Proposed Regulation Changes 
6 CCR 1011-1 Chapter IV General Hospitals
Table of Contents
1.	Statutory Authority and Applicability***
2.	Definitions
3.	Governing Board***
4.	Administrative Officer***
5.	Medical Staff***
6.	Nursing Staff
7.	Personnel***
8.	Medical Records Department***
9.	Anesthesia Services
10.	Laboratory Services***
11.	Obstetrics Department***
12.	Dietary Services
13.	Emergency Services
14.	Outpatient Services
15.	Infection Control Services***
16.	Respiratory Care Services
17.	Critical Care Services
18.	Occupational and Physical Therapy Services
19.	General Patient Care Services
20.	Pediatric Patient Care Services
21.	Pharmaceutical Services
22.	Psychiatric Patient Care Services
23.	Surgical and Recovery Services
24.	Diagnostic Imaging Services***
25.	Nuclear Medicine Services***
26.	Central Medical-Surgical Supply Services
27.	Housekeeping Services***
28.	Linen and Laundry Services***
29.	Maintenance Services***
30.	Waste Disposal Services***

***Denotes sections which have substantive amendments.
CHAPTER IV	GENERAL HOSPITALS
I	GENERAL PROVISIONS
1	Statutory Authority and Applicability {New language.  Codifies existing practice.}
(1)	Authority to establish minimum standards through regulation and to administer and enforce such regulations is provided by Sections 25-1.5-103 and 25-3-101, C.R.S., et seq.
(2)	All hospitals shall meet applicable federal and state statutes and regulations, including but not limited to:
		(a)	6 CCR 1011-1, Chapter II.
		(b)	This Chapter IV, except as noted in subpagraphs (i) and (ii), below:
			(i)	facilities that are federally certified or are undergoing federal certificaton under 42 CFR 482 et seq as long term hospitals shall meet the requirements of this chapter, except that they shall not be required to have an emergency department, obstetric services or anesthesia services.
			(ii)	Facilities that have 25 inpatient beds or less and are federally certified or undergoing federal certification under 42 CFR 485.600 et seq as critical access hospitals shall meet the requirements of this chapter, except that the level of staffing, hours of operation, and quality management requirements shall not exceed the requirements established in the aforementioned federal regulations.  
(3)	If services are contracted, the contracted services shall meet the standards herein.

2	1.01 DEFINITIONs {Reorganization only.  No substantive changes intended.}
(1)	“Department” means the Department of Public Health and Environment.
(2)	“General hospital” means a health facility that, under an organized medical staff, offers and provides twenty-four hours per day, seven days per week, inpatient services, emergency medical and surgical care, continuous nursing services, and necessary ancillary services, to individuals for the diagnosis or treatment of injury, illness, pregnancy, or disability.
	(a) 1.02.  A general hospital may offer and provide, but is not limited to, outpatient, preventive, therapeutic, surgical, diagnostic, rehabilitative, or any other supportive services for periods of less than twenty-four hours per day.
	(b) 1.03.  Services offered or provided by a general hospital may be provided directly or by contractual agreement in compliance with the regulations.
	(c) 1.04.  A general hospital may provide services through the use of more than one physical location pursuant to the provisions of Chapter II, sections 2.3, 2.6, and 2.7 of these regulations.
(2)	“Critical Care Unit” means a designated area of the hospital containing a grouping of single bedrooms or enclosures accommodating not more than 6 beds each, and providing particularized facilities and services to care for patients who require continuing, acute observation and concentrated, highly proficient care. When such unit is provided the requirements listed herein shall be observed.  {Moved from Part 14 Critical Care Units, now Part 17 Critical Care Services}
(3)	“Governing Board” means the board of trustees, directors, or other governing body in whom the ulitmate authority and responsibility for the conduct of the hospital is vested.
(4)	DEFINITION. “Patient Care Unit” means a designated area of the hospital that provides a bedroom or a grouping of bedrooms with respective supporting facilities and services to provide adequate nursing care and clinical management of inpatients; and that is thereby planned, organized, operated, and maintained to function as a separate and distinct unit. {Moved from Part 19, Patient Care Unit now Part 19, General Patient Care Services}
(4)	Inhalation therapy “Respiratory care” is that service which is organized to provide facilities, equipment, and personnel who are qualified by training, experience and ability to treat conditions caused by deficiencies or abnormalities associated with respiration. {Moved from Part 13 Inhalation Therapy, now Part 16 Respiratory Care Services}
(5)	23.32  SURGICAL RECOVERY ROOM. Definition: “Surgical recovery room” means a Ddesignated room(s) designed, equipped, staffed, and operated to provide close, individual surveillance of patients recovering from acute affects of anesthesia, surgery, and diagnostic procedures. {Moved from Part 23 Surgical Suite, now Part 23 Surgical and Recovery Room Services}

32	GOVERNING BOARD {Substantive changes intended}
DEFINITION. Governing Board means the board of trustees, directors, or other governing body in whom the ulitmate authority and responsibility for the conduct of the hospital is vested.
3.101	ORGANIZATION & Staffing 
(1)	The governing board shall be organized formally with written constitution or articles of incorporation and by-laws, have meetings at regularly stated intervals, and maintain records of these meetings.
(2)	The governing board should shall appoint an administrative officer who is qualified by training and experience in hospital administration and delegate to him or her the executive authority and responsibility for the administration of the hospital.
(3)	1.2 MEDICAL STAFF. The governing board shall appoint the medical staff. Appointments shall be made following consideration of the recommendations by the medical staff. The governing board shall establish formal liaison with; and approve the by-laws, rules, and regulations of the medical staff.
(4)	1.3.  The governing board shall provide facilities personnel and services necessary for the welfare and safety of patients.  
3.102	PROGRAMMATIC FUNCTIONS.  The governing board shall:
(1)	1.3 The governing board shall provide facilities, personnel and services and departments necessary for the welfare and safety of patients.  
(2)	1.3  The governing board has a responsibility for the program of all groups performing functions be responsible for all the functions performed within the hospital.  
(3)		1.3.1  It shall also organize and conduct training programs in the safe management of patients.
(4)		adopt a written emergency management plan.
		(a)	at minimum, the plan shall address the following emergency situations:
			(i)	loss of heat or air conditioning.
			(ii)	unanticipated interruption of serve of utilities, including water, gas, and electricity either within the facility or within a local widespread area.
			(iii)	fire, explosion, or other physical damage to the hospital.
			(iv)	local and widespread weather emergencies or natural disaster.
			(v)	pandemics or other situations where the community’s need for services excees the availability of beds and services regularly offered by the hospital.  The hospital response for emergency epidemics shall be directed by 6 CCR 1009-5, Regulation 2 – Preparations by General or Critical Access Hospitals for an Emergency Epidemic.
		(b)	at minimum, the plan shall address the following components of the facility response:
			(i)	the responsibilities of those involved in the emergency management activities within the facility, including authority to activate the plan.
			(ii)	patient triage, care, and discharge.
			(iii)	staff education and training.
3.103	Equipment and Supplies
	(1)	The governing board shall provide equipment and supplies service necessary for the welfare and safety of patients.
3.104	FACILITIES
	(1)	1.3  The governing board shall provide facilities, personnel, and services necessary for the welfare and safety of patients.
(2)	1.3.1  The governing board of the hospital shall be responsible for defining and promulgating the safety limitations of the environment of various patient locations based on the medical procedures involved, the choice of electric distribution and grounding systems, and all electric appliances used in the location. 
(3)	The governing board shall also be responsible for establishing a testing and maintenance program to detect and correct degradation of the safety features of the selected systems and equipment used.

42	ADMINISTRATIVE OFFICER {Substantive changes intended}
4.101	 2.2  ORGANIZATION and staffing  
	(1)	The facility shall have an 2.1  RESPONSIBILITY. The administrative officer who shall be responsible for the onsite administration of the hospital and shall maintain liaison between the governing board and the medical staff.
