Sec. 175-9-006 - STANDARDS OF OPERATION, CARE AND TREATMENT

§ 175-9-006. STANDARDS OF OPERATION, CARE AND TREATMENT

175 NAC 9-006.01 through 006.08 and 9-006.14 apply to the following hospitals: general acute, critical access, long-term care, psychiatric or mental and rehabilitation unless specified otherwise. Each hospital must organize, manage and administer resources to promote the attainment of its objectives and purposes, and in a manner consistent with its size, resources, and particular needs to ensure each patient receives the necessary service, care, and treatment. The major organizational divisions in each hospital must include a governing authority, an administration and a medical staff. In addition, the basic organization, responsibility and operation of each hospital must be described in a set of governing instruments which will vary with the form of organization but which must include a constitution or articles of incorporation, bylaws and medical staff bylaws. The governing instruments must describe the makeup of the governing authority, the terms of office and method of election or appointment and removal of governing authority members and officers, and the responsibilities of governing authority members, officers and standing committees.

006.01 Governing Authority

Each hospital must have a governing authority that oversees and establishes the policy direction for the hospital. The governing authority meets at regular, stated intervals and at other times necessary for proper operation of the hospital and keeps written minutes of its meetings and actions.

9-006.01A The governing authority responsibilities include:

1. Monitoring policies to assure appropriate administration and management of the facility;

2. Maintaining the hospital's compliance with all applicable state statutes and relevant rules and regulations;

3. Ensuring the quality of all services, care and treatment provided to patients whether those services, care or treatment are furnished by hospital staff or through contract with the hospital;

4. Designating an administrator who is responsible for the day to day management of the hospital;

5. Defining the duties and responsibilities of the administrator in writing;

6. Notifying the Department in writing within five working days when a vacancy in the administrator position occurs, including who will be responsible for the position until another administrator is appointed;

7. Notifying the Department in writing within five working days when the administrator vacancy is filled indicating effective date and name of person appointed administrator;

8. Determining which categories of practitioners are eligible candidates for appointment to the medical staff;

9. Ensuring that under no circumstances is the accordance of medical staff membership or clinical privileges in the hospital dependent solely upon certification, fellowship or membership in a specialty body or society although Board certification can be one permissible criterion;

10. Appointment and reappointment of medical staff members and delineating their clinical privileges, according to the procedures for credentials review established by the medical staff and approved by the governing authority;

11. In collaboration with the medical staff, establishing criteria for membership on the medical staff or clinical privileges;

12. Rendering within a fixed period of time the final decision regarding medical staff recommendations for denial of staff appointments and reappointments, as well as for the denial, limitation, suspension or revocation of privileges.

There must be a mechanism provided in the medical staff bylaws, rules and regulations for review of decisions, including the right to be heard when requested by the practitioner;

13. Ensuring the medical staff is accountable to the governing authority for the quality of medical care and treatment;

14. Ensuring a medical staff committee and a utilization review committee are formed and operated for the purpose of reviewing the medical and hospital care provided and the use of hospital resources to assist individual physicians, administrators and nurses in maintaining and providing a high standard of medical and hospital care and promoting the efficient use of the hospital;

15. Ensuring that any person engaged in work in or about the hospital and having any information or knowledge relating to the medical and hospital care provided or the efficient use of the hospital facilities, provides all related facts and information to the hospital medical staff committee or utilization review committee upon request by the committee(s). Such facts and information include, for example, medical records, quality assurance records, pharmacy records, observations or personal knowledge, and other similar information and documents related to the care and treatment provided by the hospital and the efficient use of its facilities.

16. Periodically reviewing reports and recommendations regarding all Quality Assurance/Performance Improvement activities and Medical Staff and Utilization Review Committee reports. Reports must be utilized to implement programs and policies to maintain and improve the quality of patient care and treatment;

17. Establishing a means for liaison and communication between the governing authority, the medical staff and administration and promote effective communication and coordination of services among the various hospital departments, administration and the medical staff;

18. Approving the organization, bylaws, rules and regulations, and policies and procedures of the medical staff and the departments in the hospital;

19. Establishing visitation policies which are in the best interest of patients, including, but not limited to, protection from communicable diseases, protection from exposure to deleterious substances and hazardous equipment and assurance of health and safety of patients; and

20. Determining if emergency medical technician-intermediates or emergency medical technician-paramedics may perform activities within their scope of practice as either an employee or volunteer within the hospital.

9-006.01B Administration: The administrator is responsible for planning, organizing, and directing the day to day operation of the hospital. The administrator must report and be directly responsible to the governing authority in all matters related to the maintenance, operation, and management of the hospital. The administrator's responsibilities include:

1. Being on the premises a sufficient number of hours to permit adequate attention to the management of the hospital;

2. Providing for the protection of patients' health, safety, and well-being;

3. Maintaining staff appropriate to meet patient needs;

4. Designating a substitute, who is responsible and accountable for management of the facility, to act in the absence of the administrator;

5. Developing procedures which require the reporting of any evidence of abuse, neglect, or exploitation of any patient served by the hospital in accordance with Neb. Rev. Stat. § 28-732 of the Adult Protective Services Act or in the case of a child, in accordance with Neb. Rev. Stat. § 28-711; and

6. Ensuring an investigation is completed on suspected abuse, neglect or exploitation and that steps are taken to prevent and protect patients.

006.02 Medical Staff

Each hospital must have a medical staff that operates under medical staff bylaws approved by the governing authority. Two or more hospitals may share a single medical staff, provided that all medical staff functions are completed for each hospital. The medical staff must be organized in a manner and must function in a manner consistent with the size, needs and resources of the hospital and of the medical staff.

9-006.02A Medical Staff Responsibilities: The medical staff must be responsible to the governing authority for the quality of medical care and treatment provided in the hospital and must:

1. Participate in a Quality Assurance/Performance Improvement program to determine the status of patient care and treatment;

2. Abide by hospital and medical staff policies;

3. Establish a disciplinary process for infraction of the policies;

4. Recommend criteria and procedures for appointment and reappointment to the medical staff and for delineating clinical privileging to facilitate the provision of quality patient care and treatment; and

5. Determine the supervision of and training for emergency medical technician-intermediates or emergency medical technician-paramedics.

