TITLE 7 HEALTH
CHAPTER 7 HOSPITALS
PART 2 REQUIREMENTS
FOR ACUTE CARE, LIMITED SERVICES AND SPECIAL
HOSPITALS
7.7.2.1 ISSUING AGENCY: New Mexico Department of Health,
Division of Health Improvement, Health Facility Licensing & Certification
Bureau.
[7.7.2.1 NMAC - Rp, 7.7.2.1 NMAC,
06-15-04]
7.7.2.2 SCOPE: These requirements apply to public
and private hospitals as defined in Section 7.7.2.7 of these requirements. Facilities that are specifically exempt under
Section 24-1-2 (D), NMSA 1978, from being treated as
hospitals for purposes of regulation under Section 24-1-5, NMSA
1978, and these requirements, are physicians’ clinics and offices, nursing
homes, as well as health centers and correctional institutions that are
operated by the state.
[7.7.2.2 NMAC - Rp, 7.7.2.2 NMAC,
06-15-04]
7.7.2.3 STATUTORY
AUTHORITY: The requirements set
forth herein are promulgated by the secretary of the department of health,
pursuant to the general authority granted under Section 9-7-6 (E), NMSA 1978, as amended and the authority granted under
Sections 24-1-2 (D), 24-1-3 (I) and 24-1-5, NMSA
1978, of the Public Health Act as amended.
[7.7.2.3 NMAC - Rp, 7.7.2.3 NMAC,
06-15-04]
7.7.2.4 DURATION: Permanent.
[7.7.2.4 NMAC - Rp, 7.7.2.4 NMAC,
06-15-04]
7.7.2.5 EFFECTIVE
DATE: June 15, 2004, unless a later date is specified at the end of a
section.
[7.7.2.5 NMAC - Rp, 7.7.2.5 NMAC,
06-15-04]
7.7.2.6 OBJECTIVE:
A. Establish standards for
licensing hospitals in order to ensure that hospital patients receive adequate
care and treatment and that the health and safety of patients and hospital
employees are protected.
B. Establish standards for the
construction, maintenance and operation of hospitals.
C. Regulate such hospitals in
providing the appropriate level of care for patients.
D. Provide for hospital compliance
with these requirements through surveys to identify any areas that could be
dangerous or harmful to the health, safety, or welfare of the patients and
staff.
[7.7.2.6 NMAC - Rp, 7.7.2.6 NMAC,
06-15-04]
7.7.2.7 DEFINITIONS.
A. “Abuse” means injury, sexual
misuse, or neglect resulting in harm of an individual patient.
B. “Acute-care hospital” means a hospital providing emergency
services, in-patient medical and nursing care for acute illness, injury, surgery
or obstetrics; ancillary services such as pharmacy,
clinical laboratory, radiology, and dietary are required for acute-care
hospitals.
C. “Allied health personnel” means
persons who are not physicians, podiatrists, psychologists or dentists who may be
admitted to practice in the hospital through the medical staff credentialing
process, and includes:
(1) “licensed independent practitioner”
means an advanced practice professional registered nurse permitted by law to
provide care without direction or supervision within the scope of the
individual’s license and consistent with individually granted privileges; this
includes certified nurse midwives, certified nurse practitioners and clinical
nurse specialists;
(2) “certified registered nurse
anesthetist” means an advanced practice professional registered nurse
permitted by law to provide anesthesia care; in an interdependent role as a
member of a health care team in which medical care of the patient is directed
by a medical physician, osteopathic physician, dentist or podiatrist licensed
in the state of New Mexico; the certified registered nurse anesthetist shall
collaborate with the medical physician, osteopathic physician, dentist or
podiatrist concerning the anesthesia care or the patient; collaboration means
the process in which each health care provider contributes their respective
expertise;
(3) “physician
assistant” means a person licensed as a physician assistant by the New
Mexico board of medical examiners, pursuant to Section 61-6-6, NMSA 1978.
D. “Amended license” means a change of administrator,
name, location, capacity, classification of any units as listed in these
requirements requires a new license:
(1) the application
shall be on a form provided by the licensing authority;
(2) the application
shall be accompanied by the required fee for an amended license; and
(3) the application
shall be submitted at least 10 working days prior to the change.
E. “Annual net revenue” means, as
determined from the hospitals governing board’s approved audited financial
statement for an annual time period, the hospital’s net patient services
revenue; net patient services revenue does not include net operating
revenue from other sources, such as medical office rental and cafeteria; annual
net revenue is determined after deductions for:
(1) contractual
allowances;
(2) uncompensated
care and bad debt;
(3) charity care; and
(4) annual net
revenue excludes other non-operating revenues, including but not limited to,
income from endowments, investments, gifts and bequests, and net gain on sale
of fixed assess.
F. “Annual cost of care” means with respect to the
requirements of Section 24-1-5.8 NMSA 1978 (2003),
the billed charges of providing emergency services and general health care to
nonpaying patients and low-income reimbursed patients.
G. “Annual license” means a license
issued for a one-year period to a hospital that has met all license prior to
the initial state licensing survey, or when the licensing authority finds
partial compliance with these requirements.
H. “Applicant” means the individual
who, or organization which, applies for a license; if the applicant is an
organization, then the individual signing the application on behalf of the
organization must have the authority to sign for the organization.
I. “Audiologist” means a person
licensed under the Speech-Language Pathology and Audiology
Act, Sections 61-14B-1 to 61-14B-16, NMSA 1978, to
practice audiology.
J. “Automated medication management
system” means an automatic device that compounds. measures,
counts, packages and delivers a specified quantity of dosage units for a
designated product and which collects, controls and maintains all transaction
information.
K. “CMS” means center for medicare & medicaid services.
L. “Consultant pharmacist” means a
person licensed in New Mexico under the Pharmacy Act. Section
61-11-2 (D), NMSA 1978, as a consultant pharmacist.
M. “Critical access hospital” means
a hospital with special characteristics, duly certified as such by centers for medicare and medicaid services
(CMS) and is in compliance with the conditions of participation for such
facilities; such critical access hospitals are deemed as meeting the intent of
these requirements and may be licensed accordingly by the licensing authority.
N. “Dentist” means a person
licensed to practice dentistry under the Dental Act, Sections 61-5-1 to
61-5-22, NMSA 1978.
O. “Department” means the New
Mexico department of health.
P. “Dietician” means a person who
is eligible for registration as a dietitian by the commission on dietetic registration
of the American dietetic association, or who has a baccalaureate degree with
major studies in food and nutrition, dietetics, or food service management.
Q. “Dietetic service supervisor”
means a person who:
(1) is a qualified
dietitian with one year of supervisory experience in the dietetic service of a
health care institution; or
(2) is a graduate of
a dietetic technician or dietetic assistant training program, approved by the
American dietetic association and has consultation from a qualified dietitian;
or
(3) is a graduate of
a state-approved course that provided 90 or more hours of classroom instruction
in food service supervision and has experience as a supervisor in a health care
institution with consultation from a dietitian; if the supervisor is not a
qualified dietitian then consultation from a qualified dietician must be
provided.
R. “Distinct emergency service” means an emergency distinct
department that provides a medical screening examination and treatment of a
medical condition manifesting itself by acute symptoms of sufficient severity
(including severe pain, psychiatric disturbances or symptoms of substance
abuse) that requires immediate medical attention.
S. “Drill” means the practice of a
planned activity at full dress intensity.
T. “Emergency care for sexual assault
survivors” means medical examinations, procedures and services provided by
a hospital to a sexual assault survivor following an alleged sexual assault.
U. “Emergency contraception” means a drug approved by the federal
food and drug administration that prevents pregnancy after sexual intercourse.
V. “Emotional abuse” means verbal
behavior, harassment, or other actions that result in emotional or behavioral
problems, physical manifestations, disordered or delayed development.
W. “Exercise” means the practice of a planned activity at less than full-dress
intensity.
X. “Financial interest” means any equity, security, lease or
debt interest in the hospital; financial interest also includes any equity,
security, and lease or debt interest in any real property used by the hospital
or in any entity that receives compensation arising from the use real property
by the hospital.
Y. “Health physicist” means a
person holding a master’s degree or doctorate in an appropriate discipline of radiologic physics or who has equivalent education and
experience.
Z. “Hospital” means a facility
offering in-patient services, nursing, overnight care on a 24-hour basis for
diagnosing, treating, and providing medical, psychological or surgical care for
three or more separate individuals who have a physical or mental illness,
disease, injury, a rehabilitative condition or are pregnant; use of the term
“hospital” for any facility not duly licensed according to these requirements
is prohibited; any acute care hospital shall have emergency services, inpatient
medical and nursing care for acute illness, injury, surgery, and obstetrics;
any limited services hospital shall have emergency services, inpatient medical
and nursing care for acute illness, injury and surgery; ancillary services such
as pharmacy, clinical laboratory, radiology, and dietary are required for
acute-care or limited service hospitals.
AA. “Long
term acute-care hospital” means a hospital providing long term, in-patient
medical care for medically-complex patients whose length of stay averages
greater than 25 days; ancillary support services such as pharmacy, clinical
laboratory, radiology, and dietary are required for long-term acute-care
hospitals.
BB. “Low-income
patient” means a patient
whose family or household income does not exceed two hundred percent of the
most current federal poverty level.
CC. “Rehabilitation hospital”
means a special hospital that primarily provides rehabilitative care to
inpatients.
DD. “Legally authorized person” means a
parent of a minor, a court appointed guardian or a person authorized by the
patient in accordance with law to act on the patient’s behalf.
EE. “Licensed
practical nurse” means a person licensed as a practical nurse under the
Nursing Practice Act, Sections 61-3-1 through 61-3-30, NMSA 1978.
FF. “Licensee” means the person(s)
who, or organization which, has an ownership, leasehold, or similar interest in
the hospital and in whose name a license has been issued and who is legally
responsible for compliance with these requirements.
GG. “Licensing authority” means the
agency within the department vested with the authority to enforce these
requirements.
HH. “Limited services hospital” means a hospital that limits
admissions according to medical or surgical specialty, type of disease or medical
condition, or a hospital that limits its inpatient hospital services to
surgical services or invasive diagnostic treatment procedures; a limited
services hospital must have emergency services, inpatient medical and nursing
care for acute illness, injury, and surgery, and must offer ancillary services
including pharmacy, clinical laboratory, radiology, and dietary; a limited
services hospital does not include:
(1) a hospital
licensed by the department as a special hospital;
(2) an eleemosynary
hospital that does not bill patients for the services provided; and
(3) a hospital that
has been granted a license prior to January 1, 2003.
II. “Local community” means with respect to the requirements
of Section 24-1-5.8 NMSA
1978 (2003), the New Mexico standard metropolitan statistical area or county in
which a limited services hospital or an acute-care hospital applies to be
licensed or becomes initially licensed by the department at any time after
January 1, 2003; if the applicant seeks licensure of a facility within the
boundaries of a New Mexico standard metropolitan statistical area, the local
community for purposes of that application is that standard metropolitan
statistical area; if the applicant seeks licensure of a facility not within the
boundaries of a New Mexico standard metropolitan statistical area, the local
community for purposed of that application is the New Mexico county.
JJ. “Local emergency operations plan” means the all-hazard emergency
operations plan maintained by a jurisdiction at the local level that
coordinates local level functional plans, hazard specific plans, and response
specific plans into an effective and efficient whole.
KK. “Medically and factually accurate and
objective” means verified or
supported by the weight of research conducted in compliance with accepted
scientific methods and standards; published in peer-reviewed journals; and
recognized as accurate and objective by leading professional organizations and
agencies with relevant expertise in the field of obstetrics and gynecology,
such as the American college of obstetricians and gynecologists.
LL. “Medical staff” means the
hospital’s organized component of physicians, podiatrists, psychologists, dentists
and allied health personnel who have been appointed by the governing body of
the hospital and granted specific privileges for the purpose of providing care
for the patients of the hospital.
MM. “Misappropriation of property” means the deliberate misplacement,
misappropriation of patients’ property, or wrongful, temporary or permanent use
of a patient’s belongings or money without the patients’ consent.
NN. “National incident management
system” means the core set
of doctrine, concepts, principles, terminology, and organizational processes,
required by homeland security presidential directive 5, that
will be used to manage domestic incidents to enable effective, efficient,
and collaborative action at all levels.
OO. “National response plan” means the single all-hazard incident
management plan, required by homeland security presidential directive 5, that
addresses the five domains of disaster and emergency management: awareness,
prevention, preparedness, response, and recovery and that will govern all
disaster and emergency management planning beginning in federal fiscal year
2005 (October 1, 2004-September 30, 2005).
PP. “Neglect” means the failure to provide goods
and services necessary to avoid physical harm, mental anguish, or mental
illness.
QQ. “New Mexico
state all-hazard emergency operations plan” means the all-hazard emergency operations plan maintained by the
state of New Mexico that coordinates state level functional plans, hazard
specific plans, and response specific plans with local emergency operations
plans into an effective an efficient whole.
RR. “Nonpaying
patients” means with respect
to the requirements of Section 24-1-5.8 NMSA 1978
(2003), patients whose care is substantially uncompensated, including patients
classified as charity care or bad debit.
SS. “Nosocomial”
means an infection pertaining to or originating in a hospital not present or
incubating prior to admittance to a hospital.
TT. “Occupational therapist” means a person
licensed as an occupational therapist under the Occupational Therapy Act,
Sections 61-12A-1 to 61- 12A-20, NMSA
1978.
UU. “Pharmacist” means a person
licensed in New Mexico under the Pharmacy Act, 61-11-1 to 61-11-29, NMSA 1978.
VV. “Pharmacy” means a place where
drugs are compounded or dispensed that is licensed by the New Mexico board of
pharmacy.
WW. “Physical
abuse” means damaging or potentially damaging acts or incidents that result
in bodily injury or death.
XX. “Physical therapist” means a person
licensed to practice physical therapy under the Physical Therapy Act, Sections
61-12-1 to 61-12-21, NMSA
1978.
YY. “Physician” means a person
licensed to practice medicine or osteopathy by the New Mexico board of medical
examiners, pursuant to Section 61-6-10, NMSA 1978 or
the osteopathic medical examiners board pursuant to Sections 61-10-1 through
61-10-21, NMSA 1978.
ZZ. “Physician owner” means a
physician, podiatrist, dentist licensed by the New Mexico board of dental
health care pursuant to Section 61-5A-12NMSA 1978, or any other person licensed
in New Mexico as a health care practitioner permitted by the hospital to refer,
admit or treat hospital patients, and who has a financial interest in the
hospital.
AAA. “Podiatrist”
means a person licensed to practice podiatry or podiatric medicine and surgery
under the Podiatry Act, Sections 61-8-1 to 61-8-16, NMSA 1978.
BBB. “Privileges”
means the authorization of the medical staff members to provide care to
hospital patients in the area in which the person has expertise as a result of
education, training and experience.
CCC. “Psychologist”
means a person licensed to practice psychology under the Professional
Psychologists’ Act, Sections 61-9-1 through 61-9-18, NMSA 1978.
DDD. “Psychiatric
hospital” means a special hospital that primarily provides by or under the
supervision of a physician, psychological and/or psychiatric services for the
diagnosis and treatment of mentally ill persons.
EEE. “Registered nurse” means a person
licensed as a professional registered nurse under the Nursing Practice Act,
Sections 61-3-1 through 61-3-30, NMSA
1978.
FFF. “Reporting year” means with respect to he provision of
financial, utilization, and services information for the hospital’s last full
and audited annual accounting period.
GGG. “Respiratory care practitioner” means
a person who is licensed under the Respiratory Care Act, Sections 61-12B-1 to
61-12B-16, NMSA 1978.
HHH. “Sexual assault” means the crime of criminal sexual
penetration that may result in pregnancy.
III. “Sexual assault survivor” means a person who alleges or is
alleged to have been sexually assaulted and who presents as a patient to a
hospital.
JJJ. “Special hospital” means a hospital
that treats patients that have a diagnosis-related group
classifications for two-thirds of all its patients that fall into no
more than two major diagnosis categories, or if at least two-thirds of its
patients are classified in a specific diagnosis category; an example of a
special hospital is a psychiatric or rehabilitation hospital.
KKK. “Speech pathologist” means a person
who is licensed under the Speech-Language Pathology and Audiology
Act, Sections 61-14B-1 to 61-14B-16, NMSA 1978 to
practice speech language pathology.
LLL. “Variance”
means an act on the part of the licensing authority to refrain from enforcing
compliance with a portion or portions of these requirements for an unspecified
period of time where the granting of a variance will not create a danger to the
health, safety, or welfare of parents or staff of a hospital and is at the sole
discretion of the licensing authority.
MMM. “Waive/waiver”
means an act on the part of the licensing authority to refrain from enforcing
compliance with a portion or portions of these requirements for a limited
period of time less than one year, provided the health, safety, or welfare of
patients and staff are not in danger; waivers are issued at the sole discretion
of the licensing authority.
[7.7.2.7 NMAC - Rp, 7.7.2.7 NMAC,
06-15-04; A, 03-15-06]
7.7.2.8 REQUIRED
LICENSURE BY THE DEPARTMENT: Procedures applicable after January 1,
2003: This section addresses the requirements of Section 24-1-5.8 NMSA 1978 (2003) and applies to local communities in which
an acute-care hospital or a limited services hospital applies to be licensed or
becomes initially licensed by the department at any time after January 1, 2003.
A. No hospital may operate in New
Mexico unless it is licensed in accordance with the requirements of the New
Mexico department of health.
B. The department shall issue a
license to an acute-care hospital or a limited services hospital that meets the
requirements of this rule and agrees to:
(1) continuously
maintain and operate an emergency department that provides emergency medical
services as defined in Section 7.7.2.38 NMAC; and
(2) when applicable,
participate in the medicare, medicaid
and county indigent care programs; and
(3) require a
physician owner to disclose and document in the patient’s medical record a
financial interest in the hospital before referring a patient to the hospital.
C. Comply with the same quality
standards applied to other hospitals.
D. Provide emergency services and general
health care to a number of nonpaying patients and low-income reimbursed
patients in the same proportion as the patients that are treated in acute-care
hospitals in the local community, as determined by the department provided that
the annual cost of the care required to be provided pursuant to paragraph (5)
shall not exceed an amount equal to five percent of the hospital’s annual net
revenue for the previous fiscal year from audited financial statements.
E. Require a health care provider
to disclose a financial interest before referring a patient to the hospital.
F. Reporting Requirements-General. The department, in accordance with
the requirements of Section 24-1-5.8 NMSA 1978 (2003)
requires the provision of information necessary to determine the annual cost of
care for emergency and general health care to nonpaying and low-income
reimbursed patients, including the number of nonpaying and low-income
reimbursed patients treated, for the hospital’s last full and audited
accounting period. This period is called
the most recent reporting year.
G. Reporting Hospitals. After January 1, 2003, an application
to the department for an initial license by an acute-care hospital or limited
services hospital in a local community will require the provision of information
necessary to determine the annual cost of care for emergency and general health
care to nonpaying and low-income reimbursed patients, including the number of
nonpaying and low-income reimbursed patients treated, for the most current
reporting year. The following hospitals
must report to the department within 30 days of notice from the department of
application for an initial license by an acute-care hospital or limited
services hospital:
(1) all limited
services hospitals in the local community;
(2) all acute-care
hospitals in the local community;
(3) the limited services hospital applying for
the initial license or the acute-care hospital applying for the initial license
must submit a business plan that provides information necessary to determine
the projected annual cost of care for emergency and general health care to
nonpaying and low-income reimbursed patients, including the number of nonpaying
and low-income reimbursed patients.
