Sec.19-13-D3. Short-term hospitals, general and special

(a) Physical plant.

(1) The hospital buildings shall be of sound construction and shall provide adequate space and equipment for patient accommodations and for service and other areas, in accordance with the requirements of the Department of Public Health. Properly equipped diagnostic and therapeutic facilities shall be provided.

(2) The hospital buildings and equipment shall meet the requirements of the most current Fire Safety Code pursuant to section 29-292 of the Connecticut General Statutes. Annually, the licensee shall submit a current certificate of inspection by the local fire marshal to the Department of Public Health.

(3) Areas in which explosive gases are used, and areas in which radioactive materials are used, shall meet the requirements of the Department of Public Health for adequate protection of patients and personnel.

(4) The hospital buildings and equipment shall be maintained in a good state of repair and shall be kept clean at all times.

(5) Each hospital that provides maternity service shall have appropriate space available and equipment for labor, delivery, recovery and post-partum care. The hospital may configure the physical space and composition of maternity service through:

(A) traditional obstetrical components (various rooms and locations used for each patient); or,

(B) labor/delivery/delivery units (birthing room with separate post-partum care); or,

(C) labor/delivery, recovery/post-partum units (single room); or,

(D) a combination of the configurations listed in subparagraphs (A) to (C) inclusive of this subdivision.

(b) Administration.

(1) The hospital shall be managed by a governing board whose duties shall include, as a minimum:

(A) Adoption of bylaws, rules and regulations, including medical staff bylaws;

(B) annual or biennial appointment of the medical staff;

(C) appointment of a competent hospital administrator who shall be qualified as a result of either (i) the completion of a Master's level or doctoral level degree and at least three years of experience in hospital management or administration, or (ii) at least five years in hospital management or administration. These requirements shall not apply to an administrator already in place as of the effective date of this regulation.

(2) The administrator shall be responsible to the governing board for the management and operation of the hospital and for the employment of personnel. The administrator may attend meetings of the governing board and meetings of the medical staff.

(3) Personnel shall be employed in sufficient numbers and of adequate qualifications that the functions of the hospital may be performed efficiently.

(c) Medical staff.

(1) There shall be an organized medical staff of not fewer than five physicians, one of whom shall serve as a chief or president of the medical staff.

(2) The medical staff shall adopt written rules and regulations governing its own activities, subject to approval by the governing board of the hospital. As a minimum, these shall include:

(A) Method of control of privileges granted to members of the medical staff;

(B) method of control of clinical work;

(C) provision for regular staff conferences;

(D) appointment of a medical executive committee, or its equivalent, and other committees as appropriate;

(E) procedure for recommending appointments to the medical staff and for hearing complaints regarding the conduct of members and referring the same, with recommendations, to the governing board.

(3) Medical staff conferences shall be held at least once each quarter, either as general medical staff meetings or through departments. Minutes and a record of attendance shall be kept for each such meeting.

(4) Each hospital shall have, as a minimum, the following departments: medicine, pathology and radiology. Hospitals may operate other departments. If surgery or obstetrics is performed in the hospital, there shall be a department of anesthesia. If a hospital operates departments in surgery, obstetrics, psychiatry, or anesthesia, each such department shall have a chief.

(A) Each chief shall be a licensed physician; responsible for supervising the overall quality of his department; and qualified on the basis of postgraduate education, equivalent training, or Board certification in the area for which the licensed physician is chief.

(B) If there is a maternity service or if there are eight hundred or more children under age twelve admitted to the hospital annually, there shall be a department of pediatrics to include on the active staff at least two physicians who have completed a residency training program approved by either the American Board of Pediatrics or the American Board of Family Medicine and one such physician shall be designated chief of that service.

(5) Psychiatric services. There shall be at least one registered nurse or licensed practical nurse with specialized psychiatric experience and training on duty at all times on the service. There shall be available a licensed clinical social worker, a registered nurse and at least one additional staff person who is qualified by education and professional discipline to assess and develop care plan interventions pertinent to the individual patient's needs.

(d) Medical records.

(1) There shall be a medical record department with adequate space, equipment and qualified personnel, including a records manager or director who possesses sufficient training and experience to oversee the medical records department.

(2) A medical record shall be started for each patient at the time of admission with complete identification data and a nurse's or other licensed practitioner's notation of condition on admission. Upon admission, an admission note and orders of the attending or admitting physician shall be added to the medical record. The medical record of every patient shall contain a complete history and physical examination which, except in emergencies, shall have been completed no more than seven days prior to admission or within forty-eight hours after admission. This requirement is satisfied if a history and physical examination was performed within thirty days prior to the admission and updated no more than seven days prior to, or within forty-eight hours after, the admission. The recording of the history and physical examination shall be, except in emergencies, placed in the record prior to any surgery and within the timeframe set forth in the hospital's policies in all other cases.

