Hospital Licensure - AHCA

[Pages:292]ST - H0000 - INITIAL COMMENTS

Title INITIAL COMMENTS Type Memo Tag

Agency for Health Care Administration

ASPEN: Regulation Set (RS)

Aspen State Regulation Set: H 6.08 HOSPITAL LICENSURE

Printed 09/09/2021

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Regulation Definition

ST - H0001 - Child Abuse & Neglect - Policy Adoption

Title Child Abuse & Neglect - Policy Adoption Type Rule

59A-3.280(1) FAC; 395.1023(1) FS

Regulation Definition 59A-3.280 (1) Every licensed hospital admitting or treating shall adopt and incorporate a policy that requires every staff member to report any case of actual or suspected child abuse or neglect pursuant to chapter 39, F.S. 395.1023 Each licensed facility shall adopt a protocol that, at a minimum, requires the facility to: (1) Incorporate a facility policy that every staff member has an affirmative duty to report, pursuant to chapter 39, any actual

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Interpretive Guideline These guidelines are meant solely to provide guidance to surveyors in the survey process. Add the most current Baker Act Regulation Set to the survey if the Hospital is a designated Baker Act Receiving Facility. To generate a list, use AHCA's Florida Health Finder website and filter by provider type and check the box at the bottom for "Baker Act Receiving Facility".

Interpretive Guideline - Request the Child Abuse and Neglect Policy. - Review that the policy mandates that every staff member report actual or suspected child abuse or neglect to the Department of Children and Family Services Abuse Registry. - Interview staff to determine how this policy of mandated reporting is distributed to staff . - Interview staff to ascertain their knowledge of when, how, where, and what to report to DCF (1-800-962-2873).

Agency for Health Care Administration

ASPEN: Regulation Set (RS)

Printed 09/09/2021

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Aspen State Regulation Set: H 6.08 HOSPITAL LICENSURE

or suspected case of child abuse, abandonment, or neglect

ST - H0002 - Child Abuse & Neglect - Report A/N to DCF

Title Child Abuse & Neglect - Report A/N to DCF Type Rule

59A-3.280(1)(a) FAC

Regulation Definition

(1) Every licensed hospital admitting or treating shall adopt and incorporate a policy that requires every staff member to report any case of actual or suspected child abuse or neglect pursuant to chapter 39, F.S.

Interpretive Guideline

- Request and review the hospital policy and procedure for reporting suspected child abuse/neglect - Request any cases of alleged child abuse/neglect from the Risk Manager. - Review for immediate and appropriate reporting.

(a) Each report of actual or suspected child abuse or neglect shall be made immediately to the Department of Children and Family Services' Florida Abuse Hotline, statewide toll free number 1(800)962-2873 or to the local office of the Department of Children and Family Services responsible for investigating such reports.

ST - H0003 - Child Abuse & Neglect -Report To Med Examiner

Title Child Abuse & Neglect -Report To Med Examiner Type Rule

59A-3.280(1)(b) FAC

Regulation Definition

(b) Any person required to report suspected child abuse or neglect, who has reasonable cause to suspect that a child died as a result of abuse or neglect, shall report his suspicion to the local medical examiner.

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Interpretive Guideline

- Request and review records concerning suspected and actual child abuse or neglect resulting in death. - Verify report of such suspicions to Medical Examiner. - Review Child Abuse & Neglect Policy for the specific reporting of a death to the local/appropriate medical examiner. - Review policy for clarity as to where to report.

Agency for Health Care Administration

ASPEN: Regulation Set (RS)

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Aspen State Regulation Set: H 6.08 HOSPITAL LICENSURE

- Interview staff for knowledge of this policy.

ST - H0004 - Child Abuse & Neglect - Physician Liaison

Title Child Abuse & Neglect - Physician Liaison Type Rule

59A-3.280(2) FAC; 395.1023(2) FS

Regulation Definition

59A-3.280 (2) Each hospital admitting or treating children shall designate, at the request of the Department of Children and Family Services, a staff physician, ARNP or PA to act as a liaison between the hospital, the child protective investigator and the child protection team.