H. Reporting Requirements-Specific.
The reporting requirement for information necessary to determine the annual
cost of care for emergency and general health care to nonpaying and low-income
reimbursed patients, including the number of nonpaying and low-income
reimbursed patients treated, for the hospital’s last full and audited
accounting period, shall be satisfied by the provision of a certified statement
by the hospital’s chief executive officer and an independent certified public
accountant attesting to the accuracy of the above required information, in the
format determined by the department. The
department shall conduct, as determined necessary, an independent audit to
validate the information provided in the certified statement.
I. Determination of Proportionality
by the Department. Based upon the certified statements and business plan(s)
submitted, the department shall determine whether the application for licensure
will provide emergency services and general health care to the number of nonpaying
patients and low-income reimbursed patients in the same proportion as the
proportion of nonpaying and low-income reimbursed patients that are treated in
acute-care hospitals in the local community.
Upon that determination by the department that the proportional
requirements are met by the applicant and the receipt of a certified statement
by the applicant’s chief executive officer that the proportions will be
maintained, and other rule requirements are met by the applicant, the
department may issue a license consistent with the requirements of Section
24-1.5.8 NMSA 1978 (2003).
J. Limitation on Costs to Achieve
Proportionality. The acute-care hospital or limited service hospital
applying for licensure after January 1, 2003 shall submit to the department on
an annual basis a certified statement from an independent certified public
accountant setting out for that reporting year the hospital’s annual
cost incurred in the provision of care to low-income reimbursed patients
and to nonpaying patients, in order to satisfy the hospital’s proportionality
requirements. Submission to the
department of such certified statement from an independent certified public
accountant shall be made by the hospital within 30 days of its acceptance by
the hospital’s board of directors of the annual audited financial
statement. The cost incurred in the
provision of care to low-income reimbursed patients and nonpaying patients to
satisfy the hospital’s proportionality requirements is
limited to five percent of the hospital’s annual net revenue.
K. Penalties for Non-Reporting.
Failure to meet the reporting requirements set out in this rule within the
proscribed timeliness may result in a civil monetary penalty not to exceed
$500,000, in the suspension or revocation of the hospital’s license, the
referral to CMS for sanctions under the medicare and medicaid program.
L. Penalties for Failure to Provide
Proportional Services. Failure by an acute-care hospital or limited service
hospital applying for licensure after January 1, 2003 to provide proportional
services to nonpaying and low-income reimbursed patients, as required by this
section, in any year following licensure, as determined from the information
submitted annually by the hospital’s chief executive officer and an independent
certified public accountant may result in the Department’s imposition of one or
more of the following penalties:
(1) a department-directed or department
approved plan of correction in which the hospital’s failure to provide proportional
services to nonpaying and low-income reimbursed patients is remedied in
subsequent years through the additional provision of services to nonpaying and
low-income reimbursed patients beyond the proportion established by the
department for such years;
(2) a civil monetary
penalty not to exceed $500,000;
(3) suspension or
revocation of the hospital’s license; and
(4) referral to CMS
for sanctions under the medicare and medicaid programs.
M. Annual Reporting. Acute-care
hospitals or limited services hospitals licensed after January 1, 2003, and all
acute-care hospitals in the local community, shall submit to the department on
an annual basis a certified statement from an independent certified public
accountant that sets out:
(1) the annual cost
of care for emergency and general health care to nonpaying and low-income
reimbursed patients;
(2) the annual net
patient service revenue;
(3) the number of
nonpaying and low-income reimbursed patients treated; and
(4) the total number
of patients treated.
N. Physician Owner Disclosure of
Financial Interest Requirements, Disclosure Required. The physician owner
of a limited services hospital or an acute-care hospital initially licensed by
the department at any time after January 1, 2003 shall not make a referral of a
patient for the provision of health care items or services to such limited services
hospital or the acute-care hospital unless, in advance of any such referral,
the referring physician owner discloses to the patient the existence and the
nature of physician’s ownership interest.
O. Disclosure of Financial Interest by
a Physician Owner. The
disclosure of financial interest by a physician owner, as required in this
section, shall be made in writing, prior to or at the time of the referral, and
shall be furnished to:
(1) the patient, or
the patient’s authorized representative, and
(2) the acute-care hospital or the limited
services hospital licensed by the department at any time after January 1, 2003,
in which the referring physician owner has a financial interest, for inclusion
in the hospital’s permanent patient’s medical record; the acute-care hospital
or the limited services hospital licensed by the department at any time after
January 1, 2003 must permit inspection of the patient’s medical record by
authorized employees of the department to determine the hospital’s compliance
with this requirement, regardless of the hospital’s deemed status.
P. Written Disclosure of Financial
Interest by a Physician Owner.
The written disclosure of financial interest by a physician owner, as required
in this section, shall include:
(1) the physician’s
name, address, and telephone number;
(2) the name and address of the limited
services hospital or the acute-care hospital licensed by the department at any
time after January 1, 2003 to which the patient is being referred by the
physician;
(3) the nature of the
items or services, which the patient is to receive from the hospital to which
the patient is being referred;
(4)
the existence, nature and extent of the
physician’s financial interest in the hospital to which the patient is being
referred; and
(5) a signed
acknowledgement by the patient or the patient’s authorized representative that the
required disclosure has been furnished.
Q. To be approved by the New Mexico
department of health, a hospital shall comply with these requirements and with
all other applicable state laws and local ordinances. Staff of the hospital
shall be licensed or registered, as appropriate, in accordance with applicable
laws.
R. An application for licensure
shall be submitted to the department on a form prescribed by the
department. All applications must have
the following information:
(1) name of administrator or chief executive officer;
(2) type of facility
to be operated and types of services that will be offered;
(3) location of the
hospital; and
(4) statement of ownership,
which must include:
(a) the
name and principle business address of each officer and director for the
corporation;
(b) the
name and business address of each stockholder owning 10 percent or more of the
stock;
(c) copy
of the current organizational chart; and
(d) such
other information or documents as may be required by the department for the
proper administration and enforcement of the licensing law and requirements.
S. The department shall review and
make a determination on an application for licensure within 90 working days of
receipt of the application.
T. Separate licenses shall be
required for hospitals that are maintained on separate premises even though
they are under the same management. This does not apply to outpatient
departments or clinics of hospitals designated as such which are maintained and
operated on separate premises within the same county or, if in another county,
not to exceed a one hour drive time from the parent facility. Separate licenses shall not be required for
separate buildings on the same grounds or adjacent grounds.
U. Applications submitted for
proposed construction of new hospitals or additions to licensed hospitals shall
include architectural plans and specifications.
V. Information contained in such
applications shall be on file in the department and available to interested
individuals and community agencies.
[7.7.2.8 NMAC - Rp, 7.7.2.8 NMAC,
06-15-04; A, 03-15-06]
7.7.2.9 TYPES
OF LICENSE:
A. “Annual license”: an annual license is issued for a
one-year period to a hospital that has met all requirements of these
requirements.
B. “Temporary license”: the
licensing authority may, at its sole discretion, issue a temporary license
prior to the initial state licensing survey, or when the licensing authority
finds partial compliance with these requirements.
(1) A temporary license shall cover a period
of time, not to exceed 120 days, during which the facility must correct all
specified deficiencies.
(2) In accordance with Section 24-1-5 (D) NMSA 1978, no more than two consecutive temporary licenses
shall be issued.
C. “Amended license”: a licensee
must apply to the licensing authority for an amended license when there is any
change of administrator, name, location, capacity, classification of any unit
as listed in these requirements:
(1) the application
must be on a form provided by the licensing authority;
(2) application must
be accompanied by the required fee for an amended license; and
(3) application must
be submitted at least 10 working days prior to the change.
[7.7.2.9 NMAC - Rp, 7.7.2.9 NMAC,
06-15-04]
7.7.2.10 LICENSE
RENEWAL:
A. The licensee must submit a
renewal application on forms provided by the licensing authority, along with
the required fee prior to the expiration of the current license.
B. Upon receipt of the renewal
application and the required fee prior to expiration of current license, the
licensing authority will issue a new license effective the day following the
date of expiration of the current license if the facility is in substantial
compliance with these requirements.
[7.7.2.10 NMAC - Rp, 7.7.2.10
NMAC, 06-15-04]
7.7.2.11 POSTING:
The license, or a copy thereof, shall be conspicuously posted in a location
accessible to public view within the hospital.
[7.7.2.11 NMAC - Rp, 7.7.2.11
NMAC, 06-15-04]
7.7.2.12 NON-TRANSFERABLE
REGISTRATION OF LICENSE: A license shall not be transferred by assignment
or otherwise to other persons or locations.
The license shall be void and must be returned to the licensing
authority when any one of the following situations occur:
A. ownership of the hospital
changes;
B. the facility changes location;
C. the licensee of the hospital
changes; or
D. the hospital discontinues
operation.
[7.7.2.12 NMAC - Rp, 7.7.2.12
NMAC, 06-15-04]
7.7.2.13 EXPIRATION
OF LICENSE: A license will expire at midnight on the day indicated on the
license as the expiration date, unless sooner renewed, suspended, or revoked,
or:
A. on the day a facility
discontinues operation; or
B. on the day a facility is sold, leased,
or otherwise changes ownership and/or licensee; or
C. on the day a facility changes
location.
[7.7.2.13 NMAC - Rp, 7.7.2.13
NMAC, 06-15-04]
7.7.2.14 SUSPENSION
OF LICENSE WITHOUT PRIOR HEARING:
In accordance with 24-1-5 (H), NMSA 1978, if the licensing
authority determines immediate action is required to protect human health and
safety, the licensing authority may suspend a license. A hearing must be held in accordance with the
regulations governing adjudicatory hearings, New Mexico department of health, 7
NMAC 1.2. [Recompiled as 7.1.2 NMAC]
[7.7.2.14 NMAC - Rp, 7.7.2.14
NMAC, 06-15-04]
7.7.2.15 GROUNDS
FOR REVOCATION OR SUSPENSION OF LICENSE, DENIAL OF INITIAL OR RENEWAL
APPLICATION FOR LICENSE, OR IMPOSITION OF INTERMEDIATE SANCTIONS OR CIVIL
MONETARY PENALTIES: A license may be denied, revoked or suspended, or
intermediate sanctions or civil monetary penalties may be imposed after notice
and opportunity for a hearing for any of the following reasons:
A. failure to comply with any
provisions of these requirements;
B. failure to allow survey by
authorized representatives of the licensing authority;
C. permitting any person while active
in the operation of a facility licensed pursuant to these requirements to be
impaired by the use of prescribed or non-prescribed drugs, including alcohol;
D. misrepresentation or
falsification of any information provided to the licensing authority;
E. the discovery of repeat
violations of these requirements during surveys; or
F. the
failure to provide the required care and services as outlined by these
requirements.
[7.7.2.15 NMAC - Rp, 7.7.2.15
NMAC, 06-15-04]
7.7.2.16 HEARING
PROCEDURES:
A. An applicant or licensee subject
to an adverse action may request an administrative appeal.
B. Hearing procedures for an
administrative appeal of an adverse action taken by the licensing authority
against the hospital as outlined in Section 14 and 15 above will be held in
accordance with adjudicatory hearings, New Mexico department of health, 7 NMAC
1.2. [Recompiled as 7.1.2 NMAC]
C. A copy of the adjudicatory
hearing procedures will be furnished to the hospital at the time an adverse
action is taken against the licensee by the licensing authority. A copy may be
requested at any time by contacting the licensing authority.
[7.7.2.16 NMAC - Rp, 7.7.2.16
NMAC, 06-15-04]
7.7.2.17 WAIVERS
AND VARIANCES:
A. Applications. All applications
for the grant of a waiver or variance shall be made in writing to the licensing
authority, specifying the following:
(1) the rule from
which the waiver or variance is requested;
(2) the time period
for which the waiver or variance is requested;
(3) if the request is
for a variance, the specific alternative action which the facility proposes;
(4) the reasons for
request; and
(5) an explanation of
why the health, safety, and welfare of the residents or staff are not
endangered by the condition.
B. Requests for a waiver or
variance may be made at any time.
C. The licensing authority may
require additional information from the hospital prior to acting on the
request.
(1) Grants and Denials. The licensing
authority shall grant or deny each request for waiver or variance in
writing. Notice of a denial shall
contain the reasons for denial. The decisions to grant, modify, or deny a
request for a waiver or variance is subject to appeal one time only.
(2) The terms of a requested variance may be
modified upon agreement between the licensing authority and the hospital.
D. The licensing authority may
impose whatever conditions on the granting of a waiver or variance it considers
necessary.
E. The licensing authority may
limit the duration of any waiver.
[7.7.2.17 NMAC - Rp, 7.7.2.17
NMAC, 06-15-04]
7.7.2.18 GOVERNING
BODY:
A. General Requirements. The
hospital shall have an effective governing body, which is legally responsible
for the management and provision of all hospital services, maintenance of the
hospital services and the quality thereof.
B. Responsibilities. By-laws.
The governing body shall adopt by-laws.
The by-laws shall be in writing and shall be available to all members of
the governing body as well as the public. The by-laws shall:
(1) stipulate the
basis upon which members are selected, their terms of office and their duties
and requirements;
(2) specify to whom
responsibilities for operation and maintenance of the hospital, including
evaluation of hospital practices, may be delegated, and the methods established
by the governing body for holding these individuals responsible;
(3) require a
physician owner or other provider to disclose to the patient or the patient’s
representative and document for the patient’s medical record a financial
interest in the hospital before referring a patient to the hospital;
(4) provide for the
designation of officers, if any, their terms of office and their duties, and
for the organization of the governing body;
(5) specify the frequency with which meetings
shall be held;
(6) allow for the
organization of committees, either standing or ad hoc, to assist the board in
carrying out their responsibilities;
(7) provide for the
appointment of members of the medical staff; during periods of routine
operation, and during disaster and emergency; and
(8) provide
mechanisms for the formal approval of the organization, by-laws and rules of
the medical staff.
C. Meetings.
(1) The governing body shall meet at regular
intervals as stated in its by-laws.
(2) Meetings shall be held frequently enough
for the governing body to carry on necessary planning for growth and
development and to evaluate the performance of the hospital, including the care
utilization of physical and financial assets and the delegation to the
CEO/administrator for the hiring and direction of personnel.
(3) Minutes of meetings shall reflect
pertinent business conducted.
D. Committees.
(1) The governing body shall appoint
committees. There shall be an executive committee and others as allowed by
bylaws.
(2) The number and types of committees shall
be consistent with the size and scope of activities of the hospital
(3) The executive committee or the governing
body as a whole shall establish operating guidelines for the activities and
general policies of the various hospital services and committees established by
the governing body.
(4) Written minutes,
or reports, which reflect business conducted by the executive committee
shall be maintained for review by the governing body.
(5) Other committees, which may include
finance, joint conference, quality improvement and plant and safety management
committees, shall function in a manner consistent with their duties assigned by
the governing body and shall maintain written minutes or reports which reflect
the performance of these duties. If the
governing body does not appoint a committee for a particular area, a member or
members of the governing body shall assure the performance of the duties
normally assigned to a committee for that area.
E. Medical Staff Liaison. The governing body shall establish a
formal means of liaison with the medical staff by a joint conference committee
or by other means as follows:
(1) a direct and effective method of
communication with the medical staff shall be established on a formal, regular
basis, and shall be documented in written minutes or reports which are
distributed to designated members of the governing body and the active medical
staff; and
(2) liaison shall be
a responsibility of the joint conference committee or its equivalent and the
executive committee for designated members of the governing body.
F. Medical Staff Appointments. The governing body shall appoint
members of the medical staff in accordance with the approved medical staff
by-laws.
(1) A formal procedure shall be established,
governed by written rules covering application for medical staff membership and
the method of processing applications during periods of routine operation, and
during disaster and emergency.
(2) The procedure related to the submission
and processing of applications shall involve the chief executive
officer/administrator, the credentials committee of the medical staff or its
equivalent, and the governing body.
(3) Action taken by the governing body on
applications for medical staff appointments shall be in writing; and available
to the licensing authority during surveys or complaint investigations.
(4) Written notification of applicants shall
be made by either the governing body or its designated representative.
(5) Applicants selected for medical staff
appointment shall sign an agreement to abide by the medical staff rules and
by-laws.
(6) The governing body shall establish a
procedure for appeal and hearing by the governing body or a designated
committee if the applicant or the medical staff wishes to contest the decision
on an application for medical staff appointments.
G. Appointment of Chief
Executive Officer/Administrator. The governing body shall appoint an administrator or a chief
executive officer/administrator for the hospital. The governing body shall
review the performance of the chief executive officer/administrator at least
annually.
H. Patient Care. The governing body shall establish a
policy, which requires that every patient be under the care of a licensed,
independent practitioner as determined by the medical staff and governmental
body.
I. Physical Plant Requirements.
The governing body shall be responsible for providing a physical plant equipped
and staffed to maintain the needed facilities and services for patients.
J. Risk Management. The facility shall have a risk
management program. State, county or
city facilities must have a risk management plan in accordance with the general
services department rules.
K. Discharge Planning.
(1) The governing body shall assure that the
hospital maintains an effective, ongoing program coordinated with community
resources to facilitate the provision of appropriate follow-up care to patients
who are discharged.
(2) The hospital shall have current
information on community resources available for continuing care of discharged
patients.
(3) The discharge planning program shall:
(a) have
a mechanism to identify patients who require discharge planning to provide
continuity of medical care to meet their identified needs;
(b) initiate
discharge planning in a timely manner;
(c) identify the role
of the patient’s provider, nursing staff, social work staff, other appropriate
staff, the patient, and the patient’s family or representative in the initiation
and implementation of the discharge planning process;
(d) assure
documentation in the medical record of the discharge plan;
(e) allow
for the timely and effective transmittal of all medical, social, economic
information concerning the patient to persons responsible for subsequent care
of the patient;
(f) provide that every
patient, or their legal representatives, receive relevant information
concerning their health needs and is involved in his or her own discharge
planning; and
(g) be
reviewed at least once a year to evaluate effectiveness.
[7.7.2.18 NMAC - Rp, 7.7.2.18
NMAC, 06-15-04; A, 03-15-06]
7.7.2.19 POLICIES: Every hospital shall have written
policies approved by the governing board and shall include provisions for
implementation, and for access by the patient, on:
A. Patient rights and
responsibilities: a list of these patient rights and responsibilities shall be
available in languages appropriate to the ethnic needs of the community;
(1) The policies on patient rights and
responsibilities shall provide that:
(a) patients may not be denied appropriate
hospital care because of the patient’s race creed, color, national origin,
religion, sex, sexual orientation, marital status, age, disability or source of
payment;
(b) patients
shall be treated with consideration, respect, and recognition of their
individuality, including the need for privacy in treatment;
(c) the
individual patient’s medical records, including all computerized medical
information, shall be kept confidential in accordance with applicable federal,
state and local laws;
(d) the patient or any
person authorized by statute or in writing by the patient shall have access to
the patient’s medical record but access to patient’s psychiatric records may be
limited by treating professionals when specific hospital policies specify
requirements for limiting access;
(e) every
patient shall be entitled to know who has overall responsibility for the
patient’s care;
(f) every patient,
legally authorized person or any person authorized in writing by the patient,
shall receive, from the appropriate person within the facility, information
about his illness, course of treatment and prognosis for recovery in terms the
patient can understand;
(g) every
patient, or his designate representative, where appropriate, shall have the
opportunity to participate to the fullest extent possible in planning for his
care and treatment;
(h) every
patient, or his designated representative, shall be given, at the time of
admission, a copy of the patient’s rights and responsibilities;
(i) except in
emergencies, the consent of the patient, or their legally authorized
representative, shall be obtained before treatment is administered;
(j) any
patient may refuse treatment to the extent permitted by law and shall be
informed of the medical consequences of the refusal;
(k) the patient, the
patient’s legally authorized representative, or person granted the power to
authorize medical treatment, shall be fully informed and give consent for the
patient’s participation in any form of research or experimentation;
(l) except in
emergencies, the patient may be transferred to another facility only with a
full explanation of the reason for the transfer, provision for continuing care;
and acceptance by the receiving institution;
(m) every
patient may examine and receive an explanation of the patient’s hospital bill
regardless of source of payment, and may receive upon request, information
relating to financial assistance available through the hospital;
(n) every patient shall
be informed of his responsibility to comply with hospital rules, cooperate in
the patient’s own treatment, provide a complete and accurate medical history,
be respectful of other patients, staff and property, and provide required
information concerning payment of charges;
(o) every patient shall
be informed in writing about the hospital’s policies and procedures for
initiation, review and resolution of patient complaints, including the address
where complaints may be filed with the department;
(p) every
patient shall be allowed to designate who may be permitted to visit during the
hospital stay in accordance with the hospital policy; and
(q) every
patient shall have freedom from physical or verbal abuse, harassment and
inappropriate physical and chemical restraints;
(r) hospitals
must be in compliance with CMS’s patient rights condition of participation.
