District of Columbia Administrative Code

222 SARS-CoV-2 TESTING FOR IN-PERSON WORK AND LEARNING 222.1 A person who is not fully vaccinated and who must report, in person, to work in the District of Columbia is not required to have an order from a physician or other authorized health professional in order to be receive S…

223 SARS-CoV-2 VACCINE ADMINISTRATION 223.1 An individual, including a medical assistant or a health technician, who is not licensed, registered, or certified to practice a health occupation pursuant to Chapter 12 of Subtitle I of Chapter 3 of the District of Columbia Official Co…

224 CONTINUING EDUCATION FOR SARS-CoV-2 VACCINE COUNSELING 224.1 In addition to any other continuing education requirements and subject to subsection 224.2, a person licensed to practice one of the following professions must complete two (2) hours of continuing education on SARS-…

230 COVID-19 VACCINATION REQUIREMENTS FOR HEALTHCARE WORKERS 230.1 Each of the persons described in § 230.2, unless granted an exemption under § 231 of this chapter, shall: Receive the first and second dose of the Pfizer-BioNTech COVID-19 vaccine, or receive a second dose of a di…

231 EXEMPTIONS FROM COVID-19 VACCINATION REQUIREMENTS FOR HEALTHCARE WORKERS 231.1 A person who is otherwise required to be vaccinated against COVID-19 pursuant to § 230 shall be exempt from the COVID-19 vaccination requirement if the person is granted an exemption from a healthc…

299 DEFINITIONS 299.1 When used in this chapter, the following words and phrases shall have the meanings ascribed: ACIP - the Advisory Committee on Immunization Practices of the CDC. Act - An Act to authorize the Commissioners of the District of Columbia to make regulations to pr…

2000 GENERAL PROVISIONS 2000.1 This chapter shall provide minimum standards for the establishment and maintenance of hospitals in order to protect the public interest by promoting the health, welfare, and safety of individuals in hospitals. 2000.2 In the absence of requirements i…

2001 STANDARDS OF COMPLIANCE 2001.1 The provisions of this chapter set forth the minimal requirements for the establishment, maintenance, and operation of hospitals. 2001.2 Wherever in this chapter or in other applicable standards the performance requirements are not specified, t…

2002 LICENSE REQUIREMENTS 2002.1 Except as otherwise expressly provided for in this chapter, no person shall operate or hold himself or herself out as operating a hospital in the District of Columbia, whether public or private, for profit or not for profit, without being licensed…

2003 CERTIFICATES REQUIRED 2003.1 No license to operate a hospital shall be issued by the Director until the certifications required under this section have been issued. 2003.2 Upon satisfactory proof being submitted, the Director shall certify that the services that are, or are …

2004 INITIAL LICENSURE 2004.1 Prior to initial licensure of a facility, the Director shall conduct an on-site inspection to determine compliance with the applicable statutes and rules governing the facility. 2004.2 The Director shall send a written report of the findings to the f…

2005 LICENSE RENEWAL 2005.1 The Director shall conduct an on-site inspection of a facility to determine compliance with the statutes and rules governing the facility prior to the expiration of the license. Unless otherwise notified, inspections shall be unannounced. 2005.2 The Di…

2006 REMOVAL PERMITS 2006.1 No hospital or part of a hospital shall move from the premises for which a license has been issued to any other premises without first having obtained from the Director a permit to move to the premises not covered by the license issued to the hospital.…

2007 COMPLAINT INVESTIGATIONS 2007.1 The Director may receive any and all complaints alleging violations of the requirements contained in the applicable laws and regulations, and may conduct unannounced investigations to determine the validity of the complaints. 2007.2 The facili…

2008 VARIANCES 2008.1 The Director may grant a variance from any of the requirements of the applicable statutes and the rules of this chapter, if the applicant can show undue hardship and the variance can satisfy the following conditions: (a) It is not inconsistent with other sta…

2009 CIVIL PENALTIES 2009.1 Violation of any provision of this chapter may be subject to penalties in accordance with § 10 of the Act. 2009.2 In accordance with § 10(e) of the Act, civil fines, penalties, and related costs may be imposed against a hospital for the violation of an…

