels of professional competence.
(b) Privileges granted shall be commensurate
					 with an individual's qualifications, experience, and present
					 capabilities.
(c) No applicant
					 shall be denied medical staff privileges on the basis of sex, race, creed,
					 color, or national origin or on the basis of any other criterion lacking
					 professional or ethical justification, including association with a prepaid
					 group practice.
Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part IV - Health Facilities › Subpart B - General and Special Hospitals › Chapter 107 - MEDICAL STAFF › GENERAL PROVISIONS › Section 107.5 - Membership appointment and reappointment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The governing body shall affirm or refuse
					 the appointment of any physician or dentist to the medical staff or the
					 granting of clinical privileges to any practitioner after considering the
					 recommendation of the active medical staff in accordance with the procedure
					 established pursuant to subsection (b).
(b) Formal application for membership and for
					 granting of clinical privileges shall follow established procedures set forth
					 in the bylaws, rules and regulations of the medical staff. These procedures
					 shall provide the following:
(1) A written
					 record of the application, which shall include the scope of privileges sought
					 and granted.
(2) A review,
					 summarized on record with appropriate documentation, of the qualifications of
					 the applicant.
(3) A reasoned
					 statement, in writing, by the medical staff recommending or declining to
					 recommend the applicant.
(4)
					 Written notice to the applicant of the recommendation of the medical staff,
					 including notice of an applicant's right to a hearing and reexamination before
					 the medical staff or the governing body, or both.
(5) A review by a joint committee of the
					 active medical staff and the governing body in cases where the governing body
					 does not concur in the medical staff's recommendation regarding the granting or
					 refusing of clinical privileges. Such review shall occur prior to the rendering
					 of a final decision by the governing body.
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 107.11 - Principle

Current through Register Vol. 54, No. 28, July 13, 2024
The medical staff shall develop and adopt, subject to the
						approval of the governing body, a set 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 › MEDICAL STAFF BYLAWS, RULES AND REGULATIONS › Section 107.12 - Content of bylaws, rules and regulations

Current through Register Vol. 54, No. 28, July 13, 2024
The medical staff bylaws, rules and regulations shall
						provide for at least the following:
(1)
Organizational
					 structure.
The organizational structure of the medical staff,
					 consistent with §§
											107.21-107.26 (relating to organization
					 of the medical staff) shall be delineated.
(2)
Staff privileges.
Qualifications for staff membership shall be specified, as shall procedures for
					 admission, retention, assignment and reduction or withdrawal of privileges.
					 This delineation of privileges shall also address specifically the privileges
					 of house staff and house staff officers.
(3)
Credentials review.
The
					 bylaws shall establish procedures and standards whereby staff credentials will
					 be reviewed.
(4)
Appeals.
The bylaws shall provide for the establishment of
					 fair hearing and appellate review mechanisms, which will be available if
					 requested by the practitioner in connection with medical staff recommendations
					 for denial of staff appointments, as well as the denial of reappointments, or
					 the curtailment, suspension or revocation of privileges. It is recognized that
					 the mechanism for individuals applying for initial medical staff appointments
					 or privileges may differ from that which is applicable to medical staff
					 members.
(5)
Nonphysician
					 clinical privileges and duties.
Clinical privileges and duties of
					 specified professional personnel, as defined in paragraph (14), as well as
					 responsibilities of the physician members of the medical staff in relation to
					 specified professional personnel, shall be delineated and approved by the
					 medical staff.
(6)
Ethics.
The bylaws shall require each member of the medical
					 staff and applicant for staff membership to state in writing that:
(i) He may not rebate a portion of a fee or
					 accept other inducements in exchange for a patient referral.
(ii) He may not deceive a patient as to the
					 identity of an operating surgeon, or another medical practitioner providing
					 treatment or services.
(iii) He may
					 not delegate the responsibility for diagnosis or care of hospitalized patients
					 to another medical practitioner unless he believes the practitioner to be
					 qualified to undertake this responsibility.