(2) The policies on patient rights and
responsibilities shall also provide that patients who receive treatment for
mental illness, or developmental disability, in addition to the rights listed
herein, have the rights provided in section 43-1-6 NMSA
1978.
(3) Hospital staff assigned to provide direct
patient care shall be informed of, and demonstrate their understanding of, the
policies on patient rights and responsibilities through orientation and
appropriate in-service training activities.
B. Movement of Visitors: The
hospital shall develop policies regarding the movement of visitors, which
provide for infection control and patient privacy, but also allow the patient
appropriate freedom as to the time, nature, and location of visit.
C. Use of Volunteers:
(1) the scope of volunteer
activities shall be delineated in hospital policies and procedures and shall
cover periods of routine operation and periods of disaster and emergency
operation;
(2) volunteers may
assist with patient care only under direct supervision of appropriate hospital
personnel and after appropriate, documented in-service training; volunteers may
not perform procedures permitted only by a licensed health care provider;
(3) no volunteer
under 16 years of age may assist with or render direct patient care.
D. Identification: The hospital
shall develop a method to identify employees, patients, personnel records and
patient files.
E. Cancer Reporting: every
hospital shall report to the tumor registry all malignant neoplasms
that are diagnosed by the hospital and all malignant neoplasm’s diagnosed
elsewhere if the individual is subsequently admitted to the hospital; the
report of each malignant neoplasm shall be made on a form prescribed or
approved by the department and shall be submitted to the UNM
tumor registry within six months after the diagnosis is made or within six
months after the individual’s first admission to the hospital if the neoplasm
is diagnosed elsewhere, as appropriate; in this paragraph, “malignant neoplasm”
means an in situ or invasive tumor of the human body, but does not include a squamous cell carcinoma or basal cell carcinoma arising in
the skin.
F. Post - Mortem Examinations:
(1) the hospital
shall have policies for notifying all personnel of special handling needs
during post-mortem procedures;
(2) the hospital
shall have policies for the release of a deceased human body to a funeral
director or other authorized person.
G. Tagging of Bodies: all deceased
human bodies to be removed from a hospital shall be tagged by staff of the
hospital; a red tag shall be used to indicate the possibility of the presence
of the communicable or infectious disease or radioactive materials. If the body is in a container, a tag shall
also be applied to the outside of the container.
H. Autopsy: Reports are to be
distributed to the primary provider and become part of the patient’s clinical
record.
I. Withholding of Resuscitative
Services from Patients.
(1) A policy shall be developed in
consultation with the medical staff, nursing staff, and other appropriate
bodies and shall be adopted by medical staff and approved by the governing
body. The policy shall describe:
(a) a mechanism(s)
for reaching decisions about the withholding of resuscitative services from
individual patients;
(b) the
mechanism(s) for resolving conflicts in decision making, should they arise;
(c) the roles of
physicians and, when applicable, of nursing personnel, other appropriate staff,
and family members in the decision to withhold resuscitative services;
(d) provisions
designed to assure that patients’ rights are respected when decisions are made
to withhold resuscitative services;
(e) a requirement that
patients, or their legal representative(s), and family members must be afforded
the opportunity to make their wishes known about decisions affecting the
patient’s end of life care;
(f) a
requirement that appropriate orders be written by the physician or other
licensed independent practitioners primarily responsible for the patient and
that documentation be made in the patient’s medical record.
(2) A decision to withhold resuscitative
services does not absolve the hospital from providing basic patient care.
J. Anatomical Gifts: A policy
shall be adopted and implemented for organ and tissue donation in accordance
with Section 7.7.2.42 NMAC; the policy shall include procedures to assist the
medical, surgical and nursing staff in identifying, evaluating and reporting
potential organ and tissue donors.
K. Reporting: A policy for
compliance with all applicable state and federal reporting requirements must be
adopted and updated as necessary; such federal requirements include but are not
limited to the New Mexico health policy commission, the national practitioner
data bank and the healthcare integrity and protection data bank.
[7.7.2.19 NMAC - Rp, 7.7.2.19
NMAC, 06-15-04; A, 03-15-06]
7.7.2.20 CHIEF
EXECUTIVE OFFICER/ADMINISTRATOR:
A. Appointment. The hospital shall
be directed by a chief executive officer/administrator. The chief executive
officer/administrator shall be appointed by the governing body, shall be
responsible for the management of the hospital and shall provide liaison among
the governing body, medical staff, nursing services and other services of the
hospital.
B. Qualification. The chief executive
officer/administrator shall:
(1) be a college or
university graduate from an accredited college or university, with three years
of experience in a health care facility; or
(2) possess a college or university graduate
degree in hospital, health care administration, or an advanced degree such as
an MPH or an MBA with a health concentration; or
(3) have been hired
and be acting in the capacity of the facility’s chief executive
officer/administrator before the effective date of these requirements.
C. Responsibilities. The chief executive
officer/administrator shall:
(1) keep the governing body fully informed
about the quality of patient care, the management and financial status of the
hospital, survey results and the adequacy of physical plant, equipment and
personnel;
(2) organize the day-to-day functions of the
hospital;
(3) establish formal means of staff evaluation
and accountability on the part of subordinates to whom duties have been
assigned;
(4) provide for the maintenance
of an accurate, current and complete personnel record for each hospital
employee;
(5) ensure that there is sufficient
communication among the governing body, medical staff, nursing services and
other services, hold interdepartmental and departmental meetings, where
appropriate, attend or be represented at the meetings on a regular basis, and
report to the governing body on the pertinent activities of the hospital;
(6) provide the department with any
information required to document compliance with the Public Health Act, Section
24-1-1 et seq., NMSA 1978, and provide reasonable
means for examining records and gathering the information;
(7) be responsible
for the preparation of policies and procedures on the withholding of
resuscitative services from patients.
[7.7.2.20 NMAC - Rp, 7.7.2.20
NMAC, 06-15-04]
7.7.2.21 EMPLOYEE
HEALTH: The hospital shall have
an employee health program under the direction of a physician, an authorized
licensed independent practitioner or professional registered nurse, which shall
include.
A. Post Hiring Health Screen. A
post hiring health screening shall be required for all employees and persons
who will have frequent and direct contact with patients. The assessment shall
be completed and the results known prior to the assumption of duties by persons
who will have direct contact with patients.
The screening shall include:
(1) a health history,
including a history of communicable diseases and immunizations;
(2) a PPD tuberculin skin test and, if necessary, a chest
roentgenogram to determine whether disease is present, unless medically
contra-indicated.
B. Health History for Volunteers. A health history of communicable
diseases and immunizations shall be obtained prior to any volunteer assuming
duties that involve direct patient care.
C. Protection Against
Rubella. Vaccination or confirmed immunity against rubella shall be
required for everyone who has direct contact with rubella patients, pediatric
patients or female patients of childbearing age. No individual without
documented vaccination against or immunity to rubella may be placed in a
position in which he or she has direct contact with rubella patients, pediatric
patients or female patients of childbearing age.
[7.7.2.21 NMAC - Rp, 7.7.2.21
NMAC, 06-15-04]
7.7.2.22 INFECTION
CONTROL:
A. Program. The hospital shall have
an infection control program designed to reduce the number of infections, including
nosocomial infections, within the hospital.
B. Program Approval.
(1) Purpose: The governing body or medical
staff shall approve an infection control program to carry out surveillance and
investigation of infections in the hospital and to implement measures designed
to reduce these infections to the extent possible.
(2) Responsibilities: The infection control program shall:
(a) establish
techniques and systems for discovering and isolating infections occurring in
the hospital;
(b) establish
written infection control policies and procedures, which govern the use of
aseptic technique and procedures in all areas of the hospital;
(c) establish a method of control used in
relation to the sterilization of supplies and solutions; there shall be a
written policy requiring identification of sterile items and specified time
periods in which sterile items shall be reprocessed;
(d) establish policies
specifying when employees or persons providing contractual services with infections or contagious conditions,
including carriers of infectious organisms, shall be relieved from, or reassigned
duties, until there is evidence that the disease or condition poses no
significant risk to others;
(e) at
least annually assess effectiveness of the infection control process; and
(f) establish
effective guidelines for the disposition of infectious materials in accordance
with the local, state and federal guidelines.
C. Education: The hospital shall
provide training to all appropriate hospital personnel on the epidemiology,
etiology, transmission, prevention and elimination of infection, as follows:
(1) aseptic technique: all appropriate personnel shall be educated in the practice of
aseptic techniques such as hand-washing and scrubbing practices, standard precautions,
personal hygiene, masking and dressing techniques, disinfecting and sterilizing
techniques and the handling and storage of patient care equipment and supplies,
to include the handling of needles and sharp instruments; and
(2) orientation and
in-service: new employees shall receive appropriate orientation and on-the- job
training, and all employees shall participate in a continuing in-service
program; the participation shall be documented.
D. General
Infection Control Provisions.
(1) There shall be regular inspection and
cleaning of air intake sources, screens and filters, with special attention
given to high risk areas of the hospital as determined by the infection control
committee.
(2) A sanitary environment shall be maintained
to avoid sources and transmission of infection.
(3) Proper facilities shall be maintained, and
techniques used, for disposal of infectious wastes, as well as sanitary disposal
of all other wastes.
(4) Hand-washing facilities shall be provided
in patient care areas for the use of hospital personnel.
(5) Sterilizing services shall be available at
all times.
(6)
Soiled linen shall be contained and
secured at the point generated. It can be transported to a designated area or
cleaning facilities. No special
precautions beyond the standard precautions are necessary. Soiled bed linen shall be placed immediately in
a container available for this purpose and sent to the laundry promptly.
(7) Tuberculosis exposure control plan.
(a) A program to minimize
the risk of infectious tuberculosis among or between health care workers,
patients, or visitors and others shall be developed.
(b) This program shall
include: a comprehensive facility-wide risk assessment, early identification,
isolation, and treatment of potentially infectious tuberculosis patients,
effective engineering controls to prevent the spread, and reduce the
concentration of, infectious droplet nuclei, a
written, respiratory protection program to protect health care workers from
exposure, education, counseling, and screening processes for health care
workers.
E. Reporting Disease: Hospitals
shall report cases and suspected cases of notifiable
conditions as listed in 7.4.3.13 NMAC to the New Mexico department of health
pursuant to New Mexico regulations governing the control of disease and
conditions of public health significance, New Mexico department of health,
7.4.3 NMAC or any superceding regulation.
F. Policies and Procedures. There shall be written policies and
procedures pertinent to care of patients with communicable diseases that shall
include standard precautions.
(1) These policies and procedures shall be
developed by administrative, medical, and nursing staff.
(2) The policies and procedures shall be
applicable within the hospital, designed to ensure safe and adequate care to
patients, safety to hospital employees, and consistent with applicable laws and
regulations.
(3) Policies shall be made known to, and readily available to all hospital employees as well
as the medical and nursing staff, and shall be followed in the care of
patients, and shall be kept current by periodic review and revision.
[7.7.2.22 NMAC - Rp, 7.7.2.22
NMAC, 06-15-04; A, 03-15-06]
7.7.2.23 QUALITY
IMPROVEMENT:
A. Responsibility of the Governing
Body: The governing body shall ensure that the hospital has a written
quality improvement program for monitoring, evaluating and improving the
quality of patient care and the ancillary services in the hospital on an
on-going basis. The program shall
promote the most effective and efficient use of available health facilities and
services consistent with patient needs and professionally recognized standards
of health care.
B. Responsibilities of the Chief
Executive Officer/Administrator and the Chief of the Medical Staff. As part of the quality improvement
program, the chief executive officer/administrator and chief of the medical
staff shall ensure that:
(1) the hospital’s
quality improvement program is implemented and evaluated for effectiveness for
all patient care and all services;
(2) the findings of the program are
incorporated into a well defined method of assessing staff performance in
relation to patient care and the provision of services; and
(3) program findings,
actions and results of the hospital’s quality improvement program are reported
to the chief executive officer/administrator, chief of medical staff and
governing body not less than annually.
C. Evaluation of Care to be
Problem-Focused.
(1) Monitoring and evaluation of the quality
of care given patients and services provided shall focus on identifying patient
care problems and opportunities for improving patient care.
(2) Evaluation of care and services shall be
problem-focused whenever serious events occur which
have a major impact on patient care
and services, or when the hospital receives a quality-of-care concern or
complaint.
D. Evaluation of Care and Services to
Use Variety of Sources. The quality of care given patients shall be
evaluated using a variety of data sources, including, but not limited to,
medical records, hospital information systems, published research, literature
comparison, peer review organization data, patient satisfaction findings, and
when available, third party information.
E. Activities. Hospitals shall document how each of the monitoring and evaluation
activities has produced data used to institute changes to improve quality of
care or services and promote more efficient use of facilities and services.
Quality improvement activities shall:
(1) emphasize
identification and analysis of patterns of patient care and suggest possible
changes for maintaining consistently high quality care and effective and
efficient use of services;
(2) identify and analyze factors related to
the patient care rendered in the facility and, where indicated, make recommendations to the
governing body, chief executive officer/administrator and chief of the medical
staff for changes that are beneficial to patients, staff, the facility and the
community; and
(3) document the
monitoring and evaluation activities performed and indicate how the results of
these activities have been used to institute changes to improve the quality and
a appropriateness of the care provided.
F. Evaluation of the Program. The
chief executive officer/administrator and chief of medical staff shall be
involved in evaluation of the effectiveness of the quality improvement program
which is evaluated by clinical and administrative staff at least once a year
and that the results are communicated to the governing body.
[7.7.2.23 NMAC - Rp, 7.7.2.23
NMAC, 06-15-04]
7.7.2.24 UTILIZATION
MANAGEMENT:
A. Plan: Every hospital shall have
in operation a written utilization management plan designed to ensure that
quality patient care is provided in the most appropriate manner. The plan should address potential over and
under utilization as well as the efficient use of resources for patients.
(1) Description of Plan. The written
utilization management plan shall include at a minimum at least the following:
(a) a delineation of
the responsibilities and authority of those involved in the performance of
utilization management activities, including utilization management personnel,
administrative personnel, and, when applicable, any qualified outside
organization contracting to perform review activities specified in the plan;
(b) a
conflict of interest statement stating that reviews may not be conducted by any
person who has a proprietary interest in any hospital or by any person who was
professionally involved in the care of the patient whose case is being
reviewed;
(c) a
confidentiality policy applicable to all utilization management activities,
including any findings and recommendations;
(d) a description of
the process by which the hospital identifies and resolves utilization related
problems, including the appropriateness and medical necessity of admissions,
continued stays, and supportive services, as well as delays in the provision of
supportive services; and
(e) the
following activities shall be incorporated into the process: analysis of
profiles and patterns of care, feedback of results of profile analysis to the
medical staff, documentation of specific actions taken to correct aberrant
practice patterns or other utilization management problems, and evaluation of
the effectiveness of action taken.
(2) The plan must include the procedures for
conducting review, including the time period within which the review is to be
performed following admission and in assigning continued stay review dates.
(3) A mechanism for the provision of discharge
planning as set forth under these requirements must be included.
(4) Responsibility for performance. The plan
shall be approved by the medical staff, administration and governing body.
Hospital administration shall assure the effective implementation of the plan.
B. Conduct of Review.
(1) Written measurable criteria that have been
approved by the medical staff shall be utilized when performing reviews.
(2) Non-physician health care professionals
may participate in the development of review criteria and conduct of review
relative to services provided by their peers.
(3) Determinations regarding the medical
necessity and appropriateness of care provided shall be based upon information
documented in the medical record. The
medical staff member primarily responsible for the patient’s care shall be
notified whenever it is determined that an admission or continued stay is not
medically necessary, and shall be afforded the opportunity to present his or
her own views before a final determination is made. At least two medical staff members shall make
a determination when the medical staff member primarily responsible for the
patient’s care disagrees.
(4) Different rules may apply to beneficiaries
of, or enrollees in, plans which provide medicare or medicaid
services. If the hospital is a member
of, or has a contractual relationship with, a risk bearing entity, and such risk
bearing entity has a contract with CMS or with the New Mexico medicaid authority (single state agency), then the
applicable federal or state requirements shall apply to enrollees under such a
plan.
(5) Written notice of any decision that an
admission or continued stay is not medically necessary shall be given to the
appropriate hospital department, the medical staff member primarily responsible
for care of the patient and the patient no later than 72 hours after the
determination.
C. Records and Reporting. Records
shall be kept of hospital utilization management recommendations made to the
medical staff and to the governing body as necessary. Recommendations relevant
to hospital operations or administration shall be reported to administration.
[7.7.2.24 NMAC - Rp, 7.7.2.24
NMAC, 06-15-04]
7.7.2.25 DISASTER AND EMERGENCY
MANAGEMENT:
A. Plan: Each hospital shall have
in operation a written plan for disaster and emergency management developed
with the involvement of the hospital’s executive, medical, and nursing staff
and designed to ensure that each hospital is prepared to provide effective and
efficient response to disasters and emergencies occurring in the community
directly served by each hospital and in neighboring communities in New Mexico
and adjacent states.
(1) Description of Plan: The written plan for
disaster and emergency management shall:
(a) identify the responsibilities and authorities
of those involved in the conduct of disaster and emergency management
activities within the hospital, including the responsibility and authority of
chief executive officer of the hospital for the activation of the plan;
(b) be consistent
with the concepts, principles, standards, guidelines, and terminology of the
national response plan and the national incident management system;
(c) be coordinated with
the local emergency operations plan, or the metropolitan medical response
system plan, of the community directly served and with the New Mexico state
all-hazard emergency operations plan;
(d) address the
natural, accidental, negligent, and intentional hazards, identified through a
hazard vulnerability analysis, to which the hospitals may be expected to
respond;
(e) provide for direction, planning,
education, training, exercise, drill, staff qualification and certification,
equipment acquisition and certification, resource management, communications
and information management, and ongoing management, improvement and
maintenance;
(f) describe the direct responses of the
hospital to disaster and emergency occurring in the community directly served
by the hospital, the overflow and back-up responses of the hospital to disaster
and emergency occurring in neighboring communities not directly served, and the
efforts of the hospital in support organized and sponsored health professional
disaster and emergency volunteer teams.