	(2)	2.2  The hospital shall be organized formally to carry out its responsibilities. The administrative officer shall be responsible for developing and implementing a written The plan of organization defining with the authority, responsibility, and functions of each category of all personnel should be defined clearly in writing.
4.102	Programmatic Functions
	(1)  2.3  POLICIES. The administrative officer shall be responsible for the development of hospital policies and procedures for employee and medical staff use.  
Each department head should be encouraged to participate in the development of written policies which are consonant with policies established for the operation of the hospital.
	2.4	ACCOUNTING. An audit shall be performed at least annually by a qualified auditor independent of the hospital.
Accounting procedures should be carried out in accordance with a recognized system of hospital accounting.
1.3.1 . The governing board of the hospital shall be responsible for defining and promulgating the safety limitations of the environment of various patient locations based on the medical procedures involved, the choice of electric distribution and grounding systems, and all electric appliances used in the location.  It shall also organize and conduct training programs in the safe management of patients.  The governing board shall also be responsible for establishing a testing and maintenance program to detect and correct degradation of the safety features of the selected systems and equipment used.  
4.103	Equipment and Supplies.  Reserved.  
4.104	FACILITIES.  Reserved.

5 3	MEDICAL STAFF  {Substantive changes intended}
5.101	3.1  ORGANIZATION and Staffing 
	(1)	3.1  All hospitals shall have an organized medical staff with written rules, regulations, and by-laws. The by-laws shall make provision for application, appointment, privileges, discipline, control, right of appeal, attendance at medical staff meetings, committees, and professional conduct in the hospital.
	(2)	3.2   CHIEF OF STAFF. A physician from the organized medical staff shall be appointed or elected as chief of staff.
	(3)	3.3  MEETINGS. The medical staff shall meet regularly and maintain written records of these meetings.
5.102	PROGRAMMATIC FUNCTIONS
	(1)	3.4  MEDICAL AUDIT. There shall be a medical audit committee to review systematically the work of the medical staff with respect to quality of medical care.
	3.5  TISSUE. There shall be a tissue committee (1) that may be a part of the medical audit committee to study and report to the medical staff.
(2)	Medical records shall include final diagnosis with completion of medical records within 30 days following discharge.  
3.6  MEDICAL RECORDS. There shall be a medical records committee (1) that supervises and appraises the quality of medical records: 1} The medical record shall contain sufficient information to properly identify the patient, to justify the diagnosis and treatment, and to Indicate the patient's progress. 2) Only members of the medical or house staff shall write or dictate medical histories and physical examinations; the dental staff the dental histories. 3) Each record shall be authenticated and signed by a licensed physician, those on dental treatment also signed by a licensed dentist. {Moved to Medical Records Section}
(3)	The admitting diagnosis, history, and physical examination should shall be completed within forty-eight (48) hours after the patient's admission to the hospital.
	3.7  CONSULTATIONS. Consultation with a member of the consulting or active medical staff shall be required in: 1) Major cases in which the patient is a poor risk or in which the diagnosis is obscure. The consultant shall record and sign on the medical record his findings and recommendations.
(1)	A small staff may wish to function as a committee of the whole. The structure of committee organization is a decision to be made by the medical staff so long as the required committee functions specified in 3.4, 3.5, and 3.6 are performed.
3.8	A surgeon performing major surgery shall have a competent assistant who is a licensed physician, or a competent assistant approved by the cre-dentials committee of the medical staff which shall delineate his or her privileges. If the assistant is a resident in a training program, the affiliation agreement and the hospital medical staff must delineate his or her privileges. 
(4)	6.1  CARE BY MEDICAL STAFF.  All persons admitted as patients to a hospital shall have benefit of continuing daily care of a medical staff member. Policies shall be provided for coordinating and designating responsibility when more than one member of the medical staff is treating a patient.
5.103	EQUIPMENT AND SUPPLIES.  Reserved.
5.104	FACILITIES.  Reserved.  

6 16	NURSING SERVICE DEPARTMENT {Reorganization only.  No substantive changes intended.}
6.101	ORGANIZATION AND STAFFING
(1)	16.1  ORGANIZATION.  There shall be a nursing department Department of Nursing.  The Nnursing Ddepartment shall be organized formally to provide complete, effective care to each patient.  
(2)	16.2  DIRECTOR OF NURSING SERVICES.  The nursing service department shall be under the direction of a registered nurse qualified by education and experience to direct effective nursing care.
(3)	16.3  MASTER STAFFING PLAN.  There shall be a master plan of nurse staffing for providing continuous registered nurse coverage, for distribution of nursing personnel, for replacement of nursing personnel, and for forecasting future needs.  The nursing care required by different types of patients shall be the major consideration in determining the number, quality, and category of nursing personnel that are needed in any given situation.
(4)	16.1  ORGANIZATION.  The authority and responsibility of each nurse and nursing personnel shall be defined clearly in written policies.  16.4  REGISTERED NURSE SUPERVISION.  Licensed practical nurses and auxiliary nursing personnel shall be assigned only those duties for which they are qualified and shall be under the supervision of a registered nurse.
6.102	PROGRAMMATIC FUNCTIONS
(1)	16.5  WRITTEN PROCEDURES.  There shall be written nursing procedures that establish the standards of performance for safe, effective nursing care of patients.  These procedures shall be reviewed periodically and revised as necessary.
(2)	16.5  There should be a plan for continuous evaluation of nursing care including that of private duty nurses.  The Ddepartment of Nursing should periodically evaluate the adequacy of facilities in terms of patient and nursing needs, and participate in planning facilities and services.
6.103	EQUIPMENT.  Reserved.
6.104	FACILITIES.  Reserved.

7	PERSONNEL  {Substantive changes intended}
7.101	Organization and Staffing
	(1)	5.1  OBJECTIVES.  The purposes and objectives of the hospital shall be explained to all personnel.There should  be written personnel policies , rules, and regulations that govern the conditions of employment, the management of employees, the types of functions to be performed, and the quality and quantity of hospital service to be maintained.  Following approval by the governing board, copies should be distributed to all employees.  Each hospital department or service shall have written organizational policies and procedures that identify the scope of the services to be provided, the lines of authority and accountability and the qualifications of the personnel performing the services.  Such policies and procedures shall be made available to employees.
	(2)	5.2 DEPARTMENTAL. Each department or service of the hospital shall be under the direction of a person qualified by training, experience, and ability to direct effective services the department or service.
	(3)	5.2  There should shall be sufficient qualified personnel in each department or service to properly operate the department or service.
	(4)	Facility staff shall be licensed or registered in accordance with applicable state laws and regulations. 
	(5)	5.2  All persons assigned to the direct care of or service to patients should shall be prepared through formal education and on-the-job training in the principles, the policies, the procedures, and the techniques involved so that the welfare of patients will be safeguarded.
7.102	Programmatic Functions
	5.2  There should be an education program for all hospital personnel to keep the employees abreast of changing methods and new techniques in hospital services.
	(1)	5.3  RECORDS.  There shall be personnel records on each person of the hospital staff including employment application and verification of credentials licensure, competencies and credentials for medical staff.
	(2)	 5.2  All personnel should shall have a pre-employment physical examination and such interim examinations as may be required by the hospital administration or the health service physician. The examining physician should certify that the employee, before returning from illness to duty, is free from infectious disease. Employment health policies should be arranged so personnel are free to report their illness without fear of income loss.
	(3)	5.4  LIBRARY. There shall be library services available to meet the needs of the medical staff and other professional personnel.
	(4)	Care shall be delivered in accordance with professional standards of practice.
7.103 	Equipment and Supplies.  Reserved.
7.104	Facilities.  Reserved.

8 4	MEDICAL RECORDS DEPARTMENT  {Substantive changes intended}
8.101	ORGANIZATION AND STAFFING 
	(1)	4.5  CONTENT. A complete medical record shall be maintained on every patient from the time of admission through discharge.  In addition, complete medical records shall be maintained for patients receiving emergency and outpatient services.
