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Document Citation: 59A-3.2085, F.A.C.
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FLORIDA ADMINISTRATIVE CODE
TITLE 59 AGENCY FOR HEALTH CARE ADMINISTRATION
59A HEALTH FACILITY AND AGENCY LICENSING
CHAPTER 59A-3 HOSPITAL LICENSURE
Date:
08/31/2009
Document:
59A-3.2085 Department and Services.
(1) Nutritional Care. All licensed hospitals shall have a dietetic department, service or other similarly titled unit which shall be organized, directed and staffed, and integrated with other units and departments of the hospitals in a manner designed to assure the provision of appropriate nutritional care and quality food service.
(a) The dietetic department shall be directed on a full-time basis by a registered dietitian or other individual with education or specialized training and experience in food service management, who shall be responsible to the chief executive officer or his designee for the operations of the dietetic department.
(b) If the director of the dietetic department is not a registered dietitian, the hospital shall employ a registered dietitian on at least a part-time or consulting basis to supervise the nutritional aspects of patient care and assure the provision of quality nutritional care to patients. The consulting dietitian shall regularly submit reports to the chief executive officer concerning the extent of services provided.
(c) Whether employed full-time, part-time or on a consulting basis, a registered dietitian shall provide at least the following services to the hospital on the premises on a regularly scheduled basis:
1. Liaison with administration, medical and nursing staffs;
2. Patient and family counseling as needed;
3. Approval of menus and modified diets;
4. Required nutritional assessments;
5. Participation in development of policies, procedures and continuing education programs; and
6. Evaluation of dietetic services.
(d) At least annually, a registered dietitian shall conduct a review and evaluation of the dietetic department to include:
1. A review of menus for nutritional adequacy;
2. A review of tray identification methods, patients who are not receiving oral intake, and the elapsed time between the evening meal and the next substantial meal;
3. A review of the counseling and instruction given to patients and their families with special dietary needs;
4. A review of committee activities concerning nutritional care; and
5. A review of the appearance, palatability, serving temperature, patient acceptability and choice, and retention of nutrient value of food served by the dietetic department.
(e) Nothing in this section shall prevent a hospital from employing an outside food management company for the provision of dietetic services, provided the requirements of this section are met, and the contract specifies this compliance.
(f) The dietetic department, service or other similarly titled unit shall employ sufficient qualified personnel under competent supervision to meet the dietary needs of patients.
(g) Personnel in the dietetic department shall receive, as appropriate to their level of responsibility, instruction in:
1. Personal hygiene and infection control;
2. Food handling, preparation, serving and storage; cleaning and safe operation of equipment;
3. Waste disposal;
4. Portion control;
5. Diet instruction; and
6. The writing of modified diets and the recording of pertinent dietetic information in the patient's medical record.
(h) Personnel in the dietetic department shall receive at least quarterly in-service training of which a record shall be kept by the dietetic department.
(i) The dietetic department, service or other similarly titled unit shall be guided by written policies and procedures that cover food procurement, preparation and service. Dietetic department policies and procedures shall be developed by the director of the dietetic department with nutritional care policies and procedures developed by a registered dietitian, shall be subject to annual review, revised as necessary, dated to indicate the time of last review, and enforced. Written dietetic policies shall include at least the following:
1. A description of food purchasing, storage, inventory, preparation, service, and disposal policies and procedures.
2. A requirement that diet orders be recorded in the patient's medical record by an authorized individual before the diet is served to the patient.
3. The proper use and adherence to standards for nutritional care as specified in the diet manual which is at least in accordance with the Recommended Dietary Allowances (1989) of the Food and Nutrition Board, National Research Council and National Academy of Sciences.
4. A requirement for patients who are on oral intake and do not have specific dietary requirements, that at least three meals or their equivalent be provided daily, with not more than a 15 hour span between the evening meal and breakfast.
5. A requirement that temperatures for holding and serving cold foods be below 45 degrees F, and for hot foods be above 140 degrees F.
6. A requirement that a supply of non-perishable foods sufficient to serve a hospital's patients for at least a one week period be available.
7. A requirement that written reports of sanitary inspections be kept on file, with a record of actions undertaken to comply with recommendations.
8. A description of the role of the dietetic department in the hospital's internal and external disaster plans.
9. Menus.
10. The role of the dietetic department in the preparation, storage, distribution and administration of enteric feeding, tube feeding and total parenteral nutrition programs.
11. Alterations in diets or diet schedules, including the provision of food service to patients who do not receive regular meal service.
12. Ancillary dietetic services, as appropriate, including food storage and kitchens on patient care units, formula supply, cafeterias, vending operations and ice making.
13. Personal hygiene and health of dietetic personnel.
14. A description of dietetic department policies and procedures designed to provide for infection control including a monitoring system to assure that dietetic personnel are free from communicable infections and open skin lesions.
15. A description of the identification system used for patient trays and other methods for assuring that each patient receives the appropriate diet as ordered.
16. Safety practices, including the control of electrical, flammable, mechanical, and as appropriate, radiation hazards.
17. Compliance with Chapter 64E-11, F.A.C.
(j) The dietetic department shall be designed and equipped to facilitate the safe, sanitary, and timely provision of food service to meet the nutritional needs of patients.
(k) The dietetic department shall have adequate equipment and facilities to prepare and distribute food, protect food from contamination and spoilage, to store foods under sanitary and secure conditions, and to provide adequate lighting, ventilation and humidity control.
(l) The dietetic department shall thoroughly cleanse and sanitize food contact surfaces, utensils, dishes and equipment between periods of use, shall ensure that adequate toilet, hand-washing and hand-drying facilities are conveniently available, and provide for adequate dishwashing and utensil washing equipment that prevent recontamination and are apart from food preparation areas.
(m) The dietetic department shall ensure that all walk-in refrigerators and freezers can be opened from inside and that all food and nonfood supplies are clearly labeled. Where stored in the same refrigerator, all nonfood supplies and specimens shall be stored on separate shelves from food supplies.
(n) The dietetic department shall implement methods to prevent contamination in the making, storage, and dispensing of ice.
(o) The dietetic department shall ensure that disposable containers and utensils are discarded after one use, and that worn or damaged dishes and glassware are discarded.
(p) The dietetic department shall hold, transfer, and dispose of garbage in a manner which does not create a nuisance or breeding place for pests or otherwise permit the transmission of disease.
(q) All matters pertaining to food service shall comply with Chapter 64E-11, F.A.C. Information on specifications, operation and maintenance of all major and fixed dietetic department equipment shall be maintained. A preventive and corrective maintenance program on such equipment shall be conducted and recorded.
(r) Dietetic services shall be provided in accordance with written orders by the individual responsible for the patient and appropriate information shall be recorded in the patient's medical record. Such information shall include:
1. A summary of the dietary history and a nutritional assessment when the past dietary pattern is known to have a bearing on the patient's condition;
2. Timely and periodic assessments of the patient's nutrient intake and tolerance to the prescribed diet modification, including the effect of the patient's appetite and food habits on food intake and any substitutions made;
3. A description or copy of diet information forwarded to another organization when a patient is discharged.
(s) Within 24 hours of admission and within 24 hours of any subsequent orders for diet modification, the diet order shall be confirmed by the practitioner responsible for the patient receiving oral alimentation.
(t) Each hospital shall establish appropriate quality control mechanisms to assure that:
1. All menus are evaluated for nutritional adequacy.
2. There is a means for identifying those patients who are not receiving oral intake.
3. Special diets are monitored.
4. The nutritional intake of patients is assessed and recorded as appropriate.
5. Effort is made to assure appetizing appearance, palatability, proper serving temperature, and retention of nutritional value of food.
6. Whenever possible, patient food preferences are respected and appropriate dietary substitutions are made available.
7. Surveys of patient acceptance of food are conducted, particularly for long-stay patients.
(2) Pharmacy. Each hospital shall develop and monitor procedures to assure the proper use of medications. Such procedures shall address prescription and ordering, preparation and dispensing, administration, and patient monitoring for medication effects. For purposes of providing medication services, each Class I and Class II hospital shall have on the premises, and each Class III hospital shall have on the premises or by contract, a pharmacy, pharmaceutical department or service, or similarly titled unit, and, when applicable, shall present evidence that it holds a current institutional or community pharmacy permit under the provisions of the Florida Pharmacy Act, Chapter 465, F.S.
(a) Each hospital shall maintain a hospital formulary or drug list which is developed and maintained by appropriate hospital staff, which shall be regularly updated. The formulary shall include the availability of non-legend medications, but does not preclude the use of unlisted drugs. Where unlisted drugs are used, there shall be a written policy and procedure for their prescription and procurement. Selection of medications for inclusion on the formulary shall be based on need, effectiveness, risks, and costs.
(b) Each hospital shall ensure that individuals who prescribe or order medications are legally authorized through the granting of clinical privileges.
(c) All drugs shall be prepared and stored under proper conditions of sanitation, temperature, light, moisture, ventilation, security and segregation to promote patient safety and proper utilization and efficacy.
(d) All medications shall be appropriately labeled as to applicable accessory or cautionary statements and their expiration date, shall be dispensed in as ready-to-administer forms as possible, and in quantities consistent with the patient's needs which are designed to ensure minimization of errors and diversion.
(e) The pharmacist shall review each order before dispensing the medication, with the exception of situations in which a licensed independent practitioner with appropriate clinical privileges controls prescription ordering, preparation and administration of medicine. The pharmacist shall verify the order with the prescriber when there is a question.
(f) All medications shall be prepared and dispensed consistent with applicable law and rules governing professional licensure and pharmacy operation and in accordance with professional standards of pharmacy practice.
(g) A medication profile shall be developed and maintained by the pharmacy department for each patient and shall be available to staff responsible for the patient's care. The medication profile shall include at least the name, birth date, sex, pertinent health problems and diagnoses, current medication therapy, medication allergies or sensitivities, and potential drug or food interactions.
