10A N.C. Admin. Code 13S.0319

Current through Register Vol. 39, No. 12, December 1, 2024

Section 13S .0319 - POLICIES AND PROCEDURES AND ADMINISTRATIVE RECORDS

(a) The following documents and references shall be on file in the administrative office of the clinic:

(1) documents evidencing control and ownerships, such as deeds, leases, or incorporation or partnership papers;

(2) policies and procedures of the governing authority, as required by Rule .0318 of this Section;

(3) minutes of the governing authority meetings;

(4) minutes of the clinic's professional and administrative staff meetings;

(5) a current copy of the rules of this Subchapter;

(6) reports of inspections, reviews, and corrective actions taken related to licensure; and

(7) contracts and agreements related to care and services provided by the clinic as a party.

(b) All operating licenses, permits, and certificates shall be displayed on the licensed premises.

(c) The governing authority shall prepare a manual of clinic policies and procedures for use by employees, medical staff, and physicians to assist them in understanding their responsibilities within the organizational framework of the clinic. These shall include:

(1) patient selection and exclusion criteria;

(2) clinical discharge criteria;

(3) emergency protocols as required by Rule .0326;

(4) policy and procedure for validating the full and true name of the patient;

(5) policy and procedure for abortion procedures performed at the clinic;

(6) policy and procedure for the provision of patient privacy in the recovery area of the clinic;

(7) protocol for determining gestational age as defined in Rule .0101(5) of this Subchapter; and

(8) protocol for referral of patients declined services by the clinic.

10A N.C. Admin. Code 13S .0319

Authority G.S. 131E-153.5; 143B-165;
Codifier determined that findings of need did not meet criteria for emergency rule on October 30, 2023;
Emergency Rule North Carolina Register Volume 38, Issue 11, December 1, 2023 effective 11/14/2023, exp. 1/30/2024 (Emergency).

Temporary Adoption by North Carolina Register Volume 38, Issue 17, March 1, 2024 effective 2/8/2024, exp. 11/26/2024.

Amended by North Carolina Register Volume 39, Issue 09, November 1, 2024 effective 10/1/2024.