9-006.02B Medical Staff Appointment: Membership on the medical staff must be limited to those disciplines specified in the medical staff bylaws, rules and regulations or other similar governance document. Criteria for appointment and reappointment must include, at a minimum, continuing licensure or authority to practice in Nebraska. The medical staff must:

1. Initially review the background, experience, training and credentials of applicants for medical staff membership;

2. Make recommendations to the governing authority with regard to membership and category of memberships; and

3. Make recommendations to the governing authority regarding reappointment to the medical staff.

9-006.02C Clinical Privileges: The medical staff must establish a written process for the delineation of clinical privileges. The scope of privileges to be delineated must be stated with sufficient clarity to indicate the nature and extent of privileges. The process must include, but is not limited to:

1. The disciplines and the procedures/tasks for which medical staff must be privileged to perform;

2. The process by which application for clinical privileges is made and reviewed;

3. The process for notification of clinical privilege decisions; and

4. The process for appealing decisions to deny, limit, or otherwise modify privileges.

9-006.02D Medical Staff Bylaws: The medical staff must recommend and adhere to bylaws to carry out its responsibilities, subject to adoption by the governing authority. Medical staff bylaws must include, but are not limited to, the following:

1. A description of how the medical staff is organized;

2. The time frame for medical staff meetings and the rules for conducting business;

3. Methods for evaluating clinical practice in the hospital;

4. Criteria and procedures for membership and clinical privileges;

5. The procedure for medical staff adoption and amendment of medical staff bylaws; and

6. Provision for establishing a utilization review committee.

006.03 Staff Requirements

Each hospital must maintain a sufficient number of staff with the qualifications, training and skills necessary to meet patient needs. The hospital must be staffed 24 hours per day. The rotation of staff and the determination of when specifically licensed, registered or certified staff must be present in the hospital must be determined according to operational and patient care needs.

9-006.03A Employment Eligibility: Each hospital must ensure and maintain evidence of the following:

9-006.03A1 Staff Credentials: Each hospital must verify:

1. The current active licensure, registration, certification or other credentials in accordance with applicable state law, prior to staff assuming job responsibilities and must have procedures for verifying that the current status is maintained; and

2. That an emergency medical technician-intermediate or an emergency medical technician-paramedic providing service in the hospital is employed by or serving as a volunteer member of an emergency medical service licensed by the Department.

9-006.03A2 Health Status: Each hospital must establish and implement policies and procedures related to the health status of staff to prevent the transmission of disease to patients.

9-006.03A2a Each hospital must ensure a health history screening is completed for each staff prior to assuming job responsibilities and must require staff to have a physical examination when the results of the health history screening indicate the examination is necessary.

9-006.03A3 Criminal Background and Registry Checks: Each hospital must complete and maintain documentation of pre-employment criminal background and registry checks on each unlicensed direct care staff member.

9-006.03A3a Criminal Background Checks: The hospital must complete a criminal background check through a governmental law enforcement agency or a private entity that maintains criminal background information.

9-006.03A3b Registry Checks: The hospital must check for adverse findings with each of the following registries:

1. Nurse Aide Registry;

2. Adult Protective Services Central Registry;

3. Central Register of Child Protection Cases; and

4. Nebraska State Patrol Sex Offender Registry.

9-006.03A3c The hospital must:

1. Determine how to use the criminal background and registry information, except for the Nurse Aide Registry, in making hiring decisions;

2. Decide whether employment can begin prior to receiving the criminal background and registry information; and

3. Document any decision to hire a person with a criminal background or adverse registry findings, except for the Nurse Aide Registry. The documentation must include the basis for the decision and how it will not pose a threat to patient safety or patient property.

9-006.03A3d The hospital must not employ a person with an adverse finding on the Nurse Aide Registry regarding patient abuse, neglect, or misappropriation of patient property.

9-006.03B Training: Each hospital must ensure staff receive training in order to perform assigned job responsibilities.

9-006.03B1 Orientation: Each hospital must provide and maintain evidence of an orientation program for all new staff and, as needed, for existing staff who are given new assignments. The orientation program must include an explanation of the:

1. Job duties and responsibilities;

2. Hospital's sanitation and infection control programs;

3. Organizational structure within the hospital;

4. Patient rights;

5. Patient care policies and procedures;

6. Personnel policies and procedures;

7. Emergency procedures;

8. Disaster preparedness plan; and

9. Reporting requirements for abuse, neglect or exploitation in accordance with the Adult Protective Service Act, Neb. Rev. Stat. § 28-372, or in the case of a child in accordance with Neb. Rev. Stat. § 28-711, and with hospital policies and procedures.

9-006.03B1a Each hospital that approves emergency medical technician-intermediates and emergency medical technician-paramedics to provide service as either an employee or a volunteer must provide orientation to registered nurses, physicians, and physician assistants involved in the supervision of emergency medical technician-intermediates and emergency medical technician-paramedics. The orientation must include:

1. Information regarding the scope of practice of an emergency medical technician-intermediate or emergency medical technician-paramedic; and

2. Supervision requirements, as determined by the medical staff of the hospital, for emergency medical technician-intermediates and emergency medical technician-paramedics, to perform activities within their scope of practice as defined in 172 NAC 11, Regulations Governing Out-of-Hospital Emergency Care Providers, Section 11-006.

9-006.03B2 Ongoing Training: Each hospital must provide and maintain evidence of ongoing/continuous inservices or continuing education for staff. A record must be maintained including date, topics and participants.

9-006.03C Employment Record: Each hospital must maintain a current employment record for each staff person. The record must contain, at a minimum, information on orientation, inservices, credentialing and health history screening.

