R432. Health and Human Services, Health Care Facility Licensing.

R432-100. General Hospital Standards.

R432-100-1. Authority and Purpose.

(1) Sections 26B-2-202 and 26B-2-203 authorize this rule.

(2)(a) This rule promotes public health and welfare through the establishment and enforcement of licensure standards.

(b) This rule sets standards for the construction and operation of a general hospital. The standards of patient care apply to inpatient, outpatient, and satellite services.

R432-100-2. Definitions.

Terms used in this rule are defined in Rule R432-1. Additionally:

(1) "Caregiver" means an individual designated by a patient of the hospital to assist with continuing care that can be given in the patient's residence after discharge.

(2) "County of the first class or second class" means the same as described in Section 17-50-501.

(3) "Hospital blood services" are defined as follows:

(a) "Blood bank" means a facility that combines the functions of a donor center and transfusion service within the same facility;

(b) "Donor center" means a facility that procures, prepares, processes, stores, and transports blood and blood components; or

(c) "Transfusion service" means a facility that stores, determines compatibility, transfuses blood and blood components, and monitors transfused patients for any adverse effect.

(4) "Satellite emergency department" means the same as defined in Section 26B-2-203.

(5) "Swing-bed" means a hospital room that can switch from inpatient acute care status to skilled care status.

(6) "Type I Acute or Critical Access Hospital" means a hospital that offers comprehensive emergency care 24 hours a day in-house, with at least one physician experienced in emergency care on staff in the emergency care area.

(7) "Type II Acute or Critical Access Hospital" means a hospital that offers emergency care 24 hours a day, with at least one physician experienced in emergency care on duty in the emergency care area, and with specialty consultation available within 30 minutes by members of the medical staff.

(8) "Type III Acute or Critical Access Hospital" means a hospital that offers emergency care 24 hours a day, with at least one physician available to the emergency care area within 30 minutes through a medical staff call roster.

(9) "Type IV Acute or Critical Access Hospital" means a hospital that offers emergency first aid treatment to patients, staff, and visitors; and to persons who may be unaware of, or unable to, immediately reach services in other facilities.

R432-100-3. Construction, Facilities, and Equipment Standards.

A licensee shall comply with Rule R432-4 when constructing and maintaining a general hospital and satellite services.

R432-100-4. Hospital Swing-Bed and Transitional Care Units.

(1) A licensee that operates a hospital with designated swing-bed units or transitional care units shall comply with this section.

(2) In addition to this rule, a licensee that operates designated hospital swing-beds shall comply with:

(a) Section R432-150-4, Scope of Services;

(b) Section R432-150-5, Adult Day Care Services;

(d) Section R432-150-11, Resident Rights;

(e) Section R432-150-12, Resident Assessment;

(f) Section R432-150-13, Restraint Policy;

(g) Section R432-150-14, Quality of Care;

(h) Section R432-150-15, Physician Services;

(i) Section R432-150-16, Laboratory Services;

(j) Section R432-150-17, Pharmacy Services;

(k) Section R432-150-18, Recreation Therapy;

(l) Section R432-150-20, Admission, Transfer, and Discharge; and

(m) Section R432-150-22, Food Services.

(3) A transitional care unit requires licensure as a nursing care facility under a separate licensing category and the licensee shall conform to the requirements of Rule R432-150.

R432-100-5. Governing Body.

(1) Each licensee shall have a governing body referred to in this rule as the board.

(2) The board members are legally responsible for the conduct of the hospital staff. The board members are also responsible for the appointment of the medical staff and an administrator assigned to carry out the requirements of Section R432-100-6.

(3) The licensee shall ensure that the board is organized in accordance with the articles of incorporation or bylaws that specify:

(a) the board's functional organization, including any standing committee;

(b) the duties and responsibilities of each board member;

(d) the frequency of meetings;

(e) the mechanism for formal approval of the organization, bylaws, rules of the medical staff, and hospital departments;

(f) the method for election or appointment to the board;

(g) the methods established by the board for holding such individuals responsible;

(h) the methods for removal of board members and officers;

(i) the numbers or percentages of members that constitute a quorum for board meetings;

(j) the size of the board;

(k) the terms of office of the board; and

(l) to who responsibility for operation and maintenance of the hospital, including evaluation of hospital practices, may be delegated.

(4) The board members shall:

(a) meet at least quarterly; and

(b) keep written minutes of meetings and actions and distribute copies to members of the board.

(5)(a) The board members shall employ a competent administrator and vest this person with authority and responsibility for carrying out board policies.

(b) The board shall define, in writing, the administrator's qualifications, responsibilities, authority, and accountability.

(6) The board, through officers, committees, medical, and other staff, shall:

(a) appoint members of the medical staff and delineate clinical privileges;

(b) approve organization, bylaws, and rules of medical staff and hospital departments;

(d) maintain a list of the scope and nature of any contracted services.

R432-100-6. Administrator.

(1) The administrator shall establish and maintain an organizational structure for the hospital indicating the authority and responsibility of various positions, departments, and services within the hospital.

(2) The administrator shall:

(a) advise the board in the formulation of hospital policies and procedures;

(b) appoint a member of the staff to oversee compliance with the requirements of the Utah Anatomical Gift Act;

(d) designate, in writing, a person to act in the administrator's absence;

(e) ensure that each applicant for medical and professional staff membership is oriented to agency or hospital bylaws and shall agree in writing to abide by each condition;

(f) ensure that patient billing practices comply with Section 26B-2-219;

(g) ensure that policies and procedures are implemented and followed;

(h) function as liaison between the board, the medical staff, the nursing staff, and departments of the hospital;

(i) maintain a written record of any business transactions and patient services provided in the hospital and submit reports as requested to the board;

(j) review and revise policies and procedures to reflect current hospital practice; and

(k) submit to OL, upon receipt from any accrediting organization, copies of each:

(i) certificate;

(ii) survey report; and

(iii) recommendation of any survey result.

R432-100-7. Medical and Professional Staff.

(1) Each licensee shall have an organized medical and professional staff that operates under bylaws approved by the board.

(2) The medical and professional staff shall advise and be accountable to the board for the quality of medical care provided to patients.

(3)(a) The medical and professional staff shall adopt bylaws and policies and procedures to establish and maintain a qualified medical and professional staff, including current licensure, relevant training and experience, and competency to perform the privileges requested.

(b) The bylaws shall address:

(i) a fair hearing and appeal process;

(ii) temporary credentialing and privileging of staff in emergency or disaster situations;

(iii) the appointment and re-appointment process;

(iv) the delineation of privileges;

(v) the necessary qualifications for membership; and

(vi) the participation and documentation of continuing education.

(4)(a) A fully qualified physician who is licensed by the Department of Commerce shall supervise and direct the medical care of each person admitted to the hospital.

(b) During an emergency or disaster situation, a member of the credentialed and privileged staff shall supervise temporary credentialed practitioners.

(5) The licensee may not deny an applicant that is a podiatrist or psychologist solely on the grounds that the podiatrist or psychologist is not licensed to practice medicine under Title 58, Chapter 67, Utah Medical Practice Act or Title 58, Chapter 68, Utah Osteopathic Medical Practice Act.

(6) Membership and privileges may not be denied on any ground that is otherwise prohibited by law.

(7) The licensee shall orient each applicant for medical and professional staff membership to the bylaws and ensure the applicant agrees, in writing, to abide by each condition.

(8) The medical and professional staff shall review each applicant and grant privileges based on the scope of the applicant's license and abilities.

(9) The medical and professional staff shall review appointments and re-appointments to the medical and professional staff at least every three years.

(10) During an emergency or disaster situation, the licensee shall ensure that each temporary practitioner is oriented to the temporary practitioner assigned area.

R432-100-8. Personnel Management Service.

(1) The licensee shall organize the personnel management system to ensure personnel are competent to perform respective duties, services, and functions.