	(2)	4.3  PERSONNEL. A registered record administrator or other trained medical record practitioner shall be responsible for the administration and functions of the medical record department.
	(3)	4.3.1  There shall be a sufficient number of regular full-time and part-time employees so that medical record services may be provided as needed.
8.102	PROGRAMMATIC FUNCTIONS
	(1)	4.1  Medical records should shall be stored safely to provide protection from loss, damage, and unauthorized use.
	(2)	4.2  PRESERVATION. With the exception of medical records of minors (individuals under the age of 18 years) medical records shall be preserved as original records on microfilm for no less than ten years after the most recent patient care usage, after which time records may be destroyed at the discretion of the facility. Medical records shall be preserved as original records, on microfilm or electronically:
		(a)	 4.2.1  Medical records of minors shall be preserved for the period of minority plus 10 years (i.e. 28 years less age of minor at time of most recent patient care usage of the medical record).  for minors, for the period of minority plus 10 years (i.e., until the patient is age 28) or 10 years after the most recent patient usage, whichever is later. 
		(b)	for adults, for 10 years after the most recent patient care usage of the medical record.  
(3)	After the required time of record preservation, records may be destroyed at the discretion of the facility.  4.2.2  Facilities shall establish procedures for notification to patients whose records are to be destroyed prior to the destruction of such records.
(4) 	If a facility ceases operation, the facility shall make provision for secure, safe storage, and prompt retrieval of all medical records for the period specified in 8.102 (2).  The hospital shall publicize in a widely circulated newpaper(s) in the facility’s service area a notice indicating where medical records can be retrieved.  
4.2.3	The sole responsibility for the destruction of all medical records shall be in the facility involved but in no case shall records be destroyed prior to consultation with legal counsel.
4.2.4	Nothing in this section shall be construed to affect the requirements for the destruction of public records as set. out in Part 1 of Article 80 of Title 24, C.R.S. 1973.
	(5)	4.4  ENTRIES. All orders for diagnostic procedures, treatments, and medications shall be signed by the physician or other licensed practitioner as authorized by law submitting them and entered in the medical record in ink or in type. The prompt completion of a medical record shall be the responsibility of the attending physician or other practitioner authorized by law. Authentication may be by written signature, identifiable initials or computer key. The use of rubber stamp signatures is acceptable under the following strict conditions:
	(a)	1.  The physician or other practitioner authorized by law whose signature the rubber stamp represents is the only one who has possession of the stamp and is the only one who uses it; and
	(b)	2.  The physician or other practitioner authorized by law places in the administrative offices of the hospital a signed statement to the effect that he or she is the only one who has the stamp and is the only one who will use it.
	(6)	4.5  CONTENT. A complete medical record shall be maintained on every patient from the time of admission through discharge. The content of patient records shall be as follows.  
	(a)	4.5.2  MEDICAL - SURGICAL DATA:  All patient records shall include the following:  
(i)	Adequate identification - sociological data (including hospital number assigned to patient.)
(ii)	Chief complaint and present illness.
(iii)	History of disease or injury.
(iv)	Past, family, and personal history.
(v)	Physical examination reports.
Provisional diagnosis.
(vi)	Reports of any special examinations, including clinical and pathological laboratory findings, X-ray findings, etc  8.7.1  Original copies of all pathology test results must shall be posted in the patient's medical record, to include reports of tests referred to another laboratory.
(vii)	24.4  MEDICAL RECORD.  A written report of the findings and evaluation of each diagnostic imaging X-ray examination or treatment shall be signed by the physician or other practitioner authorized by law responsible for the procedure, as applicable. and shall be made a part of the patient's medical record.
(viii)	Reports of consultations by consulting physicians, when applicable.
(ix)	Treatment and progress notes signed by the attending physician or other practitioner authorized by law.
(x)	Findings of clinical or other staff involved in the care of the patient.
(xi)	Nursing notes 4.5.3	NURSING RECORDS
(xii) 19.26	MEDICATION RECORDING.  All medications administered shall be recorded on the patient's medical record and include including the name, strength, dosage, mode of administration of the medication; date, time, and signature of the person administering.
(xiii)	Signed informed consent forms
Complete surgical and dental reports, when applicable.
Condition on discharge.
Final diagnosis.
(xii)	Final diagnosis, secondary diagnosis, complications.
(xiii)	disposition of the case and instructions for follow-up care
(xiv)	Autopsy protocol, if any.
Discharge summary.
Signed permission for surgery, anesthesia, autopsy and other procedures when necessary.  
(xv)	As applicable, physical therapy/occupational therapy treatment records to include 18.2.4  Treatment records shall include a prescription and/or order for treatment signed by the physician, progress notes of the physical/occupational therapist, and results of special tests and measurements.

(b)	4.5.1	ADMISSION AND DISCHARGE RECORD: Inpatient records shall include the following:
	(i)	Date and time of admission and discharge.
Adequate identification - sociological data (including hospital number assigned to patient.)
(ii)	Admission diagnosis.
Final diagnosis, secondary diagnosis, complications.
Operative procedures.
(iii)	Discharge summary, with outcome of hospitalization.  If the patient is discharged in less than 24 hours, the discharge summary may be included in the physician’s progress notes.   Condition on discharge
Signature of attending physician.
	(c)	4.6  CONTENT, SURGICAL. Records of all patients undergoing surgery shall include , in addition to the requirements for medical records the following:
	(i)	History, physical, special examinations, and diagnosis recorded prior to operation.
(ii)Anesthesia record, including post-anesthetic condition signed by the anesthetist, anesthesiologist, or surgeon or licensed practitioner authorized by law to sign the record.
(iii)	Complete description of operative procedures and findings including the provisional diagnosis prior to the operative procedure, and post-operative diagnosis recorded and signed by the attending surgeon promptly following the operation. 
(iv)	The pathologist's report on all tissues removed at the operation.
	(d)	4.7  CONTENT, OBSTETRIC.  Records of all obstetric patients shall include , in addition to the requirements for medical records, the following:
(i)	Record of previous obstetric history and pre-natal care including blood serology, and RH factor determination.
(ii)	Admission obstetrical examination report describing conditions of mother and fetus.
(iii)	Complete description of progress of labor and delivery, including reasons for induction and operative procedures.
(iv)	Records of anesthesia, analgesia, and medications given in the course of labor and delivery.
(v)	Records of fetal heart rate and vital signs.
(vi)	Signed report of consultants when such services have been obtained.
(vii)	Names of assistants present during delivery.
(viii)	Progress notes including descriptions of involution of uterus, type of lochia, condition of breast and nipples, and report of condition of infant following delivery.
	(e)	4.8  CONTENT, NEWBORN.  Records of newborn infants shall be maintained as separate records and shall contain the following:
	(i)	Date and time of birth, birth weight and length, period of gestation, sex.
(ii)	Parents' names and addresses.
(iii)	Type of identification placed on infant in delivery room.
(iv)	Description of complications of pregnancy or delivery including premature rupture of membranes; condition at birth including color, quality of cry, method and duration of resuscitation.
(v)	Record of prophylactic instillation into each eye at delivery.
(vi)	Results of PKU tests newborn screening required by law and regulation.
(vii)	Report of initial physical examination, including any abnormalities, signed by the attending physician.
(viii)	Progress notes including temperature, weight, and feeding charts; number, consistency, and color of stools; condition of eyes and umbilical cord; condition and color of skin; and motor behavior.
(f)	4.9  HOSPITAL RECORDS.  The following hospital records shall be maintained:
	(i)	Daily census
Hospital services statistics.
(ii)	Admissions and discharges analysis record.
(iii)	Chronological Retister register of all deliveries including live and stillbirths. 
