10.12.01.05

.05 Administration.

A. Administrator.

(1) Each facility shall have an administrator, who is responsible for the daily operation of the facility, including but not limited to:

(a) Consulting with the staff to develop and implement the facility's policies and procedures required under §C of this regulation;

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

(c) Coordinating the provision of services that the facility provides;

(d) Training the staff on the facility's policies and procedures and applicable federal, State, and local laws and regulations; and

(e) Ensuring that all personnel:

(i) Receive orientation and have experience sufficient to demonstrate competency to perform assigned patient care duties, including proper infection control practices;

(ii) Are licensed or certified by an appropriate occupational licensing board to practice in this State, if required by law; and

(iii) Perform or delegate duties and responsibilities in accordance with standards of practice as defined by the Health Occupations Article, Annotated Code of Maryland.

(2) The administrator shall ensure that:

(a) The facility's policies and procedures as described in §C of this regulation are:

(i) Reviewed by staff at least annually and are revised as necessary; and

(ii) Available at all times for staff inspection and reference; and

(b) All appropriate personnel implement all policies and procedures as adopted.

B. Medical Director.

(1) The surgical abortion facility shall have a medical director who:

(a) Is responsible for the overall medical care that is provided by the facility; and

(b) Advises and consults with the staff of the facility on all medical issues relating to services provided by the facility.

(2) The medical director shall be a physician licensed to practice in Maryland.

C. Policies and Procedures. The facility shall have policies and procedures concerning the following:

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

(2) Personnel practices, including but not limited to:

(a) Procedures for the accountability of personnel involved in patient care;

(b) Job descriptions on file for all personnel: and

(c) Procedures to ensure personnel are free from communicable diseases;

(3) Postoperative recovery, if applicable;

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

(5) Infection control for patients and staff;

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

(7) Preventive maintenance for equipment to ensure proper operation and safety; and

(8) The services and procedures specified in Regulations .07—.12 of this chapter.