The proposed amendments and adoptions of rules in Chapters 10A NCAC 13B Licensing of Hospitals and 10A NCAC 13C Licensing of. 10A NCAC 13B – General Requirements: Access and Safety. 10A NCAC 13B – Construction Requirements: Special Care Unit. 10A NCAC 13B MECHANICAL REQUIREMENTS (a) Prior to occupancy of the facility, the facility shall obtain documentation verifying that all mechanical.

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Formal appointment for membership and granting of clinical privileges shall follow procedures set forth in the by-laws, rules or regulations of the medical staff. Each annual report shall be submitted by January 1. Copies of the facilities’ Patient’s Bill of Rights shall be made available through one of the following ways: This report must be written or dictated following surgery and signed by the surgeon in compliance with medical staff rules. The Commission will receive written objections until 5: The rehabilitation aide shall be listed on the North Carolina Nurse Aide Registry and have received additional staff training as listed in Rule.

The provisional license shall remain in effect until:. If the physician restricts the patient’s access to information in the patient’s medical record, the physician shall record the reasons on the patient’s medical record.

Rule Actions

The minimum nursing hours per spinal cord injury patient in the unit shall be 6. The notice shall include:. Nutritional care policies and procedures shall be written by 10w qualified dietitian.


The average negotiated settlement shall be calculated using the average amount charged all patients eligible for the hospital’s financial assistance policy, including self-pay patients. July 13, ; Eff. As used in these Rules, the term physical restraint does not apply to the use of professionally recognized methods for therapeutic holds of brief duration five minutes or less.

The committee shall include but is not limited to:. The medical staff shall ensure that minutes are taken at each meeting and retained in accordance with the policy of the facility.


Return or exhaust air registers shall be near the floor; 2 Bottom of exhaust or return registers shall be no less than 3 inches 7. The number of air changes may be reduced or varied to any extent required for odor control when the space is not in use. Additional adjustments may be needed when space is unused or unoccupied and air systems are de-energized or reduced. The items contained in the ACOT recommendations must be explained to the potential donor in language and terms which he or she can understand and then be signed by the donor and the signature witnessed.

This Rule does not apply to the dispensing of medications from a pharmacy utilizing a unit of use drug delivery system. These policies and procedures shall cover at least the following areas: The beds in this level may serve as a “step-down” ncaf from Level IV. Utilization data shall be submitted annually upon request by the Division. The approval shall be based on an on-site inspection by the Division or by documentation as may be required by the Division.


Patient needs shall be reassessed when warranted by the patient’s condition. Test results shall be maintained in the facility maintenance files. February 1, ; Amended Eff.

September 30, ; Ncwc Amendment Eff. December 1, ; Pursuant to G. Facilities shall have the ability to store and transfuse autologous blood. For purposes of this Section, “Observation bed” means 10w bed used for no more hcac hours, to evaluate and determine the condition and disposition of a patient and is not considered a part of the hospital’s licensed bed capacity.

These minutes shall reflect the transactions, conclusions and recommendations of the meetings.

NC DHSR: Hospital and Ambulatory Surgical Facility Rules

10w Policies and procedures shall include:. A facility using an outside pharmacist or pharmaceutical service must have a contract with that pharmacist or service.

The issuance of a provisional license is not a procedural prerequisite to the revocation of a license pursuant to Subparagraphs e 12 or 3 of this Rule.

Air movement for rooms 1a dashes and non-patient areas may vary as necessary to satisfy the requirements of those spaces. In case of such usage, a legible copy of the laboratory report must be included in the patient record.