Conn. Agencies Regs. § 19-13-D4a - Short-term hospitals, Children's General

(a) Physical plant.
(1) The hospital buildings shall be of sound construction and shall provide adequate space and equipment for patient accommodations and for service and other areas, in accordance with the requirements of the state department of health. Properly equipped diagnostic and therapeutic facilities shall he provided.
(2) The hospital buildings and equipment shall meet the requirements of the state fire safety code. (Reg. 29-40-1 et seq.) Annual application for a license shall be accompanied by a certificate of inspection by the local fire marshal.
(3) Areas in which explosive gases are used, and areas in which radioactive materials are used, shall meet the requirements of the state department of health for adequate protection of patients and personnel.
(4) The hospital buildings and equipment shall be maintained in a good state of repair and shall be kept clean at all times.
(b) Administration. (1) The hospital shall be managed by a governing board whose duties shall include, as a minimum:
(A) Adoption of bylaws, rules and regulations, including medical staff bylaws;
(B) annual appointment of the medical staff;
(C) appointment of an administrator who shall he qualified as a result of the completion of postgraduate training approved by the Association of University Programs in Hospital Administration or three years experience as an assistant administrator under an administrator whose qualifications for such training are approved by the public health council;
(D) establishment of a joint conference committee composed of an equal number of representatives of the governing board and of the medical staff, and the administrator of the hospital. (2) The administrator shall be responsible to the governing board for the management and operation of the hospital and for the employment of personnel. He shall attend meetings of the governing board and meetings of the medical staff and shall be a member of the joint conference committee. (3) Personnel shall be employed in sufficient numbers and of adequate qualifications that the functions of the hospital may be performed efficiently.
(c) Medical staff.
(1) There shall be an organized medical staff of not fewer than five physicians, one of whom shall serve as a chief or president of the medical staff.
(2) The medical staff shall adopt written rules and regulations governing its own activities, subject to approval by the governing board of the hospital. As a minimum, these shall include:
(A) Method of control of privileges granted to members of the medical staff;
(B) method of control of clinical work;
(C) provision for regular staff conferences;
(D) regulations for preparation of medical records;
(E) appointment of committees to include medical record committee (or medical audit committee), representatives to joint conference committee and others as necessary;
(F) procedures for recommending appointments to the medical staff and for hearing complaints regarding the conduct of members and referring the same, with recommendations, to the governing board. (3) Medical staff conferences shall be held once each month or more frequently. If all clinical groups hold departmental conferences at least monthly, general staff conferences may be less frequent but there shall be a minimum of four each year, and each physician on the active staff shall be required to attend a minimum of ten departmental or general staff meetings or a combination thereof each year. Conferences shall be planned to implement improved service to patients and shall be devoted primarily to thorough review and analysis of clinical work and discussion of interesting cases. All meetings shall be attended by at least fifty percent of the active staff members. Minutes and a record of attendance shall be kept. (4) Qualifications of certain department heads: (A) If surgery is performed in the hospital, there shall be a department of surgery under the overall direction of a chief who shall be responsible for supervising the quality of all surgical procedures performed. Such chief shall be a physician qualified on the basis of postgraduate approved training or equivalent experience or a combination of both; (B) if surgery is performed, there shall be a department of anesthesiology under the overall direction of a chief who shall be responsible for supervising the adequacy of anesthesia given. Such chief shall be a physician qualified on the basis of approved postgraduate training or equivalent experience or a combination of both; (C) there shall be departments of pathology, pediatrics and radiology, each of which will be under the overall direction of a chief who shall be responsible for supervising the quality of service given. Such chief shall be a physician qualified on the basis of postgraduate approved training or experience, or a combination of both; (D) Psychiatric services: When there is an inpatient psychiatric service there shall be a department of psychiatry under the overall supervision of a chief who shall be a physician qualified on the basis of certification by the American Board of Psychiatry or with sufficient postgraduate psychiatric residency training or experience or combination thereof to be eligible to take the examinations of that board. In addition to record requirements specified for general hospitals, the medical records for psychiatric patients shall also include a psychiatric examination recorded within seven days of admission of the patient. The ratio of registered nurses and other nursing personnel on duty shall conform to the requirements in the rest of the hospital, provided where possible there shall be at least one nurse with specialized psychiatric experience and provided there shall not be less than one registered nurse or one licensed practical nurse on duty at all times on the service. If the nurse in charge is a licensed practical nurse, such nurse shall have had specialized psychiatric training. There shall be available a qualified social worker, a qualified psychologist and at least one activity worker, preferably a registered occupational therapist wherever possible. Statistical reports of psychiatric admissions and discharges and any sudden deaths shall be made to the department of mental health.