(2) The licensee shall ensure there are written policies, procedures, and performance standards that include:

(a)(i) direct care staff having current cardiopulmonary resuscitation (CPR) certification, which requires:

(ii) an in-person course, to include skills testing and evaluation on-site with a licensed instructor;

(b) direct care staff receiving continued competency training in current patient care practices;

(d) employee health screening, including tuberculosis skin testing:

(i) within two weeks of:

(A) development of symptoms of tuberculosis;

(B) initial hiring; or

(ii) done by the Mantoux method or another Food and Drug Administration (FDA)-approved in vitro serologic test and follow-up for tuberculosis in accordance with Rule R388-804; and

(iii) which may be exempt for an employee with a known positive reaction to skin testing;

(e) Occupational Safety and Health Administration regulations regarding bloodborne pathogens being implemented and followed;

(f) job descriptions for each position or employee; and

(g) periodic employee performance evaluations.

(3) The licensee shall ensure that medical and professional personnel are registered, certified, or licensed as required by the Department of Commerce within 45 days of employment.

(4) The licensee shall maintain a copy of each current certificate, license, or registration available for department review.

(5) The licensee shall provide annual documented in-service training for direct care and housekeeping staff that addresses the requirements for reporting abuse, neglect, or exploitation of children or adults.

(6)(a) The licensee may utilize a volunteer in the daily activities of the hospital but a volunteer may not be included in the hospital staffing plan in lieu of hospital employees.

(b) The licensee shall screen and supervise a volunteer according to hospital policy.

(c) The licensee shall ensure that a volunteer is familiar with hospital volunteer policies, including patient rights and hospital emergency procedures.

(7) If the licensee participates in a professional graduate education program, the licensee shall ensure that there are policies and procedures specifying the patient care responsibilities and supervision of the graduate education program participants.

R432-100-9. Quality Improvement Plan.

(1) The board members shall ensure that there is a well-defined quality improvement plan designed to improve patient care.

(2) The plan shall:

(a) be consistent with the delivery of patient care;

(b) be implemented and include a system for the collection of indicator data;

(d) implement actions designed to eliminate identified problems and improve patient care;

(e) include a system for assessing identified problems, concerns, and opportunities for improvement of patient care; and

(f) include an incident reporting system to identify problems, concerns, and opportunities for improvement of patient care.

(3)(a) The licensee shall maintain a quality improvement committee.

(b) The quality improvement committee shall maintain written minutes documenting any corrective action and result and make these minutes available for department review.

(4) The quality improvement committee shall report findings and concerns, at least quarterly, to the board, the medical staff, and the administrator.

(5) The licensee shall ensure that infection reporting is integrated into the quality improvement plan and is reported to the department in accordance with Rule R386-702.

R432-100-10. Infection Control.

(1) The licensee shall implement a hospital-wide infection control program that includes:

(a) a system for reporting, evaluating, and investigating infections;

(b) an employee health program;

(d) documented in-service education for departments and services related to infection control;

(e) laboratory services;

(f) methods for isolation depending on the medical condition involved;

(g) orientation of new employees;

(h) preventative, surveillance, and control procedures; and

(i) review and evaluation of aseptic, isolation, and sanitation techniques.

(2) The licensee shall incorporate infection control reporting data into the hospital quality improvement plan.

(3) The licensee shall ensure that:

(a) reuse data is incorporated into the hospital infection control identification and reporting processes;

(b) reuse data is incorporated into the quality improvement plan;

(d) there are specific policies and procedures for each type of reusable item;

(e) there are written infection control policies and procedures for each area of the hospital, including requirements dictated by the physical layout, personnel, and equipment involved; and

(f) there are written policies for the selection, storage, handling, use, and disposition of disposable or reusable items.

R432-100-11. Patient Rights.

(1) The licensee shall inform each patient during admission of patient rights and support the exercise of the patient's right to:

(a) access medical records and purchase, at a cost not to exceed the community standard, photocopies of that patient's record;

(b) be examined and treated in surroundings designed to give visual and auditory privacy;

(c) be free from mental and physical abuse and from chemical and, except in emergencies, physical restraints, except as authorized in writing by a licensed practitioner for a specified and limited period or when necessary to protect the patient from self-injury or from injuring another;

(d) be fully informed of that patient's medical health status in a language the patient can understand;

(e) express any complaint regarding the care received and to have that complaint resolved when possible;

(f) formulate an advance health care directive in accordance with the Title 75A, Chapter 3, Health Care Decisions;

(g) participate in the decision-making process in managing that patient's health care with the patient's physician, or to have a designated representative involved;

(h) refuse to participate in experimental treatment or research;

(i) refuse treatment;

(j) reasonable access to care; and

(k) uniform, considerate, and respectful care.

(2)(a) The licensee shall establish a policy and inform patients and legal representatives regarding the withholding of resuscitative services and the forgoing or withdrawing of life-sustaining treatment and end-of-life care.

(b) The licensee shall ensure the policy is consistent with Title 75A, Chapter 3, Health Care Decisions.

R432-100-12. Patient Designated Caregiver.

(1) The licensee shall give a patient admitted to the hospital the opportunity to designate a caregiver to assist the patient with continuing care after discharge from the hospital.

(a) The licensee shall document the designated caregiver in the patient record and include contact information.

(b) If the patient declines to designate a caregiver, the licensee shall document the patient's choice in the medical record.

(2) The licensee shall notify the designated caregiver as soon as practicable before:

(a) the patient is discharged back to the patient's own residence; or

(b) the patient is transferred to another health facility.

(3) The licensee shall document each date and time of any attempt to contact the designated caregiver in the patient record.

(4) If the licensee cannot contact the designated caregiver when changes occur, the lack of contact may not interfere with, delay, or otherwise affect the medical care provided to the patient or the transfer or discharge of the patient.

(5) The patient may give written consent to allow the licensee to release medical information to the designated caregiver, pursuant to the hospital's established procedures for the release of personal health information.

(6) Before the patient is discharged, the licensee shall provide a written discharge plan for continuing care needs to the patient and designated caregiver, that shall include:

(a) a description of continuing care tasks that the patient requires, in a culturally competent manner;

(b) contact information for any other health care resources necessary to meet the patient's needs; and

(7) Before the patient is discharged, the licensee shall provide the designated caregiver with an opportunity for instruction in continuing care tasks outlined in the discharge plan, that shall include:

(a) demonstration of the continuing care tasks by hospital personnel;

(b) education and counseling about medications, including dosing and proper use of delivery devices; and

(c) opportunity for the patient and designated caregiver to ask questions and receive answers regarding the continuing care tasks.

(8) The licensee shall document the instruction given to the patient and designated caregiver in the patient record, to include the date, time, and contents of the instructions.

R432-100-13. Nursing Care Services.

(1)(a) The licensee shall ensure that there is an organized nursing department that is integrated with other departments and services.

(b) The licensee shall ensure the chief nursing officer of the nursing department is a registered nurse with demonstrated ability in nursing practice and administration.

(c) The chief nursing officer shall approve the nursing policies and procedures, nursing standards of patient care, and standards of nursing practice.

(d) The licensee shall ensure a registered nurse is designated and authorized to act in the chief nursing officer's absence.

(e) Nursing tasks may be delegated pursuant to Section R156-31b-701a.

(2) The licensee shall ensure qualified registered nurses are on duty 24 hours a day to give patients nursing care that requires the judgment and special skills of a registered nurse.

(3) The nursing department shall develop and maintain a system for determining staffing requirements for nursing care on the basis of demonstrated patient need, intervention priority for care, patient load, and acuity levels.

(4)(a) The licensee shall ensure nursing care is documented for each patient from the time of admission through discharge.

(b) A registered nurse shall document each patient's nursing care and coordinate interdisciplinary care.

(i) clinical diagnoses;

(ii) intervention identified to meet the patient's needs;

(iii) nursing care provided and the patient's response;

(iv) the ability of the patient, family, or designated caregiver to manage the continued care after discharge;

(v) the assessments of each patient's needs; and

(vi) the outcome of the care provided.

(d) Before discharge, each patient shall receive written instructions for any follow-up care or treatment.

R432-100-14. Critical Care Unit.

