10-144-112 Me. Code R. § 3

Current through 2024-51, December 18, 2024

Section 144-112-3 - STANDARDS

3.1 Federal standards and certification requirements. All applicants and licensees must comply with the federal standards and certification requirements for hospitals, adopted by the United States Department of Health and Human Services Centers for Medicare and Medicaid Services (CMS) as set forth in 42 C.F.R. § 482.1 through § 482.104 and§ 485.601 through§ 485.647, revised as of October 1, 2007, which is incorporated herein by reference.

3.1.1 Copies of the federal standards and certification requirements can be found at 42 C.F.R. § 482.1 through § 482.104 and§ 485.601 through§ 485.647, revised as of October 1, 2007, or may be obtained from the Maine Department of Health and Human Services, Division of Licensing and Regulatory Services, 11 State House Station, Augusta, Maine 04333, orthe Maine Office of the Secretary of State, 101 State House Station, Augusta, Maine 04333.

3.1.2 A violation of any of the federal standards and certification requirements constitutes a violation of the state of Maine Rules for the Licensing of Hospitals, 10-144 C.M.R. Ch. 112.

3.2 Patient Rights in Critical Access Hospitals. A critical access hospital must protect patient rights and comply with the conditions for patient rights contained in 42 C.F.R. § 482.13, revised as of October 1, 2007, which is incorporated herein by reference as described in Section 3.1.

3.3 Federal Standards for Distinct Part Hospital Units.

3.3.1 Psychiatric Unit. All applicants and licensees must also comply with the federal standards and certification requirements for psychiatric units, adopted by the United States Department of Health and Human Services Centers for Medicare and Medicaid Services (CMS) as set forth in 42 C.F.R. § 412.25 and § 412.27, revised as of October 1, 2007, which is incorporated herein by reference.

3.3.2 Rehabilitation Unit. All applicants and licensees must comply with the federal standards and certification requirements for rehabilitation units, adopted by the United States Department of Health and Human Services Centers for Medicare and Medicaid Services (CMS) as set forth in 42 C.F.R. § 412.25, § 412.29, and § 412.30, revised as of October 1, 2007, which is incorporated herein by reference.

3.3.3 Copies. Copies of the federal standards and certification requirements for distinct part hospital units can be found at 42 C.F.R. § 412.25, § 412.27, § 412.29, and § 412.30, revised as of October 1, 2007, or may be obtained from the Maine Department of Health and Human Services, Division of Licensing and Regulatory Services, 11 State House Station, Augusta, Maine 04333, orthe Maine Office of the Secretary of State, 101 State House Station, Augusta, Maine 04333.

3.3.4 Violations. A violation of any of the federal standards and certification requirements for distinct part hospital units constitutes a violation of the state of Maine Rules for the Licensing of Hospitals, 10-144 C.M.R. Ch. 112.

3.4 Requirements for Medicare patients apply to all patients. Wherever the federal standards and certification requirements refer to requirements, standards or conditions applying to Medicare patients, for purpose of state licensing they must apply to all patients, regardless of payment source.

3.5 Maine laws and rules. In addition to compliance with the federal standards and certification requirements in Section 3.1, the following state laws and rules apply:

3.5.1Grievance procedure for recipients of mental health services. Pursuant to 22 M.R.S.A. §1719, private psychiatric hospitals, including any part of a general or specialty hospital that operates a distinct part for the provision of psychiatric services under these rules, and state psychiatric facilities, as defined in 34-B M.R.S.A. §3801(6), are subject to the grievance procedures set forth in 14-193 C.M.R. Chapter 1 (Rights of Recipients of Mental Health Services) and 14-472 C.M.R. Chapter 1 (Rights of Recipients of Mental Health Services who are Children in Need of Treatment).

3.5.1.1 A violation of the Rights of Recipients of Mental Health Services or the Rights of Recipients of Mental Health Services who are Children in Need of Treatment constitutes a violation of the state of Maine Rules for the Licensing of Hospitals.