(h) The hospital shall develop and implement a process for providing medications when the pharmacy is closed that ensures adequate control, accountability, and the appropriate use of medications.
(i) The hospital shall ensure there is an adequate and proper supply of emergency drugs within the pharmacy and in designated areas of the hospital.
(j) Receipt, distribution and administration of controlled drugs are documented by the pharmacy, nursing service and other personnel, to ensure adequate control and accountability in accordance with state and federal law.
(k) The hospital shall ensure that the administration of drugs shall take place in accordance with written policies, approved by the professional staff and designed to ensure that all medications are administered safely and efficiently.
(l) Each hospital's pharmacy shall be directed by a licensed pharmacist, who may supervise satellite pharmacies, and who may be hired on a contract basis. The director of the hospital pharmacy, or other licensed pharmacists who are properly designated, shall be available to the hospital at all times, whether on duty or on call.
(m) Administration of drugs shall be undertaken only upon the orders of authorized members of the professional staff, where the orders are verified before administration, the patient is identified, and the dosage and medication is noted in the patient's chart or medical record.
(n) Investigational medications shall be used only in accordance with specific hospital policy which addresses:
1. Review and approval of hospital participation in investigational studies by the appropriate hospital committee;
2. Requirements for informed consent by the patient;
3. Administration in accordance with an approved protocol;
4. Administration by personnel approved by the principal investigator after they have received information and demonstrated an understanding of the basic pharmacologic information about the medications; and
5. Documentation of doses dispensed, administered and destroyed.
(o) Each hospital shall have a system for the ongoing monitoring of each patient for medication effectiveness and actual or potential adverse effects or toxicity which includes:
1. A collaborative assessment of the effect of the medication on the patient based on observation and information gathered and maintained in the patient's medical record and medication profile;
2. A process for the definition, identification, and review of significant medication errors and adverse drug reactions are reported in a timely manner in accordance with written procedures. Significant adverse drug reactions shall be reported promptly to the Food and Drug Administration;
3. Information from the medication monitoring is used to assess the continued administration of the medication;
4. Conclusions and findings of the medication monitoring are communicated to the appropriate health care personnel involved in the patient's care.
(p) Each hospital shall have written policies and procedures governing the selection, procurement, distribution, administration, and record-keeping of all drugs, including provision for maintaining patient confidentiality. The policies and procedures shall be reviewed at least annually, dated to indicate time of last review, revised as necessary, and enforced.
(q) Parenteral nutrition services, when provided, shall be designed, implemented, and maintained to address assessment and reassessment of the patient, initial ordering and ongoing maintenance of medication orders, preparation and dispensing, administration, and assessing the effects on the patient.
(3) Surgical Department. Each Class I and Class II hospital, and each Class III hospital providing operative and other invasive procedures, shall be organized under written policies and procedures regarding surgical privileges, maintenance of the operating rooms, and evaluation and recording of treatment of the patient. All surgical department policies and procedures shall be available to the AHCA, shall be reviewed annually, dated to indicate time of last review, revised as necessary, and enforced. These procedures shall require:
(a) The determination of the appropriateness of the procedure for a patient to be based on:
1. The patient's medical, anesthetic, and drug history;
2. The patient's physical status;
3. Diagnostic data;
4. The risks and benefits of the procedure; and
5. The need to administer blood or blood components.
(b) The risks and benefits of the procedure are discussed with the patient prior to documenting informed consent and includes alternative options, if they exist, the need and risk of blood transfusions and available alternatives, and anesthesia options and risks.
(c) A preanesthesia evaluation of the patient shall be performed prior to surgery, except in the case of extreme emergency.
(d) Plans of care for the patient are formulated and documented in the medical record prior to the performance of surgery and shall include a plan for anesthesia, nursing care, the operative or invasive procedure, and the level of post-procedure care.
(e) The measurement of the patient's physiological status is assessed during the administration of anesthesia and the surgical procedure.
(f) The post-procedure status of the patient is assessed on admission to the recovery area and prior to discharge from the recovery area.
(g) The patient is discharged by a qualified practitioner.
(h) Each hospital's surgical department shall be organized functionally and physically as a distinct entity within the hospital. The operating room and accessory services shall be located in a manner to prevent through traffic, control traffic in and out, and maximize infection control.
(i) Each hospital shall designate a physician as medical advisor to the surgical department and a registered nurse to direct nursing services within the operating rooms of a surgical department.
(j) Each hospital shall document that all surgical nursing staff have received at least annual continuing education in safety, infection control and cardiopulmonary resuscitation.
(k) Each hospital shall maintain a roster of physicians specifying the surgical privileges of each, shall review the roster annually and revise it as necessary.
(l) A roster of "on-call" surgeons shall be promptly available at the operating room nursing stations.
(m) Each hospital's surgical department shall maintain a record on a current basis that contains at least the following information:
1. Patient's name;
2. Hospital number;
3. Preoperative diagnosis;
4. Post-operative diagnosis;
5. Procedure;
6. Names of surgeon, first assistant, and anesthetist;
7. Type of anesthetic; and
8. Complications, if any.
(n) Regardless of whether surgery is classified as major or minor, each hospital shall ensure, prior to any surgery being performed, except in emergency situations:
1. That there is a complete history and physical workup in the chart of every patient or, if such has been transcribed, but not yet recorded in the patient's chart, that there is a statement to that effect and an admission noted by the physician in the chart; and
2. That there is evidence of informed consent for the operation in the patient's chart.
(o) Each hospital shall ensure that immediately following each surgery, there is an operative report describing techniques and findings that is written or dictated and signed by the surgeon.
(p) The following minimum equipment shall be in each operating room suite:
1. Call-in system;
2. Oxygen, and means of administration;
3. Mechanical ventilatory assistance equipment, including airways, manual breathing bag, and ventilator and respirator;
4. Cardiac defibrillator with synchronization capability;
5. Respiratory and cardiac monitoring equipment;
6. Thoracentesis and closed thoracostomy sets;
7. Tracheostomy set, tourniquets, vascular cutdown sets, infusion pumps, laryngoscopes and endotracheal tubes;
8. Tracheobronchial and gastric suction equipment; and
9. A portable x-ray which shall be available, but need not be physically present in the operating suite.
(q) All infections of clean surgical cases shall be recorded and reported to the appropriate infections control authority, and a procedure shall exist for the investigation of such cases.
(r) A roster of "on-call" surgeons shall be promptly available at the operating room nursing stations.
(s) An on-call surgeon must be promptly available to the hospital when a call for services has been placed.
(4) Anesthesia Department. Each Class I and Class II hospital, and each Class III hospital providing surgical or obstetrical services, shall have an anesthesia department, service or similarly titled unit directed by a physician member of the organized professional staff.
(a) The anesthesia department of each hospital shall have written policies and procedures that are approved by the organized medical staff, are reviewed annually, dated at time of last review, revised, and enforced as necessary. Such written policies and procedures shall include at least the following requirements:
1. A preanesthesia evaluation of the patient by the physician, or qualified oral surgeon in the case of patients without medical problems admitted for dental procedures, or certified registered nurse anesthetist where authorized by established protocol approved by the medical staff, except in the case of emergencies.
2. A review of the patient's condition immediately prior to induction of anesthesia.
3. A mechanism for release of patients from postanesthesia care.
4. A recording of all pertinent events taking place during the induction of, maintenance of, and emergence from anesthesia.
5. Guidelines for the safe use of all general anesthetic agents used in the hospital.
(b) The responsibilities and qualifications of all anesthesia personnel, including physician, nurse and dentist anesthetists and all trainees, must be defined in a policy statement, job description, or other appropriate document.
(c) Anesthetic safety regulations shall be developed, posted, and enforced. Such regulations shall include at least the following:
1. A requirement that all operating room electrical and anesthesia equipment be inspected on no less than a semi-annual basis, and that a written record of the results and corrective action be maintained.
2. A requirement that flammable anesthetic agents be employed only in areas in which a conductive pathway can be maintained between the patient and a conductive floor.
3. A requirement that each anesthetic gas machine have a pin-index or equivalent safety system.
4. A requirement that all reusable anesthesia equipment coming in direct contact with the patient be cleaned or sterilized in the manner prescribed by current medical standards.
(5) Nursing Service. Each hospital shall be organized and staffed to provide quality nursing care to each patient. Where a hospital's organizational structure does not have a nursing department or service, it shall document the organizational steps it has taken to assure that oversight of the quality of nursing care provided to each patient is accomplished.
(a) Each hospital shall document the relationship of the nursing department to other units of the hospital by an organizational chart, and each nursing department shall have a written organizational plan that delineates lines of authority, accountability and communication. The nursing department shall assure that the following nursing management functions are fulfilled:
1. Review and approval of policies and procedures that relate to qualifications and employment of nurses.
2. Establishment of standards for nursing care and mechanisms for evaluating such care.
3. Implementing approved policies of the nursing department.
4. Assuring that a written evaluation is made of the performance of registered nurses and ancillary nursing personnel at the end of any probationary period and at a defined interval thereafter.
5. Each hospital shall employ a registered nurse on a full time basis who shall have the authority and responsibility for managing nursing services and taking all reasonable steps to assure that a uniformly optimal level of nursing care is provided throughout the hospital.
(b) The registered nurse shall be responsible for ensuring that a review and evaluation of the quality and appropriateness of nursing care is accomplished. The review and evaluation shall be based on written criteria, shall be performed at least quarterly, and shall examine the provision of nursing care and its effect on patients.
(c) The registered nurse shall ensure that education and training programs for nursing personnel are available and are designed to augment nurses' knowledge of pertinent new developments in patient care and maintain current competence. Cardiopulmonary resuscitation training shall be conducted as often as necessary, but not less than annually, for all nursing staff members who cannot otherwise document their competence.
(d) Each hospital shall develop written standards of nursing practice and related policies and procedures to define and describe the scope and conduct of patient care provided by the nursing staff. These policies and procedures shall be reviewed at least annually, revised as necessary, dated to indicate the time of the last review, signed by the responsible reviewing authority, and enforced.