395.1023 Each licensed facility shall adopt a protocol that, at a minimum, requires the facility to: (2) In any case involving suspected child abuse, abandonment, or neglect, designate, at the request of the department, a staff physician to act as a liaison between the hospital and the Department of Children and Families office which is investigating the suspected abuse, abandonment, or neglect, and the Child Protection Team, as defined in s. 39.01, when the case is referred to such a team.

ST - H0005 - Child Abuse & Neglect - Policy Reporting

Title Child Abuse & Neglect - Policy Reporting Type Rule

59A-3.280(3) FAC

Interpretive Guideline

- Review documentation for a protocol re: appointment of a physician liaison. - Review documentation to ensure that, in instances in which DCF has so requested, the facility has actually appointed a qualified individual to serve as the physician liaison (interview physician as appropriate)

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Agency for Health Care Administration

ASPEN: Regulation Set (RS)

Printed 09/09/2021

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Aspen State Regulation Set: H 6.08 HOSPITAL LICENSURE

Regulation Definition

(3) Child Abuse and Neglect Policy Reporting. Each hospital admitting or treating children shall formulate a child abuse and neglect policy and shall submit a copy of this policy to the Department of Children and Family Services, Office of Family Safety, 1317 Winewood Boulevard - Building 1, Tallahassee, Florida 32399-0700.

Interpretive Guideline

-Verify the submission of the facility Child Abuse and Neglect Policy to the Department of Children and Family Services, Office of Family Safety.

ST - H0006 - Child Abuse & Neglect - Copy of Policy Sent

Title Child Abuse & Neglect - Copy of Policy Sent Type Rule

59A-3.280(4) FAC; 395.1023(2) FS

Regulation Definition

59A-3.280(4) Remedies. Failure to comply with these rules will result in a fine being imposed in accordance with the provisions of Sections 395.1023 and 39.205, F.S.

395.1023(2) ... Each general hospital and appropriate specialty hospital shall comply with the provisions of this section and shall notify the agency and the department of its compliance by sending a copy of its policy to the agency and the department as required by rule. The failure by a general hospital or appropriate specialty hospital to comply shall be punished by a fine not exceeding $1,000, to be fixed, imposed, and collected by the agency. Each day in violation is considered a separate offense.

Interpretive Guideline

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Agency for Health Care Administration

ASPEN: Regulation Set (RS)

Printed 09/09/2021

Aspen State Regulation Set: H 6.08 HOSPITAL LICENSURE

ST - H0007 - COMPREHENSIVE EMERGENCY MANAGEMENT PLAN

Title COMPREHENSIVE EMERGENCY MANAGEMENT PLAN Type Rule

59A-3.078(2, 4-6 & 8-10); 395.1056(1)

Regulation Definition

59A-3.078 Comprehensive Emergency Management Plan. (2) The emergency management plan shall be developed in conjunction with other agencies and providers of health care services within the local community pursuant to section 395.1055(1)(c), F.S., and in accordance with the "Emergency Management Planning Criteria for Hospitals," AHCA Form 3130-8005-September 94, which is incorporated by reference. The form is available from the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #31, Tallahassee, Florida 32308. The plan shall include: (a) Provisions for internal and external disasters and emergencies; (b) A description of the hospital's role in community wide emergency management plans; (c) Information about how the hospital plans to implement specific procedures outlined in the hospital's emergency management plan; (d) Precautionary measures, including voluntary cessation of hospital admissions, to be taken by the hospital in preparation and response to warnings of inclement weather, or other potential emergency conditions; (e) Provisions for the management of patients, including the discharge of all patients that meet discharge requirements, in the event of an evacuation order, at the direction of the hospital administrator, or when a determination is made by the Agency that the condition of the facility or its support services is sufficient to render it a hazard to the health and safety of

oRegSet.rpt

Interpretive Guideline

- Verify there is a plan approved by the county emergency management agency on file in the facility. - Where is the plan located? Is it immediately accessible by hospital staff? [59A-3.078 (5)] - Has the hospital tested the implementation of the CEMP as required? - Review required staff training. - Interview personnel regarding their role during emergencies.

59A-3.303(6), FAC refers to Intensive Residential Treatment Programs.

Refer to CORE Tag Z830 for additional requirements.

