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Title 15: Mississippi State Department of Health
Part 16: Health Facilities
Subpart 1: Health Facilities Licensure and Certification
CHAPTER 41 MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI HOSPITALS
Subchapter 1 AUTHORITY AND LICENSE
Rule 41.1.1. Adoption of Regulations and Minimum Standards. By virtue of authority vested in
it by the Mississippi Code Annotated Sections 41-9-1 through 41-9-35, or as otherwise
amended, the Mississippi Department of Health does hereby adopt and promulgate the
following regulations and standards for hospitals.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 2 DEFINITIONS
Rule 41.2.1. Hospital. “Hospital means a place devoted primarily to the maintenance and operation
of facilities for the diagnosis, treatment and care of individuals suffering from physical
or mental infirmity, illness, disease, injury or deformity, or a place devoted primarily to
providing obstetrical or other medical, surgical, or nursing care of individuals, whether
any such place be organized or operated for profit and whether any such place be
publicly or privately owned. The term “hospital” does not include convalescent or
boarding homes, children’s homes, homes for the aged or other like establishments
where room and board only are provided, nor does it include offices or clinics where
patients are not regularly kept as bed patients.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.2.2. Person. “Person means any individual, firm, partnership, corporation, company,
association or joint stock association, and the legal successor thereof.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.2.3. Governmental Unit. “Governmental Unit” means the state, or any county,
municipality or other political subdivision or any department, division, board, or
other agency of any of the foregoing, excluding all federal establishments.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.2.4. Licensing Agency. “Licensing agency” means the Mississippi Department of
Health.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.2.5. License. No person or governmental unit shall establish, conduct, or maintain a
hospital in this state without a license.
Provisional License. Within its discretion, the Mississippi State Department of Health
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may issue a provisional license when a temporary condition of non-compliance with
these regulations exists in one or more particulars. A provisional license shall be issued
only if the Department of Health is satisfied that preparations are being made to qualify
for a regular license and that the health and safety of patients will not be endangered.
The license issued under this condition shall be valid until the issuance of a regular
license but shall not exceed five months following date of issuance whichever may be
sooner.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.2.6. Application for License. An application for a license shall be made to the
licensing agency upon forms provided by the licensing agency and shall contain
such information as the licensing agency reasonably requires.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.2.7. Licensure Fees. Each initial and renewal licensure application, unless
suspended or revoked, shall be accompanied by a fee as set by the Board, made
payable to the Mississippi State department of Health, either by business check,
money order, or electronic means. Renewal of licenses shall occur on an annual
basis. Fees are non-refundable.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.2.8. User Fee. A “user fee” in an amount set by the Board, shall be assessed by the
licensing agency for the purpose of the required reviewing and inspections of the
proposal of any hospital in which there are additions, renovations,
modernizations, expansion, alterations, conversions, modifications or replacement
of the entire facility involved in the proposal. This fee includes the reviewing of
architectural plans in all required steps. Fees are to be made payable to the
Mississippi State Department of Health, and paid by either a business check,
money order, or electronic means.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.2.9. Renewal of License. A license, unless suspended or revoked, shall be renewable
annually, upon filing by the licensee, and approval by the licensing agency of an
annual report upon such uniform dates and containing such information as the
licensing agency requires and upon paying the annual fee for such license.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.2.10. Issuance of License. Each license shall be issued only for the premises and
persons or governmental units names in the application and shall not be
transferable or assignable except with the written approval of the licensing
agency.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.2.11. Posting of License. Licenses shall be posted in a conspicuous place on the
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licensed premises.
Rule 41.2.12. Trauma Registry. Collection of data on patients who receive hospital care for
certain types of injuries. Such data are primarily designed to ensure quality of
trauma care and outcomes in individual institutions and trauma systems but have the
secondary purpose of providing useful data for the surveillance of injury,
morbidity, and mortality.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 3 DENIAL OR REVOCATION OF LICENSE.
Rule 41.3.1.
The licensing agency, after notice and opportunity for hearing to the applicant or
licensee, is authorized to deny, suspend, or revoke a license in any case in which
it finds that there has been a substantial failure to comply with the requirements
established in these regulations and standards.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 4 ADMINISTRATION:
OWNERSHIP
Rule 41.4.1. There shall be full disclosure of hospital ownership and control. In its Initial
Application for Hospital License the hospital shall disclose:
1. The ownership of the hospital, including the names and addresses of the
following: all stockholders, if the owner is a corporation; the partners, if
the owner is a partnership; or the owner(s), if individually owned.
2. The name, address, and capacity of each officer and each member of the
governing body, as well as the individual(s) directly responsible for the
operation of the hospital.
3. Owner's proof of financial ability for continuous operation.
4. The name and address of the resident agent for service of process within the
State of Mississippi if the owner shall not reside or be domiciled in the State
of Mississippi.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.4.2. Annually in its Application for Renewal of Hospital License the hospital shall
report:
1. The name and address of the owner.
2. The name and address of the operator.
3. The name, address and capacity of each officer and each member of the
governing body, as well as the individual(s) responsible for the operation
of the hospital.
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Rule 41.4.3. When any changes shall be made in the constituency of the governing body, the
officers, or the individual(s) directly responsible for the operation of the hospital,
the hospital shall notify the licensing agency in writing within 15 days of such
changes and shall also furnish to it a certified copy of that portion of the minutes
of the governing body dealing with such changes.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.4.4. When change of ownership of a hospital is contemplated, the hospital shall notify
the licensing agency in writing at least 30 days prior to the proposed date of
change of ownership, giving the name and address of the proposed new owner.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.4.5. The hospital shall notify the licensing agency in writing within 24 hours after any
change of ownership and shall surrender its license there with.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 5 GOVERNING AUTHORITY
Rule 41.5.1. The hospital shall have an organized governing body, or designated person(s) so
functioning, that has overall responsibility for the conduct of the hospital in a
manner consistent with the objective of making available high quality patient
care. The governing body shall be the supreme authority in the hospital,
responsible for the management of the hospital and appointment of the medical
staff. The governing body shall adopt bylaws in accordance with legal
requirements and with its community responsibility, identifying the purposes of
the hospital and the means of fulfilling them, and shall at least:
1. Be in writing available to all members of the governing body.
2. Contain the name of the governing body.
3. State the manner in which the members of the governing body, the officers
and the administrative personnel are selected, the terms for which they are
elected or appointed, and their duties and responsibilities.
4. Specify to whom authority for operation and maintenance of the hospital,
including evaluation of hospital practices, may be delegated; and the
methods established by the governing body for holding such individuals
responsible.
5. Provide a schedule of meetings of the governing body at sufficiently
frequent intervals to permit it an evaluation of the performance of the
hospital as an institution and to carry on necessary planning for the proper
developments and growth of the hospital, with written minutes to be kept
of all such meetings.
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6. Provide the method of appointment, re-appointment, and removal of
members of the medical staff.
7. Provide mechanisms for the formal approval of the organization, bylaws,
and rules and regulations of the medical staff and its department in the
hospital.
Facility Discontinuation/Closure of Service:
1. Discontinuation of Service: Facilities proposing the closure/discontinuation of
patient medical care services that are listed on the facility’s hospital licensure
application and/or a Certificate of Need (CON) regulated service, shall notify the
Department in writing a minimum of 30 days prior to closure and include the
effective closure date. The notification to the Department shall include, but is not
limited to:
A. The type of services that will no longer be provided due to closure;
B. The reason for closure;
C. The location where the patients have been/will be transferred;
D. The plan for storage of patient medical records; and
E. Plan for notifying the public.
2. Closure: Facilities proposing the permanent closure of a hospital shall notify the
Department in writing at of the intent to close a minimum of 30 days in advance of
the closure date. The notice of closure shall include, but is not limited to:
A. Effective date of permanent closure;
B. The number of beds eliminated;
C. Summary of services being eliminated;
D. A description of the nearest available comparable services in the community;
E. The Plan for the maintenance and retention of the patient medical records; and
F. On the date of closure, the license shall be returned to Department.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 6 MANAGEMENT
Rule 41.6.1. The governing body shall appoint an administrator whose, authority, and duties
shall be defined in a written statement adopted by the governing body, the
medical staff and all other branches and departments of the hospital. An
administrator appointed on or after February 14, 2005, shall have at least a
bachelor’s degree and one (1) year experience in a health-related field.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.6.2. The administrator shall be vested with sufficient authority to adequately perform
all of the duties and responsibilities of his position, both written and implied.
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SOURCE: Miss. Code Ann. §41-9-17
Rule 41.6.3. The governing body, through the administrator, shall provide appropriate physical
resources and personnel required to meet the needs of the patients, and shall
participate in planning to meet the health needs of the community.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.6.4. The governing body, through its administrator, shall take all reasonable steps to
comply with all applicable federal, state, and local laws and regulations.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.6.5. The governing body, through its administrator, shall provide for the control and
use of the physical and financial resources of the hospital.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.6.6. The governing body shall delegate to the medical staff the authority to evaluate
the professional competence of staff members and applicants for medical staff
membership and/or clinical privileges. It shall hold the medical staff responsible
for making recommendations to the governing body concerning initial staff
appointments, re-appointments, removals and/or assignment or curtailment of
clinical privileges.
SOURCE: Miss. Code Ann. §41-9-17
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Rule 41.6.7. The governing body shall have the authority and responsibility for the
appointment, reappointment, and removal of the members of the medical staff
and other practitioners who have been granted clinical privileges.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.6.8. Appointment, reappointment, and removal of the members of the medical staff
and other practitioners with clinical privileges shall be based upon well-defined
written criteria set forth in the bylaws.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.6.9. The governing body shall utilize the advice of the medical staff in granting and
defining the scope of clinical privileges to individual physicians, dentists and
other practitioners requesting clinical privileges. If the medical staff does not
include a physician or practitioner of the same specialty, the medical staff shall
consult with the appropriate licensure boards regarding scope of practice before
making recommendations to the governing body regarding clinical privileges.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.6.10. No applicant shall be denied medical staff privileges in any publicly owned
hospital on the basis of any criteria lacking professional justification.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.6.11. A mechanism shall be established in the bylaws for review by a joint committee
when the governing body disagrees with the recommendations of the medical
staff.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.6.12. All physicians, dentists and other practitioners applying for medical staff
membership and/or clinical privileges must sign an agreement to abide by the
medical staff by-laws and rules and regulations.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.6.13. The governing body shall inform applicants for medical staff membership and/or
clinical privileges of the disposition of their application in a reasonable time.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.6.14. The medical staff bylaws and rules and regulations shall be subject to governing
body approval, which shall not be unreasonably withheld. These shall include an
effective formal means for the medical staff to participate in the development of
hospital policy relative to patient care.
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SOURCE: Miss. Code Ann. §41-9-17
Rule 41.6.15. The governing body shall require that the medical staff establish controls that are
designed to insure the achievement and maintenance of high standards of
professional ethical practices, and shall:
1. Establish policies that ensure that only members of the medical staff dental
staff or other practitioners designated by the governing body admit patients
to the hospital.
2. Ensure that a physician member of the medical staff is responsible for the
care of each patient with respect to any medical or psychiatric problem that
is present on admission or develops during hospitalization and is not
specifically within the scope of practice of other practitioners with clinical
privileges as defined by State law.
3. Each individual hospital in the state shall decide by its "credentialing
committee", or by whatever name it uses for the functions of credentialing,
whether or not it chooses to abide by the amendments as set out in Chapters
1, 2, 3, and 4 hereof, as pertaining to dental staff.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.6.16. If it shall be the policy of the hospital for physicians rendering consecutive
services under contract with the hospital to bill hospital patients separately for
their services, all hospital patients shall be advised, upon entering or prior to
leaving the hospital, that they may expect a separate and additional bill for any
such services as may have been rendered them.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.6.17. Criminal History Record Checks.
1. Employee. For the purpose of fingerprinting and criminal background
history checks, employee shall mean any individual employed by a covered
entity. The term employee”, also includes any individual who by contract
with the covered entity provides direct patient care in a patient’s, resident’s,
or client’s room or in treatment rooms.
The term employee does not include healthcare professional/technical
students, as defined in Section 37-29-232, performing clinical training in a
licensed entity under contracts between their schools and the licensed entity,
and does not include students at high schools who observe the treatment and
care of patients in
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a licensed entity as part of the requirements of an allied health course taught in
the school if:
A. The student is under the supervision of a licensed healthcare
provider; and
B. The student has signed the affidavit that is on file at the student’s
school stating that he or she has not been convicted of or plead
guilty or nolo contendere to a felony of possession or sale of drugs,
murder, manslaughter, armed robbery, rape, sexual battery, any sex
offenses listed in section 45-33-23 (g), child abuse, arson, grand
larceny, burglary, gratification of lust, aggravated assault, or
felonious abuse and/or battery of a vulnerable adult, or that any
such conviction or plea was reversed on appeal or a pardon was
granted for the conviction or plea.
C. Further, applicants and employees of the University of Mississippi
Medical Center for whom criminal history record checks and
fingerprinting are obtained in accordance with Section 37-115-41
are exempt from application of the term employee under Section
43-11-13.
2. Covered Entity. For the purpose of criminal history record checks,
“covered entity” means a licensed entity or a healthcare professional
staffing agency.
3. Licensed Entity. For the purpose of criminal history record checks, the
term “licensed entity” means a hospital, nursing home, personal care
home, home health agency or hospice.
4. Health Care Professional/Vocational Technical Academic Program. For
the purpose of criminal history record checks, “health care
professional/vocational
technical academic program” means an academic program in medicine,
nursing, dentistry, occupational therapy, physical therapy, social services,
speech therapy, or other allied-health professional whose purpose is to prepare
professionals to render patient care services.
5. Health Care Professional/Vocational Technical Student. For purposes of
criminal history record checks, the term means a student enrolled in a
healthcare professional/vocational technical academic program.
6. Direct Patient Care or Services. For purposes of fingerprinting and criminal
background history checks, the term “direct patient care” means direct hands-
on medical patient care and services provided by an individual in a patient,
resident or client’s room treatment room or recovery room. Individuals
providing direct patient care may be directly employed by the facility or
provides patient care on a contractual basis.
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7. Documented Disciplinary Action. For the purpose of fingerprinting and
criminal background history checks, the term “documented disciplinary action”
means any action taken against an employee for abuse or neglect of a patient.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.6.18. Criminal History Record Checks.
1. Pursuant to Section 43-11-13, Mississippi Code of 1972, the covered entity
shall require to be performed a disciplinary check with the professional
licensing agency, if any, for each employee to determine if any disciplinary
action has been taken against the employee by the agency, and a criminal
history record check on:
A. Every new employee of a covered entity who provides direct patient care or
services; and
B. Any individual seeking new employment with a covered entity whose
initial criminal history record check is over two years old.
2. Except as otherwise provided in this paragraph, no employee hired on or
after July 01, 2003, shall be permitted to provide direct patient care until the
results of the criminal history record check revealed no disqualifying record
or the employee has been granted a waiver. Provided the covered entity has
documented evidence of submission of fingerprints for the background
check, any person may be employed and provide direct patient care on a
temporary basis pending the results of the criminal history record check but
any employment offer, contract, or arrangement with the person shall be
voidable, if he/she receives a disqualifying criminal record check, and no
waiver is granted.
3. If such criminal history record check discloses a felony conviction; a guilty
plea; and/or a plea of nolo contendere to a felony for one (1) or more of the
following crimes which has not been reversed on appeal, or for which a
pardon has not been granted, the applicant/employee shall not be eligible
to be employed at the licensed facility:
A. possession or sale of drugs
B. murder
C. manslaughter
D. armed robbery
E. rape
F. sexual battery
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G. sex offense listed in Section 45-33-23(g), Mississippi Code of 1972
H. child abuse
I. arson
J. grand larceny
K. burglary
L. gratification of lust
M. aggravated assault
N. felonious abuse and/or battery of vulnerable adult
4. Documentation of verification of the employee’s disciplinary status, if any,
with the employee’s professional licensing agency as applicable, and
evidence of submission of the employee’s fingerprints to the licensing
agency must be on file and maintained by the facility prior to the new
employees first date of
employment. The covered entity shall maintain on file evidence of
verification of the employee’s disciplinary status from any applicable
professional licensing agency and of submission and/or completion of the
criminal record check, the signed affidavit, if applicable, and/or a copy of
the referenced notarized letter addressing the individual’s suitability for such
employment.
5. Pursuant to Section 43-11-13, Mississippi Code of 1972, the licensing
agency shall require every employee of a covered entity employed prior to
July 01, 2003, to sign an affidavit stating that he or she does not have a
criminal history as outlined in paragraph (c) above.
6. From and after December 31, 2003, no employee of a covered entity hired
before July 01, 2003, shall be permitted to provide direct patient care
unless the employee has signed an affidavit as required by this section. The
covered entity shall place the affidavit in the employee’s personnel file as
proof of compliance with this section.
7. If a person signs the affidavit required by this section, and it is later
determined that the person actually had been convicted of or pleaded guilty
or nolo contendere to any of the offenses listed herein, and the conviction or
pleas has not been reversed on appeal or a pardon has not been granted for
the conviction or plea, the person is guilty of perjury as set out in Section
43-11-13, Mississippi Code of 1972. The covered entity shall immediately
institute termination proceedings against the employee pursuant to the
facility’s policies and procedures.
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8. The covered entity may, in its discretion, allow any employee unable to sign
the affidavit required by paragraph (g) of this subsection or any employee
applicant aggrieved by the employment decision under this subsection to
appear before the covered entity’s hiring officer, or his or her designee, to
show mitigating circumstances that may exist and allow the employee or
employee applicant to be employed at the covered entity. The covered
entity, upon report and recommendation of the hiring officer, may grant
waivers for those mitigating circumstances, which shall include, but not be
limited to: (1) age at which the crime was committed; (2) circumstances
surrounding the crime; (3) length of time since the conviction and criminal
history since the conviction; (4) work history; (5) current employment and
character references; and (6) other evidence demonstrating the ability of the
individual does not pose a threat to the health or safety of the patients in the
licensed facility.
9. The licensing agency may charge the covered entity submitting the
fingerprints a fee not to exceed Fifty Dollars ($50.00).
10. Should results of an employee applicant’s criminal history record check
reveal no disqualifying event, then the covered entity shall, within two (2)
weeks of the notification of no disqualifying event, provide the employee
applicant with a notarized letter signed by the chief executive officer of
the covered entity, or his or her authorized designee, confirming the
employee applicant’s suitability for employment based on his or her
criminal history record check. An employee applicant may use that letter
for a period of two (2) years from the date of the letter to seek
employment at any covered entity licensed by the Mississippi Department
of Health without the necessity of an additional criminal record check.
Any covered entity presented with the letter may rely on the letter with
respect to an employee applicant’s criminal background and is not
required for a period of two (2) years from the date of the letter to conduct
or have conducted a criminal history check as required in this subsection.
11. For individuals contacted through a third party who provide direct patient
care as defined herein, the covered entity shall require proof of a criminal
history record check.
12. Pursuant to Section 43-11-13, Mississippi Code of 1972, the licensing
agency, the covered entity, and their agents, officer, employees, attorneys,
and representatives, shall be presumed to be acting in good faith for any
employment decision or action taken under this section. The presumption
of good faith may be overcome by a preponderance of the evidence in any
civil action. No licensing agency, covered entity, nor their agents, officers,
employees, attorneys, and representatives shall be held liable in any
employment discrimination suit in which an allegation of discrimination is
made regarding an employment decision authorized under this section.
Source: Miss. Code Ann. §41-9-13
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Subchapter 7 THE MEDICAL STAFF
Rule 41.7.1. The hospital shall have an organized medical staff that has the overall
responsibility for the quality of all medical care provided to patients, and for the
ethical conduct and professional practices of its members as well as for
accounting therefore to the governing body. Each member of the medical staff
shall be qualified for staff membership and for the exercise of the clinical
privileges granted to him.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.7.2. The medical staff shall be limited to individuals who are licensed to practice
medicine, osteopathy, or dentistry in the State of Mississippi, and such other
practitioners as determined by the governing body. Such members must be
appropriately licensed or certified and shall be professionally and ethically
qualified for the positions to which they are appointed.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.7.3. Clinical privileges granted to dentists shall be based on their training, experience,
demonstrated competence and judgment.
1. The scope and extent of surgical procedures that each dentist may perform
must be specifically defined and recommended in the same manner as
surgical privileges for physicians.
2. Surgical procedures performed by dentists shall be under the overall
supervision of the Chief of Surgery. In hospitals where a Chief of Surgery
is not designated, they shall be under the overall supervision of a
competent surgeon approved by the Chief of Staff or president of the
medical staff.
3. All dental patients must receive the same basis medical appraisal by a
physician as patients admitted for other services except patients admitted by a
qualified oral surgeon. An oral surgeon who admits a patient without medical
problems may complete an admission history and a physical examination and
assess the medical risks of the procedure to the patient if qualified to do so.
Criteria to be used in identifying such a qualified oral surgeon shall include,
but shall not necessarily be limited to, the following: successful completion
of a postgraduate program in oral surgery accredited by a nationally
recognized accrediting body approved by the United States Office of
Education; and, as determined by the medical staff, evidence that the oral
surgeon who admitted the patient is currently competent to conduct a
complete history and physical examination to determine the patient's ability
to undergo the oral surgical procedure the oral surgeon proposes to perform.
4. Patients with medical problems admitted to the hospital by qualified oral
surgeons and patients admitted for dental care by individuals who are not
qualified oral surgeons shall receive the same basic medical appraisal as
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patients admitted for other services. This includes having a physician who
either is a member of the medical staff or is approved by the medical staff
perform an admission history, a physical examination, and an evaluation
of the overall medical risk and record the findings in the medical record.
The responsible dentist shall take into account their commendations of
this consultation in the overall assessment of the specific procedure
proposed and the effect of the procedure on the patient. When significant
medical abnormality is present, the final decision must be a joint
responsibility of the dentist and the medical consultant. The dentist shall
be responsible for that part of the history and physical examination related
to dentistry. A physician member of the medical staff shall be responsible
for the care of any medical problem that may be present on admission or
that may arise during hospitalization of dental patients.
