Authority: AS 18.20.010
7 AAC 12.210. Medical staff
(a) A hospital described in 7 AAC 12.200
must have a medical staff.
(b) The medical staff shall organize and adopt, with the approval of the governing body, bylaws and rules which provide for
(1) eligibility for medical staff membership, and recommending appointments to the governing body;
(2) appointment of committees, including executive, credentials, medical records, tissue and transfusion, infection control, pharmacy and therapeutics, and utilization review committees, which shall keep written minutes of their meetings, including committee activities and recommendations; and
(3) election of officers, including a chief of staff, and quarterly meetings, with minutes and records of attendance to be maintained for at least five years.
(c) The medical staff shall
(1) recommend annually to the governing body the appointment of and the medical and surgical privileges for each member of the medical staff;
(2) ensure that a physician is available to respond to an emergency at all times;
(3) place each patient under the care of a member of the medical staff;
(4) require that an order of a practitioner, including a telephonic or other oral order, be reduced to writing and, within three days after the order is given, be dated, timed, and either initialed or signed by that practitioner or by another practitioner responsible for the care of the patient, even if the order did not originate with the other practitioner;
(5) ensure that the use of an investigational drug is properly supervised by a member of the medical staff, that an informed consent form provided by the sponsoring company or agency is used, and that complete records on the drug, including protocol and side effects, are maintained;
(6) establish procedures for circumstances in which consultation is required;
(7) establish standards for care by residents, interns, and medical students in accordance with a residency training program approved by the Council on Education of the American Medical Association, the American Dental Association, or applicable specialty boards;
(8) review at regular intervals clinical and scientific work, medical services, and maintenance of accurate medical records;
(9) establish guidelines for referral to a pathologist of tissues removed by surgery; and
(10) ensure that the medical history and physical examination for each patient are completed no more than 30 days before, or 24 hours after, admission; if completed within 30 days before admission, the medical staff must ensure that within 24 hours after admission
(A) an updated history and examination are completed to determine any change in the patient's condition; and
(B) the updated history and examination required under (A) of this paragraph are documented in the patient's medical record, with any change noted.
History: Eff. 11/19/83, Register 88; am 12/3/2006, Register 180; am 9/30/2007, Register 183
Authority: AS 47.32.010
7 AAC 12.215. Psychiatric hospitals
(a) A hospital which is primarily engaged in providing to inpatients psychiatric services for the diagnosis and treatment of mental illness is a psychiatric hospital and must comply with the provisions of this section.
(b) A psychiatric hospital must have the following minimum staff and on-site services, in addition to those required by 7
(1) a medical service, supervised by a physician;
(2) a psychiatric service, supervised by a psychiatrist;
(3) a psychological service, which includes one or more psychologists employed on a full-time, regular part-time, or consulting basis;
(4) a social work service which includes one or more social workers employed on a full-time, part-time or consulting basis, under the direction of the medical staff;
(5) a nursing service, under the direction of a registered nurse who has the following qualifications:
(A) a master's degree in psychiatric nursing or a related field with one year of experience in nursing administration; or
(B) a baccalaureate degree in nursing with 2 years of experience in psychiatric nursing and two years of experience in nursing administration; and
(6) sufficient registered nursing personnel to give direct nursing care, and to plan, supervise, and coordinate care given by other mental health workers.
(c) In addition to the services listed in (b) of this section, a psychiatric hospital must provide the following services, either directly or through a contract with outside providers:
(1) psychological testing and counseling;
(2) assessment, screening and diagnostic services;
(3) individual psychotherapy;
(4) group therapy;
(5) family therapy; and
(6) therapeutic occupational and activity programs.