(2) Exercise and Drill of Plan: Exercises and drills of the plan, both
internally, and in conjunction with local and state disaster and emergency
exercises and drills, shall be conducted at least twice a year to practice
response and to serve as a basis for plan improvement.
(3) Evaluation and Revision of Plan: The
appropriateness and adequacy of the plan shall be evaluated on an annual basis,
and the plan shall be revised as necessary.
B. Communications Systems: With
the assistance of the New Mexico department of health each hospital shall
establish and maintain connections with the various disaster and emergency
management communications systems in New Mexico.
C. Bed Polling: Each hospital
shall participate in the electronic bed polling system operated by the New
Mexico department of health.
D. Mutual Aid Agreements and
Regional Response Plans: Coordination of hospital disaster and emergency
management plans with local emergency operations plans and with the New Mexico
state all-hazard emergency operations plan shall be recognized to serve the
purposes of individual mutual aid agreements and of regional response plans.
E. Public Health Emergency
Response: In the event that a public health emergency is declared pursuant
to the Public Health Response Act, Sections 12-10A- to 12-10A-19, NMSA 1978, the secretary of health, in coordination with
the secretary of public safety and the director of homeland security, may:
(1) utilize, secure
or evacuate health care facilities for public use; and
(2) inspect, regulate
the allocation, sale, dispensing, or distribution of, or ration health care
supplies in short supply within New Mexico.
[7.7.2.25 NMAC - Rp, 7.7.2.25
NMAC, 06-15-04; 7.7.2.25 NMAC - N, 03-15-06]
7.7.2.26 MEDICAL STAFF:
A. General Requirements:
(1) Organization and Accountability: The
hospital shall have a medical staff organized under by-laws approved by the
governing body. The medical staff shall be responsible to the governing body of
the hospital for the quality of all medical care provided patients in the
hospital and for the ethical and professional practices of its members.
(2) Responsibility of Members: Members of the
medical staff shall comply with medical staff and hospital policies. The
medical staff by-laws shall prescribe disciplinary procedures for infraction of
hospital and medical staff policies by members of the medical staff. There
shall be evidence that the disciplinary procedures are applied where
appropriate.
B. Membership.
(1) Active Staff: A hospital shall have an
active medical staff, which performs all the organizational duties pertaining
to the medical staff. Active staff
membership shall be limited to individuals, as defined in Subsection LL of
7.7.2.7 NMAC of these requirements, who are currently licensed. Individuals may be granted membership in
accordance with the medical staff by-laws and rules, and in accordance with the
by-laws of the hospital.
(2) Other staff: The medical staff may include
one or more categories defined in the medical staff by-laws in addition to the
active staff including a category to cover appointment during periods of
disaster and emergency.
C. Appointment.
(1) Governing Body Responsibilities:
(a) medical staff
appointments shall be made by the governing body, taking into account
recommendations made by the active medical staff;
(b) the
governing body shall biennially ensure that members of the medical staff are
qualified legally and professionally for the position to which they are
appointed;
(c) the hospital,
through its medical staff, shall require applicants for medical staff
membership to provide, in addition to other medical staff requirements, a
complete list of all hospital medical staff memberships held within five years
prior to application; and
(d) hospital medical
staff applications shall require reporting any malpractice action, any
previously successful and currently pending challenges to licensure in this or
another state, and any loss or pending action affecting medical staff
membership or privileges at another hospital.
(2) Medical staff responsibilities:
(a) to select its
members and delineate their privileges, the hospital medical staff shall have a
system, based on specific standards for evaluation of each applicant by a
credentials committee, which makes recommendations to the medical staff and to
the governing body; and
(b) the medical staff
may include one or more categories of medical staff defined in the medical
staff by-laws in addition to the active medical staff, including a category to
cover appointment during periods of disaster and emergency, but this in no way
modifies the duties and responsibilities of the active staff.
D. Criteria for Appointment.
(1) Criteria for selection shall include the
individual’s current licensure, health status, professional performance,
judgment and clinical and technical skills.
(2) All qualified candidates shall be
considered by the credentials committee or during periods of disaster and
emergency by a member of the medical staff or administration who represents the
credentials committee.
(3) Re-appointments shall be made at least
biennially and recorded in the minutes or files of the governing body. Reappointment
policies shall provide for a periodic appraisal of each member of the staff,
including consideration at the time of reappointment of information concerning
the individual’s current licensure, health status, professional performance,
judgment and clinical and technical skills. Recommendations for re-appointments
shall be noted in the minutes of the meetings of the appropriate committee.
(4) Temporary staff privileges may be granted
for a limited period if the individual is qualified for membership on the
medical staff.
(5) Disaster and emergency privileges may be
granted to qualified individuals during disasters and emergencies.
(6) A copy of the scope of privileges to be
accorded the individual shall be distributed to appropriate hospital staff. The
privileges of each staff member shall be specifically stated or the medical
staff shall define a classification system. If a system involving
classifications is used, the scope of the categories shall be well defined, and
the standards that must be met by the applicant, shall be clearly stated for
each category.
(7) If other categories of staff membership are
to be established for allied health personnel, the necessary qualifications,
privileges and rights shall be delineated in accordance with the medical staff
by-laws.
E. Consultations.
(1) The medical staff must have established policies
concerning the holding of consultations.
(2) Except in an emergency, consultations are
required when:
(a) the
patient is not a good medical or surgical risk;
(b) the
diagnosis is obscure;
(c) there
is doubt as to the best therapeutic measures to be utilized; or
(d) when
the patient, or legally authorized person, requests such consultation.
(3) Consultations must be included in the
medical record. When operative procedures are involved, the consultation note,
except in an emergency, shall be recorded prior to the operation.
(4) The patient’s physician or authorized
licensed independent practitioner is responsible for requesting consultations
when indicated. It is the duty of the medical staff to make certain that
members of the medical staff contact consultants as needed.
F. By-Laws.
(1) Adoption and Purpose: By-laws shall be adopted
by the medical staff and approved by the governing body to govern and enable
the medical staff to carry out its responsibilities. The by-laws of the medical
staff shall be a precise and clear statement of the policies under which the
medical staff regulates itself.
(2) Content: Medical staff by-laws and rules
shall include:
(a) a
descriptive outline of the medical staff organization;
(b) a statement of the necessary
qualifications which each member must possess to be privileged to work in the
hospital, during periods of routine operation, as well as during periods of
disaster and emergency, and of the duties and privileges of each category of
medical staff;
(c) a
procedure for granting or withdrawing privileges to each member; and an appeal
process for privilege withdrawal or refusal;
(d) a
mechanism for appeal of decisions regarding medical staff membership and
privileges;
(e) provision
for regular meetings of the medical staff;
(f) provision
for keeping timely, accurate and complete records;
(g) provisions
for routine examination of all patients upon admission and recording of the
preoperative diagnosis prior to surgery;
(h) a
stipulation that a surgical operation is permitted only with the consent of the
patient or legally authorized person except in emergencies;
(i)
statements concerning the request for the
performance of consultations, and instances where consultations are require;
and
(j) a
statement specifying categories of personnel duly authorized to accept and
implement medical staff orders.
G. Governance.
(1) The medical staff shall have the numbers
and kinds of officers necessary for the governance of the staff.
(2) Officers shall be members of the active
staff and shall be elected by the active medical staff.
H. Meetings.
(1) Number and Frequency: The number and
frequency of medical staff meetings shall be determined by the active medical
staff and clearly stated in the by-laws of the medical staff. At a minimum the executive committee of the
medical staff shall meet at least quarterly.
(2) Attendance: Attendance records shall be
kept of medical staff meetings. Attendance requirements for each individual
member shall be clearly stated in the by-laws of the medical staff.
(3) Purpose: Full medical staff meetings shall
be held to conduct the general business of the medical staff and to review the
significant findings identified through the quality improvement program.
(4) Minutes: Minutes of all meetings shall be
kept.
I. Committees.
(1) Establishment: The medical staff shall
establish committees of the medical staff and is responsible for their
performance.
(2) Executive committee: The medical staff
shall have an executive committee to coordinate the activities and general
policies of the various departments, act for the staff as a whole under
limitations that may be imposed by the medical staff bylaws, and receive and
act upon the reports of all other medical staff committees.
J. Administrative Structure: Hospitals may create services to fulfill
medical staff responsibilities. Services are responsible for the quality of
care rendered to patients under their care.
[7.7.2.26 NMAC - Rp, 7.7.2.26
NMAC, 06-15-04; 7.7.2.26 NMAC - Rn, 7.7.2.25 NMAC
& A, 03-15-06]
7.7.2.27 NURSING
SERVICES:
A. Requirement. The hospital shall
provide a 24-hour nursing service, supervised by a professional registered
nurse, and have a licensed practical nurse or professional registered nurse on
duty at all times.
B. Administration.
(1) The nursing services shall be directed by
a professional registered nurse with appropriate education and experience to
direct the service. A professional
registered nurse with administrative authority shall be designated to act in
the absence of the director of the nursing services. Appropriate administrative staffing shall be
provided on all shifts.
(2) There shall be a written plan showing the
flow of authority throughout the nursing service, with delineation of the
responsibilities and duties of each category of nursing staff.
(3) The delineation of responsibilities and
duties for each category of the nursing staff shall be in the form of a written
job description for each category.
C. Staffing.
(1) An adequate number of professional
registered nurses shall be on duty at all times to meet the nursing care needs
of the patients. There shall be
qualified supervisory personnel for each service or unit to ensure adequate
patient care management.
(2) The number of nursing personnel for all
patient care services of the hospital shall be consistent with the nursing care
needs of the hospital’s patients.
(3)
The staffing pattern shall ensure the availability of professional
registered nurses to assess, plan, implement and direct the nursing care for
all patients on a 24-hour basis.
D. Patient Care.
(1) Care planning:
(a) All nursing care shall be planned and
directed by professional registered nurses. A professional registered nurse
shall be on duty and immediately available to give direct patient care when
needed.
(b) A professional registered nurse shall be
available at all times to render direct care in the facility.
(2) Care determinants:
(a) A professional
registered nurse shall assign the nursing care of each patient to other nursing
personnel in accordance with the patient’s needs and the preparation and
competence of the available nursing staff.
(b) The ratio of
licensed nursing personnel to patients shall be determined by the acuity of
patients, the patient census, and complexity of care that must be provided.
(c) A professional
registered nurse shall plan, supervise and evaluate the care of all patients,
including the care assigned to licensed practical/vocational nurses and
non-licensed care givers.
(d) There shall be
other nursing personnel in sufficient numbers to provide nursing care not
requiring the services of a professional registered nurse.
(3) Special care units: Areas providing
specialized nursing care shall be well defined by policies and procedures
specific to the nursing services provided. These areas may include, but shall
not be limited to, intensive care, coronary care, obstetrics, nursery, renal
units, burn units, and emergency rooms.
(a) Specific policies
and procedures shall supplement basic hospital nursing policies and procedures.
Nursing policies and procedures of special care units shall keep pace with best
practice and new knowledge and shall include but not be limited to: protocols
for resuscitation and disaster situations, immediate availability of emergency
equipment and drugs, appropriate and safe storage of pharmaceuticals and biologicals, programs for maintenance and safe operation of
all equipment, appropriate infection-control measures, control of visitors and
non-essential personnel, and documentation of quality improvement.
(b) Special-care unit nursing services shall be
integrated with other hospital departments and services.
(c) Supervision of
nursing care in the unit shall be provided by a professional registered nurse
with relevant education, training, experience, and demonstrated current
competence.
(d) All nursing
personnel shall be prepared for their responsibilities in the special-care unit
through appropriate orientation, ongoing in-service training, and continuing
education programs. Each hospital shall have a planned, formal training program
for all nurses and shall be of sufficient duration and substance to cover all
patient-care responsibilities in the special care unit.
E. Staff Qualifications.
(1) Individuals selected for the nursing staff
shall be qualified by education, experience, and current competence for the
positions to which they are appointed.
(2) The education and experience
qualifications of the director of nursing supervisors, and other medical
professionals shall be commensurate with the scope and complexity of the
services of the hospital.
(3) The functions and qualifications of
nursing personnel shall be clearly defined in relation to the duties and
responsibilities delegated to them.
(4) Personnel records, including application
forms and verifications of current licensure and credentials, shall be on file.
(5) Nursing management shall make decisions
about the selection and promotion of nursing personnel based on their
qualifications and capabilities and shall recommend the termination of
employment when necessary.
(6) Approval: There shall be a policy and
procedure to ensure that hospital nursing personnel for whom registration, a
license or other approval is required by law shall have valid and current
registration, licensure or other approval.
(7) There shall be a policy and procedure
governing the qualifications and selection of nursing personnel during periods
of disaster and emergency.
F. Evaluation and Review of Nursing
Care: There shall be a review and evaluation of the nursing care provided
for patients. There shall be written nursing care procedures and plans of care.
(1) Responsible staff: A licensed professional
registered nurse shall plan, supervise, and evaluate the nursing care for each
patient.
(2) The director of nursing is responsible for
the effective use of care plans by the nursing staff.
(3) Nursing care plan: Nursing care plans
shall be kept current. Plans shall
indicate nursing care needed, how it is to be accomplished, and methods,
approaches, and modifications necessary to obtain best results for patients.
(4) Nursing notes: Nursing notes shall be
legible, informative and descriptive of the nursing care given and include
information and observations of significance so that they contribute to the
continuity of patient care.
G. Orientation and In-Service.
(1) There shall be a comprehensive and
thorough employee orientation program for all nursing services personnel.
(2)
The facility shall provide orientation to nursing services personnel
before they provide care to patients.
H. Hospital Relationships.
(1) General: The nursing service shall have
well-established working relationships with the medical staff and with other
hospital staff that provide and contribute to patient care.
(2) Policies: Written policies and procedures
affecting nursing services shall be developed and reviewed with the
participation of the director of nursing or designee, in consultation with
other appropriate health professionals and administration. The governing body shall approve the
policies. The nursing service shall be represented on hospital committees that
affect patient care policies and practices.
I. Documentation, Staff Meetings and
Evaluation.
(1) Nursing care policies and procedures that
reflect optimal standards of nursing practice shall be written and approved,
and shall be reviewed and revised as necessary to keep pace with current
knowledge. Written nursing care policies
and procedures shall be available on each nursing unit.
(2) There shall be a written nursing care plan
for each patient, which shall include the elements of assessment, planning,
intervention and evaluation.
(3) Documentation of nursing care shall be
pertinent and concise and shall describe patient status needs, problems,
capabilities and limitations. Nursing intervention and patient response shall
be noted.
(4) Meetings of the nursing staff shall be
held at least once every two months to discuss patient care, nursing services
problems and administrative policies.
Minutes of all meetings shall be kept and shall be available to all
staff members.
(5) The nursing services director shall ensure
that there is ongoing review and evaluation of the nursing care provided for
patients and shall assure that nursing care standards and objectives are established
and met. If the nursing department is
decentralized into clinical departmental services or clinical programs are
established, there shall be one administrator to whom the nursing directors
shall be accountable and who has the responsibility to assure one standard of
nursing practice within the organization.
J. Additional Patient Care
Requirements.
(1) In this subsection, “circulating nurse”
means a professional registered nurse who is present during an operation to
provide emotional support to the patient, assist with the anesthesia induction,
and throughout the surgical procedure or delivery, coordinate the activities of
the room, monitor the traffic in the room, maintain an accurate account of
urine and blood loss, and who, before the surgical procedure or delivery is
completed, informs the recovery rooms of specials needs and ensures that the
sponge, needle and instrument counts have been done according to hospital
policy.
(2) Obstetrical: Every patient admitted in
labor shall be assessed initially by a professional registered nurse or
physician.
(3) Surgical:
(a) A professional
registered nurse shall supervise the operating room(s).
(b) A qualified professional registered nurse
shall function as the circulating nurse in the surgical and obstetrical room
whenever general anesthesia is used and on all local anesthesia cases involving
a high degree of patient risk. Individual surgical technologists and licensed
practical nurses may function as assistants under the direct supervision of a
qualified professional registered nurse.
(4) Temporary nursing personnel:
(a) When contract
nursing personnel from outside registries or agencies are used by the hospital,
the nursing services shall have a means for evaluating the credentials and
competence of these personnel. Contract nursing personnel shall function under
the direction and supervision of a qualified professional registered nurse from
the hospital nursing staff. The
temporary nursing personnel shall have an orientation to the facility.
(b) If private duty
nursing personnel are employed by the patients, the nursing department shall
ensure the private duty nursing agency has a means for evaluating the
credentials and competence of these personnel. The hospital shall have policies
regarding use of these personnel in the facility.
(5) Medications: Only the following shall be
permitted in accordance with the Nurse Practice Act and the requirements of the
board of nursing:
(a) a
professional registered nurse may pass medications;
(b) a
licensed practical nurse or a student nurse in an approved school of nursing
under the supervision of a licensed professional registered nurse may pass
medications;
(c) medications
may not be prepared by nursing personnel on one shift for administration during
succeeding shifts;
(d) medication
administration may not be delegated to unlicensed personnel.;
(6) Reporting:
The hospital shall have effective policies and procedures for reporting
transfusion reactions, adverse drug reactions, accidents and medication
errors. The medical staff shall review
summary reports of these reactions, accidents and errors at least quarterly.
[7.7.2.27 NMAC - Rp, 7.7.2.27
NMAC, 06-15-04; 7.7.2.27 NMAC - Rn, 7.7.2.26 NMAC
& A, 03-15-06]
7.7.2.28 DIETARY
SERVICES: The hospital shall
provide a 24-hour dietary service or contract for a 24-hour dietary services
which meets the requirements of this section, and which shall provide meals and
other nutritional care to its patients.
The dietary service shall be integrated with other services of the
hospital.
A. Administrative.
(1) There shall be written policies and
procedures for food storage, preparation and service and clinical aspects
developed by the dietitian.
(2) There shall be a qualified person serving
as full-time director of the service who shall be responsible for the daily
management aspects of the service.
(3) The dietitian shall participate in the
nutritional aspects of patient care by means that include assessing the
nutritional status of patients, instructing patients, recording diet histories,
interpreting and integrating therapeutic principles, participating
appropriately in patient rounds and conferences, and recording in medical
records and sharing specialized knowledge with others on the medical team.
(4) There shall be written job descriptions
for all dietary employees.
(5) The dietitian shall be responsible for
maintaining a current diet manual for therapeutic diets, approved jointly by
the dietitian and a qualified member of the medical staff. The dietetic manual shall be developed on
recognized current therapeutic practices.
The dietitian shall recommend this manual to a qualified member of the
medical staff for approval for use in the facility. All changes must be submitted to a qualified
member of the medical staff for approval prior to inclusion in the manual.
(6) There shall be an in service training
program for dietary employees which shall include
instruction in proper storage, preparation and serving food, safety,
appropriate personal hygiene and infection control.
(7) A menu cycle shall be available and
posted. Substitutions of equal nutritional value are acceptable and shall be
noted. The hospital must keep for 30 days a record of each menu as served.
(8) A hospital that contracts for its dietary
services shall be in compliance with this section if the contracted services meets all applicable rules of this section.
B. Facilities.
(1) Adequate facilities shall be provided to
meet the dietary needs of the patients.
(2) Sanitary conditions shall be maintained
for the storage, preparation and distribution of food.
(3) All dietary areas shall be appropriately
located, adequate in size, well-lighted, ventilated and maintained in a clean
and orderly condition.
(4) Equipment and work areas shall be clean
and orderly. Effective procedures for cleaning and sanitizing all equipment and
work areas shall be followed consistently to safeguard the health of the
patients, staff and visitors.
