Arkansas Administrative Code

20 CAR § 41-108. Administration reports. (a) It shall be the duty of the administrator or his or her designee to report all infectious or communicable diseases in the facility to the Department of Health as required by: (1) The Rules Pertaining to Reportable Diseases, 20 CAR pt. …

20 CAR § 41-109. Patient identification. Each patient admitted to the hospital shall have an identification bracelet applied during the admission process.

20 CAR § 41-110. Patient care service. (a) Organization. (1) Nursing services shall be directed by a nurse executive who is a registered nurse qualified by advanced education and management experience. (2)(A) The nurse executive’s education and experience shall be directly relate…

20 CAR § 41-111. Medications. (a)(1) All medical orders (medications and treatments) shall be: (A) Documented; and (B) Signed by the prescriber. (2) Telephone/verbal orders should be used infrequently. (3) When used they shall be: (A) Given only to licensed nurses; and (B) Signed…

20 CAR § 41-112. Restraints. (a) Restraint use should be: (1) Implemented in the least restrictive manner possible; (2) Applied in accordance with safe and appropriate techniques; and (3) Ended at the earliest possible time. (b)(1) Each order for the application of restraints sha…

20 CAR § 41-113. Health Information Services. (a) General requirements. (1) A medical record shall be maintained for each patient admitted for care in the hospital. (2) The original, or a copy of the original when the original is not available, of all reports shall be filed in th…

20 CAR § 41-114. Medical record requirements for outpatient services, emergency room, observation services, and psychiatric records. (a) Outpatient records. An outpatient record shall: (1) Be completed for each outpatient; and (2) Include the following: (A)(i) History and physica…

20 CAR § 41-115. Pharmacy. (a)(1) All hospitals shall have adequate provision for pharmaceutical services regarding the procurement, storage, distribution, and control of all medications. (2) There shall be compliance with all federal and state rules and regulations, including th…

20 CAR § 41-116. Food and nutrition services. (a) Administration. (1)(A) The food and nutrition services shall be under the daily, including weekends, onsite supervision of a qualified individual. (B) The individual shall be at a minimum a certified dietary manager and: (i) Be re…

20 CAR § 41-117. Infection prevention and control. (a) General. (1) The facility shall develop and use a coordinated process that effectively reduces the risk of endemic and epidemic healthcare-associated infections (HAI) in: (A) Patients; (B) Healthcare workers; and (C) Visitors…

20 CAR § 41-118. Laboratory. (a) General. (1)(A) Each hospital shall provide laboratory services onsite commensurate with the needs of patients that are admitted. (B) Provision shall be made for the performance of laboratory examinations in the following categories: (i) Chemistry…

20 CAR § 41-119. Radiological services. (a) Radiology. (1) Each hospital shall have shockproof diagnostic X-ray facilities. (2)(A) Radiological services shall be under the direction of a physician who is a member of the medical staff. (B) The physician director shall be certified…

20 CAR § 41-120. Physical therapy. (a) “Licensed physical therapist” means any person licensed to practice physical therapy by the Arkansas State Board of Physical Therapy. (b)(1) The practice of licensed physical therapy assistants shall be performed under the supervision of the…

20 CAR § 41-121. Occupational therapy. In facilities with an organized occupational therapy department, the following shall apply: (1) Occupational therapy services shall be under the direction of a physician member of the medical staff; (2) Occupational therapy services shall be…

20 CAR § 41-122. Speech pathology/audiology services. In facilities with an organized speech language pathology/audiology services department, the following shall apply: (1) Speech pathology/audiology services shall be under the direction of a physician member of the medical staf…

20 CAR § 41-123. Recreational therapy. In facilities with organized recreational therapy services, the following shall apply: (1) Recreational therapy services shall be under the direction of a physician member of the medical staff; (2) Recreational therapy services shall be supe…

20 CAR § 41-124. Pet therapy program. (a) Definitions. As used in this section: (1) “Handler” means an individual who has been specifically credentialed and authorized by the hospital to participate in, and to accompany and control pets participating in, the program; (2) “Pet” me…