006.04 Patient Rights

Each hospital must protect and promote each patient's rights. This includes the establishment and implementation of written policies and procedures, which include, but are not limited to, the following rights. Each patient or designee, when appropriate, must have the right to:

1. Respectful and safe care given by competent personnel;

2. Be informed of patient rights during the admission process;

3. Be informed in advance about care and treatment and of any change;

4. Participate in the development and implementation of a plan of care and any changes;

5. Make informed decisions regarding care and to receive information necessary to make decisions;

6. Refuse treatment and to be informed of the medical consequences of refusing treatment;

7. Formulate advance directives and to have the hospital comply with the directives unless the hospital notifies the patient of the inability to do so;

8. Personal privacy and confidentiality of medical records;

9. Be free from abuse, neglect, and exploitation;

10. Access information contained in his/her medical record within a reasonable time frame when requested, subject to limited circumstances where the attending physician determines it would be harmful to disclose the information to the patient for therapeutic reasons;

11. Be free from chemical and physical restraints that are not medically necessary;

12. Receive hospital services without discrimination based upon race, color, religion, gender, national origin, or payer. Hospitals are not required to provide uncompensated or free care and treatment unless otherwise required by law; and

13. Voice complaints and file grievances without discrimination or reprisal and have those complaints and grievances addressed.

9-006.04A Grievances: Each hospital must establish and implement a written process that promptly addresses grievances filed by patients or their representatives. The process includes, but is not limited to:

1. A procedure for submission of grievances which is made available to patients or representatives;

2. Time frames and procedures for review of grievances and provision of a response; and

3. How information from grievances and responses are utilized to improve the quality of patient care and treatment.

006.05 Quality Assurance/Performance Improvement

Each hospital must have an effective, hospital-wide quality assurance/performance improvement program to evaluate care and treatment provided to patients. The program, must include, but is not limited to:

1. Establishment of appropriate committees such as a medical staff and utilization review committee for the purpose of reviewing the medical and hospital care as required under Neb. Rev. Stat. § 71-2046 with the power and authority provided under Neb. Rev. Stat. § 71-2047;

2. A written plan of implementation;

3. All services provided including contracted services;

4. The tracking of outpatient surgical procedures that result in unplanned patient admissions to a hospital within 72 hours of a procedure, due to post surgical complications;

5. Evaluation of care and treatment provided both by staff and through contract;

6. Appropriate action to address problems found through the program;

7. Evaluation of the outcome for any action taken; and

8. Reporting to the governing authority.

006.06 Patient Care and Treatment

Each hospital must provide the necessary care and treatment within the hospital's ability to meet the needs of patients. Care and treatment provided must meet prevailing professional standards and scope of practice requirements. Each hospital must establish and implement written policies and procedures that encompass care and treatment provided to patients.

9-006.06A Plan of Care: A plan of care must be established, implemented and kept current to meet the identified needs for each inpatient. The plan of care must be interdisciplinary when appropriate to meet individual needs of patients.

9-006.06B Administration of Medications: Each hospital must establish and implement policies and procedures to ensure patients receive medications only as legally prescribed by a medical practitioner in accordance with the Five Rights and prevailing professional standards.

9-006.06B1 Methods of Administration of Medications: When the hospital is responsible for the administration of medications, it must be accomplished by the following methods:

9-006.06B1a Self-Administration: The hospital must allow patients to self-administer medications, with or without supervision, when assessment determines patient is capable of doing so.

9-006.06B1b Licensed Health Care Professional: When the hospital utilizes licensed health care professionals for whom medication administration is included in the scope of practice, the hospital must ensure the medications are properly administered in accordance with prevailing professional standards.

9-006.06B1c Provision of Medication by a Person Other Than a Licensed Health Care Professional: When the hospital utilizes persons other than a licensed health care professional in the provision of medications, the hospital must follow 172 NAC 95 Regulations Governing the Provision of Medications by Medication Aides and Other Unlicensed Persons and 172 NAC 96 Regulations Governing the Medication Aide Registry. Each hospital must establish and implement policies and procedures:

1. To ensure that medication aides who provide medications are trained and have demonstrated the minimum competency standards specified in 172 NAC 95-004;

2. To ensure that competency assessments and/or courses for medication aides have been completed in accordance with the provisions of 172 NAC 96-005;

3. That specify how direction and monitoring will occur when the hospital allows medication aides to perform the routine/acceptable activities authorized by 172 NAC 95-005 and as follows:

a. Provide routine medication; and

b. Provision of medications by the following routes:

(1) Oral, which includes any medication given by mouth including sublingual (placing under the tongue) and buccal (placing between the cheek and gum) routes and oral sprays;

(2) Inhalation, which includes inhalers and nebulizers, including oxygen given by inhalation;

(3) Topical application of sprays, creams, ointments, and lotions and transdermal patches; and

(4) Instillation by drops, ointments and sprays into the eyes, ears and nose;

4. That specify how direction and monitoring will occur when the hospital allows medication aides to perform the additional activities authorized by 172 NAC 95-009, which include, but are not limited to:

a. Provision of PRN medications;

b. Provision of medications by additional routes, including, but not limited to, gastrostomy tube, rectal and vaginal; and/or

c. Participation in monitoring;

5. That specify how competency determinations will be made for medication aides to perform routine and additional activities pertaining to medication provision;

6. That specify how written direction will be provided for medication aides to perform the additional activities authorized by 172 NAC 95-009;

7. That specify how records of medication provision by medication aides will be recorded and maintained; and

8. That specify how medication errors made by medication aides and adverse reactions to medications will be reported. The reporting must be:

a. Made to the identified person responsible for direction and monitoring;

b. Made immediately upon discovery; and

c. Documented in patient medical records.

9-006.06B2 Each hospital must establish and implement policies and procedures for reporting any errors in administration or provision of prescribed medications to the prescriber in a timely manner upon discovery and a written report of the error prepared.

9-006.06B3 Each hospital must establish and implement policies and procedures for reporting any adverse reaction to a medication in a timely manner upon discovery to the prescriber and for documenting the event in the patient's medical record.