(5) Lavatories specifically for hand-washing
shall include hot and cold running water, soap, and disposable towels or air
dryers, and shall be conveniently located throughout the service area for use
by dietary staff.
(6) The dietary service shall have written
reports of the most recent environmental or licensing inspection on file at the
hospital with notation made by the hospital of action taken to comply with
recommendations or citations.
(7) Dry or staple food items shall be stored
off the floor in a ventilated room which is not subject to sewage or waste
water back-flow or contamination by condensation, leakage, rodents or vermin.
(8) All perishable foods shall be refrigerated
and the temperature maintained at, or below, 40 degrees Fahrenheit.
(9) Hot food shall be maintained at 140
degrees Fahrenheit, or higher.
(10) Foods being displayed or transported shall
be protected from environmental contamination and maintained at proper
temperatures in clean containers, cabinets or serving carts.
(11) Dishwashing procedures and techniques
shall be well-developed and understood by the responsible staff, with periodic
monitoring of the operation of the detergent dispenser, washing, rinsing, and
sanitizing temperatures and the cleanliness of machine and jets, and
thermostatic controls.
(12) A daily log of recorded temperatures for
all refrigerators, freezers, steam tables and dishwashers must be maintained
and available for inspection for 30 days.
(13) All garbage and kitchen refuse not
disposed of through a garbage disposal unit shall be kept in watertight
containers with close-fitting covers and disposed of daily in a safe and
sanitary manner.
(14) Food and non-food supplies shall be
clearly labeled and dated and shall be stored in separate areas.
(15) No hazardous non-food items shall be
stored in the proximity of materials that could compromise the safety of the
food supply.
(16) The dietitian shall be responsible for,
and active in, the hospital’s quality improvement program.
C. Records.
(1) A systematic record shall be maintained of
all diets.
(2) Therapeutic diets shall be prescribed by
an authorized individual in written orders on the medical record.
(3) Nutritional needs shall be in accordance
with physicians’ orders and, to the extent medically possible, in accordance
with the “recommended daily dietary allowance” of the food and nutrition board
of the national research council, national academy of sciences. A current
edition of these standards shall be available in the dietary service.
(4) The qualified staff person who instructs
the patient in home diet shall document this in the medical record.
D. Sanitation. All practices shall
be in accordance with the standards of the New Mexico environment department.
(1) Kitchen sanitation.
(a) Equipment and work areas shall be clean
and orderly. Surfaces with which food or beverages come into contact shall be
of smooth, impervious material free of open seams, not readily corrosible and easily accessible for cleaning.
(b) Utensils shall be
stored in a clean, dry place protected from contamination.
(c) The walls, ceiling
and floors of all rooms in which food or drink is stored, prepared or served
shall be kept clean and in good repair.
(2) Washing and sanitizing of kitchenware.
(a) All reusable
tableware and kitchenware shall be cleaned in accordance with procedures as
outlined by the New Mexico environment department, which shall include separate
steps for pre-washing, washing, rinsing and sanitizing.
(b) Dishwashing
procedures and techniques shall be well-developed, understood by dishwashing
staff and carried out according to policy. To make sure that service ware is
sanitized and to prevent recontamination, correct temperature maintenance shall
be monitored during cleaning cycles.
(3) Canned or preserved foods.
(a) All processed food
shall be procured from sources that process the food under regulated quality
and sanitation controls. This does not preclude the use of local fresh produce.
(b) The hospital may not use home-canned
foods.
(4) Cooks and food handlers. Cooks and food
handlers shall wear clean outer garments and hair nets or caps and gloves as
needed, and shall keep their hands clean at all times when engaged in handling
food, drink, utensils or equipment. Food handlers must obtain a tuberculosis
test, prior to employment and as often as required thereafter according to
hospital policy.
(5) Milk.
(a) Raw milk shall not be used.
(b) Milk for drinking
shall be grade A pasteurized whole milk (3 1/4%) milk fat or greater and not
less than (8 ¼% milk solids, not fat) or any other grade A fluid milk product
as defined in the New Mexico Restaurant Act (includes skim milk, low-fat milk,
and cream products) unless otherwise requested by the patient or as a part of a
therapeutic diet.
(c) Condensed,
evaporated, and/or dried milk products which are recognized nationally, may be
employed as “additives” in cooked food preparation but shall not be substituted
or served to patients (adult, child, or infant) in place of milk as approved
for drinking purposes. These products shall be handled and stored in accordance
with the requirements of the current dietary practices.
[7.7.2.28 NMAC - Rp, 7.7.2.28
NMAC, 06-15-04; 7.7.2.28 NMAC - Rn, 7.7.2.27 NMAC,
03-15-06]
7.7.2.29 PHARMACY
SERVICES:
A. Organization.
(1) Pharmacy:
The hospital pharmacy including pharmaceuticals contained in disaster
and emergency caches held by the hospital, shall be supervised by a designated
pharmacist-in-charge who is employed part-time or full-time. If employed part-time, the pharmacist shall
visit the facility at least every 72 hours.
(2) Other storage: If there is no pharmacy,
pre-labeled, prepackaged medications shall be stored in, and distributed from,
an automated medication management system, which is under the supervision of
the pharmacist-in-charge.
(3) Pharmacist accountability: The
pharmacist-in-charge shall have appropriate administrative oversight and shall
prepare a pharmacy policy and procedure manual that shall be reviewed and
updated at least annually.
B. Facility.
(1) Space and Equipment: The pharmacy shall
meet the space and equipment requirements specified by the New Mexico board of
pharmacy.
(2) Security: The pharmacist shall control
access to the pharmacy and any automated medication system devices. Established
procedures shall assure accountability for all doses of drugs removed when the
pharmacist is not present. Only a
designated licensed nurse may remove drugs from the pharmacy when the
pharmacist is not present.
(3) Drug preparation areas: All drug storage
and preparation areas within the facility shall be the responsibility of the
pharmacist and inspected at least monthly.
(4) Pharmacy policies and procedures should
address practices to be followed when compounding, reconstituting, and
repackaging medications to assure adherence to professional standards of
practice for cleanliness and infection control.
(5) Schedule II controlled substance storage:
Schedule II controlled substances that are stored in the pharmacy shall be
stored in a separate locked storage.
C. Personnel.
(1) The pharmacist shall be assisted by an
adequate number of competent and qualified personnel. Job descriptions for all
categories shall be prepared and revised as necessary.
(2) A pharmacist shall be on call during all
absences of the designated pharmacist from the facility.
D. Records. Hospital pharmacies shall maintain all
dangerous drug distribution records that are required by applicable state and
federal laws and regulations, including:
(1) floor stock
dangerous drug description records; and
(2) inpatient
dangerous drug description records:
(a) schedule
II controlled substance distribution records must be kept separate;
(b) schedule
III-V controlled substance distribution records must be readily retrievable;
(c) an
annual inventory of schedule II-V controlled substances shall be conducted and
a record maintained along with the procurement records for these drugs;
(d) when automated
drug distribution systems are utilized, they shall produce transaction records
that meet the above records keeping requirement;
(e) the
pharmacist shall maintain records of quality improvement monitoring of
automated drug distribution systems.
E. Other Responsibilities of the
Pharmacist.
(1) When limited doses of a drug are removed
from the pharmacy when the pharmacist is not present:
(a) the pharmacist
shall verify the withdrawal within 72 hours of the withdrawal;
(b) a
drug regimen review, pursuant to a new medication order, will be conducted by a
pharmacist, either on-site or by electronic transmission, within 24 hours of
the new order.
(2) The pharmacist also shall:
(a) provide
drug information to staff and patients of the facility;
(b) maintain
current drug use reference manuals;
(c) provide
and document in-service education to the facility’s professional staff;
(d) in
conjunction with the practitioners, nurses, and other professional staff,
review significant adverse drug reactions; and
(e) review
each medication order for safety and appropriateness and communicate with the prescribers when indicated.
[7.7.2.29 NMAC - Rp, 7.7.2.29
NMAC, 06-15-04; 7.7.2.29 NMAC - Rn, 7.7.2.28 NMAC
& A, 03-15-06]
7.7.2.30 MEDICAL
RECORDS SERVICES:
A. Medical Record. A medical record
shall be maintained for every patient admitted for care in the hospital. The
record shall be kept confidential and released only in accordance with the
Sections 14-6-1, 14-6-2 NMSA 1978 and, where
appropriate, Section 43-1-19 NMSA 1978.
B. Service. The hospital shall have
a medical records service with administrative responsibility for all medical
records maintained by the hospital.
(1) Confidentiality:
(a) Written consent of
the patient or legally authorized person shall be required for release of
medical information to persons not otherwise authorized to receive this information.
(b) Original medical
records may not be removed from the hospital except by authorized persons who
are acting in accordance with a court order, and where measures are taken to
protect the record from loss, defacement, tampering and unauthorized access.
(2) Preservation: There shall be a written
policy for the preservation of medical records The retention period shall be
for 10 years following the last treatment date of the patient, except in the
case of minor children whose records shall be retained to the age of majority,
plus one year.
(a) Laboratory test
records and reports may be destroyed one year after the date of the test
recorded or reported therein provided that one copy is placed in the patient’s
record, or stored electronically in the hospital’s information system. The
hospital is responsible for electronic storage.
(b) X-ray films may be
destroyed four years after the date of exposure, if there are in the hospital
record written findings of a radiologist who has read such x-ray films. At
anytime after the third year after the date of exposure, and upon proper
identification, the patient may recover his own x-ray films as may be retained
pursuant to this section. The written radiological findings shall be retained
as provided by these requirements.
(3) Personnel:
(a) Adequate numbers of
personnel who are qualified to supervise and operate the service shall be
provided.
(b) A registered
medical records administrator or an accredited records technician shall head
the services, except that if such a professionally qualified person is not in
charge of medical records, a consultant who is a registered records
administrator or an accredited records technician shall organize the service,
train the medical records personnel and make at least quarterly visits to the
hospital to evaluate the records and the operation of the service, and prepare
written reports of findings within 30 days.
(c) In this
subdivision, “a registered record administrator” or an “accredited record
technician” is an individual who has successfully completed the examination
requirements of the American Medical Record Association.
(4) Availability:
(a) The system for
identifying and filing records shall permit prompt retrieval of each patient’s
medical records.
(b) A master patient
index shall include at least the patient’s full name, sex, birth date and
medical record number and/or reference to treatment dates.
(c) Filing equipment
and space shall be adequate to maintain the records and facilitate retrieval.
(d) The inpatient,
ambulatory care and emergency records of patients shall be kept in such a way
that all patient care information can be provided for patient care when the
patient is admitted to the hospital, when the patient appears for a
pre-scheduled outpatient visit, or as needed for emergency services.
(e) Pertinent medical
record information obtained from other providers including patient tracking
information for patients admitted during disaster and emergency shall be
available to facilitate continuity of the patient’s care.
(f) The original or
legally reproduced form of all clinical information pertaining to a patient’s
stay shall be filed in the medical record folder as a unit record. When this is
not feasible a system must be in place to provide prompt retrieval of all
medical records when a patient is admitted.
(5) Coding and indexing:
(a) Records shall be
coded and indexed according to diagnosis, operation and physician Indexing
shall be kept current within six months from the discharge of the patient.
(b) Any recognized
system may be used for coding diagnoses, operations and procedures.
(c) The indices shall
list all diagnoses for which the patient was treated during the hospitalization
and the operations and procedures, which were performed during the
hospitalization.
C. Medical Record Contents. The
medical record staff shall ensure that each patient’s medical records contain:
(1) accurate and adequate patient identification data;
(2) a concise
statement of complaints, including the chief complaint, which led the patient
to seek medical care and the date of onset and duration of each;
(3) a health history, containing a description
of present illness, past history of illness and pertinent family and social
history to be made part of the record within the first 24 hours after
admission;
(4) a statement about
the results of the physical examination, including all positive and negative
findings resulting from an inventory of systems;
(5) the provisional
diagnosis;
(6) all diagnostic and
therapeutic orders;
(7) all clinical
laboratory, x-ray reports and other diagnostic reports;
(8) consultation
reports containing a written opinion by the consultant that reflects, when
appropriate, an actual examination of the patient and the patient’s medical
records;
(9) except in an
emergency, a current, thorough history and physical work-up shall be recorded
in the medical record of every patient prior to surgery;
(10) an operative report describing techniques
and findings written or dictated immediately after surgery; the completed
operative report is authenticated by the surgeon and filed in the medical
record as soon as possible after surgery or available electronically in the
hospital information system; when the operative report is not placed in the
medical record immediately after surgery, a progress note is entered
immediately;
(11) a post operative
documentation record of the patient’s discharge from the post anesthesia care
area;
(12) tissue reports, including a report of
microscopic findings if hospital policies require that microscopic examination
be done; if only microscopic examination is warranted, a statement that the
tissue has been received and a microscopic description of the findings shall be
provided by the laboratory and filed in the medical record;
(13) progress notes
providing a chronological picture of the patient’s progress sufficient to
delineate the course and the results of treatment;
(14) a definitive
final diagnosis including all relevant treatment and operative procedures
performed expressed in the terminology of a recognized system of disease
nomenclature;
(15) a discharge
summary including the final diagnosis, the reason for hospitalization, the
significant findings, the procedures performed, the condition of the patient on
discharge and any specific instructions given the patient and/or family. A
final progress note is acceptable when stay is less than [48 hours and in case
of normal newborn infants and uncomplicated obstetrical deliveries;
(16) autopsy findings
when an autopsy is performed; and
(17) for comprehensive inpatient programs the
following information shall be present as well: rehabilitation evaluation
including medical, psycho-social history and physical exam; rehabilitation
plans including goals for treatment; documentation of patient care conferences
held minimally every two weeks, or as indicated, by appropriate disciplines
involved in the care and treatment of the patient, in which the patient’s
treatment and response to rehabilitation services shall be evaluated and
modified as indicated.
D. Authentication. Only members of
the hospital staff or other professional personnel authorized by the hospital
shall record and authenticate entries in the medical record. Documentation of
medical staff participation in the care of the patient shall be evidenced by at
least:
(1) the signature on
the patient’s health history as the required by medical staff by-laws and
results of his or her physical examination;
(2) periodic progress
notes or countersignatures as defined by the hospital rules and regulations;
(3) the surgeon’s
signature on the operative report; and
(4) the signature as
required by medical staff by-laws on the face sheet and discharge summary.
E. Completion.
(1) Current records and those on discharged
patients shall be completed promptly.
(2) If a patient is readmitted within 30 days for
the same or related condition, there shall be a reference to the previous
history with an interval note, and any pertinent changes in physical findings
shall be recorded.
(3) All records of discharged patients shall
be completed within a reasonable period of time specified in the medical staff
by-laws, but not to exceed 30 days after
discharge, excepting autopsy reports.
F. Maternity Patient Records.
(1) Prenatal findings: Except in an emergency,
before a maternity patient may be admitted to a hospital, a legible copy of the
prenatal history shall be submitted to the hospital’s obstetrical staff. The
prenatal history shall note complication, Rh
determination and other matters essential to adequate care.
(2) Maternal medical record: Each obstetric
patient shall have a complete hospital record, which shall include:
(a) patient
identification, prenatal history and findings;
(b) the labor and
delivery record, including anesthesia;
(c) medicine
and treatment sheet, including nursing notes;
(d) any
laboratory and x-rays reports;
(e) any medical
consultant’s notes; and
(f) an
estimate of blood loss.
G. Newborn Medical Records. Each
newborn patient shall have a complete hospital record which shall include:
(1) a record of
pertinent material data, type of labor and delivery, and the condition of the
infant at birth;
(2) a record of
physical examinations;
(3) progress sheets
to include medicine, treatment, weights, feeding and temperatures; and
(4) the notes of any
medical consultant.
H. Fetal Death. In the case of a
fetal death, the weight and length of the fetus shall be recorded on the
delivery record.
I. Authentication of all Entries.
(1) Documentation.
(a) All entries in
medical records by hospital staff and medical staff shall be legible,
permanently recorded, dated and authenticated with the name and title of the
person making the entry.
(b) All orders shall be
recorded and authenticated. All verbal
and telephone orders shall be authenticated by the prescribing practitioner, or
a practitioner authorized to sign on behalf of the prescribing physician, in
writing within 72 hours.
(c) A rubber stamp
reproduction of a person’s signature or an electronic signature may be used
instead of a handwritten signature, if: the stamp is used only by the person
whose signature the stamp replicates, the facility possesses a statement signed
by the person, certifying that only that person(s) shall possess and use the
stamp.
(2) Symbols and abbreviations: Symbols
and abbreviations may be used in medical records if approved by a written
facility policy, which defines the symbols and abbreviations and controls their
use. There shall be only one meaning per symbol.
[7.7.2.30 NMAC - Rp, 7.7.2.30
NMAC, 06-15-04; 7.7.2.30 NMAC - Rn, 7.7.2.29 NMAC
& A, 03-15-06]
7.7.2.31 LABORATORY
SERVICES:
A. Services and Facilities.
(1) The extent and complexity of laboratory
services shall be commensurate with the size, scope, and nature of the hospital
and the needs of the medical staff.
(2) Necessary space, facilities and equipment
to perform both the basic minimum and all other services shall be provided by
the hospital either on-site or by contracts and services.
(3) All equipment shall be made to carry out adequate
clinical laboratory examinations and services, as appropriate for the care of
the patients. In the case of work
performed, the original report or a legally reproduced copy of the report from
the laboratory shall be contained in the medical record.
B. Availability.
(1) Laboratory services shall be available at
all times, and there shall be a sufficient number of qualified laboratory
testing personnel and support staff to perform promptly and efficiently the
tests required of the pathology and medical laboratory services.
(2) Adequate provision shall be made for
ensuring the availability of emergency laboratory services, either in the
hospital or under arrangements with another laboratory. These services shall be
available twenty-four (24) hours a day, seven days a week, including holidays,
and shall include the referral of specimens potentially related to disaster and
emergency to the scientific laboratory division of the New Mexico department of
health for confirmation, or rejection, of that relationship, and the reporting
of notifiable conditions to the office of
epidemiology of the New Mexico department of health and to the local public
health office.
(3) A hospital that has contracted for
laboratory services is in compliance with this paragraph if the contracted
services have a current CLIA certificate at the
appropriate level of testing.
C. Personnel.
(1) A qualified medical technologist shall be a
graduate of a medical technology program approved by a nationally recognized
body or has documented equivalent education, training, and/or experience; a
qualified medical lab technician shall be a graduate of a program approved by
the federal department of health and human services.
(2) The laboratory may not perform procedures
and tests that are outside the scope of training of laboratory personnel.
D. Records.
(1) Laboratory test records and reports may be
destroyed four years after the date of the test with the exception of minor
children whose records must be maintained until the age of majority plus one
year.
(2) The laboratory director shall be
responsible for the laboratory report.
(3) A mechanism by which the clinical
laboratory report shall be authenticated by testing personnel shall be
delineated in the laboratory services’ policies and procedures.
(4) The laboratory shall have procedures for
ensuring that all requests for tests are ordered in writing by individuals
authorized by the medical staff.
(5) The hospital shall have available a copy
of their current CLIA certificate or a verification
of current CLIA certificate by contractor.
E. Anatomical Pathology.
(1) Pathologist.
(a) Anatomical
pathology services shall be under the direct supervision of a pathologist. If
it is on a consultative basis, the hospital shall provide for, at minimum,
monthly consultative visits by the pathologist. The pathologist must be
available in person or electronically at all times.
(b) The pathologist
shall participate in lab quality improvement and department conferences.
(c) The pathologist
shall be responsible for establishing qualifications of pathology laboratory
staff.
