La. Admin. Code tit. 48 § I-9323

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

Section I-9323 - Administration

A. In accordance with the hospital policy, there shall be a full-time, administrator who is responsible for the operation of the hospital commensurate with the authority conferred by the governing body. Beginning June 1, 2025, no administrator shall be administrator of more than one licensed hospital.

B. The chief executive officer or administrator of the hospital shall have at least one of the following qualifications:

1. a master's degree and at least three years of full-time experience in progressively responsible management positions in healthcare;

2. a baccalaureate degree and at least five years of full-time experience in progressively responsible management positions in healthcare; or

3. at least 10 years of full-time experience in hospital administration;

a. hospital administrators employed in Louisiana licensed hospitals at the time the final regulations are adopted and become effective shall be deemed to meet the qualifications as long as the individual holds their current position. If the individual leaves their current position as hospital administrator, they shall meet one of the qualifications above to be re-employed into such a position.

C. There shall be sufficient qualified personnel to properly operate each department of the hospital and provide quality patient care and related services.

D. All new employees, including volunteer workers, prior to or at the time of employment and annually thereafter shall be verified to be free of tuberculosis in a communicable state.

E. The hospital shall have policies and procedures that define how the facility will comply with current regulations regarding healthcare screenings of hospital personnel.

F. The hospital shall have policies and procedures and require all personnel to immediately report any signs or symptoms of a communicable disease or personal illness to their supervisor or administrator as appropriate for possible reassignment or other appropriate action to prevent the disease or illness from spreading to other patients or personnel.

G. The hospital shall have policies and procedures that define how the facility shall:

1. comply with the provisions of the Safe Haven Act inclusive of training and designating responsible employees;

2. comply with the regulations for checking the DSW registry for new employees, rehired employees, or when an employee has a break in service;

3. comply with obtaining criminal history checks on unlicensed assistive personnel or other direct care staff upon hiring or reemploying or when employee has a break in service. Such policy shall address the disposition of any charges;

4. prevent, respond to, report, and mitigate instances of healthcare workplace violence; and

5. comply with all reporting requirements including, but not limited to, the induced termination of pregnancy (ITOP) form and other documentation as required by federal, state, and local statutes, laws, ordinances, and department rules and regulations.

La. Admin. Code tit. 48, § I-9323

Promulgated by the Department of Health and Human Resources, Office of the Secretary, LR 13:246 (April 1987), amended by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 21:177 (February 1995), LR 29:2407 (November 2003), Amended by the Department of Health, Health Standards Section, LR 501481 (10/1/2024).

AUTHORITY NOTE: Promulgated in accordance with R.S.36:254 and R.S. 40:2100-2115.