La. Admin. Code tit. 48 § I-8439

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-8439 - General Provisions

A. Administration

1. The administrative staff shall be qualified and adequate to assure adherence to all licensing standards.

2. Qualifications of all facility staff shall meet or exceed those required by federal regulations.

3. Facility compliance with licensing standards shall determine adequacy of available administrative oversight.

4. Facilities shall be organized so that administrative personnel do not perform any clinical duties and/or make clinical decisions, unless the individual is licensed or certified to make clinical decisions.

B. Referrals, Credentials, and Contract Services

1. Facility personnel shall report referral violations of laws, rules, and professional and ethical codes of conduct to HSS and to appropriate licensing boards when applicable. The facility shall maintain records and have written policies governing staff conduct and reporting procedures that comply with this requirement.

2. The facility administrator is responsible for assuring that all credentials are from accredited institutions, are legal, and have been verified to deter the fraudulent use of credentials.

3. The facility must have formal written agreements with outside professionals or other entities retained to provide contract services. Written agreements shall express the responsibilities between the two parties, be signed by both parties and shall either be time-limited or remain in effect until either party terminates the agreement in writing.

C. Staffing Criteria. Each facility shall develop and implement staffing level criteria to assure compliance with all licensing standards and to provide quality care within the established parameters of current standards of practice.

1. Consideration for determination of adequate nursing staffing levels will include:

a. acuity of patients;

b. physical design of facility;

c. equipment design and complexity; and

d. additional pertinent information as needed.

2. A registered nurse or physician shall be present during and after treatment and until the last patient has left the facility.

3. Any experience used to qualify for any position must be counted by using one year of experience equals 12 months of full-time work.

4. A person may hold more than one position within the facility if that person is qualified to function in both capacities, and the required hours for each job are separate and apart for each position.

5. Social work staffing shall be based on the staffing guidelines developed by the Council of Nephrology Social Workers which addresses the following:

a. treatment setting;

b. number of patients seen or anticipated to be seen in a year;

c. their psychological risk (acuity); and

d. the number of mutually agreed upon social work functions, including, but not limited to:

i. psycho-social evaluations;

ii. casework counseling;

iii. group work;

iv. information and referral;

v. facilitating community agency referral;

vi. team care planning and collaboration;

vii. transfer planning;

viii. pre-admission planning;

ix. discharge planning

x. facilitating use of hospital and/or facility services

xi. patient/family education;

xii. financial assistance;

xiii. staff consultation; and

xiv. community health services.

La. Admin. Code tit. 48, § I-8439

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 28:2197 (October 2002), amended LR 30:433 (March 2004).

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:153 and R.S. 40:2117.4.