R432-600-7. Clinic Protocols, Policies, and Procedures

  (1) The licensee shall develop and implement written policies and procedures with the medical director and the administrator in accordance with State law including:

  (a) Patient eligibility criteria;

  (b) Physician competency criteria;

  (c) Informed consent;

  (d) For Type II Clinics, policy must indicate a limit on the number of weeks within the second trimester of pregnancy during which abortions can be safely performed in the clinic;

  (e) For Type II Clinics, an emergency treatment transfer plan which shall include:

  (i) patient acknowledgment of the transfer plan;

  (ii) notification to the receiving hospital when a patient requires emergency transfer;

  (iii) explanation of how information will be provided to receiving hospital for proper care and treatment of the individual transferred;

  (iv) plan for security and accountability of the personal effects of the individual transferred; and

  (v) mode of transportation for the transfer.

  (f) If an abortion is performed when an unborn child is sufficiently developed to have any reasonable possibility of survival outside its mother's womb, the medical procedure used must be that which, in the best medical judgment of the physician, will give the unborn child the best chance of survival. (Refer to Section 76-7-307.)

  (g) Pre and post counseling;

  (h) Clinic operational functions;

  (i) Patient care and patient rights policies;

  (j) A quality assurance committee;

  (k) Ongoing relevant training program for all clinic personnel;

  (l) Emergency and disaster plans;

  (m) Fire evacuation plans.