(e) The nursing process of assessment, planning, intervention and evaluation shall be documented for each hospitalized patient from admission through discharge.
1. Each patient's nursing needs shall be assessed by a registered nurse at the time of admission or within the period established by each facility's policy.
2. Nursing goals shall be consistent with the therapy prescribed by the responsible medical practitioner.
3. Nursing intervention and patient response, and patient status on discharge from the hospital, must be noted on the medical record.
(f) A sufficient number of qualified registered nurses shall be on duty at all times to give patients the nursing care that requires the judgment and specialized skills of a registered nurse, and shall be sufficient to ensure immediate availability of a registered nurse for bedside care of any patient when needed, to assure prompt recognition of an untoward change in a patient's condition, and to facilitate appropriate intervention by nursing, medical or other hospital staff members.
(g) Each Class I and Class II hospital shall have at least one licensed registered nurse on duty at all times on each floor or similarly titled part of the hospital for rendering patient care services.
(h) Each hospital shall maintain a list of licensed personnel, including private duty and per diem nurses, with each individual's current license number, and documentation of the nurses' hours of employment, and unit of employment within the hospital.
(6) Housekeeping Services. Each hospital shall have an organized housekeeping department with a qualified person designated as responsible for all housekeeping functions. The designated supervisor of housekeeping shall be responsible for developing written policies and procedures for coordinating housekeeping services with other departments, developing a work plan and assignments for housekeeping staff, and developing a plan for obtaining relief housekeeping personnel.
(a) Each hospital shall employ a sufficient number of housekeeping personnel to fulfill the responsibilities of the housekeeping department seven days a week.
(b) When housekeeping services are provided by a third party, the hospital shall have a formal written agreement with the third party provider on file.
(c) Each hospital shall develop, implement, and maintain an effective housekeeping plan to ensure that the facility is maintained in compliance with the following:
1. The facility and its contents shall be kept free from dust, dirt, debris, and noxious odors;
2. All rooms and corridors shall be maintained in a clean, safe, and orderly condition, and shall be properly ventilated to prevent condensation, mold growth, and noxious odors;
3. All walls and ceilings, including doors, windows, skylights, screens, and similar closures shall be kept clean;
4. All mattresses, pillows, and other bedding; window coverings, including curtains, blinds, and shades, cubicle curtains and privacy screens; and furniture shall be kept clean;
5. Floors shall be kept clean and free from spillage, and non-skid wax shall be used on all waxed floors;
6. Articles in storage shall be elevated from the floor;
7. Aisles in storage areas shall be kept unobstructed;
8. All garbage and refuse from patient areas shall be collected daily and stored in a manner to make it inaccessible to insects and rodents;
9. Garbage or refuse storage rooms, if used, shall be kept clean, shall be vermin-proof, and shall be large enough to store the garbage and refuse containers that accumulate. Outside garbage or refuse storage areas or enclosures shall be large enough to store the garbage and refuse containers that accumulate, and shall be kept clean. Outside storage of unprotected plastic bags, wet strength paper bags, or baled units containing garbage or refuse is prohibited. Garbage and refuse containers, dumpsters, and compactor systems located outside shall be stored on or above a smooth surface of non-absorbent material, such as concrete or machine-laid asphalt, that is kept clean and maintained in good repair; and
10. Garbage and refuse shall be removed from both interior and outside storage areas as often as necessary to prevent sanitary nuisance conditions. If garbage and refuse are disposed of on the facility premises, the method of disposal shall not create a sanitary nuisance and shall comply with the provisions of Chapter 17-7, F.A.C.
(d) Each hospital shall ensure that:
1. There is a sufficient quantity of linen, including at least sheets, pillow cases, drawsheets or their alternative, blankets, towels and washcloths to provide comfortable, clean and sanitary conditions for each patient at all times;
2. Written policies and procedures for linen and laundry services, including methods of collection, storage, and transportation are developed, implemented, and maintained in conjunction with the policies and procedures developed by the infection control committee;
3. Soiled linen and laundry are collected in a way that minimizes microbial dissemination into the environment;
4. Separate containers are used for transporting clean linen and laundry, and soiled linen and laundry;
5. Soiled linen and laundry are stored in a ventilated area separate from any other supplies, and are not stored, sorted, rinsed, or laundered in patient rooms, bathrooms, areas of food preparation or storage, or areas in which clean material and equipment are stored; and
6. When linen and laundry services are provided by a third party, the third party provider shall be required to maintain at least the standards contained herein, and shall ensure that clean linen is packaged and protected from contamination until received by the facility.
(e) Effective control methods shall be employed to protect against the entrance into the facility and the breeding or presence on the premises of flies, roaches, rodents, and other vermin. Use of pesticides shall be in accordance with Chapter 5E-14, Part No. 1, F.A.C.
(f) Each hospital shall develop and implement, in coordination with the infection control committee, written procedures for the cleaning of the physical plant, equipment, and reusable supplies. Such procedures shall include:
1. Special written procedures for cleaning all infectious disease areas;
2. Special written procedures for cleaning all operating room suites, delivery suites, nurseries, intensive and other critical care units, the emergency suite, and other areas performing similar functions; and
3. Special written procedures for the separate handling and storage of both clean and dirty linen, with special attention being given to identification, separation and handling of linens from isolation or infectious disease areas.
(7) Ambulatory Care Services. Each hospital offering ambulatory care services under it's hospital license shall establish policies and procedures to ensure that quality care based on the needs of the patient will be delivered at all times.
(a) Ambulatory care services shall be under the direction of a licensed physician(s) responsible for the clinical direction of patient care and treatment services, and whose qualifications, authority, and responsibilities are defined in writing as approved by the governing body.
(b) Ambulatory care services shall be staffed with appropriately trained and qualified individuals to provide the scope of services anticipated to meet the needs of the patients.
(c) Each patient's general medical condition shall be managed by a physician with appropriate clinical privileges, as determined by medical staff bylaws.
(d) When any ambulatory care services are provided by non-hospital employees, the provider shall meet all safety requirements, abide by all pertinent rules and regulations of the hospital and medical staff, and document the quality improvement measures to be implemented.
(e) The provisions of ambulatory nursing care shall be supervised by a registered nurse who is qualified by relevant training and experience in ambulatory care.
(f) Sufficient personnel shall be on duty to provide efficient and effective patient care services.
(g) The scope of services offered, and the relationship of the ambulatory services program to other hospital units, as well as all supervisory relationships within the program, shall be defined in writing, and must be provided in accordance with the standards set by the governing body's bylaws and the rules and regulations of the medical staff.
(h) Written policies and procedures to guide the operation of the ambulatory services program shall be developed, reviewed, and revised as necessary, dated to indicate the time of last revision, and enforced.
(i) A medical record must be maintained on every patient who receives ambulatory care services. Medical records shall be managed and maintained in accordance with acceptable professional standards and practices. Confidentiality and disclosure of patient information contained in the health record must be maintained in accordance with hospital policy and state and federal law. Each patient's medical record must include at a minimum, the following information, and be updated as necessary:
1. Patient identification;
2. Relevant history of the illness or injury and of physical findings;
3. Diagnostic and therapeutic orders;
4. Clinical observations, including the results of treatment;
5. Reports of procedures and tests, and their results;
6. Diagnosis or impression;
7. Allergies;
8. Referrals to practitioners or providers of services internal or external to the hospital;
9. Communications to and from practitioners or providers of service external to the hospital;
10. Growth charts for children and adolescents as needed when the service is the source of primary care; and
11. Immunization status of children and adolescents and others as determined by law and/or hospital policy.
(j) To facilitate the ongoing provision of care, a problem list of known significant diagnoses, conditions, procedures, drug allergies and medications shall be maintained for each patient who receives ambulatory services. The problem list shall be initiated no later than the third visit and include items based on any initial medical history and physical examination, and updated on subsequent visits with additional information as necessary. The problem list shall include at least the following items:
1. Known significant medical diagnoses and conditions;
2. Known significant surgical and invasive procedures;
3. Known adverse and allergic reactions to drugs; and
4. Medications known to be prescribed for and/or used by the patient.
(8) Obstetrical Department. If provided, obstetrical services shall include labor, delivery, and nursery facilities, and be formally organized and operated to provide complete and effective care for each patient.
(a) Except in hospitals licensed for 75 beds or less, the obstetrical service shall be separated from other patient care rooms and shall have separate nursing staff. When obstetrical services are provided in hospitals of 75 beds or less, there shall be:
1. A written and enforced policy concerning the placement of obstetrical patients in a manner most conducive to meet their special needs, and
2. A demonstration by the hospital that its nursing staff possesses specialized skills in obstetrics and pediatrics, whether by training or by obstetrical experience, and can provide service to obstetrical patients and their infants on a 24 hour basis, whether on duty, on call, or on a consultative basis.
(b) In those hospitals with a formally organized obstetrical department, clean gynecological and surgical patients may be admitted to the unit under specific written controls approved by the medical staff and governing authority when there is a written demonstrated need in each case.
(c) Every infant born in a hospital shall be properly identified immediately at the time of birth. Identification of the infant shall be done in the delivery room, birthing room, or other place of birth within the hospital, before either the mother or the infant is transferred to another part of the facility.
(9) Laboratories and Pathology Services. Clinical Laboratory-Every hospital must provide on the premises or by contract with a laboratory licensed under Chapter 483, Part I, F.S., a clinical laboratory to provide those services commensurate with the hospital's needs and which conforms to the provisions of Chapter 483, Part I, F.S., and Chapter 59A-7, F.A.C.
(a) Provisions shall be made to carry out clinical laboratory examinations, including routine chemistry, microbiology, hematology, general immunology, and urinalysis.
(b) Provision shall be made for assuring the availability of emergency laboratory services. Such services shall be available 24 hours a day, seven days a week, including holidays.
(c) Reports of all examinations shall be filed with the patient's record.
