N.H. Admin. Code § He-P 812.16

Current through Register No. 45, November 7, 2024

Section He-P 812.16 - Organization and Administration

(a) Each ASC shall have a governing body whose duties include:

(1) Management and control of the operation of the ASC;

(2) Assessment and improvement of the quality of care and services;

(3) Appointment of the ASC administrator;

(4) Adoption of policies and procedures defining responsibilities for the operation of the ASC and the establishment of a medical staff;

(5) Approval of medical staff policies and procedures establishing the medical staff responsibilities;

(6) Responsibility for management of the overall operation and fiscal viability of the ASC;

(7) Responsibility for determination of the qualifications for appointment for all managers, medical staff and personnel; and

(8) Ensuring compliance with all relevant health and safety requirements of federal, state and local laws rules and regulations.

(b) If the ASC is a sole proprietorship, the duties in (1) above shall pertain to the individual in ownership status.

(c) Each ASC shall have a full-time administrator who:

(1) Meets one of the following qualifications:

a. The administrator shall have a master's degree from an accredited institution in business administration or a health-related field;

b. The administrator shall have a bachelor's degree from an accredited institution and at least 2 years of experience working in a health-related field; or

c. The administrator shall be a registered nurse and have at least 3 years of experience working in a health-related field; and

(2) Shall be responsible to the governing body for the daily management and operation of the ASC including:

a. Management and fiscal matters;

b. Implementing the policies and procedures adopted by the governing body;

c. The employment and termination of personnel necessary for the efficient operation of the ASC;

d. The designation of an alternate, in writing, who shall be responsible for the daily management and operation of the ASC in the absence of the administrator;

e. Attendance at meetings of the governing body, medical staff, and personnel, to serve as a liaison to the governing body;

f. The planning, organizing, and directing of such other activities as may be delegated by the governing body;

g. The delegation of responsibility to subordinates as appropriate;

h. Ensuring development and implementation of ASC policies and procedures on:

1. Patient's rights as required by RSA 151:20-21;

2. Advanced directives as required by RSA 137-J;

3. Discharge planning as required by RSA 151:26;

4. Organ and tissue donor identification and procurement, as applicable;

5. Withholding of resuscitative services from patients pursuant to RSA 137-J; and

6. Adverse event reporting; and

i. Notifying the department, directly or through delegation, as specified in He-P 812.15, of any adverse event involving a patient; and

(3) May hold more than one position within the ASC provided the individual meets the qualifications of each position.

(c) Each ASC shall have a medical staff in accordance with the policies and procedures established under (a) (4) above.

(d) There shall be a full-time director of nursing services who:

(1) Is currently licensed in the state of New Hampshire pursuant to RSA 326-B, or licensed pursuant to the multi-state compact;

(2) Has a minimum of 4 years' relevant experience;

(3) Is responsible for:

a. Establishment of standards of nursing practice used in the ASC;

b. Ensuring that the admission process and patient assessment process coordinates patient requirements for nursing care with available nursing resources;

c. Participating with the governing body, administrator and medical staff to improve the quality of nursing care at the ASC; and

d. Nursing care as authorized by their nurse practice act and according to RSA 326-B; and

(4) May hold more than one position within the ASC provided the director of nursing meets the qualifications of each position.

N.H. Admin. Code § He-P 812.16

#9727-A, eff 6-18-10

Amended by Volume XXXVIII Number 28, Filed July 12, 2018, Proposed by #12557, Effective 6/26/2018, Expires 12/24/2018.

Amended by Volume XXXIX Number 50, Filed December 12, 2019, Proposed by #12926, Effective 11/26/2019, Expires 11/26/2029.