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Title: Section 407.5 - Administrative requirements

Effective Date


407.5 Administrative requirements.

(a) PCH and CAH administration. PCHs and CAHs shall comply with the requirements of section 405.3 of this Title regarding administration.

(b) Admission/discharge/transfer.

(1) General.

(i) The administrative and medical/professional staff shall develop for approval by the governing body written admission and discharge policies designed to protect the health and safety of patients, and shall not assign or delegate the functions of admission and discharge to any referral agency.

(ii) The priority use of inpatient beds in the hospital shall be for short stay acute cases that can be discharged or transferred within a limited period of time. A PCH or CAH certified to provide swing-bed services shall ensure the timely availability of acute care beds at all times.

(iii) Long term cases shall be assigned to the swing-bed capacity of the hospital.

(2) Admissions.

(i) Each patient shall be advised of his or her rights pursuant to section 407.7 of this Part and, as appropriate, the criteria for Medicaid eligibility.

(ii) No person shall be denied admission to the hospital because of race, creed, national origin, sex, disability (subject to the capacity of the hospital to provide necessary treatment), sexual orientation or source of payment.

(iii) Except in emergencies, patients shall be admitted only upon referral and under the care of a licensed and currently registered practitioner who has been granted admitting privileges by the governing body. The patient's condition and provisional diagnosis shall be established on admission by the patient's admitting practitioner and shall be noted in the patient's medical record.

(iv) Except in emergencies and under exceptional circumstances (i.e., weather, availability of transport, equipment or staff), a hospital shall admit as patients only those persons who require the type of medical services authorized by the hospital's operating certificate and specified in the hospital's written admission and discharge policies.

(a) Authorized admissions to CAHs shall involve only patients that, by the judgement of the admitting practitioner, are determined to have medical needs that can be managed and resolved within the 96 hour time period allowed for inpatient services pursuant to 42 CFR section 485.620 as expressly set forth in subdivision (c) of section 407.2 of this Part. Patients presenting with conditions that have the reasonable potential for requiring a greater amount of time to resolve shall be transferred to a more appropriate full service hospital.

(b) Authorized admissions criteria for PCHs shall be developed locally based on the service and resource capabilities of the PCH, its supporting full service hospital(s) and, if appropriate, any network in which it operates. Expected length of stay necessary to meet a patient's medical needs shall not be used as a criterion for admission to PCHs.

(v) PCHs and CAHs shall comply with the provisions of paragraphs (6) through (14) of subdivision (b) of section 405.9 of this Title.

(3) Sexual offense evidence. PCHs and CAHs shall comply with the provision of subdivision (c) of section 405.9 of this Title regarding the maintenance of sexual offense evidence.

(4) Child abuse and maltreatment. PCHs and CAHs shall comply with the provisions of subdivision (d) of section 405.9 of this Title with respect to identification, assessment, reporting and management of cases of suspected child abuse and maltreatment.

(5) Domestic violence. PCHs and CAHs shall comply with the provisions of section 405.9(e) of this Title with regard to the
identification, assessment, treatment and appropriate referral of cases of suspected or confirmed domestic violence.

(6) Discharge/transfer. Hospitals shall comply with the provisions of paragraph (1) of subdivision (i) of section 405.9 of this Title concerning discharge/transfer. In addition, PCHs and CAHs shall comply with the following:

(i) in carrying out discharge planning requirements, PCHs and CAHs that are members of a rural health network may include as the discharge planning coordinator a member of the network utilization review committee who has appropriate training and experience to perform such duties;

(ii) ensure that discharge planning staff have available current information regarding home care programs, institutional health care providers, and other support services, including their scope of services, admission and discharge policies and payment criteria;

(iii) each removal, transfer or discharge shall be carried out in accordance with written PCH/CAH policy, and if the facilitity is a member of a rural health network, network policy. Such policies shall specify referral arrangements and transfer protocols outlining the duties and responsibilities involved in determining the necessity of a transfer and for personnel involved in the transfer and shall be set forth in written agreements between the PCH/CAH and appropriate receiving hospital(s); and
(iv) each patient being removed or discharged shall be provided with information and/or assistance as required for linking the patient with a community based primary care provider.

(c) Incident reporting. PCHs/CAHs shall comply with the provisions of section 405.8 of this Title regarding incident reporting.

(d) Medical records. PCHs/CAHs shall comply with the provisions of section 405.10 of this Title regarding medical records.

(e) Request for consent to an anatomical gift. PCHs/CAHs shall comply with the provisions of section 405.25 of this Title regarding requests for consent to an anatomical gift.

(f) Utilization review. PCHs/CAHs shall comply with the provisions of section 405.26 of this Title regarding utilization review.

(g) Information policy and other reporting requirements. PCHs/CAHs shall comply with the provision of sections 86-1.2, 86-1.3 and 400.18 of this Title regarding information policy and other reporting requirements.


VOLUME C (Title 10)