20 CAR § 41-125. Specialized services — Surgical services. (a) Organization and supervision. (1) An organizational plan shall be developed. (2) Surgical services shall be under the medical direction of a qualified physician or a physician committee. (3) A surgical services regist…

20 CAR § 41-126. Specialized services — Postanesthesia care unit. (a) Postanesthesia care unit (PACU) services shall be provided in a well-organized manner under the: (1) Direction of a qualified physician; and (2) Supervision of a registered nurse. (b)(1) Policies and procedures…

20 CAR § 41-127. Specialized services — Ambulatory surgery services. (a)(1) There shall be policies and procedures specific to ambulatory surgery services. (2) Policies and procedures for the department shall have evidence of ongoing review and/or revision. (3) The first page of …

20 CAR § 41-128. Specialized services — Anesthesia services. (a) Organization and staffing. (1) Anesthesia services shall be provided in a well-organized manner under the direction of a qualified physician. (2) The service is responsible for all anesthesia administered. (b)(1) Th…

20 CAR § 41-129. Specialized services — Labor, delivery, labor delivery recovery (LDR), labor delivery recovery postpartum (LDRP), postpartum, and maternal child education. (a) Labor room and/or LDR, LDRP room. (1)(A) Provisions shall be made for patients in labor in either a: (i…

20 CAR § 41-130. Nursery services. (a) The newborn nursery shall be under the direct supervision of a registered nurse with clinical skills in newborn nursing. (b) The newborn nursery shall be located within or adjacent to the postpartum unit. (c) The following requirements shall…

20 CAR § 41-131. Specialized services — Critical care. (a) A critical care unit is a section of the hospital where intensive care nursing, necessary monitoring and treatment equipment, and supplies are provided to those patients who, in the opinion of the attending physician, req…

20 CAR § 41-132. Specialized services — Dental services. (a)(1) Dental services shall comply with the requirements of this section. (2) See: (A) 20 CAR § 41-110, patient care service; (B) 20 CAR § 41-113, Health Information Services; (C) 20 CAR § 41-115, pharmacy; and (D) All app…

20 CAR § 41-133. Specialized services — Central sterilization and supply. (a)(1) Each hospital shall provide central medical and surgical supply services with facilities that are responsible for processing, sterilizing, storing, and distributing supplies and equipment to all unit…

20 CAR § 41-134. Specialized services — Respiratory care. (a) Respiratory care services shall be under the direction of a physician member of the medical staff. (b) Respiratory care services, including equipment, shall be supervised by a qualified and trained respiratory therapis…

20 CAR § 41-135. Specialized service — Emergency services. (a) Note. Federal Emergency Medical Treatment & Labor Act, 42 U.S.C. § 1395dd requirements apply. (b)(1) Every licensed hospital shall have a dedicated emergency department. (2) The following hospitals are excepted: (A) P…

20 CAR § 41-136. Specialized service — Psychiatric services. (a) Psychiatric care units in general hospitals shall meet the construction requirements of 20 CAR § 41-151, physical facilities — psychiatric nursing unit, and shall in all respects comply with the requirements of 20 C…

20 CAR § 41-137. Specialized service — Care of patients with pulmonary disease in general hospitals. In addition to the patient care services requirements set forth in 20 CAR § 41-110, the policies and procedures shall include specialized procedures specific to respiratory diseas…

20 CAR § 41-138. Ambulatory surgery centers. (a)(1) A facility in which surgical services are offered that require the use of general or intravenous anesthetics and where, in the opinion of the attending physician, hospitalization is unnecessary, shall be considered an ambulatory…

20 CAR § 41-139. Outpatient psychiatric centers. (a)(1) Any facility in which psychiatric services are offered for a period of eight (8) to sixteen (16) hours a day and where, in the opinion of the attending psychiatrist, hospitalization as defined in the present licensure law is…

20 CAR § 41-140. Rehabilitation hospitals and units. (a) General requirements. (1)(A) “Rehabilitation hospital” means a hospital or a distinct part of a hospital as designated in 20 CAR § 41-102, definitions, of this part that: (i) Is used for the primary purpose of providing reh…

20 CAR § 41-141. Recuperation centers. (a) Any facility that includes inpatient beds with an organized medical staff, and with medical services including physician services and continuous nursing services to provide treatment for patients who are not in an acute phase of illness …

