Hawaii Administrative Code

(a) There shall be an organized medical staff that has overall responsibility for the quality of medical care provided to patients, and for the ethical conduct and professional practices of its members. (b) The medical staff shall develop and adopt by-laws and rules to: (1) Estab…

(a) Nuclear medicine services, when provided, shall be under the direction of a physician qualified in nuclear medicine. Appropriate space and facilities shall be provided for this activity. Notes Haw. Code R. § 11-93-23 [Eff. 3/3/86; ren AUG 3, 1992] (Auth: HRS §§ 321-9, 321-11)…

(a) Each hospital shall have nursing staff sufficient in number and qualifications to meet the nursing needs of the patients. (b) The hospital shall maintain an organized nursing staff which will be responsible to the hospital administrator for the professional performance of its…

(a) Anatomical pathology and clinical laboratory services shall be available at all times to meet patient needs, either within the hospital or by contract with a laboratory approved by the department. Pathology services shall be directed and supervised by a physician certified, o…

(a) Written policies regarding the rights and responsibilities of patients during their stay in the facility shall be established and shall be made available to the patient, to any guardian, next of kin, sponsoring agency or representative payee, and to the public. The facility's…

(a) When a hospital has a pediatric unit, it shall be maintained as follows: (1) The facilities for the care and treatment of children shall be designated and set apart from all other services including the newborn service. (2) Pediatric bedrooms shall have a maximum of four pati…

(a) The hospital shall either employ sufficient licensed pharmacists or have a written contract with a licensed pharmacist to provide services necessary to meet patients' medication needs, to provide consultation on methods and procedures for ordering, monitoring and assessment, …

(a) If individuals suffering from mental illness or substance abuse are cared for in the hospital, the requirements of this section, in addition to the basic rules contained in this subchapter, shall be required in order to provide the psychiatric services. This section shall app…

(a) The facility shall meet all requirements for licensure under state law. All hospitals shall be licensed except those operated by the federal government or agency thereof. The proprietor, the governing body, or the person in charge shall formally apply in writing to the direct…

(a) Radiology consultation and services shall be regularly and conveniently available to meet the needs of the patients. (b) Radiology services shall be directed by a radiologist and be staffed by qualified technical personnel. Space, equipment and supplies shall be made availabl…

(a) If the facility provides specialized and supportive rehabilitation services (e.g., occupational therapy, physical therapy, or speech therapy), either directly or through arrangements, the services shall be organized and shall be directed by an appropriately qualified physicia…

(a) Sanitation shall comply with all applicable laws of the State of Hawaii and rules of the department relating to sanitation. (b) Written summary reports of inspections by state or local health authorities, records of action taken to correct deficiencies, and to follow recommen…

(a) Staffing: (1) If the facility offers social services, a member of the staff of the facility shall be designated as responsible for social services; (2) The director of the social work department, or a social worker consultant shall be licensed, certified, or registered in acc…

(a) The scope of services provided in each special care unit shall be specified in writing. (b) Each special care unit shall have policies and procedures which relate to the care provided in the unit and shall be reviewed annually. (c) The special care unit shall be directed by a…

(a) If surgical services are provided, the surgical department shall: (1) Be directed by an appropriately qualified physician. (2) Have effective policies and procedures regarding surgical privileges, maintenance of the operating rooms and evaluation of the surgical patient. (3) …

The facility shall establish transfer agreements which make feasible the transfer of patients and transfer summaries between hospitals, skilled nursing, and intermediate care facilities. Notes Haw. Code R. § 11-93-36 [Eff. 3/3/86; ren AUG 3, 1992] (Auth: HRS §§ 321-9, 321-11) (Im…

Every person who violates any of the provisions of this chapter shall be penalized as provided in chapter 321, HRS. Notes Haw. Code R. § 11-93-37 [Eff. 3/3/86; ren AUG 3, 1992] (Auth: HRS §§ 321-9, 321-11, 321-18) (Imp: HRS §§ 321-9, 321-11, 321-18)

Notes Haw. Code R. §§ 11-93-38 through 11-93-48

(a) There shall be available in any hospital which provides surgical or obstetrical services an anesthesia service. (b) The anesthesia service shall be directed by a physician member of the medical staff. The anesthesia service shall comply with the provisions of the N.F.P.A Code…

If any provision of this chapter or the application thereof to any person or circumstances is held invalid, the remainder of this chapter, or the application of the provision to other persons or circumstances shall not be affected thereby." Notes Haw. Code R. § 11-93-49 [Eff. 3/3…

Where the facility does not employ a qualified person to render a required or necessary service, it shall contract in writing with a qualified person or provider. Written contracts shall include, but not be limited to: (1) The responsibilities and scope of employment of parties, …

The provisions of this subchapter are to establish minimum requirements for the protection of the health, welfare and safety of patients, newborns, personnel and the public in freestanding birthing facilities. These shall not be construed as lowering standards, ordinances, or reg…

As used in this subchapter: "Administrator" means the person to whom it is delegated the responsibility for interpretation and implementation of the policies and program established by the governing body. This may be the same person as the medical director or midwife. "Birthing r…