(d) Pathology Laboratory-Each hospital shall provide on the premises or by contract with a laboratory licensed under Chapter 483, Part I, F.S., pathology laboratory services commensurate with hospital's needs and which conforms with the provisions of Chapter 483, Part I, F.S., and Chapter 59A-7, F.A.C.
(e) All specimens removed in operations shall be sent to a pathologist for examination, except when another suitable means of verification of removal is routinely employed, when there is an authenticated report to document the removal, and when quality of care will not be compromised by the exception. Hospitals may establish a policy for excepting certain categories of specimens from examination when it determines quality of care will not be compromised or examination will yield no useful information. Signed reports on all specimens removed in an operation, whether documented by a pathologist or through an alternative means, shall be filed with the patient's record.
(f) If the hospital does not maintain a pathology laboratory there shall be policy established and enforced, which meets the provisions of paragraph (a).
(g) Blood Bank Services-Each hospital shall either maintain on the premises, or by contract have convenient access to, a blood banking service which is under the control and supervision of a pathologist or other authorized physician to perform those services commensurate with the facility's needs, and ensure that the laboratory is licensed under the provisions of Chapter 483, Part I, F.S., and Chapter 59A-7, F.A.C.
(h) Records shall be kept on file indicating the receipt and disposition of all blood provided to patients in the facility.
(i) All Class I and Class II hospitals, and all Class III hospitals utilizing blood and blood by-products, shall:
1. Maintain facilities for procurement, safekeeping and transfusion of blood and blood products, or have them readily available;
2. Maintain a temperature alarm system for blood storage facilities, where applicable, which is tested and inspected quarterly and is otherwise safe.
3. The alarm system must be audible, and must monitor proper blood and blood product storage temperature over a 24-hour period.
4. Tests of the alarm system must be documented.
5. If blood is stored or maintained for transfusion outside of a monitored refrigerator, the laboratory must ensure and document that storage conditions, including temperature, are appropriate to prevent deterioration of the blood or blood product.
6. Promptly dispose of blood which has exceeded its expiration date.
(j) Class III hospitals not utilizing blood and blood by-products need not maintain blood storage facilities.
(10) Radiology Services. Each Class I and Class II hospital shall provide on the premises, and each Class III hospital shall provide on the premises or by contract, diagnostic imaging facilities according to the needs of the hospital and conform to Chapter 404, F.S., Chapter 64E-5, F.A.C., Part IV, Chapter 468, F.S., and Chapter 64E-3, F.A.C.
(a) The radiology department or other similarly titled part shall be maintained free of hazards for patients and personnel.
(b) Each hospital shall have a radiologist either full time or part time on a consulting basis to discharge professional radiology services.
(c) Each hospital shall have certified radiologic technologists or basic x-ray machine operator in hospitals of 150 beds or less, and shall be on duty or on call at all times, pursuant to Part IV, Chapter 468, F.S.; and Chapter 64E-3, F.A.C.
(d) The use of all diagnostic imaging apparatus shall be limited to personnel designated as specified in Part IV, Chapter 468, F.S., and Chapter 64E-3, F.A.C.
(e) The credentials of each person providing diagnostic and therapeutic radiation, imaging and nuclear medicine services, including formal training, on-the-job experience, and certification or licensure where applicable, shall be maintained on file at all times.
(f) Each hospital shall maintain and enforce policies and procedures for the provision of all diagnostic and therapeutic radiation, imaging, and nuclear medicine services, and ensure compliance with the requirements of Chapter 64E-5, F.A.C. Such policies and procedures shall be written, reviewed annually, and revised as necessary in conformance with Chapter 64E-5, F.A.C., and shall be dated as to time of last review.
(g) Each hospital shall require that all diagnostic and therapeutic radiology, imaging or nuclear medicine services be performed only upon written order of a licensed physician. The request and all results must be recorded in the patient's medical record;
(h) Each hospital shall ensure documentation, and reporting to the Bureau of Radiation Control of the Department of Health of all misadministration of radioactive materials, as those terms are defined by Chapter 64E-5, F.A.C.
(i) Each hospital shall maintain and document in writing a quality control program designed to minimize the unnecessary duplication of radiographic studies, to minimize exposure time of patients and personnel, and to maximize the quality of diagnostic information and therapy provided.
(11) Respiratory Therapy. Each hospital shall have written policies and procedures describing the scope of diagnostic and therapeutic respiratory services provided to patients of the hospital. This document shall contain written guidelines for the transfer or referral of patients requiring respiratory care services not provided at the hospital.
(a) When respiratory care services are provided outside the hospital, the hospital shall ensure by contract or other enforceable mechanism that such services meet all safety requirements and quality control measures required by the hospital.
(b) Respiratory care services provided within a hospital shall have medical direction provided by a physician member of the organized medical staff with special interest and knowledge in the management of acute and chronic respiratory problems. The physician director shall be responsible for the overall direction of respiratory services, for conducting a review of the quality, safety and appropriateness of respiratory care services at least quarterly, and shall be available for any required respiratory care consultation.
(c) Respiratory care services in a hospital may be supervised by a technical director who is registered or certified by the National Board of Respiratory Care Inc., or has the documented equivalent education, training and experience. Other respiratory care personnel shall provide respiratory care commensurate with their documented training, experience, and competence.
(d) The formal training of respiratory therapy students shall be carried out only in programs accredited by appropriate professional educational organizations. Individuals in student status shall be directly supervised when engaged in patient care activities.
(e) The education, training and experience of personnel who provide respiratory care services shall be documented, and shall be related to each individual's level of participation in the provision of respiratory care services.
(f) Nonphysician respiratory care personnel shall not perform patient procedures associated with a potential hazard, including arterial puncture for obtaining blood samples, unless authorized in writing by the physician director of the respiratory care service acting in accordance with professional staff policy.
(g) All personnel providing respiratory care services shall participate in relevant in-service education programs. Such participation shall occur at least annually, and shall include instruction in safety, infection control, and cardiopulmonary resuscitation, except for individuals who can otherwise demonstrate their competence.
(h) There shall be written policies and procedures specifying the scope and conduct of patient care rendered in the provision of respiratory care services. All policies and procedures must be approved by the physician director, reviewed at least annually, revised as necessary, dated to indicate the time of last review, and enforced. Respiratory care policies shall include at least the following:
1. Specification as to who may perform specific procedures and provide instruction, under what circumstances, and under what degree of supervision.
2. Assembly and sequential operation of equipment and accessories to implement therapeutic regimes.
3. Steps to be taken in the event of adverse reactions, and other emergencies.
4. Procurement, handling, storage and dispensing of therapeutic gases.
5. Infection control measures, including specifics as to changing and cleansing of equipment.
6. Administration of medications in accordance with the physician's order.
(i) The respiratory care service shall have sufficient equipment and facilities to assure the safe, effective and timely provision of respiratory care service to patients.
1. All equipment shall be calibrated and operated according to manufacturer's specifications, and shall be periodically inspected and maintained.
2. Where piped-in gas is used, an evaluation shall be made prior to use to assure identification of the gas and its delivery within an established safe pressure range.
3. Ventilators used for continuous assistance or controlled breathing shall have operative alarm systems at all times.
(j) Prescriptions for respiratory care shall specify the type, frequency and duration of treatment and, as appropriate, the type and dose of medication, the type of dilutent, and the oxygen concentration, and shall be incorporated into the patient's medical record.
(12) Special Care Units. The hospital shall ensure that a special care unit is a physically and functionally distinct entity within the hospital, has controlled access, and has an effective means of isolation for patients suffering from communicable or infectious disease or acute mental disorder. Special care units shall provide:
(a) Direct or indirect visual observation by unit staff of all patients from one or more vantage points;
(b) A direct intercommunication or alarm system between the nurse's station and the bedside; and
(c) Beds that are adjustable to positions required by the patient, that are easily movable, and that have a locking or stabilizing mechanism to attain a secure, stationary position. Headboards, when present, shall be removable or adjustable to permit ready access to the patient's head.
(d) Each special care unit shall be advised by a physician who is a member of the organized medical staff, shall have its relationship to other departments and units of the hospital specified in writing (organizational chart), and shall provide relevant in-service education programs to all staff including, but not limited to, annual education concerning cardiopulmonary resuscitation and safety and infection control requirements.
(e) Written policies and procedures shall be developed concerning the scope and provision of care in each special care unit. Such policies and procedures shall be reviewed at least annually, revised as necessary, dated to indicate the time of last review, enforced, and include at least the following:
1. Specific criteria for the admission and discharge of patients;
2. A system for informing the responsible physician of changes in the patient's condition;
3. Methods for procurement of equipment and drugs at all times;
4. Specific procedures relating to infection and traffic control;
5. Specification as to who may perform special procedures, under what circumstances, and under what degree of supervision; and specific policies as to the use of standing orders; and
6. A protocol for handling emergency conditions related to the breakdown of essential equipment.
(f) No hospital shall hold itself out as a Trauma Center unless it has been verified by the Department of Health and Rehabilitative Services in accordance with the Trauma Center provisions of Section 395.401, F.S. Any violation of the Trauma Center provisions shall subject any violator to appropriate remedies provided by Section 395.1065, F.S.
(13) Adult Diagnostic Cardiac Catheterization Program. All licensed hospitals that establish adult diagnostic cardiac catheterization laboratory services under Section 408.0361, F.S., shall operate in compliance with the guidelines of the American College of Cardiology/American Heart Association regarding the operation of diagnostic cardiac catheterization laboratories. Hospitals are considered to be in compliance with American College of Cardiology/American Heart Association guidelines when they adhere to standards regarding staffing, physician training and experience, operating procedures, equipment, physical plant, and patient selection criteria to ensure patient quality and safety. The applicable guideline, herein incorporated by reference, is the American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards: Bashore et al, ACC/SCA&I Clinical Expert Consensus Document on Catheterization Laboratory Standards, JACC Vol. 37, No. 8, June 2001: 2170-214 (American College of Cardiology/American Heart Association guidelines). Aspects of the guideline related to pediatric services or outpatient cardiac catheterization in freestanding non-hospital settings are not applicable to this rule. All such licensed hospitals shall have a department, service or other similarly titled unit which shall be organized, directed and staffed, and integrated with other units and departments of the hospitals in a manner designed to assure the provision of quality patient care.
