10.05.01.06

.06 Administration.

A. The licensee is responsible for the overall conduct of the facility and for compliance with applicable laws and regulations.

B. Governing Body. The governing body shall identify the administrator who has been given the authority and responsibility for overall policy and fiscal management of the facility. The governing body shall develop a written organizational plan.

C. Administrator. The administrator is responsible for the daily operation of the facility, including but not limited to:

(1) Implementing the facility's policies and coordinating the provision of services that the facility provides;

(2) Organizing and coordinating the administrative functions of the facility;

(3) Establishing procedures for the accountability of those personnel involved in patient care;

(4) Familiarizing the staff with the facility's policies and procedures, and with applicable federal, State, and local laws and regulations;

(5) Participating in the development, negotiation, and implementation of agreements or contracts into which the facility enters; and

(6) Participating in the development of organizational and fiscal planning for the facility.

D. Policies and Procedures. The administrator, in consultation with the medical director, shall develop and implement policies and procedures governing the operation of the facility which include at a minimum:

(1) A description of the scope and delivery of services provided by the facility either directly or through contractual arrangements;

(2) A description of the provision of complete and partial charity care for indigent and Medicaid patients to promote access to all services regardless of an individual's ability to pay;

(3) Personnel practices;

(4) Discharge protocols and aftercare plans;

(5) Postoperative recovery, if applicable;

(6) The transfer or referral of patients who require services that are not provided by the facility;

(7) The transportation of a patient to the nearest appropriate hospital in the event of an emergency situation;

(8) Infection control for patients and staff;

(9) Pertinent safety practices, including the control of fire and mechanical hazards; and

(10) Preventive maintenance for equipment to ensure proper operation and safety.

E. The administrator shall ensure that all:

(1) Policies and procedures are reviewed by staff at least annually and are revised as necessary;

(2) Policies and procedures are available at all times for staff inspection and use; and

(3) Appropriate personnel implement all policies and procedures as adopted.