9-006.06B4 Handling of Medications: Each hospital must establish and implement procedures to ensure that patients receive medications as prescribed by a medical practitioner. At a minimum, the following must be evident:

1. A current policy and procedure manual regarding the handling of drugs in the hospital;

2. A shift count of all controlled substances at each nursing unit which have been dispensed as multiple-dose floor stock or individual patient prescriptions. Unit-dose systems which do not exceed 24 hours duration may be exempt from this requirement; and

3. Only authorized personnel designated by hospital policy are allowed access to medications.

9-006.06B5 Medication Record: Each hospital must maintain records in sufficient detail to assure that patients receive the medications prescribed by a medical practitioner and maintain records to protect medications against theft and loss. Each inpatient must have an individual medication administration record which includes, but is not limited to:

1. The identification of the patient;

2. The name of the medication given;

3. The date, time, dosage, method of administration or provision for each medication, identification of the person who administered or provided the medication and any refusal by the patient; and

4. The patient's medication allergies and sensitivities.

9-006.06C Nutrition: Each hospital must provide for the daily nutritional needs of all patients, including the provision of any diets ordered by a medical practitioner.

9-006.06C1 A current diet manual acceptable to dietary, nursing and medical staff must be maintained and available for reference.

9-006.06C2 Education on matters of diet and nutrition must be available to patients when appropriate.

9-006.06C3 Assessments of the nutritional status of patients must be conducted by a licensed medical nutrition therapist as required by Neb. Rev. Stat. §§ 71-1,286 to 71-1,287 and 172 NAC 61 Regulations Governing the Practice of Medical Nutrition Therapy.

9-006.06D Patient Education: Each hospital must establish and implement a process to provide patients and/or their designee appropriate education to assist in understanding the identified condition and the necessary care and treatment.

9-006.06E Discharge Planning: Each hospital must provide discharge planning to patients who request information or who are identified as likely to suffer adverse health consequences upon discharge if there is not adequate discharge planning. The discharge planning program includes, but is not limited to:

1. A system for timely evaluation of any discharge planning needs of patients;

2. Identification of staff responsible for the program;

3. Development of a discharge plan with the patient or representative when need is identified;

4. Maintenance of a complete and accurate list of community-based services, resources and facilities to which patients can be referred; and

5. Arrangement for the initial implementation of a discharge plan including transfer of necessary medical information.

006.07 Record Keeping Requirements

Each hospital must maintain records and reports in a manner to ensure accuracy and easy retrieval.

9-006.07A Medical Records: A medical record must be maintained for every patient, including newborn infants, admitted for care in the hospital or treated in the emergency or outpatient service. Medical records may be created and maintained in written or electronic form, or a combination of both, provided the record meets 175 NAC 9. Medical records must contain sufficient information to clearly identify the patient, to justify the diagnosis and treatment and to document the results accurately.

9-006.07A1 Content: Each medical record must contain, when applicable, the following information:

1. Identification data;

2. Chief complaint;

3. Present illness;

4. History and physical examination;

5. Admitting diagnosis;

6. All pathology/laboratory and radiology reports;

7. Properly executed informed consent forms;

8. Consultation reports;

9. Medical practitioner orders;

10. Documentation of all care and treatment, medical and surgical;

11. Tissue report;

12. Progress notes of all disciplines;

13. Discharge summary and final diagnosis;

14. Autopsy findings; and

15. Advance directives, if available.

9-006.07A2 Medical records must contain entries which are dated, legible, and indelible. The author of each entry must be identified and authenticated. Authentication must include signature, written initials, or computer entry.

9-006.07A3 Telephone or verbal orders of authorized individuals are accepted and transcribed by qualified personnel who are identified by title or category in the medical staff bylaws or rules and regulations. Telephone or verbal orders must be authenticated as soon as is practical by the medical practitioner who is responsible for ordering, providing or evaluating the service furnished.

9-006.07A4 The hospital must monitor and require medical records be completed within 30 days of discharge of the patient.

9-006.07A5 Retention: The medical record of each patient must be maintained and preserved, in original, microfilm, electronic or other similar form, for a period of at least ten years following discharge or in the case of minors, the records must be kept until three years after the age of majority has been attained. In cases in which a hospital ceases operation, all medical records of patients must be transferred as directed by the patient or authorized representative to the hospital or other health care facility or health care service to which the patient is transferred. All other medical records that have not reached the required time for destruction must be stored to assure confidentiality and the Department must be notified of the address where stored.

9-006.07A6 Confidentiality: Medical records must be kept confidential, available only for use by authorized persons or as otherwise permitted by law. Records must be available for examination by authorized representatives of the Department.

9-006.07A7 Access: Patient information and/or records will be released only with consent of the patient or designee or as permitted by law. When a patient is transferred to another health care facility or service, appropriate information for continuity of care must be sent to the receiving health care facility or service.

9-006.07A8 Destruction: Medical records may be destroyed only when they are in excess of the retention requirements specified in 175 NAC 9-006.07A 5. In order to ensure the patient's right of confidentiality, medical records are destroyed or disposed of by shredding, incineration, electronic deletion, or another equally effective protective measure.

9-006.07B Other Records/Reports: In addition to patient medical records, each hospital must maintain, when applicable, the following:

9-006.07B1 A permanent patient index that includes, but is not limited to:

1. Name and identification numbers of each patient;

2. Dates of admission and discharge;

3. Name of admitting physician; and

4. Disposition or place to which patient was discharged/transferred.

9-006.07B2 Administrative records and reports including governing authority and departmental meeting minutes, staff orientation and inservice records and staff schedules as worked for a minimum of three years, unless longer is required by law.

9-006.07B3 Records of all reports made regarding abuse, neglect or exploitation as required by Neb. Rev. Stat. §§ 28-372 and 28-711.

006.08 Infection Control

Each hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control and investigation of infections and communicable diseases.

9-006.08A The infection control program must include, but is not limited to:

1. All departments/services of the hospital;

2. The responsible person(s) for the program;

3. A system for identifying, reporting, investigating and controlling infections, communicable diseases, and nosocomial infections of patients and staff;

4. A definition of nosocomial infection;

5. A system for the early detection of infectious outbreaks to contain and prevent further spread of infection;

6. A method of monitoring treatment of infection for appropriateness and for alteration of treatment when necessary;

7. Implementation of corrective action plans; and

8. Mechanism for evaluation of the program.

006.09 General Acute Hospital Requirements

Each general acute hospital must have a duly constituted governing authority and organized medical staff and must provide medical, nursing, surgical, anesthesia, laboratory, diagnostic radiology, pharmacy and dietary services on an inpatient or outpatient basis.

