Agency for Health Care Administration

ST - H0000 - INITIAL COMMENTS

Title INITIAL COMMENTS Type Memo Tag

Agency for Health Care Administration

ASPEN: Regulation Set (RS)

Aspen State Regulation Set: H 6.04 HOSPITAL LICENSURE

Printed 07/05/2019

Page 1 of 281

Regulation Definition

ST - H0001 - Child Abuse & Neglect - Policy Adoption

Title Child Abuse & Neglect - Policy Adoption Type Rule

59A-3.280(1) FAC; 395.1023(1) FS

Regulation Definition 59A-3.280 (1) Every licensed hospital admitting or treating shall adopt and incorporate a policy that requires every staff member to report any case of actual or suspected child abuse or neglect pursuant to Chapter 39, F.S. 395.1023 Each licensed facility shall adopt a protocol that, at a minimum, requires the facility to: (1) Incorporate a facility policy that every staff member has an affirmative duty to report, pursuant to chapter 39, any actual

oRegSet.rpt

Interpretive Guideline These guidelines are meant solely to provide guidance to surveyors in the survey process. Add the most current Baker Act Regulation Set to the survey if the Hospital is a designated Baker Act Receiving Facility. To generate a list, use AHCA's Florida Health Finder website and filter by provider type and check the box at the bottom for "Baker Act Receiving Facility".

Interpretive Guideline - Request the Child Abuse and Neglect Policy. - Review that the policy mandates that every staff member report actual or suspected child abuse or neglect to the Department of Children and Family Services Abuse Registry. - Interview staff to determine how this policy of mandated reporting is distributed to staff . - Interview staff to ascertain their knowledge of when, how, where, and what to report to DCF (1-800-962-2873).

Agency for Health Care Administration

ASPEN: Regulation Set (RS)

Printed 07/05/2019

Page 2 of 281

Aspen State Regulation Set: H 6.04 HOSPITAL LICENSURE

or suspected case of child abuse, abandonment, or neglect; ...

ST - H0002 - Child Abuse & Neglect - Report A/N to DCF

Title Child Abuse & Neglect - Report A/N to DCF Type Rule

59A-3.280(1)(a) FAC

Regulation Definition

(1) Every licensed hospital admitting or treating shall adopt and incorporate a policy that requires every staff member to report any case of actual or suspected child abuse or neglect pursuant to chapter 39, F.S.

Interpretive Guideline

- Request and review the hospital policy and procedure for reporting suspected child abuse/neglect - Request any cases of alleged child abuse/neglect from the Risk Manager. - Review for immediate and appropriate reporting.

(a) Each report of actual or suspected child abuse or neglect shall be made immediately to the Department of Children and Family Services' Florida Abuse Hotline, statewide toll free number 1(800) 962-2873 or to the local office of the Department of Children and Family Services responsible for investigating such reports.

ST - H0003 - Child Abuse & Neglect -Report To Med Examiner

Title Child Abuse & Neglect -Report To Med Examiner Type Rule

59A-3.280(1)(b) FAC

Regulation Definition

(b) Any person required to report suspected child abuse or neglect, who has reasonable cause to suspect that a child died as a result of abuse or neglect, shall report his suspicion to the local medical examiner.

oRegSet.rpt

Interpretive Guideline

- Request and review records concerning suspected and actual child abuse or neglect resulting in death. - Verify report of such suspicions to Medical Examiner. - Review Child Abuse & Neglect Policy for the specific reporting of a death to the local/appropriate medical examiner. - Review policy for clarity as to where to report.

Agency for Health Care Administration

ASPEN: Regulation Set (RS)

Printed 07/05/2019

Page 3 of 281

Aspen State Regulation Set: H 6.04 HOSPITAL LICENSURE

- Interview staff for knowledge of this policy.

ST - H0004 - Child Abuse & Neglect - Physician Liaison

Title Child Abuse & Neglect - Physician Liaison Type Rule

59A-3.280(2) FAC; 395.1023(2) FS

Regulation Definition

59A-3.280 (2) Each hospital admitting or treating children shall designate, at the request of the Department of Children and Family Services, a staff physician, ARNP or PA to act as a liaison between the hospital, the child protective investigator and the child protection team.