(d) An autopsy may be
performed only by a pathologist, other qualified individuals qualified by the
office of medical investigator or another qualified physician.
(2) Tissue examination.
(a) The medical staff
and a pathologist shall determine which tissue specimens require macroscopic
examination and which require both macroscopic and microscopic examinations.
(b) The hospital shall
maintain an ongoing file of tissue slides and blocks, for a minimum of ten (10)
years. Use of outside laboratory
facilities for storage and maintenance of records, slides and blocks is
permitted.
(c) If the hospital
does not have a pathologist or otherwise qualified physician, there shall be a
written plan for sending all tissues requiring examination to a pathologist
outside the hospital.
(d) A log of all
tissues sent outside the hospital for examination shall be maintained.
Arrangements for tissue examinations done outside the hospital shall be made
with a certified laboratory, or a laboratory approved for the federal CLIA program.
(e) Specimens shall be
considered hazardous waste and shall be disposed of in a safe manner.
(3) Records.
(a) All reports of
macroscopic and microscopic tissue examination must be authenticated by the
pathologist or other qualified physician.
(b) Provisions shall be
made for the prompt filing of examination results in the patient’s medical
record and for notification of the provider who requested the examination.
(c) The autopsy report
shall be distributed to the provider and shall be made a part of the patient’s
record.
(d) Duplicate records
of the examination reports shall be kept in the laboratory and maintained in a
manner, which permits ready identification and accessibility for a minimum of
two years.
(4) Blood Bank.
(a) The blood bank
shall be operated according to standards set by the accrediting agency; either
the FDA or CLIA, whichever is more stringent.
(b) Records shall be
kept on file in the laboratory service and in the patient medical records
according to CLIA guidelines to indicate the receipt
and disposition of all blood and blood products provided to patients in the
hospital.
(5)
Laboratory Certification. The hospital laboratory shall successfully
participate in proficiency testing programs that are offered or approved by CMS
in those specialties for which the laboratory offers services. Provisions shall
be made for an acceptable quality control program covering all types of
analysis performed by the laboratory and any other department performing any
other laboratory tests.
[7.7.2.31 NMAC - Rp, 7.7.2.31
NMAC, 06-15-04; 7.7.2.31 NMAC - Rn, 7.7.2.30 NMAC
& A, 03-15-06]
7.7.2.32 RADIOLOGICAL
SERVICES:
A. Diagnostic X-Ray Services.
(1) Requirement. The hospital shall make
diagnostic x-ray services available.
These services shall meet professionally approved standards for safety
and the qualifications of personnel in addition to the requirements set out in
this subsection.
(2) Location. The hospital shall have
diagnostic x-ray facilities available in the hospital building proper or clinic
or medical facility that is readily accessible to the hospital’s patients,
physicians and staff.
(3) Policies. Written policies and procedures
shall be developed and maintained by the person responsible for the service in
consultation with other appropriate health professionals and
administration. The governing body shall
approve the policies. The administrative
and medical stall shall approve the procedures where appropriate.
(4) Safety.
(a) The radiological
service shall be free of hazards for patients and personnel.
(b) Proper safety
precautions shall be maintained against fire and explosion hazards, electrical
hazards and radiation hazards.
(c) Hospital x-ray
facilities shall be inspected by a qualified radiation physicist or by the New
Mexico environment department radiation consultant at least once every two
years. Hazards identified by inspections shall be properly and promptly
corrected.
(d) Radiological equipment and radiation
services shall conform with the requirements of the
Radiation Protection Act, Sections 74-3-1 through 74-3-16, NMSA
1978.
(e) Attention shall be
paid to current safety design and good operating procedures for use of
fluoroscopes. Records shall be maintained of the output of all fluoroscopes.
(f) Policies based on
medical staff recommendations shall be established for the administration of
the application and removal of radium element, it’s
disintegration products and other radioactive isotopes.
(5) Personnel.
(a) A physician shall have
overall responsibility for the radiological service. This physician shall be
certified or eligible for certification by the American board of
radiology. If such a radiologist is not
available on a full-time or regular part-time basis, a physician, with training
and experience in radiology, may administer the service. In this circumstance,
a radiologist, qualified as above, shall provide consultation services at
suitable intervals to assure high quality service.
(b) A sufficient number
of personnel capable of supervising and carrying out the radiological services
shall be provided. Their training must
conform to the requirements set out in the Medical Radiation Health and Safety Act,
Sections 61-14E-1 through 61-15E-12, NMSA 1978 and
regulations promulgated by the New Mexico environment department titled Radiologic Technology Certification, 20.3.20 NMAC.
(c) The interpretation
of radiological examinations shall be made by physicians qualified in the
field.
(d) The hospital shall
have a board-certified radiologist, full-time, part-time or on a consulting
basis, who is qualified to interpret films that require specialized knowledge
for accurate reading.
(e) A technologist shall be on duty or on call
at all times.
(f) Only personnel
designated as qualified by the state radiology technologist licensing body may
use the x-ray apparatus, and only similarly designated personnel may apply and
remove the radium element, its disintegration products and radioactive
isotopes. Only properly trained persons
authorized by the medical director of the radiological service may operate
fluoroscopic equipment.
(6) Records.
(a) Authenticated
radiological reports shall be filed in the patient’s medical record.
(b) Written orders by the
attending physician or other individual authorized by medical staff for an
x-ray examination shall contain a concise statement of the reason for the
examination.
(c) Interpretations of
x-rays shall be written or dictated and signed by a qualified physician or
other individual authorized by the medical staff.
(d) Copies of
interpretive findings shall be retained in the medical record for at least 10
years. Scans and other image records shall be retained for at least four years.
B. Therapeutic X-Rays Services. If therapeutic x-ray services are provided,
they shall meet professionally approved standards for safety and for
qualifications of personnel. The
physician in charge shall be appropriately qualified. Only a physician qualified by training and
experience may prescribe radiotherapy treatments.
[7.7.2.32 NMAC - Rp, 7.7.2.32
NMAC, 06-15-04; 7.7.2.32 NMAC - Rn, 7.7.2.31 NMAC,
03-15-06]
7.7.2.33 NUCLEAR
MEDICINE SERVICES:
A. Nuclear Medicine Service.
(1) Requirement. If a hospital provides
nuclear medicine services, the services shall meet the needs of the hospital’s
patients in accordance with acceptable standards of professional practice.
(2) Organization and Staffing:
(a) the
organization of the nuclear medicine services shall be appropriate for the
scope and complexity of the services offered;
(b) there
shall be a physician director who is qualified in nuclear medicine to be
responsible for the nuclear medicine service;
(c) the qualifications,
education, training, functions and legal responsibilities of nuclear medicine
personnel shall be specified by the director of the service and approved by the
medical staff and chief executive officer/administrator based upon the
assurance that personnel are appropriately licensed by the state radiology
technologist licensing body; and
(d) all persons who
administer radiopharmaceuticals shall be approved by the medical staff and in
accordance with applicable federal, state and local laws; the numbers and types
of personnel assigned to nuclear medicine shall be appropriate for the scope
and complexity of the services offered.
(3) Location. Nuclear medicine services
shall be provided in an area of the hospital that is adequately shielded.
(4) Radioactive. Radioactive materials
shall be prepared, labeled, used, transported, stored and disposed of in
accordance with applicable regulations, i.e. the Radiation Protection Act
74-1-9, 74-3-5, 74-3-9, NMSA 1974, and all
regulations promulgated thereunder.
(5)
Equipment and supplies.
(a) Equipment and
supplies shall be appropriate for the types of nuclear medicine services
offered and shall be maintained for safe and efficient performance.
(b) All equipment shall be maintained in safe
operating condition and shall be inspected, tested and calibrated at least
annually by a radiation or health physicist.
(6) Records.
(a) Authenticated and
dated reports of nuclear medicine interpretations, consultations and therapy
shall be made part of the patient’s medical record and copies shall be retained
by the service.
(b) Records shall note
the amount of radiopharmaceuticals administered, the
identity of the recipient, the supplier and lot number and the date of therapy.
(c) The hospital shall
provide for monitoring the staff’s exposure to radiation. The cumulative
radiation exposure for each staff member shall be recorded in the service’s
records at least monthly.
(d) Records of the
receipt and disposition of radiopharmaceuticals shall be maintained.
Documentation of instrument performance and records of inspection shall be
retained in the service.
B. Mobile Nuclear Medicine Services.
The use of mobile nuclear medicine services by a facility to meet the
diagnostic needs of its patients shall be subject to approval of the medical
staff and the chief executive officer/administrator. The services offered by
the mobile nuclear medicine unit shall comply with all applicable rules of this
section.
[7.7.2.33 NMAC - Rp, 7.7.2.33
NMAC, 06-15-04; 7.7.2.33 NMAC - Rn, 7.7.2.32 NMAC,
03-15-06]
7.7.2.34 CLINICAL
SERVICES:
A. Policies and Procedures.
Hospitals which have surgery, anesthesia, dental, maternity, and other services
which may be optional services shall have effective written policies and procedures,
in addition to those set forth under these requirements, relating to the
staffing and functions of each services in order to protect the health and
safety of the patients.
B. Surgery.
(1) Policies.
(a) Surgical privileges shall be delineated
for each of the medical staff performing surgery in accordance with the
individual’s competencies and a copy shall be available to operating room
supervisor.
(b) The surgical
service shall have a written policy to ensure patient safety if a member of the
surgical team becomes non-functional.
(c) The surgical
service shall have the ability to retrieve information needed for infection surveillance,
identification of personnel who assisted at operative procedures, and the
compiling of needed data.
(d) There shall be
adequate provision for immediate post-operative care. A patient may be directly
discharged from post-anesthetic recovery status, upon direction by an
anesthesiologist, another qualified physician or a certified registered nurse
anesthetist.
(e) A procedure for the
identification, investigation, and elimination of nosocomial
infection associated with surgical services. There shall be a written procedure
for investigating unusual levels of infection.
(f) Rules and policies
relating to the operating rooms shall be available and posted in appropriate
locations inside and outside the operating rooms.
(g) The hospital shall
have policies which clearly identify the patient, the site, and/or side of the
procedure.
(h) Prior to commencing
surgery the person responsible for administering anesthesia, or the surgeon
must verify the patient’s identity, the site and/or side of the body to be
operated on, and ascertain that a record of the following appears in the
patient’s medical record: an interval
medical history and physical examination performed and recorded according to
hospital policy, appropriate screening
tests, based on the needs of the patient, accomplished and recorded according
to hospital policy, a properly executed
informed consent, in writing for the contemplated surgical procedure, except in
emergencies.
(2) Supervision. A professional registered
nurse who is qualified by training and experience to supervise the operating
rooms shall supervise the operating rooms.
(3) Environment. If explosive gases are used,
the services shall have appropriate policies, in writing, for safe use of these
gases.
C. Anesthesia.
(1) Policies.
(a) The anesthesia service shall have
effective written policies and procedures to protect the health and safety of
all patients.
(b) If explosive gases
are used, the service shall have appropriate policies, in writing, for safe use
of these gases.
(2) Anesthesia use requirements.
(a) Every surgical
patient shall have a pre-anesthetic assessment, intra-operative monitoring, and
post-anesthesia assessment prior to discharge from a post-anesthesia level of
care, according to hospital policy.
(b) In hospitals where
there is no organized anesthesia service, the surgical service shall assume the
responsibility for establishing general policies and supervising the
administration of anesthetics.
(c) Anesthesia shall be
administered only by a licensed practitioner permitted by the state to
administer anesthetics.
(d) If a general or regional anesthetic is
used and an MD or DO is not a member of the operating team, an MD or DO shall
be immediately available on the hospital premises.
D. Dental Service. All dental services shall meet the following
requirements.
(1) Dentists performing surgical procedures at
the hospital shall be members of the medical staff.
(2) Surgical procedures performed by dentists
shall be under the overall supervision of an M.D. or D.O.,
unless the dentist is a licensed oral surgeon.
(3) There shall be policies for referral of
patients in need of dental services. These policies will be readily available
to all emergency care staff.
E. Maternity.
(1)
Definitions: In this subsection.
(a) “Neonatal” means
pertaining to the first 27 days following birth.
(b) “Oxytocics” means any of several drugs that stimulate the
smooth muscle of the uterus to contract and that are used to initiate labor at
term.
(c) “Perinatal” means pertaining to the mother, fetus or infant,
in anticipation of and during delivery, and in the first post partum week.
(d) “Perinatal care center” means an organized hospital-based
health care service which includes a high-risk maternity service and a neonatal
intensive care unit capable of providing case management for the most serious
types of maternal, fetal and neonatal illness and abnormalities.
(2) Reporting numbers of beds and bassinets.
The number of beds and bassinets for maternity patients and newborn infants, shall be designated by the hospital and reported to
the licensing authority.
(3) Maternity admission requirements. The
hospital shall have written policies regarding standards of practice for
maternity and non-maternity patients who may be admitted to the maternity unit.
(4) High risk infants. Each maternity service
shall have adequate facilities, personnel, equipment
and support services for the care of high-risk infants, including premature
infants, or a written plan for prompt transfer of these infants to a recognized
intensive infant care or perinatal care center.
(5) Institutional transfer of infants.
(a) Written policies
and procedures for inter-hospital transfer of perinatal
and neonatal patients shall be established by hospitals which are involved in
the transfer of these patients.
(b) A perinatal care center or high-risk maternity service and
the sending hospital shall jointly develop policies and procedures for the
transport of high-risk maternity patients.
(c) Policies, personnel
and equipment for the transfer of infants from one hospital to another shall be
available to each hospital’s maternity service. The proper execution of
transfer is a joint responsibility of the sending and receiving hospitals.
(6) Personnel.
(a) The labor,
delivery, postpartum and nursery areas of maternity units shall have available
the continuous services and supervision of a professional registered nurse for
whom there shall be documentation of qualifications to care for women and
infants during labor, delivery and in the postpartum period.
(b) When a maternity unit requires additional
staff on an emergency basis, the needed personnel may be transferred from
another service if they meet the infection control criteria.
(c) The service shall
have written policies that state which emergency procedures may be initiated by
the professional registered nurse in the maternity service.
(7) Infection control.
(a) The infection
surveillance and control program in the maternity service shall be integrated
with that of the entire hospital.
(b) Surgery on
non-maternity patients may not be performed in the delivery suite, except in
emergencies.
(c) Hospitals unable to effectively isolate
and care for infants shall have an approved written plan for transferring the
infants to hospitals where the necessary isolation and care can be provided.
(8) Labor and delivery.
(a) The hospital shall
have written policies and procedures that specify who is responsible for, and
what is to be documented for, the care of the patient in labor and delivery,
including alternative birthing rooms.
(b) Equipment that is
needed for normal delivery and the management of complications and emergencies
occurring with either the mother or infant shall be provided and maintained in
the labor and delivery unit. The medical staff and the nursing staff shall
determine the items needed.
(c) The facility shall
have policies for the performing of newborn genetic screening.
(d) Written standing
orders shall exist allowing nurses qualified by
documented training and experience to discontinue the oxytocic
drip should circumstances warrant discontinuance.
(e) The hospital shall
be responsible for proper identification of newborns in its care.
(9) Postpartum care. The hospital shall have
written policies and procedures for nursing assessments of the postpartum
patient during the entire postpartum course.
(10) Newborn nursery and the care of newborns.
(a) Oxygen, medical air
and suction shall be readily available to every nursery.
(b) Hospitals that may
require special formula preparation shall develop appropriate written policies
and procedures.
(c) Newborn infants
shall be screened for hearing sensitivity prior to being discharged.
(d) In the event that a
newborn infant is brought to the hospital after birth and has not received a
hearing sensitivity screening, the attending physician, nurse, audiologist or
authorized staff shall arrange for a hearing sensitivity screening to be
performed by a program approved by children’s medical services of the
department of health.
(e) The hospital shall
have effective written policies and procedures to assure that newborn infants,
who are brought to the hospital for emergency services, receive a hearing
sensitivity screening.
(f) Documentation of
the hearing sensitivity screening shall be entered into the infant’s medical
record as subject to Subsection G of 7.7.2.29 NMAC.
(g) Parents or the
legally authorized person may waive the requirements for the newborn hearing
sensitivity screening in writing if they object to the screening on the grounds
that it conflicts with their religious beliefs.
The waiver for the hearing screening shall be after the parents or
legally authorized person have been provided with both written and oral
explanations by the infant’s physician so that they may make an informed
decision. The document of waiver shall
be placed in the newborn infant’s medical record.
(h) Parent(s) who have
lawful custody of the infant screened for hearing sensitivity shall be notified
of the test results.
(i)
Hospitals that permit minor siblings to visit the maternity unit shall
have written policies and procedures detailing this practice.
(11) Discharge of infants.
(a) An infant may be
discharged only to a parent who has lawful custody of the infant or to an
individual who is legally authorized to receive the infant. If the infant is
discharged to a legally authorized individual, that individual shall provide
identification and, if applicable, the identification of the agency the
individual represents.
(b) The hospital shall
record the identity of the parent or legally authorized individual who received
the infant in the infant’s medical record.
[7.7.2.34 NMAC - Rp, 7.7.2.34
NMAC; 06-15-04; 7.7.2.34 NMAC - Rn, 7.7.2.33 NMAC,
03-15-06]
7.7.2.35 REHABILITATION
SERVICES:
A. Organization.
(1) A Hospital may have either inclusive
rehabilitation services or separate services for physical therapy, occupational
therapy, speech language pathology, recreational therapy or audiology.
(2) Rehabilitation services shall have written
policies and procedures governing the management and care of patients.
(3) The services provided on each service
shall be given by or provided under the supervision of a qualified professional
therapist.
(4) Facility space and equipment for
rehabilitation services shall be adequate to meet the needs of patients
receiving care.
B. Orders. Physical therapy,
occupational therapy, speech language pathology therapy, Recreational therapy,
and/or audiology services shall be provided in
accordance with orders of practitioners who are authorized.
C. Additional Requirements for Separate
Rehabilitation Services.
(1) Definition: A rehabilitation unit or
facility is defined as a designated unit, or hospital that primarily provides
physiological rehabilitation services to inpatients and/or outpatients.
(2) If the facility maintains a separate
rehabilitation unit, or hospital, there shall be medical directorship by an
individual who has the necessary knowledge, experience and capabilities to
direct the rehabilitation services. The
medical director shall be a qualified professional physician.
(3) Additional treatment plan and staffing
requirements.
(a) The rehabilitation
unit, or hospital, shall have sufficient staff to provide an optimal program
for those who require rehabilitation services. Periodic evaluations of staffing
requirements based on patients serviced shall be undertaken to assure
rehabilitation needs can be met.
(b) The rehabilitation
staff shall plan, implement and modify written individualized treatment plans
for patients based on their intake assessment.
(c) Nursing services
shall be provided under the direction of a professional registered nurse with background
and/or training in rehabilitation nursing.
Professional registered nurses who are qualified in the care of
rehabilitation nursing services shall supervise nursing care.
(d) Psychological
services shall be provided by or given under the supervision of, an
appropriately licensed psychologist or psychiatrist. There shall be a sufficient number of
psychologists, consultants and or support personnel to provide optimal patient
and/or family evaluations and treatment.
(e) Social work
services shall be provided by a sufficient number of qualified social work
staff to provide optimal patient and family consultation related to social work
rehabilitation services and indicated community resource planning.
(f) Therapy services
staff shall be sufficient in number and have sufficient support personnel to
provide optimal assessments and treatment(s) to patients served.