9-006.09A Medical Services: Medical services must be provided in a manner sufficient to meet the medical needs of patients. Medical services must be given under the direction and supervision of a physician member of the medical staff.

9-006.09A1 There must be written policies and procedures that govern medical services approved by the medical staff.

9-006.09A2 There must be a mechanism for a sample review of medical services provided to evaluate the quality of services furnished to both inpatients and outpatients.

9-006.09B Nursing Services: Each hospital must have an organized nursing department, including a departmental plan of administrative authority with written delineation of responsibilities and duties of each category of nursing personnel in the form of written job descriptions.

9-006.09B1 Each hospital must have a registered nurse on duty 24 hours a day, seven days a week and registered nursing service available for all patients at all times.

9-006.09B2 Each hospital must have a person designated as fulltime Director of Nursing, Chief Nursing Executive or other similar title who is a registered nurse having a current license in the State of Nebraska. The Director of Nursing may serve as charge nurse in hospitals of 25 beds or less. A registered nurse must be designated to act as director in the director's absence.

9-006.09B3 A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available.

9-006.09B4 A registered nurse must be responsible for supervision and direction of nursing care.

9-006.09B5 Registered nurses on duty must be sufficient to provide nursing care and supervision in the patient areas.

9-006.09B6 Nursing care policies and procedures must be in writing and consistent with generally accepted practice.

9-006.09B7 There must be a continuing planned staff development program for all nursing department personnel. A record must be maintained including date, topic and participants. Specialized training of personnel to permit them to perform particular procedures or render specialized care, whether as part of a training program or as individualized instruction must be documented.

9-006.09B8 A schedule of nursing department personnel must be maintained for each area, including first initial and last name of staff member, title, and hours of duty. Nursing schedules must be maintained for not less than three years.

9-006.09B9 Each hospital must establish appropriate policies and procedures for those personnel authorized to receive telephone and verbal diagnostic and therapeutic orders.

9-006.09B10 There must be sufficient staff by qualifications and numbers on each shift to assist directly and indirectly in the provision of care or treatment to meet patient needs.

9-006.09C Surgical Services: Each hospital must provide surgical services in a manner sufficient to meet the needs of patients. Surgical services must be under the direction of a qualified physician member of the medical staff who must be responsible for the quality and scope of surgical services. Surgical services must be provided by medical practitioners who are authorized by their scope of practice and who have received privileges that define and describe the scope and conduct of surgical services that can be performed at the hospital.

9-006.09C1 Written policies and procedures must be established and implemented that define and describe the scope and conduct of surgical services and ensure safe and competent delivery of surgical services to patients. These policies and procedures are approved by the medical staff and include, but are not limited to:

1. Restrictions on access to the surgical suite and recovery room areas;

2. Proper attire in the surgical suite and recovery room areas;

3. Sterilization and disinfection of equipment and supplies;

4. Aseptic surveillance and practice;

5. Maintenance of a roster in the surgical suite which delineates the surgical privileges granted to each medical practitioner;

6. Maintenance of an operating room record log that includes, but is not limited to:

a. Name and identification number of each patient;

b. Date and inclusive time of surgical procedure;

c. Surgical procedure(s) performed;

d. Name(s) of surgeons and any assistants;

e. Name of nursing personnel (scrub and circulating);

f. Type of anesthesia; and

g. Name and title of person administering anesthesia.

7. Responsibility for the supervision of the surgical suite and recovery room;

8. Immediate availability of an emergency call system, cardiac monitor, defibrillator, suction and emergency airway supplies;

9. Availability of blood and blood products;

10. Requirement for patient history and physical examination;

11. Requirements for testing and disposal of surgical specimens;

12. Circumstances that require the presence of an assistant during surgery;

13. Procedures for handling infectious cases;

14. Immediate post-surgical care; and

15. Operative report requirements.

9-006.09C2 Each hospital must, at least annually, provide surgeons performing surgery at the hospital a report as to the number and rates of surgical infections in surgical patients of the surgeons as required by Neb. Rev. Stat. § 71-2083.

9-006.09C3 Each hospital that provides outpatient surgical services must evaluate patients for proper recovery before discharge. Qualified personnel must remain with the patient until the patient's status is stable and protective reflexes have returned to normal. A patient may be discharged only when a medical practitioner and hospital policies determine it is safe and appropriate to discharge. The hospital must establish medical criteria for discharge which are consistent with prevailing professional standards.

9-006.09D Anesthesia Services: Each hospital must provide anesthesia services in a manner sufficient to meet the needs of patients. Anesthesia is provided only by qualified individuals who are allowed to administer anesthesia under their scope of practice. This does not prohibit administration of anesthesia by medical or nurse anesthetist students under the supervision of a qualified individual.

9-006.09D1 Written policies and procedures must be established and implemented to ensure safe and competent delivery of anesthesia services to patients. These policies and procedures must be approved by the medical staff and include, but are not limited to:

1. Equipment maintenance;

2. Safety measures to guard against hazards;

3. Infection control measures; and

4. Pre and post anesthesia evaluations for inpatients and outpatients.

9-006.09E Laboratory Services: Each hospital must provide clinical laboratory services and these services may be available on the premises or through written agreement to meet the needs of patients. All laboratory testing, whether provided directly by the hospital or through agreement, must comply with the Clinical Laboratory Improvement Amendments of 1988 as amended (CLIA). Laboratory services must be under the direction of a physician, preferably a pathologist.

9-006.09E1 Each hospital provides or has available necessary laboratory services as determined by the medical staff.

9-006.09E2 The hospital must have accessible emergency laboratory services including urinalysis, complete blood counts, blood typing and cross matching and other necessary emergency laboratory work as determined by the medical staff.

9-006.09E3 Provision must be made for proper receipt and reporting of tissue specimens.

9-006.09E4 The medical staff must determine which tissue specimens require a macroscopic examination and which require both macroscopic and microscopic examinations.

