10A NCAC 13B .3503      FUNCTIONS

The governing body shall:

(1)           provide management, physical resources and personnel required to meet the needs of the patients for which it is licensed;

(2)           require management to establish a quality control mechanism which includes as an integral part a risk management component and an infection control program;

(3)           formulate short-range and long-range plans for the development of the facility;

(4)           conform to all applicable federal, State and local laws and regulations;

(5)           provide for the control and use of the physical and financial resources of the facility;

(6)           review the annual audit, budget and periodic reports of the financial operations of the facility;

(7)           consider the advice of the medical staff in granting and defining the scope of clinical privileges to individuals.  When the governing body does not concur in the medical staff recommendation regarding the clinical privileges of an individual, there shall be a review of the recommendation by a joint committee of the medical staff and governing body before a final decision is reached by the governing body;

(8)           require that applicants be informed of the disposition of their application for medical staff membership or clinical privileges, or both, within an established period of time after their application has been submitted;

(9)           review and approve the medical staff bylaws, rules and regulations body;

(10)         delegate to the medical staff the authority to evaluate the professional competence of staff members and applicants for staff privileges and hold the medical staff responsible for recommending initial staff appointments, reappointments and assignments or curtailments of privileges;

(11)         require that resources be made available to address the emotional and spiritual needs of patients either directly or through referral or arrangement with community agencies;

(12)         maintain effective communication with the medical staff which shall be established, through:

(a)           meetings with the Executive Committee of the Medical Staff;

(b)           service by the president of the medical staff as a member of the governing body with or without a vote;

(c)           appointment of individual medical staff members to governing body committees; or

(d)           a joint conference committee;

(13)         require the medical staff to establish controls that are designed to provide that standards of ethical professional practices are met;

(14)         provide the necessary staff support to facilitate utilization review and infection control within the facility and to support quality control, any other medical staff functions required by this Subchapter or by the facility bylaws;

(15)         meet the following disclosure requirements:

(a)           provide data required by the Division;

(b)           disclose the facility's average daily inpatient charge upon request of the Division; and

(c)           disclose the identity of persons owning 5.0 percent or more of the facility as well as the facility's officers and members of the governing body upon request;

(16)         establish a procedure for reporting the occurrence and disposition of any unusual incidents.  These procedures shall require that:

(a)           incident reports are analyzed and summarized; and

(b)           corrective action is taken as indicated by the analysis of incident reports;

(17)         in a facility with one or more units, or portions of units, however described, utilized for psychiatric or substance abuse treatment, adopt policies implementing the provisions of G.S. 122C, Article 3, and Article 5, Parts, 2, 3, 4, 5, 7, and 8;

(18)         develop arrangements for the provision of extended care and other long-term healthcare services.  Such services shall be provided in the facility or by outside resources through a transfer agreement or referrals;

(19)         provide and implement a written plan for the care or for the referral, or for both, of patients who require mental health or substance abuse services while in the hospital;

(20)         develop a conflict of interest policy which shall apply to all governing body members and corporate officers.  All governing body members shall execute a conflict of interest statement;

(21)         prohibit members of the governing body from engaging in the following forms of self-dealing:

(a)           the sale, exchange or leasing of property or services between the facility and a governing board member, his employer or an organization substantially controlled by him on a basis less favorable to the facility than that on which such property or service is made available to the general public;

(b)           furnishing of goods, services or facilities by a facility to a governing board member, unless such furnishing is made on a basis not more favorable than that on which such goods, services, or facilities are made available to the general public or employees of the facility; or

(c)           any transfer to or use by or for the benefit of a governing board member of the income or assets of a facility, except by purchase for fair market value; and

(22)         prohibit the lease, sale, or exclusive use of any facility buildings or facilities receiving a license in accordance with this Subchapter to any entity which provides medical or other health services to the facility's patients, unless there is full, complete disclosure to and approval from the Division.


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

Eff. January 1, 1996.