(d) A psychiatric hospital must have policies and procedures which require that it
(1) have a transfer agreement with a general acute care hospital which includes provision for transfer of a patient's records upon transfer of the patient;
(2) admit and discharge patients in accordance with AS 47.30;
(3) provide for each patient a written treatment plan, developed with the patient's participation as far as practicable, which incorporates a comprehensive interdisciplinary approach based on the patient's medical, social, and psychiatric or psychological evaluations;
(4) include as part of each patient's evaluation
(A) a medical history;
(B) a history of the current onset of illness, including the circumstances leading to admission;
(C) a description of the patient's current mental status, including attitudes, behavior, intellectual and memory functioning, and orientation;
(D) a descriptive inventory of the patient's assets; and
(E) if the patient is a child or adolescent, a report on the patient's developmental as well as chronological age;
(5) provide organized therapeutic activities with consideration for the interests and needs of the patients;
(6) document in each patient's medical record the patient's attitude and response to treatment;
(7) establish and implement guidelines for use of physical restraints and seclusion rooms which include the following requirements:
(A) the location of a seclusion room which allows for direct supervision and observation by staff;
(B) construction of a seclusion room which minimizes opportunity for concealment, escape, injury, or suicide, including locks and doors which open outwards;
(C) recording in a patient's medical record the time the patient spent in seclusion or restraints;
(D) visiting a patient who is in restraints or seclusion at least hourly, and providing the patient with adequate opportunity for exercise, access to bathroom facilities, and time out of restraints or seclusion;
(E) limiting the use of restraints or seclusion to situations in which alternative means will not protect the patient or others from injury; and
(F) when practicable, consultation with the patient regarding the patient's preference among available forms of adequate, medically advisable restraints, including medication;
(8) establish and implement guidelines for administration of a drug when given in an unusually high dose or when given for a purpose other than that for which the drug is customarily used, and for circumstances under which electroconvulsive shock therapy may be administered;
(9) provide that each treatment unit within the hospital keeps a confidential log of all referrals it initiates or receives;
(10) provide an area in which a patient can meet with an outside community service provider and other hospital personnel who assist in fulfilling the goals and objectives of the treatment plan;
(11) have a committee of the medical staff periodically evaluate the services provided and make appropriate recommendations to the medical staff and administration; and
(12) establish and implement
(A) controls for contraband;
(B) security controls and management for potentially dangerous individuals, and for patients committed before October 1, 1982 under
and after September 30, 1982 under AS 12.47;
(C) preventive measures for suicide or self-harm;
(D) admission criteria for a psychiatric security unit; and
(E) controls for storage and handling of police officers' weapons.
(e) If a psychiatric hospital permits human subject research, it must
(1) have written policies which describe the purpose and conduct of all research using the hospital's staff, patients, or services, and which require that
(A) written agreements entered into by subjects do not include exculpatory language through which the subject waives any legal rights or which releases the hospital or its staff from liability for negligence;
(B) when research findings are made public, the anonymity of individual patients is assured; and
(C) when bodily integrity is violated, including by the use of electroconvulsive shock therapy and chemotherapy, supervision be provided by a physician; and
(2) establish an interdisciplinary review committee comprised of both hospital staff members and other knowledgeable persons, for the purpose of reviewing research activities within the facility.
(f) If a psychiatric hospital provides aftercare service, that service must include a written individualized treatment plan designed to establish continuing contact for the care of each patient and explain the risks, benefits, and side effects of medication programs to the patient.
(g) A psychiatric hospital must provide for educational or training programs for all children of school age who are educable or trainable and who are expected to be patients for longer than one month. The programs must
(1) conform to educational requirements established by law and be under direction of teachers certified to teach in Alaska; and
(2) if provided by a public school system, include provisions for transportation of the patients to and from school and supervision of them during the transportation.
History: Eff. 11/19/83, Register 88
Authority: AS 18.20.010
7 AAC 12.220. Substance abuse hospitals
(a) A hospital or unit of a hospital which is operated for the primary purpose of treatment of alcoholism or substance abuse through an integrated program of medical, psychological, and social evaluation and services, and in which the major portion of the required evaluation and services is furnished within the facility is a substance abuse hospital, and must comply with the provisions of this section.
(b) A substance abuse hospital must have written policies, which are available to the public upon request, regarding admission criteria and treatment methods.