(a) Licensure.
1. A hospital seeking a license for an adult diagnostic cardiac catheterization laboratory services program shall submit an application on a form provided by the Agency, AHCA Form 3130-5003, August 09, License Application Adult Inpatient Diagnostic Cardiac Catheterization, incorporated herein by reference and available at (http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Hospital_Outpatient/hospital.shtml#acs), signed by the chief executive officer of the hospital, confirming the hospital's intent and ability to comply with Section 408.0361(1), F.S.
2. Hospitals with adult diagnostic cardiac catheterization services programs must renew their licenses at the time of the hospital licensure renewal, providing the information in Section 408.0361(1), F.S. Failure to renew the hospital's license or failure to update the information in Section 408.0361(1), F.S., shall cause the license to expire.
(b) Definitions. The following definitions shall apply specifically to all adult diagnostic cardiac catheterization programs, as described in this subsection 59A-3.2085(13), F.A.C.:
1. "Diagnostic Cardiac Catheterization" means a procedure requiring the passage of a catheter into one or more cardiac chambers of the left and right heart, with or without coronary arteriograms, for the purpose of diagnosing congenital or acquired cardiovascular diseases, or for determining measurement of blood pressure flow; and also includes the selective catheterization of the coronary ostia with injection of contrast medium into the coronary arteries.
2. "Adult" means a person fifteen years of age or older.
3. Therapeutic Procedures. An adult diagnostic cardiac catheterization program established pursuant to Section 408.0361, F.S., shall not provide therapeutic services, such as percutaneous coronary intervention or stent insertion, intended to treat an identified condition or the administering of intra-coronary drugs, such as thrombolytic agents.
4. Diagnostic Procedures. Procedures performed in the adult diagnostic cardiac catheterization laboratory shall include, for example, the following:
a. Left heart catheterization with coronary angiography and left ventriculography;
b. Right heart catheterization;
c. Hemodynamic monitoring line insertion;
d. Aortogram;
e. Emergency temporary pacemaker insertion;
f. Myocardial biopsy;
g. Diagnostic trans-septal procedures;
h. Intra-coronary ultrasound (CVIS);
i. Fluoroscopy; and
j. Hemodynamic stress testing.
(c) Support Equipment. A crash cart containing the necessary medication and equipment for ventilatory support shall be located in each cardiac catheterization procedure room. A listing of all crash cart contents shall be readily available. At the beginning of each shift, the crash cart shall be checked for intact lock; the defribrillator and corresponding equipment shall be checked for function and operational capacity. A log shall be maintained indicating review.
(d) Radiographic Cardiac Imaging Systems. A quality improvement program for radiographic imaging systems shall include measures of image quality, dynamic range and modulation transfer function. Documentation indicating the manner in which this requirement will be met shall be available for the Agency's review.
(e) Physical Plant Requirements. Section 419.2.1.2, Florida Building Code, contains the physical plant requirements for the adult diagnostic cardiac catheterization program.
(f) Personnel Requirements. There shall be an adequate number of trained personnel available. At a minimum, a team involved in cardiac catheterization shall consist of a physician, one registered nurse, and one technician.
(g) Quality Improvement Program. A quality improvement program for the adult diagnostic cardiac catheterization program laboratory shall include an assessment of proficiency in diagnostic coronary procedures, as described in the American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards: Bashore et al, ACC/SCA&I Clinical Expert Consensus Document on Catheterization Laboratory Standards, JACC Vol. 37, No. 8, June 2001: 2170-214 guidelines. Essential data elements for the quality improvement program include the individual physician procedural volume and major complication rate; the institutional procedural complication rate; relevant clinical and demographic information about patients; verification of data accuracy; and procedures for patient, physician and staff confidentiality. Documentation indicating the manner in which this requirement will be met shall be available for the Agency's review.
(h) Emergency Services.
1. All providers of adult diagnostic cardiac catheterization program services in a hospital not licensed as a Level II adult cardiovascular services provider shall have written transfer agreements developed specifically for diagnostic cardiac catheterization patients with one or more hospitals that operate a Level II adult cardiovascular services program. Written agreements must be in place to ensure safe and efficient emergency transfer of a patient within 60 minutes. Transfer time is defined as the number of minutes between the recognition of an emergency as noted in the hospital's internal log and the patient's arrival at the receiving hospital. Transfer and transport agreements must be reviewed and tested at least every 3 months, with appropriate documentation maintained, including the hospital's internal log or emergency medical services data.
2. Patients at high risk for diagnostic catheterization complications shall be referred for diagnostic catheterization services to hospitals licensed as a Level II adult cardiovascular services provider. Hospitals not licensed as a Level II adult cardiovascular services provider must have documented patient selection and exclusion criteria and provision for identification of emergency situations requiring transfer to a hospital with a Level II adult cardiovascular services program. Documentation indicating the manner in which this requirement will be met shall be available for the Agency's review.
(i) Policy and Procedure Manual for Medicaid and Charity Care.
1. Each provider of adult diagnostic cardiac catheterization services shall maintain a policy and procedure manual, available for review by the Agency, which documents a plan to provide services to Medicaid and charity care patients.
2. At a minimum, the policy and procedure manual shall document specific outreach programs directed at Medicaid and charity care patients for adult diagnostic cardiac catheterization services.
(j) Enforcement. Enforcement of these rules shall follow procedures established in Rule 59A-3.253, F.A.C.
(k) In case of conflict between the provisions of this rule and the American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards: Bashore et al, ACC/SCA&I Clinical Expert Consensus Document on Catheterization Laboratory Standards, JACC Vol. 37, No. 8, June 2001: 2170-214 guidelines, the provisions of this part shall prevail.
(14) Mobile Surgical Facility. A mobile surgical facility as defined in Section 395.002(21), F.S., provides elective surgical care under contract with the Department of Corrections or a private correctional facility operating pursuant to Chapter 957, F.S., and not to the general public. The mobile surgical facility shall comply with the provisions of this chapter, except as modified herein.
(a) Licensure Procedure. Each application for a mobile surgical facility license, or renewal thereof, shall be accompanied by a license fee of $ 1500.00. The agency shall issue a single license, which identifies the mobile surgical facility. This license is not transferable.
(b) Licensure Inspection. The agency shall inspect a mobile surgical facility at initial licensure pursuant to Section 395.0161(1)(f), F.S. This subsection shall only apply to mobile surgical facilities operating under contracts entered into on or after July 1, 1998.
(c) Governing Body. Each mobile surgical facility shall have its own governing body that assumes full responsibility for the legal and ethical conduct of the facility consistent with its contract with the Department of Corrections. The governing body is organized under approved written bylaws, rules and regulations, which are reviewed annually and updated as required.
(d) Organized Medical Staff. Each mobile surgical facility shall have an organized medical staff approved by the governing body in accordance with its contract with the Department of Corrections, with the delegated responsibility to provide for the quality of all medical care and other appropriate health care provided to patients, for planning for the improvement of that care, and for the ethical conduct and professional practices of its members.
(e) Services Provided. Each mobile surgical facility shall have written policies and procedures describing the scope of services provided to the inmate patients of the correctional facility. Services provided by the mobile surgical facility include but not limited to:
1. Surgical Services. The surgical service shall be organized under written policies and procedures relating to surgical staff privileges, anesthesia, function standards, staffing patterns and quality maintenance of the mobile surgical facility.
2. Anesthesia Services. The mobile surgical facility anesthesia services shall be organized under written policies and procedures relating to anesthesia staff privileges, the administration of anesthesia, and the maintenance of strict safety controls.
3. Nursing Services. The mobile surgical facility shall have written policies and procedures relating to patient care, establishment of standards for nursing care, and mechanisms for evaluating such care, and nursing services.
4. Laboratories. The mobile surgical facility shall provide on the premises or through arrangement with a laboratory licensed under Chapter 483, F.S., and Chapter 59A-7, F.A.C., a clinical laboratory to provide those services commensurate with the mobile surgical facility's needs.
5. Radiological Services. The mobile surgical facility shall provide within the facility, or through arrangement, diagnostic radiological services commensurate with its needs.
6. Housekeeping Service. The mobile surgical facility housekeeping service shall be organized under effective written policies and procedures relating to personnel, equipment, materials, maintenance, and cleaning of all areas of the mobile surgical facility.
7. Surveillance, Prevention, and Control of Infection. Each mobile surgical facility shall establish an infection control program involving members of its medical staff, nursing staff, other professional and administrative staff as appropriate.
8. Patient Rights. The mobile surgical facility shall develop and adopt policies and procedures for the protection of patients rights pursuant to Sections 381.026, FS.
9. Medical Records. Each mobile surgical facility shall use a problem oriented medical record for each patient, which shall be initiated at the time of intake or admission and which shall contain all pertinent information pursuant to 59A-3.217, F.A.C.
10. Coordination of Care. Each mobile surgical facility shall develop and implement policies and procedures on discharge planning pursuant to Rule 59A-3.2055, F.A.C. Documentation of the discharge plan in the patient's medical record shall include an assessment of appropriate services to meet the patient needs following surgery.
11. Quality Assessment and Improvement. The mobile surgical facility shall have an ongoing quality improvement system designed to objectively and systematically monitor and evaluate the quality and appropriateness of patient care and opportunities to improve the quality of care provided pursuant to Rule 59A-3.216, F.A.C.
12. Comprehensive Emergency Management Plan. The mobile surgical facility shall have a comprehensive emergency management plan for internal or external disasters. The comprehensive emergency management Plan shall be reviewed and approved by the county office of emergency management and updated annually as required.
(15) Stroke centers.