[7.7.2.35 NMAC - Rp, 7.7.2.35
NMAC, 06-15-04; 7.7.2.35 NMAC - Rn, 7.7.2.34 NMAC,
03-15-06]
7.7.2.36 RESPIRATORY
CARE SERVICES:
A. Direction. If respiratory care
services are offered by the hospital, the service shall be under the medical
direction of a qualified physician.
B. Policies and Procedures.
Respiratory care services shall be provided in accordance with written policies
and procedures that shall be approved by the medical staff. The policies and
procedures shall address at a minimum:
(1) assembly and
operation of mechanical aids to ventilation;
(2) management of
adverse reactions to respiratory care services;
(3) administration of
medications in accordance with physicians’ orders;
(4)
personnel who may perform specific procedures,
under what circumstances and under what degree of supervision; and
(5) procurement,
handling, storage and dispensing of therapeutic gases.
C. Personnel. Respiratory care services shall be provided
by personnel qualified by education, training, experience and demonstrated
competence.
D. Physicians’ Orders. Respiratory
care services shall be provided in accordance with the orders of a physician.
The staff person authorized to take orders shall transcribe oral orders given
by a physician into the medical record.
E. Oxygen. Oxygen monitoring
equipment, including oxygen analyzers, shall be available and shall be checked
for proper function prior to use but at least daily. Oxygen concentrations shall be
documented. There shall be a written
policy, which states how frequently oxygen humidifiers are to be cleaned.
[7.7.2.36 NMAC - Rp, 7.7.2.36
NMAC, 06-15-04; 7.7.2.36 NMAC - Rn, 7.7.2.35 NMAC,
03-15-06]
7.7.2.37 OUTPATIENT
SERVICES:
A. Medical Direction. If outpatient services are offered by the
hospital, the services shall be under the direction of a qualified member of
the medical staff.
B. Administration.
(1) The outpatient service shall be organized into
sections or clinics, the number of which shall depend on the size and the
degree of departmentalization of the medical staff, the available facilities
and the needs of the patients for whom it accepts responsibility.
(2) Outpatient clinics shall be coordinated
with corresponding inpatient services.
(3) On their initial visit to the service,
patients shall receive an appropriate health assessment with follow-up as
indicated.
C. Personnel.
(1) The outpatient services shall have
adequate numbers of qualified personnel.
(2) A professional registered nurse shall be
responsible for the nursing care of the outpatient service.
D. Facilities.
(1) Facilities shall be provided to ensure
that the outpatient service is operated efficiently and to protect the health
and safety of the patients.
(2) The number of examination and treatment
rooms shall be adequate in relation to the volume and nature of work performed.
(3) Suitable facilities for necessary
laboratory and other diagnostic tests shall be available either through the
hospital or by arrangement with an independent CLIA
certified laboratory.
[7.7.2.37 NMAC - Rp, 7.7.2.37
NMAC, 06-15-04; 7.7.2.37 NMAC - Rn, 7.7.2.36 NMAC,
03-15-06]
7.7.2.38 EMERGENCY
SERVICES:
A. Minimum Care Requirements. Acute-care or limited services hospitals must
provide an area in the facility with adequate space and emergency equipment
needed to treat emergency patients.
Written policies for the care of such patients must be readily available
to all patient care staff.
B. Distinct Emergency Service. If
the hospital has a distinct emergency service:
(1) the emergency
service shall be directed by personnel who are qualified by training and
experience to direct the emergency service and shall be integrated with other
services of the hospital;
(2) the policies and
procedures governing medical care provided by the emergency service shall be
established by, and are a continuing responsibility of, the medical staff;
(3) emergency
services shall be supervised by a member of the medical staff, and nursing
functions shall be the responsibility of a professional registered nurse;
(4) the hospital’s
emergency services shall be coordinated with local / state / federal mass
casualty plans and
(5) written policies and procedures shall be
established prescribing a course of action, including policies for transferring
a patient to an appropriate facility when the patient’s medical status
indicates the need for emergency care which the hospital cannot provide, to be followed in the care of
persons who:
(a) manifest
severe emotional disturbances;
(b) are
under the influence of alcohol or other drugs;
(c) are
victims of suspected abuse or are victims of other suspected criminal acts;
(d) have
a contagious disease;
(e) have
been contaminated by hazardous, chemical, biological or radioactive materials;
(f) are
diagnosed dead on arrival; or
(g) present
other conditions requiring special directions regarding action to be taken.
(6) A hospital that provides emergency care
for sexual assault survivors shall:
(a) provide
each sexual assault survivor with medically and factually accurate and
(b) objective
written and oral information about emergency contraception as described in
their policies and procedures;
(c) orally
and in writing inform each sexual assault survivor for her option to be
provided emergency contraception at the hospital; and
(d) provide
emergency contraception at the hospital to each sexual assault survivor who
requests it and document it in the patient’s medical record.
(7) The provision of emergency contraception
pills shall include the initial dose that the sexual assault survivor can take
at the hospital as well as the subsequent dose that the sexual assault survivor
may self-administer 12 hours following the initial dose or in accordance with
accepted standards of practice for the administration of emergency
contraception.
(8) A communications system employing
telephone, radiotelephone or similar means shall be in use to establish and
maintain contact with the police department, emergency medical services, rescue
squads and other emergency services of the community.
(9)
A list of emergency referral services shall be available in the basic
emergency service. This list shall include the name, address and telephone
number of such services as:
(a) police
department;
(b) rape
or domestic crisis center;
(c) burn
center;
(d) drug
abuse center;
(e) New Mexico poison
center;
(f) suicide
prevention center;
(g) the
office of epidemiology of the New Mexico department of health;
(h) local
public health office;
(i)
clergy;
(j) emergency
psychiatric service;
(k) chronic
dialysis service;
(l) renal transplant
center;
(m) intensive
care newborn nursery;
(n) radiation
accident management service;
(o) ambulance
transport and rescue service, including military resources;
(p) county
coroner or medical examiner;
(q) hazardous
materials management service;
(r) anti-venom
service;
(s) emergency
and dental service;
(t) local emergency operations center.
(10) The hospital shall have the following
service capabilities:
(a) adequate
monitoring and therapeutic equipment;
(b) laboratory
service shall be capable of providing the necessary support for the emergency
service;
(c) radiological
service shall be capable of providing the necessary support of the emergency
service;
(d) services
shall be available for life threatening situations adequate for the size and
scope of the facility and staff;
(e) the hospital
shall have readily available the services of a blood bank containing common
types of blood and blood derivatives.
C. Physical Environment.
(1) The emergency service shall be provided
with the facilities, equipment, drugs, supplies and space needed for prompt
diagnosis and emergency treatment.
(2) Facilities for the emergency
service shall be separate and independent of the operating room.
(3) The location of the emergency service
shall be in close proximity to an exterior entrance of the hospital.
D. Personnel.
(1) There shall be sufficient medical and
nursing personnel available for the emergency service at all times. All medical and nursing personnel assigned to
emergency services shall be trained in cardiopulmonary resuscitation.
(2) The medical staff shall ensure that
qualified members of the medical staff are available at all times for the
emergency service, either on duty or on call, and that an authorized medical
staff member is responsible for all patients who arrive for treatment in the
emergency service.
(3) If unable to reach the patient within 15
minutes, the physician or a licensed independent practitioner shall provide
specific instructions to the emergency staff on duty if emergency measures are
necessary. These instructions may take
the form of written protocols approved by the medical staff.
E. A sufficient number of professional
registered nurses qualified by training and/or experience to work in emergency
services shall be available to deal with the number and severity of emergency
service cases.
F. The hospital shall ensure that all personnel
who provide care to sexual assault survivors have documented training in the
provision of medically and factually accurate and objective information about
emergency contraception within 60 days of employment.
G. Complaints.
(1) Complaints of failure to provide services
required by the Sexual Assault Survivors Emergency Care Act may be filed with
the department.
(2) The department shall investigate every
complaint it receives regarding failure of a hospital to provide services
required by the Sexual Assault Survivors Emergency Care Act to determine the
action to b taken to satisfy the complaint.
(3) If the department determines that a
hospital has failed to provide the services required in the Sexual Assault
Survivors Emergency Care Act, the department shall:
(a) issue a written
warning to the hospital upon receipt of a complaint that the hospital is not
providing the services required by the Sexual Assault Survivors Emergency Care
Act; and
(b)
based on the department’s investigation of the first complaint, require
the hospital to correct the deficiency leading to the complaint.
(4) If after the issuance of a written warning to the hospital
pursuant to Subsection D of this section, the department finds that the
hospital has failed to provide services required by the Sexual Assault
Survivors Emergency Care Act, the department shall, for a second through fifth
complaint, impose on the hospital a fine of one thousand dollars ($1,000):
(a) per sexual assault
survivor who is found by the department to have been denied medically and
factually accurate and objective information about emergency contraception or
who is not offered or provided emergency contraception; or
(b) per
month from the date of the complaint alleging noncompliance until the hospital
provides training pursuant to the rules of the department.
(5) For the sixth and subsequent complaint
against the same hospital if the department finds the hospital has failed to
provide services required by the Sexual Assault Survivors Emergency Care Act,
the department shall impose an intermediate sanction pursuant to Section
24-1-5.2 NMSA 1978 or suspend or revoke the license
of the hospital issued pursuant to the Public Health Act.
H. Medical Records.
(1) Adequate medical records to permit
continuity or care after provision of emergency services shall be maintained on
all patients. The emergency room patient record shall contain:
(a) patient
identification;
(b) history
of disease or injury;
(c) physical
findings;
(d) laboratory
and x-ray reports, if any;
(e) diagnosis;
(f) record
of treatment;
(g) disposition
of the case;
(h) appropriate time
notations, including time of the patient’s arrival, time of physician
notification, time of treatment, including administration of medications, time
of patient discharge or transfer from the service or time of death.
(2) Where appropriate, medical records of
emergency services shall be integrated with those of the inpatient and
outpatient services.
I. Emergency Committee. An
emergency services committee composed of physician, professional registered
nurses and other appropriate hospital staff shall review emergency services and
medical records for appropriateness of patient care on at least a quarterly
basis. The committee shall make
appropriate recommendations to the medical staff and hospital administrative
staff based on its findings. This review may be part of a hospital’s overall
quality improvement program. Minutes of
these meetings shall be maintained for a one year period.
J. Equipment and Supplies. All
equipment and supplies necessary for life support shall be available, including
but not limited to, airway control and ventilation equipment, suction devices,
cardiac monitor, defibrillator, pacemaker capability, apparatus to establish
central venous pressure monitoring, intravenous fluids and administration
devices.
[7.7.2.38 NMAC - Rp, 7.7.2.38
NMAC, 06-15-04; 7.7.2.38 NMAC - Rn, 7.7.2.37 NMAC
& A, 03-15-06]
7.7.2.39 SOCIAL
WORK SERVICES:
A. Organized Service. If the
healthcare system provides social work services there should be corresponding
written policies and procedures governing the scope and provision of
services. If the system does not have
employed providers for social work services, then they must be obtained via
consultation with outside sources.
B. Personnel.
(1) Direction. Social work services shall be directed by
personnel who have:
(a) a master’s degree
in social work from a graduate school of social work accredited by the council
on social work education, and has one year of social work experience in a
health care setting; or
(b) a
bachelor’s degree in social work, sociology or psychology; meets the national
association of social workers standards of membership; and has one year of
social work experience in a health care setting.
(2) Staff.
The social work services staff, in addition to the service director, may
include social workers, caseworkers and social work assistants at various
levels of social work training and experience.
(3) Number of Staff. There shall be a sufficient number of social
work services staff to carry out the purpose and functions of the service.
C. Service. The social work
services shall be integrated with other services of the hospital. Staff shall participate, as appropriate, in
patient rounds, medical staff seminars, nursing staff conferences, and in
conferences with individual physicians, nurses, and other personnel concerned
with the care of a patient and the patient’s family.
D. Functions. Social work services
shall address the psychosocial needs of the patients, their families and others
designated by the patient as these relate to health care. Services shall be clearly documented in the
record.
E. Environment. The facilities or
social work services staff shall provide privacy interviews with patients,
their family members and others designated by the patients.
F. Quality Improvement. The
service shall be part of the hospital’s performance improvement program.
[7.7.2.39 NMAC - Rp, 7.7.2.39
NMAC, 06-15-04; 7.7.2.39 NMAC - Rn, 7.7.2.38 NMAC,
03-15-06]
7.7.2.40 ADDITIONAL
REQUIREMENTS FOR PSYCHIATRIC HOSPITALS:
A. Additional Medical Record
Requirements. The medical records maintained by a psychiatric hospital
shall document the degree and intensity of the treatment provided to
individuals who are furnished services by the facility. A patient’s medical
record shall contain:
(1) identification
data, including the patient’s legal status;
(2) the reason for
treatment or chief complaint in the words of the patient, when possible, as well
as observations or concerns expressed by others;
(3) the psychiatric evaluation, including
medical history containing a record of mental status and noting the onset of
illness, the circumstances leading to admission, attitudes, behavior, estimate
of intellectual functions, memory functioning, orientation and an inventory of
the patient’s personality assets recorded in descriptive fashion;
(4) social services records, including reports
of interviews with patients, family members and others and an assessment of
home plans, family attitudes and community resource contacts as well as social
history;
(5) a comprehensive
treatment plan based on an inventory of the patient’s strengths and disabilities,
which shall include:
(a) at
least one diagnosis;
(b) short-term
and long-range goals;
(c) the
specific treatment modalities used; and
(d) the
responsibilities of each member of the treatment team.
(6) staff shall plan,
implement and revise, as indicated, a written, individualized treatment program
for each patient based on:
(a) the degree of
psychological impairment and appropriate measures to be taken to relieve
treatable distress and to compensate for nonreversible impairments;
(b) the
patient’s capacity for social interaction;
(c) environmental
and physical limitations such as seclusion room or restraints, required to
safeguard the individual’s health and safety with an appropriate plan of care;
and
(d) the
individual’s potential for discharge and successful care management on an
outpatient basis.
(7) the documentation
of all active therapeutic efforts and interventions;
(8) progress notes related to treatment needs
and the treatment plan are reviewed, revised and recorded at least weekly as
the status of the patient requires by the physician, nurse, social worker and
staff from other appropriate disciplines involved in active treatment
modalities, as indicated by the patient’s condition; and
(9) discharge
information, including:
(a) recommendations
from appropriate services concerning follow-up care; and
(b) at
least one diagnosis.
B. Additional Treatment Plan and
Staffing Requirements.
(1) The hospital shall have enough staff with
appropriate qualifications to carry out an active plan of psychiatric treatment
for individuals who are furnished services in the facility.
(2) The treatment of psychiatric inpatients
shall be under the supervision of a qualified physician who shall provide for
taking an active role in an intensive treatment program.
(3)
If non-psychiatric medical and surgical diagnostic and treatment
services are not available within the facility, qualified consultants or
attending physicians shall be immediately available if a patient should need
this attention, or an adequate arrangement shall be in place for immediate transfer of the patient to
an acute-care hospital.
(4) Nursing services shall be under the
supervision of a professional registered nurse qualified to care for
psychiatric patients and, by demonstrated competence, to participate in
interdisciplinary formulation of individual treatment plans, to give skilled
nursing care and therapy, and to direct, supervise and educate others who
assist in implementing the nursing component of each patient’s treatment plan.
(5) Professional registered nurses and other
nursing personnel shall participate in inter-disciplinary meetings affecting
the planning and implementation of treatment plans for patients, including
diagnostic conferences, treatment planning sessions and meetings held to
consider alternative facilities and community resources.
(6) Psychological services shall be under the
supervision of a psychologist licensed under the Professional Psychologists
Act, Section 61-9-1 through 61-9-18 NMSA 1978. There
shall be enough psychologists, consultants and support personnel qualified to
carry out their duties to:
(a) assist
in essential diagnostic formulations;
(b) participate in
program development and evaluation;
(c) participate
in therapeutic interventions and in interdisciplinary conferences and meetings
held to establish diagnoses, goals and treatment programs.
(7) The number of social work staff qualified
to carry out their duties shall be adequate for the hospital to meet the
specific needs of individuals patients and their
families and develop community resources and for consultation to other staff
and community agencies. The social work staff shall:
(a) provide
psychosocial data for diagnosis and treatment planning;
(b) provide
direct therapeutic services; and
(c) participate
in interdisciplinary conferences and meetings on diagnostic formulation and
treatment planning, including identification and use of alternative facilities
and community resources.
(8) The
number of qualified therapists and therapist assistants shall be sufficient to
provide needed therapeutic activities, including, when appropriate,
occupational, recreational, and physical therapy, to ensure that appropriate
treatment is provided to each patient.
(9) The total number of rehabilitation
personnel, including consultants, shall be sufficient to permit appropriate
representation and participation in inter-disciplinary conferences and
meetings, including diagnostic conferences, which affect the planning and
implementation of activity and rehabilitation programs.
[7.7.2.40 NMAC - Rp, 7.7.2.40
NMAC, 06-15-04; 7.7.2.40 NMAC - Rn, 7.7.2.39 NMAC,
03-15-06]
7.7.2.41 PHYSICAL
ENVIRONMENT:
A. General. The buildings of the hospital
shall be constructed and maintained so that they are functional for diagnosis
and treatment and for the delivery of the hospital services appropriate to the
needs of the community and with due regard for protecting the life, health and
safety of the patients and staff. The provisions of this section apply to all
new, remodeled and existing construction unless otherwise noted.
B. Definitions in 7.7.2.41 NMAC.
(1) “Building, existing” means a building erected
prior to the adoption of this requirement, or one for which a legal building
permit has been issued.
(2) “Existing construction” means a building,
which is in place or is being constructed with plans approved by the department
prior to the effective date of this chapter.
(3) “Full-term nursery” means an area in the
hospital designated for the care of infants who are born following a full-term
pregnancy and without complications, until discharged to a parent or other
legally authorized person.
(4) “Intermediate nursery” means an area in
the hospital designated for the care of infants immediately following birth who
require observation due to complications, and for the care of infants who
require observation following placement in the critical care nursery, until
discharged to a parent or other legally authorized person.
(5) “Life safety code” means the standard
adopted by the national fire protection association (NFPA)
known as NFPA 101 life safety code.
(6) “New construction” means construction for
the first time of any building or addition or remodeling to an existing building,
the plans for which are approved after the effective date of this chapter.
(7) “Remodeling” means to make over or rebuild
any portion of an existing building or structure and thereby modify its
structure, structural strength, fire hazard character, exits, heating and
ventilation systems, electrical system or internal circulation, as previously
approved by the department. Where exterior walls are in place but interior
walls are not in place at the time of the effective date of this chapter,
construction of interior walls shall be considered remodeling. “Remodeling”
does not include repairs necessary for the maintenance of a building or
structure.
(8) “Special care unit” means an organized
health care service that combines specialized facilities and staff for the
intensive care and management of patients in a crisis or potential crisis
state. “Special care units” include psychiatric special care, coronary care,
surgical intensive care, medical intensive care and burn units, but do not
include post-obstetrical or post-surgical recovery units or neonatal intensive
care units.
C. Approvals. The hospital shall keep all documentation of
inspections on file in the hospital following any inspections by state and
local authorities for a period of five years.
D. Fire Protection.
(1) Basic Responsibility: The hospital shall
provide fire protection adequate to ensure the safety of patients, staff and
others on the hospital’s premises. Necessary safeguards such as extinguishers,
sprinkling and detection devices, fire and smoke barriers, and ventilation
control barriers shall be installed and maintained to ensure rapid and
effective fire and smoke control.