(1) A licensee that provides a critical care unit shall comply with the requirements of this section. The scope of services as delineated in hospital policy and board approval shall dictate the medical direction for the unit.

(2) A designated, qualified, registered nurse manager with relevant education, training, and experience in critical care shall provide critical care unit nursing direction. The nurse manager shall:

(a) assure that a registered nurse who has advanced life support certification is on duty and present in the unit 24 hours a day;

(b) coordinate the care provided by any nursing service personnel in the critical care unit; and

(3) The licensee shall ensure that each critical care unit is designed and equipped to facilitate the safe and effective care of the patient population served and make equipment and supplies available to the unit as determined by hospital policy in accordance with the needs of the patients.

(4)(a) The licensee shall ensure that an emergency cart is readily available to the unit and contains appropriate drugs and equipment according to hospital policy.

(b) The nursing manager shall check the cart, or the cart locking mechanism, every shift and after each use to assure that items required for immediate patient care are in place in the cart and in usable condition.

(5) The licensee shall ensure that the following support services are immediately available to the critical care unit on a 24-hour basis:

(a) blood bank or supply;

(b) clinical laboratory; and

(6) If the licensee provides dialysis services, the dialysis services shall comply with:

(a) Section R432-650-7; and

(b) Section R432-650-12.

R432-100-15. Surgical Services.

(1)(a) The licensee shall integrate surgical services provided by the hospital with other departments or services of the hospital and specify in writing the relationship, objective, and scope of each surgical service.

(b) A person appointed and authorized by the administrator shall provide administrative direction of surgical services.

(d) A qualified registered nurse shall supervise the provision of surgical nursing care.

(e) A qualified registered nurse shall direct and supervise the operating room suites. The operating room suites supervisor shall have authority and responsibility for:

(i) assuring that the planned procedure is within the scope of privileges granted to the physician;

(ii) maintaining the operating room register; and

(iii) other administrative functions, including serving on patient care committees.

(f) The licensee shall establish a policy governing the use of obstetrical delivery and operating rooms to ensure that any patient with parturition imminent, or with an obstetrical emergency requiring immediate medical intervention to preserve the health and life of the parent or the infant, is given priority over other obstetrical and non-emergent surgical procedures.

(g) A qualified surgical assistant shall assist as needed in operations in accordance with hospital bylaws.

(h) A surgical technician or licensed practical nurse may serve as a scrub nurse under the direct supervision of a registered nurse but may not function as a circulation nurse in the operating rooms, unless the scrub nurse is a registered nurse.

(i)(i) An outpatient surgical patient may not be routinely admitted to the hospital as an inpatient.

(ii) The licensee shall complete a systematic review process to evaluate patients who require hospitalization after outpatient surgery.

(2) The licensee shall establish, control and consistently monitor a safe operating room environment that ensures:

(a) surgical equipment, including suction facilities and instruments, is provided and maintained in good condition to assure safe and aseptic treatment of surgical cases;

(b) the following equipment shall be available to the operating suite:

(i) a call-in system;

(ii) a cardiac monitor;

(iii) a defibrillator;

(iv) a ventilation support system;

(v) an aspirator; and

(vi) equipment for CPR;

(d) traffic in and out of the operating room is controlled and there is no through traffic.

(3) The administration of anesthetics shall conform to the requirements of Section R432-100-16.

(4) Removal of surgical specimens shall conform with the requirements of Section R432-100-23.

R432-100-16. Anesthesia Services.

(1) The licensee shall provide facilities and equipment for the administration of anesthesia commensurate with the clinical and surgical procedures planned for the institution on a 24-hour basis.

(2) The hospital administrator shall appoint and authorize an individual to provide administrative direction of anesthesia services.

(3) A member of the medical staff shall provide the medical direction of anesthesia services.

(4) A member of the medical staff, including an anesthesiologist, other qualified physician, dentist, oral surgeon, or certified registered nurse anesthetist, shall provide anesthesia care within the scope of that member's practice and license.

(5) A qualified physician, dentist, or oral surgeon shall have documented training that includes the equivalent of 40 days preceptorship with an anesthesiologist and be able to perform at least:

(a) any procedure commonly used to make the patient insensate to pain during the performance of surgical, obstetrical, and other pain-producing clinical procedures;

(b) life support functions during the administration of anesthesia, including induction and intubation procedures; and

(6) The medical staff shall clearly define the responsibilities and privileges of the person administering anesthesia.

(7) The medical staff shall inform both the patient and the operating surgeon before surgery of who will be administering anesthesia.

(8) A Medicaid certified hospital licensee shall comply with the requirements of 42 CFR 482.52(a) (2007).

(9) The licensee shall prohibit the use of flammable anesthetic agents for anesthesia or for the pre-operative preparation of the surgical field.

(10) The licensee shall ensure that anesthetic equipment is inspected and tested by the person administering anesthesia before use in accordance with hospital policy.

R432-100-17. Emergency Care Service.

(1)(a) Each licensee shall self-evaluate and classify to show capability in providing emergency care. Type I, II, or III categories represent acute care hospitals and critical access hospitals, and Type IV category represents specialty hospitals.

(b) A Type I acute or critical access hospital licensee shall provide in-hospital support by members of the medical staff for:

(i) anesthesia services;

(ii) medical;

(iii) obstetric;

(iv) orthopedic;

(v) pediatric; and

(vi) surgical.

(c) The licensee shall ensure specialty consultation is available within 30 minutes, or two-way voice communication is available for the initial consultation.

(d) A Type III licensee shall ensure that specialty consultation is available by request of the attending medical staff member by transfer to a Type I or Type II hospital where care can be provided.

(e) A general hospital licensee operating a satellite emergency department in a county of first or second class shall:

(i) comply with Section 26B-2-203;

(ii) submit to the department any initial and renewal application and applicable fee; and

(iii) have the capability to conduct the following clinical laboratory tests and analyses available on-site during hours of operation:

(A) core blood panels;

(B) critical care and cardiac marker tests;

(D) specialized emergency analyses.

(f) The licensee shall ensure clinical laboratory services are immediately available to meet the emergency diagnostic and stabilizing needs of any patient presenting to the satellite emergency department in a county of first or second class.

(g) The licensee shall develop, implement, and maintain a written policy, approved by the medical staff and governing body, that identifies the specific laboratory tests and analyses to be performed at the satellite emergency department in a county of first or second class, including:

(i) a list of emergency laboratory tests available at the facility;

(ii) the required turnaround time for any critical laboratory result; and

(iii) any protocol for obtaining an emergency test not performed on-site.

(2)(a) The licensee shall organize and staff the emergency service with qualified individuals based on the defined capability of the hospital.

(b) An individual appointed and authorized by the hospital administrator shall direct the emergency services.

(c)(i) One or more members of the medical staff shall define in writing and provide medical direction of emergency services.

(ii) The medical staff shall provide back-up and on-call coverage for emergency services and as needed for emergency specialty services.

(d) A licensed practitioner is responsible for the evaluation and treatment of a patient who goes to or is brought to the emergency care area including:

(i) an appropriate medical screening examination;

(ii) if necessary for definitive treatment, an appropriate transfer to another medical facility that has agreed to accept the patient for care; and

(iii) stabilizing treatment.

(e) Trained personnel using guidelines by the emergency room director and approved by the medical staff may determine the priority that a physician sees a person seeking emergency care.

(f) The licensee shall post rosters designating medical staff members on duty or on-call for primary coverage and specialty consultation in the emergency care area.

(g) A designated registered nurse who is qualified by relevant training, experience, and current competence in emergency care shall supervise the care provided by nursing service personnel in the department, including that:

(i) the emergency nurse supervisor shall ensure that there is enough nursing service personnel for the types and volume of patients served;

(ii) the emergency nurse supervisor shall participate in internal committee activities concerned with the emergency service; and

(iii) Type I and II emergency department licensees shall have at least one registered nurse with advanced cardiac life support certification, and enough other nursing staff assigned and on duty within the emergency care area.

(h) The licensee shall ensure that the emergency service is integrated with other departments in the hospital.