(d) Medical records.
(1) There shall be a medical record department with adequate space, equipment and qualified personnel, to include at least one registered record librarian or a person with equivalent training and experience, in a hospital of one hundred beds or over.
(2) A medical record shall be started for each patient at the time of admission with complete identification data and a nurse's notation of condition on admission. To this shall be added immediately an admission note and orders by the attending or a resident physician. A complete history and physical examination shall be recorded by the physician within twenty-four hours of admission and always before surgery, except in cases of unusual emergency.
(3) All medical records shall include proper identification data; the clinical records shall be prepared accurately and completed promptly by the physicians and shall include sufficient information to justify the diagnosis and warrant the treatment; doctor's orders, nurse's notes and charts shall be kept current in an acceptable manner; all entries shall be signed by the person responsible for them.
(4) Medical records other than nurse's notes shall be filed in an accessible manner in the hospital and shall be kept for a minimum of twenty-five years after discharge of patients, except that original medical records may be destroyed sooner if they are microfilmed by a process approved by the state department of health.
(5) Medical records shall be completed within thirty days after discharge of the patient except in unusual circumstances which shall be specified in the medical staff rules and regulations. Persistent failure by a physician to maintain proper records of his patients, promptly prepared and completed, shall constitute grounds for suspending or withdrawing his medical staff privileges.
(6) For patients transferred to a nursing home a transcript of the medical examination and a summary of significant laboratory and x-ray findings, diagnosis and suggested treatment shall accompany the patient.
(e) Nursing service.
(1) There shall be a competent nurse as director of nursing service, registered in Connecticut, with specialized training or experience in pediatric nursing, who shall be responsible to the administrator for nursing service in the hospital.
(2) The ratio of patients to registered nurses on duty on an individual nursing unit shall be one to twenty patients or fraction thereof.
(3) The ratio of patients to all nursing staff, registered nurses, licensed practical nurses and other nursing attendants on duty in the hospital shall not exceed seven patients, or fraction thereof, to one from 7 a.m. to 3 p.m., seven patients, or fraction thereof, to one from 3 p.m. to 11 p.m., and fifteen patients, or fraction thereof, to one from 11 p.m. to 7 a.m.
(f) Diagnostic and therapeutic facilities. Facilities, equipment and qualified personnel, under competent medical supervision, shall be provided for necessary diagnostic and therapeutic procedures, adequate for the needs of the hospital. These shall include, as a minimum, a clinical laboratory, pathology services, a radiology department and an operating room.
(g) Pharmacy. (1) There shall be a competent pharmacist, registered in Connecticut, who shall be responsible to the administrator for all pharmaceutical services in the hospital. In general and special hospitals of one hundred beds or more, he shall serve on a full-time basis. (2) The hospital pharmacy shall be operated in compliance with all applicable state and federal drug laws and regulations. (3) The premises shall be kept clean, adequately lighted, and ventilated, and the equipment and facilities necessary for compounding, dispensing, manufacturing, producing or processing of drugs shall be maintained in good order. (4) Drugs used in the hospital shall meet standards established by the United States Pharmacopeia, The National Formulary or the Federal Food and Drug Administration and shall be stored and kept so as to insure their proper purity and strength. A medical staff pharmacy committee in conference with the pharmacist shall formulate policies to control the administration of toxic or dangerous drugs with specific reference to the duration of the order and the dosage.
(h) Dietary Service.
(1) Adequate space, equipment and qualified personnel shall be provided to ensure proper selection, storage, preparation and serving of regular and special diets to patients at regularly scheduled hours.
(2) Menus shall be posted and shall meet state department of health requirements for basic nutritional needs.
(3) Methods of dishwashing and sanitizing, food handling and garbage disposal shall comply with the requirements of the state department of health.
(i) General.
(1) The hospital shall have an adequate laundry service. This may be provided within the hospital or purchased outside the hospital.
(2) Adequate housekeeping and maintenance services shall be provided.
(3) Proper heat, hot water, lighting and ventilation shall be maintained at all times.
(4) There shall be a system of communication sufficient to meet the needs of the hospital.
(5) Other departments, professional and service, shall be provided as necessary to the size and scope of the hospital.
(6) The management, personnel, equipment, facilities, sanitation and maintenance of the hospital shall be such as reasonably to ensure the health, comfort and safety of the patients at all times.
(7) Reports of suicides or accidents or injuries which may result in a permanent defect, scar or handicap shall be made to the state department of health within twenty-four hours.
(j) Emergencies. Provision shall be made to maintain essential services during disaster and similar emergency situations.

Notes

Conn. Agencies Regs. § 19-13-D4a
Effective April 4, 1972; Amended August 27, 2004

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