5. A physician member of the medical staff must be responsible for the care of
any medical problem that may be present or that may arise during the
hospitalization of dental patients.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.7.4. All clinical privileges shall be based on training, experience, demonstrated
competence, and judgment.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.7.5. The medical staff shall be organized to accomplish its required functions; it shall
provide for selection or appointment of its officers, executive committee,
department head or service chiefs.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.7.6. The medical staff must provide a framework in which the duties, functions, and
responsibilities of the medical staff can be carried out. The complexity of the
organization will depend on the size of the hospital and the scope of the activities
of the medical staff.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.7.7. There shall be such officers of the medical staff as to provide effective governing
of the medical staff and to provide effective medical care. There should be at
least a president, vice-president, and secretary-treasurer of the medical staff, or
other similar titles.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.7.8. The medical staff shall participate in the maintenance of high professional
standards by representation on committees concerned with patient care.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.7.9. The medical staff should participate in continuous study and evaluation of factors
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relating to patient care in the hospital's internal environment. This should include
participation in the development of hospital policies and procedures in-so-far as
they affect patient care.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.7.10. The development and surveillance of pharmacy and therapeutic practices in
relation to drug utilization must be performed by the medical staff in cooperation
with the pharmacist.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.7.11. The medical staff shall see that there is adequate documentation of medical events
by a review of discharged patients that shall insure those medical records meet the
required standards of completeness, clinical pertinence, and promptness or
completion of following discharge.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.7.12. The medical staff shall actively participate in the study of hospital-associated
infections, and infection potentials, and must promote a preventive and corrective
program designed to minimize their hazards.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.7.13. The medical staff and the hospital’s administration must evaluate their ability to
manage internal and external disasters and other emergency situations. Medical
staff responsibilities shall be clearly outlined.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.7.14. There shall be regular medical staff meetings to review the clinical work of
members and to complete medical staff administrative duties.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.7.15. The medical staff shall provide a continuing program of professional education or
give evidence of participation in such a program.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.7.16. The medical staff shall develop and adopt bylaws and rules and regulations to
establish a framework for self-government and a means of accountability to the
governing body, such bylaws and rules and regulations to be approved by the
governing body.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.7.17. The medical staff bylaws and rules and regulations, as a minimum, shall:
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1. Contain the name of the organization.
2. Delineate the organizational structure of the medical staff.
3. Specify the qualifications and procedures for admission to and retention of
staff membership, including the delineation, assignment, reduction, and
withdrawal of clinical privileges.
4. Specify the method of reviewing the qualifications of staff members.
5. Provide an appeal mechanism relative to medical staff recommendations for
denial, curtailment, suspension, or revocation of clinical privileges in any
hospital having an open staff. This mechanism shall provide for review of
decisions including the right to be heard at each step of the process when
requested by the practitioner.
6. Delineate clinical privileges of non-physician practitioners, as well as
responsibilities of the physician members of the medical staff in relation to
non- physician practitioners. A non-physician practitioner is a health
professional licensed or otherwise authorized by the state to provide a range
of independent or interdependent health services. Such providers include
but are not limited to chiropractors, licensed professional counselors,
licensed social workers, nurse practitioners/physician assistants (including
nurse anesthetists), psychologists, podiatrists, and optometrists.
7. Require a pledge that each practitioner will conduct his practice in
accordance with high ethical traditions and will refrain from:
A. Rebating a portion of a fee or receiving other inducements in
exchange for a patient referral.
B. Deceiving a patient as to the identity of an operating surgeon or
any other medical practitioner providing services.
C. Delegating the responsibility of hospitalized patients to another
medical practitioner who is not qualified to undertake this
responsibility.
8. Provide for methods of selection of officers and clinical department or service
chairmen.
9. Outline the responsibilities of the medical staff officers and clinical department
or service chairmen.
10. Specify composition and functions of standing committees or standing
committee functions as required by the complexity of the hospital.
11. Establish requirements regarding the frequency of and attendance at general and
17
departmental meetings of the medical staff.
12. Require that the evaluation of the significance of medical histories, the
authentication of medical histories, and the performance and recording of
physical examinations and prescribing of treatment be carried out by
those with appropriate licenses and clinical privileges within their sphere
of authorization.
13. Establish requirements regarding the completion of medical records.
14. Provide for a mechanism by which the medical staff consults with and reports to
the governing body.
15. Adopt rules and regulations that contain specific statements covering procedures
that foster optimal achievable patient care, including the care provided in the
emergency service area.
16. Provide that each practitioner shall on application for clinical privileges sign an
agreement to abide by the current medical staff bylaws and rules and regulations
and the hospital bylaws.
17. Provide for records of attendance and minutes that adequately reflect the
transactions, conclusions, and recommendations of the medical staff.
18. Require and include procedures for evaluation of medical care.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 8 DESIGN AND CONSTRUCTION ELEMENTS: PHYSICAL PLANT
Rule 41.8.1.
General. Every institution subject to these Minimum Standards shall be housed
in a safe building which contains all the facilities required to render the services
contemplated in the application for license.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.8.2. Codes. The term “safe” as used in Rule 41.8.1 hereof shall be interpreted in the
light of compliance with the requirements of the codes recognized by this agency
on date of construction which are incorporated by reference as a part of these
Minimum Standards; included are the Life Safety Code of the National Fire
Protection Association, American National Standards Institute, Standards Number
A-17.1, and A-17.3, Safety Code for Elevators and Escalators, the American
Institute of Architects (AIA), Guidelines for Design and Construction of Hospital
and Health Care Facilities, and references incorporated as body of all afore
mentioned standards.
1. Life Safety Code compliance relative to construction date:
A. Buildings constructed after February 14, 2005, shall comply with the
edition of the Life Safety Code (NFPA 101) recognized by this
18
agency on the date of construction.
B. Building constructed prior to February 14, 2005, shall comply with
existing chapter of the Life Safety Code recognized by this
agency.
2. For minimum standards governing Heating, Ventilation, and Air
Conditioning (HVAC), area design, space allocation, parking
requirements, and other considerations not specifically addressed by local
authority or standards referenced herein, compliance with the AIA
guidelines will be deemed acceptable.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 9 SUBMISSION OF PLANS AND SPECIFICATIONS
Rule 41.9.1. Construction shall not be started for any institution subject to these standards
(whether new or remodeling or additions to an existing licensed hospital) until the
plans and specifications for such construction or remodeling have been submitted
to the Licensing Agency in writing and its approval of the changes given in
writing.
1. Exception: Foundation changes made necessary by unanticipated conditions,
or any conditions which present a hazard to life or property if not immediately
corrected.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.9.2. Plans and specifications for any substantial hospital construction or remodeling
should be prepared by competent architects and engineers licensed to practice in
the state and who assume responsibility for supervising the construction. The
following plans shall be submitted to the Licensing Agency for review:
1. Preliminary Plans - To include schematics of buildings, plot plans showing
size and shape of entire site, existing structures, if any, streets and location
and characteristics of all needed utilities, floor plans of every floor
dimensioned and with proposed use of each room or area shown. If for
additions or remodeling, provide plan or of existing building showing all
proposed alterations, outline specifications to include a general description of
the construction, type of finishes, and type of heating, ventilating, plumbing,
and electrical systems proposed.
2. Final Working Drawings and Specifications - Complete and in sufficient
detail to be the basis for the award of construction contracts.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.9.3. All plans submitted for review must be accompanied in their first submission by
an order of the governing board indicating the type and scope of license to be
applied for or a Certificate of Need.
19
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.9.4. Plans receiving approval of the Licensing Agency upon which construction has
not begun within six (6) months following such approval must be resubmitted for
approval.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.9.5. In all new facilities, plans must be submitted to all regulatory agencies, such as
the County Health Department, etc., for approval prior to starting construction.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.9.6. Upon completion of construction an inspection shall be made by the Licensing
Agency and approval given prior to occupying the building or any part thereof.
The state and county health departments shall have access to the job site during
regular business hours and shall conduct construction progress inspections as
deemed necessary by the agency.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.9.7. Environment. All hospitals shall be so located that they are reasonably free from
undue noises, smoke, dust, or foul odors, and should not be located adjacent to
railroads, freight yards, schools, children's playgrounds, airports, industrial plants
or disposal plants. The proposed site for new hospitals shall be approved by the
department. No new facilities shall be located nearer than 1000 ft. to a cross-
country petroleum or gas pipeline.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.9.8. Zoning Restrictions. The locations of an institution shall comply with all local
zoning ordinances.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.9.9. Access. Institutions located in rural areas must be served by good roads which
can be kept passable at all times.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.9.10. Elevators. One power driven elevator is required in all hospitals having patient
rooms, operating suite, or delivery suite above the first floor. Two or more
elevators are required if 60 or more patients are housed above the ground floor.
Minimum cab dimensions required for elevators transporting patients is 76" x 50"
inside clear measurements: hatchway and cab doors 3'8" wide, minimum.
Elevators are subject to the requirements of referenced standard listed in
paragraph 602, Codes, of this regulation.
SOURCE: Miss. Code Ann. §41-9-17
20
Subchapter 10 FIRE REPORTING AND PROTECTION
Rule 41.10.1. Duty to report all fires, explosions, natural disasters, avoidable deaths or
avoidable serious or life-threatening injuries to patients shall be reported by
telephone to the department by the next working day after the occurrence. The
licensing agency will provide the appropriate forms to the facility which shall be
completed and returned within fifteen (15) calendar days of the occurrence. All
reports shall be complete, thorough, and shall record at a minimum the casual
factors, date, time of occurrence, and exact location of occurrence whether inside
or outside of the facility. Attached thereto shall be all police, fire, and/or other
official reports. There must be a telephone in the building to summon help in case
of fire.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.10.2. All new construction or renovation with the licensing agency’s approval date
on or after February 14, 2005, shall be protected throughout by a sprinkler
system.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.10.3. Heating and Ventilating. Suitable artificial heat shall be furnished to
maintain75 degrees F inside temperature with 10 degrees F outside
temperature. Circulating hot water from a remote boiler or vapor steam with
circulating pump sand controls on emergency electrical service to provide
heating in case of power failures are the preferred methods of heating.
Electrical heating will be approved provided a standby electrical generator is
provided of capacity to furnish 80% of the maximum heating load in addition
to other power and lighting loads that maybe connected to it, or the hospital is
supplied by two electric service lines connected to separate transformers at the
sub-station so arranged that electric service can be maintained in case of failure
of one line or transformer.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 11 PLUMBING
Rule 41.11.1. All institutions subject to these standards shall be connected to an approved
municipal water system or to a private supply whose purity has been certified by
the laboratory of the Department of Health. Private supplies must be sampled,
tested, and its purity certified at least twice annually and immediately following
any repair or modification to the underground lines, the elevated tank, or to the
well or pump. Supply must be adequate, both as to volume and pressure for
firefighting purposes. Deficiencies in either must be remedied by the provision
of auxiliary pumps, pressure tanks or elevated tanks as may be required.
SOURCE: Miss. Code Ann. §41-9-17
21
Rule 41.11.2. An approved method of supplying hot water for all hospital uses must be
provided. Water to lavatories and scrub sinks must be 100 degrees-115ºF. Water
to mechanical dishwashers must be delivered at 180 degrees F for rinsing.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.11.3. Supply piping within the building shall be in accordance with the local code.
Special care must be taken to avoid use of any device or installation which might
cause contamination of the supply through back-siphonage or cross connections.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 12 SEWAGE DISPOSAL
Rule 41.12.1. All institutions subject to these standards shall dispose of all sanitary wastes
through connection to a suitable municipal sewerage system or through a private
sewerage system that has been approved in writing by the Division of
Environmental Services, Onsite Wastewater of the Department of Health.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.12.2. All fixtures located in the kitchen, including the dishwasher, shall be installed
so as to empty into a drain which is not directly connected to the sanitary
house drain. Kitchen drain may empty into a manhole or catch basin having a
perforated cover with an elevation of at least 24" below the kitchen floor
evaluation, and hence to the sewer. Exceptions: existing licensed institutions
which have no plumbing fixtures installed on floors which are above the floor
on which the kitchen is located.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 13 EQUIPMENT
Rule 41.13.1. Medical Equipment Management. In order to ensure safe and reliable
operation of medical equipment, qualified personnel shall maintain all medical
equipment, regardless of ownership. Such maintenance shall be based upon
criteria such as manufacturer’s recommendations, common industry practices and
current hospital experience and shall include the following:
1. Current equipment inventory.
2. Periodic electrical safety inspections and preventive maintenance.
3. Documentation of all testing and maintenance activities, inclusive of any
repairs.
4. Reporting and investigating equipment problems, failures, and user errors
that may have an adverse effect on patient safety or the quality of care.
22
5. Monitoring and acting on equipment hazard notice and recalls.
6. Monitoring and reporting incidents in which a medical device is
suspected or attributed to the death, serious injury, or serious illness
of any individual, as required by the Safe Medical Devices Act of
1990.
7. The facility shall maintain life support equipment utilizing maintenance
strategies designed to minimize clinical and physical risks inherent in use
of such equipment.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.13.2. Electric Nurse Call. There shall be installed a low voltage nurse call system for
every bed and such other areas as deemed necessary, with annunciator at nurses’
station and nurses work area.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 14 EMERGENCY ELECTRIC SERVICE
Rule 41.14.1. General. To provide electricity during an interruption of the normal electric
supply that could affect the medical care, treatment, or safety of the occupants, an
emergency source of electricity shall be provided and connected to certain circuits
for lighting and power.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.14.2. Source. The source of this emergency electric service shall be an emergency
generator, with a stand-by supply of fuel for 24 hours.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.14.3. Patient Rooms: Each patient room shall meet the following requirements:
1. Area. Shall provide 120 sq. ft. of floor area for a single bedroom and 100 sq.
ft. per bed in multi-bedrooms with new construction or renovation approved
by the licensing agency on or after February 14, 2005.
2. Ceiling Height. Shall be 8'0" minimum.
3. Windows. All rooms housing patients shall be outside rooms and shall have
window area equal to 1/8th of the floor area. The sill shall not be higher
than 36inches above the floor and shall be above grade. Windows shall not
have any obstruction to vision (wall, cooling tower, etc.) within 50 feet as
measured perpendicular to the plane of the window.
4. Storage. Each patient shall be provided with a hanging storage space of not
less than 16" x 24" x 52" for personal belongings.
23
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.14.4. Furnishings:
1. Bed. Each patient room shall be equipped with an adjustable bed.
2. Bedside Cabinet. A bedside cabinet shall be provided for each patient. It
should contain a water service, bedpan, urinal, emesis basin, and bath
basin. (These may be disposable.)
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.14.5. Rooms shall be equipped with curtains or blinds at windows. All curtains shall
have a flame spread of 25 or less.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.14.6. Cubicle curtains or equivalent built-in devices for privacy in all multi-bedrooms
shall be provided. They shall have a flame spread of 25 or less. Cubicle curtains
shall encircle the bed on three sides. Must comply with mesh webbing for
sprinkler systems.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.14.7. A lavatory equipped with wrist action handles, shall be located in the room
or in a private toilet room. (If a water closet is provided, a bedpan washer is
recommended.)
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.14.8. Patient bed light shall be provided which shall be capable of control by the
patient. Provide a night light bright enough for the staff to perform routine duties
but dim enough so as not to disturb the patient.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.14.9. Service Areas. The size of each service area will depend on the number and type
beds within the unit and shall include the following:
1. Nurse Station. For nurses charting, doctors charting, communication and
storage for supplies and nurses’ personal effects.
2. Staff Toilet with Lavatory. Convenient to nurse’s station.
3. Clean Work Room. For storage and assembly of supplies for nursing
procedures. Shall contain cabinets or storage carts, work counter and
sink.
4. Soiled Utility. Shall contain deep sink, work counter, waste receptacle,
soiled linen receptacle, and provision for washing bedpans if not
24
provided elsewhere.
5. Medicine Station. Adjacent to nurses’ station, with sink, small
refrigerator, locked storage, narcotic locker with a light in the nurse’s
station that indicates when the door is open and work counter. (May be in
clean work room in self-contained cabinet.)
6. Clean Linen Storage. A closet large enough to hold an adequate supply of
clean linen.
7. Provision for between-meal nourishments.
8. Patient Bath. At least one tub or shower-stall for each 18 patients not
served by private bath.
9. Stretcher and Wheelchair Storage Area.
10. Fire Extinguisher. One (1) approved Class ABC unit for each 3000 sq. ft.
11. Janitor's Closet. Closet large enough to contain floor receptor with
plumbing and space for some supplies and mop buckets.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.14.10. Isolation Room: (At least one per hospital). It shall contain:
1. One patient bed per room.
2. Private lavatory and toilet.
3. View window 10" x 10" in door.
4. Anteroom with door to corridor and door into patient room. This anteroom
shall have a lavatory, shelving, space for linen hamper, and hanging space
adequate for isolation techniques. Supply and exhaust are to be separate
from the patient room supply and exhaust.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.14.11. Detention Room. If a detention room is provided, it shall be provided with key-
only lock on all doors operated from both sides and security screen on the window
for disturbed or confused patients. The isolation room may be modified for this
purpose.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 15 SPECIAL CARE
Rule 41.15.1. In addition to the requirements for patient rooms and service areas, a special care
area, where provided, shall meet fire safety standards and electrical hazard
standards applicable to intensive care units, cardiac units, and other such areas.
25
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.15.2. A waiting room shall be provided in this area and shall contain 10 sq. ft. per bed.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.15.3. Newborn Nursery shall have:
1. Lavatory with wrist action blade handles.
2. Emergency nurses call.
3. Oxygen, with equipment for measuring oxygen content.
4. Facilities for viewing the babies.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.15.4. Each full-term nursery shall contain no more than 12 bassinets with a minimum
area of 24 sq. ft. for each bassinet. An examination and work room shall be
provided. One work room may serve more than one nursery. The nursery is to be
entered only through the work room. There shall be a separate bassinet for each
infant consisting of stand, removable basket, cabinet, or table for storage of
individual utensils and supplies.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.15.5. Janitor's closet shall be provided. (See Rule 41.14.9(11)).
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.15.6. Specific provisions shall be made to take care of premature babies. Incubators
suitable for the care of premature infants shall be provided.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.15.7. Nursery heating shall be variable from 75 degrees - 80 degrees, with provisions
for maintaining a relative humidity above 50%.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.15.8. All electric receptacles in each nursery shall be on the emergency circuit.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.15.9. Pediatric Unit (if provided as a separate unit) shall contain:
1. Patient room as described in Rule 41.14.3.
26
2. 50 sq. ft. per crib, with adequate space provided for person in attendance.
3. Service areas, in addition to those described in Rule 41.14.9, shall
include a treatment room with lavatory with wrist action blade
handles.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.15.10. Psychiatric Unit, if provided, shall contain rooms and service areas as described in
Rule 41.14.3 and Rule 41.14.9. In addition, there shall be physician’s office,
examining room, conference room, dining room and day room.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 16 SURGICAL SUITE
Rule 41.16.1. This area shall be located so as to prevent through traffic and shall contain:
1. At least one operating room, with adequate sterile storage cabinets, for the first
50beds and thereafter the number of rooms should be based on the expected
surgical workload.
2. Recovery room with charting space, medication storage and preparation and
sink are required. Oxygen, suction, and other life supporting equipment
must be immediately available to the patient and shall meet the
requirements of National Fire Protection Association NFPA 99.
3. A service area which shall include:
A. Surgical supervisor's station.
B. Provision for high-speed sterilization of dropped instruments readily
available to operating room.
C. Medicine preparation and storage area.
D. Scrub station for two persons to scrub simultaneously.
E. Clean up room with a two-compartment sink and drain board and
space for a dirty linen hamper.
F. Anesthesia storage in compliance with National Fire Protection
Association NFPA 99.
G. Oxygen and nitrous oxide storage in compliance with National Fire
Protection Association NFPA (99).
H. Janitors closet (See Rule 41.14.9).
27
I. Physicians’ locker room containing toilet and shower with entry
from non-sterile area and exit into sub-sterile area.
J. Nurses' locker room containing toilet and shower with entry from
non-sterile area and exit into sub-sterile area.
K. Storage for transport beds.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.16.2. All finishes shall be capable of repeated scrubbings.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.16.3. Heating and cooling in accordance with AIA guidelines.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.16.4. Special lighting shall be supplied that eliminated shadows in the operating field
with enough background illumination to avoid excessive contrast. Emergency
lighting shall comply with Subchapter 14.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.16.5. Fire extinguishers shall be provided and distributed in accordance with NFPA10.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 17 CENTRAL STERILE SUPPLY
Rule 41.17.1. The following areas shall be separate:
1. Receiving and Clean-Up Area. To contain a two-compartment sink with
two drain boards.
2. Pack Make Up. Shall have autoclaves, work counter and unsterile storage.
3. Sterile Storage Area. Should have pass-through to corridor.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 18 OBSTETRICAL SUITE
Rule 41.18.1. The requirements of this area are the same as Rule 41.17.1 except for Rule
41.17.1(2) & (3).
SOURCE: Miss. Code Ann. §41-9-17
28
Rule 41.18.2. A labor room shall be provided with necessary equipment, a lavatory with wrist
action blade handles, and shall be acoustically treated.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 19 OUTPATIENT AND TRAUMA AREA
Rule 41.19.1. This area shall be located to prevent outpatient from traversing inpatient areas and
shall include:
1. A well-marked and sheltered entry with nearby parking and access for
ambulance.
2. Waiting room with public telephone, drinking fountain, and toilet.
3. Admission and record area.
4. Examination and treatment rooms containing lavatory with wrist action
blade handles and nurse call station. These rooms shall be so arranged
that stretcher patients can be examined and treated.
5. Trauma room adequate for cast work and with sufficient lighting for
detailed examinations.
