North Dakota Administrative Code

1. The general acute hospital must be constructed, arranged, and maintained to ensure the safety and well-being of the patients and must provide facilities for diagnosis and treatment and for special services appropriate to the hospital. a. The physical plant must comply with the…

1. General acute hospitals shall comply with the fire code standards. This compliance is subject to review and approval by the state fire marshal's office. 2. Primary care hospitals are subject to the fire control requirements for general acute hospitals in this section. 3. Speci…

1. The general acute hospital shall have a written procedure to be followed in case of fire, explosion, or other emergency. It shall specify individuals to be notified, locations of alarm signals and extinguishers, evacuation routes, procedures for evacuating helpless patients, f…

The hospital shall have an ongoing, facilitywide, written quality improvement program and risk management program approved by the governing body with implementation plans that evaluate and improve the quality of patient care, governance, and managerial and support activities. 1. …

The hospital shall have a hospitalwide program for the surveillance, prevention, and control of infections consistent with the occupational safety and health administration and centers for disease control standards regulations specific to infection control. 18 1. The general acut…

1. The general acute hospital shall have an organized medical staff that is accountable to the governing body in accordance with written bylaws, rules, and regulations approved by the governing body. The medical staff shall adopt and enforce bylaws, rules, and regulations to carr…

1. The general acute hospital shall have a plan of administrative authority with delineation of responsibilities and duties for nursing personnel, including written job descriptions. a. Nursing services must be under the direction of a nurse executive (director of nursing) who is…

1. The general acute hospital shall ensure that a patient care plan is developed for each patient in coordination with the patient and appropriate health care personnel consistent with the licensed health care practitioner's orders. a. Initial assessment must begin upon admission…

1. The general acute hospital shall design, implement, and document educational programs to orient new employees and to keep all staff current on new and expanding programs, techniques, equipment, and concepts of quality care. The following topics must be covered annually: a. Inf…

1. The general acute hospital shall provide dietary service to meet the needs of the patients served and shall ensure the following: a. The hospital shall designate an employee to be responsible for the total food service of the facility. If this employee is not a licensed regist…

1. The general acute hospital shall establish and implement procedures to ensure that the hospital has a medical records service with administrative responsibility for medical records. a. A medical record must be maintained and kept confidential, in accordance with accepted medic…

1. General acute hospitals shall provide pharmaceutical services consistent with chapter 61-07-01. The hospital, upon receipt, shall submit to the department a copy of the annual board of pharmacy hospital inspection report under subsection 2 of section 61-07-01-13 and plans of c…

1. General acute hospitals shall have a well-organized, adequately supervised, clinical laboratory service available with the necessary space, facilities, and equipment and qualified, licensed staffing to perform these services commensurate with the hospital's needs for its patie…

1. The general acute hospital shall provide and maintain radiology services sufficient to perform and interpret the radiological examinations necessary for the diagnosis and treatment of patients, to the extent that the complexity of services are commensurate with the size, scope…

1. If the acute hospital provides nuclear medicine services, the services must be provided to meet the needs of the patients and in a safe and effective manner. a. The hospital shall have available written verification of compliance with article 33-10. b. The hospital shall have …

1. Each general acute hospital shall provide emergency services to its inpatients. If the hospital does not provide emergency services to the public, it shall be prepared to provide immediate lifesaving measures to individuals who may appear for emergency care and arrange for the…

1. Social services must be provided in all general acute hospitals by a qualified social worker or a social services designee to meet the needs of the patients. Hospitals utilizing social services designees must have quarterly consultation by a qualified social worker. a. Records…

1. General acute hospitals shall provide basic rehabilitation services, including physical, occupational, and speech pathology and audiology to meet the needs of the patients served. a. Basic rehabilitation services must be provided by qualified staff licensed or certified consis…

1. The general acute hospital shall provide the housekeeping and related services necessary to maintain a sanitary and comfortable environment. a. The hospital shall provide personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive …

1. The general acute hospital that provides surgical services shall have effective policies and procedures regarding surgical privileges, maintenance of the operating rooms, and evaluation of the surgical patient. a. Surgical services must be provided in a manner sufficient to me…

1. Postoperative recovery services must be provided by all general acute hospitals in which surgery is performed. 39 a. Recovery services must be provided in a room where patients who have undergone surgical procedures can be immediately observed, receive specialized care by sele…

1. General acute hospitals shall provide central services consistent with at least the following: a. The central services must be provided with adequate direction, staffing, and facilities to provide service to all services in the hospital. b. Policies and procedures must be deve…

1. General acute hospitals providing surgical services shall provide anesthesia services to meet the needs of the patients served and shall ensure the following: a. The anesthesia service must be under the direction of a qualified physician who is a member of the medical staff. b…

1. If the general acute hospital provides respiratory care services, the services must be under the supervision of a licensed health care practitioner, organized and integrated with other services of the hospital. a. Respiratory care policies and procedures must be developed, imp…

