A facility shall have all of the following:

(1)           an organized governing body;

(2)           a chief executive officer;

(3)           an organized medical staff;

(4)           an organized nursing staff;

(5)           continuous medical services;

(6)           continuous nursing services;

(7)           permanent on-site facilities for the care of patients 24 hours a day;

(8)           a hospital-wide infection control program;

(9)           minimum on-site clinical provisions as follows:

(a)           appropriately equipped inpatient care areas;

(b)           nursing care units;

(c)           diagnostic and treatment areas to include on-site laboratory and imaging facilities with the capacity to provide immediate response to patient emergencies;

(d)           pharmaceutical services in compliance with the Pharmacy Laws of North Carolina;

(e)           facilities to assure the sterilization of equipment and supplies;

(f)            medical records services;

(g)           provision for social work services;

(h)           current reference sources to meet staff needs; and

(i)            nutrition services.

(10)         minimum supportive capabilities or facilities as follows:

(a)           nutrition and dietetic services;

(b)           scheduled general and preventive maintenance services for building, services and biomedical equipment;

(c)           capability for obtaining police and fire protection, emergency transportation, grounds-keeping, and snow removal;

(d)           personnel recruitment, training and continuing education;

(e)           business management capability;

(f)            short and long-range planning capability;

(g)           financial plan to provide continuity of operation under both normal and emergency conditions;

(h)           provision for patient, employee, and visitor safety; and

(i)            policies for preventive and corrective maintenance including procedures to be followed in the event of a breakdown of essential equipment.

(11)         facilities must comply with construction rules in Sections .6000 - .6200 of this Subchapter.

(12)         a risk management program as follows:

(a)           a specific staff member shall be assigned responsibility for development and administration of the program;

(b)           a written policy statement evidencing a current commitment to the risk management program together with written procedures, policies and educational programs applicable to a risk management program which are reviewed at least every three years and updated as necessary;

(c)           established lines of communication between the risk management program and other functions relating to quality of patient care, safety, and professional staff performance; and

(d)           a written report of the activities of the risk management program shall be annually submitted to the governing body.

(13)         a quality assessment and improvement program which provides:

(a)           continuous assessment and evaluation of patient care and related services in all services and departments;

(b)           a designated individual to coordinate the quality assessment and improvement program who will assist in the establishment of quality assessment and improvement plans and reporting methods for each service and department;

(c)           a committee made up of representatives of the medical and nursing staff, administration, and other services or departments as defined by the hospital to coordinate the program, meet at least quarterly and maintain minutes of the meetings and committee activities; and

(d)           for each service and department as defined by the hospital to be involved in the continuous assessment, monitoring and evaluation of patient care and related services.


History Note:        Authority G.S. 131E-75; 131E-79;

Eff. January 1, 1996;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 22, 2017.