9-006.09F Radiology Services: Each hospital must provide radiology services and these services may be available on the premises or through written agreement to meet the needs of patients.

9-006.09F1 Radiology services must be under the direction of a physician, preferably a radiologist, and must comply with the provisions of Neb. Rev. Stat. §§ 71-3501 to 71-3520, the Radiation Control Act, and the regulations promulgated thereunder.

9-006.09F2 Personnel performing medical radiography procedures must be licensed in accordance with Neb. Rev. Stat. §§ 71-3515.01 to 71-3515.02 and the regulations promulgated thereunder.

9-006.09F3 Each hospital must have available emergency radiology services.

9-006.09F4 All x-ray films must be reviewed and interpreted by a physician. Complete reports of the results of x-ray examinations must be kept on file for not less than five years and a copy must be filed in the patient's medical record.

9-006.09G Pharmacy Services: Pharmacy services must be provided to meet the needs of patients directly or through written agreement, and must be under the supervision of a pharmacist licensed in Nebraska. The storage, control, handling, compounding and dispensing of drugs, devices and biologicals must be in accordance with Neb. Rev. Stat. §§ 71-1,142 to 71-1, 147.59 and the regulations promulgated thereunder.

9-006.09G1 Emergency drugs, devices and biologicals as determined by the medical staff must be readily available for use at designated locations when an emergency occurs.

9-006.09G2 Current and accurate records must be kept on the receipt and disposition of all controlled substances.

9-006.09G3 The supply of drugs, devices and biologicals and controlled substances must be protected and restricted to use for legally authorized purposes.

9-006.09G4 Abuses and losses of controlled substances must be reported in accordance with Neb. Rev. Stat. §§ 28-401 to 28-445, the Uniform Controlled Substances Act, and the regulations promulgated thereunder.

9-006.09G5 Drugs, devices and biologicals must be stored in locked areas in accordance with the manufacturer's instructions for temperature, light, humidity or other storage instructions.

9-006.09G6 Drugs, devices and biologicals must be removed from the pharmacy or storage area only by personnel designated in hospital policies and in accordance with state and federal law.

9-006.09G7 The supply of drugs, devices and biologicals must be checked on a regular basis to ensure expired, mislabeled, unlabeled or unusable products are not available for patient use and are disposed of in accordance with hospital policies and state and federal law.

9-006.09G8 Information relating to interactions, contraindications, side effects, toxicology, dosage, indications for use, and routes of administration for drugs, devices and biologicals must be available to staff.

9-006.09H Dietary Services: Dietary services must be provided directly or through written agreement to meet the general nutritional needs of patients and must be supervised by a registered dietitian. If there is not a full-time registered dietitian, a person must be designated as full-time director of dietary services and is responsible for the daily management of dietary services.

9-006.09H1 There must be written policies and procedures established and implemented that provide dietary services to meet patient needs.

9-006.09H2 There must be a sufficient number of trained staff to provide dietary services.

9-006.09H3 Menus must be planned, written and followed to meet the nutritional needs of patients.

9-006.09H4 Meals must be served to patients at appropriate intervals.

9-006.09H5 Each hospital stores, prepares, protects, serves and disposes of food in a safe and sanitary manner and in accordance with the Food Code.

9-006.09I Emergency Services: Critical Access Hospitals must provide emergency services on a 24-hour basis. General Acute, Long-Term Care, Psychiatric or Mental and Rehabilitation Hospitals are not required to provide emergency services. However, if provided, there must be an easily accessible emergency area which must be equipped and staffed to ensure that ill or injured persons can be promptly assessed and treated or transferred to a hospital capable of providing needed specialized services. Emergency services must be under the direction of a physician member of the medical staff who must be responsible for the quality and scope of emergency services.

9-006.09I1 Each hospital that provides emergency services must establish and implement written policies and procedures which include, but are not limited to:

1. Provision for 24 hour per day medical and nursing services by medical staff and registered nurses on duty or on call;

2. Medical and nursing personnel must be qualified in emergency care to carry out the written emergency procedures and needs anticipated by the hospital;

3. Emergency drugs, devices, biologicals, equipment and supplies must be available for immediate use in the emergency area for treating life-threatening conditions;

4. A medical record must be kept for each patient receiving emergency services and must be integrated into the patient's medical record;

5. An emergency room log that documents:

a. Patient name;

b. Date, time and method of arrival;

c. Physical findings;

d. Care and treatment provided;

e. Name of treating medical practitioner; and

f. Disposition including time; and

6. Provision of written instructions to patients for care and an oral explanation of those instructions.

9-006.09I2 Any hospital that ceases to provide emergency services must notify the Department as soon as possible prior to the action.

9-006.09J Critical Care Unit Services: If a hospital provides critical care unit services, e.g., an intensive care, coronary care, intensive newborn nursery, burn unit, or transplant unit, the unit must be under the direction of a physician member of the medical staff, qualified to direct such services, and who must be responsible for the quality and scope of services.

9-006.09J1 Each hospital that provides special care unit services must establish and implement written policies and procedures which include, but are not limited to:

1. The scope and care for patients in each special care unit service;

2. Supervision by a qualified registered nurse;

3. The special equipment, medications and supplies that are to be immediately available in the unit for provision of care and treatment and to carry out the functions of the unit;

4. Qualifications of personnel assigned to provide care in the unit;

5. Medical and nursing staff coverage for the unit; and

6. Admission and discharge criteria.

9-006.09K Obstetrical and Newborn Services: Obstetrical and newborn services, if provided, must be under the direction of a physician member of the medical staff, qualified to direct such services, and who must be responsible for the quality and scope of services.

9-006.09K1 Each hospital that provides obstetrical and newborn services must establish and implement written policies and procedures which include, but are not limited to:

1. The scope of and care for patients receiving obstetrical and newborn services;

2. Supervision of nursing care including labor, delivery, and nursery by a qualified registered nurse;

3. The drugs, devices, biologicals, equipment and supplies that are to be immediately available for provision of care;

4. Appropriate attire to be worn during labor and delivery and in the nursery;

5. The flow of hospital staff between the obstetric and newborn units and other patient care areas;

6. The use of oxytocic drugs and administration of anesthetics, sedatives, analgesics and other drugs, devices and biologicals;

7. Care and staff responsibilities during induction or augmentation of labor;

8. The presence of fathers or other support persons during labor and delivery;

9. The method for correct identification of the newborn and mother; and

10. Immediate care of a newborn.

9-006.09L Pediatric Services: Pediatric services, if provided, must be under the direction of a physician member of the medical staff, qualified to direct the services, and who must be responsible for the quality and scope of services.