(a) Primary Stroke Centers. A hospital program will be designated as a primary stroke center on the basis of that hospital providing to the Agency for Health Care Administration an affidavit on AHCA Form 3130-8009, December 2005, which is incorporated by reference, signed by the Chief Executive Officer of the hospital, attesting that the program has been certified by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as a primary stroke center, or that the program meets the criteria applicable to primary stroke centers as outlined in the Joint Commission on Accreditation of Healthcare Organizations: Disease-Specific Care Certification Manual, 2nd Edition, Oakbrook Terrace, IL; © Joint Commission Resources, 2005. Reprinted with permission. Attestation must also indicate that the program meets requirements outlined in the "Updated Primary Stroke Center Certification Appendix for the Disease-Specific Care Manual," which are incorporated by reference. Copies of these standards are available from the Agency for Health Care Administration Hospital and Outpatient Services Unit, or from the Joint Commission on the Accreditation of Healthcare Organizations at One Renaissance Boulevard, Oak Terrace, IL 60181. Hospitals shall ensure that stroke centers establish specific procedures for screening patients that recognize that numerous conditions, including cardiac disorders, often mimic stroke in children. Stroke centers should ensure that transfer to an appropriate facility for specialized care is provided to children and young adults with known childhood diagnoses.
(b) Comprehensive Stroke Center (CSC). Hospitals shall ensure that stroke centers establish specific procedures for screening patients that recognize that numerous conditions, including cardiac disorders, often mimic stroke in children. Stroke centers should ensure that transfer to an appropriate facility for specialized care is provided to children and young adults with known childhood diagnoses. A hospital's program may be designated as a Comprehensive Stroke Center on the basis of that hospital providing to the Agency for Health Care Administration an affidavit signed by the Chief Executive Officer of the hospital that the program has received initial Primary Stroke Center designation as provided in paragraph59A-3.2085(15)(a), F.A.C., and that the program meets the following criteria:
1. A comprehensive stroke center shall have health care personnel with clinical expertise in a number of disciplines available.
a. Health care personnel disciplines in a CSC shall include:
(I) A designated comprehensive stroke center medical director;
(II) Neurologists, neurosurgeons, surgeons with expertise performing carotid endartrectomy, diagnostic neuroradiologist(s), and physician(s) with expertise in endovascular neuroInterventional procedures and other pertinent physicians;
(III) Emergency department (ED) physician(s) and nurses trained in the care of stroke patients;
(IV) Nursing staff in the stroke unit with particular neurologic expertise who are trained in the overall care of stroke patients;
(V) Nursing staff in intensive care unit (ICU) with specialized training in care of patients with complex and/or severe neurological/neurosurgical conditions;
(VI) Advanced Practice Nurse(s) with particular expertise in neurological and/or neurosurgical evaluation and treatment, physician(s) with specialized expertise in critical care for patients with severe and/or complex neurological/neurosurgical conditions;
(VII) Physician(s) with specialized expertise in critical care for patients with severe and/or complex neurological/neurosurgical conditions;
(VIII) Physician(s) with expertise in performing and interpreting trans-thoracic echocardiography, transesophageal echocardiography, carotid duplex ultrasound and transcranial Doppler;
(IX) Physician(s) and therapist(s) with training in rehabilitation, including physical, occupational and speech therapy; and
(X) A multidisciplinary team of health care professionals with expertise or experience in stroke, representing clinical or neuropsychology, nutrition services, pharmacy (including a Pharmacy Doctorate (Pharm D) with stroke expertise), case management and social workers.
b. Availability of medical personnel:
(I) Neurosurgical expertise must be available in a CSC on a 24 hours per day, 7 days per week basis and in-house within 2 hours. The attending neurosurgeon(s) at a CSC should have expertise in cerebrovascular surgery.
(II) Neurologist(s) with special expertise in the management of stroke patients should be available 24 hours per day, 7 days per week.
(III) Endovascular/Neurointerventionist(s) should be on active full-time staff. However, when this service is temporarily unavailable, pre-arranged transfer agreements must be in place for the rapid transfer of patients needing these treatments to an appropriate facility.
2. Advanced Diagnostic Capabilities.
a. Magnetic resonance imaging (MRI) and related technologies.
b. Catheter angiography.
c. Coaxial Tomography (CT) angiography.
d. Extracranial ultrasonography.
e. Carotid duplex.
f. Transcranial Doppler.
g. Transthoracic and trans-esophageal echocardiography.
h. Tests of cerebral blood flow and metabolism.
i. Comprehensive hematological and hypercoagulability profile testing.
3. Neurological Surgery and Endovascular Interventions.
a. Angioplasty and stenting of intracranial and extracranial arterial stenosis.
b. Endovascular therapy of acute stroke.
c. Endovascular treatment (coiling) of intracranial aneurysms.
d. Endovascular and surgical repair of arteriovenous malformations (AVM) and arteriovenous fistulae (AVF).
e. Surgical clipping of intracranial aneurysms.
f. Intracranial angioplasty for vasospasm.
g. Surgical resection of AVMs and AVFs.
h. Placement of ventriculostomies and ventriculoperitoneal shunts.
i. Evacuation of intracranial hematomas.
j. Carotid endarterectomy.
k. Decompressive craniectomy.
4. Specialized Infrastructure.
a. Emergency Medical Services (EMS) Link - The CSC collaborates with EMS leadership:
(I) To ensure that EMS assessment and management at the scene includes the use of a stroke triage assessment tool (consistent with the Florida Department of Health sample).
(II) To ensure that EMS assessment/management at the scene is consistent with evidence-based practice.
(III) To facilitate inter-facility transfers.
(IV) To maintain an on-going communication system with EMS providers regarding availability of services.
b. Referral and Triage - A CSC shall maintain:
(I) An acute stroke team available 24 hours per day, 7 days per week, including: ED physician(s), nurses for ED patients, neurologist, neurospecialist RNs, radiologist with additional staffing/technology including: 24 hours per day, 7 days per week CT availability, STAT lab testing/pharmacy and registration.
(II) A system for facilitating inter-facility transfers.
(III) Defined access telephone numbers in a system for accepting appropriate transfer.
c. Inpatient Units - These specialized units should have a subspecialty Medical Director with particular expertise in stroke (intensivist, pulmonologist, neurologist, neurosurgeon or neuro-intensivist) who demonstrates ongoing professional growth by obtaining at least 6 CME credits in cerebrovascular care annually.
(I) ICU with medical and nursing personnel who have special training, skills and knowledge in the management of patients with all forms of neurological/neurosurgical conditions that require intensive care.
(II) Acute Stroke Unit with medical and nursing personnel who have training, skills and knowledge sufficient to care for patients with neurological conditions, particularly acute stroke patients, and who are appropriately trained in neurological assessment and management.
d. Rehabilitation and Post Stroke Continuum of Care -
(I) A CSC shall provide inpatient post-stroke rehabilitation.
(II) A CSC shall utilize healthcare professionals who can assess and treat cognitive, behavioral, and emotional changes related to stroke (i.e., clinical psychologists or clinical neuropsychologists).
(III) A CSC shall ensure discharge planning that is appropriate to the level of post-acute care required.
(IV) A CSC shall ensure continuing arrangements post-discharge for rehabilitation needs and medical management.
(V) A CSC shall ensure that patients meeting acute care rehabilitation admission criteria are transferred to a CARF/JCAHO accredited acute rehabilitation facility.
e. Education -
(I) The CSC shall fulfill the educational needs of its medical and paramedical professionals by offering ongoing professional education for all disciplines.
(II) The CSC shall provide education to the public as well as to inpatients and families on risk factor reduction/management, primary and secondary prevention of stroke, the warning signs and symptoms of stroke, and the medical management and rehabilitation for stroke patients.
(III) The CSC shall supplement community resources for stroke and stroke support groups.
f. Professional standards for nursing - The CSC shall provide a career development track to develop neuroscience nursing, particularly in the area of cerebrovascular disease.
(I) ICU and neuroscience/stroke unit nursing staff will be familiar with stroke specific neurological assessment tools such as the National Institute for Health (NIH) Stroke Scale.
(II) ICU nursing staff must be trained to assess neurologic function and be trained to provide all aspects of neuro critical care.
(III) Nurses in the ICU caring for stroke patients, and nurses in neuroscience units must obtain at least 8 hours of continuing education credits (4 hours continuing education in the formalized CEU credits and 4 hours of continuing education related to their specialty that can be verified through documentation of participation).
g. Research - A CSC shall have the professional and administrative infrastructure necessary to conduct clinical trials and should have participated in stroke clinical trials within the last year and actively participate in ongoing clinical stroke trials.
5. Quality Improvement and Clinical Outcomes Measurement.
a. The purpose of a quality improvement program is analysis of data, correction of errors, systems improvements, and ongoing improvement in patient care and delivery of services.
b. A multidisciplinary institutional Quality Improvement Committee should meet on a regular basis to monitor quality benchmarks and review clinical complications.
c. Specific benchmarks, outcomes, and indicators should be defined, monitored, and reviewed on a regular basis for quality assurance purposes. Outcomes for procedures such as carotid endarterectomy, carotid stenting, IVtPA, endovascular/interventional stroke therapy, intracerebral aneurysm coiling, and intracerebral aneurysm clipping should be monitored.
d. A database and/or registry should be established that allows for tracking of parameters such as length of stay, treatments received, discharge destination and status, incidence of complications (such as aspiration pneumonia, urinary tract infection, deep venous thrombosis), and discharge medications and comparing to institutions across the United States.
e. A CSC shall participate in a national and/or state registry (or registries) for acute stroke therapy clinical outcomes, including IVtPA and endovascular/interventional stroke therapy.
(16) Level I Adult Cardiovascular Services.
(a) Licensure.
