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Virginia Administrative Code (Last Updated: January 10, 2017) |
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Title 12. Health |
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Agency 5. Department of Health |
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Chapter 410. Regulations for the Licensure of Hospitals in Virginia |
Section 1170. Policy and procedures manual
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A. Each outpatient surgical hospital shall develop a policy and procedures manual that shall include provisions covering the following items:
1. The types of emergency and elective procedures that may be performed in the facility.
2. Types of anesthesia that may be used.
3. Admissions and discharges, including criteria for evaluating the patient before admission and before discharge.
4. Written informed consent of patient prior to the initiation of any procedures.
5. Procedures for housekeeping and infection control and prevention.
6. Disaster preparedness.
7. Facility security.
B. A copy of approved policies and procedures and revisions thereto shall be made available to the OLC upon request.
C. Each outpatient surgical hospital shall establish a protocol relating to the rights and responsibilities of patients based on Joint Commission on Accreditation of Healthcare Organizations' Standards for Ambulatory Care (2000 Hospital Accreditation Standards, January 2000). The protocol shall include a process reasonably designed to inform patients of their rights and responsibilities. Patients shall be given a copy of their rights and responsibilities upon admission.
D. Each outpatient surgical hospital shall obtain a criminal history record check pursuant to § 32.1-126.02 of the Code of Virginia on any compensated employee not licensed by the Board of Pharmacy whose job duties provide access to controlled substances within the outpatient surgical hospital pharmacy.
Historical Notes
Derived from VR355-33-500 § 4.3, eff. July 28, 1993; amended, Volume 11, Issue 08, eff. April 1, 1995; Volume 19, Issue 01, eff. November 1, 2002; Volume 23, Issue 10, eff. March 1, 2007; Volume 28, Issue 02, eff. November 1, 2011.