(i) The licensee shall provide clinical laboratory services with the capability of performing any routine studies and standard analyses of blood, urine, and other body fluids.

(j) The licensee shall ensure that a supply of blood is available 24 hours a day.

(k) The licensee shall ensure that diagnostic radiology services is available 24 hours a day.

(l) The licensee shall define, in writing, the duties and responsibilities of personnel, including physicians and nurses, providing care within the emergency service area.

(3)(a) Each licensee shall define the scope of emergency services in writing and implement a plan for emergency care, based on community needs and on the capabilities of the hospital.

(b) Each licensee shall comply with federal anti-dumping regulations as defined in 19 CFR 351.101 (1998).

(d) Each licensee shall have a communication system that permits instant contact with law enforcement agencies, rescue squads, ambulance services, and other emergency services within the community.

(e) The licensee shall have emergency department policies and protocols that address:

(i) the care, security, and control of incarcerated individuals or people to be detained for police or protective custody;

(ii) handling of hazardous materials and contaminated patients;

(iii) providing care to an unemancipated minor not accompanied by parent or guardian, or to an unaccompanied unconscious patient;

(iv) reporting of persons dead-on-arrival to the proper authorities including the legal requirements for the collection and preservation of evidence; and

(v) the evaluation and handling of alleged or suspected child or adult abuse cases.

(f) The licensee shall develop criteria to alert emergency department and service personnel to possible child or adult abuse. The criteria shall address:

(i) suspected domestic abuse of elders, spouses, partners, and children;

(ii) suspected physical assault;

(iii) suspected rape or sexual molestation;

(iv) the collection, retention, and safeguarding of specimens, photographs, and other evidentiary materials; and

(v) visual and auditory privacy during examination and consultation of patients.

(g) The licensee shall make a list available in the emergency department that outlines private and public community agencies and resources that provide, arrange, evaluate, and care for the victims of abuse.

(4) The licensee shall make reasonable and timely efforts to contact the guardian, parents, or next of kin of any unaccompanied minor, or any unaccompanied unconscious patient admitted to the emergency department.

R432-100-18. Perinatal Services.

(1)(a) Each licensee shall designate its capability to provide perinatal, antepartum, labor, delivery, postpartum, and nursery care in accordance with Level I basic, Level II specialty, or Level III sub-specialty or tertiary care.

(b) A qualified member of the hospital staff shall provide administrative, medical and nursing direction, and oversight for perinatal services according to each hospital's designated level of care.

(c) The licensee shall ensure a qualified registered nurse is immediately available 24 hours a day with enough trained competent staff to meet the designated level.

(d) The licensee shall ensure support personnel are available to the perinatal care service according to each hospital's designated level of care.

(2) Each licensee shall establish and implement security protocols for perinatal patients.

(3) The perinatal department shall include facilities and equipment for antepartum, labor and delivery, nursery, postpartum, and optional birthing rooms.

(4) The licensee shall ensure that perinatal areas are located and arranged to avoid non-related traffic to and from other areas.

(5)(a) The licensee shall isolate patients with infections or other communicable conditions.

(b) The licensee may not use maternity rooms for patients other than maternity patients.

(6) The licensee shall have at least one surgical suite for operative delivery.

(7) The licensee shall maintain and make immediately available, equipment and supplies for the parent and newborn, including:

(a) a clock capable of showing seconds;

(b) a device to assess fetal heart rate;

(c) a newborn warming unit with temperature controls that comply with Underwriters' Laboratories requirements. The unit shall have capability for administering oxygen and suctioning;

(d) an adjustable examination light;

(e) emergency medications, intravenous fluids, and related supplies and equipment;

(f) equipment to monitor and maintain the optimum body temperature of the newborn;

(g) furnishings suitable for labor, birth, and recovery;

(h) mechanical suction and bulb suction;

(i) oxygen with flow meters and masks or equivalent; and

(j) resuscitation equipment.

(8) The licensee shall maintain a delivery room record keeping system for cross-referencing information with other departments.

(9) If birthing rooms are provided, the licensee shall equip them in accordance with this section.

(10) The licensee shall ensure that the nursery includes facilities and equipment according to its designated level of care, including an individual bassinet for each infant, with space between bassinets as follows:

(a) Level I Basic: Full Term or Well Baby Nursery: 24 inches between bassinets;

(b) Level II Specialty: Continuous Care Nursery: four feet between bassinets; or

(11) The licensee shall ensure the availability of the following equipment and supplies:

(a) a covered soiled-diaper container with removable lining;

(b) a linen hamper with removable bag for soiled linen other than diapers;

(d) a supply of medication immediately available for emergencies;

(e) a wall thermometer;

(f) an individual thermometer, or one with disposable tips, for each infant;

(g) an oxygen concentration monitoring device;

(h) accurate scales; and

(i) oxygen, oxygen equipment, and suction equipment.

(12) The licensee shall maintain temperature between 70-80 degrees Fahrenheit in the nursery area.

(13) The licensee shall make infant formula storage space available that conforms to the manufacturer's recommendations. Only single-use bottles may be used for newborn feeding.

(14) The licensee shall provide a furnished suspect nursery or isolation area that has a separate hand washing facility and equipment and supplies to be used for any infant who:

(a) has a communicable disease;

(b) is delivered of an ill parent infected with a communicable disease;

(d) is readmitted after discharge from a hospital.

(15) The licensee shall:

(a) instill a prophylactic solution in the eyes of the infant within three hours of birth in accordance with Section R386-702-14;

(b) not try to delay the imminent, normal birth of a child;

(d) perform disease screening, including phenylketonuria (PKU), in accordance with Section 26B-4-319.

R432-100-19. Pediatric Services.

(1)(a) If the licensee provides pediatric services, the services shall be under the direction of a member of the medical staff who is experienced in pediatrics and whose functions and scope of responsibility are defined by the medical staff.

(b) A pediatrics qualified registered nurse shall supervise pediatric nursing care and shall supervise the documentation of the implementation of pediatric patient care on an interdisciplinary plan of care.

(c) If the licensee provides a pediatric unit, the licensee shall ensure there is an interdisciplinary committee responsible for policy development and review of practice within the unit. The committee shall include representatives from administration, the medical and nursing staff, and rehabilitative support staff.

(d) A licensee that admits pediatric patients shall have written policies and procedures specifying the criteria for admission to the hospital and conditions requiring transfer when indicated. These policies and procedures shall consider and address the resources available at the hospital, specifically, in terms of personnel, space, equipment, and supplies.

(e) The licensee shall:

(i) assess each pediatric patient for maturity and development that incorporates information obtained from the maturity and development assessment into the plan of care;

(ii) establish and implement security protocols for pediatric patients; and

(iii) provide a safe area for diversional play activities.

(2) A licensee that admits pediatric patients shall have equipment and supplies in accordance with the hospital's scope of pediatric services.

(3) The licensee shall have written guidelines for the placement or room assignment of pediatric patients according to patient acuity under usual, specific, or unusual conditions within the hospital that shall address the use of:

(a) cribs;

(b) bassinets;

(d) proper use of restraints, bed rails, and other safety devices.

(4) The licensee shall place infant patients in beds where frequent observation is possible.

(5) The licensee shall ensure that pediatric patients other than infants are placed in beds to allow frequent observation according to each patient's assessed care needs.

(6) Personnel working with pediatric patients shall have specific training and experience relating to the care of pediatric patients.

(7) Orientation and in-service training provided by the licensee for pediatric care staff shall include pediatric-specific training on:

(a) child abuse and neglect;

(b) drugs;

(d) intravenous therapy;

(e) pediatric emergency procedures;

(f) the emotional needs and behavioral management of hospitalized children;

(g) toxicology; and

(h) other topics according to the needs of the pediatric patients.

R432-100-20. Respiratory Care Services.

(1) A person authorized by the hospital administrator shall provide administrative direction of respiratory care services.

(2)(a) A member of the medical staff who has the responsibility and authority for the overall direction of respiratory care services shall direct the respiratory care service.