2010 DENIAL, SUSPENSION, AND REVOCATION OF A HEALTH CARE FACILITY LICENSE 2010.1 The Director may refuse to issue or renew or may revoke, or may suspend a license issued pursuant to this chapter for one or more of the reasons listed in § 5(a)(2)(F) of the Act. 2010.2 Except for a…

2011 SUMMARY SUSPENSION AND LICENSURE CONVERSION, HEARINGS 2011.1 Notwithstanding any other provision of this chapter, the Director, pursuant to § 6(d)(l) of the Act, and under conditions described in that section may do the following: (a) Convert the facility's license to a prov…

2012 SERVICE OF NOTICE 2012.1 Any notice required by this chapter may be served either personally or by certified mail, return receipt requested, directed to the applicant or licensee at the last known address as shown by the records of the Department. 2012.2 If notice is served …

2013 CONDUCT OF HEARINGS 2013.1 Every hearing before the Office of Administrative Hearings shall be open to the public and shall be in accordance with its rules of procedure and this chapter. 2013.2 An applicant or licensee entitled to a hearing shall have the following rights: (…

2014 GOVERNING BODY AND ADMINISTRATION 2014.1 Each hospital shall have a governing body which shall have the authority and responsibility for the direction and policy of the hospital. 2014.2 The governing body's responsibilities shall include: (a) Monitoring policies to assure ap…

2015 ADMINISTRATOR 2015.1 The administrator shall be responsible for planning, organizing, and directing the day to day operation of the hospital. The administrator shall report and be directly responsible to the governing body in all matters related to the maintenance, operation…

2016 GENERAL STAFF REQUIREMENTS 2016.1 Each hospital shall maintain a sufficient number of staff with the qualifications, training and skills necessary to meet patient needs. The hospital shall be staffed twenty-four (24) hours per day. 2016.2 Each hospital shall ensure and maint…

2017 HEALTH SCREENINGS AND EXAMINATIONS 2017.1 A hospital’s policies and procedures for health screening and examinations to prevent the transmission of communicable diseases must comply with the Americans with Disabilities Act (ADA) and the Genetic Information Nondiscrimination …

2018 STAFF TRAINING 2018.1 Each hospital shall ensure that staff receive training in order to perform assigned job responsibilities. 2018.2 Each hospital shall provide and maintain evidence of an orientation program for all new staff and, as needed, for existing staff who are giv…

2019 MEDICAL STAFF 2019.1. Each hospital shall have a medical staff that shall be responsible for carrying out the provisions of the bylaws, consistent with rules and regulations, and shall recommend to the governing body bylaws, or amendments to the bylaws, as they deem appropri…

2020 AVAILABILITY OF PHYSICIANS 2020.1 Each general hospital shall have a physician available on the premises at all times. 2020.2 Each special hospital shall at all times have a physician available on the premises or available on call; Provided, that when the Director, after con…

2021 NURSING STAFF 2021.1 Each hospital shall provide a nursing staff that is adequate for the diagnostic facilities and services, therapeutic facilities and services, and rehabilitation facilities and services that the hospital undertakes to provide. 2021.2 The Department of Nur…

2022 PATIENT RIGHTS 2022.1 Each hospital shall protect and promote each patient's rights. This includes the establishment and implementation of written policies and procedures, which include, but are not limited to, the following rights. Each patient or designee, when appropriate…

2023 GRIEVANCES 2023.1 Each hospital shall establish and implement a written process that promptly addresses grievances filed by patients or their representatives. The process includes, but is not limited to: (a) A procedure for submission of grievances which is made available to…

2024 PATIENT CARE AND TREATMENT 2024.1 Except in the case of emergency, no medication or treatment other than dental shall be given to any patient without an order of a physician or other qualified health professional. A physician order shall include physician approved protocols.…

2025 ERRORS IN PROVISION AND ADMINISTRATION OF MEDICATIONS 2025.1 Each hospital shall establish and implement policies and procedures for reporting any errors in administration or provision of prescribed medications. Errors shall be reported to the prescriber in a timely manner u…

2026 SEPARATE PATIENT CARE 2026.1 Each hospital regularly providing care for obstetric conditions, pediatric conditions, and psychiatric conditions shall have one (1) or more physically and functionally separate care units for each category of conditions for which care is regular…

2027 RESTRAINT OR SECLUSION OF PATIENTS 2027.1 Every general hospital, special hospital for adults with one hundred (100) or more beds, and every special hospital that maintains a psychiatric service for adults shall provide one (1) or more security rooms. 2027.2 All other specia…

