Ala. Admin. Code r. 420-5-11-.02

Current through Register Vol. 42, No. 10, July 31, 2024

Section 420-5-11-.02 - Administration

(1)Governing Authority.

(a) Responsibility. The governing authority or the owner or the person or persons designated by the owner as the governing authority shall be the supreme authority of the facility including the appointment of a qualified medical staff, or in the absence of an organized medical staff, a medical doctor.

(b) Organization. The governing authority shall be formally organized in accordance with a written constitution and/or bylaws. In the event the governing authority consists of one person, this requirement must still be met. Such constitution and/or bylaws shall include:

1. Identification of the facility.

2. The purpose for which the facility is organized.

3. Describe qualifications for membership in the governing body, election, and tenure of office.

4. Provide for the election and specification of duties of officers.

5. Establish regular and special meetings of the governing body.

6. Describe method of amending bylaws.

7. Establish quorum requirements.

8. Appointment and duties of the chief executive officer.

(c) Meetings. The governing authority shall meet at least annually. A copy of the minutes of these meetings shall be kept as a permanent record of the facility.

(d) Notification of Chief Executive Officer. The State Board of Health shall be advised of the chief executive officer's name within 15 days of his appointment.

(2)The Chief Executive Officer.

(a) Responsibility.

1. The chief executive officer is also referred to as the facility administrator.

2. There shall be a competent, well trained chief executive officer who shall assume executive authority and responsibility for directing, coordinating, and supervising the overall activities of the center. The chief executive officer and the medical director or other qualified employee of the facility may be one and the same person, depending upon the size and degree of management and supervision required for appropriate operation of the center.

3. The chief executive officer shall designate a qualified individual to represent him in his absence.

(b) Enforcement of Medical Staff Regulations. As the authorized representative of the governing authority, the chief executive officer shall have the authority to enforce medical staff rules and regulations with regard to patient care, after consultation with appropriate members of the medical staff.

(c) Policies and Procedures. The chief executive officer shall be responsible for assuring either directly or through delegation of authority that policies promulgated by the governing authority are carried out. Appropriate procedures to enforce these policies, assure proper patient care and safety, and meet requirements of these Rules shall be developed in writing.

(3)Personnel.

(a) Medical Director. In the absence of organized medical staff, the center will have an appointed medical director. The functions provided by the medical director include:

1. To maintain a liaison role with the medical community.

2. To participate in quality of care review functions, such as utilization review and peer review program evaluation. Either minutes of this review will be maintained or procedure manuals shall be annotated to reflect the review, date, and persons involved in the review.

3. To establish, with the participation of professional staff, criteria for the adequacy of individual patient treatment presumptions.

4. To advise facility staff on problems in patient care management and to participate in inservice training.

5. To participate in staff evaluation of service concepts and techniques.

6. To advise on the development of new programs and modification of existing programs.

7. To advise on matters of a medical nature.

8. To assure that services required by law to be prescribed by a physician, when available, are provided in such a way as to assure acceptable levels of quality.

(b) Director of Nursing Services. If nursing services are not provided, AAC Rules 420-5-11-.02(3)(b) and (c) do not apply. A registered professional nurse shall be responsible for proper performance of nursing services provided in the center.

(c) Responsibilities of Director of Nursing Services.

1. Work within the framework of policies set forth by the medical director.

2. Develop nursing service policies and procedures.

3. Develop a job description for each nursing position.

4. Provide a thorough orientation for new nursing personnel, including written verification of their competency.

5. Provide supervision of nursing service personnel.

6. Provide ongoing inservice.

7. Verifications of license and physical exams to ensure they are current.

8. Ensure that adequate nursing personnel are provided to meet the needs of patients.

(d) Non-Nursing Service Personnel. Non-nursing service personnel, i.e., counselors, housekeeping, office, etc., shall be assigned in sufficient numbers and with sufficient training to meet the needs of patients.

(e) Personnel Policies. Facilities shall make available to each employee a manual setting forth personnel policies as approved by the governing body. These policies shall include, but not be limited to, the following: purpose; organizational structure; facility programs; personnel qualifications; employment procedures to include application for employment; term of probationary service; work attendance; leave policies; general payroll information; evaluation; disciplinary measures; responsibilities to facility and to patients; dress; benefits; appeal or grievance process; and termination. These policies shall be reviewed and updated yearly by the governing body.

(g) Qualifications.

1. Professional staff members shall meet all educational requirements as approved by a nationally recognized accrediting body, and/or shall currently hold certification by a national association, or shall have documented equivalent training and/or experience. All professional personnel shall be licensed, if applicable, under state statute for the profession in which they practice.

2. Position descriptions shall be written for all employees and volunteer personnel. Position description shall specify qualifications, duties, positions supervised, and whom the employee or volunteer will report to.

3. Provisions must be established to maintain competency of staff members through inservice training, continuing education courses, or other means.

(4)Disaster Plan.

(a) Written Disaster Plan.

1. Rehabilitation centers shall have a written disaster plan which contains procedures to be followed in the event of fire, explosion, or other disaster. The plan must address the following:

(i) Notification of emergency services and designated personnel.

(ii) Assignment of specific responsibilities to all personnel.