(b) When the scope of services warrants, a technical director who is registered or certified by the National Board for Respiratory Care, or has the equivalent education, training, and experience shall supervise the respiratory care services.

(c) The technical director shall inform physicians about the use and potential hazards in the use of any respiratory care equipment.

(3)(a) The responsible licensed practitioner shall provide respiratory care services to patients in accordance with a written prescription that specifies the type, frequency, and duration of the treatment; and when appropriate, the type and dose of medication, the type of diluent, and the oxygen concentration.

(b) The licensee shall have equipment to perform any pulmonary function study or blood-gas analysis.

(c) The licensee shall ensure availability of resuscitation, ventilatory, and oxygenation support equipment in accordance with the needs of the patient population served.

R432-100-21. Rehabilitation Therapy Services.

(1)(a) If rehabilitation therapy services are provided by the licensee, the services may include physical therapy, speech therapy, and occupational therapy.

(b) A qualified, licensed provider who has clinical responsibility for the specific therapy service shall direct rehabilitation therapy services.

(c) Support personnel shall perform patient services that are commensurate with each person's documented training and experience.

(d)(i) Rehabilitation therapy services may be initiated by a member of the medical staff or by a licensed rehabilitation therapist.

(ii) A physician's written request for services shall include reference to the diagnosis or condition for the treatment that is planned, and any contraindications.

(iii) The patient's physician shall be responsible for the specific medical problem or condition that necessitated the referral.

(2) Rehabilitation therapy services provided to the patient shall include evaluation of the patient, establishment of goals, development of a plan of treatment, regular and frequent assessment, maintenance of treatment and progress records, and periodic assessment of the quality and appropriateness of the care provided.

R432-100-22. Radiology Services.

(1)(a) The licensee shall provide an organized radiology department offering services that are in accordance with the needs and size of the institution.

(b) A person appointed and authorized by the hospital administrator shall direct the radiology services.

(c)(i) A member of the medical staff shall provide medical direction of the department.

(ii) If a radiologist is not the medical director of the radiology services, the licensee shall retain the services of a radiologist.

(iii) If a radiologist provides services on less than a full-time basis, the time commitment shall allow the radiologist to complete the necessary functions to meet the radiological needs of the patients and the medical staff.

(d) The radiologist shall:

(i) assure the availability of information regarding the purpose and yield of radiological procedures and the risks of radiation;

(ii) develop technique charts that include part, thickness, exposure factors, focal film distances, and either a grid or screen technique; and

(iii) maintain a quality control program that minimizes unnecessary duplication of radiographic studies and maximizes the quality of diagnostic information available.

(e) The licensee shall ensure at least one licensed radiologic technologist is on duty or available as needed.

(f) Only a member of the medical staff or other person authorized by the hospital shall authorize the performance of diagnostic radiology services.

(g) If the licensee provides radiation oncology services, the following shall apply:

(i) physicians and staff who provide radiation oncology services have delineated privileges; and

(ii) the medical director of the radiation oncology services is a physician member of the medical staff who is qualified by education and experience in radiation oncology.

(2)(a) The licensee shall integrate radiologic medical with the hospital patient record.

(b) Any request for radiologic services shall contain the reasons for the examinations.

(c) The licensee shall file authenticated reports of these examinations in the patient's medical record as soon as possible.

(d) The licensee shall keep radiological film in accordance with hospital policy.

(e) If requested by the attending physician and if the quality of the radiograph permits, the radiology department may officially enter the interpretations of the radiologic examinations performed outside of the hospital in the patient's medical record.

(f)(i) The licensee shall file radiotherapy summaries as follows:

(A) documented in the medical record of the patient receiving radiotherapy for treatment or palliation of a malignancy and reflect the histologically substantiated diagnosis, unless otherwise justified;

(B) in the patient's medical record; and

(ii) The licensee may additionally file radiotherapy summaries in the radiotherapy department.

R432-100-23. Laboratory and Pathology Services.

(1)(a) The licensee shall provide laboratory and pathology services that are in accordance with the needs and size of the institution.

(b) A person appointed and authorized by the hospital administrator shall provide administrative direction of laboratory and pathology services.

(2) Laboratory and pathology services shall make inspection reports, as described in 42 U.S.C. 263a, the Clinical Laboratory Improvement Amendments of 1988, as required for construction plan review in Section R432-4-7 available for department review.

(3) Laboratories certified by the US Centers for Medicare and Medicaid Services (CMS)-approved accrediting agency are in compliance with this section and the licensee shall ensure any accrediting agency inspection reports are available for department review.

R432-100-24. Blood Services.

(1)(a) The licensee's blood service shall establish and maintain an appropriate blood inventory in the hospital, have immediate access to community blood services or other institutions, or have an up-to-date list of donors, equipment, and trained personnel to draw and process blood.

(b) The licensee shall collect, store, and handle blood or blood components in such a manner that they maintain potency and safety.

(2) The licensee shall ensure any donor center, transfusion service, or blood bank is accredited as follows:

(a) hospital blood banks and donor centers are accredited by the FDA; or

(b) hospital transfusion services are certified by CMS or any accrediting organization approved by CMS.

(3) The licensee shall ensure that results of the accrediting organization survey are available for department review.

R432-100-25. Pharmacy Services.

(1)(a) The pharmacy of a licensee currently accredited and conforming to the standards of the Joint Commission is determined to be in compliance with this section.

(b) If a licensee is not accredited by the Joint Commission, then the licensee's pharmacy services shall comply with the requirements in this section.

(2) A licensed pharmacist shall direct the pharmacy department and service.

(3) The licensee shall employ personnel in keeping with the size and activity of the department and service.

(4) If the licensee uses only a drug room and the size of the hospital does not warrant a full-time pharmacist, a consultant pharmacist may be employed.

(5) The pharmacist is responsible for developing, supervising, and coordinating the activities of the pharmacy.

(6) The licensee shall provide access to emergency pharmaceutical services.

(7) The licensee shall ensure the pharmacist is trained in the specific functions and scope of the hospital pharmacy.

(8) The licensee shall provide facilities for the safe storage, preparation, safeguarding, and dispensing of drugs and ensure:

(a) a current toxicology reference, and other references as needed for effective pharmacy operation and professional information, are available;

(b) double-locked storage is provided for any controlled substance and electronically controlled storage of a narcotic is permitted if the hospital uses automated dispensing technology;

(d) any room-temperature medication is stored in a room where the temperature is maintained between 59 and 80 degrees Fahrenheit (F); and

(e) any refrigerated medication is stored in a refrigerator where the temperature is maintained between 36 and 46 degrees F.

(9) The licensee shall maintain records of the transactions of the pharmacy and medication storage unit and coordinate with other hospital records.

(10)(a) In accordance with Section R156-17b-605, the licensee shall:

(i) maintain a recorded and signed floor-stock controlled substance count once per shift; or

(ii) use automated dispensing technology.

(b) A licensee that uses automated dispensing technology shall implement a system for accounting of controlled substances dispensed by the automated dispensing system.

(c) The record shall list the name of the patient receiving the controlled substance, the date, type of substance, dosage, and signature of the person administering the substance.

(11)(a) The director of the pharmaceutical department or service shall develop written policies and procedures, in coordination with the medical staff, that pertain to the intra-hospital drug distribution system and the safe administration of drugs.

(b) Medical staff shall administer drugs that are provided to floor units in accordance with hospital policies and procedures.

(c) The medical staff, in coordination with the pharmacist, shall establish standard stop orders for medications not specifically prescribed in regard to time or number of doses.

(d) The pharmacist shall have full responsibility for dispensing of drugs.

(e) The licensee shall ensure there is a policy stating who may have access to the pharmacy or drug room when the pharmacist is not available.

(f) The licensee shall ensure there is a documentation system for the accounting and replacement of drugs, including narcotics, to the emergency department.

(g) The licensee shall ensure medication errors and adverse drug reactions are reported immediately in accordance with written procedures including notification of the practitioner who ordered the drug.

R432-100-26. Social Services.

(1)(a) If a licensee provides an organized social services department, a qualified social worker shall direct the social work services.