2028 PATIENT NUTRITION 2028.1 Each hospital shall provide for the daily nutritional needs of all patients, including the provision of any diets ordered by a medical practitioner. 2028.2 A current diet manual acceptable to dietary, nursing and medical staff shall be maintained and…

2029 DISCHARGE PLANNING 2029.1 Each hospital shall provide discharge planning to patients. The discharge planning program includes, but is not limited to: (a) A system for timely evaluation of any discharge planning needs of patients; (b) Identification of staff responsible for t…

2030 RECORD KEEPING REQUIREMENTS 2030.1 Each hospital shall maintain records and reports in a manner to ensure accuracy and easy retrieval. 2030.2 A medical record shall be maintained for every patient, including newborn infants, admitted for care in the hospital or treated in th…

2031 PHYSICAL PLANT STANDARDS 2031.1 All hospitals shall be designed, constructed and maintained in a manner that is safe, clean, and functional for the type of care and treatment to be provided. The physical plant standards for facilities, which include support services, care an…

2032 MEDICAL SERVICES 2032.1 In the absence of applicable requirements in this chapter, the following services shall be operated in accordance with the indicated provisions of the Medicare/Medicaid participation requirements: (a) Pharmaceutical services, Title 42 of the Code of F…

2033 CARE AND TREATMENT AREAS 2033.1 The hospital shall not share the following care and treatment areas among detached structures or with other facilities operated by another licensee: (a) Staff Areas: Facilities that provide nursing services shall provide the following support …

2034 CONSTRUCTION STANDARDS 2034.1 All hospitals shall be designed, constructed, and maintained in a manner that is safe, clean, and functional for the type of care and treatment to be provided. The standards for the facilities are set forth below. 2034.2 New construction shall c…

2035 ENVIRONMENT 2035.1 All facilities shall comply with the following applicable codes and standards to provide a safe environment: (a) Life Safety Code (National Fire Protection Association 101); and (b) The Food Code, Title 25 of the District of Columbia Municipal Regulations …

2036 BUILDING SYSTEMS 2036.1 Hospitals shall have building systems that are designed, installed and operated in such a manner as to provide for the safety, comfort, and well being of the patient. 2036.2 Water and Sewer Systems: The hospital shall have and maintain an accessible, …

2037 HOUSEKEEPING AND MAINTENANCE 2037.1 Each hospital shall provide a safe, clean and comfortable environment for patients. 2037.2 Housekeeping and Maintenance: The hospital shall provide the necessary housekeeping and maintenance to protect the health and safety of patients. In…

2038 MRSA INFECTION PREVENTION 2038.1 Each hospital shall have written infection prevention and control policies and procedures. 2038.2 Each hospital shall identify MRSA colonized patients in an intensive care unit or other at-risk unit. 2038.3 Each patient colonized or infected …

2039 TESTING FOR SYNTHETIC CANNABINOID SURVEILLANCE 2039.1 When a patient presents to a hospital with a reported or witnessed use of a synthetic cannabinoid and with signs and symptoms of overdose for which the treating clinician would otherwise order a standard urine drug screen…

2099 DEFINITIONS 2099.1 When used in this chapter, the following terms and phrases shall have the meanings ascribed: Abuse - any knowing, reckless, or intentional act or omission by a provider that causes or is likely to cause or contribute to, or which caused or is likely to hav…

2100 NEWBORN HEARING SCREENING 2100.1 Each institution shall establish a Newborn Hearing Screening Service according to the following requirements: (a) Each institution shall designate a person to be responsible for the newborn hearing screening service in that institution. (b) A…

2101 METABOLIC DISORDERS 2101.1 Each institution shall make available blood tests to screen each newborn delivered or cared for at the institution for the following metabolic disorders: (a) 2,4-Dienoyl-CoA reductase deficiency; (b) 2-Methylbutyl-CoA dehydrogenase deficiency; (c) …

2199 DEFINITIONS 2199.1 When used in this chapter, the following terms and phrases shall have the meanings ascribed: 2,4-Dienoyl-CoA reductase deficiency—an autosomal recessive genetic disorder characterized by a deficiency of 2,4 Dienoyl CoA Reductase necessary for the degradati…