(iv)	Register of all surgeries performed (entered daily)
(v)	Diagnostic index.
(vi)	Operative Index.
(vii)	Physician index.
Number index.
(viii)	Death register.
(ix)	Patient master card file.
(x)	Register of out-patient and emergency room admissions and visits.
8.103	EQUIPMENT AND SUPPLIES
	(1)	4.1  FACILITIES. Each facility hospital shall provide medical record room or other suitable medical record facilities with adequate supplies and equipment FOR THE SAFE STORAGE AND PROMPT RETRIEVAL OF MEDICAL RECORDS.
8.104	FACILITIES
	(1)	4.1  FACILITIES. Each hospital shall provide a medical record room or other suitable medical record facilities with adequate supplies and equipment.
(2)	In the case of new hospital construction or modification of an existing hospital facility the hospital shall have a medical record department with administrative responsibility for medical records and 4.1.1 through 4.1.2 shall apply the following shall apply:
	(a)	4.1.1  Each hospital shall provide a medical record department and other medical record facilities with supplies and equipment for medical record functions and services. This department shall include:
	(i)	A.  Active Record Storage Area.
	(ii)	B.  Record Review and Dictating Room for physicians.
	(iii)	C. Work area for sorting, recording, typing, filing and other assigned medical record functions shall be separate from the record review and dictating room. Consideration should be given to isolation of noisy equipment. Accommodations should be provided for conducting medical record business with hospital paramedical personnel or public individuals for legitimate access to medical records.
	(iv)	D.  Medical record storage area within the department.
	(v)	E.  Inactive medical record storage area. (May be omitted if microfilming used.) Medical record department shall be located in an area of the hospital that is convenient to most of the professional staff.
	(b)	4.1.2  Security measures shall be maintained by mechanical means in the absence of medical record supervision, to preserve confidentiality and to provide protection from loss, damage and unauthorized use of the medical records.

6	ADMISSIONS  {Text moved to Part 5, Medical Staff and Part 19, General Patient Care Services }
9 7	ANESTHESIA Services  {Reorganization and clarification only.  No substantive changes intended.  Substantive deletions reflect changes to Life Safety Code requirements expected to be promulgated at the June 20, 2007 Board of Health Hearing.} 
9.101	ORGANIZATION AND STAFFING
(1)	The hospital shall provide anesthesia services commensurate with the services provided by the hospital.
(2)	7.4  STAFFING.  (1)  ADMINISTRATION.  General or regional anesthesia or analgesia shall be administered only by a physician qualified by training, experience, and ability in anesthesiology; or a registered nurse anesthetist graduated from a certified school. In case of dental treatment, dentists may administer local anesthetics.
9.102	PROGRAMMATIC FUNCTIONS
(3)	7.4  STAFFING. (2)  NURSING.  Patients recovering from anesthesia shall remain under continuous care of a registered nurse. Nurses shall have been instructed in the care of post-anesthetic patients, shall have no other duties during the time they are caring for such patients. and shall have facilities for immediate communication with the attending surgeon, anesthesiologist, or qualified substitute present in the hospital.
9.103	EQUIPMENT 
(1)	7.1  REQUIREMENT.  There shall be facilities and equipment for the administration of anesthesia that are is commensurate with the clinical procedures and programs conducted within the hospital.
7.5	EQUIPMENT 1)  ANESTHESIA MACHINES. Persons administering anesthesia shall insure that anesthetic gas cylinders are installed properly on machines that are pin-indexed.
(2)	7.5  EQUIPMENT (2)  STERILIZATION.  Anesthesia equipment shall be cleaned properly and sterilized after each use excepting multi-use heat sensitive equipment may be disinfected using a process that is bactericidal, tuberculocidal and virucidal. Hypodermic needles, syringes, and allied equipment shall be sterilized, unless disposed of after use. Written procedures shall be developed for these processes.
9.104	FACILITIES
	(1)	7.1  REQUIREMENT.  There shall be facilities and equipment for the administration of anesthesia that are commensurate with the clinical procedures and programs conducted within the hospital.
7.4  STAFFING. (2)  NURSING.  Areas used to care for post-anesthetic patients Nurses shall have been instructed in the care of post-anesthetic patients, shall have no other duties during the time for caring for such patients and shall have facilities for immediate communication with the attending surgeon, anesthesiologist, or qualified substitute present in the hospital.
7.2	SAFETY.
The design, equipment and storage for anesthetics shall be in accord with or equal to the Standards specified in National Fire Protection Association 99, Standard for Health Care Facilities, 1999 Edition, Chapter 12. The hospital shall recognize the dangers of ignition of anesthetic gases to patients and shall make provisions to minimize this hazard in accordance with such standards. Emergency rooms and operating areas that ordinarily administer such anesthetics may be exempt from this requirement provided that a written resolution is signed by the hospital board that no flammable anesthetic agents will be used in these areas and that appropriate notices are permanently and conspicuously affixed to the wall in each area and room.
7.3	STORAGE.
(1)	An anesthesia storage room shall be provided for the storage of combustible anesthetic agents. Gravity or mechanical ventilation shall be provided to the outside with intake and discharge ducts. In case of new hospital construction, or modification of an existing hospital facility, if flammable anesthetic agents are used, an anesthetic. A storage room must be provided for the storage of combustible anesthetic agents in accordance with National Fire Protection Association 99, Standard for Health Care Facilities, Chapters 4 And 5,1999 Edition.
(2)	Two physically separated storage facilities shall be furnished, one for flammable anesthetic agents and volatile liquids, if used, and the other for gases which support combustion, namely nitrous oxide and oxygen. Cylinders shall be adequately secured.

10 8	LABORATORY SERVICES {Substantive changes intended}
10.100	CLINICAL PATHOLOGY
10.200	BLOOD BANKING
10.100	CLINICAL PATHOLOGY 
10.101	ORGANIZATION AND STAFFING
	(1)	8.2  SERVICES  8.2.1  Clinical pathology services shall be made available as required by the needs of the medical staff.  8.2.2  Emergency laboratory services shall be made available whenever needed.
(2)	8.3  PERSONNEL 8.3.1  PATHOLOGIST. The laboratory shall be under the supervision of a physician, certified in clinical pathology, either on a full-time, part-time, or consulting basis. The pathologist shall provide, at a minimum, monthly consultative visits. The pathologist shall coordinate with the administrator in the hiring of laboratory personnel to help ensure all technologists are adequately qualified to carry out the duties required of them.
(3)	8.3.2  TECHNOLOGISTS. There must shall be a sufficient number of clinical laboratory technologists, qualified by training and experience, to promptly and proficiently perform the laboratory tests and examinations required of them.
10.102	PROGRAMMATIC FUNCTIONS
(1)	8.7.3  All laboratory work clinical pathology services must shall be ordered by a physician or a person authorized by law to use the results of such findings.
(2)	Clinical pathology services shall comply with the requirements set forth in the Clinical Laboratory Improvement Amendments (CLIA).
(3)	8.6  POLICIES AND PROCEDURES.8.6.1  Policies and procedures.
(a)	A manual outlining all procedures performed in the laboratory must shall be complete and readily available for reference.
(b)	8.6.2  The conditions and procedures for referring specimens to another laboratory be in writing and available in the laboratory.
(c)	8.9.6  Procedures for the adequate precautions for discarding specimens shall be in use -- sterilization, incineration, or both.
(4)	Records
(a)	8.7  RECORDS A record system must shall be established which ensures that specimens are adequately identified, properly processed, and permanently recorded.
(b)	8.7.2  Duplicate copies of all reports must shall be kept in the laboratory in a manner which permits ready identification and accessibility, for at least four years plus the current fiscal year. {CLIA has section on records retention – retention for most records is 2 years (42 CFR 495.1105.}
8.4	QUALITY CONTROL.
8.4.1	INTERNAL QUALITY CONTROL.
(a)	There must be an adequate quality control program in effect including the use, where applicable, of reference or control sera and other biological samples, concurrent calibrating standards, and records of all standard and control readings.