6. Storage for sterile supplies.
7. Medicine preparation and storage area that can be locked.
8. Transport bed and wheelchair storage.
9. Janitor’s closet (See Rule 41.14.9).
10. Dirty Utility area.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.19.2. The walls and floors shall be capable of repeated washings in all areas except
trauma area which shall have floors, walls, and ceilings capable of repeated
washings.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 20 RADIOLOGY SUITE
Rule 41.20.1. This area should be as close to outpatient area as practical. It shall contain:
1. Radiographic room or rooms.
2. Film processing room.
29
3. Film filing room.
4. Toilet available to each fluoroscopy room.
5. Dressing room (at least two per radiographic room).
6. Patient waiting area.
7. Administrative area, including space for film viewing.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 21 LABORATORY
Rule 41.21.1. Adequate space for the following services shall be provided: chemistry,
bacteriology, serology, pathology, and hematology. Provision shall be made
for:
1. Glass washing and sterilizing.
2. Administrative area, to include space for records and files.
3. Blood storage.
4. Specimen collection toilet (This may be primarily for other use).
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 22 DRUG ROOM
Rule 41.22.1. Adequate space shall be provided for storage of drugs and for keeping of
necessary records. The room shall be capable of being securely locked in
accordance with regulations regarding storage of dangerous drugs.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 23 DIETARY
Rule 41.23.1. Construction and equipment shall comply with Department of Health regulations,
and shall include:
1. Food preparation center. Provide lavatory (without mirror) with wrist action
blades, soap dispenser and disposable towel dispenser. All cooking
appliances to have ventilating hood.
2. Food serving facilities. If dining space is provided, it shall contain a
minimum of15 sq. ft. per person seated.
3. Dishwashing room. Provide commercial type dishwashing equipment.
30
4. Pot washing facilities.
5. Refrigerated storage (three-day supply).
6. Day storage (three-day supply).
7. Cart cleaning facilities (can be in dishwashing room).
8. Can wash and storage (must be fly-tight).
9. Cart storage.
10. Dietitian's office.
11. Janitor’s closet (See Rule 41.14.9(11)).
12. Personnel toilets and lockers convenient to, but not in, the kitchen proper.
13. Approved automatic fire extinguisher system in range hood. In addition,
Class K extinguisher to be installed in the kitchen.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 24 ADMINISTRATIVE AREA
Rule 41.24.1. Administrative Area. To include:
1. Business office with information desk cashier's station and personnel toilets.
2. Administrator's office.
3. Admitting area.
4. Lobby or foyer, with public toilets.
5. Medical Library (This area should be as close to medical records as possible).
6. Space for conferences and in-service training.
7. Medical records - office and storage.
8. Director of Nurses' office.
9. Fire Extinguisher. An approved Class 2A unit shall be provided.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.24.2. Housekeeping Area. To include:
1. Housekeeper's office.
31
2. Storage space for staff carts, if used.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.24.3. Laundry. To include:
1. Soiled linen room with lavatory with wrist action blades.
2. Clean linen and mending area. (To include space for storage of clean linen
carts).
3. Laundry process room. Commercial type equipment sufficient for the
needs of the hospital unless contract service is used.
4. Janitor’s closet (See Rule 41.14.9(11)).
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.24.4. General Storage. There shall be a one-hour fire rated lockable room, or separate
building provided, which contains at least 18 sq. ft. per licensed bed.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.24.5. Boiler Room. Space shall be adequate for the installation and maintenance of the
required machinery.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.24.6. Maintenance Area. Sufficient area for performing routine maintenance activities
shall be provided and shall include office for maintenance engineer.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 25 NURSING SERVICES EMERGENCY
Rule 41.25.1. General. The hospital shall have a procedure for taking care of emergency cases.
Participation shall not be limited to hospitals which have organized emergency
services or departments. There shall be effective policies and procedures relating
to the staff, functions of the service, and emergency room medical records and
adequate facilities in order to assure the health and safety of the patients.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 26 ORGANIZATION AND DIRECTION
Rule 41.26.1. The department or service shall be organized, directed by qualified personnel, and
integrated with other departments of the hospital.
SOURCE: Miss. Code Ann. §41-9-17
32
Rule 41.26.2. There shall be written policies which shall be enforced to control emergency room
procedures.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.26.3. The policies and procedures governing medical care provided in the emergency
service or department shall be established by and shall be a continuing
responsibility of the medical staff. The Emergency Department shall have written
policies and procedures governing the receipt of patients from emergency medical
services and the transfer of patients to a receiving facility. The policies must
comply with Mississippi Emergency Medical Services Rules and Regulations.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.26.4. The emergency service shall be supervised by a qualified member of the medical
staff, and nursing functions shall be the responsibility of a registered professional
nurse.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.26.5. The administrative functions shall be the responsibility of a member of the
hospital administration.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 27 FACILITIES
Rule 41.27.1. Facilities shall be provided to assure prompt diagnosis and emergency treatment.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.27.2. Facilities shall be separate and independent of the operating room.
Rule 41.27.3. Freestanding Emergency Room (FER). Means a facility open twenty-four hours
a day for the treatment of urgent and emergent medical conditions which is not
located on a hospital campus. In order to be eligible for licensure under this
chapter, the freestanding emergency room shall be located at least fifteen (15)
miles from the nearest hospital-based emergency room in any rural community
where the federal Centers for Medicaid & Medicare Services (CMS) had
previously designated a rural hospital as a critical access hospital and that
designation has been revoked. A FER shall not retain any patient beyond 23 hours
and 59 minutes under normal operations and shall not hold itself out as an
emergency hospital.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.27.4. Diagnostic and treatment equipment, drugs, supplies, and space, including a
sufficient number of treatment rooms, shall be adequate in terms of the size and
scope of services provided.
33
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 28 MEDICAL AND NURSING PERSONNEL
Rule 41.28.1. There shall be adequate medical and nursing personnel available at all times.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.28.2. The medical staff shall be responsible for insuring adequate medical coverage for
emergency services.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.28.3. Qualified physicians shall be regularly available at all times for the emergency
service, either on duty or on call.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.28.4. Qualified nurses shall be available at all times and in sufficient number to deal
with the number and extent of emergency services.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 29 MEDICAL RECORDS
Rule 41.29.1. Adequate medical records on each patient shall be kept. The emergency medical
record shall contain:
1. Patient identification.
2. History of disease or injury.
3. Physical findings.
4. Laboratory and x-ray reports, if any.
5. Diagnosis.
6. Record of treatment.
7. Disposition of the case.
8. Signature of a physician.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.29.2. Medical records for patients treated in the emergency service shall be maintained
and correlated with other hospital records in accordance with Medical Records
section.
34
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.29.3. Where appropriate, medical records of emergency services shall be integrated
with those of the inpatient and outpatient services.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.29.4. An emergency service register shall be maintained and shall contain at least: date
and time, patient identification, injury or disease, treatment, and the name of the
doctor.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 30 NURSING
Rule 41.30.1. The hospital shall maintain an organized nursing staff to provide high quality
nursing care for the needs of the patients and to be responsible to the hospital for
the professional performance of its members. The nursing service shall be under
the direction of a legally and professionally qualified registered nurse. There
shall also be a sufficient number of duly licensed registered nurses on duty at all
times to plan, assign, supervise, and evaluate nursing care, as well as to give
patients the nursing care that requires judgment and specialized skills of a
registered nurse.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.2. The director of nursing service shall be qualified by education, experience, and
demonstrated ability to organize, coordinate, and evaluate the work of the service.
He or she shall be qualified in the fields of nursing and administration consistent
with the complexity and scope of operation of the hospital and shall be
responsible to the administrator for developing and implementing policies and
procedures of the service in the hospital.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.3. Individual staffing patterns shall be developed for each nursing care unit,
including the surgical and obstetrical suites, each special care unit, and outpatient
services. The staffing patterns shall provide for sufficient nursing personnel and
for adequate supervision and direction by registered nurses consistent with the
size and complexity of the hospital.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.4. There shall be an adequate number of registered nurses readily available to
patients requiring their services. A registered nurse must plan, supervise, and
evaluate the nursing care of each patient.
SOURCE: Miss. Code Ann. §41-9-17
35
Rule 41.30.5. Licensed practical nurses currently licensed to practice within the state, as well as
other ancillary nursing personnel, may be used to give nursing care that does not
require the skill and judgment of a registered nurse. Their performance shall be
supervised by one or more registered nurses.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.6. To develop better patterns of utilization of nursing personnel, periodic evaluation
of the activities and effectiveness of the nursing staff should be conducted
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.7. The nursing service shall have a current written organizational plan that delineates
its functional structure and its mechanisms for cooperative planning and decision
making. This plan shall be an integral part of the overall hospital plan and its
shall:
1. Be made available to all nursing personnel.
2. Be reviewed periodically and revised as necessary.
3. Reflect the staffing pattern for nursing personnel throughout the hospital.
4. Delineate the functions for which nursing service is responsible.
5. Indicate all positions required to carry out such functions.
6. Contain job descriptions for each position classification in nursing service
that delineate the functions, responsibilities, and desired qualifications of
each classification, and should be made available to nursing personnel at
the time of employment.
7. Indicate the lines of communication within nursing service.
8. Define the relationships of nursing service to all other services and
departments in the hospital.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.8. If the hospital provides clinical facilities for the education and training of nursing
students, licensed practical nurses, nurses’ aides, or other categories of nursing
personnel, there shall be a written agreement that defines the role and
responsibility of both the nursing service and the education program.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.9. In the planning, decision making, and formulation of policies that affect the
operation of nursing service, the nursing care of patients, or the patients'
environment, the recommendations of representatives of nursing service should be
36
considered.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.10. In hospitals where the size of the nursing staff permits, nursing committees should
be formally organized to facilitate the establishment and attainment of goals and
objectives of the nursing service.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.11. Written nursing care and administrative policies and procedures shall be
developed to provide the nursing staff with acceptable methods of meeting its
responsibilities and achieving projected goals through realistic and attainable
goals.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.12. Nursing care policies and procedures shall be consistent with professionally
recognized standards of nursing practice and shall be in accordance with Nurse
Practice Act of the State of Mississippi. They should take into account new
equipment and current practice.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.13. Policies shall be developed to address the following:
1. Noting diagnostic and therapeutic orders.
2. Assignment of nursing care to patients.
3. Administration of medications.
4. Charting by nursing personnel.
5. Infection control.
6. Patient and personnel safety.
7. Prevention of pressure sores.
8. Prevention of medication errors.
9. Reporting of adverse drug reactions.
10. Comprehensive assessment.
11. Pain Management.
SOURCE: Miss. Code Ann. §41-9-17
37
Rule 41.30.14. All nursing personnel, including non-employee licensed nurses who are working
in the hospital, must adhere to the hospital’s policies and procedures.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.15. Policies and procedures shall be developed to include plans for orientation for all
newly employed and non-employee nursing personnel. The policies and
procedures shall specify specific subjects and topics to be covered in the
orientation process. The facility shall maintain documented evidence of
orientation of all nursing personnel.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.16. Written copies of the procedure manual shall be available to the nursing staff in
every nursing care unit and service area and to other services and departments in
the hospital. The nursing procedure manual should be used to:
1. Provide a basis for training programs to enable new nursing personnel to
acquire local knowledge and current skills.
2. Provide a ready reference on procedures for all nursing personnel.
3. Standardize procedures and equipment.
4. Provide a basis for evaluation and study to insure continued
improvements in techniques.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.17. The nursing policies and procedures shall be developed, periodically reviewed,
and revised as necessary by nursing representatives in cooperation with
administration, the medical staff, and other hospital services and departments
concerned. All revisions shall be dated to indicate the date of the latest review.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.18. There shall be evidence established that the nursing service provides safe,
efficient, and therapeutically effective nursing care through the planning of
each patient's care and the effective implementation of the plans.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.19. A brief and pertinent written nursing care plan should be developed for each
patient. It should include:
1. Medication, treatment, and other items ordered by individuals granted
clinical privileges and by authorized house staff members.
2. Nursing care needed.
38
3. Long-term goals and short-term goals.
4. Patient and family teaching and instructional programs.
5. The socio-psychological needs of the patient.
6. Preventative nursing care.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.20. The nursing care plan should be initiated upon admission of the patient and, as a
part of the long-term goal, should include discharge plans. Nursing records and
reports that reflect the patient's progress and the nursing care planned should be
maintained.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.21. Meetings of the nursing staff shall be held at least monthly in order to discuss
nursing service problems and policies. Minutes of these meetings shall be kept.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.22. An in-service education program shall be provided for the improvement of
nursing care and service through increased proficiency and knowledge of nursing
personnel. The in-service program shall be planned, scheduled, documented, and
held on a continuing basis.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.23. All nursing personnel shall have training and a program of in-service and
continuing education commensurate with the duties and responsibilities of the
individual. All training shall be documented for each individual so employed.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.24. The in-service should include but not limit topics to pressure sore prevention,
prevention of medication errors, pain management, patient’s rights, and
dignity.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.25. In hospitals where cardiac monitors are used on the nursing unit, rather than in a
separate and distinct "Special Care Unit" as described in Subchapter 36 of these
standards, special training, protocols, and staffing are required. Initial coronary
care course that has been approved by the Mississippi State Board of Nursing that
will include as a minimum the basic Cardiac Life Support Course is required for
all Registered Nurses and Licensed Practical Nurses who have responsibilities for
caring for cardiac monitored patients. A program of in-service and continuing
education commensurate with the duties and responsibilities of the individual
39
shall be established and documented for each individual so employed.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.26. Protocols. Protocols shall be established and approved for response of trained,
experienced Registered Professional Nurses to codes or cardiac emergencies that
deal with lethal arrhythmias, hypotension, defibrillation, heart block and
respiratory arrest by the nursing service and medical staff of each hospital.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.30.27. Staffing. Nurse staffing will be evaluated on an individual basis for compliance.
Factors to be considered are number of patients on monitors, layout of facility and
proximity of emergency room to nursing unit, volume of services in the OB and
Nursery and the emergency room, the number of patients on the medical/surgical
floor and other responsibilities that the RN may have other than the ones
described above. A sufficient number of RNs shall be available to meet the needs
of the patients served. In the event that a hospital has patients on cardiac monitors
in use in one area of the hospital and an emergency room in another area, the
facility must have more than one RN in house to care for the patient.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 31 OBSTETRICS AND NEWBORN NURSERY ORGANIZATION
Rule 41.31.1. Obstetrics and newborn nursery services shall be under the direction of a member
of the staff of physicians who has been duly appointed for this service and who
has experience in maternity and newborn care.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.31.2. There shall be a qualified professional registered nurse responsible at all times for
the nursing care of maternity patients and newborn infants.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.31.3. Provisions shall be made for pre-employment and annual health examinations for
all personnel on this service.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.31.4. Physical facilities for perinatal care in hospitals shall be conducive to care that
meets the normal physiologic and psychosocial needs of mothers, neonates, and
their families. The facilities provide for deviations from the norm consistent with
professionally recognized standards/guidelines.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.31.5. The obstetrical service should have facilities for the following components:
SOURCE: Miss. Code Ann. §41-9-17
40
1. Antepartum care and testing.
2. Fetal diagnostic services.
3. Admission/observation/waiting.
4. Labor.
5. Delivery/cesarean birth.
6. Newborn nursery.
7. Newborn Intensive Care (Levels II and III only).
8. Recovery and postpartum care.
9. Visitation.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.31.6. Any facility providing obstetric care shall have at least the following services
available:
1. Identification of high-risk mothers and fetuses.
2. Equipment for continuous fetal heart rate monitoring or capability of
following auscultation guidelines.
3. Capabilities to begin a cesarean delivery within 30 minutes of a decision to do
so.
4. Blood and fresh-frozen plasma for transfusion.
5. Anesthesia on a 24-hour basis.
6. Radiology and ultrasound examination.
7. Neonatal resuscitation, including equipment and trained personnel.
8. Laboratory testing on a 24-hour basis.
9. Consultation and transfer agreement.
10. Nursery.
11. Data collection and retrieval.
12. Patient education.
SOURCE: Miss. Code Ann. §41-9-17
41
Rule 41.31.7. Staffing. The facility is staffed to meet its patient care commitments consistent
with professionally recognized guidelines. There must be a registered nurse
immediately available for direct patient care.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.31.8. Level I.
1. Surveillance and care of all patients admitted to the obstetric service, with
an established triage system for identifying high-risk mothers who should
be transferred to a facility that provides level II and III care prior to
delivery.
2. Proper detection and supportive care of unanticipated maternal-fetal problems
that occur during labor and delivery.
3. Performance of cesarean delivery.
4. Care of postpartum conditions.
5. Personnel trained in neonatal resuscitation in the hospital at all times.
6. Stabilization of unexpectedly small or sick neonates before transfer to a
facility that provides level II or III care.
7. Evaluation of the condition of healthy neonates and continuing care of
these neonates until their discharge.
8. Patient education.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.31.9. Level II.
1. Performance of level I services.
2. Management of high-risk mothers and neonates admitted and evaluated
for continued management and/or appropriate transfer.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.31.10. Level III.
1. Provision of full range of perinatal care services for all mothers and neonates.
2. Research support.
3. Completion, analysis, and evaluation of regional data.
42
Rule 41.31.11. Antepartum Care. There should be policies for the care of pregnant patients
with obstetric, medical, or surgical complications and for maternal transfer.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.31.12. Intra-partum Services: Labor and Delivery. Intra-partum care should be both
personalized and comprehensive with continuous surveillance of the mother and
fetus. There should be written policies and procedures in regard to:
1. Assessment.
2. Admission.
3. Medical records (including complete prenatal history and physical).
4. Consent forms.
5. Management of labor including assessment of fetal well-being.
6. Term patients.
7. Preterm patients.
8. Premature rupture of membranes.
9. Preeclampsia/eclampsia.
10. Third trimester hemorrhage.
11. Pregnancy Induced Hypertension (PIH).
12. Patients receiving oxytoxics or tocolytics.
13. Patients with stillbirths and miscarriages.
14. Pain control during Labor and Delivery.
15. Management of Delivery.
16. Emergency cesarean delivery (capability within 30 minutes).
17. Assessment of fetal maturity prior to repeat cesarean delivery or
induction of labor.
18. Vaginal birth after cesarean delivery.
19. Assessment and care of neonate in the delivery room.
20. Infection control in the Obstetric and newborn areas.
43
21. A delivery room record shall be kept that will indicate:
A. The name of the patient.
B. Date of delivery.
C. Sex of Infant.
D. Apgar.
E. Weight.
F. Name of physician.
G. Name of persons assisting.
H. What complications, if any, occurred.
I. Type of anesthesia used.
J. Name of person administering anesthesia.
22. Maternal transfer.
23. Immediate postpartum/recovery care.
24. Housekeeping.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.31.13. Newborn Care. There shall be policies and procedures for providing care of the
neonate including:
1. Immediate stabilization period.
2. Neonate identification and security.
3. Assessment of neonatal risks.
4. Cord blood, Combs, and serology testing.
5. Eye care.
6. Subsequent care.
7. Administration of Vitamin K.
8. Neonatal screening.
9. Circumcision.
44
10. Parent education.
11. Visitation.
12. Admission of neonates born outside of facility.
13. Housekeeping.
14. Care of or stabilization and transfer of high-risk neonates.
15. Postpartum. There shall be policies and procedures for postpartum
care of mother.
16. Assessment.
17. Subsequent care (bed rest, ambulation, diet, care of the vulva, care of the
bowel and bladder functions, bathing, care of the breasts, temperature
elevation).
18. Postpartum sterilization.
19. Immunization. RHIG and Rubella.
20. Discharge
planning.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 32 OUTPATIENT
Rule 41.32.1. Hospitals rendering outpatient services shall have effective policies and
procedures relating to the staff, functions of the service, and outpatient medical
records and adequate facilities in order to assure the health and safety of the
patients.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 33 ORGANIZATION
Rule 41.33.1. The outpatient department shall be organized into sections according to medical
specialties (clinics), the number of which depends on the size and the degree of
departmentalization of the medical staff, available facilities, and the needs of the
patients for whom it accepts responsibility.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.33.2. The outpatient department shall have appropriate cooperative arrangements and
communications with the community agencies such as other outpatient
departments, public health nursing agencies, the department of health, and welfare
45
agencies.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.33.3. Clinics shall be integrated with corresponding inpatient services.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.33.4. Clinics shall be maintained for the following purposes:
1. Care of ambulatory patient unrelated to inpatient admission or discharge.
2. Study of preadmission patients.
3. Follow-up of discharge hospital patients.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.33.5. Patients, on their initial visit to the department, shall receive a general medical
evaluation and patients under continuous care shall receive an adequate periodic
re-evaluation.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.33.6. Established medical screening procedures shall be employed routinely.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 34 PERSONNEL
Rule 41.34.1. There shall be such professional and non-professional personnel as are required
for efficient operation.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.34.2. The outpatient service shall be supervised by a qualified member of the medical
staff. Either this physician or a qualified administrator shall be responsible for
administrative services.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.34.3. A registered professional nurse shall be responsible for the nursing services of the
department.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.34.4. The number and type of other personnel employed shall reflect the volume and
type of work carried out and the type of patient served in the outpatient
department.
46
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 35 FACILITIES
Rule 41.35.1. Facilities shall be provided to assure the efficient operation of the department.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.35.2. The number of examination and treatment rooms shall be adequate in relation to
the volume and nature of work performed.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.35.3. Suitable facilities for necessary diagnostic tests shall be available either through
the hospital or some other facility approved to provide these services.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.35.4. Medical Records. Shall be maintained and correlated with other hospital records
in accordance with Subchapter 48, Medical Records.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.35.5. Liaison Conferences. Conference, both departmental and inter-departmental,
shall be conducted to maintain close liaison between the various sections within
the department and with other hospital services, and minutes shall be kept.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 36 SPECIAL CARE UNIT
Rule 41.36.1. Special care units, if provided, shall be properly organized, directed, and
integrated with other departments or services of the hospital.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.36.2. The hospital organizational plan shall provide for the identification of each
special care unit and delineate appropriate relationships with other clinical areas
of the hospital. Each such unit shall be under the direction of a qualified
physician who has a special interest in, and preferable additional experience in
providing, this type of care. This physician shall also be one who is readily
available - The director of the special care unit should be responsible for the
implementation of established policy, which should include at least:
1. Rules for proper utilization of the services.
2. Provision for participation in appropriate training programs for the safe
and effective use of diagnostic and therapeutic equipment for
cardiopulmonary resuscitation and for other aspects of intensive care.
