Or. Admin. R. 333-700-0075 - Administrative Authority and Management
(1) Every facility shall be organized,
equipped, and administered to provide adequate care for each person
admitted.
(2) The governing body,
the owner, or the person or persons designated by the owner or governing body
shall be the authority responsible for the management and control of the
facility, and shall not:
(a) Permit, aid or
abet the commission of any unlawful act relating to the securing of a license,
or the operation of the facility; and
(b) With the exception of abusive or
disruptive patients, refuse to admit and treat, on the basis of medical need,
alcohol and substance abusers, mentally ill or intellectually disabled patients
solely on the basis of their substance abuse or mental illness. Discharge of
patients exhibiting violent, threatening, disruptive, or abusive behavior shall
be handled as outlined in OAR
333-700-0115(2)(f).
(3) The governing authority shall
formulate and implement a written set of bylaws or other appropriate policies
and procedures for the operation of the facility. These shall:
(a) State the purpose of the
facility;
(b) Specify by title the
person who is responsible for the operation and maintenance of the facility,
and methods established by the governing body for holding that person
responsible;
(c) Provide for at
least annual meetings of the governing body; and
(d) Provide a policy and procedure manual
that is designed to ensure professional and safe care for patients including,
but not limited to:
(A) Admission
criteria;
(B) Rights and
responsibilities of patients;
(C)
Care of patients;
(D) Patient
grievance procedures;
(E) Infection
control policies;
(F) Personnel
qualifications and training requirements;
(G) Consultant qualifications, functions, and
responsibilities;
(H) Reprocessing
of hemodialyzers;
(I) Emergency
management of patients;
(J) Annual
reviews of the facilities policies, procedures and operation; and
(K) A facility-wide Quality Assessment and
Performance Improvement (QAPI) program to evaluate the provision of patient
care. The program shall have a written plan of implementation. Quality data
shall be reviewed and analyzed quarterly. The QAPI program shall be reviewed at
least annually. It shall be designed to effectively identify and correct
problems. Written documentation of QAPI activities shall be available at the
facility.
(4)
The governing body shall review implementation of these policies at least
annually to ensure that the intent of the policies is carried out. These
policies shall be developed by the physician responsible for supervising and
directing the provision of dialysis services, or the facility's organized
medical staff, with the advice from a group of professional personnel
associated with the facility, including, but not limited to, one or more
physicians and one or more registered nurses experienced in rendering dialysis
care.
(5) An administrator shall be
appointed by the governing body, shall be responsible for the management of the
facility, and shall assure adherence to facility policies and procedures. The
required full time nurse manager may serve as the administrator. Any change in
the administrator shall be reported to the Division in writing within 30 days.
The administrator must have sufficient experience in the management of dialysis
facilities, or appropriate education so as to assure that they are qualified to
carry out their responsibilities.
(6) The following documents shall be
available at the facility:
(a) Appropriate
documents showing control and ownership;
(b) Bylaws, policies and procedures of the
governing body;
(c) Minutes of the
governing body meetings;
(d)
Minutes of the facility's professional staff meetings;
(e) Reports of inspections, reviews, and
corrective actions taken related to licensure;
(f) Minutes of the facility's quality
improvement meetings; and
(g)
Contracts and agreements to which the facility is a party.
(7) Medical Staff:
(a) If more than one physician practices at
the facility, the physicians shall be organized as a Medical Staff with
appropriate bylaws approved by the governing body. The medical staff shall meet
at least once a year, and minutes shall be maintained at the facility of such
meetings;
(b) The Governing Body
shall designate a qualified physician as the physician-director of the
facility. The physician-director shall be responsible for the development and
implementation of patient care policies and medical staff bylaws, rules, and
regulations;
(c) A qualified
physician with demonstrated experience in the care of patients receiving
dialysis shall be on call and available to patients within a reasonable time
frame;
(d) The facility shall
require and the medical director shall ensure that any adverse medical patient
outcomes are communicated to the patient's physician, and that the facility
takes appropriate corrective action.
(8) Transfer Agreement: Each facility shall
have in effect an agreement with one or more hospitals, for the provision of
inpatient care or other hospital services. The transfer agreement shall provide
the basis for an effective working agreement under which the services of the
hospital are promptly available to the facility's patients as needed. The
facility shall have on file documentation of this agreement. There shall be
reasonable assurances that:
(a) Transfer of
patients must be effected between the hospital and the facility whenever such
transfer is deemed medically necessary by the physician, with timely acceptance
and admission;
(b) There shall be
interchange, within one working day, of medical or other necessary information
useful in the medical care of the patient transferred to a hospital, or to
another facility; and
(c) Security
and accountability are assured for the patient's personal effects.
(9) The patient care policies
shall cover the following:
(a) Scope of
services provided by the facility (either directly or under
arrangement);
(b) Admission and
discharge policies (in relation to both in-facility care and home
care);
(c) Medical supervision and
physician services;
(d) Patient
care plans, frequency of review, and methods of implementation;
(e) Care of patients in medical and other
emergencies;
(f) Pharmaceutical
services;
(g) Medical records
(including those maintained onsite, maintained offsite by the facility,
maintained in the patients' homes);
(h) Administrative records;
(i) Use and maintenance of the physical plant
and equipment; and
(j) The
provision of home dialysis support services, if offered.
(10) The physician-director of the facility
must be designated in writing and must be responsible for the execution of
patient care policies. If the responsibility for day-to-day execution of
patient care policies has been delegated by a physician-director to a
registered nurse, the physician-director shall provide medical guidance in such
matters.
(11) The facility policy
shall provide that, whenever feasible, hours for dialysis are scheduled for
patient convenience and that arrangements are made to accommodate employed
patients who wish to be dialyzed during their non-working hours.
(12) The governing body shall adopt policies
to ensure there is evaluation of the progress each patient is making toward the
goals stated in the patient's care plan. Such evaluations shall be carried out
through regularly scheduled conferences, with participation by the staff
involved in the patient's care.
(13) Medical supervision and emergency
coverage: The governing body of the facility shall ensure that the health care
of every patient is under the continuing supervision of a physician.
(14) The physician responsible for the
patient's medical supervision shall evaluate the patient's immediate and
long-term needs and shall prescribe a planned regimen of care which covers
indicated dialysis and other treatments, services, medications, diet, special
procedures recommended for the health and safety of the patient, and plans for
continuing care and discharge. Such plans are made with input from other
professional personnel involved in the care of the patient. The facility staff
must ensure the physician orders are implemented appropriately.
(15) The governing body must ensure that
medical care is available for emergencies during the hours the facility is in
operation. The facility shall post at the nursing/monitoring station a roster
with the names of the physicians to be called and how they can be reached.
There shall be a system in place that must direct patients who call during
non-operational hours to appropriate assistance.
Notes
Stat. Auth.: ORS 441.015 & 441.025
Stats. Implemented: ORS 441.025 & 441.055
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