(2) New Construction: Any new construction or
remodeling shall meet the applicable provisions of the current edition of the
building code, fire code, life safety code, and AIA
guidelines for hospitals and health care facilities.
(3) Existing Facilities: Any existing hospital
shall be considered to have met the
requirements of this subsection if, prior to the promulgation of this
chapter, the hospital complied with and continues to comply with the applicable
provisions of the 1967, 1973 or the current edition of the life safety code,
with or without waivers.
(4) Equivalent Compliance: Any existing
facility that does not meet all requirements of the applicable life safety code
may be considered in compliance with life safety code if the facility achieves
a passing score on the fire safety evaluation system (FSES)
developed by the U.S. department of commerce, national bureau of standards, to
establish safety equivalencies under the life safety code.
E. General Construction.
(1) Prior to any construction, one copy of
schematic plans shall be submitted to the licensing authority for review and
preliminary approval.
(2) Before construction is started, one copy
of final plans and specifications which, are used for bidding purposes shall be
submitted to the licensing authority for review and approval. Plans must be
prepared, sealed, signed and dated by an architect registered in the state of
New Mexico.
(3) If on-site construction above the
foundation is not started within 12 months of the date of approval of the final
plans and specifications, the approval under these requirements shall be void
and the plans and specifications must be resubmitted for reconsideration of
approval.
(4) Before any construction change(s) is
undertaken affecting the approved final plans, modified plans shall be
submitted to the licensing authority for review and approval. The licensing authority shall notify the
hospital in writing of any conflict with this subchapter found in its review of
modified plans and specifications.
(5) General:
Projects involving alterations of, and additions to, existing buildings
shall be programmed and phased so that on-site construction will comply with
all codes and minimize disruptions of existing functions. Access, exit ways,
and fire protection shall be so maintained that the safety of the occupants
will not be jeopardized during construction.
(6) Minimum requirements: All requirements
listed in Subsection G of 7.7.2.41 NMAC New Construction, relating to new
construction projects, are applicable to renovation projects involving
additions or alterations. When existing conditions make changes impractical to
accomplish, minor deviations from functional requirements may be permitted with
the approval of the licensing authority if the intent of the requirements is
met and if the care and safety of patients will not be jeopardized.
(7) Nonconforming condition: When doing
renovation work, if it is found to be infeasible to correct all of the
non-conforming conditions in the existing facility in accordance with these
standards, acceptable compliance status may be recognized by the licensing
agency if the operation of the facility, necessary access by the handicapped,
and safety of the patients, are not jeopardized by the remaining non-conforming
conditions.
(a) Plan approval and
building permit by the construction industries division or local building
department, are also required for any new construction or remodeling.
(b) Copies of the life
safety codes and related codes can be obtained from the national fire
protection association, 11 tracy
drive, avon, MA 02322.
F. Construction and Inspections. Construction shall not commence until
plan-review deficiencies have been satisfactorily resolved.
(1) The completed construction shall be in
compliance with the approved drawings and specifications, including all addenda
or modifications approved for the project.
(2) A final inspection of the facility will be
scheduled for the purpose of verifying compliance with the licensing standards,
and approved plans and specifications.
(3) The facility shall not occupy any new
structure or major addition or renovation space until the appropriate
permission has been received from the local building and fire authorities and
the licensing authority.
G. New Construction.
(1) General: Every hospital building hereafter
constructed, every building hereafter converted for use as a hospital, and
every addition and/or alteration hereafter made to a hospital shall comply with
the requirements of these standards.
(a) Compliance with
these standards does not constitute release from the requirements of other
applicable state and local codes and ordinances. These standards must be
followed where they exceed other codes and ordinances.
(b) No building may be
converted for use as a licensed hospital, which because of its location,
physical condition, state of repair, or arrangement of facilities, would be
hazardous to the health and safety of the patients who would be housed in such
a building. Any hospital or related institution that has been vacated in excess
of one year or used for occupancy other than health care will be classified as
a new facility.
(c) All new
construction, remodeling and additions must meet requirements set forth by
these standards, the building and fire codes and by the Americans with
Disabilities Act (ADA), for accessibility for persons with disabilities.
(2) Codes and standards: In addition to
compliance with these standards, all other applicable building codes,
ordinances, and regulations under city, county or other state agency
jurisdiction shall be observed.
(a) Compliance with
local codes shall be pre-requisite for licensing. In areas not subject to local
building codes, the state building codes shall be pre-requisite for licensing,
as adopted.
(b) New construction for acute-care hospitals,
limited services hospitals and special hospitals are governed by the current
editions of the following codes and standards: uniform building code (UBC), uniform plumbing code (UPC),
uniform mechanical code (UMC), national electric code
(NEC), national fire protection association standards (NFPA),
American national standards institute (ANSI), American society of heating,
refrigerating, and air conditioning engineers (ASHREA),
American institute of architects (AIA), academy of
architecture for health guidelines for design and construction of hospital and
health care facilities, NFPA101, and New Mexico building code (NMBC).
H. Patient Rooms-General.
(1) Bed capacity: Each hospital’s bed capacity
may not exceed the capacity approved by the licensing authority.
(2) Privacy:
Visual privacy shall be provided for each patient in multi-bed patient
rooms. In new or remodeled construction, cubicle curtains shall be provided.
(3) Toilet room:
(a) In new
construction, each patient room shall have access to one toilet without
entering the general corridor area. One toilet room shall serve no more than four
beds and no more than two patient rooms.
Where the toilet room serves more than two beds an additional hand
washing shall be placed in the patient room.
(b) In new and
remodeled construction, the door to the patient toilet room shall swing into
the patient room, or two-way hardware shall be provided.
(c) The minimum door
width to the patient toilet room shall be 36 inches (91.4 cm) for new
construction. The door shall swing
outward or be double acting.
(4) Minimum floor area: The minimum floor area
per bed shall be 100 square feet of clear floor area in multi-bed patient
rooms, and 120 square feet of clear floor area in single-bed patient rooms,
exclusive of toilet rooms, closets, lockers, wardrobes, alcoves or vestibules.
(5) Minimum furnishing:
(a) A hospital-type bed
with suitable mattress, pillow and the necessary coverings shall be provided
for each patient.
(b) There shall be a
bedside table or stand and chair for each patient.
(c) Each patient shall
have within his/her room adequate storage space suitable for hanging full-length
garments and for storing personal effects.
I. Isolation
Room(s). Rooms shall be provided for isolation of patients whose condition require isolation for physical health reasons.
(1) Each isolation room shall have a separate
toilet, bathtub (or shower), and a hand washing sink. These shall be arranged to permit access from
the bed area without passing through the work area of the vestibule or
anteroom.
(2) Each room shall have an area for hand washing,
gowning, and storage of soiled materials located directly outside or
immediately inside the entry door to the room.
(3) Each room shall have self-closing devices
on all room exit doors. All wall,
ceiling and floor penetrations in the room shall be sealed tightly.
J. Patient Care.
(1) Nursing station or administrative center:
Nursing stations or administrative centers in patient care areas of the
hospital may be located to serve more than one nursing unit, but at least one
of these service areas shall be provided on each nursing floor or wing. The
station or center shall contain:
(a) storage
for records, manuals and administrative supplies;
(b) an
area for charting when the charts of patients are not maintained at patient
rooms;
(c) hand
washing sink conveniently accessible to the nurse station;
(d) staff
toilet room: in new construction, a
staff toilet room and hand washing sink shall be provided on each nursing unit;
and
(e) securable
closet or cabinet for the personal articles of nursing personnel, located in or
near the nursing station.
(2) Utility areas: A utility area room for soiled linen and
other clean articles shall be readily accessible to each nursing utility
area. Each room shall have:
(a) storage
facilities for supplies;
(b) a
hand washing sink;
(c) work
counters; and
(d) a
waste receptacle.
(3) Bathing Facilities: Showers and
bathtubs. When individual bathing
facilities are not provided in patient rooms, there shall be at least one
shower and/or one bathtub for each 12 beds without such facilities. Each bathtub or shower shall be in an
individual room or enclosure that provides privacy for bathing, drying, and
dressing. One special bathing facility,
including space for attendants, shall be provided for patients on stretchers,
carts and wheelchairs for each 100 beds or fraction thereof.
(4) Equipment and supply storage: An equipment
and supply storage room or alcove shall be provided for storage of equipment
necessary for patient care. Its location
shall not interfere with the flow of traffic.
(5) Corridors and passageways: Corridors and
passageways in patient care areas shall be free of obstacles.
(6) Housekeeping closet: A housekeeping closet
shall be provided on the nursing unit or sufficient cleaning supplies and
equipment shall be readily accessible to the nursing unit.
(7) Patient call system: A reliable call
mechanism shall be provided in locations where patients may be left unattended,
including patients’ rooms, toilet and bathing areas and designed high risk
treatment areas where individuals may need to summon assistance.
K. Additional Requirements for
Particular Patient Care Areas.
(1) Special care units.
(a) In new
construction, sufficient viewing panels shall be provided in doors and walls
for observation of patients. Curtains or
other means shall be provided to cover the viewing panels when privacy is
desired.
(b) In new
construction, a sink equipped for hand-washing and a toilet shall be provided
in each private patient room. In
multi-bed rooms at least one sink and one toilet for each six beds shall be
provided. Individual wall-hung toilet facilities with private curtains or
another means of safeguarding privacy may be substituted for a toilet room.
(c) In new
construction, all beds shall be arranged to permit visual observation of the
patient by the nursing staff from the nursing station. In existing facilities,
if visual observation is not possible from the nursing station, sufficient
staffing or television monitoring shall permit continuous visual observation of
the patient.
(d) In new
construction, the dimensions and clearances in special care unit patient rooms
shall be as follows: single bed rooms shall have minimum dimensions of 10 feet
by 12 feet, multi-bed rooms shall have minimum side clearances between beds of
at least seven feet, and in all rooms the clearance at each side of each bed
shall be not less than three feet six inches and the clearance at the foot of
each bed shall be not less than four feet.
(2) Psychiatric units: The requirements for
patient room under Paragraph (8) of Subsection B of 7.7.2.41 NMAC apply to
patient rooms in psychiatric nursing units and psychiatric hospital except as
follows:
(a) in
new construction or remodeling, a staff emergency call system shall be
included. When justified by psychiatric
program requirements and with the approval of the licensing authority, call
cords from wall-mounted stations of individual patients rooms may be removed;
(b) doors
to patient rooms and patient toilet room doors may not be lockable from the
inside;
(c) patients’
clothing and personal items may be stored in a separate designated area which
is locked;
(d) moveable
hospital beds are not required for ambulatory patients.
(3) Surgical and recovery facilities must:
(a) have
at least one room equipped for surgery and used exclusively for this purpose;
(b) have
a scrub room or scrub area adjacent to the surgery room used exclusively for
this purpose;
(c) have
a clean-up or utility room;
(d) have
a storage space for sterile supplies;
(e) have
means for calling for assistance in an emergency in each operating room;
(f) have
housekeeping facilities adequate to maintain the operating room or rooms;
(g) have
a flash sterilizer, unless sterilization facilities are accessible from the
surgery area;
(h) be
located and arranged to prevent unrelated traffic through the suite;
(i)
ensure the room or rooms for post-anesthesia recovery of surgical
patients shall at a minimum contain a medications storage area, hand-washing
facilities and sufficient storage space for needed supplies and equipment; and
(j) have
available oxygen and suctioning equipment in the operating suite and recovery
rooms.
(4) Labor and delivery.
(a) The labor and
delivery unit shall be located and arranged to prevent unrelated traffic
through the unit.
(b) Facilities within
the labor and delivery unit shall include: at least one room equipped as a
delivery room and used exclusively for obstetrical purposes, a scrub-up room
adjacent to the operative delivery unit if operative deliveries are performed,
a clean-up or utility room with a flush-rim clinical sink, and a separate
janitor’s closet with room for housekeeping supplies for the unit.
(c) In new
construction, in addition to lightning for general room illumination, adjustable
examination and treatment lights shall be provided for each labor bed.
(d) The following
equipment shall be available: sleeping unit for each infant, and a clock.
(e) Space for necessary
housekeeping equipment in or near the nursery is required.
(f) An examination area
and workspace for each nursery shall be provided.
(5) Isolation nursery.
(a) If an isolation nursery is provided in new
construction: the isolation nursery shall be within the general nursery area
and may not open directly to another nursery, and access to the isolation
nursery shall be through an anteroom which shall have at least a sink equipped
for hand-washing, gowning facilities, an enclosed storage space for clean linen
and equipment and a closed hamper for disposal of refuse.
(b) A private patient
room with hand-washing facilities may be used as an isolation nursery.
(6) Postpartum lounge area: The lounge and
dining room when provided for maternity patients shall be separate from other
areas.
L. Other Physical Environment
(1) Thresholds and expansion joint: Thresholds
and expansion joint covers shall be flush with the floor surface to facilitate
the use of wheelchairs and carts, and as may be required by OSHA. Expansion and seismic joints shall be
constructed to restrict the passage of smoke.
(2) Emergency fuel and water: The hospital
shall make provisions for obtaining emergency fuel and water supplies.
(3) Emergency lighting system: The emergency
lighting system and equipment shall be tested at least monthly.
(4) Diagnostic and therapeutic facilities,
supplies and equipment: Diagnostic and therapeutic facilities supplies and
equipment shall be sufficient in number and in good repair to permit medical
and nursing staffs to provide an acceptable level of patient care.
(5) Walls and ceilings: The walls and ceilings
shall be kept in good repair. Loose,
cracked or peeling wallpaper and paint of walls and ceilings shall be replaced
or repaired. Washable ceilings shall be
provided in surgery rooms, delivery rooms, janitor closets and utility rooms.
(6) Floors:
All floor materials shall be easy to clean and have wear and moisture
resistance appropriate for the location.
Floors in areas used for food preparation or food assembly shall be
water-resistant and grease-proof and shall be kept clean and in good repair.
(7) Cords:
Electrical cords shall be maintained in good repair.
(8)
Carpeting:
(a) Carpeting may not
be installed in rooms used primarily for food preparation and storage, dish and
utensil washing, cleaning of linen an utensils, storage of janitor supplies,
laundry processing, hydrotherapy, toiling and bathing, patient isolation or
patient examination.
(b) Carpeting,
including any underlying padding, shall have a flame spread rating
permitted by the national fire
protection association’s national fire codes. Certified proof by the
manufacturer of this test for the specific product shall be available in the
facility. Certification by the installer
that the material installed is the product referred to in the test shall be
obtained by the facility. Carpeting may
not in any case be applied to walls except where flame spread rating can be
shown to be twenty-five (25) or less.
(9) Acoustical tile: Acoustical tile shall be
non-combustible and non-asbestos.
(10) Wastebaskets: Wastebaskets shall be made
of non-combustible materials.
(11) Fire report: All incidents of fire in a
facility shall be reported in writing to the licensing authority within 72
hours of the incident.
M. Maintenance. The hospital must maintain written evidence
of routine maintenance performed for the facility, supplies and equipment to
ensure an acceptable level of safety and quality.
[7.7.2.41 NMAC - Rp, 7.7.2.41
NMAC, 06-15-04; 7.7.2.41 NMAC - Rn, 7.7.2.40 NMAC,
& A, 03-15-06]
7.7.2.42 OTHER
REQUIREMENTS:
A. Anatomical Gifts. The
hospital will adopt and implement organ and tissue donation policies and
procedures to assist the medical, surgical and nursing staff in identifying and
evaluating potential organ or tissue donors.
(1) Organ bank: Means a facility certified by
CMS for storage of human body parts.
(2) Decedent.
Means a deceased individual who made a gift of all or
part of his body.
(3) Donor.
Means an individual who makes a gift of all or part of
his body.
(4) Eye bank. Means any non-profit agency
which is organized to procure eye tissue for the purpose of transplantation or
research and which meets the medical standards set by the eye bank association
of America.
(5) Organ procurement agency. Means any non-profit agency designated by the
health care financing administration to procure and place human organs and
tissues for transplantation, therapy, or research.
(6) Part. Includes organs,
tissues, eyes, bones, arteries, blood, other fluids and other portions of human
body.
(7) Person. Means an
individual, corporation, government or governmental subdivision or agency,
business trust, estate, trust, partnership or association or any other legal
entity.
(8) State. Includes any
state, district, commonwealth territory, insular possession and any other area
subject to the legislative authority of the United States of America.
B. Procedures.
(1) The organ and tissue donation policy and
procedure shall conform to the CMS conditions of participation for organ and
tissue donations.
(2) All physician and hospital personnel shall
make every reasonable effort to carry out the organ and tissue donation policy
and procedure adopted by the hospital so that the wishes of a donor may be
conveyed to an appropriate local organ procurement agency or eye bank and the
necessary donation documents may be properly executed.
(3) Consent from next of kin. Persons authorized to donate anatomical gifts
on behalf of the
decedent shall conform with the
Uniform Anatomical Gift Act, N.M. Laws 2000, Chapter 54, or applicable
subsequent statutes.
(4) Every hospital shall develop and implement
a policy and procedure for the determination of brain death pursuant to Section
12-2.4 NMSA 1978.
(5) Laws pertaining to notification of the
office of the medical investigator shall be complied with in all cases of
reportable deaths.
(6) The requirements of this section apply
only to acute-care hospitals and limited services hospitals in New Mexico.
[7.7.2.42 NMAC - Rp, 7.7.2.42
NMAC, 06-15-04; 7.7.2.42 NMAC - Rn, 7.7.2.41 NMAC,
03-15-06]
7.7.2.43 RELATED
REGULATIONS AND CODES: Hospitals subject to these requirements are also subject to other
regulations, codes and standards as the same may from time to time be amended
as follows:
A. Health Facility Licensure Fees
and Procedures, New Mexico department of health, 7 NMAC 1.7 (10-31-96). [7.1.7
NMAC]
B. Health Facility Sanctions and
Civil Monetary Penalties, 7 NMAC 1.8 (10-31-96) [Recompiled as 7.1.8 NMAC]
C. Adjudicatory Hearings, New
Mexico department of health, 7 NMAC 1.2 (2-1-96). [Recompiled as 7.1.2 NMAC]
D. Building, fire, electrical,
plumbing and mechanical codes; the most current edition, adaptation by the
state of New Mexico.
E. The current edition of the AIA guidelines for
construction and design of hospitals and healthcare facilities, adopted in
the state of New Mexico.
[7.7.2.43 NMAC - Rn, 7.7.2.42
NMAC, 03-15-06]
HISTORY OF 7.7.2 NMAC:
Pre-NMAC History: The material in this part
was derived from that previously filed with the state records center &
archives under HED 89-1 (PHD), New Mexico Regulations
Governing General and Special Hospitals, filed April 25, 1989.
History of Repealed Material: 7 NMAC 7.2, Requirements
for General and Special Hospitals (filed 10-18-1996) repealed 6-01-2000.
7.7.2 NMAC, Requirements for General and Special Hospitals
(filed 04-27-2000) repealed 07-01-2004.
Other History:
HED 89-1 (PHD), New Mexico
Regulations Governing General and Special Hospitals (filed April 25, 1989)
renumbered, reformatted and replaced by 7 NMAC 7.2, Requirements for General
and Special Hospitals, effective 10-31-96.
7 NMAC 7.2, Requirements for General and Special Hospitals
(filed October 18, 1996) replaced by 7.7.2 NMAC, Requirements for General and
Special Hospitals, effective 06-01-2000.
7.7.2 NMAC, Requirements for General and Special Hospitals
(filed 04-27-2000) replaced by 7.7.2 NMAC, Requirements for Acute Care, Limited
Services and Special Hospitals, effective 06-15-2004.
