10A NCAC 13B .3503 FUNCTIONS

(a) The governing body shall:

(1) provide management, physical resources, and personnel determined by the governing body to be required to meet the needs of patients for treatment as authorized by the facility's license;

(2) require facility administration to establish a quality control mechanism that includes a risk management component and an infection control program;

(3) formulate short-range and long-range plans as defined in the facility bylaws, policies, rules, and regulations;

(4) conform to all applicable State and federal laws, rules, and regulations, and applicable local ordinances;

(5) provide for the control and use of the physical and financial resources of the facility;

(6) review the annual audit, budget, and periodic reports of the financial operations of the facility;

(7) consider the recommendation of the medical staff in granting and defining the scope of clinical privileges to individuals in accordance with medical staff bylaws requirements for making such recommendations and the facility bylaws established by the governing body for the review and final determination of such recommendations;

(8) require that applicants be informed of the disposition of their application for medical staff membership or clinical privileges in accordance with the facility bylaws established by the governing body, after an application has been submitted;

(9) review and approve the medical staff bylaws, rules, and regulations;

(10) delegate to the medical staff the authority to:

(A) evaluate the professional competence of medical staff members and applicants for medical staff membership and clinical privileges; and

(B) recommend to the governing body initial medical staff appointments, reappointments, and assignments or curtailments of privileges;

(11) require that resources be made available to address the emotional and spiritual needs of patients either directly or through referral or arrangement with community agencies;

(12) maintain communication with the medical staff which may be established through:

(A) meetings with the executive committee of the medical staff;

(B) service by the president of the medical staff as a member of the governing body with or without a vote;

(D) a joint conference committee that will be a committee of the governing body and the medical staff composed of equal representatives of each of the governing body, the chairman of the board or designee, the medical staff, and the chief of the medical staff or designee, respectively;

(13) require the medical staff to establish controls that are designed to provide that standards of ethical professional practices are met;

(14) provide administrative staff support to facilitate utilization review and infection control within the facility, to support quality control and any other medical staff functions required by this Subchapter or by the facility bylaws;

(15) meet the following disclosure requirements:

(A) provide data required by the Division;

(B) disclose the facility's average daily inpatient charge upon request of the Division; and

(C) disclose the identity of persons owning five percent or more of the facility as well as the facility's officers and members of the governing body upon request;

(16) establish a procedure for reporting the occurrence and disposition of allegations of abuse or neglect of patients and incidents involving quality of care or physical environment at the facility. These procedures shall require that:

(A) incident reports are analyzed and summarized by a designated party; and

(B) corrective action is taken based upon the analysis of incident reports;

(17) in a facility with one or more units, or portions of units, however described, utilized for psychiatric or substance abuse treatment, adopt policies implementing the provisions of G.S. 122C, Article 3, and Article 5, Parts, 2, 3, 4, 5, 7, and 8;

(18) develop arrangements for the provision of extended care and other long-term healthcare services. Such services shall be provided in the facility or by outside resources through a transfer agreement or referrals;

(19) provide and implement a written plan for the care or for the referral, or both, of patients who require mental health or substance abuse services while in the facility;

(20) develop a conflict of interest policy which shall apply to all governing body members and facility administration. All governing body members shall execute a conflict of interest statement; and

(21) conduct direct consultations with the medical staff at least twice during the year.

(b) For the purposes of this Rule, "direct consultations" means the governing body, or a subcommittee of the governing body, meets with the leader(s) of the medical staff(s), or his or her designee(s) either face-to-face or via a telecommunications system permitting immediate, synchronous communication.

(c) The direct consultations shall consist of discussions of matters related to the quality of medical care provided to the hospital's patients, including quality matters arising out of the following:

(1) the scope and complexity of services offered by the facility;

(2) specific clinical populations served by the facility;

(3) limitations on medical staff membership other than peer review or corrective action in individual cases;

(4) circumstances relating to medical staff access to a facility resource; or

(5) any issues of patient safety and quality of care that a hospital's quality assessment and performance improvement program might identify as needing the attention of the governing body in consultation with the medical staff.

(d) For the purposes of this Rule, "specific clinical populations" includes those individuals who may be treated at the facility by the medical staff in place at the time of the consultation.

History Note: Authority G.S. 131E-14.2; 131E-79; 42 CFR 482.12; 42 CFR 482.22;

Eff. January 1, 1996;

Readopted Eff. July 1, 2020.