(c) A substance abuse hospital must provide the following medical staff and services in addition to those required by 7
(1) continuous supervision during the detoxification process by a physician or by registered nurse under the direct supervision of a physician;
(2) supervision by a physician or by a registered nurse under the direct supervision of a physician during the diagnosis and treatment of medical and psychiatric illnesses derived from or associated with substance abuse;
(3) a social or psychological evaluation that includes the drinking or substance abuse history of the patient, and a determination of current mental and emotional state, cultural background, vocational history, familial relationships, educational background, socio-economic status, and a descriptive inventory of the patient's assets;
(4) a medical evaluation;
(5) an individualized treatment plan that is based upon the social or psychological and medical evaluations, and which
(A) includes short- and long-term treatment goals, and estimated duration of treatment and a discharge plan; and
(B) is, whenever practicable, developed with the participation of the patient;
(6) organized therapeutic activities, developed with consideration for the interests and needs of the patients; and
(7) an area in which patients can meet with outside community service providers and other program personnel who assist in fulfilling the goals and objectives of the treatment plan.
(d) A committee of the medical staff shall periodically evaluate the services provided and make appropriate recommendations to the medical staff and administration.
(e) A substance abuse hospital must have written policies regarding the use of restraints which include the following requirements:
(1) recording in a patient's medical record the time the patient spent in restraints;
(2) visiting a patient who is in restraints at least hourly, and providing the patient with adequate opportunity for exercise, access to bathroom facilities, and time out of restraints; and
(3) limiting the use of restraints to situations in which alternative means will not protect the patient or others from injury.
(f) A substance abuse hospital must routinely report on patient outreach services and recommendations to any individual, agency, or organization that has assisted in the identification or referral of a substance abuse patient.
History: Eff. 11/19/83, Register 88
Authority: AS 18.20.010
7 AAC 12.225. Rehabilitation hospitals
(a) A rehabilitation hospital or unit of a hospital that is operated primarily for the purpose of assisting in the restoration of persons with physical disabilities, communication, language, or self-image disorders, through an integrated program of medical, psychological, social, and vocational evaluation and services, and in which the major portion of the evaluation and services is furnished within the facility, is a rehabilitation hospital and must comply with the provisions of this section.
(b) A rehabilitation hospital must provide, in addition to services required in 7 AAC 12.205,
physical therapy and occupational therapy services.
(c) A physician who is certified by the American Board of Physical Medicine and Rehabilitation must have responsibility for the general direction and supervision of the medical services provided and the coordination of all services provided.
(d) An inpatient must be under the care of a member of the medical staff.
(e) A patient at a rehabilitation hospital must receive a written evaluation, testing, and an individualized treatment plan, which includes short- and long-term goals, the estimated duration of treatment, and a discharge plan. When practicable, the individualized treatment plan must be developed with the participation of the patient.
(f) Staff members who are involved in the care of a patient shall hold a patient care review conference as often as needed to coordinate rehabilitation and medical services provided to the patient. The treatment plan and goals must be reevaluated periodically, based on a reassessment of the patient's status within 7 to 14 calendar days of the initial assessment, and within 7 to 14 calendar days of each subsequent reassessment unless, in the treating physician's discretion, a subsequent reassessment is deferred beyond 14 calendar days. If the treating physician determines that a subsequent reassessment is to be deferred beyond 14 calendar days, the basis for that determination must be included in the patient's medical record.
(g) Patient participation in a treatment plan, and any involvement by the patient's family in that plan, must be recorded in the patient's medical record.
History: Eff. 11/19/83, Register 88
Authority: AS 18.20.010
Editor's note: With Register 179, October 2006 and under the authority of
, the regulations attorney changed obsolete terminology concerning persons with disabilities in conformity with ch. 25, SLA 2006.
255. Services required.
258. Use of restraints or psychoactive drugs.
260. Medical director.
265. Physician services.
270. Staff duties.
275. Nursing and medical services.
280. Rehabilitation services.
285. Activity program.
290. Drug regimen review.
7 AAC 12.250. Scope
A facility that is not an acute care hospital and that provides nursing care and related medical services over a period of 24 hours each day to individuals admitted because of illness, disease, or physical infirmity is a nursing facility, and must comply with 7 AAC 12.250
- 7 AAC 12.290.