47
3. Plans for supervision of the collection and analysis of clinical data needed
for the retrospective evaluation of the care provided in the unit.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.36.3. The activities within a multipurpose special care unit should be guided by a multi-
disciplinary committee, with one member serving as director of the unit.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.36.4. Special care unit personnel shall be prepared for their responsibilities through
appropriate training and educational programs.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.36.5. All nursing personnel assigned to a special care unit must have completed an
educational course specifically oriented to their level of participation in the care
of seriously ill patients.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.36.6. A continuing education program developed specifically for the personnel in the
unit must be provided in order to enable them to maintain and improve their
skills, as well as to learn new techniques.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.36.7. Registered nurses and health care personnel may serve as assistant or backup
personnel under the direct supervision of a qualified special care unit nurse. All
nurses with patient care responsibility in the unit must have the ability to
recognize clinical signs and symptoms that require notification of a physician.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.36.8. Whatever the design or purpose of the unit, enough space shall be provided
around each bed to make it easily accessible for routine and emergency care of the
patients and also to accommodate bulky equipment that may be needed.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.36.9. Oxygen and suction and properly grounded electrical outlets shall be readily
available to every patient. Each bed shall be readily adjustable to various
therapeutic positions, easily moved for transport, shall have a locking mechanism
for a secure stationary position and, where feasible a removable headboard.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.36.10. Direct visual observation of all patients should be possible from a central vantage
point, yet patients should have a reasonable amount of privacy. They should be
sheltered as much as possible from the activity and noise of the unit by partitions,
48
drapes, and acoustic ceilings, but caution should be exercised in the use of
carpeting and under carpet padding both as to fire resistance and potential
production of toxic fumes in case of fire.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.36.11. There shall be an alarm system for special care unit personnel to summon
additional personnel in an emergency. The alarm should be connected to any area
where unit personnel might be, such as physician's sleeping rooms, consultation
rooms, nurse’s lounges, and nurses' stations.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.36.12. The kind and quality of equipment in the special care unit shall depend upon the
needs of the patients treated. Diagnostic monitoring and resuscitative equipment,
such as respiratory assist apparatus, defibrillators, pacemakers, phlebotomy and
tracheostomy sets, endotracheal tubes, laryngoscopes, and other such devices
should be easily available within the unit, and in good working order. There shall
be a written preventive maintenance program that includes techniques for
cleaning and for contamination control, as well as for the periodic testing of all
equipment.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.36.13. When any electronic devices are used on patients, especially patients who have
intravenous catheters or wires leading to the heart, special safety precautions
related to proper grounding, current leakage and device-safety must be observed.
Electrically operated beds are a potential electrical hazard where the patient is
physically connected to any other electrical device.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.36.14. Expert advice concerning the safe use of, and preventive maintenance for, all
biomedical devices and electrical installations shall be readily available at all
times. Documentation of safety testing should be provided on a regular basis to
the unit director.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.36.15. There shall be specific written policies and procedures for each special care unit,
which supplement the basic hospital policies and procedures.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.36.16. Because of the intensity of care given within the unit, and of the critical nature of
the illnesses of patients cared for in it, written policies, and procedures additional
to basic hospital policies should be developed to guide personnel in the
management of the unique situations within the unit. These policies and
procedures should be developed and approved by the medical staff, in cooperation
49
with the nursing staff and with other hospital departments and services and the
hospital administration as necessary. They should be periodically reviewed and
revised as indicated.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 37 SURGERY AND ANESTHESIA
Rule 41.37.1. General. Surgical services are optional, but if this service is provided, there shall
be effective policies and procedures regarding surgical privileges, maintenance of
the operating rooms, and evaluation of the surgical patient.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 38 SURGERY
Rule 41.38.1. Surgical privileges shall be delineated for all physicians doing surgery in
accordance with the competencies of each physician. A roster of surgeons
specifying the surgical privileges of each shall be kept in the confidential files of
the operation room supervisor and in the files of the administrator.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.38.2. In any procedure with unusual hazard to life, there shall be present and scrubbed
as first assistant a physician designated by the credentials committee as being
qualified to assist in major surgery.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.38.3. The operating room register shall be complete and up to date.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.38.4. There shall be a complete history and physical work-up in the chart of every
patient prior to surgery (whether the surgery is major or minor).
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.38.5. A properly executed consent form for operation shall be in the patient's chart
prior to surgery.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.38.6. There shall be adequate provision for immediate post-operative care.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.38.7. An operative report describing techniques and findings shall be written or dictated
immediately following surgery and signed by the surgeon.
50
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.38.8. All infections of clean surgical cases shall be recorded and reported to the
administration. A procedure shall exist for the investigation of such cases.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.38.9. The operating rooms shall be supervised by an experienced registered
professional nurse.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.38.10. The following equipment shall be available to the operating suites: Call-in
system, resuscitator, defibrillator, aspirator, thoracotomy set, and tracheotomy set.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.38.11. The operating room suite and accessory services shall be so located that traffic in
and out can be controlled and there is no through traffic.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.38.12. Precautions shall be taken to eliminate hazards of explosions, including use of
shoes with conductive soles and prohibition of nylon garments.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.38.13. Rules and regulations or policies related to the operating room shall be available
and posted.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 39 ANESTHESIA
Rule 41.39.1. The Department of Anesthesia shall have effective policies and procedures
regarding staff privileges, the administration of anesthetics, and the maintenance
of strict safety controls.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.39.2. The Department of Anesthesia shall be responsible for all anesthetics
administered in the hospital.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.39.3. In hospitals where there is no Department of Anesthesia, the Department of
Surgery shall assume the responsibility for establishing general policies for the
administration of anesthetics.
SOURCE: Miss. Code Ann. §41-9-17
51
Rule 41.39.4. Safety precautions shall be accordance with NFPA Bulletin 56A.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 40 GENERAL SERVICES: DIETARY ORGANIZATION
Rule 41.40.1. The hospital shall have an organized dietary department directed by qualified
personnel. However, a hospital which has a contract with an outside food
management company may be found to meet this requirement if the company has
a therapeutic dietitian who serves, as required by scope and complexity of the
service, on a full-time, part-time, or consultant basis to the hospital.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.40.2. There shall be written policies and procedures for food storage, preparation, and
service developed by a qualified dietitian (preferably meeting the American
Dietetic Association's standards for qualification).
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.40.3. The number of personnel, such as cooks, bakers, dishwashers, and clerks shall be
adequate to perform effectively all defined functions.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.40.4. Written job descriptions of all dietary employees shall be available.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.40.5. There shall be procedures to control dietary employees with infectious and open
lesions. Routine health examinations shall meet local and state codes for food
service personnel.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.40.6. There shall be an in-service training program for dietary employees which
includes the proper handling of food and personal grooming.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 41 FACILITIES
Rule 41.41.1. Written reports of inspections by the Department of Health of action taken to
comply with recommendations are to be kept on file at the hospital with notation
made by the hospital.
SOURCE: Miss. Code Ann. §41-9-17
52
Rule 41.41.2. Dry or staple food items shall be stored at least 12 inches off the floor in a
ventilated room which is not subject to sewage or wastewater back-flow, or
contamination by condensation, leakage, rodents, or vermin.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.41.3. All perishable foods shall be refrigerated at the appropriate temperature and in an
orderly and sanitary manner. Each refrigerator shall contain a thermometer in
good working order.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.41.4. Foods being displayed or transported shall be protected from contamination.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.41.5. Dishwashing procedures and techniques shall be developed and carried out in
compliance with the state and local health codes.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.41.6. All garbage and kitchen refuse which is not disposed of mechanically shall be
kept in leak proof non-absorbent containers with close fitting covers and be
disposed or routinely in a manner that will not permit transmission of disease, a
nuisance, or a breeding place for flies. All garbage containers are to be
thoroughly cleaned inside and outside each time emptied. No garbage or kitchen
refuse may be used as feed for swine.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.41.7. Diets. There shall be a systematic record of diets, correlated when appropriate,
with the medical records. The dietitian shall have available an up-to-date manual
or regimens for all therapeutic diets, approved jointly by the dietitian and medical
staff, which is available to dietary supervisory personnel. Diets served to patients
shall be in compliance with these established diet principles.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 42 ENVIRONMENT AND SAFETY: FIRE CONTROL AND
INTERNAL DISASTER
Rule 41.42.1. The hospital shall provide fire protection by the elimination of fire hazards the
installation of necessary safeguards such as extinguishers, sprinkling devices, fire
barriers to insure rapid and effective fire control and the adoption of written fire
control and evacuation plans rehearsed at least three times a year by key
personnel.
SOURCE: Miss. Code Ann. §41-9-17
53
Rule 41.42.2. Written fire control plans shall contain provisions for prompt reporting of all fires
extinguishing fires; protection of patients, personnel, and guests’ evacuation;
training of personnel in use of first aid firefighting equipment; and cooperation
with firefighting authorities.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.42.3. There shall be rigidly enforced written rules and regulations governing proper
routine methods of handling and storing of flammable and explosive agents,
particularly in operating rooms and laboratories, and governing the provision of
oxygen therapy.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.42.4. The hospital shall have:
1. Written evidence of regular inspection and approval by state or local fire
control agencies.
2. Stairwells kept closed by fire doors or equipped with unimpaired
automatic closing devices.
3. Fire extinguishers refilled when necessary and kept in condition for instant
use. There shall be an annual inspection of each fire extinguisher which shall
include a tag showing the month and year of the inspection and the initials
of the inspector.
4. Conductive floors with the required equipment and ungrounded electrical
circuits in areas subject to explosion hazards.
5. Proper routine storage and prompt disposal of trash.
6. "No Smoking" signs prominently displayed where appropriate, with rules
governing the ban on smoking in designated areas of the hospital enforced
and obeyed by all personnel.
7. Fire regulations easily available to all personnel and all fire codes
rigidly observed and carried out.
8. Corridors and exits clear of all obstructions except for permanently
mounted handrails.
9. Holiday decorations consisting of natural foliage or plant material
are not permitted.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 43 EMERGENCY OPERATIONS PLAN (EOP)
54
Rule 41.43.1. The licensed entity shall develop and maintain a written preparedness plan utilizing
the Emergency Operations Plan Template developed by the Mississippi State
Department of Health, Office of Emergency Planning and Response. The licensed
entity shall utilize “All Hazards” and “Whole Community” approach to emergency
and disaster planning. The plan must include procedures to be followed in the event
of any pandemic, act of terrorism, or man-made or natural disaster as appropriate for
the specific geographical location. The final draft of the Emergency Operations Plan
(EOP), will be reviewed by the Office of Emergency Planning and Response,
Mississippi State Department of Health, or their designates, for conformance with the
“All Hazards Emergency Preparedness and Response Plan.” Particular attention shall
be given to critical areas of concern which may arise during any “all hazards”
emergency whether required to evacuate or to sustain in place. Additional plan
criteria or a specified EOP format may be required as deemed necessary by the
Office of Emergency Planning and Response. The eight (8) critical areas of
consideration are:
1. Communications - Facility status reports shall be submitted in a format
and afrequency as required by the Office of Emergency Planning and
Response;
2. Resources and Assets;
3. Safety and Security;
4. Smoke Detectors/Extinguishers (refer to NFPA 10);
5. Staffing;
6. Utilities;
7. Clinical Activities; and
8. Continuity of Operations Planning (COOP) to include surge and alternate care
sites.
Emergency Operations Plans (EOPs) must be exercised and reviewed annually or
as directed by the Office of Emergency Planning and Response. Written evidence
of current verification or review of provider EOPs, by the Office of Emergency
Planning and Response, shall accompany all applications for facility license
renewals.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 44 FACILITY FIRE PREPAREDNESS
Rule 41.44.1. Fire Drills. Fire drills shall be conducted one (1) per shift per quarter. Employees
shall participate in a fire drill at least four (4) times per year.
55
1. Written Records. Written records of all drills shall be maintained,
indicating content of and attendance at each drill.
2. A fire evacuation plan shall be posted in each facility in a conspicuous place
and kept current.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 45 SANITARY ENVIRONMENT
Rule 41.45.1. The hospital shall provide a sanitary environment to avoid sources and
transmission of infections.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.45.2. An infection committee, composed of members of the medical and nursing staffs
and administration, shall be established and shall be responsible for investigating,
controlling, and preventing infections in the hospital.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.45.3. There shall be written procedures to govern the use of aseptic techniques and
procedures in all areas of the hospital.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.45.4. To keep infections at a minimum, such procedures and techniques shall be
regularly reviewed by the infection committee.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.45.5. There shall be a method of control used in relation to the sterilization and water
and a written policy requiring sterile supplies to be re-processed at specified time
periods.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.45.6. Continuing education shall be provided to all hospital personnel on the cause,
effect, transmission, prevention, and elimination of infections.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.45.7. A continuing process shall be enforced for inspection and reporting of any
hospital employee with an infection who may be in contact with patients, their
food or laundry.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.45.8. Regulated Medical Waste. "Infectious medical wastes" includes solid or liquid
wastes which may contain pathogens with sufficient virulence and quantity such
56
that exposure to the waste by a susceptible host has been proven to result in an
infectious disease. For purposes of this Regulation, the following wastes shall be
considered to be infectious medical wastes:
1. Wastes resulting from the care of patients and animals who have Class I and
(or) II diseases that are transmitted by blood and body fluid as defined in the
rules and regulations governing reportable diseases as defined by the
Mississippi Department of Health;
2. Cultures and stocks of infectious agents; including specimen cultures
collected from medical and pathological laboratories, cultures and stocks of
infectious agents from research and industrial laboratories, wastes from the
production of biologicals, discarded live and attenuated vaccines, and culture
dishes and devices used to transfer, inoculate, and mix cultures;
3. Blood and blood products such as serum, plasma, and other blood components;
4. Pathological wastes, such as tissues, organs, body parts, and body fluids
that are removed during surgery and autopsy;
5. Contaminated carcasses, body parts, and bedding of animals that were
exposed to pathogens in medical research;
6. All discarded sharps (e.g., hypodermic needles, syringes, Pasteur pipettes,
broken glass, scalpel blades) which have come into contact with infectious
agents;
7. Other wastes determined infectious by the generator or so classified
by the Department of Health.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.45.9. "Medical Waste" means all waste generated in direct patient care or in
diagnostic or research areas that is non-infectious but aesthetically repugnant if
found in the environment.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.45.10. Medical Waste Management Plan. All generators of infectious medical waste
and medical waste shall have a medical waste management plan in accordance
with Adopted Standards for the Regulation of Medical Waste.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 46 HOUSEKEEPING
Rule 41.46.1. The housekeeping functions of the hospital shall be under the direction of a
certified executive housekeeper, or other person knowledgeable about and capable
of maintaining the aseptic conditions required in the various departments of the
hospital.
57
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.46.2. There shall be adequate space provided for the storage of housekeeping
equipment and supplies and for the housekeeper to maintain adequate records of
the housekeeping operations.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.46.3. Separate janitor's closets and separate cleaning equipment and supplies shall be
maintained for the following areas and shall not be used for cleaning in any other
location:
1. Surgical Suites.
2. Delivery Suites.
3. Newborn Nursery.
4. Dietary Department.
5. Emergency Service Area.
6. Patient Areas.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.46.4. Additional janitor's closets, equipment and supplies should be provided for
laboratories, radiology, offices, locker rooms and other areas of the hospital.
Housekeeping equipment or supplies used for cleaning in isolation or
contaminated areas shall not be used in any other area of the hospital before it has
been properly cleaned and sterilized.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.46.5. All areas of the hospital, including the building and grounds, shall be kept clean
and orderly.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.46.6. There shall be frequent cleaning of floors, walls, woodwork, and windows.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.46.7. The premises must be kept free of rodent and insect infestations.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.46.8. Accumulated waste material and rubbish must be removed at frequent intervals.
58
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.46.9. No flammable cleaning agents or other flammable liquids or gases shall be stored
in any janitor's closet or other area of the hospital except in a properly fire rated,
and properly ventilated storage area specifically designed for such storage.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 47 LAUNDRY & LINEN
Rule 41.47.1. Laundry and linen service shall be under the direction of a person knowledgeable
about the capable of maintaining the sanitary requirements of the hospital in the
care of both clean and soiled linens. This person shall report directly to the
administrator of the hospital.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.47.2. If the hospital maintains its own laundry, it shall have separate areas for:
1. Collection of soiled linens.
2. Washing, drying, and ironing.
3. Clean linen storage.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.47.3. The laundry design and operation shall comply with all appropriate codes and
regulations to assure that it will not be a health or safety hazard to hospital
patients and personnel.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.47.4. If the hospital uses a laundry not controlled by the hospital, that laundry must
maintain the sanitary requirements of hospitals regarding the processing of its
linens and must maintain a satisfactory schedule of pick-up and delivery.
Sanitary practices shall be checked by periodic laboratory tests.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.47.5. Hospitals shall maintain an adequate supply of clean linens at all times.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.47.6. Adequate clean linen storage shall be readily accessible to nurses' stations.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.47.7. Dirty linen storage shall be well ventilated and shall be located convenient to the
laundry or service entrance of the hospital. The storage of appreciable quantities
59
of soiled linens is discouraged.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 48 MEDICAL RECORDS - ORGANIZATION
Rule 41.48.1. The hospital shall have a medical record department with administrative
responsibility for medical records. A medical record shall be maintained, in
accordance with accepted professional principles, for each patient receiving care
in the hospital.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.48.2. Such records shall be kept confidential and only authorized personnel shall have
access to the records.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.48.3. Written consent of the patient or the patient’s legal representative shall be
presented as authority for release of medical information and this release shall
become part of the medical record.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.48.4. Medical records shall not be removed from the hospital environment except upon
subpoena.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.48.5. Preservation. Records shall be preserved, either in the original or by
reproduction, for a period of time not less than that set forth in Title 41, Chapter 9
of the Mississippi Code of 1972.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 49 PERSONNEL
Rule 41.49.1. Qualified personnel adequate to supervise and conduct the department shall be
provided.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.49.2. Preferably a Registered Health Information Administrator or Registered Health
Information Technician shall head the department. If such a professionally
qualified person is not in charge of medical records, one shall be employed either
on a part-time or consultative basis to organize the department, train the regular
personnel, and make periodic visits to the hospital to evaluate the records and the
operation of the department.
SOURCE: Miss. Code Ann. §41-9-17
60
Subchapter 50 IDENTIFICATION AND FILING
Rule 41.50.1. A system of identification and filing to ensure the prompt location of a patient's
medical record shall be maintained.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.50.2. A master patient index shall be maintained and shall bear at least the full name of
the patient, the address, the birth date, and the medical record number.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.50.3. Filing equipment and space shall be adequate to house the records and facilitate
retrieval.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.50.4. A unit record should be maintained so that both inpatient and outpatient treatment
are in one folder.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 51 CENTRALIZATION OF REPORTS
Rule 41.51.1. All clinical information pertaining to a patient's stay shall be centralized in the
patient's record.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.51.2. The original of all reports originating in the hospital shall be filed in the medical
records.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.51.3. All reports or records shall be completed and filed within a period consistent with
good medical practice and not longer than 30 days following discharge.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.51.4. INDEXES - RESERVED
Rule 41.51.5. Records shall be indexed according to disease, operation, and physician and shall
be kept up to date. For indexing, any recognized system may be used.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.51.6. Diagnoses and Operations. shall be expressed in terminology which describes
the morbid condition both as to site and ethological factors or the method or
procedure.
61
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.51.7. Indexing shall be current within six months following discharge of the patient.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.51.8. Content. The medical record shall contain sufficient information to justify the
diagnosis and warrant the treatment and end results. The medical record shall
contain the following information: Identification date, chief complaint, present
illness, physician's orders, past history, family history, physical examination,
provisional diagnosis, clinical laboratory reports, x-ray reports, consultations,
treatment medical and surgical, tissue report, progress notes, final diagnosis,
discharge summary, autopsy findings.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.51.9. Authorship. Only practitioners authorized by the governing body to perform
medical histories and physical examinations shall be permitted to write or dictate
medical histories and physical examinations.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 52 ENTRIES
Rule 41.52.1. All entries must be legible and complete and must be authenticated and dated
promptly by the person (identified by name and discipline) responsible for
ordering, providing, or evaluating the service furnished. All orders/entries must be
dated, timed, and authenticated promptly by the prescribing physician or another
physician responsible for the care of the patient, even if the order did not originate
with him or her. Authentication may include signatures, written initials, or
computer entry.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.52.2. Entries in the medical records may be made only by individuals as specified in
hospital and medical staff policies. All entries in the medical record must be
dated and authenticated, and a method established to identify the authors of
entries. Such identification may include written signatures initials or computer
key. When rubber stamp signatures are authorized, the individual whose
signature the stamp represents shall place in the administrative offices of the
hospital, a signed statement to the effect that he/she is the only one who has the
stamp and uses it. There shall be no delegation to another individual. A list of
computer codes and written signatures must be readily available and maintained
under adequate safeguards. There shall be sanctions established for improper or
unauthorized use of stamp and computer key signatures.
SOURCE: Miss. Code Ann. §41-9-17
62
Rule 41.52.3. A single signature on the face sheet of the record shall not suffice to authenticate
the entire record.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.52.4. In hospitals with house staff, the attending physician shall countersign at least the
history and physical examination and summary written by the house staff.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 53 PROMPTNESS OF RECORD COMPLETION
Rule 41.53.1.
Current records shall be completed within 24 to 48 hours following admission.
Verbal orders shall be authenticated in accordance with facility policy and, in the
absence of a facility policy, no later than 30 days after discharge.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.53.2. Records of patients discharged shall be completed within 30 days following
discharge. The staff regulations of the hospital shall provide for the suspension or
termination of staff membership and/or clinical privileges of practitioners who are
persistently delinquent in completing records.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.53.3. If a patient is readmitted within a month for the same condition, reference to the
previous history with an interval note and physical examination shall suffice.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.53.4. Medical Library. The medical library shall have modern textbooks and current
periodicals relative to the clinical services offered.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 54 ANCILLARY SERVICES: DENTAL, REHABILITATION, PHYSICAL
THERAPY, OCCUPATIONAL THERAPY & SPEECHPATHOLOGY
Rule 41.54.1. General. Dental and rehabilitation departments are optional, but if these optional
services are present, there shall be effective policies and procedures relating to the
staff and the functions of the services in order to assure the health and safety of
the patients.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 55 DEPARTMENT OF DENTISTRY AND DENTAL STAFF
63
Rule 41.55.1. According to the procedure established for the appointment of the medical staff,
one or more dentists may be appointed to the dental staff. If the dental service is
organized, its organization shall be comparable to that of other services or
departments. Whether or not the dental service is organized as a department, the
following requirements shall be met:
1. Members of the dental staff shall be qualified legally, professionally, and
ethically for the positions to which they are appointed.
