(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 be 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
(4) The hospital
buildings and equipment shall be maintained in a good state of repair and shall
be kept clean at all times.
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 a competent
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
(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.
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
(D) regulations for
preparation of medical records;
appointment of committees, to include medical record committee (or medical
audit committee), representatives to joint conference committee and others as
(F) procedure 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. 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 seventy-five per cent of the active staff
members. Minutes and a record of attendance shall be kept.
(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.
medical records shall include proper identification data; the clinical records
shall be prepared accurately and completed promptly by physicians and shall
include sufficient information to justify the diagnosis and warrant the
treatment; doctors' orders, nurses' notes and charts shall be kept current in
an acceptable manner; all entries shall be signed by the person responsible for
(4) Medical records 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
fourteen 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.
(1) There shall be competent nurse as
director of nursing service, registered in Connecticut, who shall be
responsible to the administration for nursing service in the hospital.
(2) The ratio of patients to
registered nurses on duty throughout the hospital shall at no time exceed
thirty patients, or fraction thereof, to one registered nurse from 7 a.m. to 3
p.m.; thirty-five patients, or fraction thereof, to one registered nurse from 3
p.m. to 11 p.m.; and forty-five patients, or fraction thereof, to one
registered nurse from 11 p.m. to 7 a.m.
(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 ten patients, or fraction
thereof, to one from 7 a.m. to 3 p.m.; twelve 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.
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 and radiological services as
approved by the state department of health. Provision for surgical and
pathological services, if not available in the hospital, shall be made by
affiliation with a hospital qualified to render such services.
(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 chronic disease and
rehabilitation hospitals with more than one hundred beds, he shall serve on a
(2) The hospital
pharmacy shall be operated in compliance with all applicable state and federal
drug laws and regulations.
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 dosage.
(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
(2) Menus shall be prepared
and posted and shall meet state department of health requirements for basic
(3) Methods of
dishwashing and sanitizing, food handling and garbage disposal shall comply
with the requirements of the state department of health.
(1) The hospital shall have an adequate
laundry service. This may be provided within the hospital or purchased outside
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
(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) When a
patient ceases to breathe and has no detectable pulse or blood pressure, the
body shall be moved promptly to an otherwise unoccupied room in the same
institution pending pronouncement of death by a physician who has personally
viewed the body as required in section
7-62 of the General
Statutes. The facility shall make available a room which will provide for the
dignified holding of the body of the deceased person where it will not be
exposed to the view of patients or visitors. The room so designated may be used
for other purposes when not required for this purpose.
Emergencies. Provision shall
be made to maintain essential services during emergency situations.
(1) Adequate facilities, equipment and
qualified personnel under competent medical supervision shall be provided for
diagnostic and therapeutic procedures necessary for the care of patients with a
wide range of chronic diseases.
Provision shall be made for physical and occupational therapy and for
supervised recreational activities.
(1) Purpose. Each long-term hospital, chronic
disease hospital including state facilities shall develop an infection
prevention, surveillance, and control program which shall have as its purpose
the protection of patients and personnel from hospital-associated infections
and community-associated infections in patients admitted to the
(2) Authority. The
hospital's regulations governing the structure and function of this program
shall be approved by, and become a part of the bylaws or rules and regulations
of, the medical staff of the hospital. The authority for this program shall be
delegated to a hospital infection control committee which shall report on its
activities with recommendations on a regular basis to the medical executive
committee for its consideration and action.
(3) Committee membership. The membership of
this committee shall include physicians from each major clinical department,
representatives from the nursing service, pharmacy, laboratory, hospital
administration, inhalation and physical therapy departments; and as appropriate
a representative of the departments of central supply, dietary, laundry,
housekeeping and the local health director.
(4) Committee function. The infection control
committee shall (a) adopt working definitions of hospital associated
infections; (b) develop standards for surveillance of incidence of nosocomial
infection and conditions predisposing to infection; (c) develop a mechanism for
monitoring and reporting infections in patients and environmental conditions
with infection potential; (d) develop a mechanism for evaluation of infection
and environmental infection potential, including identification wherever
possible of hospital-associated infections and periodic review of the clinical
use of antibiotics in patient care; (e) develop control measures including
isolation policy, aseptic techniques, and a personnel health program.
(5) Chairman. The chairman of the hospital
infection control committee shall be a physician or health care professional
qualified by education or experience and with a special interest in, infection
(6) Coordinator. There
shall be an individual employed by the hospital qualified by education or
experience in infection prevention, surveillance, and control who shall conduct
these aspects of the program as directed by the hospital infection control
committee. This individual shall be directly responsible to, and be a member
of, the infection control committee. This individual shall make a monthly
report to this committee. The time allotted to this position shall be in
accordance with current national and professional standards.
(7) Meetings. The infection control committee
shall meet at least monthly. As a minimum, it shall (a) review information
obtained from day-to-day surveillance activities of the program; (b) review and
revise existing standards; (c) report to the medical executive
(8) Education. There
shall be regular in-service education programs regarding infection prevention,
surveillance, and control for all appropriate hospital personnel, documentation
of these programs shall be available to the state department of health for
(9) Records. The minutes of
the committee shall document the review and evaluation of these data and the
development and revision of measures for control of infection. These records
shall be available to the state department of health for review.