3.5.1.2 Copies of the Rights of Recipients of Mental Health Services or the Rights of Recipients of Mental Health Services who are Children in Need of Treatment may be obtained from the Maine Department of Health and Human Services, Division of Licensing and Regulatory Services, 11 State House Station, Augusta, Maine 04333, orthe Maine Office of the Secretary of State, 101 State House Station, Augusta, Maine 04333.

3.5.1.3 Appeals to department. The commissioner shall be responsible for issuing final decisions for any grievance appealed to the department level in accordance with the procedures set forth in 14-193 C.M.R. Chapter 1 (Rights of Recipients of Mental Health Services) and 14-472 C.M.R. Chapter 1 (Rights of Recipients of Mental Health Services who are Children in Need of Treatment).

3.5.2 Patient visitors. Pursuant to 22 M.R.S.A. §1711-D, a patient may designate persons to be considered as immediate family members for the purpose of granting visitation rights. The following provisions apply to the designation of visitors under this rule.

3.5.2.1 The patient must be 18 years of age or older or a minor who is authorized by law to consent to health care.

3.5.2.2 The patient must be a patient in a critical care unit that restricts visitors to immediate family members, or emergency room that restricts visitors to immediate family members.

3.5.2.3 The patient may designate visitors under this rule by communicating the designation to a healthcare provider at the hospital orally or in writing. The patient may designate visitors, change the designation or revoke the designation at any time.

3.5.2.4 A hospital must provide patients with a process to designate visitors under this rule and must note in the patient's medical record the names of designated visitors, the date of the designation and any changes in the designation.

3.5.2.5 Except as provided in Section 3.5.2.6, a hospital may not deny visitation to the patient by a designated visitor during hospital visiting hours.

3.5.2.6 A hospital may deny visitation with a patient to any visitor designated under Section 3.5.2, if:

3.5.2.6.1 The hospital denies all visitors;

3.5.2.6.2 The hospital determines that the presence of the visitor might endanger the health or safety of the patient or interfere with the primary operations of the hospital; or

3.5.2.6.3 The patient has communicated orally or in writing the choice not to visit with the visitor.

3.5.3 Patient access to patient records. A patient may submit a written request for copies of the patient's medical and treatment records after discharge from a hospital, pursuant to 22 M.R.S.A. §§1711 and 1711-B. A copy of 22 M.R.S.A. §§1711 and 1711-B may be obtained from the Maine Department of Health and Human Services, Division of Licensing and Regulatory Services, 11 State House Station, Augusta, Maine 04333, orthe Maine Office of the Secretary of State, 101 State House Station, Augusta, Maine 04333.

3.5.4 Fees charged for records. Fees charged to patients for copies of requested copies of a patient's medical and treatment records shall be in accordance with 22 M.R.S.A. §1711-A. A copy of this statute may be obtained from the Maine Department of Health and Human Services, Division of Licensing and Regulatory Services, 11 State House Station, Augusta, Maine 04333, orthe Maine Office of the Secretary of State, 101 State House Station, Augusta, Maine 04333.

3.5.5 Record Retention. Records must be retained for a period of seven (7) years. If the patient is a minor, the record must be retained for at least six (6) years after the minor's age of majority. In addition, all licensees must comply with applicable federal and state laws and rules governing record retention.

3.5.6 Confidentiality of health care information. Confidentiality of health care information must be maintained in accordance with 22 M.R.S.A. §1711-C and the federal Health Insurance Portability and Accountability Act, 42 U.S.C. § 201et seq. ( 42 U.S.C. § 1320 d-2) (1996), or other applicable law. A copy of these laws may be obtained from the Department of Health and Human Services, Division of Licensing and Regulatory Services, #11 State House Station, Augusta, Maine 04333, orthe Maine Office of the Secretary of State, 101 State House Station, Augusta, Maine 04333.

3.5.7 Itemized bill. Pursuant to 22 M.R.S.A. §1712, each hospital must give written notice to all patients, or their legal guardians, at the time of the patient's discharge that, upon request by the patient, the hospital will provide the patient with an itemized bill.