2. Patients admitted for dental services shall be admitted by the dentist either
to the department of dentistry, or, if there is no department, to an organized
clinical service.
3. There shall be a physician in attendance who is responsible for the medical
care of the patient throughout the hospital stay. A medical survey shall be
done and recorded by a member of the medical staff before dental surgery is
performed. A medical survey may be done by an oral surgeon as outlined in
Rule 41.7.3.
4. There shall be specific bylaws concerning the dental staff written as
combined medical - dental staff bylaws or separate or adjunct dental
bylaws.
5. The staff bylaws and rules and regulations shall specifically delineate the
rights and privileges of the dentists.
6. Complete records, both medical and dental, shall be required on each
dental patient and shall be a part of the hospital records.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 56 REHABILITATION, PHYSICAL THERAPY, OCCUPATIONAL
THERAPY, AND SPEECH PATHOLOGY DEPARTMENTS
Rule 41.56.1. These services may be provided. If provided, they shall have effective policies
and procedures relating to the organization and functions of the services and be
staffed by qualified therapists.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.56.2. The department head shall have the necessary knowledge, experience, and
capabilities to properly supervise and administer the department. A rehabilitation
department head shall be a psychiatrist or other physician with pertinent
experience. If separate therapy departments are maintained, the department head
shall be a qualified therapist (as is appropriate) or a physician with pertinent
experience.
SOURCE: Miss. Code Ann. §41-9-17
64
Rule 41.56.3. If physical therapy services are offered, the services shall be given by or under the
supervision of a qualified physical therapist. A qualified physical therapist shall
be a graduate of a program in physical therapy approved by the Council on
Medical Education of the American Medical Association (in collaboration with
the American Physical Therapy Association) or its equivalent and hold a current
Mississippi license. Additional properly trained and supervised personnel shall be
sufficient to meet the needs of the department.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.56.4. If occupational therapy services are offered, the services shall be given by or
under the supervision of a professional licensed occupational therapist and hold a
current Mississippi license. Other properly trained and supervised personnel,
such as licensed occupational therapy assistants and aides, shall be sufficient to
meet the needs of the department.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.56.5. If speech pathology services are offered, the service shall be given by a qualified
speech pathologist and hold a current Mississippi license.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.56.6. Facilities and equipment for physical and occupational therapy shall be adequate
to meet the needs of the services and shall be in good condition.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.56.7. Physical therapy, occupational therapy, and speech pathology shall be given in
accordance with a physician's orders.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.56.8. Complete records shall be maintained for each patient receiving therapy services
and are to include evaluations and clinical notes.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 57 LABORATORY - ORGANIZATION
Rule 41.57.1. The hospital shall have a well-organized, adequately supervised and staffed
clinical laboratory with the necessary space, facilities, and equipment to perform
those services commensurate with the hospital's needs for its patients.
Anatomical pathology services and transfusion services shall be available either in
the hospital or by arrangement with other facilities.
SOURCE: Miss. Code Ann. §41-9-17
65
Rule 41.57.2. All equipment shall be in good working order, routinely quality controlled, and
precise in terms of calibration. The laboratory shall be in compliance with all
applicable federal requirements for clinical laboratories. (Clinical Laboratory
Improvement Amendments of 1988 at 42 CFR Part 493)
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 58 CLINICAL LABORATORY EXAMINATIONS
Rule 41.58.1. Provision shall be made to carry out adequate clinical laboratory examinations
including chemistry, microbiology, hematology, coagulation, general
immunology, and clinical microscopy either in the hospital or an approved outside
laboratory.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.58.2. In the case of work performed by an outside laboratory, the original report from
such laboratory shall be contained in the medical record. For results received
directly from the testing laboratory’s computer, there may not be a paper copy,
which is acceptable.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 59 AVAILABILITY OF FACILITIES AND SERVICES
Rule 41.59.1. Adequate provision shall be made for assuring the availability of emergency
laboratory services, either in the hospital or under arrangements with an approved
outside laboratory. Such services shall be available 24 hours a day, seven days a
week, including holidays.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.59.2. Where services are provided by an outside laboratory, the conditions, procedures,
and availability of services offered shall be in writing and available in the
hospital.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 60 PERSONNEL
Rule 41.60.1. Services shall be under the technical supervision of a physician with training and
experience in clinical laboratory services.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.60.2. All personnel in the laboratory must meet the qualification and training
requirements specified in the federal Clinical Laboratory Improvement
Amendments of 1988 (CLIA).
66
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 61 LABORATORY REPORT
Rule 41.61.1. Reports shall be filed with the patient's medical record and duplicate copies kept
in the department. For data filed electronically, it is not necessary to retain paper
copies in the laboratory. The laboratory must be able to identify the analyst and
date completed for all procedures and tests.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.61.2. The laboratory director shall be responsible for the laboratory report.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.61.3. There shall be a procedure for assuring that all tests are ordered by a physician.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 62 PATHOLOGIST SERVICES
Rule 41.62.1. Services shall be under the direct supervision of a pathologist on a full-time,
regular part-time, or regular consultative basis. If the latter pertains, the hospital
shall provide for, as a minimum, quarterly consultative visits by a pathologist.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.62.2. The pathologist should participate in staff, departmental and clinical-pathologic
conferences.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.62.3. The pathologist shall be responsible for assuring the qualifications of his staff
meet CLIA’88 requirements. The pathologist must provide for in-service and
continuing education for the staff.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 63 TISSUE EXAMINATIONS
Rule 41.63.1. All tissues removed during surgery, shall be examined. The extent of
examination shall be determined by the pathology department.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.63.2. All tissues removed from patients during surgery shall be macroscopically, and if
necessary, microscopically examined by the pathologist.
SOURCE: Miss. Code Ann. §41-9-17
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Rule 41.63.3. A list of tissues which routinely require microscopic examination shall be
developed in writing by the pathologist or designated physician with the approval
of the medical staff.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.63.4. A tissue file shall be maintained in the hospital.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.63.5. In the absence of a pathologist or suitable physician substituted, there shall be an
established plan for sending to a pathologist outside the hospital all tissues
requiring examination.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 64 REPORTS OF TISSUE EXAMINATION
Rule 41.64.1. Signed reports of tissue examinations shall be filed within the patient's medical
record and duplicate copies kept in the department.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.64.2. All reports of macro and microscopic examinations performed shall be signed by
the pathologist or designated physician.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.64.3. Provision shall be made for the prompt filing of examination results in the
patient's medical record and notification of the physician requesting the
examination.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.64.4. Duplicate copies of the examination reports shall be filed in the laboratory in a
manner which permits ready identification and accessibility.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 65 BLOOD AND BLOOD PRODUCTS
Rule 41.65.1. Facilities for procurement, safekeeping and transfusion of blood products shall be
provided or readily available consistent with the size and scope of operation of the
hospital.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.65.2. The hospital shall maintain, as a minimum, proper blood storage facilities under
adequate control and supervision of the pathologist or other authorized physician.
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SOURCE: Miss. Code Ann. §41-9-17
Rule 41.65.3. For emergency situations the hospital shall maintain at least a minimum blood
supply in the hospital at all times or be able to obtain blood quickly from
community blood banks or institutions.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.65.4. Where the hospital depends on outside blood banks, there shall be an agreement
governing the procurement, transfer and availability of blood which is reviewed
and approved by the medical staff, administration, and governing body.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.65.5. There shall be provision for prompt blood typing and compatibility testing, and
for laboratory investigation of transfusion reactions, either through the hospital or
by arrangement with others on a continuous basis, under the supervision of a
physician.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.65.6. Blood storage facilities in the hospital shall have an adequate temperature alarm
system that is regularly inspected. The alarm system must be audible and monitor
proper blood storage temperature over a 24-hour period. If blood is stored or
maintained for transfusion outside of a monitored refrigerator, the laboratory must
ensure and document that the storage conditions (including temperature) are
appropriate to prevent deterioration of the blood or blood product.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.65.7. Records shall be kept on file indicating the receipt and disposition of all blood
products that are received into the hospital.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.65.8. Samples of each unit of blood transfused at the hospital shall be retained
according to the instructions of the committee indicated in Rule 41.65.9 for
further retesting in the event of reactions.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.65.9. A committee of the medical staff or its equivalent shall review all transfusions of
blood or blood products and make recommendations concerning policies
governing such practices.
SOURCE: Miss. Code Ann. §41-9-17
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Rule 41.65.10. The review committee shall investigate all transfusion reactions occurring in the
hospital and make recommendations to the medical staff regarding improvements
in transfusion procedures.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 66 PHARMACY OR DRUG ROOM ORGANIZATION
Rule 41.66.1. The hospital shall have a pharmacy directed by a registered pharmacist, or a drug
room under competent supervision. The pharmacy or drug room shall be
administered in accordance with accepted professional principles.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.66.2. Provision shall be made for emergency pharmaceutical services.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.66.3. If the hospital does not have a staff pharmacist, a consulting pharmacist shall have
overall responsibility for control and distribution of drugs and a designated
individual or individuals shall have responsibility for day-to-day operation of the
pharmacy.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 67 RECORDS
Rule 41.67.1. Records shall be kept of the transactions of the pharmacy (or drug room) and
correlated with other hospital records where indicated. Such special records shall
be kept as required by law.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.67.2. The pharmacy shall establish and maintain a satisfactory system of records and
accountability in accordance with the policies of the hospital for maintaining
adequate control over the requisitioning and dispensing of all drugs and
pharmaceutical supplies.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.67.3. A record of the stock on hand and of the dispensing of all narcotic drugs shall be
maintained in such a manner that the disposition of any particular item may be
readily traced.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.67.4. Records for prescription drugs dispensed to each patient (inpatients and
outpatients) shall be maintained which contain the full name of the patient and the
prescribing physician, the prescription number, the name, and strength of the
drug,
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the date of issue, the expiration date for all time-dated medications, the lot and
control number of the drug, and the name of the manufacturer (or trademark)
dispensed.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.67.5. The label of each individual prescription medication container shall bear the lot
and control number of the drug, the name of the manufacturer (or trademark) and,
unless the physician directs otherwise, the name of the medication dispensed.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 68 CONTROL OF TOXIC OR DANGEROUS DRUGS
Rule 41.68.1. Policies shall be established to control the administration of toxic or dangerous
drugs with specific reference to the duration of the order and the dosage.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.68.2. The medical staff shall establish a written policy that all toxic or dangerous
medications, not specifically prescribed as to time or number of doses, will be
automatically stopped after a reasonable time limit set by the staff.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.68.3. The classification ordinarily thought of as toxic, dangerous or abuse drugs shall
be narcotics sedatives, anticoagulants, antibiotics, oxytocic and cortisone
products, antineoplastic agents and shall include other categories so established
by federal, state, or local laws.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.68.4. Drugs to be Dispensed. Therapeutic ingredients of medications dispensed shall
be those included (or approved for inclusion) in the United States Pharmacopoeia,
National Formulary, United State Homeopathic Pharmacopoeia, New Drugs, or
Accepted Dental Premedies (except for any drugs unfavorably evaluated therein),
or those approved for use by the pharmacy and drug therapeutics committee.
There shall be available a formulary or list of drugs accepted for use in the
hospital which is developed and amended at regular intervals by the pharmacy
and therapeutics committee (or equivalent committee) with the cooperation of the
pharmacist (consulting or otherwise) and the administration.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 69 REGULATION CONTROLLED SUBSTANCES IN
ANESTHETIZING AREAS
71
Rule 41.69.1. Dispensing Controlled Substances. All controlled substances shall be dispensed
to the responsible person (Supervisor, CRNA, Anesthesiologist, etc.) designated
to handle controlled substances in the operating room by a Registered Pharmacist
in the hospital. When the controlled substance is dispensed, the following
information shall be recorded into the controlled substance (proof-of-use) record.
1. Signature of pharmacist dispensing the controlled substance.
2. Signature of designated licensed person receiving the controlled substance.
3. The date and time-controlled substance is dispensed.
4. The name, the strength, and quantity of controlled substance dispensed.
5. The serial number assigned to that particular record, which corresponds to
same number recorded in the pharmacy's dispensing record.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.69.2. Security/Storage of Controlled Substances. When not in use, all controlled
substances shall be maintained in a securely locked, substantially constructed
cabinet or area. All controlled substance storage cabinets shall be permanently
affixed. Controlled substances removed from the controlled substance cabinet
shall not be left unattended.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.69.3. Controlled Substance Administration Accountability. The administration of
all controlled substances to patients shall be carefully recorded into the anesthesia
record. The following information shall be transferred from the anesthesia record
to the controlled substance record by the administering practitioner during the
shift in which the controlled substance was administered.
1. The patient's name.
2. The name of the controlled substance and the dosage administered.
3. The date and time the controlled substance is administered.
4. The signature of the practitioner administering the controlled substance.
5. The wastage of any controlled substance.
6. The balance of controlled substances remaining after the administration of
any quantity of the controlled substance.
7. Day-ending or shift-evening verification of count of balances of
controlled substances remaining and controlling substances
administered shall be
72
accomplished by two (2) designated licensed persons whose signatures shall be
affixed to a permanent record.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.69.4. Waste of Controlled Substances
1. All partially used quantities of controlled substances shall be wasted at the
end of each case by the practitioner, in the presence of a licensed person.
The quantity, expressed in milligrams, shall be recorded by the wasting
practitioner into the anesthesia record and into the controlled substance
record followed by his or her signature. The licensed person witnessing this
wastage of controlled substances shall co-sign the controlled substance
record.
2. All unused and unopened quantities of controlled substances which have
been removed from the controlled substance cabinet shall be returned to the
cabinet by the practitioner at the end of each shift.
3. Any return of controlled substances to the pharmacy in the hospital must
be documented by a registered pharmacist responsible for controlled
substance handing in the hospital.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.69.5. Verification of Controlled Substances Administration. The hospital shall
implement procedures whereby, on a periodic basis, a registered pharmacist shall
reconcile quantities of controlled substances dispensed in the hospital to the
anesthetizing area against the controlled substance record in said area. Any
discrepancies shall be reported to the Director of Nursing and to the Chief
Executive Officer of the hospital. Upon completion, all controlled substance
records shall be returned from the anesthetizing area to the hospital's pharmacy by
the designated responsible person in the anesthetizing area.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 70 RADIOLOGY
Rule 41.70.1. Radiological Services. The hospital shall maintain or have available
radiological services according to needs of the hospital, either in the hospital
building proper or in an adjacent clinic or medical facility that is readily
accessible to the hospital patients, physicians, and personnel. If therapeutic x-ray
services are also provided, they, as well as the diagnostic services, shall meet
professionally approved standards for safety and personnel qualifications.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 71 HAZARDS TO PATIENTS AND PERSONNEL
73
Rule 41.71.1. The radiology department shall be free of hazards to patients and personnel.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.71.2. Proper safety precautions shall be maintained against fire and explosion hazards,
electrical hazards, and radiation hazards.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.71.3. Periodic inspection shall be made by Department of Health or a radiation
physicist, and hazards so identified shall be promptly corrected.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.71.4. Radiation workers shall be checked periodically for amount of radiation exposure
by the use of exposure meters or badge tests.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.71.5. With fluoroscopes, attention shall be paid to modern safety design and operating
procedures; records shall be maintained of the output of all fluoroscopes.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.71.6. Regulations based on medical staff recommendations shall be established as to the
administration of the application and removal of radium element, its disintegration
products, and other radioactive isotopes.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 72 PERSONNEL
Rule 41.72.1. Personnel adequate to supervise and conduct the services shall be provided,
and the interpretation of radiological examinations shall be made by physicians
competent in the field.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.72.2. The hospital shall have a qualified radiologist, either full-time or part-time, on a
consulting basis, both to give direction to the department and to interpret films
that require specialized knowledge for accurate reading. If the hospital is small
and a radiologist cannot come to the hospital regularly, selected x-ray films shall
be sent to a radiologist for interpretation.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.72.3. If the activities of the radiology department extend to radiotherapy, the physician
in charge shall be appropriately qualified.
74
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.72.4. The amount of qualified radiologist's and technologist's time shall be sufficient to
meet the hospital's requirement. A technologist shall be on duty or on call at all
times.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.72.5. The use of all x-ray apparatus shall be limited to personnel designated as qualified
by the radiologist or by an appropriately constituted committee of the medical
staff. The same limitation shall apply to personnel applying and removing radium
element, its disintegration products, and radioactive isotopes. The use of
fluoroscopes shall be limited to physicians or technologist under the direction of a
physician.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 73 SIGNED REPORTS
Rule 41.73.1. Signed reports shall be filed with the patient's medical record.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.73.2. Requests by the attending physician for x-ray examination shall contain a concise
statement of reason for the examination.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.73.3. Reports of interpretations shall be written or dictated and signed by the
radiologist.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.73.4. X-ray reports and roentgenographies shall be preserved according to statute.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 74 SOCIAL WORK
Rule 41.74.1. Hospitals without an organized Social Work Department may provide this
service. If such department is provided, there shall be effective policies and
procedures relating to the staff and the functions of the service.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.74.2. If the facility offers social services, a member of the staff of the facility shall be
responsible for social services. If the designated person is not a qualified social
worker, the facility has a written agreement with a qualified social worker, or
75
recognized social agency for consultation and assistance on a regularly scheduled
basis.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.74.3. A qualified social worker is an individual who is currently licensed by the State of
Mississippi and has one (1) year of experience in a health care setting.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 75 UTILIZATION REVIEW PLAN
Rule 41.75.1. The hospital must have in effect a utilization review (UR) plan that provides
for review of services furnished by the institution and by members of the
medical staff to patients.
1. The UR plan must provide for review for patients with respect to the
medical necessity of:
A. Admissions to the institution;
B. The duration of stays; and
C. Professional services furnished including drugs and biologicals.
2. Review of admissions may be performed before, at, or after hospital admission.
3. Reviews may be conducted on a sample basis.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 76 UTILIZATION REVIEW COMMITTEE
Rule 41.76.1. A UR committee consisting of two or more practitioners must carry out the UR
function. At least two of the members of the committee must be Doctor of
Medicine or osteopathy. The other members may be any of the other types of
practitioners.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.76.2. The committee must review professional services provided to determine medical
necessity and to promote the most efficient use of available health facilities and
services.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 77 QUALITY ASSESSMENT AND PERFORMANCE
IMPROVEMENT (QAPI) PROGRAM
76
Rule 41.77.1. The hospital must develop, implement, and maintain an effective, ongoing,
hospital-wide, data-driven quality assessment and performance improvement
program.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.77.2. The hospital’s governing body must ensure that the program reflects the
complexity of the hospital’s organization and services; involves all hospital
departments and services (including those services furnished under contract or
arrangement); and focuses on indicators related to improved health outcomes and
the prevention and reduction of medical errors.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.77.3. The hospital must maintain and demonstrate evidence of its QAPI program for
review by the Department.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 78 QAPI PROGRAM SCOPE
Rule 41.78.1. The program must include, but not be limited to, an ongoing program that shows
measurable improvement in indicators for which there is evidence that it will
improve health outcomes and will identify and reduce medical errors.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.78.2. The hospital must measure, analyze, and track quality indicators, including
adverse patient events, and other aspects of performance that assess processes of
care, hospital service and operations.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 79 QAPI PROGRAM DATA
Rule 41.79.1.
The hospital must use the data collected to:
1. Monitor the effectiveness and safety of services and quality of care; and
2. to identify opportunities for improvement and changes that will
lead to improvement.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.79.2. The frequency and detail of data collection must be specified by the hospital’s
governing body.
SOURCE: Miss. Code Ann. §41-9-17
77
Subchapter 80 QAPI PROGRAM ACTIVITIES
Rule 41.80.1. The hospital must set priorities for its performance improvement activities that:
1. Focus on high-risk, high-volume, or problem-prone areas;
2. Consider the incidence, prevalence, and severity of problems in those areas;
3. Affect health outcomes and quality of care; and
4. Affect patient safety.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.80.2. Performance improvement activities must track medical errors and adverse patient
events, analyze their causes, and implement preventive actions and mechanisms
that include feedback and learning throughout the hospital.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.80.3. The hospital must take actions aimed at performance improvement and, after
implementing those actions, the hospital must measure its success, and track
performance to ensure that improvements are sustained.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 81 PERFORMANCE IMPROVEMENT PROJECTS
Rule 41.81.1. As part of its quality assessment and performance improvement program, the
hospital must conduct performance improvement projects.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.81.2. The number and scope of distinct improvement projects conducted annually must
be proportional to the scope and complexity of the hospital’s services and
operations.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.81.3. The hospital must document what quality improvement projects are being
conducted, the reasons for conducting these projects, and the measurable progress
achieved on these projects.
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 82 TRAUMA REGISTRY
Rule 41.82.1. All licensed hospitals which have organized emergency services or departments
must participate in the statewide trauma registry for the purpose of supporting
78
peer review and performance improvement activities at the local, regional and
state levels. Since this data relates to specific trauma patients and is used to
evaluate and improve the quality of health care services, this data is confidential
and will be governed by Miss. Code Ann. §41-59-77 (as amended). Compliance
with the above will be evidenced by:
1. Documentation of utilization of the Trauma Registry data in the
trauma performance improvement process and
2. Timely submission of Trauma Registry Data to the Bureau of EMS at
least monthly.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.82.2. Data Submission Requirements: Patients to be included in the trauma registry are
defined in “Mississippi Trauma Care System: Rules and Regulations (as
amended).
SOURCE: Miss. Code Ann. §41-9-17
Subchapter 83 FREESTANDING EMERGENCY DEPARTMENTS
Rule 41.83.1. Adoption of Regulations and Minimum Standards. By virtue of authority
vested in it by the Mississippi Code Annotated Sections 41-75-1 through 41-75-
13, or as otherwise amended, the Mississippi Department of Health does hereby
adopt and promulgate the following regulations and standards for Freestanding
Emergency Departments (FED).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.2 Compliance with Rules, Regulations and Standards. The FED shall:
1. Comply with all applicable Medicare provider-based regulations. The FED
shall comply with all regulations that apply to clinical services and staffing
for emergency departments, as set forth in the MSDH Minimum Standards
of Operation for Mississippi Hospitals.
