6 Colo. Code Regs. § 1011-1 Chapter 04, pt. 13

Current through Register Vol. 47, No. 20, October 25, 2024

Part 13 - GENERAL PATIENT CARE SERVICES

13.1 The hospital shall provide inpatient and outpatient care services. Services shall be provided in accordance with nationally-recognized standards of practice, hospital policy and procedure, medical orders, and the established care plan.

13.2 Admissions

(A) Each patient admitted to the hospital shall have a visible means of identification placed on their person.

(1) The hospital may use other means of identification, in accordance with documented policies and procedures, if visible means of identification placed on the patient compromises medical or personal safety.

(B) No patient shall be admitted for inpatient care to any room or area other than one regularly designated as a patient bedroom. There shall be no more patients admitted to a patient bedroom than the number for which the room is designed and equipped. Exceptions may be made in the event of federally, state, or locally-declared.

(C) Except in emergent situations, patients shall only be accepted for care and services when the hospital can meet their identified and reasonably anticipated care, treatment, and service needs.

13.3 Written policies and procedures shall be developed and implemented by each department/ or service that provides direct patient care. These policies shall address, at a minimum, the following:

(A) Procedures for medical emergencies, which address the following requirements.

(1) Resuscitation services shall be available throughout the hospital.

(2) The medical staff shall develop and implement a policy and procedure outlining the scope of services provided to patients receiving services who develop emergency medical conditions.

(3) The hospital shall be organized and equipped to meet the needs of patients receiving services who develop emergency medical conditions.

(a) The following shall be readily available at all times in areas where care is provided:

(i) oxygen;

(ii) suction;

(iii) portable emergency equipment, supplies, and medications; and

(iv) compatible supplies and equipment for immediate intravenous therapy.

(4) The hospital shall ensure all medical staff, nursing staff, and auxiliary personnel are trained to provide emergency services commensurate with the hospital's scope of services, and in accordance with nationally-recognized standards of care.

(5) The medical staff shall conduct ongoing assessments of the emergency medical services provided to patients receiving services, as part of the hospital's quality management program, established in Part 8, Quality Management Program.

(B) Coordination of care across multiple services or departments, as applicable.

(C) Transfer of inpatients to a higher level of care when their needs exceed the hospital's scope of services.

13.4 The hospital shall provide the necessary equipment, supplies, and medications commensurate with the scope of services.

13.5 Patient Assessment

(A) Patient assessments shall document patient needs, capabilities, limitations, and goals. Qualified staff shall:

(1) Conduct an initial assessment of the patient's physical and psychological status; and

(2) Conduct an assessment or screening upon each initial contact with therapy, social, nursing, and dietary services, and at regular intervals thereafter.

13.6 Patient Care Planning

(A) A care plan shall be prepared for each patient, and be reviewed and revised as needed. Care plans shall:

(1) Contain goals, both short-term and long-term as applicable, and timeframes for meeting such goals;

(2) Be in writing, and kept current;

(3) Be updated when there is a change in the patient's condition;

(4) Be individualized and designed to meet the patient's needs;

(5) Demonstrate patient-centered coordination when the patient is receiving services from multiple departments or services; and

(6) Address the pain management needs of the patient.

(B) Staff shall evaluate the patient's progress based on the goals established in the care plan.

(C) The complete care plan shall be easily identifiable and accessible within the medical record.

13.7 Orders

(A) Medications and treatments shall be given only on the order of a physician or licensed independent practitioner.

(B) Except as specified in subparagraph (E) below, orders shall be written and shall include the date, time, practitioner giving the order, and specifications of the order. For medications, the name, strength, dosage, frequency, and route of administration shall be indicated.

(C) Orders prescribing high-risk drugs, i.e., narcotics, sedatives, anticoagulants, antibiotics, etc., shall include a time limit. Such time limit shall be agreed upon by the medical staff and shall be so recorded in the policies of the organized medical staff.

(D) For all medications not specifically prescribed as to time or number of doses, the medical staff, in conjunction with the pharmacy service, shall establish stop orders for these medications.

(E) All verbal orders shall be authenticated by a physician or responsible individual who has the authority to issue verbal orders in accordance with hospital and medical staff policies or bylaws. The policies or bylaws shall require that:

(1) Authentication of a verbal order occurs within forty-eight (48) hours after the time the order is made unless a read-back and verify process pursuant to paragraph (2) of this subsection (E) is used. The individual receiving a verbal order shall record in writing the date and time of the verbal order, and sign the verbal order in accordance with hospital policies or medical staff bylaws.

