Section 553.3. Governing body responsibilities

Governing body responsibilities include:

(1) Conforming to applicable Federal, State and local law.

(2) Determining the goals and objectives of the ASF.

(3) Assuring that facilities and personnel are adequate and appropriate to carry out the goals and objectives.

(4) Establishing an organizational structure and specifying functional relationships among the various components of the ASF.

(5) Adopting bylaws or similar rules and regulations for the orderly development and management of the ASF, which:

(i) Describe the authority delegated to the person in charge and to the medical staff.

(ii) Require the governing body to review and approve the bylaws, or similar rules and regulations, of the medical staff.

(6) Adopting policies or procedures necessary for the orderly conduct of the ASF.

(7) Assuring that the quality of care is evaluated and that identified problems are appropriately addressed.

(8) Establishing personnel policies and practices which adequately support sound patient care to include the following:

(i) Require the employment of personnel with qualifications commensurate with a job’s responsibilities and authority, including appropriate licensure and certification.

(ii) Applicants for positions requiring a licensed person shall be hired only after obtaining verification of their licenses, records of education and written references.

(iii) Personnel records shall include current information relative to periodic work performance evaluations.

(iv) Compliance with Occupational Safety and Health Administration (OSHA) Universal Precautions for prevention of transmission of diseases.

(v) Written job descriptions shall exist for each type of job in the ASF.

(vi) Compliance with Federal and State regulations including, The Americans with Disabilities Act of 1990 (42 U.S.C.A. § § 12101—12213), civil rights and OSHA regulations.

(9) Reviewing legal and ethical matters concerning the ASF including the reports and disposition of unusual incidents.

(10) Maintaining effective communication throughout the ASF.

(11) Establishing a system of financial management and accountability that includes an audit appropriate for the ASF.

(12) Establishing a procedure for implementing, disseminating and enforcing a patient’s bill of rights in compliance with § 553.13 (relating to procedures for distribution).

(13) Approving major contracts or arrangements affecting the medical care provided under its auspices, including those concerning:

(i) The employment for contractual arrangements with practitioners and others providing direct patient care.

(ii) The provision of all treatment related services including, radiology, medical laboratory, pathology, anesthesia and pharmaceutical services.

(iii) The provision of care by other health care organizations.

(iv) The provision of education to students and postgraduate trainees.

(14) Formulating long-range plans in accordance with the goals and objectives of the ASF.

(15) Operating the ASF without limitation because of age, race, creed, color, sex, national origin, religion, handicap or disability.

(16) Assuring that at least one medical professional in the facility when patients are present is currently and on an ongoing basis certified in advanced cardiac life support, or its successor. If a pediatric patient is present in the facility, the certification of the medical professional shall be in advanced pediatric life support as defined in § 551.22(4) (relating to criteria for performance of ambulatory surgery on pediatric patients).

The provisions of this § 553.3 adopted January 23, 1987, effective March 25, 1987, 17 Pa.B. 376; amended July 21, 1989, effective July 22, 1989, 19 Pa.B. 3105; amended October 22, 1999, effective November 22, 1999, 29 Pa.B. 5583. Immediately preceding text appears at serial pages (247506) to (247508).