395.1023 Each licensed facility shall adopt a protocol that, at a minimum, requires the facility to: (2)In any case involving suspected child abuse, abandonment, or neglect, designate, at the request of the department, a staff physician to act as a liaison between the hospital and the Department of Children and Families office which is investigating the suspected abuse, abandonment, or neglect, and the child protection team, as defined in s. 39.01, when the case is referred to such a team..

ST - H0005 - Child Abuse & Neglect - Policy Reporting

Title Child Abuse & Neglect - Policy Reporting Type Rule

59A-3.280(3) FAC

Interpretive Guideline

- Review documentation for a protocol re: appointment of a physician liaison. - Review documentation to ensure that, in instances in which DCF has so requested, the facility has actually appointed a qualified individual to serve as the physician liaison (interview physician as appropriate)

oRegSet.rpt

Agency for Health Care Administration

ASPEN: Regulation Set (RS)

Printed 07/05/2019

Page 4 of 281

Aspen State Regulation Set: H 6.04 HOSPITAL LICENSURE

Regulation Definition

Child Abuse and Neglect Policy Reporting. Each hospital admitting or treating children shall formulate a child abuse and neglect policy and shall submit a copy of this policy to the Department of Children and Family Services, Office of Family Safety, 1317 Winewood Boulevard - Building 1, Tallahassee, Florida 32399-0700.

Interpretive Guideline

-Verify the submission of the facility Child Abuse and Neglect Policy to the Department of Children and Family Services, Office of Family Safety.

ST - H0006 - Child Abuse & Neglect - Copy of Policy Sent

Title Child Abuse & Neglect - Copy of Policy Sent Type Rule

59A-3.280(4) FAC; 395.1023(2) FS

Regulation Definition

59A-3.280(4) Remedies. Failure to comply with these rules will result in a fine being imposed in accordance with the provisions of s.395.1023, F.S. and 39.205, F.S.

395.1023(2) ... Each general hospital and appropriate specialty hospital shall comply with the provisions of this section and shall notify the agency and the department of its compliance by sending a copy of its policy to the agency and the department as required by rule. The failure by a general hospital or appropriate specialty hospital to comply shall be punished by a fine not exceeding $1,000, to be fixed, imposed, and collected by the agency. Each day in violation is considered a separate offense.

Interpretive Guideline

- Failure to comply with these rules could result in an immediate per instance, per day fine. - Surveyor should report to their Field Office Manager. - Field Office Management should review violation with AHCA General Counsel.

oRegSet.rpt

Agency for Health Care Administration

ASPEN: Regulation Set (RS)

Printed 07/05/2019

Page 5 of 281

Aspen State Regulation Set: H 6.04 HOSPITAL LICENSURE

ST - H0007 - COMPREHENSIVE EMERGENCY MANAGEMENT PLAN

Title COMPREHENSIVE EMERGENCY MANAGEMENT PLAN Type Rule

59A-3.078; 395.1055; 395.1056; 59A-3.303

Regulation Definition

59A-3.078 (1) Each hospital shall develop and adopt a written comprehensive emergency management plan for emergency care during an internal or external disaster or an emergency, which is reviewed and updated annually. (2) The emergency management plan shall be developed in conjunction with other agencies and providers of health care services within the local community pursuant to Section 395.1055(1)(c), F.S., and in accordance with the "Emergency Management Planning Criteria for Hospitals," AHCA Form 3130-8005-September 94, which is incorporated by reference. The form is available from the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop 31, Tallahassee, Florida 32308. The plan shall include: (a) Provisions for internal and external disasters and emergencies; (b) A description of the hospital's role in community wide emergency management plans; (c) Information about how the hospital plans to implement specific procedures outlined in the hospital's emergency management plan; (d) Precautionary measures, including voluntary cessation of hospital admissions, to be taken by the hospital in preparation and response to warnings of inclement weather, or other potential emergency conditions; (e) Provisions for the management of patients, including the discharge of all patients that meet discharge requirements, in

oRegSet.rpt

Interpretive Guideline

- Verify there is a plan approved by the county emergency management agency on file in the facility. - Where is the plan located? Is it immediately accessible by hospital staff? [59A-3.078 (5)] - Has the hospital tested the implementation of the EMP semiannually or in accordance with The Joint Commission guidelines? [59A-3.078 (4)] - Ask staff what their responsibilities are in implementing the plan. - Verify the facility has ensured the provisions outlined in citation text.

59A-3.303(6), FAC refers to Intensive Residential Treatment Programs.

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download