3.5.7.1 A request for an itemized bill may be made by the patient or his legal guardian at discharge or at any time within 7 years after discharge.

3.5.7.2 The hospital must provide an itemized bill to the person making the request within 30 days of request.

3.5.7.3 In addition to giving the notice required by 22 M.R.S.A. §1712 in Section 3.5.7 above, a hospital bill must be given to each patient that itemizes the cost of nursing services provided to the patient.

3.5.8 Price list. Each hospital must maintain a price list of the most common inpatient services and outpatient procedures provided by the licensee, in accordance with 22 M.R.S.A. §1718.

3.5.9 Notice of intent to destroy images. Pursuant to Resolves 2005, ch. 164, general and specialty hospitals that record images of a patient using x-rays, magnetic resonance imaging or computerized tomography must provide notice of intent to destroy or purge those images. This notice may be provided through publication in a newspaper that has broad general circulation in the region served by the hospital or directly to the patient prior to or after taking the image.

3.5.10 Notice to medical utilization review entities. Hospitals must comply with 22 M.R.S.A. §1829, requiring notification to medical utilization review entities when the hospital provides emergency treatment to a person who is insured or otherwise covered under a policy or contract that requires review of a hospitalization by the medical utilization review entity.

3.5.11 Provider lists. Hospitals must comply with 22 M.R.S.A. §1831, which requires hospitals to provide for informed patient decisions by providing lists of licensed providers of care and services for all patients prior to discharge for whom home health care or nursing care is needed.

3.5.11.1 For all patients requiring home health care, the list must include all licensed home health care providers that request to be listed and any branch offices, including addresses and phone numbers, which serve the area in which the patient resides.

3.5.11.2 For all patients requiring nursing facility care, the list must include all nursing facilities that request to be listed that serve the area in which the patient resides or wishes to reside.

3.5.11.3 The hospital must disclose to the patient any direct or indirect financial interest the hospital has in the nursing facility or home health care provider.

3.6 Administrative Segregation. Notwithstanding the limitations on restraint and seclusion in Section 3.1, a state-operated psychiatric hospital may have an Administrative Segregation program for a person arriving from a correctional facility, in beds that are not CMS-certified, to ensure patient safety and the safety of others, to maintain security, and to protect the rights of patients placed in Administrative Segregation.

3.6.1 Administrative Segregation is the temporary separation of a patient from other patients and the normal living environment for the purpose of maintaining safety and security, while a transitional plan, including a safety assessment, is completed.

3.6.2 Administrative Segregation must not exceed 120 hours.

3.6.3 Administrative Segregation must take place in a secure suite that includes a bedroom, an open room and a bathroom.

3.6.4 A chair, table, television and appropriate recreational supplies must be supplied unless the attending physician documents that these items pose a safety risk. Such determination must be made and documented consistent with the Rights of Recipients of Mental Health Services, pursuant to 14-193 C.M.R. Chapter 1.

3.6.5 The area must be observed by a camera and recorded to assist in assessing the effects of the segregation and patient tolerance. Constant visual monitoring must be maintained.

3.6.6 Administrative Segregation is only permitted when the following two criteria are met:

3.6.6.1 Administrative Segregation is necessary for patient safety or for the safety of others; and

3.6.6.2 The patient is on forensic status.

3.7 Laboratories. In addition to the requirements in Section 3.1, all laboratory services provided must be in compliance with all applicable provisions of the Clinical Laboratory Improvement Amendments of 1988, 42 U.S.C. § 263 a, as amended.

3.8 Annual notice of Whistleblowers' Protection Act. Pursuant to Resolves 2007, ch. 88, once each year, the hospital must give an individual notice to each registered nurse in its employ regarding information about the Maine Whistleblowers' Protection Act, including a copy of the text of statutory provisions in 26 M.R.S.A. Chapter 7, Subchapter 5-B.

10-144 C.M.R. ch. 112, § 3