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Agency for Health Care Administration

ASPEN: Regulation Set (RS)

Aspen State Regulation Set: H 6.08 HOSPITAL LICENSURE

patients and staff, pursuant to chapter 59A-3, F.A.C. Such provisions shall address moving patients within the hospital and relocating patients outside the hospital, including the roles and responsibilities of the physician and the hospital in the decision to move or relocate patients whose life or health is threatened; (f) Education and training of personnel in carrying out their responsibilities in accordance with the adopted plan; (g) A provision for coordinating with other hospitals that would receive relocated patients; (h) Provisions for the management of staff, including the distribution and assignment of responsibilities and functions, and the assignment of staff to accompany those patients located at off-site locations; (i) Provisions for the individual identification of patients, including the transfer of patient records; (j) Provisions to ensure that a verification check will be made to ensure relocated patients arrive at designated hospitals; (k) Provisions to ensure that medication needs will be reviewed and advance medication for relocated patients will be forwarded to respective hospitals, when permitted by existing supplies, and state and federal law; (l) Provisions for essential care and services for patients who may be relocated to the facility during a disaster or an emergency, including staffing, supplies and identification of patients; (m) Provisions for contacting relatives and necessary persons advising them of patient location changes. A procedure must also be established for responding to inquiries from patient families and the press; (n) Provisions for the management of supplies, communications, power, emergency equipment, security, and the transfer of records; (o) Provisions for coordination with designated agencies including the Red Cross and the county emergency

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Agency for Health Care Administration

ASPEN: Regulation Set (RS)

Aspen State Regulation Set: H 6.08 HOSPITAL LICENSURE

management office; and, (p) Plans for the recovery phase of the operation, to be carried out as soon as possible.

(4) The hospital shall test the implementation of the emergency management plan semiannually, either in response to a disaster or an emergency or in a planned drill, and shall evaluate and document the hospital's performance to the hospital's safety committee. As an alternative, the hospital may test its plan with the frequency specified by an accrediting organization.

(5) The emergency management plan shall be located for immediate access by hospital staff.

(6) In the event a disaster or emergency conditions have been declared by the local emergency management authority, and the hospital does not evacuate the premises, a facility may provide emergency accommodations above the licensed capacity for patients. However, the following conditions must be met: (a) The facility must report being over capacity and the conditions causing it to the Agency area office within 48 hours or as soon as practical. As an alternative, the facility may report to the Agency central office, Hospital and Outpatient Services Unit, at (850)412-4549; (b) Life safety cannot be jeopardized for any individual; (c) The essential needs of patients must be met; and, (d) The facility must be staffed to meet the essential needs of patients.

(8) If a facility evacuates during or after a disaster or an emergency situation, the facility shall not be reoccupied until a determination is made by the hospital administrator that the facility can meet the needs of the patients.

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Agency for Health Care Administration

ASPEN: Regulation Set (RS)

Aspen State Regulation Set: H 6.08 HOSPITAL LICENSURE

(9) A facility with significant structural damage shall relocate patients until approval is received from the Agency's Office of Plans and Construction that the facility can be safely reoccupied, in accordance with rule 59A-3.080, F.A.C.

(10) A facility that must evacuate the premises due to a disaster or emergency conditions shall report the evacuation to the Agency area office within 48 hours or as soon as practical. The administrator or designee is responsible for knowing the location of all patients until the patient has been discharged from the facility. The names and location of patients relocated shall be provided to the local emergency management authority or it's designee having responsibility for tracking the population at large. The licensee shall inform the Agency area office of a contact person who will be available 24 hours a day, seven days a week, until the facility is reoccupied.

395.1056(1)(a) Those portions of a comprehensive emergency management plan that address the response of a public or private hospital to an act of terrorism as defined by s. 775.30 held by the agency, a state or local law enforcement agency, a county or municipal emergency management agency, the Executive Office of the Governor, the Department of Health, or the Division of Emergency Management are confidential and exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution. (b) Information made confidential and exempt by this subsection may be disclosed by a custodial agency to another state or federal agency to prevent, detect, guard against, respond to, investigate, or manage the consequences of any attempted or actual act of terrorism, or to prosecute those persons who are responsible for such attempts or acts. (c) Portions of a comprehensive emergency management plan that address the response of a public or private hospital to an

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