1. A hospital seeking a license for a Level I adult cardiovascular services program shall submit an application on a form provided by the Agency, AHCA Form 3130-8010, August 09, License Application Level I Adult Cardiovascular Services, incorporated herein by reference and available at (http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Hospital_Outpatient/hospital.shtml#acs), to the Agency, signed by the chief executive officer of the hospital, confirming that for the most recent 12-month period, the hospital has provided a minimum of 300 adult inpatient and outpatient diagnostic cardiac catheterizations or, for the most recent 12-month period, has discharged or transferred at least 300 inpatients with the principal diagnosis of ischemic heart disease (defined by ICD-9-CM codes 410.0 through 414.9).
a. Reportable cardiac catheterization procedures are defined as single sessions with a patient in the hospital's cardiac catheterization procedure room(s), irrespective of the number of specific procedures performed during the session.
b. Reportable cardiac catheterization procedures shall be limited to those provided and billed for by the Level I licensure applicant and shall not include procedures performed at the hospital by physicians who have entered into block leases or joint venture agreements with the applicant.
2. The request shall confirm the hospital's intent and ability to comply with the American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards: Bashore et al, ACC/SCA&I Clinical Expert Consensus Document on Catheterization Laboratory Standards, JACC Vol. 37, No. 8, June 2001: 2170-214; and the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention); including guidelines for staffing, physician training and experience, operating procedures, equipment, physical plant, and patient selection criteria to ensure patient quality and safety.
3. The request shall confirm the hospital's intent and ability to comply with physical plant requirements regarding cardiac catheterization laboratories and operating rooms found in Section 419.2.1.2, Florida Building Code.
4. The request shall also include copies of one or more written transfer agreements with hospitals that operate a Level II adult cardiovascular services program, including written transport protocols to ensure safe and efficient transfer of an emergency patient within 60 minutes. Transfer time is defined as the number of minutes between the recognition of an emergency as noted in the hospital's internal log and the patient's arrival at the receiving hospital.
5. All providers of Level I adult cardiovascular services programs shall operate in compliance with subsection 59A-3.2085(13), F.A.C., the American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards: Bashore et al, ACC/SCA&I Clinical Expert Consensus Document on Catheterization Laboratory Standards, JACC Vol. 37, No. 8, June 2001: 2170-214 and the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention) guidelines regarding the operation of adult diagnostic cardiac catheterization laboratories and the provision of percutaneous coronary intervention.
6. The applicable guidelines, herein incorporated by reference, are the American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards: Bashore et al, ACC/SCA&I Clinical Expert Consensus Document on Catheterization Laboratory Standards, JACC Vol. 37, No. 8, June 2001: 2170-214; and the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). Aspects of the guideline related to pediatric services or outpatient cardiac catheterization in freestanding non-hospital settings are not applicable to this rule. Aspects of the guideline related to the provision of elective percutaneous coronary intervention only in hospitals authorized to provide open heart surgery are not applicable to this rule.
7. Hospitals are considered to be in compliance with the American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards: Bashore et al, ACC/SCA&I Clinical Expert Consensus Document on Catheterization Laboratory Standards, JACC Vol. 37, No. 8, June 2001: 2170-214 and the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention) guidelines when they adhere to standards regarding staffing, physician training and experience, operating procedures, equipment, physical plant, and patient selection criteria to ensure patient quality and safety. Hospitals must also document an ongoing quality improvement plan to ensure that the cardiac catheterization program and the percutaneous coronary intervention program meet or exceed national quality and outcome benchmarks reported by the American College of Cardiology-National Cardiovascular Data Registry.
8. Level I adult cardiovascular service providers shall report to the American College of Cardiology-National Cardiovascular Data Registry in accordance with the timetables and procedures established by the Registry. All data shall be reported using the specific data elements, definitions and transmission format as set forth by the American College of Cardiology-National Cardiovascular Data Registry.
a. Each hospital licensed to provide Level I adult cardiovascular services shall execute the required agreements with the American College of Cardiology-National Cardiovascular Data Registry to participate in the data registry.
b. Each hospital licensed to provide Level I adult cardiovascular services shall stay current with the payment of all fees necessary to continue participation in the American College of Cardiology-National Cardiovascular Data Registry.
c. Each hospital licensed to provide Level I adult cardiovascular services shall release the data reported by the American College of Cardiology-National Cardiovascular Data Registry to the Agency for Health Care Administration.
d. Each hospital licensed to provide Level I adult cardiovascular services shall use the American College of Cardiology-National Cardiovascular Data Registry data sets and use software approved by the American College of Cardiology for data reporting.
e. Each hospital licensed to provide Level I adult cardiovascular services shall ensure that software formats are established and maintained in a manner that meets American College of Cardiology-National Cardiovascular Data Registry transmission specifications and encryption requirements. If necessary, each hospital shall contract with a vendor approved by the American College of Cardiology-National Cardiovascular Data Registry for software and hardware required for data collection and reporting.
f. To the extent required by the American College of Cardiology-National Cardiovascular Data Registry, each hospital licensed to provide Level I adult cardiovascular services shall implement procedures to transmit data via a secure website or other means necessary to protect patient privacy.
g. Each hospital licensed to provide Level I adult cardiovascular services shall ensure that all appropriate data is submitted on every patient that receives medical care and is eligible for inclusion in the American College of Cardiology-National Cardiovascular Data Registry.
h. Each hospital licensed to provide Level I adult cardiovascular services shall maintain an updated and current institutional profile with the American College of Cardiology-National Cardiovascular Data Registry.
i. Each hospital licensed to provide Level I adult cardiovascular services shall ensure that data collection and reporting will only be performed by trained, competent staff and that such staff shall adhere to the American College of Cardiology-National Cardiovascular Data Registry standards.
j. Each hospital licensed to provide Level I adult cardiovascular services shall submit corrections to any data submitted to the American College of Cardiology-National Cardiovascular Data Registry as discovered by the hospital or by the American College of Cardiology-National Cardiovascular Data Registry. Such corrections shall be submitted within thirty days of discovery of the need for a correction or within such other time frame as set forth by the American College of Cardiology-National Cardiovascular Data Registry. Data submitted must be at a level that the American College of Cardiology-National Cardiovascular Data Registry will include the data in national benchmark reporting.
k. Each hospital licensed to provide Level I adult cardiovascular services shall designate an American College of Cardiology-National Cardiovascular Data Registry site manager that will serve as a primary contact between the hospital, the American College of Cardiology-National Cardiovascular Data Registry and the Agency with regard to data reporting. The identity of each site manager shall be provided to the Hospital and Outpatient Services Unit at the Agency for Health Care Administration in Tallahassee.
l. By submitting data to the American College of Cardiology-National Cardiovascular Data Registry in the manner set forth herein, each hospital shall be deemed to have certified that the data submitted for each time period is accurate, complete and verifiable.
9. Notwithstanding guidelines to the contrary in the American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards: Bashore et al, ACC/SCA&I Clinical Expert Consensus Document on Catheterization Laboratory Standards, JACC Vol. 37, No. 8, June 2001: 2170-214 and the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention), all providers of Level I adult cardiovascular services programs may provide emergency and elective percutaneous coronary intervention procedures. Aspects of the guidelines related to pediatric services or outpatient cardiac catheterization in freestanding non-hospital settings are not applicable to this rule.
10. Hospitals with Level I adult cardiovascular services programs are prohibited from providing the following procedures:
a. Any therapeutic procedure requiring transseptal puncture, or
b. Any lead extraction for a pacemaker, biventricular pacer or implanted cardioverter defibrillator.
11. Hospitals with Level I adult cardiovascular services programs must renew their licenses at the time of the hospital licensure renewal, providing the information in two through five above. Failure to renew the hospital's license or failure to update the information in two through five above shall cause the license to expire.
(b) Staffing.
1. Each cardiologist shall be an experienced physician who has performed a minimum of 75 interventional cardiology procedures, exclusive of fellowship training and within the previous 12 months from the date of the Level I adult cardiovascular licensure application or renewal application.
2. Physicians with less than 12 months experience shall fulfill applicable training requirements in the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention) prior to being allowed to perform emergency percutaneous coronary interventions in a hospital that is not licensed for a Level II adult cardiovascular services program.
3. The nursing and technical catheterization laboratory staff shall be experienced in handling acutely ill patients requiring intervention or balloon pump. Each member of the nursing and technical catheterization laboratory staff shall have at least 500 hours of previous experience in dedicated cardiac interventional laboratories at a hospital with a Level II adult cardiovascular services program. They shall be skilled in all aspects of interventional cardiology equipment, and must participate in a 24-hour-per-day, 365 day-per-year call schedule.
4. The hospital shall ensure that a member of the cardiac care nursing staff who is adept in hemodynamic monitoring and Intra-aortic Balloon Pump (IABP) management shall be in the hospital at all times.
(c) Emergency Services.
A hospital provider of Level I adult cardiovascular services program must ensure it has systems in place for the emergent transfer of patients with intra-aortic balloon pump support to one or more hospitals licensed to operate a Level II adult cardiovascular services program. Formalized written transfer agreements developed specifically for emergency Percutaneous Coronary Intervention (PCI) patients must be developed with a hospital that operates a Level II adult cardiovascular services program. Written transport protocols must be in place to ensure safe and efficient transfer of a patient within 60 minutes. Transfer time is defined as the number of minutes between the recognition of an emergency as noted in the hospital's internal log and the patient's arrival at the receiving hospital. Transfer and transport agreements must be reviewed and tested at least every 3 months, with appropriate documentation maintained.
(d) Policy and Procedure Manual for Medicaid and Charity Care.
1. Each provider of Level I adult cardiovascular services shall maintain a policy and procedure manual, available for review by the Agency, which documents a plan to provide services to Medicaid and charity care patients.
2. At a minimum, the policy and procedure manual shall document specific outreach programs directed at Medicaid and charity care patients for Level I adult cardiovascular services.
(e) Physical Plant Requirements.
Section 419.2.1.2, Florida Building Code, contains the physical plant requirements for adult cardiac catheterization laboratories operated by a licensed hospital.
(f) Enforcement.
1. Enforcement of these rules shall follow procedures established in Rule 59A-3.253, F.A.C.
2. Unless in the view of the Agency there is a threat to the health, safety or welfare of patients, Level I adult cardiovascular services programs that fail to meet provisions of this rule shall be given 15 days to develop a plan of correction that must be accepted by the Agency.