(3) All medical records shall include proper identification data; the clinical records shall be prepared accurately and completed promptly and shall include sufficient information including progress notes to justify the diagnosis and warrant the treatment; doctor's orders, nurse's notes and all entries shall be signed or initialed by the person making the entry. The medical records created or maintained by a hospital do not have to comply with the requirements of section 19a-14-40 to 19a-14-44, inclusive, of the Regulations of Connecticut State Agencies.

(4) If obstetrics is performed, a complete record of each case shall be kept which shall include such items of information as may be required by the Commissioner of Public Health and shall include all items necessary to fill out a death certificate for the mother and all items necessary to fill out a birth certificate or a death certificate for the baby.

(5) With respect to obstetrics, attending physicians shall provide to the hospital an adequate summary of the patient's office prenatal record or a copy of the prenatal record by the time of admission or, in the case of a precipitous admission, as soon as practicable thereafter.

(6) Medical records shall be filed in an accessible manner and shall be kept for a minimum of ten years after discharge of patients, except that original medical records may be destroyed sooner if they are preserved by a process consistent with current hospital industry standards. The hospital shall provide the Department of Public Health with a list of the process or processes it uses.

(7) Medical records shall be completed within thirty days after discharge of the patient except in unusual circumstances which shall be specified in the medical staff rules and regulations. One of these specified circumstances shall be that the hospital discharge summary shall be completed and shall accompany patients at the time of discharge to another health care facility. Persistent failure by a physician to maintain proper records of his patients, promptly prepared and completed, shall constitute grounds for disciplinary action with respect to medical staff privileges.

(8) Informed consent. It shall be the responsibility of each hospital to assure that the bylaws or rules and regulations of the medical staff include the requirement that, except in emergency situations, the responsible physician shall obtain proper informed consent as a prerequisite to any procedure or treatment for which it is appropriate and provide evidence of consent by a form signed by the patient or a written statement signed by the physician on the patient's hospital record. The extent of information to be supplied by the physician to the patient shall include the specific procedure or treatment, or both, the reasonably foreseeable risks, and reasonable alternatives for care or treatment.

(9) In addition to record requirements specified for general hospitals, the medical records for psychiatric patients shall also include an examination that shall be recorded not more than sixty hours after admitting the patient.

(e) Nursing service.

(1) There shall be a competent nurse, licensed in Connecticut, as director of nursing service or an equivalent position, who shall be responsible to the administrator for nursing service in the hospital.

(2) The ratio of patients to registered nurses on duty throughout the hospital shall at no time exceed twenty-five patients or fraction thereof to one registered nurse.

(3) The ratio of patients to all nursing staff, registered nurses, licensed practical nurses and other nursing attendants on duty in the hospital shall not exceed seven patients, or fraction thereof, to one from 7 a.m. to 7 p.m., and fifteen patients, or fraction thereof, to one from 7 p.m. to 7 a.m.

(4) If there is an in-patient obstetrical department, the following shall apply:

(A) The ratio of all nursing staff to patients for obstetrical services shall be no less than one nurse to each ten patients, or fraction thereof, on the 7am to 3pm shift; no less than one nurse to each fifteen patients, or fraction thereof, on the 3pm to 11pm shift; and no less than one nurse to each twenty patients, or fraction thereof, on the 11pm to 7 am shift;

(B) there shall be at least one registered nurse on duty at all times. For obstetrical services with a census of twenty or more patients, there shall also be a registered nurse on duty for overall supervision of the unit;

(C) these ratios shall be calculated without inclusion of newborns or pediatric patients.

(f) Diagnostic and therapeutic facilities. The hospital shall maintain or have available facilities, equipment and qualified personnel, under competent medical supervision, appropriate to the needs of the hospital in serving its patients. These shall include, as a minimum, a clinical laboratory, blood bank, pathological services, a radiology department and an operating room.

(g) Pharmacy.

(1) There shall be a competent pharmacist, licensed in Connecticut, who shall be responsible to the administrator for all pharmaceutical services in the hospital. In general and special hospitals of one hundred beds or more, he shall serve on a full-time basis.

(2) The hospital pharmacy shall be operated in compliance with all applicable state and federal drug laws and regulations.

(3) The premises shall be kept clean, adequately lighted, and ventilated and the equipment and facilities appropriate for compounding, dispensing, manufacturing, producing or processing of drugs shall be maintained in good order.

(4) Drugs used in the hospital shall meet standards established by the United States Pharmacopoeia, The National Formulary or the Federal Food and Drug Administration and shall be stored and kept so as to insure their proper purity and strength. A medical staff pharmacy committee in conference with the pharmacist shall formulate policies to control the administration of drugs. All drugs, disinfecting solution and other preparations shall be distinctly and correctly labeled and kept readily available in a location approved by the Commissioner of Public Health.