1. All general acute hospitals providing obstetrical services shall provide for the admission, medical care, transfer, or discharge of obstetric and neonatal patients. Obstetrical services must include the following: a. The obstetrical services must have an organized obstetric st…

1. General acute hospitals providing outpatient birth services in hospitals are subject to the outpatient birth services requirements for specialized hospitals in this section. 2. Primary care hospitals may not provide outpatient birth services. 3. Any facility that provides outp…

1. Specialized rehabilitation services in a general acute hospital must be provided in a distinct, clearly defined, special unit and are subject to the specialized rehabilitation services in hospitals requirements for specialized hospitals in this section. If in the course of the…

1. General acute hospitals providing psychiatric services are subject to the psychiatric services in hospitals requirements for specialized hospitals in this section. If, in the course of the inspection of a general acute hospital, the department finds from a review of the psychi…

The site of the hospital must be away from nuisances that may be detrimental to the proposed services, such as commercial or industrial developments, or other types of facilities that produce noise or air pollution. A site plan must be submitted to the department. History: Effect…

1. Hospitals shall contact the department prior to any substantial changes in or alterations to any portion of the structure to determine to what extent they are subject to review. A substantial change must include any alterations affecting the fire safety or structural integrity…

1. Hospitals must be designed, constructed, equipped, maintained, and operated in compliance with: a. This chapter. b. The Guidelines for Hospitals and Outpatient Facilities, 2014 edition, compiled by the facility guidelines institute. c. The national fire protection association …

1. Hospitals with a capacity of fifty beds or less may qualify for special consideration of these standards. Some functions allotted separate spaces or rooms in these standards may be combined, provided the resulting arrangement does not compromise safety and medical and nursing …

Each patient room must meet the following requirements: 2 1. A patient room may not be located on a floor unless a portion of the floor is at or above grade level. A patient room may not have its floor more than thirty inches [.76 meter] below the adjacent grade. 2. Patient rooms…

1. At least one room must be provided for toilet training. It must be accessible from the corridor and may also serve the bathing area, and must provide three feet [.91 meter] clearance at the front and both sides of the water closet. 2. Ceilings must be acoustically treated in p…

If any part of this chapter is found to conflict with federal requirements, the more stringent shall apply. Such a finding or determination shall be made by the department and shall not affect the remainder of this chapter. History: Effective July 1, 2015. General Authority: NDCC…

The following terms are defined for this chapter, chapter 33-07-04.2, and North Dakota Century Code chapter 23-16: 1. "Abuse" for the purposes of this chapter is defined in section 33-07-06-01. 2. "Adult day care" means the provision of facility services to meet the needs of indi…

If any part of this chapter or chapter 33-07-04.2 is found to conflict with federal requirements, the more stringent shall apply. Such a finding or determination shall be made by the department and shall not affect the remainder of this chapter or chapter 33-07-04.2. History: Eff…

An entity meeting the definition of nursing facility in this chapter must obtain a license from the department to operate in North Dakota. No person or entity shall establish or operate a facility without first having obtained a license. 1. Any person or entity who owns or leases…

Any provisions of this chapter or chapter 33-07-04.2 may be waived by the department for a specified period in specific instances, provided such a waiver does not adversely affect the health and safety of the residents and would result in unreasonable hardship upon the facility. …

The department may evaluate a facility's compliance with this chapter or chapter 33-07-04.2 at any time through: 1. An announced or unannounced onsite review; or 2. A request for submission of written documentation verifying compliance. History: Effective July 1, 1996. General Au…

1. A facility shall submit to the department a plan of correction addressing areas of noncompliance with the licensure requirements of this chapter and chapter 33-07-04.2. 2. A plan of correction must include: a. How the corrective action will be accomplished; b. How the facility…

The governing body is legally responsible for the quality of resident care services; for resident safety and security; for the conduct, operation, and obligations of the facility; and for ensuring compliance with all federal, state, and local laws. 1. The governing body shall est…

The facility must be constructed, arranged, and maintained to ensure the safety and well-being of the residents. 1. The physical plant must comply with the construction standards of chapter 33-07-04.2; and 2. The facility must provide an environment that is maintained, clean, com…

The facility shall have a written procedure to be followed in case of emergencies. The emergency plan must specify persons to be notified, locations of alarm signals and fire extinguishers, evacuation routes, procedures for evacuating residents, and assignment of specific tasks, …

1. The facility shall develop and implement a quality improvement program, approved by the governing body, for assessing and improving the quality of services and care provided to residents. The written program must describe objectives, organization, scope, and mechanisms for ove…

The facility shall develop and implement a facilitywide program, approved by the governing body, for surveillance, prevention, and control of infections. This program must be consistent with the centers for disease control and prevention standards specific to disease control. The…

The facility shall design, implement, and document educational programs to orient new employees and keep all staff current on new and expanding programs, techniques, equipment, and concepts of quality care. The following topics must be covered with all staff annually: 1. Safety a…