(b)	All reagents, chemicals, and microbiological culture media must be adequately labeled, to include the date received, opened, and/or prepared. Outdated supplies must be promptly discarded.  
8.4.2	EXTERNAL QUALITY CONTROL.
(a)	To the extent that the State Health Department provides proficiency testing services in one or more of the laboratory specialties, the laboratory should participate in the program in all specialties in which it performs tests: However, if the laboratory elects not to participate in the state-operated proficiency testing program, it must participate in another similar program which has been approved by the State Health Department.
(b)	Tests may not be performed in those specialties in which the laboratory fails to achieve a satisfactory performance in the state-operated or state-approved proficiency testing program. {CLIA addresses QA extensively in Subpart K – 42 CFR 493.12000 and requires pre-analytic (e.g. patient prep), analytic (e.g., calibration) and post analytic (data)}
10.103	EQUIPMENT AND SUPPLIES
(1)	8.5  EQUIPMENT. All equipment must shall be in good working order, be routinely checked and be precise in terms of calibration.
(2)	8.9.4  If tests are performed in the specialties of mycobacteriology, mycology, and/or virology, the laboratory must shall be equipped with a microbiological safety cabinet, with an adequately filtered exhaust system.
(3)	8.9.5  Vaccuum breakers must be present on sinks where specimens are handled or discarded to ensure that the water supply is not contaminated.
8.5.1	A schedule of preventive maintenance must shall be set up for all equipment.
8.5.2	A record of all preventive maintenance, repair, and calibration must be kept on each item of equipment.
8.5.3	Temperature-control equipment must be monitored daily and recorded. 
{CLIA has section on adequate equipment 42 CFR 493.1101 and on maintenance 42 CFR 493.1254 – but does not address vacuum breakers, microbiological safety cabinets}
10.104	FACILITIES.  Reserved.
8.1	SPACE  8.1.1	The hospital shall provide within the hospital adequate space for a laboratory.
8.1.2	Workbench space shall be ample, well-lighted, and convenient to sink, water, gas, suction, and electrical outlets as necessary.
8.1.3	There shall be adequate storage space for supplies.  {CLIA requires adequate space, ventilation under 42 CFR 493.1101.}
10.200	8.8 BLOOD BANKING
{Although CLIA address blood transfusion, the provisions there are not extensive.}
10.201	ORGANIZATION AND STAFFING
(1)	8.8.1  The hospital shall provide for the procurement, storage, and transfusion of blood as needed for routine and emergency cases.
10.202	PROGRAMMATIC FUNCTIONS
(1)	8.8.2  Standards of the Joint Blood Council and the American Association of Blood Banks must shall be used; or the administrative staff of the hospital must substitute, in writing, alternate standards which are safe and adequate for the collection and administration of blood and blood products.
(2)	Blood and blood products shall only be administered upon order of a physician or other practitioner authorized by law.
(3)	819.29  BLOOD TRANSFUSION.  Before administering a blood transfusion the following shall be identified accurately and verified by two persons registered nurses: 1) Patient; 2) Patient's blood specimen; 3) Type, crossmatch, and expiration date of donor blood; 4) Pilot tube and equipment used in the typing and crossmatching.
(4)	.8.5  Records must be kept which show the complete receipt and disposition of blood.
(5)	8.8.6  Each unit of blood typed and crossmatched for transfusion must be adequately identified by an attached tag which cannot be removed from the unit accidentally.
10.203	EQUIPMENT AND SUPPLIES
(1)	8.8.3  Equipment and facilities must shall be available which ensures safe storage and transfusion of blood.
(2)	8.8.4  Units of blood stored overnight must be held in a refrigerator which has Refrigerators used to store blood overnight shall have a recording thermometer and an adequate alarm system. The refrigerator must shall be on the emergency power source.
10.204	FACILITIES
(1)	8.8.3  Equipment and facilities must Facilities shall be available which ensures to ensure safe storage and transfusion of blood.
8.9	FIRE AND SAFETY. There must be established practices and procedures which will ensure that the patients and employees are protected from unnecessary physical, chemical, and biological hazards.
8.9.1	There shall be a fire escape plan posted in the laboratory in plain view of all occupants.
8.9.2	All flammable chemicals and solvents must be stored in areas specially designed for that purpose.
8.9.3	Fume hoods must be available where needed.

11  9	DELIVERY SUITE OBSTETRICS DEPARTMENT (Substantive changes intended)
9	DELIVERY SUITE LABOR AND DELIVERY 
11  17	OBSTETRIC (MATERNITY) PATIENT CARE
11.100	Labor and Delivery
11.200	Nurseries
11.100	Labor and Delivery
17.2.1  The administrative and medical procedures entailed in the management of such a unit shall be contained in the Rules and Regulations that accompany the By-Laws of the medical staff of the hospital.
17.2.2  Strict segregation of the nursery, labor, and delivery suites shall be maintained. Exception: See 9.3.1. Nothing herein shall preclude Rooming-in as defined in 15.18.
17.2.3  Room segregation is essential and shall be adhered to. Within the patient care unit, in so far as possible, it is preferable that the clean gynecological-surgical patients be segregated in a separate wing or at one end of a corridor, with the obstetric facility in the opposite wing or end of corridor.
17.2.4  Separate nursing service is desirable. If this cannot be maintained, rigid supervision of individual nurse activities is imperative.
17.2.5  Control of admissions to and transfers from this combined unit must be absolute and rigid, and constantly supervised, preferably by the chief of obstetrics or a special committee, as the case may be. The person or persons assigned this authority are responsible to the chief of staff and the authority of the hospital. It is necessary for this assigned person or his deputy to have a daily conference with the obstetric nursing supervisor. They shall be available at all times for decisions relative to problems of admission and discharge which will invariably develop.
17.2.6  The infants shall be safeguarded from exposure. The limitation of the number of visitors and the specific visiting hours usually prescribed for obstetric patients shall continue in force for all patients in the combined unit.
17.2.7  A list of suitable or acceptable cases for admission to a combined unit is the responsibility of the medical staff and hospital authorities. The admissions to the combined unit shall be adult women and the cases shall be “clean.” If an infection is found during surgery the patient shall not be returned to the obstetric unit.
11.101	ORGANIZATION AND STAFFING
(1)	The facility shall provide labor and delivery services.  The following requirements are in addition to those specified in Section 19, Patient Care Unit Part 19, General Patient Care Services.
(2)	9.10  NURSING.  The nursing service of the delivery suite shall be under the supervision of a registered nurse qualified by training and experience to direct obstetric nursing.
11.102	PROGRAMMATIC FUNCTIONS
(1)	Nursing
(a)	9.10  NURSING.  A registered nurse qualified by training and experience in delivery room nursing shall be present as a circulating nurse during each delivery. Additional registered and licensed practical nurses, or auxiliary nursing personnel shall be available as necessary. 
(b)	9.10  NURSING.  Patients shall be provided with continuous direct care by a registered nurse, either in the delivery room or in an obstetric recovery room, until vital signs are established, shock and hemorrhage are not evidenced, and the patient is awake.
(2)	9.6  OXYTOCIC DRUGS.  Policies for the administration of oxytocic drugs, analgesics, and anesthetics shall be written.
(3)	Security measures shall be instituted to safeguard against unauthorized entry and to protect the safety of newborns.  
(4)	Newborn Care
(a)	9.7  INFANT IDENTIFICATION. Identification shall be placed securely on each infant before removal from the delivery room.
(b)	9.8  INFANT PROPHYLAXIS.  Prophylaxis shall be administered to the eyes of all newborn infants.
(c)	9.9  PKU TESTING.  Blood specimens shall be taken from each newborn and submitted to an appropriate laboratory for PKU testing.  Newborn screening shall be conducted in accordance with 5 CCR 1005-4 Newborn Screening and Second Newborn Screening.
