West Virginia Code of State Rules › Agency 64 - Health › Title 64 - LEGISLATIVE RULE WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES › Series 64-12 - Hospital Licensure › Section 64-12-4 - Administration of the Hospital

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1.
				Governing Authority.
4.1.1. The governing
				authority or owner is the highest authority responsible for the management and
				control of the hospital including employment of a hospital administrator, a
				licensed nursing home administrator when applicable and appointment of medical
				staff. The administrator is responsible for the direction and control of the
				hospital operation in accordance with policies established by the governing
				authority. The medical staff is responsible for the quality of medical care
				provided and for submitting reports on the quality of this care to the
				governing body of the hospital at defined intervals.
4.1.2. The governing authority is legally
				responsible for the management and control of the hospital. In the discharge of
				its duties, the governing authority exercises its responsibility for the care
				of patients through the medical staff. The governing authority is responsible
				for the establishment of policies and compliance with the requirements of this
				rule.
4.1.3. The governing
				authority shall adopt bylaws, subject to amendment, which require it to:
4.1.3.a. Appoint members to the medical
				staff;
4.1.3.b. Approve the bylaws
				and regulations of the medical staff;
4.1.3.c. Define the committees of the
				governing authority and their functions and responsibilities;
4.1.3.d. Develop and maintain a formal
				liaison with the medical staff;
4.1.3.e. Appoint a full-time administrator
				and delegate to him or her executive authority and responsibility;
4.1.3.f. Maintain an up-to-date file of all
				medical and ancillary staff licensed, registered, or certified by the
				appropriate agency of the state;
4.1.3.g. Provide for the proper control of
				all assets and funds, including requiring annual audits;
4.1.3.h. Provide for an assessment of all
				hospital clinical departments and functions provided directly or under contract
				through review and approval of the hospital's quality improvement reports at
				intervals defined by the governing body, but at least yearly;
4.1.3.i. Determine the scope of services to
				be offered by the hospital; and
4.1.3.j. Ensure the hospital is meeting all
				state requirements, inclusive of certificate of need, for the addition or
				termination of services, and notification of the Department of Health, Office
				of Health Facility Licensure and Certification of the addition or termination
				of services.
4.1.4. The
				governing authority shall record, sign, and retain in the hospital as a
				permanent record minutes of all of its meetings and the meetings of all of its
				committees, including a record of attendance for a minimum of five
				years.
4.1.5. The governing
				authority shall ensure for the provisions of a safe physical plant, equipped,
				and staffed to maintain adequate facilities and services for hospital
				patients.
4.1.6. The governing
				authority shall ensure there is a system in place to prevent, control,
				investigate, and resolve, through appropriate actions, infections, and
				communicable diseases within the hospital.
4.1.7. The governing authority is responsible
				for the effective operation of the patient grievance process.