(h) Dietary service.

(1) Adequate space, equipment and qualified personnel shall be provided to ensure proper selection, storage, preparation and serving of regular and special diets to patients at regularly scheduled hours.

(2) Menus shall be prepared and shall meet basic nutritional needs.

(3) Methods of dishwashing and sanitizing, food handling and garbage disposal shall comply with the requirements of the Department of Public Health.

(i) General.

(1) The hospital shall have an adequate laundry service.

(2) Adequate housekeeping and maintenance services shall be provided.

(3) Proper heat, hot water, lighting and ventilation shall be maintained at all times.

(4) There shall be a system of communication sufficient to meet the needs of the hospital.

(5) Periodic licensure inspection shall be for the purpose of verifying that a hospital is in compliance with state requirements for licensure. The inspection focuses on, but is not limited to, the performance of the facility since the prior licensure inspection. Additional inspections shall be performed as necessary to address specific concerns or complaints relating to hospital performance or patient care. Any article which presents evidence of any crime being committed therein may be removed and delivered to the appropriate law enforcement official or the state agency having jurisdiction according to law.

(6) The management, personnel, equipment, facilities, sanitation and maintenance of the hospital shall be such as reasonably to ensure the health, comfort and safety of the patients at all times.

(7) When a patient appears to have ceased all vital bodily functions irreversibly, the body shall be moved promptly to an otherwise unoccupied room in the same institution pending pronouncement of death pursuant to section 7-62b of the Connecticut General Statutes. The facility shall make available a room which will provide for the dignified holding of the body of the deceased person, where it will not be exposed to the view of patients or visitors. The room so designated may be used for other purposes when not required for this purpose.

(8) Services may be furnished under contract, including but not limited to shared services.

(j) Emergencies.

(1) Provision shall be made to maintain essential services during disaster and similar emergency situations.

(2) Each general hospital shall be organized in such a way as to provide adequate care for persons with acute emergencies at all hours.

(3) In a city or town with two or more hospitals, the operation by one such hospital, under a mutual agreement, acceptable to the Connecticut Department of Public Health, of an emergency room twenty-four hours a day shall be considered satisfactory compliance with this section; in other hospitals arrangements shall be made to operate an emergency room twenty-four hours a day with a physician to be available within twenty minutes of the call to the physician.

(k) Maternity service. The following procedures shall be carried out for each case admitted to a maternity service.

(1) For each maternity patient, her attending physician shall provide to the hospital a statement of compliance with Section 19a-90 of the Connecticut General Statutes.

(2) Before removal from the delivery room, each newborn infant shall be marked using an appropriate identification method which shall remain with the child at all times while the child is in the hospital.

(3) Subject to the exceptions provided in Section 19a-219 of the Connecticut General Statutes, the physician in attendance at the birth of any infant, or the physician's designated agent, shall instill into the eyes of such infant, immediately after birth, one or two drops of a prophylactic solution approved by the Department of Public Health for the purpose of preventing inflammation of the eyes of the newborn.

(4) Any indication of postpartum maternity infection shall be reported immediately to the physician responsible for the care of the patient, and in addition, to the physician responsible for the care of the newborn infant of such maternity patient. Any obstetrical patient with any infection which may be contagious shall be isolated from other maternity patients. Any infant showing evidence of infection of any kind or any infant exposed to an infected mother shall be isolated from other infants, in a manner approved by the Commissioner of Public Health.

(l) Infection control. The hospital shall provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There shall be an active program for the surveillance, prevention, control and investigation of infections and communicable diseases.

(1) The hospital shall designate a person or persons as infection control officer(s) who is a physician, or an individual qualified in infection control through education or experience to develop and implement policies governing control of infections and communicable diseases:

(A) The infection control officer(s) shall develop a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel;

(B) The infection control officer(s) shall maintain a log of incidents related to infections and communicable diseases.

(2) The infection control officer(s), in conjunction with the hospital administrator, medical staff, and director of nursing, shall:

(A) ensure that the hospital-wide quality assurance program and training programs address problems identified by the infection control officer(s); and

(B) be responsible for the implementation of corrective action plans in identified problem areas.

(3) The infection control program shall hold monthly meetings, chaired by a physician qualified in and with a special interest in infection control to:

(A) review information obtained from day-to-day surveillance activities of the program;

(B) review and revise existing standards; and

(C) report to the medical executive committee and/or other hospital committees as appropriate about its activities.

(4) The minutes of the meetings shall document the review and evaluation of the data and the development and revision of measures for control of infection. These records shall be available to the State Department of Public Health for review.

(Effective March 19, 1987; Amended March 30, 2004; Amended August 3, 2007)