9.10  NURSING.  A record book should be maintained with chronological entries of all deliveries. {Concept moved to Medical Records}
(5)	9.11  RECOVERY ROOM. If an obstetric recovery room is provided, it shall be restricted to use for obstetric patients only.
11.103	EQUIPMENT AND SUPPLIES
(1)	9.5  EQUIPMENT.  Each delivery room shall be equipped with the following:  1) Incubator approved by the Underwriters Laboratories; 2) Suction and resuscitation equipment for adults and infants; 3) Anesthesia machines and supplies for inhalation, spinal, and saddle-block ansthesia anesthesia; 4) Instruments and supplies for management of normal delivery, obstetric emergencies; 5) Emergency drugs, solutions, and supplies; 6) Infant identification.
11.104	FACILITIES
(1)	17.1  FACILITIES. The obstetric (maternity) patient care unit in the hospital should be isolated from other patient care units, both architecturally and nursing-wise.  However, if necessary, under specific controls, the presence of clean gynecological and surgical cases may be admitted on the obstetric patient care unit.
(2)	9.1 LOCATION.  The delivery suite and labor room(s) shall be located so as to minimize traffic to patients, visitors, and personnel from other areas of the hospital.
(3)	9.2  LABOR ROOM(S).  The design of and equipment in labor room(s) shall meet the requirements for a private bedroom specified in Section 19, Part 19, General Patient Care Services except that windows need not be provided if mechanical ventilation is installed.
(4)	9.3  NUMBER OF DELIVERY ROOMS.  The delivery suite shall be provided with at least one delivery room should be equipped for major obstetrical operative procedures, including caesarian section. In case of new hospital construction, or modification of an existing hospital facility the following shall apply:
(a)	9.3.1  In hospitals of 30 beds or less, one operating suite may be used for surgical or delivery procedures, providing there is a labor room equipped for emergency delivery adjacent and accessible to the suite and with a minimum area of 180 sq. ft., no dimension to be less than 12'0" except ceiling height. If explosive anesthesia is to be used in the emergency delivery room, the room must meet the requirements in the “Standard For the Use Of Inhalation Anesthetics” National Fire Protection Bulletin NO. 56A, 1972. Ventilation of the emergency delivery room must be either a separate system from that in the operating suite, allowing recirculation in each area, or if connected to the same system as the operating Suite, the system must provide 100% exhaust with no recirculation.
(b)	9.3.1  Sub-sterilizing room adjacent; to delivery room(s) will not be required unless major gynecological surgical procedures are performed in the delivery room.
(5)	9.4  DESIGN. The requirements specified in Part 23, Surgical and Recovery Services, Section 23.104, with the exception of the requirements for the operating room Section 23, 23.1 through 23.33 excluding 23.13, shall be met.
(6)	9.4  DESIGN.In hospitals under 50 beds, separate nurses and doctors locker rooms with toilets and showers for each suite are desirable but not mandatory.
11.200	15NURSERY(IES) SERVICES  {Substantive changes intended}
11.201	ORGANIZATION AND STAFFING
(1)	The hospital shall provide nursery services.  The following requirements are in addition to those specified in Section 19, Patient Care Unit Part 19, General Patient Care Services.  
(2)	15.11  POLICIES.  Written policies and procedures shall be established for nursery personnel.  A qualified physician shall be designated as Chief of the Nursery Service.  Nursery services shall be under the supervision of a qualified physician.  
(3)	15.14NURSING. A registered nurse shall supervise at all times the nursing care of newborn infants. At no time shall an infant be left unattended in the nursery.  Nursing personnel assigned to the care of newborn infants should not care for other patients.
11.202	PROGRAMMATIC FUNCTIONS
15.0  Standards and recommendations for Hospital Care of Newborn Infants, Committee on Fetus and Newborn, American Academy of Pediatrics, 5th Edition, should be used for guidelines.
15.2	NUMBER OF INFANTS. - Deleted
(1)	15.11  POLICIES.  Written policies and procedures shall be established for nursery personnel. A qualified physician shall be designated as Chief of the Nursery Service.
15.12  CONTROL AND CLOTHING.  Only authorized individual shall be permitted in the nursery. Nursing personnel, assigned to the nursery(ies), shall wear short sleeve gowns to permit washing to elbows. Physicians shall wear gowns when examining babies.
(2)	15.13  HANDWASHING.  Personnel shall wash their hands before and after handling each infant.
(3)	Security measures shall be instituted to safeguard against unauthorized entry and to protect the safety of newborns.  
15.15	INFANT CARE. - Deleted
(1)	15.16  INFANT FEEDING. Infants shall be held for feedings. Propping bottles is prohibited.
(2)	15.17  INFANT TRANSFER TO MOTHER. A common conveyor shall not be used to transport infants to mothers.
(3)	15.19  INFANT EXAMINATION. Each infant shall be examined upon admission to the nursery and daily until discharge.
(4)	15.20  ROOMING-IN.  Special features of rooming-in are that it 1) provides the mother and infant with a natural mother-child experience while under the care of maternity personnel; 2) fosters infant feeding on a permissive plan; 3) facilitates instruction of mothers and fathers in infant care; and 4) reduces the incidence of cross infection among infants.  Rooming in is not a method of saving nursing time or decreasing nursing personnel needed. Nursing personnel should be adequately prepared to teach mothers to understand and care for their babies. Details may be obtained by referring to Standards and Recommendations for Hospital Care of Newborn Infants.
(5)	15.18  ISOLATION.  Isolation of infectious disease cases shall be conducted in accordance with written neonatal standards of practice.  must be accomplished by one of the following: 1) Removing patient to a forced draft reverse isolation incubator in either (a) an intensive care nursery or (b) another nursing care area of the same hospital; or 2) Placing the patient in a constantly staffed isolation room not shared with the nursery and with separate scrub facilities; or 3) Removing patient to an intensive care referral center.  17.3  ISOLATION. If an infant is isolated with his mother, both shall be isolated in a private room.

11.203	EQUIPMENT AND SUPPLIES
(3)	15.9  EQUIPMENT. The following equipment shall be provided in each nursery: 1) Easily cleaned bassinet for each infant, with storage space for the individual infant supplies in a compartment in bassinet or on individual table; 2) Incubator or warmer; 3) Infant emergency equipment and supplies essential to resuscitation; 4) Lavatory with mixing faucet, knee, foot or automatically operated, soap and sanitary hand-drying accommodations; 4) 5) Diaper, soiled “linen, and waste receptacles with foot controls and disposable impervious liners, 6) Soiled linen waste receptacles with foot controls and disposable impervious liners,  6) 7) Accurate easily cleaned scales; 7) Piped oxygen with outlets, one for every four bassinets; 8) 9) In the case of new hospital construction, or modification of an existing hospital facility a nurse call shall be provided.
11.204	FACILITIES
(1)	LOCATION. The nursery should be located in the maternity patient care unit as close to the mothers as possible and away from the line of traffic of others than maternity services. The nursery(ies) shall be separated physically and functionally from other hospital services.
(2)	SIZE. A minimum of twenty-four (24) square feet per infant shall be provided within the nursery. Thirty square feet are recommended.
(3)	CONTROL AREA.  A control area shall be provided to serve as a work space and nursery entry for security.
(4)	OBSERVATION WINDOWS.  A fixed view window shall be provided between nursery(ies) and control area or between two nursery(ies). Fixed view windows between the nurseries and corridor shall be wire glass set in steel frames. In the case of new hospital construction or modification of an existing hospital facility, the view windows shall be 1/4 inch thick welded wire glass set in steel frames. Curtains or drapes when used in nurseries shall be laundered frequently and maintained flame-retardant.