2. Provide data to their Trauma Region and the department’s Trauma Registry
through participation in the Mississippi Trauma Care System (MTS).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.3 Definitions. The definitions specific to the FED are:
1. Freestanding Emergency Room. “Freestanding Emergency Room” is a
facility open twenty-four hours a day for the treatment of urgent and
emergent medical conditions which is not located on a hospital campus. In
order to eligible for licensure under this chapter, the freestanding
79
emergency room shall be located at least fifteen (15) miles from the nearest
hospital-based emergency room in any rural community where the federal
Centers for Medicaid & Medicare Services (CMS) had previously
designated a rural hospital as a critical access hospital and that designation
has been revoked.
2. Licensing Agency. “Licensing agency” means the Mississippi State
Department of Health.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.4 License. No person or governmental unit shall establish, conduct, or maintain a
Freestanding Emergency Department in this state without a license.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.5 Application for License. An application for a license shall be made to the
licensing agency upon forms provided by the licensing agency and shall contain
such information as the licensing agency reasonably requires.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.6 Licensure and User Fees. Such fees shall be paid to the licensing agency by
electronic payment, business check, certified check, or money order. A license
shall not be issued to any FED until such fee is received by the licensing agency.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.7 User Fee. A “user fee” shall be assessed by the licensing agency for the purpose
of the required reviewing and inspections of the proposal of any FED in which
there are additions, renovations, modernizations, expansion, alterations,
conversions, modifications, or replacement of the entire facility involved in the
proposal. This fee includes the reviewing of architectural plans in all required
steps.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.8 Renewal of License. A license, unless suspended or revoked, shall be renewable
annually by submitting an application, paying an annual fee and submitting such
reports as required by the licensing agency, including annual information reports.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.9 Issuance of License. Each license shall be issued only for the premises and
persons or governmental units names in the application and shall not be
transferable or assignable except with the written approval of the licensing
agency.
80
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.10 Denial or Revocation of a License. The licensing agency, after notice and
opportunity for hearing to the applicant or licensee, is authorized to deny,
suspend, or revoke a license in any case in which it finds that there has been a
substantial failure to comply with the requirements established in these
regulations and standards.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.11 Ownership. There shall be full disclosure of FED ownership and control.
Annually, in its application for renewal of an FED License, the facility shall
report the name and address of the owner and the name and address of the
individual(s) responsible for operation of the FED.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.12 Change of Ownership. When change of ownership of a FED is contemplated,
the FED shall notify the licensing agency, in writing, at least 30 days prior to the
proposed date of change of ownership, giving the name and address of the
proposed new owner and all other documents as required by the licensing agency.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.13 Governing Authority. The FED shall have an organized governing body, or
designated person(s):
1. That has overall responsibility for the conduct of the FED in a manner
consistent with the objective of making available high quality patient care.
2. That shall be the authority in the FED, responsible for the management of
the FED and appointment of the medical staff.
3. That shall adopt bylaws in accordance with legal requirements and with its
community responsibility, identifying the purposes of the FED and the
means of fulfilling them,
4. That shall take all reasonable steps to comply with all applicable federal,
state, and local laws and regulations.
SOURCE: Miss. Code Ann. §41-75-13
81
Rule 41.83.14. Staffing and Treatment. The FED must possess the staff and resources
necessary to evaluate all individuals presenting to the emergency department.
The FED must follow all requirements of EMTALA in regard to assuring the
medical evaluation, stabilization and transfer of a patient found to have an
emergency condition. Because of the unscheduled and episodic nature of health
emergencies and acute illness, the FED must be staffed with experienced
American Board of Medical Specialties (ABMS) or American Osteopathic
Association (AOA) board certified or board eligible physicians, nursing and
ancillary personnel who must be available 24 hours a day. The FED will also
provide treatment for individuals whose health needs are not of an emergent
nature, but for whom the FED may be the only accessible or timely entry point
into the broader health care system.
1. Each FED shall have patient transfer agreements with an EMS service and
with an acute care or trauma hospital with the capability of handling such
emergencies and to assure provisions for patient admissions, continued
emergency, and diagnostic services beyond the capability of the FED, and
the safe emergency transport of the patient, when needed.
2. As stated by the American College of Emergency Physicians (ACEP):
A. Emergency medical care must be available to all members of the public.
B. Access to appropriate emergency medical and nursing care must be
unrestricted.
C. A smooth continuum should exist among pre-hospital providers,
emergency department (ED) providers, and providers of definitive follow-
up care.
D. Evaluation, management, and treatment of patient must be appropriate and
expedient.
E. Resources should exist in the ED to accommodate each patient from the
time of arrival through evaluation, medical decision making, treatment and
disposition.
F. FEDs should have policies and plans to provide effective administration,
staffing, facility design, equipment, medication, and ancillary services.
G. The emergency physician, emergency nurse, and additional medical team
members must establish effective working relationships with other health
care providers and entities with whom they must interact. These include
emergency medical services (EMS) providers, ancillary hospital
personnel, other physicians, and other health care and social services
resources.
SOURCE: Miss. Code Ann. §41-75-13
82
Rule 41.83.15 Required Policies. The FED Emergency Department Policy Sections shall
include:
1. Resources and Planning
A. Necessary Elements
i. Administration
ii. Staffing
iii. Facility
iv. Equipment and Supplies
v. Pharmacologic/Therapeutic Drugs and Agents
vi. Safety
vii. Ancillary Services
viii. Transfer policies and procedures for critical patients
ix. Electronic Medical Record
x. Relationships and Responsibilities
2. Core Measures
A. Measure Groups
i. Median Time from FED Arrival to ED Departure for Discharged
Patients
ii. Median Time from FED Arrival to Decision to Transfer
iii. Median Time from Decision to Transfer to arrival at receiving facility
iv. Total lengths of stay and door-to-doctor times
B. Quality/Safety Metrics
i. FED will be responsible for reporting all categories required
ii. Case analysis of EMS patient outliers.
SOURCE: Miss. Code Ann. §41-75-13
83
Rule 41.83.16 FED Equipment, Instruments, and Supplies. The equipment, instruments, and
supplies listed below are required in the FED and each of the items should be
located in or immediately available to the area noted. This list does not include
routine medical/surgical supplies such as adhesive bandages, gauze pads, and
suture material, nor does it include routine office items such as paper, desks,
paper clips, and chairs.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.17. Entire FED Department shall include:
1. Central station monitoring capability
2. Physiological monitors
3. Blood flow detectors
4. Defibrillator with monitor and battery
5. Thermometers
6. Pulse oximetry
7. Nurse-call system for patient use
8. Portable suction regulator
9. Infusion pumps to include blood pumps
10. IV poles
11. Bag-valve-mask respiratory and adult and pediatric size mask
12. Portable oxygen tanks
13. Blood/fluid warmer and tubing
14. Nasogastric suction supplies
15. Nebulizer
16. Gastric lavage supplies, including large-lumen tubes and bite blocks
17. Urinary catheters, including straight catheters, Foley catheters, Coude
catheters, filiforms and followers, and appropriate collection
equipment
18. Intraosseous needles
19. Lumbar puncture sets (adult and pediatric)
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20. Blanket warmer
21. Tonometer
22. Slit lamp
23. Wheelchairs
24. Medication dispensing system with locking capabilities
25. Separately wrapped instruments (specifics will vary by department)
26. Availability of light microscopy for emergency procedures
27. Weight scales (adult and infant)
28. Tape measure
29. Ear irrigation and cerumen removal equipment
30. Vascular Doppler
31. Anoscope
32. Adult and Pediatric "code" cart
33. Suture or minor surgical procedure sets (generic)
34. Portable sonogram equipment
35. EKG machine
36. Point of care testing
37. X-ray view box and hot light
38. Film boxes for holding x-rays
39. Chart Rack
40. Computer system
41. Internet capabilities
42. Patient tracking system
43. Radio or other device for communication with ambulances
44. Patient discharge instruction system
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45. Patient registration system/ Information services
46. Intradepartmental staff communication system- pagers, mobile phones
47. ED charting system for physician, nursing, and attending
physician documentation equipment
48. Reference materials including toxicology resource information
49. Personal protective equipment- gloves, eye goggles, face mask, gowns, head,
and foot covers
50. Linen (pillows, towels, wash cloths, gowns, blankets)
51. Patient belongings or clothing bag
52. Security needs -including restraints and wand-type or free-standing metal
53. detectors as indicated
54. Equipment for adequate housekeeping
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.18. FED General Examination Rooms shall include:
1. Examination tables or stretchers appropriate to the area.
2. For any area in which seriously ill patients are managed, a stretcher with
capability for changes in position, attached IV poles, and a holder for
portable oxygen tank should be used.
3. Pelvic tables for GYN examinations.
4. Step stool
5. Chair/stool for emergency staff
6. Seating for family members or visitors
7. Adequate lighting, including procedure lights as indicated
8. Cabinets
9. Adequate sinks for handwashing, including dispensers for germicidal soap
and paper towels.
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10. Wall mounted oxygen supplies and equipment, including nasal cannulas,
facemasks, and venturi masks.
11. Wall mounted suction capability, including both tracheal cannulas and
larger cannulas.
12. Wall-mounted or portable otoscope/ophthalmoscope
13. Sphygmomanometer/stethoscope
14. Oral and nasal airways
15. Biohazard-disposal receptacles, including for sharps
16. Garbage receptacles for non-contaminated materials
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.19. FED Resuscitation Room. All items listed for general examination rooms plus:
1. Adult and Pediatric "code cart" to include appropriate medication charts
2. Capability for direct communication with nursing station, preferably hands free
3. Radiography equipment
4. Radiographic view boxes and hot light
5. Airways needs
A. Big-valve-mask respirator (adult, pediatric, and infant)
Cricothyroidotomy instruments and supplies
B. Endotracheal tubes, size 2.5 to 8.5 mm
C. Fiberoptic laryngoscope
D. Laryngoscopes, straight and curved blades and stylets
E. Laryngoscope mirror and supplies
F. Laryngeal Mask Airway (LMA)
G. Oral and nasal airways
H. Tracheostomy instrument and supplies
6. Breathing
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A. BiPAP Ventilation System
B. Closed-chest drainage device
C. Chest tube instruments and supplies
D. Emergency thoracotomy instruments and supplies
E. End-tidal C02 monitor18
F. Nebulizer
G. Peak flow meter
H. Pulse oximetry
I. Volume cycle ventilator
7. Circulation
A. Automatic physiological monitor, noninvasive
B. Blood/fluid infusion pumps and tubing
C. Blood/fluid warmers
D. Cardiac compression board
E. Central venous catheter setups/kits
F. Central venous pressure monitoring equipment
G. Cutdown instruments and supplies
H. Intraosseous needles
I. IV catheters, sets, tubing, poles
J. Monitor/defibrillator with pediatric paddles, internal paddles, appropriate
pads, and other supplies Pericardiocentesis instruments
K. Temporary external pacemaker
L. Transvenous and/or transthoracic pacemaker setup and supplies
M. 12-Lead ECG machine
SOURCE: Miss. Code Ann. §41-75-13
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Rule 41.83.20. Trauma and miscellaneous resuscitation shall include:
1. Blood salvage/autotransfusion device
2. Emergency obstetric instruments and supplies
3. Hypothermia thermometer
4. Infant warming equipment
5. Peritoneal lavage instruments and supplies
6. Pneumatic antishock garment, as indicated
7. Spine stabilization equipment to include cervical collars, short and long boards
8. Warming/cooling blanket
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.21 Other Special Rooms. All items listed for general examination rooms plus:
1. Orthopedic
A. Cast cutter
B. Cast and splint application supplies and equipment Cast spreader
C. Crutches
D. Extremity-splinting devices including traction splinting and fixation
pins/wires and corresponding instruments and supplies
E. Halo traction or Gardner-Wells/Trippe-Wells traction Radiograph view
and hot light
F. Suture instrument and supplies
G. Traction equipment, including hanging weights and finger traps
2. Eye/ENT
A. Eye chart
B. Ophthalmic tonometry device (applanation, Schiotz, or other)
C. Other ophthalmic supplies as indicated, including eye spud, rust ring
remover, cobalt blue light
89
D. Slit lamp
E. Ear irrigation and cerumen removal equipment
F. Epistaxis instrument and supplies, including balloon posterior packs
Frazier suction tips
G. Headlight
H. Laryngoscope mirror
I. Plastic suture instruments and supplies
3. OB-GYN
A. Fetal Doppler and ultrasound equipment
B. Obstetrics/Gynecology examination light
C. Vaginal specula in pediatric through adult sizes
D. Sexual assault evidence-collection kits (as appropriate)
E. Suture material
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.22 Required Pharmacological/Therapeutic drugs for FED. These classes of drugs
and agents are required. The medical director of the FED, representatives of the
medical staff, and the director of the pharmacy shall develop a formulary of
specific agents for use in the FED.
1. Analgesics
A. narcotic and non-narcotic
2. Anesthetics
A. topical, infiltrative, general
3. Anticonvulsants
4. Antidiabetic agents
5. Antidotes
6. Antihistamines
7. Anti-infective agents
90
A. systemic/topical
8. Anti-inflammatories
A. steroidal/non-steroidal
9. Anti-platelets
10. Aspirin
11. Plavix
12. Heparin
13. Bicarbonates
14. Blood Modifiers
15. Anticoagulants to include thrombolytics
16. Anticoagulants
17. Hemostatic agents
A. systemic
B. topical
C. plasma expanders/ extenders
18. Burn Preparations
19. Cardiovascular agents
A. Ace inhibitors
B. Adrenergic blockers
C. Adrenergic stimulants
D. Alpha/Beta blockers
E. Antiarrhythmic agents
F. Calcium channel blockers
G. Digoxin antagonist
H. Diuretics
91
I. Vasodilators
J. Vasopressors
20. Cholinesterase Inhibitors
21. Diagnostic agents
A. Blood contents
B. Stool contents
C. Testing for myasthenia gravis
D. Urine contents
22. Electrolytes
A. Cation exchange resin
B. Electrolyte replacements, parenteral and oral
C. Fluid replacement solutions
23. Gastrointestinal agents
A. Antacids
B. Anti-diarrheals
C. Emetics and Anti-emetics
D. Anti-flatulent
E. Anti-spasmodics
F. Bowel evacuants/laxatives
G. Histamine receptor antagonists
H. Proton pump inhibitors
24. Glucose elevating agents
25. Hormonal agents
26. Hypocalcemia and hypercalcemia management agents
27. Lubricants
92
28. Migraine preparations
29. Muscle relaxants
30. Narcotic antagonist
31. Nasal preparation
32. Ophthalmologic preparations
33. Otic preparations
34. Oxytocics
35. Pain Medications
36. Psychotherapeutic agents
37. Respiratory agents
A. Antitussives
B. Bronchodilators
C. Decongestants
D. Leukotriene antagonist
38. Rho(D) immune globulin
39. Salicylates
40. Sedatives and Hypnotics
41. Thrombolytics
42. Vaccinations
43. Vitamins and minerals
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.23 Radiologic, Imaging, and Other Diagnostic Services. The specific services
available and the timeliness of availability of these services for emergency
patients in FED should be determined by the medical director of the FED in
collaboration with the directors of the diagnostic services and other appropriate
individuals.
93
1. The following should be readily available 24 hours a day for emergency
patients:
A. Standard radiologic studies of bony and soft-tissue structures including,
but not limited to:
i. Cross-table lateral views of spine with full series to follow
ii. Portable chest radiographs for acutely ill patients and for verification
of placement of endotracheal tube, central line, or chest tube
iii. Soft-tissue views of the neck
iv. Soft-tissue views of subcutaneous tissues to rule out the presence of
foreign body
v. Standard chest radiographs, abdominal series, etc.
B. Pulmonary services
i. Arterial blood gas determination
ii. Peak flow determination
iii. Pulse oximetry
C. Fetal monitoring (nonstress test)/uterine monitoring
D. Cardiovascular services
i. Doppler studies
ii. 12-Lead ECGs and rhythm strips
E. Emergency ultrasound services for the diagnosis of obstetric/gynecologic,
cardiac, and hemodynamic problems and other urgent conditions.
2. The following services shall be available on an urgent basis. Such may be
provided by on duty staff or on call staff available to respond within a
reasonable period of time:
A. Nuclear medicine
i. Ventilation-perfusion lungs scans
ii. Other scintigraphy for trauma and other conditions
94
B. Radiographic
i. Arteriography/venography
ii. Computed tomography
iii. Dye-contrast studies (intravenous pyelography, gastrointestinal
contrast, etc.)
C. Vascular/flow studies including impedance plethysmography
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.24 Required Laboratory Capabilities. The medical director of the FED and the
director of laboratory services shall develop guidelines for availability and
timeliness of services for the FED. The following laboratory capabilities are
required for the FED. This list may not be comprehensive or complete.
1. Blood bank
A. Bank products availability
B. Type and cross-matching capabilities
2. Chemistry
A. Ammonia
B. Amylase
C. Anticonvulsant and other therapeutic drug levels
D. Arterial blood gases
E. Bilirubin (total and direct)
F. Calcium
G. Carboxyhemoglobin
H. Cardiac isoenzymes (including creatine kinase- MB)
I. Chloride (blood and cerebrospinal fluid [CSF])
J. Creatinine
K. Electrolytes
L. Ethanol
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M. Glucose (blood and CSF)
N. Liver-function enzymes (ALT, AST, alkaline phosphatase)
O. Methemoglobin
P. Osmolality
Q. Protein (CSF)
R. Serum magnesium
S. Urea nitrogen
3. Hematology
A. Cell count and differential (blood, CSF, and joint fluid analysis)
B. Coagulation studies
C. Erythrocyte sedimentation rate
D. Platelet count
E. Reticulocyte count
F. Sickle cell prep
4. Microbiology
A. Acid fast smear/staining
B. Chlamydia testing
C. Counter immune electrophoresis for bacterial identification
D. Gram staining and culture/sensitivities
E. Herpes testing
F. Strep screening
G. Viral culture
H. Wright stain
5. Other
A. Hepatitis screening
96
B. HIV screening
C. Prothrombin Time (PT)/International Normalized Ratio (INR), Partial
Thromboplastin Time (PTT)
i. D-dimer
D. Joint fluid and CSF analysis
E. Toxicology screening and drug levels
F. Urinalysis
G. Mononucleosis spot
H. Serology (syphilis, recombinant, immunoassay)
I. Pregnancy testing (qualitative and quantitative)
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.25 Transfer of Unstable Patients from FED to Acute Care Hospital. Once the
patient is determined to require a higher level of care than can be provided at the
FED, the physician shall immediately contact the designated EMS for transport. If
the EMS is based on site, the transport team will be notified immediately. The
physician will stabilize the emergency medical condition and determine the
transfer destination based on the specialized capabilities of facilities that are
offered at local hospitals. The FED facility will implement all procedures and
protocols for acutely ill patients before departure from the FED. Such conditions
would include, but not be limited to, STEMI, acute ischemic stroke, and cardiac
arrests. All electronic medical records and any diagnostic test results will be
transported with the patient to the receiving facility. Should a patient meeting
trauma system activation requirements arrive at the FED, the FED will transfer
the patient in accordance with the federal EMTALA regulations and the MS State
Board of Health approved System of Care Plans.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.83.26 Medical records/organization. The FED shall have a medical record
department with administrative responsibility for medical records. A medical
record shall be maintained, in accordance with accepted professional principles,
for each patient receiving care in the FED.
SOURCE: Miss. Code Ann. 41-75-13
Rule 41.83.27 Confidentiality. Medical records shall be kept confidential and only
authorized personnel shall have access to the records.
97
SOURCE: Miss. Code Ann. 41-75-13
Rule 41.83.28 Consent. Written consent of the patient or the patient’s legal representative
shall be presented as authority for release of medical information and this
release shall become part of the medical record.
SOURCE: Miss. Code Ann. 41-75-13
Rule 41.83.29 Access to records. Medical records shall not be removed from the FED
environment except upon subpoena or patient’s written consent.
SOURCE: Miss. Code Ann. 41-75-13
Rule 41.83.30 Preservation. Medical records shall be preserved, either in the original or by
reproduction, for a period of time not less than that set forth in Title 41, Chapter
9 of the Mississippi Code of 1972.
SOURCE: Miss. Code Ann. 41-75-13
SUBCHAPTER 84 MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI
PILOT FREESTANDING EMERGENCY ROOMS
Rule 41.84.1. Adoption of Regulations and Minimum Standards. By virtue of authority
vested in it by the Mississippi Code Annotated Sections 41-75-1 through 41-75-
13, or as otherwise amended, the Mississippi Department of Health does hereby
adopt and promulgate the following regulations and standards for Pilot
Freestanding Emergency Rooms (PFER).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.2 Compliance with Rules, Regulations and Standards.
The PFER shall report to the licensing agency all required data as specified by the
licensing agency at a frequency required by the licensing agency. Must include but
not limited to trauma, hospital discharge data, etc.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.3 Definitions. The definitions specific to the PFER are:
1. Licensing Agency. “Licensing agency” means the Mississippi State
Department of Health.
2. Pilot Freestanding Emergency Room (PFER). "Pilot freestanding
emergency room" is a facility open twenty-four (24) hours a day
for the treatment of urgent and emergent medical conditions that is
not located on a hospital campus. In order to be eligible for
licensure under this chapter, the pilot freestanding emergency room
shall be located at least fifteen (15) miles from the nearest hospital-
based emergency room in a county without emergency hospital
98
care that is open twenty-four (24) hours a day. A PFER shall not
retain any patient beyond 23 hours and 59 minutes under normal
operations and shall not hold itself out as an emergency hospital.
SOURCE: Miss. Code Ann. §41-75-1
Rule 41.84.4 License. No person or governmental unit shall establish, conduct, or maintain a
Pilot Freestanding Emergency Room in this state without a license. The licensing
agency shall not issue licenses for more than five (5) pilot freestanding emergency
rooms. Licensing fees will be set by the board.