9-006.09L1 Each hospital that provides care and treatment to pediatric patients in a distinct unit must establish and implement written policies and procedures which include, but are not limited to:

1. The scope of and care for pediatric patients;

2. Supervision by a qualified registered nurse;

3. Location of pediatric patients apart from adult patients and newborn infants;

4. Drugs, devices, biologicals, equipment and supplies suitable for use with pediatric patients; and

5. Policies defining conditions under which parents or support persons may stay or "room in" with pediatric patients.

9-006.09M Rehabilitation Services: Rehabilitation services, if provided, must be under the direction of a qualified individual(s), as determined by the hospital. This individual is responsible for the quality and scope of rehabilitation services.

9-006.09M1 Each hospital that provides rehabilitation services must establish and implement written policies and procedures which include, but are not limited to:

1. The scope and care of patients receiving rehabilitation services;

2. Supervision by a qualified therapist;

3. Provision of rehabilitation services by qualified personnel who are credentialed in Nebraska, if required, and who act within their scope of practice;

4. Provision of therapy in accordance with medical practitioner orders;

5. Coordination with other services in the hospital;

6. Treatment plan documentation and record keeping requirements; and

7. Equipment maintenance to ensure patient safety.

9-006.09N Respiratory Care Services: Respiratory care services, if provided, are under the direction of a physician member of the medical staff who is responsible for the quality and scope of respiratory care services.

9-006.09N1 Each hospital that provides respiratory care services must establish and implement written policies and procedures which include, but are not limited to:

1. The scope and care of patients receiving respiratory care services;

2. Supervision by a qualified respiratory care practitioner;

3. Provision of respiratory care services by qualified personnel as allowed by their scope of practice;

4. Provision of therapy must be provided in accordance with medical practitioner orders;

5. Coordination with other services in the hospital;

6. Treatment plan documentation and record keeping requirements; and

7. Equipment maintenance to ensure patient safety.

9-006.09O Social Work Services: Social work services, if provided, must be under the direction of a certified social worker who must be responsible for the quality and scope of social work services.

9-006.09O1 Each hospital that provides social work services must establish and implement written policies and procedures which include, but are not limited to:

1. The scope and care of patients receiving social work services;

2. The assessment of personal and social functioning of patients;

3. Coordination with other services in the hospital;

4. Role in intervention, discharge planning and referral of patients; and

5. Documentation and record keeping requirements.

9-006.09P Outpatient Services: Outpatient services, if provided, must be under the direction of a qualified individual(s), as determined by the hospital, who must be responsible for the quality and scope of outpatient services.

9-006.09P1 Each hospital that provides outpatient services in a distinct area on the hospital premises or at another location must establish and implement written policies and procedures which include, but are not limited to:

1. The scope and care of outpatient services;

2. Provision of outpatient services in accordance with medical practitioner orders;

3. The numbers and qualifications of staff necessary to meet patient needs based on the type and volume of services provided;

4. Documentation and record keeping requirements and procedures to integrate the outpatient medical record with existing inpatient records; and

5. Equipment and allocation of space for the provision of outpatient services to ensure safety and privacy to patients.

006.10 Critical Access Hospital

Each critical access hospital must have no more than 25 acute care inpatient beds. The average length of stay for acute care inpatients must not be more than 96 hours, and emergency services must be provided on a 24-hour basis. Critical access hospitals must have formal agreements with at least one hospital and other appropriate providers for services such as patient referral and transfer, communication systems, provision of emergency and nonemergency transportation and backup medical and emergency services. Each critical access hospital must meet the requirements to qualify for a written agreement with the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services or its successor to participate in Medicare as a critical access hospital as defined in 42 CFR 485.601 to 485.641 attached to 175 NAC 9 and incorporated by this reference. In addition to those requirements, each critical access hospital must meet the following:

1. Governing Authority regulations specified in 175 NAC 9-006.01;

2. Medical Staff regulations specified in 175 NAC 9-006.02;

3. Staff Requirement regulations specified in 175 NAC 9-006.03, except that staff are not required to be present in the hospital when there are no patients in the hospital;

4. Patient Rights regulations specified in 175 NAC 9-006.04;

5. Patient Care and Treatment regulations specified in 175 NAC 9-006.06;

6. Record Keeping Requirements specified in 175 NAC 9-006.07;

7. Nursing Services regulations specified in 175 NAC 9-006.09B except that a registered nurse is not required to be on duty 24 hours a day, 7 days a week, if there are no acute patients in the hospital;

8. Emergency services are provided on a 24-hour basis and meet the requirements specified in 175 NAC 9-006.09I;

9. Environmental Services specified in 175 NAC 9-006.14; and

10. Physical Plant requirements specified in 175 NAC 9-007.

006.11 Long-Term Care Hospital

Each long-term care hospital or distinct part of a hospital that provides the care and services of an intermediate care facility, a nursing facility or a skilled nursing facility must meet all requirements specified in 175 NAC 12 except the administrator is not required to hold a current nursing home administrator's license issued by the State of Nebraska.

006.12 Psychiatric or Mental Hospital

Each psychiatric or mental hospital must meet all requirements specified in 175 NAC 9-006.01 to 9-006.08, 9-006.14 and 9-007. If any of the services in 175 NAC 9-006.09A to 9-006.09P are provided, each hospital must meet the requirements specified in those sections. In addition, each psychiatric or mental hospital must meet the requirements of 42 CFR 482.60 to 482.62 attached to 175 NAC 9 and incorporated by this reference.