(5)	ELECTRICAL.  All electrical outlets must have a common ground. One electrical outlet shall be provided for every two bassinets. Some of the outlets shall be connected to an emergency source of power. In the case of new hospital construction, or modification of an existing hospital facility fifty (50) percent of the outlets shall be connected to an emergency source of power. The use of adapters, extension cords, and junction boxes should be discouraged.
(6)	15.6.1  LIGHTING.  The nursery(ies) shall be well lighted to permit optimal observation and for easy detection of jaundice or cyanosis. In the case of new hospital construction, or modification of an existing hospital facility, shadow-free illumination with at least 100 ft. candle intensity at the infants' level is required and is best provided by fluorescent lamps. A suggested fluorescent tube for illuminations is General Electric's fluorescent tubes F-40-CWX(deluxe cool white) or equal. Light fixtures should be provided with lenses to reduce glare. The number and exact location of fixtures cannot be recommended because ceiling height and windows influence the intensity of the illumination. Spot illumination can be provided by a portable lamp containing two 15 watt fluorescent bulbs which, when held 12” from the infant, will produce about 100 ft. candle intensity of light.
(7)	15.7  INTERIOR FINISHES.  Wall surfaces shall be washable and non-glare. Acoustical ceiling tile is permissible if it is incombustible and washable.
(8)	15.8  VENTILATION.  A minimum ventilation rate of 12 room volumes of out-door air per hour with no recirculation shall be provided by mechanical supply and exhaust air systems. Filters with a minimum efficiency of 90-99 percent in the retention of particles shall be provided. Positive air pressure relative to the air pressure of adjoining areas should be maintained. A temperature of 75-82° F. and a relative humidity of less than 50% is recommended. In the case of new hospital construction, or modification of an existing hospital facility, access openings in ducts for cleaning purposes shall be provided.
(9)	15.18  ISOLATION.  Facilities shall be available for the immediate isolation of all newborn infants who have or are suspected of having an infectious disease (e.g., infants whose possible infection constitutes a risk or danger to other newborns, including those born outside the delivery suite.)  
(10)	15.9  EQUIPMENT. The following equipment shall be provided in each nursery: 1) Easily cleaned bassinet for each infant, with storage space for the individual infant supplies in a compartment in bassinet or on individual table; 2) Incubator or warmer; 3) Infant emergency equipment and supplies essential to resuscitation; 4 1) Lavatory with mixing faucet, knee, foot or automatically operated, soap and sanitary hand-drying accommodations; 5) Diaper, soiled “linen, and waste receptacles with foot controls and disposable impervious liners, 6) Accurate easily cleaned scales; 7 2) Piped oxygen with outlets, one for every four bassinets; 8  3) In the case of new hospital construction, or modification of an existing hospital facility a nurse call shall be provided.
15.10	OBSERVATION UNIT-Deleted
15.21	FORMULA PREPARATION. Individually packed sterile formula should be used because of safety, quality control and shelf life. Water containing bottle warmers shall not be used. If formulas are prepared in the hospital, the following requirements shall be met:
15.21.1	SUPERVISION. Formula preparation shall be under the supervision of a registered nurse or dietitian.
15.21.2	ROOM. All formulas shall be prepared in a room designated exclusively for that purpose. Preparation of formulas shall be separated physically and functionally from the cleaning of equipment.
15.21.3	HANDWASHING FACILITIES. The formula room shall be equipped with a lavatory with mixing faucet and blade controls, soap, and sanitary hand-drying accommodations.
15.21.4	STORAGE. Cans of milk or commercial formula shall be removed from the shipping cartons before they are brought into the formula room. Individually packaged sterile formula from an outside source, ready for use, may be stored in any clean area of the nursery. All materials used in the formula preparation area shall be stored in the original containers clearly labeled. Only materials used in the preparation of formulas shall be stored in the preparation area of the formula room.
15.21.5	CONTROL. Only personnel directly associated with formula preparation or environmental cleaning and safety shall be permitted in the formula room. Any person entering the formula preparation room shall be free from infectious diseases.
15.21.6	CLOTHING. Each person preparing formulas shall wear a clean scrub dress.
15.21.7	HANDWASHING. Formula room personnel shall thoroughly wash hands and arms before preparing formulas.
15.21.8	PHYSICIAN ORDERS. There shall be a physician's written order for the formula to be prepared for each infant.
15.21.9	PREPARATION. During the preparation of formulas, doors and windows of the room shall be kept closed, and no one shall be permitted in the room except those involved in this duty.
15.21.10	STERILIZATION. After nippling and capping each individual bottle, the assembled units shall be subjected to a terminal heating process under pressurized steam at 230 degrees F for 10 minutes. Techniques of formula preparation should be checked by frequent bacteriologic examination.
15.21.11	LABELS. Each prepared formula bottle shall be labeled with the name of the infant and identity of formula.
15.21.12	REFRIGERATION. A refrigerator equipped with a thermometer shall be provided for the exclusive storage of formulas.
15.21.13	TRANSPORT. Bottles of formula, water, and water solution shall be covered completely when being transported through a corridor or on an elevator.
15.21.14	ISOLATION. Used bottles and nipples from pediatic or isolatic nurseries shall be washed in the nursery workroom before being returned in impervious containers to the soiled area of the formula room.
12	DIETARY SERVICES {Reorganization and clarification only.  No substantive changes intended.  Some deletions reflect changes to Life Safety Code requirements scheduled to be promulgated at the June 20, 2007 Board of Health Hearing.}
12.101	ORGANIZATION AND STAFFING
(1)	10.1  ORGANIZATION. There shall be an organized food service planned, equipped, and staffed to serve adequate meals to patients according to physicians' orders.
(2)	10.2  PERSONNEL. A dietitian or person qualified by training and experience in food service shall direct the dietary services.
12.102	PROGRAMMATIC FUNCTIONS
(1)	10.3  POLICIES. Policies and procedures for dietary practices shall be written.
(2)	10.4 ORDERS. Therapeutic Diets
(a)	All diets and nourishments shall be served as prescribed by the attending physician.
(b)	10.5  DIET MANUAL. A diet manual shall be available to medical staff and personnel for fulfilling dietary prescriptions.
(3)	10.6  MENUS.  Menus
(a)	Menus as served shall be planned at least one week in advance shall be varied to meet patient needs. Personal tastes, desires, and cultural patterns of patients shall be considered and reasonable menu adjustments made.
(b)	The menus should be posted in the kitchen area, and after use should be filed for at least four weeks. Menus should meet the requirements of the Recommended Dietary Allowances for Food and Nutrition Board,National Research Council, 1968. Rotating menus are recommended.
10.8 CODES. Food service design, equipment, and practices shall be in accordance with the Rules and Regulations Governing the Maintenance and Operation of Restaurants in the State of Colorado. Colorado Department of Health. May 1964.
(4)	10.9  FOOD SERVICES. All food served shall be from approved sources and shall meet the standards of quality as established by applicable laws and regulations. Food prepared outside the hospital shall be from sources that comply with applicable laws and regulations.
(5)	Personal Hygiene
(a)	10.18  HANDWASHING. Employees shall wash their hands thoroughly in an approved hand washing facility before starting work and as often as may be necessary to remove soil and contamination. Each employee shall wash his hands before resuming work after visiting the toilet room.
(b)	10.19  HEAD PROTECTION. All dietary employees shall wear hair nets, head-bands, caps, or other effective hair restraints.
(c)	10.20	TOBACCO. Employees shall not use tobacco in any form while engaged in food preparation, service, or equipment washing areas.
(6)	Food Storage and Handling
(a)	10.17  DISPLAYED FOOD. Unwrapped food on display for service shall be protected against contamination by counter-protector devices. Food being conveyed should be covered, completely wrapped or packaged to protect from contamination.
(b)	10.14  PERISHABLE FOODS. Potentially perishable foods shall be maintained at a temperature of 45° F. or below, or 140° F. or above. Other foods should be stored at approximately 50° F.