Provisional License. Within its discretion, the Mississippi State Department of
Health may issue a provisional license when a temporary condition of non-
compliance with these regulations exists in one or more particulars. A provisional
license shall be issued only if the Department of Health is satisfied that preparations
are being made to qualify for a regular license and that the health and safety of
patients will not be endangered. One condition on which a provisional license may
be issued is as follows: A new pilot freestanding emergency room may be issued a
provisional license prior to opening and subsequent to meeting the required
minimum staffing personnel. The license issued under this condition shall be valid
until the issuance of a regular license but shall not exceed five months following
date of issuance whichever may be sooner.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.5 Application for License. An application for a license shall be made to the
licensing agency by a licensed Mississippi hospital upon forms provided by the
licensing agency and shall contain such information as the licensing agency
reasonably requires.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.6 Licensure and User Fees. Such fees shall be paid to the licensing agency by
electronic payment, business check, certified check, or money order. A license
shall not be issued to any PFER until such fee is received by the licensing agency.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.7 User Fee. A “user fee” shall be assessed by the licensing agency for the purpose
of the required reviewing and inspections of the proposal of any PFER in which
there are additions, renovations, modernizations, expansion, alterations,
conversions, modifications, or replacement of the entire facility involved in the
proposal. This fee includes the reviewing of architectural plans in all required
steps.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.8 Renewal of License. A license, unless suspended or revoked, shall be renewable
99
annually by submitting an application, paying an annual fee and submitting such
reports as required by the licensing agency, including annual information reports.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.9 Issuance of License. Each license shall be issued only for the premises and
persons or governmental units names in the application and shall not be
transferable or assignable except with the written approval of the licensing
agency.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.10 Denial or Revocation of a License. The licensing agency, after notice and
opportunity for hearing to the applicant or licensee, is authorized to deny, suspend,
or revoke a license in any case in which it finds that there has been a substantial
failure to comply with the requirements established in these regulations and
standards.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.11 Ownership. There shall be full disclosure of PFER ownership and control.
Annually, in its application for renewal of an PFER License, the facility shall
report the name and address of the owner and the name and address of the
individual(s) responsible for operation of the PFER. All PFERs must be
affiliated with a MS licensed hospital.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.12 Change of Ownership. When change of ownership of a PFER is contemplated,
the PFER shall notify the licensing agency, in writing, at least 30 days prior to the
proposed date of change of ownership, giving the name and address of the
proposed new owner and all other documents as required by the licensing agency.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.13 Governing Authority. The PFER shall have an organized governing body, or
designated person(s):
1. That has overall responsibility for the conduct of the PFER in a manner
consistent with the objective of making available high quality patient
care.
2. That shall be the authority in the PFER, responsible for the management
of the PFER and appointment of the medical staff.
3. That shall adopt bylaws in accordance with legal requirements and with
its community responsibility, identifying the purposes of the PFER and
the means of fulfilling them,
100
4. That shall take all reasonable steps to comply with all applicable
federal, state, and local laws and regulations.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.14. Staffing and Treatment. The PFER must possess the staff and resources
necessary to evaluate all individuals presenting to the emergency department.
The PFER must follow all requirements of EMTALA in regard to assuring the
medical evaluation, stabilization and transfer of a patient found to have an
emergency condition. The PFER must follow all Board approved System of
Care Plans. Because of the unscheduled and episodic nature of health
emergencies and acute illness, the PFER must be staffed with experienced
American Board of Medical Specialties (ABMS) or American Osteopathic
Association (AOA) board certified or board eligible medical director,
physicians, nursing, and ancillary personnel who must be available 24 hours a
day. The PFER will also provide treatment for individuals whose health needs
are not of an emergent nature, but for whom the PFER may be the only
accessible or timely entry point into the broader health care system.
1. Staffing that must be available 24 hours a day on site include:
A. At-least one physician on site Certified or Board Eligible by the
American Board of Emergency Medicine or the American Board of
Osteopathic Emergency Medicine; or Certified or Board Eligible to
sit for the examination of one of the following boards: Internal
Medicine, Family Medicine, or Surgery; and shall hold a certificate
from the following approved programs: Advanced Coronary Life
Support; Advanced Trauma Life Support; Advanced Pediatric Life
Support; and shall have three years of full-time clinical experience in
emergency medicine within the past five years.
B. At-least one registered nurse on site with training in emergency
care. Registered nurse shall hold a current certification in both
Advanced Cardiac Life Support and Advanced Pediatric Life
Support, or two registered nurses on site at all times, one having
current certification in Advanced Cardiac Life Support and one
with current certification in Advanced Pediatric Life Support.
C. At-least one certified and registered radiology technologist shall
be on site at the PFER at all times.
D. At-least one person qualified to perform laboratory testing at the
level of laboratory services provided on site by the PFER shall be
on duty at all times.
101
E. Each PFER shall have a full-time administrative director who
directors the daily administrative operations of the PFER, ensures
the employees and staff are adequately trained, and provides
oversight of the maintenance of the PFER, coordination of
patient safety and quality improvement programs and activities.
F. Compliance with the above will be evidenced by:
i. Published on-call list of practitioners to the Emergency
Department; and
ii. Documentation of nursing staffing patterns to assure 24-
hour coverage.
2. Each PFER shall have patient transfer agreements with an EMS service
and with an affiliated acute care or trauma hospital with the capability of
handling such emergencies or has State Board of Health approved system
of care plan to assure provisions for patient admissions, continued
emergency, and diagnostic services beyond the capability of the PFER,
and the safe emergency transport of the patient, when needed.
3. Once the decision for transfer has been made, it is the responsibility of
the referring physician to initiate resuscitation measures within the
capabilities of the local hospital. The referring provider shall select a
mode of transport according to the patient’s needs so that the level of
care is appropriate during transport.
4. As stated by the American College of Emergency Physicians (ACEP):
A. Emergency medical care shall be available to all members of the
public 24 hours a day.
B. Access to appropriate emergency medical and nursing care
shall be unrestricted.
C. A smooth continuum should exist among pre-hospital providers,
emergency room (ER) providers, and providers of definitive
follow-up care.
D. Evaluation, management, and treatment of patient shall be
appropriate and expedient.
E. Resources should exist in the ER to accommodate each patient from
the time of arrival through evaluation, medical decision making,
treatment and disposition.
102
F. PFERs should have policies and plans to provide effective
administration, staffing, training, facility design,
equipment, medication, and ancillary services.
G. The emergency physician, emergency nurse, and additional
medical team members should establish effective working
relationships with other healthcare providers and entities with
whom they must interact. These include emergency medical
services (EMS) providers, ancillary hospital personnel, other
physicians, and other health care and social services resources.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.15 Criminal History Record Checks.
1. Employee. For the purpose of fingerprinting and criminal background
history checks, employee shall mean any individual employed by a
covered entity. The term employee”, also includes any individual who by
contract with the covered entity provides direct patient care in a patient’s,
resident’s, or client’s room or in treatment rooms.
The term employee does not include healthcare professional/technical
students, as defined in Section 37-29-232, performing clinical training in a
licensed entity under contracts between their schools and the licensed
entity, and does not include students at high schools who observe the
treatment and care of patients in a licensed entity as part of the
requirements of an allied health course taught in the school if:
A. The student is under the supervision of a licensed healthcare
provider; and
B. The student has signed the affidavit that is on file at the student’s
school stating that he or she has not been convicted of or plead
guilty or nolo contendere to a felony of possession or sale of drugs,
murder, manslaughter, armed robbery, rape, sexual battery, any sex
offenses listed in section 45-33-23 (g), child abuse, arson, grand
larceny, burglary, gratification of lust, aggravated assault, or
felonious abuse and/or battery of a vulnerable adult, or that any
such conviction or plea was reversed on appeal or a pardon was
granted for the conviction or plea.
C. Further, applicants and employees of the University of Mississippi
Medical Center for whom criminal history record checks and
fingerprinting are obtained in accordance with Section 37-115-41
are exempt from application of the term employee under Section
43-11-13.
103
2. Covered Entity. For the purpose of criminal history record checks,
“covered entity” means a licensed entity or a healthcare professional
staffing agency.
3. Licensed Entity. For the purpose of criminal history record checks, the
term “licensed entity” means a hospital, nursing home, personal care home,
home health agency or hospice.
4. Health Care Professional/Vocational Technical Academic Program. For
the purpose of criminal history record checks, “health care
professional/vocational technical academic program” means an academic
program in medicine, nursing, dentistry, occupational therapy, physical
therapy, social services, speech therapy, or other allied-health professional
whose purpose is to prepare professionals to render patient care services.
5. Health Care Professional/Vocational Technical Student. For purposes
of criminal history record checks, the term means a student enrolled in a
healthcare professional/vocational technical academic program.
6. Direct Patient Care or Services. For purposes of fingerprinting and
criminal background history checks, the term “direct patient care” means
direct hands-on medical patient care and services provided by an individual
in a patient, resident or client’s room treatment room or recovery room.
Individuals providing direct patient care may be directly employed by the
facility or provides patient care on a contractual basis.
7. Documented Disciplinary Action. For the purpose of fingerprinting and
criminal background history checks, the term “documented disciplinary
action” means any action taken against an employee for abuse or neglect of
a patient.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.16 Criminal History Record Checks.
1. Pursuant to Section 43-11-13, Mississippi Code of 1972, the covered entity
shall require to be performed a disciplinary check with the professional
licensing agency, if any, for each employee to determine if any disciplinary
action has been taken against the employee by the agency, and a criminal
history record check on:
A. Every new employee of a covered entity who provides direct patient care or
services; and
B. Any individual seeking new employment with a covered entity whose
initial criminal history record check is over two years old.
2. Except as otherwise provided in this paragraph, no employee hired on or
after July 01, 2003, shall be permitted to provide direct patient care until
104
the results of the criminal history record check revealed no disqualifying
record, or the employee has been granted a waiver. Provided the covered
entity has documented evidence of submission of fingerprints for the
background check, any person may be employed and provide direct patient
care on a temporary basis pending the results of the criminal history
record check but any employment offer, contract, or arrangement with the
person shall be voidable, if he/she receives a disqualifying criminal record
check and no waiver is granted.
3. If such criminal history record check discloses a felony conviction; a guilty
plea; and/or a plea of nolo contendere to a felony for one (1) or more of the
following crimes which has not been reversed on appeal, or for which a
pardon has not been granted, the applicant/employee shall not be eligible to
be employed at the licensed facility:
A. possession or sale of drugs
B. murder
C. manslaughter
D. armed robbery
E. rape
F. sexual battery
G. sex offense listed in Section 45-33-23(g), Mississippi Code of 1972
H. child abuse
I. arson
J. grand larceny
K. burglary
L. gratification of lust
M. aggravated assault
N. felonious abuse and/or battery of vulnerable adult
4. Documentation of verification of the employee’s disciplinary status, if any,
with the employee’s professional licensing agency as applicable, and
evidence of submission of the employee’s fingerprints to the licensing
agency must be on file and maintained by the facility prior to the new
employees first date of employment. The covered entity shall maintain on
file evidence of verification of the employee’s disciplinary status from any
applicable professional licensing agency and of submission and/or
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completion of the criminal record check, the signed affidavit, if applicable,
and/or a copy of the referenced notarized letter addressing the individual’s
suitability for such employment.
5. Pursuant to Section 43-11-13, Mississippi Code of 1972, the licensing
agency shall require every employee of a covered entity employed prior to
July 01, 2003, to sign an affidavit stating that he or she does not have a
criminal history as outlined in paragraph (c) above.
6. From and after December 31, 2003, no employee of a covered entity hired
before July 01, 2003, shall be permitted to provide direct patient care unless
the employee has signed an affidavit as required by this section. The covered
entity shall place the affidavit in the employee’s personnel file as proof of
compliance with this section.
7. If a person signs the affidavit required by this section, and it is later
determined that the person actually had been convicted of or pleaded guilty
or nolo contendere to any of the offenses listed herein, and the conviction or
pleas has not been reversed on appeal or a pardon has not been granted for
the conviction or plea, the person is guilty of perjury as set out in Section
43-11-13, Mississippi Code of 1972. The covered entity shall immediately
institute termination proceedings against the employee pursuant to the
facility’s policies and procedures.
8. The covered entity may, in its discretion, allow any employee unable to sign
the affidavit required by paragraph (g) of this subsection or any employee
applicant aggrieved by the employment decision under this subsection to
appear before the covered entity’s hiring officer, or his or her designee, to
show mitigating circumstances that may exist and allow the employee or
employee applicant to be employed at the covered entity. The covered entity,
upon report and recommendation of the hiring officer, may grant waivers for
those mitigating circumstances, which shall include, but not be limited to:
(1) age at which the crime was committed; (2) circumstances surrounding
the crime; (3) length of time since the conviction and criminal history since
the conviction; (4) work history; (5) current employment and character
references; and (6) other evidence demonstrating the ability of the individual
does not pose a threat to the health or safety of the patients in the licensed
facility.
9. The licensing agency may charge the covered entity submitting the
fingerprints a fee not to exceed Fifty Dollars ($50.00).
10. Should results of an employee applicant’s criminal history record check
reveal no disqualifying event, then the covered entity shall, within two (2)
weeks two (2) weeks of the notification of no disqualifying event, provide
the employee applicant with a notarized letter signed by the chief executive
officer of the covered entity, or his or her authorized designee, confirming
the employee applicant’s suitability for employment based on his or her
criminal history record check. An employee applicant may use that letter for
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a period of two (2) years from the date of the letter to seek employment at
any covered entity licensed by the Mississippi Department of Health without
the necessity of an additional criminal record check. Any covered entity
presented with the letter may rely on the letter with respect to an employee
applicant’s criminal background and is not required for a period of two (2)
years from the date of the letter to conduct or have conducted a criminal
history check as required in this subsection.
11. For individuals contacted through a third party who provide direct patient
care as defined herein, the covered entity shall require proof of a criminal
history record check.
12. Pursuant to Section 43-11-13, Mississippi Code of 1972, the licensing
agency, the covered entity, and their agents, officer, employees, attorneys,
and representatives, shall be presumed to be acting in good faith for any
employment decision or action taken under this section. The presumption of
good faith may be overcome by a preponderance of the evidence in any
civil action. No licensing agency, covered entity, nor their agents, officers,
employees, attorneys, and representatives shall be held liable in any
employment discrimination suit in which an allegation of discrimination is
made regarding an employment decision authorized under this section.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.17 Required Policies. The PFER Emergency Department Policy Sections shall
include:
1. Resources and Planning
A. Necessary Elements
B. Administration
C. Staffing
D. Facility
E. Equipment and Supplies
F. Pharmacologic/Therapeutic Drugs and Agents
G. Safety
H. Ancillary Services
I. Transfer policies and procedures for critical patients
J. Electronic Medical Record
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K. Relationships and Responsibilities
L. The policies and procedures governing medical care provided in
the emergency service or department shall be established by and
shall be a continuing responsibility of the medical staff. The PFER
shall have written policies and procedures governing the receipt of
patients from emergency medical services and the transfer of
patients to a receiving facility. The policies must comply with
Mississippi Emergency Medical Services Rules and Regulations.
2. Core Measures
A. Measure Groups
i. Median Time from PFER Arrival to Departure for
Discharged Patients
ii. Median Time from PFER Arrival to Decision to
Transfer
iii. Median Time from Decision to Transfer to arrival at
receiving facility
iv. Total lengths of stay and door-to-doctor times
B. Quality/Safety Metrics
i. PFER will be responsible for reporting all categories required
ii. Case analysis of EMS patient outliers.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.18 Design and Construction Elements: Physical Plant.
1. General. Every institution subject to these Minimum Standards shall be
housed in a safe building which contains all the facilities required to render
the services contemplated in the application for license.
2. Codes. The term “safe” shall be interpreted in the light of compliance with
the requirements of the codes recognized by this agency on date of
construction which are incorporated by reference as a part of these Minimum
Standards; included are the Life Safety Code of the National Fire Protection
Association, American National Standards Institute, Standards Number A-
17.1, and A-17.3, Safety Code for Elevators and Escalators, the American
Institute of Architects (AIA), Guidelines for Design and Construction of
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Hospital and Health Care Facilities, and references incorporated as body of
all afore mentioned standards.
A. Life Safety Code compliance relative to construction date:
i. Buildings constructed after February 14, 2005, shall comply
with the edition of the Life Safety Code (NFPA 101)
recognized by this agency on the date of construction.
ii. Building constructed prior to February 14, 2005, shall
comply with existing chapter of the Life Safety Code
recognized by this agency.
B. For minimum standards governing Heating, Ventilation, and Air
Conditioning (HVAC), area design, space allocation, parking
requirements, and other considerations not specifically
addressed by local authority or standards referenced herein,
compliance with the AIA guidelines will be deemed acceptable.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.19 Submission of Plans and Specifications.
1. Construction shall not be started for any institution subject to these standards
(whether new or remodeling or additions to an existing licensed hospital)
until the plans and specifications for such construction or remodeling have
been submitted to the Licensing Agency in writing and its approval of the
changes given in writing.
A. Exception: Foundation changes made necessary by unanticipated
conditions, or any conditions which present a hazard to life or
property if not immediately corrected.
2. Plans and specifications for any substantial hospital construction or
remodeling should be prepared by competent architects and engineers
licensed to practice in the state and who assume responsibility for
supervising the construction. The following plans shall be submitted to the
Licensing Agency for review:
A. Preliminary Plans - To include schematics of buildings, plot plans
showing size and shape of entire site, existing structures, if any,
streets and location and characteristics of all needed utilities, floor
plans of every floor dimensioned and with proposed use of each
room or area shown. If for additions or remodeling, provide plan or
of existing building showing all proposed alterations, outline
specifications to include a general description of the construction,
type of finishes, and type of heating, ventilating, plumbing, and
electrical systems proposed.
109
B. Final Working Drawings and Specifications - Complete and in
sufficient detail to be the basis for the award of construction
contracts.
3. All plans submitted for review must be accompanied in their first submission
by an order of the governing board indicating the type and scope of license
to be applied for or a Certificate of Need. Plans receiving approval of the
Licensing Agency upon which construction has not begun within six (6)
months following such approval must be resubmitted for approval.
A. In all new facilities, plans must be submitted to all regulatory
agencies, such as the County Health Department, etc., for
approval prior to starting construction.
B. Upon completion of construction an inspection shall be made by
the Licensing Agency and approval given prior to occupying the
building or any part thereof. The state and county health
departments shall have access to the job site during regular
business hours and shall conduct construction progress
inspections as deemed necessary by the agency.
4. Environment. All hospitals shall be so located that they are reasonably free
from undue noises, smoke, dust, or foul odors, and should not be located
adjacent to railroads, freight yards, schools, children's playgrounds, airports,
industrial plants, or disposal plants. The proposed site for new hospitals shall
be approved by the department. No new facilities shall be located nearer than
1000 ft. to a cross- country petroleum or gas pipeline.
5. Zoning Restrictions. The locations of an institution shall comply with
all local zoning ordinances.
6. Access. Institutions located in rural areas must be served by good roads
which can be kept passable at all times.
7. Elevators. One power driven elevator is required in all hospitals having
patient rooms, operating suite, or delivery suite above the first floor. Two
or more elevators are required if 60 or more patients are housed above the
ground floor. Minimum cab dimensions required for elevators transporting
patients is 76" x 50"inside clear measurements: hatchway and cab doors
3'8" wide, minimum. Elevators are subject to the requirements of
referenced standard listed in paragraph 602, Codes, of this regulation.
8. Signage. To post conspicuously in any emergency room or in a place or
places likely to be noticed by all individuals entering the emergency room,
as well as those individuals waiting for examination and treatment in areas
other than traditional emergency room (that is, entrance, admitting area,
waiting room, treatment area) to notify individuals they are in an
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emergency room and not in a clinic.
A. Patient must be notified verbally or in writing of their location on
arrival at the PFER.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.20 Fire Reporting and Protection.
1. Duty to report all fires, explosions, natural disasters, avoidable deaths or
avoidable serious or life-threatening injuries to patients shall be reported
by telephone to the department by the next working day after the
occurrence. The licensing agency will provide the appropriate forms to the
facility which shall be completed and returned within fifteen (15) calendar
days of the occurrence. All reports shall be complete, thorough, and shall
record at a minimum the casual factors, date, time of occurrence, and exact
location of occurrence whether inside or outside of the facility. Attached
thereto shall be all police, fire, and/or other official reports. There must be
a telephone in the building to summon help in case of fire.
2. All new construction or renovation with the licensing agency’s approval
date on or after February 14, 2005, shall be protected throughout by a
sprinkler system.
3. Heating and Ventilating. Suitable artificial heat shall be furnished to
maintain75 degrees F inside temperature with 10 degrees F outside
temperature. Circulating hot water from a remote boiler or vapor steam
with circulating pump sand controls on emergency electrical service to
provide heating in case of power failures are the preferred methods of
heating. Electrical heating will be approved provided a standby
electrical generator is provided of capacity to furnish 80% of the
maximum heating load in addition to other power and lighting loads
that maybe connected to it, or the hospital is supplied by two electric
service lines connected to separate transformers at the sub-station so
arranged that electric service can be maintained in case of failure of one
line or transformer.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.21 Plumbing.
All institutions subject to these standards shall be connected to an approved
municipal water system or to a private supply whose purity has been certified by the
laboratory of the Department of Health. Private supplies must be sampled, tested,
and its purity certified at least twice annually and immediately following any repair
or modification to the underground lines, the elevated tank, or to the well or pump.
Supply must be adequate, both as to volume and pressure for firefighting purposes.
Deficiencies in either must be remedied by the provision of auxiliary pumps,
111
pressure tanks or elevated tanks as may be required.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.22 Emergency Electric Service.
1. General. To provide electricity during an interruption of the normal
electric supply that could affect the medical care, treatment, or safety of
the occupants, an emergency source of electricity shall be provided and
connected to certain circuits for lighting and power.
2. Source. The source of this emergency electric service shall be an emergency
generator, with a stand-by supply of fuel for 24 hours.
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.84.23 PFER Equipment, Instruments, and Supplies
1. The equipment, instruments, and supplies listed below are required in the
PFER and each of the items should be located in or immediately available
to the area noted. This list does not include routine medical/surgical
supplies such as adhesive bandages, gauze pads, and suture material, nor
does it include routine office items such as paper, desks, paper clips, and
chairs.