20 CAR § 41-142. Psychiatric hospitals. (a) General. Any facility used for the primary purpose of providing inpatient diagnostic care and treatment of persons having mental disorders shall be considered a psychiatric hospital and shall conform with 20 CAR §§ 41-101 – 41-181. (b) …

20 CAR § 41-143. Infirmaries. (a) An infirmary shall be considered a facility established for the purpose of offering temporary medical care and/or treatment exclusively for persons residing on a designated premise, e.g., schools, reformatories, correctional institutions, etc. (b…

20 CAR § 41-144. Alcohol/drug abuse inpatient treatment center. (a) Administrative requirements. Policies and procedures for the alcohol/drug program shall include, but are not limited to, the following: (1) Staffing. Clinical staff shall be licensed or certified by appropriate s…

20 CAR § 41-145. Physical environment. (a) Building and grounds. (1) The building and equipment shall be maintained in a state of good repair at all times. (2) Facilities and their premises shall be kept clean, neat, and free of litter and rubbish. (3) Rooms for gas-fired equipme…

20 CAR § 41-146. Physical facilities. (a) General considerations. (1) The requirements set forth herein: (A) Have been established by the Department of Health; and (B) Constitute minimum requirements for the design, construction, renovation, and repair of facilities requiring lic…

20 CAR § 41-147. Physical facilities — Patient accommodations — Adult medical, surgical — Communicable or pulmonary disease. (a) Note. See other sections of this document for special care area units such as: (1) Postanesthesia care units; (2) Critical care units; (3) Rehabilitati…

20 CAR § 41-148. Physical facilities — Critical care unit. (a)(1) The critical care units require special space and equipment considerations for effective staff functions. (2) In addition, space arrangement shall include provisions for immediate access of emergency equipment from…

20 CAR § 41-149. Physical facilities — Nursery units. (a)(1) Normal newborn infants shall be housed in nurseries that comply with the standards below. (2) All nurseries other than pediatric nurseries shall be convenient to the: (A) Postpartum nursing unit; and (B) Obstetrical fac…

20 CAR § 41-150. Physical facilities — Pediatric and adolescent unit. The unit shall meet the following standards: (1) Patient rooms. Each patient room shall meet the following standards: (A) Maximum room capacity shall be four (4) patients; (B)(i) The space requirements for pedi…

20 CAR § 41-151. Physical facilities — Psychiatric nursing unit. (a)(1) When part of a general hospital, these units shall be designed for the care of inpatients. (2) Nonambulatory inpatients may be treated in a medical unit until their medical condition allows for transfer to th…

20 CAR § 41-152. Physical facilities — Surgical facilities. (a)(1) The surgical suite shall be located and arranged to preclude unrelated traffic through the suite. (2) The surgical suite shall be designed in accordance with NFPA 99 except that, within suites, mixed facilities as…

20 CAR § 41-153. Physical facilities — Obstetrical facilities. (a) General. (1) The obstetrical unit shall be located and designated to prohibit nonrelated traffic through the unit. (2) When delivery and operating rooms are in the same suite, access and service arrangements shall…

20 CAR § 41-154. Physical facilities — Emergency suite. General. The following shall be provided: (1)(A) Grade-level well-marked, illuminated, and covered entrance with direct access from public roads for ambulance and vehicle traffic. (B) Entrance and driveway shall be clearly m…

20 CAR § 41-155. Physical facilities — Imaging suite. (a) General. (1) Equipment and space shall be as required by the functional program. (2)(A) A certified physicist or other qualified expert shall specify the type, location, and amount of radiation protection to be installed i…

20 CAR § 41-156. Physical facilities — Nuclear medicine. (a) Equipment and space shall be provided to accommodate the functional program. (b)(1) A certified physicist or other qualified expert representing the owner shall specify the type, location, and amount of radiation protec…

20 CAR § 41-157. Physical facilities — Mobile, transportable, and relocatable units. (a) General. This section applies to mobile, transportable, and relocatable structures. (b) Definitions. As used in this section: (1) “Mobile unit” means any premanufactured structure, trailer, o…