(2) A hospital policy may provide for a read-back and verify process for verbal orders. A read-back and verify process shall require that the individual receiving the order record it in writing and immediately read back the order to the physician or responsible individual, who shall immediately verify that the read-back order is correct. The individual receiving the verbal order shall record in writing that the order was read back and verified. If the read-back and verify process is followed, the verbal order shall be authenticated within 30 days after the date of the patient's discharge.

(3) Verbal orders shall be used infrequently. Nothing in this section shall be interpreted to encourage the more frequent use of verbal orders by the medical staff at a hospital.

13.8 Telehealth Services

(A) The hospital may provide telehealth services to patients receiving services.

(B) All telehealth services must meet the standards herein and be provided commensurate with the patient's needs.

(C) The hospital shall develop and implement policies and procedures governing the use of telehealth. These policies shall be based on nationally-recognized guidelines and standards of practice and address, at a minimum, the following:

(1) Procedures for documenting all telehealth consultations within the patient's medical record.

(2) Procedures for ensuring telehealth providers are authorized and qualified to offer services to the patient.

(3) Training for hospital staff regarding the use of telehealth platforms and technology.

13.9 Discharge Planning

(A) The hospital shall develop a discharge plan for each inpatient.

(B) The hospital shall develop and implement policies and procedures regarding discharge planning. These policies shall be based on nationally-recognized guidelines and standards of practice and address, at a minimum, the following:

(1) The discharge planning process;

(2) The development of the discharge and evaluation plan, which shall be completed under the supervision of a registered nurse, social worker, or other appropriately qualified personnel;

(3) The qualifications of the staff responsible for implementing discharge planning;

(4) Initiation of discharge planning in a timely manner to allow for the arrangement of post-hospital care, as needed, and to avoid unnecessary delays in discharge;

(5) Regular re-evaluation of the patient's condition to identify changes that require modification of the discharge plan;

(6) The hospital's compliance with Section 25-1-128, C.R.S., regarding patient designation of a caregiver who will provide aftercare following patient discharge; and

(7) Evaluation of the discharge planning process periodically for effectiveness.

(C) The discharge plan shall:

(1) Include an evaluation of the post-hospital care needs of the patient and the availability of corresponding services, taking into consideration the patient's access to those services;

(2) Identify the role of the hospital staff, patient, patient's family, or designated representative in initiating and implementing the discharge planning process; and

(3) Be discussed with the patient or designated representative prior to leaving the hospital.

(D) For a patient with a discharge plan indicating the need for post-hospital health care services, the hospital shall:

(1) Inform the patient of the patient's freedom to choose among providers of post-hospital care as well as the choices available under the applicable health insurance coverage.

(2) Provide a comprehensive list of relevant, licensed post-hospital care providers in the geographic area requested. The information regarding post-hospital providers shall be presented in a manner that does not unduly direct patients to use a provider when such direction results in monetary or other benefits and considerations to the hospital or hospital personnel.

(3) Ensure that the receiving health care provider and, as applicable, the patient's primary care physician or licensed independent practitioner receive written documentation of the patient's discharge diagnosis, continuing care orders, current medications prior to discharge, and the patient's discharge or transfer instructions.

(a) Documentation shall also include contact information for the attending physician or licensed independent practitioner.

(b) The hospital must provide all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-hospital care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient's follow-up or ancillary care.

(E) For a patient with a discharge plan who is not transferred to another facility, the hospital shall provide the patient with:

(1) A contact to call in case the patient has questions after discharge.

(2) Written instructions about self-care, follow up care, modified diet, medications, and signs and symptoms to be reported to the practitioner, if applicable.

(F) The hospital shall prepare a discharge summary to facilitate continuity of care that is signed by the attending physician or licensed independent practitioner and includes the following:

(1) Reason for admission;

(2) Significant findings;

(3) Procedures and treatment provided;

(4) Patient's discharge condition;

(5) Patient and family instructions;

(6) A medication list indicating new, changed, or discontinued; and

(7) A list of outstanding medical issues and pending tests at the time of discharge that require follow-up.

6 CCR 1011-1 Chapter 04, pt. 13