2. Electric Nurse Call. There shall be installed a low voltage nurse call system
for every bed and such other areas as deemed necessary, with annunciator at
nurses’ station and nurses work area.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.24 Entire PFER shall include:
1. Central station monitoring capability
2. Physiological monitors
3. Blood flow detectors
4. Defibrillator with monitor and battery
5. Thermometers
6. Pulse oximetry
7. Nurse-call system for patient use
8. Portable suction regulator
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9. Infusion pumps to include blood pumps
10. IV poles
11. Bag-valve-mask respiratory and adult and pediatric size mask
12. Portable oxygen tanks
13. Blood/fluid warmer and tubing
14. Nasogastric suction supplies
15. Nebulizer
16. Gastric lavage supplies, including large-lumen tubes and bite blocks
17. Urinary catheters, including straight catheters, Foley catheters, Coude
catheters, filiforms and followers, and appropriate collection
equipment
18. Intraosseous needles
19. Lumbar puncture sets (adult and pediatric)
20. Blanket warmer
21. Tonometer
22. Slit lamp
23. Wheelchairs
24. Medication dispensing system with locking capabilities
25. Separately wrapped instruments (specifics will vary by department)
26. Availability of light microscopy for emergency procedures
27. Weight scales (adult and infant)
28. Tape measure
29. Ear irrigation and cerumen removal equipment
30. Vascular Doppler
31. Anoscope
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32. Adult and Pediatric "code" cart
33. Suture or minor surgical procedure sets (generic)
34. Portable sonogram equipment
35. EKG machine
36. Point of care testing
37. X-ray view box and hot light
38. Film boxes for holding x-rays
39. Chart Rack
40. Computer system
41. Internet capabilities
42. Patient tracking system
43. Radio or other device for communication with ambulances
44. Patient discharge instruction system
45. Patient registration system/ Information services
46. Intradepartmental staff communication system- pagers, mobile phones
47. charting system for physician, nursing, and attending
physician documentation equipment
48. Reference materials including toxicology resource information
49. Personal protective equipment- gloves, eye goggles, face mask, gowns, head,
and foot covers
50. Linen (pillows, towels, wash cloths, gowns, blankets)
51. Patient belongings or clothing bag
52. Security needs -including restraints and wand-type or free-standing metal
53. detectors as indicated
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54. Equipment for adequate housekeeping
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.25 PFER General Examination Rooms shall include:
1. Examination tables or stretchers appropriate to the area.
2. For any area in which seriously ill patients are managed, a stretcher
with capability for changes in position, attached IV poles, and a holder
for portable oxygen tank should be used.
3. Pelvic tables for GYN examinations.
4. Step stool
5. Chair/stool for emergency staff
6. Seating for family members or visitors
7. Adequate lighting, including procedure lights as indicated
8. Cabinets
9. Adequate sinks for handwashing, including dispensers for germicidal
soap and paper towels.
10. Wall mounted oxygen supplies and equipment, including nasal
cannulas, facemasks, and venturi masks.
11. Wall mounted suction capability, including both tracheal cannulas and
larger cannulas.
12. Wall-mounted or portable otoscope/ophthalmoscope
13. Sphygmomanometer/stethoscope
14. Oral and nasal airways
15. Biohazard-disposal receptacles, including for sharps
16. Garbage receptacles for non-contaminated materials
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.26 PFER Resuscitation Room. All items listed for general examination rooms plus:
115
1. Adult and Pediatric "code cart" to include appropriate medication charts
2. Capability for direct communication with nursing station, preferably hands
free
3. Radiography equipment
4. Radiographic view boxes and hot light
5. Airways needs
A. Big-valve-mask respirator (adult, pediatric, and infant)
Cricothyroidotomy instruments and supplies
B. Endotracheal tubes, size 2.5 to 8.5 mm
C. Fiberoptic laryngoscope
D. Laryngoscopes, straight and curved blades and stylets
E. Laryngoscope mirror and supplies
F. Laryngeal Mask Airway (LMA)
G. Oral and nasal airways
H. Tracheostomy instrument and supplies
6. Breathing
A. BiPAP Ventilation System
B. Closed-chest drainage device
C. Chest tube instruments and supplies
D. Emergency thoracotomy instruments and supplies
E. End-tidal C02 monitor18
F. Nebulizer
G. Peak flow meter
H. Pulse oximetry
I. Volume cycle ventilator
116
7. Circulation
A. Automatic physiological monitor, noninvasive
B. Blood/fluid infusion pumps and tubing
C. Blood/fluid warmers
D. Cardiac compression board
E. Central venous catheter setups/kits
F. Central venous pressure monitoring equipment
G. Cutdown instruments and supplies
H. Intraosseous needles
I. IV catheters, sets, tubing, poles
J. Monitor/defibrillator with pediatric paddles, internal paddles,
appropriate pads, and other supplies Pericardiocentesis
instruments
K. Temporary external pacemaker
L. Transvenous and/or transthoracic pacemaker setup and supplies
M. 12-Lead ECG machine
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.27 Trauma and miscellaneous resuscitation shall include:
1. Blood salvage/autotransfusion device
2. Emergency obstetric instruments and supplies
3. Hypothermia thermometer
4. Infant warming equipment
5. Peritoneal lavage instruments and supplies
6. Pneumatic antishock garment, as indicated
7. Spine stabilization equipment to include cervical collars, short and long boards
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8. Warming/cooling blanket
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.28 Other Special Rooms. All items listed for general examination rooms plus:
1. Orthopedic
A. Cast cutter
B. Cast and splint application supplies and equipment Cast spreader
C. Crutches
D. Extremity-splinting devices including traction splinting and
fixation pins/wires and corresponding instruments and
supplies
E. Halo traction or Gardner-Wells/Trippe-Wells traction
Radiograph view and hot light
F. Suture instrument and supplies
G. Traction equipment, including hanging weights and finger traps
2. Eye/ENT
A. Eye chart
B. Ophthalmic tonometry device (applanation, Schiotz, or other)
C. Other ophthalmic supplies as indicated, including eye spud,
rust ring remover, cobalt blue light
D. Slit lamp
E. Ear irrigation and cerumen removal equipment
F. Epistaxis instrument and supplies, including balloon posterior
packs Frazier suction tips
G. Headlight
H. Laryngoscope mirror
118
I. Plastic suture instruments and supplies
3. OB-GYN
A. Fetal Doppler and ultrasound equipment
B. Obstetrics/Gynecology examination light
C. Vaginal specula in pediatric through adult sizes
D. Sexual assault evidence-collection kits (as appropriate)
E. Suture material
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.29 Required Pharmacological/Therapeutic drugs for PFER. These classes of
drugs and agents are required. The medical director of the PFER, representatives of
the medical staff, and the director of the pharmacy shall develop a formulary of
specific agents for use in the PFER.
1. Analgesics
A. narcotic and non-narcotic
2. Anesthetics
A. topical, infiltrative, general
3. Anticonvulsants
4. Antidiabetic agents
5. Antidotes
6. Antihistamines
7. Anti-infective agents
A. systemic/topical
8. Anti-inflammatories
A. steroidal/non-steroidal
9. Anti-platelets
119
10. Aspirin
11. Plavix
12. Heparin
13. Bicarbonates
14. Blood Modifiers
15. Anticoagulants to include thrombolytics
16. Anticoagulants
17. Hemostatic agents
A. systemic
B. topical
C. plasma expanders/extenders
18. Burn Preparations
19. Cardiovascular agents
A. Ace inhibitors
B. Adrenergic blockers
C. Adrenergic stimulants
D. Alpha/Beta blockers
E. Antiarrhythmic agents
F. Calcium channel blockers
G. Digoxin antagonist
H. Diuretics
I. Vasodilators
J. Vasopressors
20. Cholinesterase Inhibitors
120
21. Diagnostic agents
A. Blood contents
B. Stool contents
C. Testing for myasthenia gravis
D. Urine contents
22. Electrolytes
A. Cation exchange resin
B. Electrolyte replacements, parenteral and oral
C. Fluid replacement solutions
23. Gastrointestinal agents
A. Antacids
B. Anti-diarrheal
C. Emetics and Anti-emetics
D. Anti-flatulent
E. Anti-spasmodic
F. Bowel evacuants/laxatives
G. Histamine receptor antagonists
H. Proton pump inhibitors
24. Glucose elevating agents
25. Hormonal agents
26. Hypocalcemia and hypercalcemia management agents
27. Lubricants
28. Migraine preparations
121
29. Muscle relaxants
30. Narcotic antagonist
31. Nasal preparation
32. Ophthalmologic preparations
33. Otic preparations
34. Oxytocics
35. Pain Medications
36. Psychotherapeutic agents
37. Respiratory agents
A. Antitussives
B. Bronchodilators
C. Decongestants
D. Leukotriene antagonist
38. Rho(D) immune globulin
39. Salicylates
40. Sedatives and Hypnotics
41. Thrombolytics
42. Vaccinations
43. Vitamins and minerals
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.30 Radiologic, Imaging, and Other Diagnostic Services. The specific services
available and the timeliness of availability of these services for emergency
patients in PFER should be determined by the medical director of the PFER in
collaboration with the directors of the diagnostic services and other appropriate
individuals.
1. The following should be readily available 24 hours a day for
122
Emergency patients:
A. Standard radiologic studies of bony and soft-tissue structures
including, but not limited to:
i. Cross-table lateral views of spine with full series to follow
ii. Portable chest radiographs for acutely ill patients and for
verification of placement of endotracheal tube, central
line, or chest tube
iii. Soft-tissue views of the neck
iv. Soft-tissue views of subcutaneous tissues to rule out the
presence of foreign body
v. Standard chest radiographs, abdominal series, etc.
B. Pulmonary services
i. Arterial blood gas determination
ii. Peak flow determination
iii. Pulse oximetry
C. Fetal monitoring (nonstress test)/uterine monitoring
D. Cardiovascular services
i. Doppler studies
ii. 12-Lead ECGs and rhythm strips
E. Emergency ultrasound services for the diagnosis of
obstetric/gynecologic, cardiac, and hemodynamic problems
and other urgent conditions.
2. The following services shall be available on an urgent basis. All equipment
listed below must be available if service is provided by the facility. Such
may be provided by on duty staff or on call staff available to respond within
a reasonable period of time:
A. Nuclear medicine
i. Ventilation-perfusion lungs scans
123
ii. Other scintigraphy for trauma and other conditions
B. Radiographic
i. Arteriography/venography
ii. Computed tomography preferred
iii. Dye-contrast studies (intravenous pyelography,
gastrointestinal contrast, etc.)
C. Vascular/flow studies including impedance plethysmography
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.31 Required Laboratory Capabilities. The medical director of the PFER and
the director of laboratory services shall develop guidelines for availability and
timeliness of services for the PFER. The following laboratory capabilities are
required for the PFER. This list may not be comprehensive or complete.
1. Blood bank
A. Bank products availability
B. Type and cross-matching capabilities
2. Chemistry
A. Ammonia
B. Amylase
C. Anticonvulsant and other therapeutic drug levels
D. Arterial blood gases
E. Bilirubin (total and direct)
F. Calcium
G. Carboxyhemoglobin
H. Cardiac isoenzymes (including creatine kinase- MB)
I. Chloride (blood and cerebrospinal fluid [CSF])
J. Creatinine
124
K. Electrolytes
L. Ethanol
M. Glucose (blood and CSF)
N. Liver-function enzymes (ALT, AST, alkaline phosphatase)
O. Methemoglobin
P. Osmolality
Q. Protein (CSF)
R. Serum magnesium
S. Urea nitrogen
3. Hematology
A. Cell count and differential (blood, CSF, and joint fluid analysis)
B. Coagulation studies
C. Erythrocyte sedimentation rate
D. Platelet count
E. Reticulocyte count
F. Sickle cell prep
4. Microbiology
A. Acid fast smear/staining
B. Chlamydia testing
C. Counter immune electrophoresis for bacterial identification
D. Gram staining and culture/sensitivities
E. Herpes testing
F. Strep screening
125
G. Viral culture
H. Wright stain
5. Other
A. Hepatitis screening
B. HIV screening
C. Prothrombin Time (PT)/International Normalized Ratio (INR),
Partial Thromboplastin Time (PTT)
i. D-dimer
D. Joint fluid and CSF analysis
E. Toxicology screening and drug levels
F. Urinalysis
G. Mononucleosis spot
H. Serology (syphilis, recombinant, immunoassay)
I. Pregnancy testing (qualitative and quantitative)
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.32 Infection Control. The PFER shall provide a sanitary environment to avoid sources
and transmission of infections and communicable diseases. There shall be an active
program for the prevention, control, and investigation of infections and
communicable diseases.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.33 Medical Waste Management Plan. All generators of infectious medical waste and
medical waste shall have a medical waste management plan in accordance with
Adopted Standards for the Regulation for Medical Waste.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.34 Food and Dietetic Services. The PFER shall have appropriate food and beverages
available for the patients. The PFER shall be responsible for meeting the nutritional
needs of patients.
SOURCE: Miss. Code Ann. §41-75-13
126
Rule 41.84.35 Transfer of Unstable Patients from PFER to Acute Care Hospital. Once the
patient is determined to require a higher level of care than can be provided at the
PFER, the physician shall immediately contact the designated EMS for transport. If
the EMS is based on site, the transport team will be notified immediately. The
physician will stabilize the emergency medical condition and determine the
transfer destination based on the specialized capabilities of facilities that are
offered at local hospitals. The PFER facility will implement all procedures and
protocols for acutely ill patients before departure from the PFER. Such conditions
would include, but not be limited to, STEMI, acute ischemic stroke, and cardiac
arrests. All electronic medical records and any diagnostic test results will be
transported with the patient to the receiving facility. Should a patient meeting
trauma system activation arrive at the PFER, the PFER will transfer the patient in
accordance with the federal EMTALA regulations and MS State Board of Health
approved System of Care Plans.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.36 Discharge Planning. The patient or their representative shall be provided written
discharge instructions regarding follow up referrals/appointments, medication
management and procurement, durable medical equipment, availability of
community resources and other identified needs at the time of discharge.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.37 Medical Records. The facility shall have a medical record department with
administrative responsibility for medical records. A medical record shall be
maintained, in accordance with accepted professional principles, for each patient
receiving care in the hospital. such records shall be kept confidential and only
authorized personnel shall have access to the records.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.38 Written Consent. Written consent of the patient or the patient’s legal representative
shall be presented as authority for release of medical information and this release
shall become part of the medical record.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.39 Medical Records. Medical records shall not be removed from the hospital
environment except upon subpoena.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.40 Preservation. Records shall be preserved, either in the original or by
reproduction, for a period of time not less than that set forth in Title 41, Chapter 9 of
the Mississippi Code of 1972.
127
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.84.41 Confidentiality. Medical records shall be kept confidential and only
authorized personnel shall have access to the records.
SOURCE: Miss. Code Ann. 41-75-13
Rule 41.84.42 Emergency Operations Plan (EOP). The licensed entity shall develop and
maintain a written preparedness plan utilizing the Emergency Operations Plan
(EOP) Template developed by the MSDH Office of Emergency Planning and
Response. “All Hazards” and “Whole Community” approach to emergency and
disaster planning. The plan must include procedures to be followed in the event of
any pandemic, act of terrorism or man-made or natural disaster as appropriate for
the specific geographical location. The final draft of the Emergency Operations Plan
(EOP), will be reviewed by the Office of Emergency Planning and Response,
Mississippi State Department of Health, or their designates, for conformance with
the “All Hazards Emergency Planning and Response Plan.” Particular attention
shall be given to critical areas of concern which may arise during any “all hazards
emergency whether required to evacuate or to sustain in place. Additional plan
criteria or a specified EOP format may be required as deemed necessary by the
Office of Emergency Planning and Response. The eight (8) critical areas of
consideration are:
1. Communications Facility status reports shall be submitted in a format and
a frequency as required by the Office of Emergency Planning and Response
2. Resources and Assets
3. Safety and Security
4. Smoke Detectors/Extinguishers (refer to NFPA 10)
5. Staffing
6. Infrastructure (Water, sewer, electricity, data systems, etc.)
7. Clinical Activities and
8. Continuity of Operations Planning (COOP) to include surge and alternate
care sites.
SOURCE: Miss. Code Ann. 41-75-13
Rule 41.84.43 Emergency Operations Plans (EOPs) must be exercised and reviewed annually or as
directed by the Office of Emergency Planning and Response. Written evidence of
current verification or review of provider EOPs, by the Office of Emergency
Planning and Response, shall accompany all applications for facility license
128
renewals.
SOURCE: Miss. Code Ann. 41-75-13
Rule 41.84.44 Facility Fire Preparedness.
1. Fire Drills. Fire drills shall be conducted one (1) per shift per quarter.
Employees shall participate in a fire drill at least four (4) times per
year.
A. Written Records. Written records of all drills shall be
maintained, indicating content of and attendance at each
drill.
B. A fire evacuation plan shall be posted in each facility in a
conspicuous place and kept current.
SOURCE: Miss. Code Ann. 41-75-13
Rule 41.84.45 Emergency Electric Services. (Refer to Subchapter 14).
SOURCE: Miss. Code Ann. 41-75-13
Subchapter 85 MINIMUM STANDARDS OF OPERATION FOR MISSISSIPPI
RURAL EMERGENCY HOSPITALS
Rule 41.85.1 Adoption of Regulations and Minimum Standards. Adoption of Regulations and
Minimum Standards. By virtue of authority vested in it by the Mississippi Code
Annotated Sections 41-9-1 through 41-9-35, or as otherwise amended, the Mississippi
Department of Health does hereby adopt and promulgate the following regulations and
standards for hospitals.
1. The Medicare and Medicaid Programs; Conditions of Participation (CoPs) for Rural
Emergency Hospitals (REH) and Critical Access Hospital CoP Updates as found in
42 CFR Parts 485 and 489 [CMS–3419–P] RIN 0938–AU92/ Rural Emergency
Hospital Conditions for Participation Part 485, Subpart E are hereby adopted.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.2
Compliance with Rules, Regulations and Standards. (Refer to Rule 41.84.2).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.3
Definitions. The definitions specific to the REH are:
1. Licensing Agency. “Licensing agency” means the Mississippi State
Department of Health.
129
2. Rural Emergency Hospital (REH). A rural emergency hospital (REH)
is a new Medicare provider designation established by Congress through
the Consolidated Appropriations Act of 2021, Section 125. The REH
designation allows Critical Access Hospitals (CAHs) and rural hospitals
with no more than 50 beds to avert potential closure and continue to
provide essential services for the communities they serve. REH’s provide
emergency services and outpatient services. REH’s do not provide acute
care inpatient services, with the exception of post-hospital extended care
services furnished in a distinct part unit licensed as a skilled-nursing
facility. Pilot Freestanding Emergency Rooms and Freestanding
Emergency Departments are not eligible to convert to a Rural Emergency
Hospital.
SOURCE: Miss. Code Ann. 41-75-1
Rule 41.85.4 License. (Refer to Rule 41.84.4).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.5 Application for License. (Refer to Rule 41.84.5).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.6 Licensure and User Fees. (Refer to Rule 41.84.6).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.7 User Fee. (Refer to Rule 41.84.7).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.8 Renewal of License. (Refer to Rule 41.84.8).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.9 Issuance of License. (Refer to Rule 41.84.90.
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.10 Denial or Revocation of a License. (Refer Rule to 41.84.10).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.11 Ownership. (Refer to Rule 41.84.11).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.12 Change of Ownership. (Refer to Rule 41.84.12).
130
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.13 Governing Authority. (Refer to Rule 41.84.13).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.14 Staffing and Treatment. (Refer to Rule 41.84.14).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.15 Criminal History Record Checks. (Refer to Rule 41.84.15).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.16 Criminal History Record Checks. (Refer to Rule 41.84.16).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.17 Required Policies. (Refer to Rule 41.84.17).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.18 Design and Construction Elements: Physical Plant. (Refer to Rule 41.84.18).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.19 Submission of Plans and Specifications. (Refer to Rule 41.84.19).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.20 Fire Reporting and Protection. (Refer to Rule 41.84.20).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.21 Plumbing. (Refer to Rule 41.84.21).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.22 Emergency Electric Service. (Refer to Rule 41.84.22).
SOURCE: Miss. Code Ann. §41-9-17
Rule 41.85.23 REH Equipment, Instruments, and Supplies. (Refer to Rule 41.84.23).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.24 Entire REH shall include. (Refer to Rule 41.84.24).
131
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.25 REH General Examination Rooms shall include. (Refer to Rule 41.84.25).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.26 REH Resuscitation Room. (Refer to Rule 41.84.26).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.27 Trauma and miscellaneous resuscitation shall include. (Refer to Rule 41.84.27).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.28 Other Special Rooms. (Refer to Rule 41.84.28).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.29 Required Pharmacological/Therapeutic drugs for REH. (Refer to Rule
41.84.28).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.30 Radiologic, Imaging, and Other Diagnostic Services. (Refer to Rule
41.84.30).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.31 Required Laboratory Capabilities. (Refer to Rule 41.84.31).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.32 Infection Control. (Refer to Rule 41.84.32).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.33 Medical Waste Management Plan. (Refer to Rule 41.84.33).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.34 Food and Dietetic Services. (Refer to Rule 41.84.34).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.35 Transfer of Unstable Patients from REH to Acute Care Hospital. (Refer to
Rule 41.84.35).
132
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.36 Discharge Planning. (Refer to Rule 41.84.36).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.37 Medical Records. (Refer to Rule 41.84.37 and Rule 41.84.39).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.38 Written Consent. (Refer to Rule 41.84.38).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.40 Preservation. (Refer to Rule 41.84.40).
SOURCE: Miss. Code Ann. §41-75-13
Rule 41.85.41 Confidentiality. (Refer to Rule 41.84.41).
SOURCE: Miss. Code Ann. 41-75-13
Rule 41.85.42 Emergency Operations Plan (EOP). (Refer to Rule 41.84.42 and Rule 41.84.43).
SOURCE: Miss. Code Ann. 41-75-13
Rule 41.85.44 Facility Fire Preparedness. (Refer to Rule 41.84.44).
SOURCE: Miss. Code Ann. 41-75-13