S.C. Code Regs. 61-102.C - Governing Authority and Management

Current through Register Vol. 46, No. 3, March 25, 2022

(1) General: Every facility shall be organized, equipped, manned and administered to provide adequate care for each person admitted.
(2) Governing Authority: The governing authority shall be the supreme authority responsible for the management control of the facility and shall develop a written set of bylaws or other appropriate policies and procedures for operation of the facility. These shall: (II)
(a) State the purpose of the facility;
(b) Specify by name the person to whom responsibility for operation and maintenance of the facility is delegated and methods established by the governing authority for holding such individual responsible;
(c) Provide for at least annual meetings of the governing authority;
(d) Provide for a policies and procedures manual which is designed to ensure professional and safe care for the patients to include but not limited to:
(1) admission criteria;
(2) extent of physician participation in the services offered;
(3) rights and responsibilities of patients;
(4) patient grievance procedures;
(5) infection control procedures;
(6) personnel training requirements;
(7) transfer of mothers who, during the course of pregnancy, labor, delivery or recovery, are determined to be ineligible for continued care;
(8) the use of IV's, food, fluids, analgesia/anesthesia, oxytocin, episiotomies, positions for delivery;
(9) provisions for the education of mother, family and others, as appropriate in birthing, newborn care, and maternal postpartum care.
(10) plans for follow-up of mother and infant after discharge from the center;
(11) plans for tests/treatments including, but not limited to, PKU, bilirubin, Rh factor, ophthalmic prophylaxis, and prophylaxis for neonatal hemorrhagic disease;
(12) plan for circumcision.
(e) Provide for annual reviews and evaluations of the facility's policies, procedures, management and operation.
(f) Provide for a facility-wide quality assurance program to evaluate the provision of patient care. The program shall be ongoing and have a written plan of implementation.
(3) Administrator: The chief administrative officer shall be selected by the governing authority and shall have charge of and be responsible for the management and administration of the facility in all its branches and departments and shall see that the bylaws and amendments thereto are complied with. Any change in the position of the chief administrative officer shall be reported immediately by the governing authority to the Department in writing. An individual shall be appointed to act in the absence of the administrator. (II)
(4) Administrative Records: The following essential documents and references shall be on file in the administrative office of the facility:
(a) appropriate documents showing control and ownership;
(b) bylaws, policies and procedures of the governing authority;
(c) minutes of the governing authority meetings if applicable;
(d) minutes of the facility's professional and administrative staff meetings;
(e) a current copy of these regulations;
(f) reports of inspections, reviews, and corrective actions taken related to licensure;
(g) contracts and agreements to which the facility is a party;
(h) a record of each accident or incident occurring in the facility.
(5) Personnel: Qualified personnel shall be employed in sufficient numbers to carry out the functions of the facility. The licensee shall obtain written applications for employment from all employees. Such applications shall contain accurate information as to education, training, experience, health and personal background of each employee. All applications for licensed personnel shall contain the South Carolina license number and/or current renewal number, if applicable. (II)
(a) All new employees who have contact with patients shall have a physical examination prior to employment, which shall include a tuberculin skin test, unless a previously positive reaction can be documented. The intradermal (Mantoux) method, using five tuberculin units of stabilized purified protein derivative (PPD) is recommended. (II)
(1) Employees with positive reactions to the pre-employment tuberculin test and those who are documented with previously positive reactions shall be given a chest x-ray to determine whether tuberculin disease is present. If tuberculosis is diagnosed, appropriate treatment should be given.
(2) Employees who complete treatment, either for disease or infection, may be exempt from further screening unless they have symptoms of tuberculosis.
(3) Positive reactors who are unable or unwilling to take preventive treatment need not receive an annual chest x-ray. These individuals shall be informed of their lifelong risk of developing and transmitting tuberculosis to individuals in the agency and in the community. They shall be informed of symptoms which may suggest the onset of tuberculosis, and of the procedure to follow in reporting suspect symptoms to a designated member of the agency staff.
(4) Employees with negative tuberculin skin tests shall have an annual tuberculin skin test.
(b) Personnel Records: A personnel record folder shall be maintained for each employee. The folder shall contain history and physicals, laboratory test results, resumes of training and experience, current job description that reflects the employee's responsibilities and work assignments, orientation and periodic evaluations. (II)
(c) Job Descriptions:
(1) Written job descriptions which adequately describe the duties of every position shall be maintained.
(2) Each job description shall include: position title, authority, specific responsibilities and minimum qualifications.
(3) Job descriptions shall be reviewed at least annually, kept current and given to each employee when assigned to the position and when revised.
(d) Orientation shall be provided to familiarize each new employee with the facility, its policies, and job responsibility.
(e) Continuing education must be provided to all non-clerical employees at least once a year. Inservice training may be provided by qualified facility staff.
(f) All professional personnel and clinical staff shall be certified in adult and neonatal American Red Cross CPR training.
(6) Emergency:
(a) All practicing and/or consulting physicians shall have admitting privileges at one or more hospitals with appropriate obstetrical services, or other arrangements approved by the Department for the transfer of emergency cases when hospitalization becomes necessary. (I)
(b) Equipment and services shall be provided to render emergency resuscitative and life-support procedures pending transfer to a hospital for both mother and infant. (I)
(c) The center shall enter into a signed written agreement with an ambulance service licensed in this state to ensure the immediate transfer of mothers and/or newborns in emergencies, where appropriate. (I)
(7) Client's Rights:
(a) The birthing center shall have written policies and procedures to assure the individual client the right to dignity, privacy, and safety. The policies and procedures shall be developed by the Director of Midwifery Services and the Director of Medical Affairs, if appropriate, and approved by the governing body.
(b) Each center shall display in a conspicuous place on the premises, a copy of the "Rights of Patients."

Notes

S.C. Code Regs. 61-102.C

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