No. 30542: R432-100. General Hospital Standards

DAR File No.: 30542
Filed: 10/04/2007, 03:59
Received by: NL

NOTICE OF REVIEW AND STATEMENT OF CONTINUATION

Concise explanation of the particular statutory provisions under which the rule is enacted and how these provisions authorize or require the rule:

Section 26-21-5 authorizes the Utah Department of Health to promulgate rules for the construction and operation of general acute care hospitals.

Summary of written comments received during and since the last five-year review of the rule from interested persons supporting or opposing the rule:

The department has received many comments on this rule. Except as noted, all resulted in amendments to the rule. They are listed below: Emergency and Disaster Plan: in 2002, Joint Commission comments suggested that states require hospitals to make one of their two annual disaster drills focused on a bioterrorism or communicable disease event. The Health Facility Committee recommended that the rule be amended and the department made an amendment effective 03/13/2003. Emergency Care Services: in 2003, comments were received that the rule should be amended to allow general acute care hospitals to designate its emergency services as Level I-III and participate in the statewide trauma system, while specialty hospitals may opt to designate their emergency services Level IV. However, a critical access hospital participating in the trauma system would need to provide at least Level III emergency care services. The Health Facility Committee concurred, and the Department amended the rule effective 01/09/2004. Perinatal Care: comments received in 2004 suggested that the rule should be amended to require hospitals which provide perinatal services to follow the newly revised Guidelines for Perinatal Care, Fifth Edition. This was already the standard for care in most regulated facilities. The Health Facility Committee agreed to such an amendment. The department amended the rule effective 05/24/2004. Medical and Professional Staff During Emergencies: comments were received that mass casualty incidents are likely to overwhelm the capacity of hospitals and the availability of adequate numbers of credentialed staff to care for emergency patients in such events. Comments recommended that the rule be amended to require hospitals to establish policies and procedures to issue temporary credentialing when there is an emergency or disaster situations. The Health Facility Committee approved the amendment and the department amended the rule effective 11/09/2004. Medical Records: a) comments in 2005 requested changes to medical records requirements. It was recommended that hospitals be allowed to use an electronic master patient index to store permanent record information, and discard hard copies after seven years; and b) comments also requested the pharmacy services section requirements be updated to recognize the audit capabilities of medication dispensing machines, so hand counts of medication would no longer be necessary when such machines were used. The Health Facility Committee approved the two changes. The department amended the rule effective 01/05/2006. Surge Capacity: comments from a federal Health Resources and Services Administration (HRSA) Bioterrorism task force recommended that the rule be modified to allow hospitals to increase their bed capacity by 20% in the event of a mass casualty incident without prior approval of the department. This would improve each hospital's ability to care for victims of such an event. The Health Facility Committee approved the amendment and the Department amended the rule effective 01/05/2006. Transitional Care Units: in 2005, comments were received to allow hospital transitional care units of 16 or fewer beds to be licensed as small health care facilities, instead of nursing care facilities. Finalization of Patient Record: comments recommended that hospitals be allowed up to 30 days after patient discharge to finalize the patient record. This would save time and money over the new federal regulation which required that all verbal orders be authenticated in the records within 48 hours, unless a state rule permitted a longer time frame. The Health Facility Committee approved the amendment which was filed by the department and made final on 04/11/2007. Restraint and Seclusion: comments in 2007 requested that the rule be amended to reflect more current federal regulations for restraint and seclusion use. The Health Facility Committee appointed a subcommittee to review the issues. If the subcommittee makes a recommendation and the Committee approves an amendment, the department will amend the rule accordingly.

Reasoned justification for continuation of the rule, including reasons why the agency disagrees with comments in opposition to the rule, if any:

This rule is required by Title 26, Chapter 21, of the Health Facility Licensure and Inspection Act. There are currently 32 general acute care hospitals licensed in the State. Without this rule, the hospitals would not be regulated or licensed. The department determined to not amend the section of the rules concerning transitional care units because doing so could potentially jeopardize the Nursing Facility Bed Tax required by Title 26, Chapter 35a. The department supports continuation of the rule as it has been amended. Any amendments recommended by the Health Facility Committee will be filed following their review.

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Systems Improvement, Licensing
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

Direct questions regarding this rule to:

Allan Elkins at the above address, by phone at 801-538-6595, by FAX at 801-538-6163, or by Internet E-mail at [e-mail]

Authorized by:

David N. Sundwall, Executive Director