(b) If a licensee does not have a full or part-time qualified social worker, the administrator shall designate an employee to coordinate and assure that social work services are provided to patients.

(c) The licensee shall ensure the social worker, or designee, is knowledgeable about community agencies, institutions, and other resources.

(2) If a licensee does not provide an organized social services department, the licensee shall obtain consultation from a qualified social worker to provide social work services.

(3) The licensee shall orient the staff to help the patient make the best use of available inpatient, outpatient, extended care, home health, and hospice services.

(4) The licensee shall integrate social services with other departments and services of the hospital.

R432-100-27. Psychiatric Services.

(1)(a) If the licensee provides psychiatric services, the licensee shall ensure the services are integrated with other departments or services of the hospital according to the nature, extent, and scope of service provided.

(b) If the licensee does not provide psychiatric services, the licensee shall have procedures to transfer patients to a facility that can provide the necessary psychiatric services.

(c) A person appointed and authorized by the hospital administrator shall provide administrative direction of psychiatric services.

(d) A qualified physician who is a member of the medical staff shall define in writing and provide medical direction of psychiatric services.

(e) Psychiatric services shall comply with:

(i) Section R432-101-13, Patient Security;

(ii) Section R432-101-14, Special Treatment Procedure;

(iii) Section R432-101-17, Admission and Discharge;

(iv) Section R432-101-20, Inpatient Services;

(v) Section R432-101-21, Adolescent or Child Treatment Program;

(vi) Section R432-101-22, Residential Treatment Services;

(vii) Section R432-101-23, Physical Restraints, Seclusion, and Behavior Management;

(viii) Section R432-101-24, Involuntary Medication Administration; and

(ix) Section R432-101-35, Penalties.

(2) If outreach services are ordered by a physician as part of the plan of care or hospital discharge plan, the outreach services may be provided in a clinic, physician's office, or the patient's home.

R432-100-28. Substance Use Disorder Rehabilitation Services.

(1)(a) A licensee may provide inpatient or outpatient substance use disorder rehabilitation services. A licensee that provides substance use disorder rehabilitation services shall staff the hospital to meet the needs of the patients or clients.

(b) An individual appointed and authorized by the hospital administrator shall provide administrative direction.

(d) The licensee shall ensure nursing services are under the direction of a full-time registered nurse.

(e) The licensee shall ensure substance use disorder counseling is under the direction of a licensed mental health therapist.

(f) A licensed substance use disorder counselor may serve as the primary therapist under the direction of an individual licensed under Title 58, Chapter 60, Mental Health Professional Practice Act.

(g) An interdisciplinary team including the physician, registered nurse, licensed mental health therapist, and substance use disorder counselor is responsible for program and treatment services. The patient or client may be included as a member of the interdisciplinary team.

(2) The licensee shall ensure that substance use disorder rehabilitation services include:

(a) a referral process where a counselor may refer any client or patient to public or private agencies for substance rehabilitation, and employment and a social assessment;

(b) comprehensive assessment that is documented and includes a physical examination, a psychiatric and psychosocial assessment, and a social assessment;

(c) detoxification care, available for the systematic reduction or elimination of a toxic agent in the body by use of rest, fluids, medication, counseling, or nursing care;

(d) educational, employment, or other counseling, available as needed;

(e) individual, group, or family counseling; and

(f) treatment services coordinated with other hospital and community services to assure continuity of care through discharge planning and aftercare referrals.

(3) The licensee shall maintain the confidentiality of medical records of substance use disorder patients and clients according to the federal guidelines in 42 CFR 2 (2024).

(4) The medical director or designee may direct the residential treatment services. Residential treatment services shall comply with Section R432-101-22.

R432-100-29. Outpatient Services.

(1) The licensee shall integrate outpatient care services with other departments or services of the hospital according to the nature, extent, and scope of services provided.

(2) Outpatient care shall meet the same standards of care that apply to inpatient care.

(3) Outpatient care includes hospital owned outpatient services and satellite services.

R432-100-30. Respite Services.

(1)(a) A remote-rural general acute licensee with a federal swing-bed designation may provide respite services to provide intermittent, time-limited care to give a primary caretaker relief from the demands of caring for an individual.

(b) The licensee may only provide respite care services if the licensee complies with this section.

(c) If the licensee provides respite care to an individual for longer than 14 consecutive days, the licensee shall admit the individual as an inpatient and is subject to the requirements of this rule applicable to non-respite inpatient admissions.

(2) The licensee may provide respite services at an hourly rate or daily rate.

(3) The licensee shall coordinate the delivery of respite services with the recipient of services, case manager, if one exists, and the family member or primary caretaker.

(4) The licensee shall document the individual's response to the respite placement and coordinate with provider agencies to ensure an uninterrupted service delivery program.

(5) The licensee shall complete:

(a) a Level 1 pre-admission screening upon the person's admission for respite services; and

(b) a service agreement that will serve as the plan of care and identifies:

(i) diet orders;

(ii) need for assistance for activities of daily living;

(iii) physician treatment orders; and

(iv) prescribed medications.

(6) The licensee shall have written policies and procedures that are available to staff regarding the respite care patients to include:

(a) behavior management interventions;

(b) handling patient funds;

(d) notification of a responsible person in the event of an emergency;

(e) philosophy of respite services;

(f) post-service summary;

(g) service agreement and admission criteria; and

(h) training and in-service requirements for employees.

(7) The licensee shall provide a copy of the resident rights to the patient upon admission.

(8) The licensee shall maintain a record for each patient who receives respite services that includes:

(a) a service agreement;

(b) a post-service summary;

(d) demographic information and patient identification data;

(e) nursing notes;

(f) physician treatment orders; and

(g) records made by staff regarding daily care of the patient in-service.

(9) If a patient has an advanced directive, the licensee shall file a copy of the directive in the record and inform staff.

(10) The licensee shall ensure that retention and storage of records complies with this rule.

(11) The licensee shall provide for confidentiality and release of information in accordance with this rule.

R432-100-31. Pet Therapy.

(1) If a licensee utilizes pet therapy, household pets such as a dog, cat, bird, fish, or hamster, may be permitted if:

(a) a licensee with a bird has procedures in place that protect patients, staff, and visitors from psittacosis;

(b) any pet is clean and disease free;

(c) a pet that is kept at the hospital, or is a frequent visitor, has current vaccinations, including rabies, as recommended by a licensed veterinarian;

(d) a pet that is not confined is kept under leash control or voice control;

(e) a small pet is kept in an appropriate enclosure; and

(f) the immediate environment of the pet is clean.

(2) A licensee that permits a pet to remain overnight shall have policies and procedures for the care, housing and feeding, and proper storage of pet food and supplies.

(3) The licensee may not permit a pet in any area where the pet's presence would create a significant health or safety hazard or nuisance to others.

(4) The licensee may not permit a pet in food preparation and storage areas.

(5) Any individual caring for a pet may not have patient care or food handling responsibilities.

R432-100-32. Dietary Service.

(1)(a) The licensee shall ensure that there is an organized dietary department under the supervision of a certified dietitian or a qualified individual who, by education or specialized training and experience, is knowledgeable in food service management. If the latter is head of the department, the individual shall retain a registered dietitian on a full-time, regular part-time, or consulting basis.

(b) A person whose qualifications, authority, responsibilities, and duties are approved by the administrator shall provide direction of the dietary service. The director shall have the administrative responsibility for the dietary service.

(c) If the services of a certified dietitian are used on less than a full-time basis, the time commitment shall permit performance of necessary functions to meet the dietary needs of the patients.

(d) The licensee shall ensure there are food service personnel to perform any necessary functions.

(2) If dietetic services are provided by an outside provider, the outside provider shall comply with the standards of this section.

(3)(a) The dietary department personnel shall provide a current diet manual, approved by the dietary department and the medical staff, to be available to dietary, medical, and nursing personnel.

(b) The dietary department personnel shall meet the food and nutritional needs of patients, including therapeutic diets, in accordance with the orders of the physician responsible for the care of the patient, or if delegated by the physician, the orders of a qualified registered dietitian in consultation with the physician, as authorized by the medical staff and in accordance with facility policy.

