216 R.I. Code R. 216-RICR-40-10-3.5

Current through December 26, 2024

Section 216-RICR-40-10-3.5 - Organization and Management

3.5.1Governing Body or Other Legal Authority

A. Each OACF shall have an organized governing body or other legal authority, ultimately responsible for:

1. The management and fiduciary control of the operation and maintenance of the OACF;

2. The conformity of the OACF with all federal, state and local laws and rules and regulations pertaining to fire, safety, sanitation, communicable and reportable diseases, patient care and other relevant health and safety requirements and this Part.

3. The administration of a policy of non-discrimination in the provision of services to patients and the employment of persons without regard to race, color, creed, national origin, gender, religion, sexual orientation, age, handicapping condition or degree of handicap, in accordance with Title VI of the Civil Rights Act of 1964; U.S. Executive Order #11246 entitled "Equal Employment Opportunity", U.S. Department of Labor regulations; Title V of the Rehabilitation Act of 1973, the Rhode Island Fair Employment Practices Act, R.I. Gen. Laws Chapter 28-5 et seq.; the Americans with Disabilities Act; and any other federal or state laws relating to discriminatory practices.

B. The governing body or other legal authority shall provide appropriate personnel, physical resources, and equipment to facilitate the delivery of ambulatory health care services, during established hours of operation.

C. The governing body or other legal authority shall adopt by-laws defining the responsibilities for the operation and performance of the OACF and identifying purposes and means of fulfilling such. In addition, the governing body or equivalent legal authority shall establish administrative/clinical policies pertaining to no less than the following:

1. The qualifications and responsibilities of the administrator;

2. The scope of health and medical services to be provided;

3. Maintain linkages and referrals with other health care facilities to assure continuity of care;

4. Quality assurance for patient care and services;

5. Provisions for a program permitting selected individuals other than physicians or other licensed, registered or certified personnel to perform extended, defined patient care functions. Said functions shall not otherwise require a license, certification or registration by state law. Such program shall include written systems of credentials review, selection, training, formal authorization of specific functions, and maintenance of a current register; and

6. Such other matters as may be relevant to the organization and operation of the OACF.

D. The governing body shall be responsible to establish a mechanism through the organization's by-laws or policies and procedures to assure that duly qualified physicians and other professionals are assigned to agency services based on appropriate education, training, experience and evidence of current professional practice and licensure as may be required by law.

3.5.2Quality Improvement Program

A. The governing body shall ensure that there is an effective, ongoing, OACF-wide quality improvement program to evaluate the provision of patient care.

B. The organized OACF-wide quality improvement program shall be ongoing and shall have a written plan of implementation. The written quality improvement plan shall include at least the following:

1. Program objectives;

2. Organization(s) involved;

3. Oversight responsibility (e.g., reports to the governing body);

4. Facility-wide scope;

5. Program administration and coordination;

6. Involvement of all patient care disciplines/services;

7. Methodology for monitoring and evaluating quality of care;

8. Priority setting and problem resolution;

9. Determination of the effectiveness of action(s) taken;

10. Documentation of the quality improvement plan review.

C. All patient care services, including services rendered by a contractor, shall be evaluated.

D. Nosocomial infections and medication therapy shall be evaluated.

E. All medical and surgical services performed in the OACF shall be evaluated for appropriateness in diagnosis and treatment.

F. The OACF shall take and document appropriate remedial action to address problems identified through the quality improvement program. The outcome(s) of the remedial action shall be documented.

G. The provisions of §§3.5.2(A) through (F) of this Part ("Quality Improvement") shall be deemed to have been met if the OACF has met similar requirements of a national accrediting body, as approved by the Director.

3.5.3Pending and Actual Labor Disputes/Actions

OACFs shall provide the Department with prompt notice of pending and actual labor disputes/actions which would impact delivery of patient care services including, but not limited to, strikes, walk-outs, and strike notices. OACFs shall provide a plan, acceptable to the Director, for continued operation of the facility, suspension of operations, or closure in the event of such actual or potential labor dispute/action.

3.5.4Administrator

A. The governing body or other legal authority of the OACF shall appoint an administrator who shall be operationally responsible for:

1. The management and operation of the OACF;

2. The compliance with policies, rules and regulations and statutory provisions pertaining to the health and safety of patients;

3. Serving as liaison between the governing body or equivalent legal authority and the staff; and

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

3.5.5Medical or Dental Director

The governing body or other legal authority of the OACF shall appoint a medical or dental director (as appropriate), licensed in Rhode Island to ensure the achievement and maintenance of the quality of health care services and the establishment of policies and procedures for health care services based on recognized standards of practice in accordance with this Part.

3.5.6Personnel

A. The OACF shall be staffed with appropriate professional and ancillary personnel who shall be assigned duties and responsibilities which are consistent with licensure/ certification requirements, their training and experience, and services rendered. Staff performing functions requiring certification and/or licensure shall be duly licensed in Rhode Island as required by statute.

B. National criminal background checks shall be conducted in accordance with R.I. Gen. Laws §§23-17.7.1 -17 and 23-17.7.1 -20 for OACF personnel whose employment involves routine contact with a patient.

C. Each OACF shall have at least one appropriate qualified health professional staff person on duty at all times during the hours of operation when services are provided.

D. The OACF shall have a physician or dentist, as appropriate, licensed in Rhode Island, who is accessible during hours of operation.

E. An OACF shall require all persons, including students, who examine, observe, or treat a patient of such facility to wear a photo identification badge which states, in a reasonably legible manner, the first name, licensure/registration status, if any, and staff position of such person.

F. Health Screening

1. Upon hire and prior to delivering services, a pre-employment health screening shall be required for each individual who has or may have direct contact with a patient in the OACF. Such health screening shall be conducted in accordance with the rules and regulations pertaining to Immunization, Testing, and Health Screening for Health Care Workers (Part 20-15-7 of this Title).

3.5.7Rights of Patients

A. Each OACF shall observe the standards of R.I. Gen. Laws § 23-17-19.1 with respect to each patient.

B. In accordance with R.I. Gen. Laws § 23-17-19.2 each OACF shall display in a conspicuous place in the licensed OACF a copy of the "Rights of Patients" as defined in R.I. Gen. Laws § 23-17-19.1.

3.5.8Administrative Records

A. Each OACF shall maintain such administrative records as may be deemed necessary by the Department. These records shall include but not be limited to:

1. Monthly statistical summary of numbers of visits and number of patients seen;

2. An administrative record, log book or appointment book containing pertinent data such as patient's name, record number, age, sex, date and stated reason for the appointment and time of visit and the name of the provider of service; and

3. A triage plan for the screening and classification of patients to determine priority needs and to utilize staff personnel and equipment efficiently.

3.5.9Uniform Reporting System

A. Each OACF shall establish and maintain records and data in such a manner as to make uniform the system of periodic reporting. The manner in which the requirements of the regulation may be met shall be prescribed from time to time in directives promulgated by the Director.

B. Each OACF shall make available for review upon request of the Department detailed statistical data pertaining to its operation, services provided, including numbers of patients, range of problems presented and treated, and facility. Such reports and data shall be made at such intervals and by such dates as determined by the Director.

216 R.I. Code R. 216-RICR-40-10-3.5