Section 17-6 - Organization and Management (a) Governing Body. The Critical Access Hospital shall have a governing body which: - (i) Has the legal authority and responsibility to operate the facility.
- (ii) Appoints an administrator who is responsible for managing the facility.
- (iv) Adopts, revises, and approves personnel policies, including; but not limited to:
- (A) Frequency of evaluations;
- (B) Insuring confidentiality of central registry information checks.
- (v) Prepare an organizational chart that reflects the administrative control and lines of authority for the delegation of responsibility from management down to the client care level.
- (vi) The governing body shall ensure that all services provided are consistent with accepted standards of practice.
- (vii) The governing body shall be accountable for the quality of care provided to the patient.
- (viii) There shall be policies and procedures for services offered, which shall be reviewed annually by the governing body. Policies required, but not limited to:
- (A) Every patient shall be under the care of a physician or under the care of a mid-level practitioner supervised by a physician.
- (B) Whenever a patient is admitted to the facility by a mid-level practitioner, the facility's sponsoring physician shall be notified of that fact, by phone or otherwise, within twenty-four (24) hours, and a written notation of the consultation and of the physician's approval or disapproval shall be maintained in the patient's record;
- (C) A physician, a mid-level practitioner or a registered nurse shall be on duty and physically available in the facility when there are inpatient's;
- (D) When there are no inpatient's, the facility may close (i.e. be unstaffed) provided an effective system is in place to ensure that a practitioner with training and experience in emergency care is on call and available by telephone or radio twenty-four (24) hours a day; and
- (E) Patient care shall meet the provisions in Section 4.(h).
- (ix) Personnel Records.
- (A) There shall be one person designated responsible for maintaining confidentiality.
- (x) Employee Health.
- (A) Policies and procedures shall be developed for employee health, including a policy identifying communicable diseases that could put the patient population at risk.
- (xi) Services.
- (A) Furnished services, including contracted services, shall comply with all applicable licensure standards;
- (B) Medical and nursing staff shall be licensed, certified, or registered according to Wyoming laws and rules; and
- (C) Staff members shall provide health services only within the scope of his or her license, certification or registration.
048-17 Wyo. Code R. § 17-6