(c) Dietary department personnel shall write regular menus and modifications for basic therapeutic diets at least one week in advance and posted in the kitchen.

(d) The menus shall provide for a variety of foods served in adequate amounts at each meal.

(e) The dietary department shall serve at least three meals daily with not more than a 14-hour span between the evening meal and breakfast. If a substantial evening snack is offered, a 16-hour time span is permitted.

(f) The dietary department shall provide a source of non-neutral exchanged water for use in preparation of no sodium meals, snacks, and beverages.

(4)(a) The dietary department personnel shall comply with Rule R392-100.

(b) The licensee shall ensure that the dietary facilities and equipment comply with federal, state, and local sanitation and safety laws and rules.

(5) The licensee shall maintain written reports of inspections by state or local health departments on file at the hospital and available for department review.

(6) The dietitian or authorized designee is responsible for documenting nutritional information in the patient's medical record.

(7) The licensee shall ensure that any dietary orders are transmitted in writing to the dietary department.

R432-100-33. Telehealth Services.

(1) If a licensee participates in telehealth, it shall develop and implement policies governing the practice of telehealth in accordance with the scope and practice of the hospital and in accordance with Section 26B-4-704.

(2) The licensee's telehealth policies shall address security, access, and retention of telemetric data.

(3) The licensee's telehealth policies shall define the privileging of physicians and allied health professionals who participate in telehealth.

R432-100-34. Medical Records.

(1)(a) The licensee shall establish a medical records department or service that is responsible for the administration, custody, and maintenance of medical records.

(b) The hospital administrator shall establish administrative direction of the medical records department and in accordance with the organizational structure and policies of the hospital.

(c) The licensee shall retain the technical services of either a registered health information administrator or a registered health information technician through employment or consultation. If retained by consultation, the individual shall visit at least quarterly and document visits through written reports to the hospital administrator.

(2)(a) The licensee shall provide secure storage, controlled access, prompt retrieval, and equipment and facilities to review medical records.

(b) The license shall ensure medical records are available for use or review by:

(i) authorized hospital personnel and agents;

(ii) department representatives to determine compliance with licensing rules;

(iii) members of the medical and professional staff; and

(iv) people authorized by the patient through a consent form.

(c) Medical records may be stored in multiple locations if the record can be retrieved or accessed in a reasonable period.

(d) If computer terminals are utilized for patient charting, the licensee shall have policies governing access and identification codes, security, and information retention.

(e) The licensee shall index a hospital medical record according to diagnosis, procedure, demographic information, and physician or licensed health practitioner and ensure the index is current within six months following discharge of the patient.

(f) Original medical records are the property of the licensee and may not be removed from the control of the licensee or the licensee's agent as defined by policy, except by court order or subpoena.

(g) The licensee shall manage medical records for individuals who have received or requested admission to an alcohol or drug program in accordance with 42 CFR 2.

(3)(a) The licensee shall ensure that medical record entries are legible, complete, authenticated, and dated by the person responsible for ordering the service, providing, or evaluating the service, or making the entry. The author shall review prepared transcriptions of dictated reports, evaluations, and consultations before authentication.

(b) The authentication may include written signatures, computer key, or other methods approved by the governing body and medical staff to identify the name and discipline of the person making the entry.

(c) Use of computer key or other methods to identify the author of a medical record entry may not be assignable or delegated to another person.

(d) The licensee shall maintain a current list of individuals approved to use the methods of authentication. Hospital policy shall identify sanctions for the unauthorized or improper use of computer codes.

(e) Qualified personnel shall accept and transcribe verbal orders for the care and treatment of the patient and authenticate them within 30 days of the patient's discharge.

(4) The licensee shall ensure:

(a) if a licensee ceases operation, the licensee shall provide secure, safe storage, and prompt retrieval of any medical records, patient indexes, and discharges for the period specified in Subsection (4)(b);

(b) medical records are kept for at least seven years and medical records of minors are kept until the age of 18 plus four years, but in no case less than seven years;

(d) medical records are reviewed at least quarterly for completeness, accuracy, and adherence to hospital policy;

(e) records of discharged patients are collected, assembled, reviewed for completeness, and authenticated within 30 days of the patient's discharge;

(f) the licensee may destroy medical records after keeping them for the minimum period, and before destroying medical records, the licensee shall notify the public by publishing a notice in a newspaper of statewide distribution a minimum of once per week for three consecutive weeks to allow a former patient to access their records; and

(g) The licensee shall permanently keep a master patient or person index that shall include:

(i) the admission and discharge dates;

(ii) the date of birth;

(iii) the medical record number;

(iv) the name of each attending physician; and

(v) the patient name.

(5) The licensee may arrange for storage of medical records with another hospital, or an approved medical record storage facility, or may return patient medical records to the attending physician if the physician is still in the community.

(6) The licensee shall establish and maintain a complete medical record for each patient admitted, or who receives hospital services. Emergency and outpatient medical records shall contain documentation of the service provided and other pertinent information in accordance with hospital policy.

(7) The licensee shall ensure that each medical record contains:

(a) a discharge summary including outcome of hospitalization, disposition of case with an autopsy report when indicated, or provisions for follow-up;

(b) admitting, secondary, and primary diagnoses;

(c) documentation of complications, hospital-acquired infections, and unfavorable reactions to medications, treatments, and anesthesia;

(d) documentation that the facility requested of each admitted person whether the person has initiated an advance health care directive, as described in Title 75A, Chapter 3, Health Care Decisions;

(e)(i) initial or admitting medical history, physical, and other examinations or evaluations; or

(ii) if updated to include changes that reflect the patient's current status, recent histories and examinations;

(f) patient identification and demographic information to include at least the patient's name, address, date of birth, sex, and emergency contact information;

(g) properly executed informed consent documents for any procedures and treatments ordered for, and received by, the patient;

(h) practitioner orders, nursing notes, reports of treatment, medication records, laboratory and radiological reports, vital signs, and other information that documents the patient condition and status; and

(i) results of consultative evaluations and findings by individuals involved in the care of the patient.

(8) A medical record of a deceased patient shall contain a completed Inquiry of Anatomical Gift form or a modified hospital death form that has been approved by the department, as required by Title 26B, Chapter 8, Part 3, Revised Uniform Anatomical Gift Act.

(9) A medical record of a surgical patient shall contain:

(a) a pre-operative history and physical examination;

(b) an anesthesia report including dosage and duration of any anesthetic and pertinent events during the induction, maintenance, and emergence from anesthesia;

(d) assistants written or dictated by the surgeon within 24 hours after the operation;

(e) surgeon's diagnosis;

(f) the name of the primary surgeon;

(g) the post-operative diagnosis;

(h) the specimen removed; and

(i) the technical procedures used.

(10) A medical record of an obstetrical patient shall contain:

(a) a discharge summary for complicated deliveries or final progress note for uncomplicated deliveries;

(b) a relevant family history;

(d) a pre-natal examination;

(e) the anesthesia or analgesia record;

(f) the length of labor and type of delivery with related notes; and

(g) the Rh status and immune globulin administration when indicated.

(11) A medical record of a newborn infant shall contain the following documentation in addition to the requirements for obstetrical medical records:

(a) a record of the physical examination completed at birth and discharge, record of ophthalmic prophylaxis, and the identification number of the newborn screening kit;

(b) a summary of the delivery room care;

(d) the number, character, and consistency of stools;

(e) the period of gestation;

(f) any reaction after birth;

(g) the temperature and weight;

(h) the authorization by the parents, state agency, or court authority if the infant is discharged to any person other than the infant's parents;

(i) the date and hour of birth;

(j) the record and results of the newborn hearing screening according to Section R398-2-6;

(k) the time of first urination; and

(l)(i) a copy of the parent's delivery room record.

(ii) In an adoption case where the identity of the parent is confidential, the licensee shall include and access the parent's record according to hospital policy.