006.13 Rehabilitation Hospital

Each rehabilitation hospital must meet all requirements specified in 175 NAC 9-006.01 to 9-006.08, 9-006.14 and 9-007. If any of the services in 175 NAC 9-006.09A to 9-006.09P are provided, each hospital must meet the requirements specified in those sections. In addition, each rehabilitation hospital must meet the following:

1. Direction and supervision of all rehabilitation services by a fulltime physician who is a member of the medical staff and is trained in rehabilitation medicine;

2. Provision of physical therapy, occupational therapy, speech pathology and audiology, social work, psychological and vocational services. These services must be organized and supervised by qualified professional personnel credentialed in Nebraska when required and who have been approved by the Governing Authority;

3. All care and treatment must be provided by qualified staff for the type of services performed in accordance with state law and prevailing professional standards;

4. There must be written policies and procedures established and implemented that govern care and treatment provided to patients to ensure health and safety needs of patients are met;

5. A preadmission screening procedure must be established and implemented to review each prospective patient's condition and medical history to determine whether the patient is likely to benefit significantly from an intensive inpatient hospital program or assessment;

6. There must be a plan of treatment for each inpatient established, implemented, reviewed and revised as needed by a physician in consultation with other professional personnel who provide services to the patient; and

7. There must be a multidisciplinary team approach in the rehabilitation of each inpatient, as documented by periodic clinical entries made in the patient's medical record to note the patient's status in relationship to goal attainment. Team conferences must be held at least every two weeks to determine the appropriateness of treatment.

006.14 Environmental Services

Each hospital must provide a safe, clean and comfortable environment for patients. Every detached building on the same premises used for care and treatment must comply with 175 NAC 9.

9-006.14A Housekeeping and Maintenance: The hospital must provide the necessary housekeeping and maintenance to protect the health and safety of patients.

9-006.14A1 The hospital's buildings and grounds must be kept clean, safe and in good repair.

9-006.14A2 All garbage and rubbish must be disposed of in such a manner as to prevent the attraction of rodents, flies and all other insects and vermin. Garbage must be disposed of in such a manner as to minimize the transmission of infectious diseases and minimize odor.

9-006.14A3 The hospital must provide and maintain adequate lighting, environmental temperatures and sound levels in all areas that are conducive to the care and treatment provided.

9-006.14A4 The hospital must maintain and equip the premises to prevent the entrance, harborage or breeding of rodents, flies and all other insects and vermin.

9-006.14B Equipment, Fixtures and Furnishings: The hospital must provide and maintain all equipment, fixtures and furnishings clean, safe and in good repair.

9-006.14B1 Common areas and patient areas must be furnished with beds, chairs, sofas, tables and storage that is comfortable and reflective of patient needs.

9-006.14B2 The hospital must provide equipment adequate to meet the care and treatment needs of patients.

9-006.14B3 The hospital must establish and implement a process designed for routine and preventative maintenance of equipment and furnishings to ensure that the equipment and furnishings are safe and function to meet the intended use.

9-006.14C Linens: The hospital must provide each patient with an adequate supply of clean bed, bath and other linens necessary for care and treatment. Linens must be in good repair.

9-006.14C1 The hospital must establish and implement procedures for the storage and handling of soiled and clean linens.

9-006.14C2 When the hospital provides laundry services, water temperatures to laundry equipment must exceed 160 degrees Fahrenheit or the laundry may be appropriately sanitized or disinfected by another acceptable method in accordance with manufacturer's instructions.

9-006.14D Pets: The hospital must assure any facility owned pet does not negatively affect patients. The hospital must have policies and procedures regarding pets that include:

1. An annual examination by a licensed veterinarian;

2. Vaccinations as recommended by the licensed veterinarian that include, at a minimum, current vaccination for rabies for dogs, cats and ferrets;

3. Provision of pet care necessary to prevent the acquisition and spread of fleas, ticks and other parasites; and

4. Responsibility for care and supervision of the pet by facility staff.

9-006.14E Environmental Safety: The hospital must be responsible for maintaining the environment in a manner that minimizes accidents.

9-006.14E1 The hospital must maintain the environment to protect the health and safety of patients by keeping surfaces smooth and free of sharp edges, mold or dirt; keeping floors free of objects and slippery or uneven surfaces and keeping the environment free of other conditions which may pose a potential risk.

9-006.14E2 The hospital must maintain all doors, stairways, passageways, aisles, or other means of exit in a manner that provides safe and adequate access for care and treatment.

9-006.14E3 The hospital must provide water for bathing and handwashing at safe and comfortable temperatures to protect patients from potential for burns or scalds.

9-006.14E3a The hospital must establish and implement policies and procedures to monitor and maintain water temperatures that accommodate patient comfort and preferences, but not to exceed the following temperatures:

1. Water temperature at patient handwashing fixtures must not exceed 120 degrees Fahrenheit.

2. Water temperatures at patient bathing and therapy fixtures must not exceed 110 degrees Fahrenheit.

9-006.14E4 The hospital must establish and implement policies and procedures to ensure hazardous/poisonous materials are properly handled and stored to prevent accidental ingestion, inhalation, or consumption of the hazardous/poisonous materials by patients.

9-006.14E5 The hospital must restrict access to mechanical equipment which may pose a danger to patients.

9-006.14F Disaster Preparedness and Management: The hospital must establish and implement disaster preparedness plans and procedures to ensure that patient care and treatment, safety, and well-being are provided and maintained during and following instances of natural (tornado, flood, etc.) or other disasters, disease outbreaks, or other similar situations. Such plans and procedures must address and delineate:

1. How the hospital will maintain the proper identification of each patient to ensure that care and treatment coincide with the patient's needs;

2. How the hospital will move patients to points of safety or provide other means of protection when all or part of the building is damaged or uninhabitable due to natural or other disaster.

3. How the hospital will protect patients during the threat of exposure to the ingestion, absorption, or inhalation of hazardous substances or materials;

4. How the hospital will provide food, water, medicine, medical supplies, and other necessary items for care and treatment in the event of a natural or other disaster; and

5. How the hospital will provide for the comfort, safety, and well-being of patients in the event of 24 or more consecutive hours of:

a. Electrical or gas outage;

b. Heating, cooling, or sewer system failure; or

c. Loss or contamination of water supply.

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