3. Failure of the hospital with a Level I adult cardiovascular services program to make improvements specified in the plan of correction shall result in the revocation of the program license. The hospital may offer evidence of mitigation and such evidence could result in a lesser sanction.
(g) In case of conflict between the provisions of this rule and the guidelines in the American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards: Bashore et al, ACC/SCA&I Clinical Expert Consensus Document on Catheterization Laboratory Standards, JACC Vol. 37, No. 8, June 2001: 2170-214 and the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention), the provisions of this part shall prevail.
(17) Level II Adult Cardiovascular Services.
(a) Licensure.
1. A hospital seeking a license for a Level II adult cardiovascular services program shall submit an application on a form provided by the Agency, AHCA Form 3130-8011, August 09, License Application Level II Adult Cardiovascular Services, incorporated herein by reference and available at (http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Hospital_Outpatient/hospital.shtml#acs), to the Agency, signed by the chief executive officer of the hospital, confirming that for the most recent 12-month period, the hospital has provided a minimum of 1,100 adult inpatient and outpatient cardiac catheterizations, of which at least 400 must be therapeutic cardiac catheterizations, or, for the most recent 12-month period, has discharged at least 800 patients with the principal diagnosis of ischemic heart disease (defined by ICD-9-CM codes 410.0 through 414.9).
Reportable cardiac catheterization procedures shall be limited to those provided and billed for by the Level II licensure applicant and shall not include procedures performed at the hospital by physicians who have entered into block leases or joint venture agreements with the applicant.
2. The request shall confirm to the hospital's intent and ability to comply with applicable guidelines in the American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards: Bashore et al, ACC/SCA&I Clinical Expert Consensus Document on Catheterization Laboratory Standards, JACC Vol. 37, No. 8, June 2001: 2170-2; in the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention); and in the ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery) Developed in Collaboration With the American Association for Thoracic Surgery and the Society of Thoracic Surgeons, including guidelines for staffing, physician training and experience, operating procedures, equipment, physical plant, and patient selection criteria to ensure patient quality and safety.
3. The request shall confirm to the hospital's intent and ability to comply with physical plant requirements regarding cardiac catheterization laboratories and operating rooms found in Section 419.2.1.2, Florida Building Code.
4. All providers of Level II adult cardiovascular services programs shall operate in compliance with subsections 59A-3.2085(13) and 59A-3.2085(16), F.A.C. and the applicable guidelines of the American College of Cardiology/American Heart Association regarding the operation of diagnostic cardiac catheterization laboratories, the provision of percutaneous coronary intervention and the provision of coronary artery bypass graft surgery.
a. The applicable guidelines, herein incorporated by reference, are the American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards: Bashore et al, ACC/SCA&I Clinical Expert Consensus Document on Catheterization Laboratory Standards, JACC Vol. 37, No. 8, June 2001: 2170-214; and
b. ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention; and
c. ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery) Developed in Collaboration With the American Association for Thoracic Surgery and the Society of Thoracic Surgeons.
d. Aspects of the guidelines related to pediatric services or outpatient cardiac catheterization in freestanding non-hospital settings are not applicable to this rule.
5. Hospitals are considered to be in compliance with the guidelines in the American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards: Bashore et al, ACC/SCA&I Clinical Expert Consensus Document on Catheterization Laboratory Standards, JACC Vol. 37, No. 8, June 2001: 2170-214; in the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention; and in the ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery) Developed in Collaboration With the American Association for Thoracic Surgery and the Society of Thoracic Surgeons when they adhere to standards regarding staffing, physician training and experience, operating procedures, equipment, physical plant, and patient selection criteria to ensure patient quality and safety. Hospitals must also document an ongoing quality improvement plan to ensure that the cardiac catheterization program, the percutaneous coronary intervention program and the cardiac surgical program meet or exceed national quality and outcome benchmarks reported by the American College of Cardiology-National Cardiovascular Data Registry and the Society of Thoracic Surgeons.
6. In addition to the requirements set forth in subparagraph (16)(a)7. of this rule, each hospital licensed to provide Level II adult cardiovascular services programs shall participate in the Society of Thoracic Surgeons National Database.
a. Each hospital licensed to provide Level II adult cardiovascular services shall report to the Society of Thoracic Surgeons National Database in accordance with the timetables and procedures established by the Database. All data shall be reported using the specific data elements, definitions and transmission format as set forth by the Society of Thoracic Surgeons.
b. Each hospital licensed to provide Level II adult cardiovascular services shall stay current with the payment of all fees necessary to continue participation in the Society of Thoracic Surgeons National Database.
c. Each hospital licensed to provide Level II adult cardiovascular services shall release the data reported by the Society of Thoracic Surgeons National Database to the Agency.
d. Each hospital licensed to provide Level II adult cardiovascular services shall use the most current version of the Society of Thoracic Surgeons National Database and use software approved by the Society of Thoracic Surgeons for data reporting.
e. Each hospital licensed to provide Level II adult cardiovascular services shall ensure that software formats are established and maintained in a manner that meets Society of Thoracic Surgeons transmission specifications and encryption requirements. If necessary, each hospital shall contract with a vendor approved by the Society of Thoracic Surgeons National Database for software and hardware required for data collection and reporting.
f. To the extent required by the Society of Thoracic Surgeons National Database, each hospital licensed to provide Level II adult cardiovascular services shall implement procedures to transmit data via a secure website or other means necessary to protect patient privacy.
g. Each hospital licensed to provide Level II adult cardiovascular services shall ensure that all appropriate data is submitted on every patient who receives medical care and is eligible for inclusion in the Society of Thoracic Surgeons National Database.
h. Each hospital licensed to provide Level II adult cardiovascular services shall maintain an updated and current institutional profile with the Society of Thoracic Surgeons National Database.
i. Each hospital licensed to provide Level II adult cardiovascular services shall ensure that data collection and reporting will only be performed by trained, competent staff and that such staff shall adhere to Society of Thoracic Surgeons National Database standards.
j. Each hospital licensed to provide Level II adult cardiovascular services shall submit corrections to any data submitted to the Society of Thoracic Surgeons National Database as discovered by the hospital or by the Society of Thoracic Surgeons National Database. Such corrections shall be submitted within thirty days of discovery of the need for a correction or within such other time frame as set forth by the Society of Thoracic Surgeons National Database. Data submitted must be at a level that the Society of Thoracic Surgeons National Database will include the data in national benchmark reporting.
k. Each hospital licensed to provide Level II adult cardiovascular services shall designate a Society of Thoracic Surgeons National Database site manager that will serve as a primary contact between the hospital, the Society of Thoracic Surgeons National Database and the Agency with regard to data reporting. The identity of each site manager shall be provided to the Hospital and Outpatient Services Unit at the Agency for Health Care Administration in Tallahassee.
l. By submitting data to the Society of Thoracic Surgeons National Database and the American College of Cardiology-National Cardiovascular Data Registry in the manner set forth herein, each hospital shall be deemed to have certified that the data submitted for each time period is accurate, complete and verifiable.
7. Hospitals with Level II adult cardiovascular services programs must renew their licenses at the time of the hospital licensure renewal, providing the information in two through four above. Failure to renew the hospital's license or failure to update the information in two through four above shall cause the license to expire.
(b) Staffing.
1. Each cardiac surgeon shall be Board certified.
a. New surgeons shall be Board certified within 4 years after completion of their fellowship.
b. Experienced surgeons with greater than 10 years experience shall document that their training and experience preceded the availability of Board certification.
2. Each cardiologist shall be an experienced physician who has performed a minimum of 75 interventional cardiology procedures, exclusive of fellowship training and within the previous 12 months from the date of the Level II adult cardiovascular licensure application or renewal application.
3. The nursing and technical catheterization laboratory staff shall be experienced in handling acutely ill patients requiring intervention or balloon pump. Each member of the nursing and technical catheterization laboratory staff shall have at least 500 hours of previous experience in dedicated cardiac interventional laboratories at a hospital with a Level II adult cardiovascular services program. They shall be skilled in all aspects of interventional cardiology equipment, and must participate in a 24-hour-per-day, 365 day-per-year call schedule.
4. The hospital shall ensure that a member of the cardiac care nursing staff who is adept in hemodynamic monitoring and Intra-aortic Balloon Pump (IABP) management shall be in the hospital at all times.
(c) Policy and Procedure Manual for Medicaid and Charity Care.
1. Each provider of adult Level II adult cardiovascular services shall maintain a policy and procedure manual, available for review by the Agency, which documents a plan to provide services to Medicaid and charity care patients.
2. At a minimum, the policy and procedure manual shall document specific outreach programs directed at Medicaid and charity care patients for Level II adult cardiovascular services.
(d) Physical Plant Requirements.
Section 419.2.1.2, Florida Building Code, contains the physical plant requirements for adult cardiac catheterization laboratories and operating rooms for cardiac surgery operated by a licensed hospital.
(e) Enforcement.
1. Enforcement of these rules shall follow procedures established in Rule 59A-3.253, F.A.C.
2. Unless in the view of the Agency there is a threat to the health, safety or welfare of patients, Level II adult cardiovascular services programs that fail to meet provisions of this rule shall be given 15 days to develop a plan of correction that must be accepted by the Agency.
3. Failure of the hospital with a Level II adult cardiovascular services program to make improvements specified in the plan of correction shall result in the revocation of the program license. The hospital may offer evidence of mitigation and such evidence could result in a lesser sanction.
(f) In case of conflict between the provisions of this rule and the guidelines in the American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards: Bashore et al, ACC/SCA&I Clinical Expert Consensus Document on Catheterization Laboratory Standards, JACC Vol. 37, No. 8, June 2001: 2170-214; the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention; and the ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery) Developed in Collaboration With the American Association for Thoracic Surgery and the Society of Thoracic Surgeons, the provisions of this part shall prevail.
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