Title: Section 405.14 - Respiratory care services

Effective Date

12/31/2013

405.14 Respiratory care services. Respiratory care services shall be provided in a manner which assures the safe and effective operation and management of staff and services necessary to provide respiratory care to hospital patients at all times. The service shall have effective and current written policies and procedures regarding staff assignments, the administration of medication, diluents and oxygen, the maintenance of safety controls and the intregration of such services with other related services of the hospital.

(a) Organization and direction. The services shall be directed by a physician who shall be responsible for the clinical aspects of organization and delivery of all respiratory care services. The physician, or another individual qualified by training and experience shall direct administrative aspects of the services.

(1) Respiratory care services shall be provided by staff who possess the necessary qualifications specified by the medical staff, consistent with provisions of the New York State Education Law.

(i) Each individual who provides respiratory care services shall be competent to provide such services as evidenced by education, training and experience and where applicable demonstrated adherence to hospital policies and procedures.

(ii) A sufficient number of qualified competent professional and support personnel shall be available to meet the respiratory care needs of the patient.

(2) Written policies and procedures shall describe mechanisms for effective management of the service, including the nature and the amount of supervision required for personnel to carry out specific procedures, as well as mechanisms governing interdepartmental relationships and communications.

(3) Staff orientation and inservice training shall be required, provided and documented in accordance with written hospital policies and procedures.

(b) Operation and service delivery. Respiratory care services shall be provided in manner which assures the achievement and maintenance of generally accepted standards of professional medical practice and patient care.

(1) Respiratory care services shall only be provided in accordance with specific hospital protocols/policies or upon the orders of members of the medical staff. The order for respiratory care services shall specify the type, frequency and duration of treatment, and, as appropriate, the type and dose of medication, the type of diluent, and the oxygen concentration, consistent with generally accepted standards of care.

(2) All respiratory care services provided shall be documented in the patient's medical record, including the type of therapy, date and time of administration, effects of therapy, and any adverse reactions.

(3) If blood gases or other clinical laboratory tests are performed in the respiratory care unit, the unit shall meet the requirements for clinical laboratories with respect to management, adequacy of facilities, proficiency testing and quality control as set forth in section 405.16 of this Part.

(4) The service shall implement a planned and systematic process of the monitoring and evaluation of the quality and appropriateness of patient care and for the resolution of identified problems. The process shall involve the reporting of findings, conclusions and recommendations to the quality assurance committee in accordance with hospital policies and procedures. (5) All equipment and services provided shall be age and size appropriate.

Volume

VOLUME C (Title 10)

up