(12) The licensee shall integrate an emergency department patient medical record into the hospital medical record, that includes:

(a) a diagnosis;

(b) disposition and discharge instructions;

(d) history and physical findings;

(e) lab and x-ray reports;

(f) record of treatment; and

(g) time and means of arrival.

(13) A medical-social services patient record shall include:

(a) any cooperative activities with community agencies;

(b) a medical-social or psychosocial study of a referred inpatient and outpatient;

(d) social therapy and rehabilitation of the patient; and

(e) the financial status of the patient.

(14) A medical record of a patient receiving rehabilitation therapy shall include:

(a) a problem list;

(b) a written plan of care appropriate to the diagnosis and condition; and

(15) The medical records department shall maintain records, reports, and documentation of admissions, discharges, and the number of autopsies performed.

(16)(a) The medical records department shall maintain vital statistic registries for births, deaths, and the number of operations performed.

(b) The medical records department shall report vital statistics data in accordance with Title 26B, Chapter 8, Part I, Vital Statistics.

R432-100-35. Central Supply Services.

(1) The licensee shall ensure a central supply service supervisor is qualified for the position by education, training, and experience.

(2)(a) The licensee shall provide central service space and equipment for the cleaning, disinfecting, packaging, sterilizing, storing, and distribution of medical and surgical patient care supplies.

(b) The licensee shall ensure the hospital central service area provides:

(i) a decontamination area that is separated by a barrier or divider to allow the receiving, cleaning, and disinfection functions to be performed separately from other central service functions;

(ii) a linen assembly or pack-making area that has ventilation to control lint and is separated from the general sterilization and processing area; and

(iii) a sterilization area that contains hospital sterilizers with approved controls and safety features and the licensee ensures:

(A) if a gas sterilizer is used, the gas sterilizer is inspected, maintained, and operated in accordance with the manufacturer's recommendations;

(B) the accuracy of the sterilizers' performance is checked by a method that includes a permanent record of each run; and

(3) The licensee shall separate the storage area into sterile and non-sterile areas and ensure:

(a) outside shipping cartons are not stored in the storage area;

(b) the storage area has temperature and humidity controls; and

(4) Staff shall wipe countertops and tables with a broad spectrum disinfectant during each shift that the central service area is staffed.

(5) Staff shall issue and launder any apparel worn in central supply according to hospital policy.

R432-100-36. Laundry Service.

(1) A person whose qualifications, authority, responsibilities, and duties are approved by the administrator shall direct the laundry service.

(2)(a) A licensee using a commercial linen service shall require written assurance from the commercial service that standards in Subsection (2) are maintained.

(b) Clean linen shall remain completely packaged and protected from contamination until received by the licensee.

(3) A licensee that maintains an in-house laundry service shall provide equipment, supplies, and staff to meet the needs of the patients and shall ensure:

(a) soiled linen is collected in a manner to minimize cross-contamination as follows:

(i) containers are properly closed as filled and before further transport;

(ii) employees handling soiled linen wear protective clothing that is removed before leaving the soiled work area;

(iii) handwashing is required after handling soiled linen and before handling clean items;

(iv) soiled linen is sorted only in a sorting area; and

(v) soiled linen is transported separately from clean linen; and

(b) the licensee maintains a supply of clean linen as follows:

(i) clean linen is covered during transport;

(ii) clean linen is handled and stored in a manner to minimize contamination from surface contact or airborne deposition; and

(iii) clean linen is stored in enclosed closet areas or carts.

(4) The licensee shall launder employee scrubs that are worn in the following areas:

(a) surgical areas; and

(b) other areas as required by 29 CFR 1910.264 (1978).

(5) If hospital employee scrubs are designated as uniforms that may be worn to and from work, the licensee shall develop and implement policies and procedures defining the scope and usage of scrubs as uniforms including hospital storage of employee scrubs, and hospital-provided scrubs in the event of contamination.

R432-100-37. Housekeeping Services.

(1) The licensee shall provide housekeeping services to maintain a clean, safe, sanitary, and healthy environment in the hospital.

(2) If the licensee contracts for housekeeping services with an outside service, the licensee shall secure a signed and dated agreement that details the services provided.

(3) The licensee shall provide safe and secure storage of cleaners and chemicals and keep cleaners and chemicals stored in areas that may be accessible to patients secure in accordance with hospital policy.

(4) The licensee shall ensure that storage and supplies in each area of the hospital are stored at least four inches off the floor, and at least 18 inches below the lowest portion of the sprinkler system.

(5) Personnel engaged in housekeeping or laundry services may not be engaged simultaneously in food service or patient care.

(6) If personnel work in food or direct patient care services, the licensee shall establish and follow a hospital policy to govern the transition from housekeeping services to patient care.

R432-100-38. Maintenance Services.

(1)(a) The licensee shall provide maintenance services to ensure that hospital equipment and grounds are maintained in a clean and sanitary condition and in a state of good repair for the safety and well-being of patients, staff, and visitors.

(b) The administrator shall employ a person qualified by experience and training to oversee hospital maintenance.

(c) If the licensee contracts for maintenance services, the licensee shall secure a signed and dated agreement that details the services provided.

(d) The licensee shall ensure a pest-control program is conducted to ensure the hospital is free from any vermin or rodent.

(e) The licensee shall maintain each entrance, exit, step, ramp, and outside walkway in a safe condition regarding snow, ice, and other hazards.

(2) The licensee shall test, calibrate, and maintain any patient care equipment in accordance with the specifications from the manufacturer and make testing frequency and calibration documentation, whether conducted internally or by an outside agency, available for department review.

(3) The licensee shall ensure hot water at public and patient faucets is delivered between 105 to 120 degrees F.

R432-100-39. Emergency Operations Plan.

(1) The licensee shall have an emergency operations plan for the maintenance of a safe environment in the event of an emergency or disaster that overwhelms the facility.

(2) The administrator or designee is responsible for the development of the plan, coordinated with applicable state and local emergency response partners and agencies. The plan shall:

(a) address delivery of essential care and services to hospital occupants utilizing crisis standards of care when staff is reduced by an emergency;

(b) address delivery of essential care and services when additional persons are present at the hospital during an emergency;

(i) emergency communications;

(ii) patient clinical and supportive activities;

(iii) safety and security;

(iv) staff responsibilities;

(v) resources and assets; and

(vi) utility management;

(d) address risks and threats identified in the licensee's annual hazard vulnerability analysis;

(e) be in writing and made available to any hospital staff;

(f) be reviewed and updated as necessary and be available for review by the department;

(g) delineate individuals who will be in charge in the event of any significant emergency;

(h) delineate the person with decision-making authority to activate the emergency operations plan;

(i) have an evacuation plan; and

(j) include readily available lists of emergency partners with multiple contact options, emergency contact lists are updated and maintained regularly by the licensee.

(3) The hospital administrator and the board shall approve the emergency operations plan.

(4) The licensee shall document any emergency incidents and responses.

(5) The licensee shall hold disaster drills or exercises twice yearly according to threats identified in the facility's annual hazard vulnerability analysis.

(6) The licensee shall have a fire emergency evacuation plan written in consultation with qualified fire safety personnel. This plan may be included in the facility's emergency operations plan.

(7) The licensee shall post evacuation routes posted in prominent locations throughout the hospital.

(8) The licensee shall document fire drills and ensure fire drill documentation is in accordance with Rule R710-4.

(9)(a) A licensee may exceed the licensed capacity by up to 20% in response to any incident that overwhelms the facility.

(b) A hospital that exceeds the licensed capacity under this provision shall notify the department within 72 hours of exceeding the licensed capacity.

(d) The department may direct that the licensee reduce the patient census to the licensed capacity at any time.

R432-100-40. Penalties.

Any person who violates this rule may be subject to the penalties in Rule R380-600 and Title 26B, Chapter 2, Part 7, Penalties and Investigations.

KEY: health care facilities

Date of Last Change: June 5, 2026

Notice of Continuation: August 22, 2025

Authorizing, and Implemented or Interpreted Law: 26B-1-202; 26B-2-202; 26B-2-203