6 CCR 1011-1 Chapter 22, pt. 3 - [Effective 3/17/2025] GOVERNING BODY
3.1 The birth
center shall have an organized governing body.
3.2 The governing body shall be responsible
for:
(A) Overseeing the overall operation and
management of the facility.
(B)
Ensuring that adequate facilities, personnel, and services necessary for the
welfare and safety of the clients are provided.
(C) Delineating the structure, membership,
and operation of the governing body in written policy, including, but not
limited to, requirements that the governing body:
(1) Meets at least annually and maintains
accurate records of such meetings; and
(2) Adopts administrative and operational
by-laws in accordance with legal requirements that include the facility's
organizational structure with lines of authority and responsibility.
3.3 In order to provide
for the overall operation and management of the facility as set forth in Part
3.2(A), the governing body shall:
(A) Define
the scope of the services provided by the facility.
(B) Ensure the development of and approve job
descriptions that delineate functional responsibilities and authority for each
employee position. Administrator and clinical director job descriptions shall
include, but not be limited to policy development, recommendation, and
implementation responsibilities.
(C) Appoint an individual or individuals, in
writing, as follows:
(1) An administrator
responsible for the day-to-day operation of the facility and fulfilling the
administrator requirements in Part 4.
(2) A clinical director with authority,
responsibility, and accountability for clinical services provided at the
facility and for fulfilling the clinical director responsibilities in Part 5.
The appointed clinical director shall be a clinical provider, as defined in
Part 2.7 of these rules, and have the necessary professional scope of practice,
as regulated under Title 12 of the Colorado Revised Statutes, to supervise the
facility's clinical providers.
(3)
The governing body may appoint a single individual to the roles in this Part
3.3(C) or may appoint separate individuals, as appropriate for the size,
structure, and operation of the birth center.
(D) Review and approve written policies and
procedures for the operation of the facility at least annually to ensure they
are consistent with current professional standards and statutory and regulatory
requirements.
(E) Review and
approve written personnel policies developed in accordance with Part
6.2(A).
(F) Maintain an effective
quality management program in accordance with
6 CCR
1011-1, Chapter 2, Part 4.
3.4 In order to ensure the provision of
adequate facilities, personnel, and services necessary for the welfare and
safety of the clients as set forth in Part 3.2(B), the governing body shall:
(A) Ensure the facility and its equipment
comply with the requirements of this chapter and are available 24 hours per
day, 7 days per week.
(B) Review
and approve the facility's clinical policies and procedures, as recommended by
the clinical director in accordance with Part 5.2.
(C) Ensure the development and maintenance of
a written emergency preparedness plan for the emergency care or relocation of
clients based on emergencies identified through an annual evaluation of all
hazards relevant to the facility. The evaluation of hazards shall include, but
is not limited to, the following natural and human-caused crises: fire(s); gas
leaks or explosions; power or other utility outages; equipment malfunction;
tornado(s); flooding; threatened or actual acts of violence; and bioterror,
pandemic, or disease outbreak events.
(D) Ensure a written plan is developed,
approved, and implemented for emergent and non-emergent transport of clients to
a hospital. At a minimum, such plan shall meet the requirements at Part 9.1 of
these rules and be reviewed annually.
(E) Ensure that staff perform the following
drills:
(1) Emergency evacuation drills per
the emergency preparedness plan developed in 3.4(C), at least semiannually;
and
(2) Emergency medical drills at
least quarterly.
(F)
Approve infection control policies and procedures developed by the clinical
director or delegated committee of clinical providers in accordance with Part
5.2 to ensure the adequate investigation, control, and prevention of
infections. The policies and procedures shall reflect a nationally recognized
standard and reflect the scope and complexity of services provided by the
facility.
(G) Appoint and
delineate, in writing, clinical privileges for each individual clinical
provider and auxiliary or contracted staff member based upon recommendations by
the clinical director or delegated committee of clinical providers in
accordance with Part 5.2(B) of these rules and commensurate with the
individual's qualifications, experience, and present capabilities.
(1) Approved clinical privileges for any
clinical provider, auxiliary staff member, or contracted clinical staff member
who is licensed, certified, or registered under Title 12 of the Colorado
Revised Statutes shall not exceed the individual's regulated professional scope
of practice.
(2) Approved clinical
privileges for birth assistants shall ensure the birth assistant serves in a
support role to a clinical provider and that they not have the authority to act
as an independent practitioner within the facility.
(3) Approved clinical privileges shall not
exceed the scope of services provided by the facility, regardless of an
individual's regulated scope of practice.
(H) Ensure that all contracts are reviewed,
revised as necessary, and approved annually.
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