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

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

Part 6 - GOVERNANCE AND LEADERSHIP

6.1 Administrator

(A) The FSED shall have an administrator or a designated person who is principally responsible for directing the daily operation of the FSED and acts as an administrative liaison with the governing body and medical director.

(B) The administrator shall be responsible for the development and implementation of:

(1) Policies and procedures for all FSED operations. The policies and procedures shall be reviewed and updated as needed, but no less than every three years.

(2) A written organizational plan defining the authority, responsibility, and function of each category of personnel.

(3) A written policy or plan defining the scope of care and services offered, which shall include emergency services, as required in Part 18, and optional primary care services as defined in Part 2.10, if provided.

(4) If primary care services are offered, the FSED administrator, in conjunction with the governing body and medical director, shall ensure that policies, procedures, and clinical guidelines are developed, implemented, and maintained for any primary care services included in the scope of care.

6.2 Governing Body

(A) An FSED shall have a governing body that is legally responsible for the conduct of the FSED.

(B) The governing body shall:

(1) Meet at least annually and maintain accurate records of such meetings.

(2) Adopt the general bylaws by which the governing body operates.

(3) Ensure that patients receive care in a safe setting, including providing the equipment, supplies, and facilities necessary for the welfare and safety of patients.

(4) Ensure that there are written procedures for:

(a) Lines of authority and accountability, and

(b) The qualifications of the personnel performing care.

(5) Ensure the approval and implementation of written policies and procedures in cooperation with the administrator and medical director.

(6) Ensure that there is sufficient staff to meet the demands for services routinely provided and coverage during periods of high demand or emergency.

(7) Ensure any disciplinary action that results in a suspension, revocation, or limitation of the privileges of a member of the provider, nursing, or ancillary staff is reported to the appropriate licensing or certification authority.

(8) Ensure that the FSED meets all of the Quality Management Program requirements of Part 8.

(9) Establish a patient transfer plan that includes:

(a) Agreements with a hospital(s) that include procedures for obtaining air or ground transportation, as appropriate.

(b) Policies and procedures for when an emergency medical condition necessitates patient transfer. The patient shall be transferred, avoiding delay in care and with consideration of transport time, to the closest, most appropriate acute care hospital with the resources necessary to meet the needs of the patient, unless either of the following dictates otherwise:

(i) The federal Emergency Medical Treatment and Active Labor Act

(EMTALA) requirements codified at 42 U.S.C. 1395dd, or

(ii) Regional trauma triage protocols.

(c) Transfer protocols to include:

(i) Coordination with the local emergency medical services system and licensed ambulance services.

(ii) Triage and stabilization to be initiated by on-duty staff.

(iii) Transfer of relevant patient information with the patient.

(iv) Compliance with all requirements as a designated or non-designated trauma center per regulation, 6 CCR 1015-4, Chapter Three, 301.3.

6.3 Medical Director

(A) A medical director shall be a physician, licensed under the laws of the State of Colorado, who is a member of the FSED's staff and who is qualified by education and experience to oversee the services provided by the FSED. The medical director shall be responsible for the quality of medical care provided to patients in the facility.

(B) The medical director shall be responsible for the development of policies and procedures related to the medical care provided. The policies and procedures shall be approved by the appropriate members of the provider staff and reviewed and updated as needed, but no less than every three years.

(C) The medical director shall serve as the formal clinical liaison with the governing body.

(D) The medical director shall ensure that services are provided in accordance with current standards of practice and are consistent with standards established through the Quality Management Program as defined in Part 8.

(E) The medical director shall be responsible for the coordination of all the professional medical consultants to the FSED, if any.

6 CCR 1011-1 Chapter 13, pt. 6