(iii) Instructions on the use of alarm systems and signals, also the location and use of fire fighting equipment and methods of fire containment.

(iv) An operational plan dealing with bomb threats, including appropriate notifications, search procedures, and evacuation of patients and personnel.

(v) Specification of evacuation routes and procedures.

(vi) Management of casualties and records.

2. Written instructions, including evacuation routes, shall be posted in conspicuous places in the facility and kept current.

(b) Drills. A simulated disaster drill shall be conducted annually. Fire drills shall be conducted quarterly at varied times and for each shift, if the facility operates multiple shifts. Written records of sufficient detail to record staff response to the fire/disaster drills shall be maintained for a period of three years.

(5)Communication.

(a) Call System. Arrangements shall be provided within the facility to summon additional personnel or help when or if needed in the event of emergency conditions. Requirements will depend on the size and physical configuration of the facility. In general, if all personnel (or occupants) are within hearing distance of any area of the facility, this would be deemed sufficient. Otherwise, there shall be a call system to all portions of the building normally occupied by personnel of the facility.

(b) Telephones. There shall be an adequate number of telephones to summon help in case of fire or other emergency, and these shall be located so as to be quickly accessible from all parts of the building.

(6)Records and Reports.

(a) Medical Records to be Kept. Rehabilitation centers shall keep adequate records, including admission and discharge notes, histories, results of examinations, nurses' notes, social service records, records of tests performed, and other records as indicated.

(b) Authentication of Records. All records shall be written, dated and signed in an indelible manner and made a part of the patient's permanent record.

(c) Filing of Records. All patient medical records shall be filed in a manner which will facilitate easy retrieval of any individual's record. If records are filed according to a number system, alphabetical cross-indexing shall be available.

(d) Title to Records. Records of patients are the physical property of the rehabilitation center and responsibility for control of them shall rest with the chief executive officer and governing authority.

(e) Records Shall be Confidential. Records and information regarding patients shall be confidential. Access to these records shall be determined by the governing authority of the facility. Inspectors for licensure or other persons authorized by State or Federal laws shall be permitted to review medical records as necessary for compliance.

(f) Preservation of Records. Medical records shall be preserved, either in the original or by microfilm for a period of not less than five years following the most recent discharge, or three years after the patient becomes of age.

(g) Personnel Records. The facility shall maintain a personnel record for each employee. As a minimum the record shall include:

1. Application for employment that contains information regarding education, experience, and if applicable, registration and/or licensure information of the applicant.

2. Record of physical examination or certificate of freedom from communicable disease.

(h) Accounting System. The facility shall establish an accounting system which properly accounts for all revenue and expenses.

(i) Fees. Fees for services shall be established and be made known to patients prior to, or at time of, entry into any program offered.

(j) Maintenance of Records. Each facility shall establish policies and appropriate safeguards to insure confidentiality, protection from unauthorized removal, protection from fire and water hazards, and limit access to those authorized by the Chief Executive Officer. Records shall be maintained for a minimum of five years. Records shall include:

1. Minutes of governing body meetings.

2. Minutes of administrative and professional staff meetings.

3. Safety and health related inspection reports.

4. Financial records.

5. Accident and incident reports which shall be recorded on a form designed for this purpose and which have documentation contained thereon which indicates a thorough investigation of the accident/incident has been conducted. These reports shall apply to patients and staff members.

6. Statistical records and correspondence files.

7. Cleaning and disinfecting of therapy equipment.

8. Machine calibration.

(k) Case Records.

1. A committee of professional staff members shall review quarterly a sample of active and closed records to determine compliance and effectiveness of established programs and procedures.

2. Case records shall contain sufficient information to identify the patient clearly, to justify the diagnosis(es) and treatment, and to document the results accurately. Required information shall, as a minimum, include:

(i) Documented evidence of the assessment of the needs of the patient, of an appropriate plan of care, and of the care and services provided.

(ii) Identification data, consent forms, and name and address of sponsor/guardian.

(iii) Medical history.

(iv) Report of physical examination, if appropriate.

(v) Observations and progress notes from each service involved.

(vi) Evaluation reports, reports of treatment and clinical findings.

(vii) Discharge summary.

(l) Transfer Agreement. Facility shall have a written plan to ensure prompt referral and backup services for patients requiring attention for an emergency or other condition necessitating hospitalization.

(m) Disposition of Records. When a rehabilitation center ceases to operate, either voluntarily or by revocation of its license, the governing body (licensee) at or prior to such action shall develop a proposed plan for the disposition of its medical records. Such plans shall be submitted to the State Committee of Public Health for approval and shall contain provisions for the proper storage, safeguarding and confidentiality, transfer and/or disposal of patient's medical records and x-ray files. Any rehabilitation center that fails to develop a plan of disposition, acceptable by the State Committee of Public Health, of its records shall dispose of its records as directed by a court of appropriate jurisdiction.

L. O'Neal Green, Rick Harris

Ala. Admin. Code r. 420-5-11-.02

Original rules effective January 1, 1981. Repealed and New Rule: Filed December 17, 2003; effective January 21, 2004.

Statutory Authority:Code of Ala. 1975, §§ 22-2-2(6), 22-21-20, etseq.