Rule 111-8-40-.26 - Respiratory/Pulmonary ServicesThe hospital shall provide or arrange for effective services to meet the respiratory/ pulmonary needs of patients and shall define in writing the scope and complexity of the respiratory/pulmonary services offered by the facility.
(a)Organization and Staffing of Respiratory/Pulmonary Services.1. The hospital shall have an organizational plan for respiratory/ pulmonary services that clearly defines the necessary staff for the services and the lines of authority and accountability.2.Director. There shall be a qualified director of respiratory/pulmonary services who is a member of the medical staff and a licensed doctor of medicine or osteopathy with knowledge, experience, and capability to supervise the services on a full-time or part-time basis including the evaluation of the effectiveness of the services in coordination with the hospital's quality management program. (i) The director shall be responsible for all clinical aspects of the organization and delivery of clinical respiratory care services, including the evaluation of the effectiveness of the services in coordination with the hospital's quality management program.(ii) The director shall be responsible for the development, implementation, and periodic review of policies, procedures, and protocols for respiratory/pulmonary care, which shall reflect the scope of services offered, including at least:(I) Routine inspection, cleaning, and maintenance procedures for respiratory equipment, as well as protocols for their assembly and operation;(II) Adverse reaction protocols;(III) Safety practices and interventions;(IV) Staff participation in emergency situations at the facility;(V) Infection control procedures;(VI) Procedures for handling, storage, and dispensing of therapeutic gases;(VII) Procedures for obtaining blood samples and analysis of samples, as applicable;(VIII) Procedures for testing of pulmonary function, as applicable;(IX) Procedures for therapeutic percussion and vibration and for broncho-pulmonary drainage, as applicable;(X) Procedures for mechanical ventilation and oxygenation support and for administration of aerosol, humidification, and therapeutic gases, as applicable;(XI) Policies for administration of medications;(XII) A system for the reissuing and discontinuing of respiratory therapy orders; and(XIII) Procedures for verbal/telephone orders taken by state-certified respiratory care professionals.3. There shall be a sufficient number of qualified competent professionals and support personnel to respond to and meet the respiratory/ pulmonary care needs of the patients.(b)Delivery of Respiratory/Pulmonary Services. Respiratory/ Pulmonary services shall be delivered in accordance with the needs of the patients. 1. Respiratory services shall be provided only in response to medical orders. Medical orders for services shall include the modality to be used, the type, frequency, and duration of treatment, and the type and dose of medications, including dilution ratios. Verbal/telephone orders for respiratory service shall be dated, timed, and given only to appropriately licensed or otherwise qualified individuals as determined by the medical staff in accordance with state law and these rules and shall be entered into the patient's medical record by those appropriately licensed or otherwise qualified individuals.2. The hospital shall provide equipment and supplies sufficient to support the scope of the respiratory services offered.3. All respiratory care services provided shall be documented in the patient's medical record, including the type of therapy, date and time of administration, effects of therapy, and any adverse reactions.4. If blood gases or other clinical laboratory tests are performed by respiratory care staff, those staff shall have demonstrated competency in the administration of the tests as point-of-care technicians.Ga. Comp. R. & Regs. R. 111-8-40-.26
O.C.G.A. Ch. 31-22, Sec. 31-7-2.1.
Original Rule entitled "Respiratory/Pulmonary Services" adopted. F. Feb. 20, 2013; eff. Mar. 12, 2013.