Conn. Agencies Regs. § 19-13-D5 - Long-term hospitals: Chronic disease hospital

(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 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 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 a competent hospital administrator;
(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) 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.
(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 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 them.
(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.
(e) Nursing service.
(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.
(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 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.
(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 chronic disease and rehabilitation hospitals with more than one hundred beds, 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 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 prepared and 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) 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.
(j) Emergencies. Provision shall be made to maintain essential services during emergency situations.
(k) Special conditions.
(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.
(2) Provision shall be made for physical and occupational therapy and for supervised recreational activities.
(l) Infection control.
(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 hospital.
(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 control.
(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 committee.
(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 review.
(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.

Notes

Conn. Agencies Regs. § 19-13-D5
Effective December 1, 1977

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