(a) It shall be unlawful for any group or person to operate a freestanding birthing facility unless it is licensed by the director. (b) Any person, or group of persons, desiring to operate a freestanding birthing facility shall apply to the director for a license on forms provide…

(a) After due notice, and after suitable opportunity for hearing, conducted in accordance with chapter 91, HRS, the director may suspend, revoke, or refuse to issue or renew a license to any governing body because of a failure to meet: (1) Requirements of this chapter; or (2) The…

(a) The administrative personnel under the direction of an administrator shall develop and carry out such administrative procedures as are necessary to achieve the objectives and policies of the governing body. (b) The administrator shall establish policies and develop procedures…

(a) The facility shall be constructed and maintained in accordance with state, and local zoning, building, fire safety and sanitation laws. (b) The facility shall be accessible to, and functional, for physically handicapped persons. (c) There shall be adequate space for preparati…

Appropriate fees, if any, as determined by the director, shall be charged by the department for obtaining a new license or obtaining a license renewal. Prior notice of the amount of the fee shall be provided to the licensee. Notes Haw. Code R. § 11-93-56 [Eff. MAR 3, 1986] (Auth:…

(a) The governing body shall be the supreme authority of the facility, responsible for the management, control and operation of the facility; including the appointment of an administrator, medical director, and professional staff. (b) The governing body shall specify which obstet…

(a) Definitive procedures governing sterilization techniques shall be developed. The written procedures shall include: (1) The technique to be used for particular instrument or group of instruments. (2) The length of time to accomplish sterilization. (3) Temperature, time and pre…

There shall be an appropriate inservice education program. This shall include, but not be limited to annual training, fire prevention, infection control, and accident prevention. There shall be adequate documentation of these educational procedures. Notes Haw. Code R. § 11-93-59 …

(a) The hospital shall be accessible to and functional for physically handicapped patients, hospital personnel, and the general public. (b) Accessibility to living and service areas. (1) There shall be adequate space to allow free movement of persons using wheelchairs, walkers, c…

(a) Provision shall be made for the handling, storage and transportation of soiled and clean laundry and for satisfactory cleaning procedures. (b) Infectious laundry shall be handled in accordance with the provisions of section 325-7, HRS or any method approved by the director. N…

(a) The medical director shall develop appropriate written policies and procedures to provide the necessary preventive, diagnostic and therapeutic services to patients in order to achieve the objectives of the facility. (b) The medical director shall cooperate with the administra…

(a) There shall be available sufficient appropriately qualified staff and necessary supporting personnel to facilitate the accurate processing, checking, indexing, filing and prompt retrieval of records and record data. (b) All patient records shall be confidential and are the pr…

(a) Each facility shall have a nursing staff which shall be directed by the director of nursing. The director of nursing shall be a qualified registered professional nurse who shall be appointed by the administrator with the approval of the governing body. The director of nursing…

(a) All abnormal tissues and fetuses shall be appropriately preserved for examination by a pathologist at the freestanding birthing facility. (b) A report of such examination shall be placed in the patient's record. Notes Haw. Code R. § 11-93-64 [Eff. MAR 3, 1986] (Auth: HRS §§ 3…

(a) All patients admitted to a facility shall have been under prior care by a member of the professional staff. (b) Patients and newborns shall remain under observation in this facility for a reasonable period of time to ensure that no immediate postpartum complications are prese…

(a) Each facility shall have a list of standing orders and procedures which shall be signed by the medical director. (b) Only medications on the standing order list of medications shall be administered in the facility and only given within the dosage ranges so specified. Document…

There shall be an organized professional staff consisting of licensed midwives and suitably qualified physicians. The professional staff shall be appointed by the governing body. Notes Haw. Code R. § 11-93-67 [Eff. MAR 3, 1986] (Auth: HRS §§ 321-9, 321-10) (Imp: HRS § 321-10)…

There shall be appropriate equipment and supplies maintained for the mother and the newborn which shall include, but not be limited to: (1) A bed suitable for labor, birth and recovery. (2) Oxygen with flow meters and masks, or equivalent. (3) Suction and bulb suction immediately…

The facility shall establish transfer agreements which will expedite the transfer of patients to hospitals when it is desirable to do so. There shall be documented evidence that a local hospital has agreed to admit, without delay, patients from the facility should the staff of th…

(a) Where a dental service is provided, the governing body shall appoint a dentist, or dentist, to the medical staff and grant appropriate privileges. (b) A dentist shall be appointed as head of the service. (c) Patients admitted for dental care shall be given an appropriate medi…

In addition to any other appropriate action to enforce these rules, the director may initiate procedures for invoking penalties as provided in chapter 321, HRS. Notes Haw. Code R. § 11-93-70 [Eff. MAR 3, 1986] (Auth: HRS §§ 321-9, 321-10) (Imp: HRS §§ 321-10, 321-18)

Notes Haw. Code R. §§ 11-93-71 through 11-93-99

(a) The food and nutrition needs of patients shall be met through a nourishing, well-balanced diet in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council and adjusted for age, sex, activity, and disability. (b) At le…

(a) The facility shall establish a written external disaster plan for the reception, treatment, and disposition of mass casualties. The plan should be developed in conjunction with other emergency facilities and services in the county, and appropriate civil authorities, and shall…