(c)	10.16  UTENSILS. Convenient and suitable utensils, including self-service, such as forks, knives, tongs, and spoons shall be used to handle food at all points where food is prepared and served.
(7)	10.15  TOXIC MATERIALS. Poisonous and toxic materials shall be labeled, stored separately from food, and used only in such ways that they will neither contaminate food nor be hazardous to employees.
(8)	Storage and Handling of Utensils
(a)	10.26  CUPS AND GLASSES. Clean cups and glasses shall be handled so that fingers do not contact inside or lip-contact surfaces.
(b)	10.27  DISINFECTION.  Portable equipment and utensils shall be cleaned, disinfected, and stored above the floor in a clean, dry location.  Utensils shall be air-dried before storing. Stored containers and utensils shall be covered or inverted.
(c)	10.28  SERVING UTENSILS. Disposable serving utensils shall be stored, handled, and dispensed to prevent contamination; and shall be used only once.
(9)	10.29  ISOLATION. Food served to patients in isolation, because of infectious diseases, shall be in disposable utensils or in utensils that shall be sterilized.
(10)	Ware Washing and Storage
(a)	10.30  MECHANICAL WASHING. If washable dishes are used, commercial-type mechanical dishwashing equipment shall be provided equipped with an easily readable thermometer in each tank. In case of new hospital construction, or modification of an existing hospital facility this equipment shall be physically separated from food preparation and service areas. Equipment and utensils shall be pref ushed or prescraped and, when necessary, presoaked to remove soil. A suitable detergent in effective concentration shall be used. Wash water shall be kept reasonably clean, and washing cycle properly timed. The wash water temperature shall be compatible with the detergent used. The final rinse water shall be unused water at temperature not less than 180° F. manifold temperature, 170° F. on the surface of the dishes. Rinsing cycles shall be timed accurately. In case of new hospital construction, or modification of an existing hospital facility, the dishwash room must be arranged such that clean dishes are discharged from the dish machine onto a clean dish table outside of the dishwash room. Only air drying shall be employed after washing and rinsing. All dishes and utensils shall be stored in clean, dry areas free of contamination.
(b)	10.31  MANUAL WASHING. Utility ware, pots, pans, and similar utensils shall be cleaned in an area separated from the dishwashing operation. 
(c)	10.32  DRAINBOARDS. Separate drainboards shall be used for soiled utensils prior to washing and for clean utensils following disinfecting.
(11)	10.37  WASTE. Garbage and refuse shall be placed in impervious containers equipped with tightly fitting covers. Containers shall be stored in a safe area or refrigerated space pending removal and shall be removed from the premises and cleaned at frequent intervals.
(12)	10.39  INFESTATION. Storage rooms, loading docks, and premises shall be free from rodent and insect infestation, odors, dust, and other sources of contamination.
12.103	EQUIPMENT AND SUPPLIES
(1)	10.12  REFRIGERATION. A minimum of two units of refrigeration shall be provided to protect foods kept on hand. Refrigerators and storerooms used for perishable foods shall be equipped with reliable thermometers.
(2)	10.13  REFRIGERATOR SAFETY. Walk-in refrigerators and freezers shall have inside lighting and inside lock releases, or an audiovisual signal system as a suitable safety device.
(3)	10.21  EQUIPMENT. Adequate equipment shall be provided for efficient preparation of meals.  Equipment and utensils should be resistant to denting, pitting, chipping, and excessive wear; should withstand repeated scrubbing, scouring, and corrosive action of cleaning and disinfecting agents; and should be in good repair.
(4)	10.22  EQUIPMENT QUALITY. Food-contact surfaces of equipment and utensils shall be smooth; free from breaks, open seams, cracks, chips, and similar imperfections; and free of difficult-to-clean internal corners and crevices.
(5)	Cutting blocks, boards, and table tops should be of hard material which is non-toxic; smooth; and free of cracks, crevices, and open seams.
(6)	10.23  COUNTER EQUIPMENT. Equipment on tables or counters, unless readily movable, shall be installed so as to facilitate cleaning and safety.
(7)	10.24  FLOOR-MOUNTED EQUIPMENT. Floor-mounted equipment, unless readily movable shall be sealed to the floor to prevent liquids or debris from settling under the equipment. Lubricated bearings and gears shall be constructed so that lubricants cannot get into the food.
(8)	10.38  WASTE GRINDERS. Food waste grinders shall be installed in compliance with applicable laws and regulations.
12.104	FACILITIES
(1)	10.7  SPACE. Adequate space shall be provided to allow for fixed and movable equipment and employee functions for receiving and storage, refrigeration, food preparation, and dishwashing and scullery.
(2)	10.10  STOREROOMS. Clean, well ventilated food storerooms shall be provided. Food when being stored, prepared, displayed, served, or sold shall be protected from contamination.
(3)	10.11  STORAGE. Containers of food shall be stored above the floor on clean racks, dollies, or other clean surfaces to protect them from contamination.
(4)	10.25  SILVERWARE.  Facilities and systems for storage of silverware shall be designed and maintained to prevent contamination.
(5)	10.33  LIGHTING. Areas for preparing food, and storing and cleaning utensils shall be adequately lighted.
(6)	10.34  VENTILATION. Rooms for preparing and serving food and washing utensils shall be well ventilated. Ventilation hood, ducts, and devices shall be designed to comply with, or equal to National Fire Protection Association Bulletin No. 96, 1964. In the case of new hospital construction, or modification of an existing hospital facility, National Fire Protection Association Bulletin No. 96, 1971 shall apply. Filters shall be readily removable for cleaning or replacement.
(7)	10.35  TOILET FACILITIES. Adequate, clean toilet facilities shall be provided.
(8)	10.36  HANDWASHING FACILITIES. Approved handwashing facilities with soap and sanitary hand-drying accommodations shall be conveniently provided. In the case of new hospital construction, or modification of an existing hospital facility, this must be provided within the kitchen area.
(9)	10.31  MANUAL WASHING.  In case of new hospital construction, or modification of an existing hospital facility, this area the area for the manual washing of utility ware, pots, pans and similar utensils must be physically separated from the dishwashing operation. Separate two-compartment sinks are required for manual washing operations, and they shall be of such length, width, and depth to permit complete immersion of equipment and utensils. In the case of new hospital construction, or modification of an existing hospital facility, each compartment shall be supplied with hot and cold water under pressure through a mixing faucet.
(10)	In the case of new hospital construction, or modification of an existing hospital facility, the following shall apply:
(c)	10.40  CART WASHING. Cart washing space must be provided, preferably in the dishwashing area. Hot water and a floor drain must be provided in this area.
(d)	10.41  A LOUNGE, complete with lockers and toilet facilities for the dietary staff must shall be provided near the kitchen.
(e)	10.42	DINING AREA(s) must be provided for staff, visitors and patients.

13  11	EMERGENCY AND OUTPATIENT SERVICES (Reorganization only.  No substantive changes intended.)
13.101	ORGANIZATION AND STAFFING
(1)	11.1  EMERGENCY UNIT.  Each general hospital shall be organized and equipped to provide emergency treatment at any hour to persons presenting or presented for this purpose. Such treatment shall be rendered in an area specifically designated for this service, and hereafter referred to as the “emergency unit department”.
(2)	11.1.1  EMERGENCY CARE PLAN. Each hospital shall have a well defined plan for the provision of emergency care. This must shall relate to community need and the capability of the hospital. If the hospital elects to transfer patients, the referring hospital must shall institute essential life saving measures and provide emergency procedures.
(3)	11.1.3  ORGANIZATION. The emergency unit department shall be organized formally as a department or service of the organized medical staff.
(4)	11.1.5  MEDICAL STAFF. Provision shall be made for medical staff coverage at any hour.
(5)	11.1.6	NURSING. A registered nurse qualified by training and experience in emergency procedures shall be available at all times to supervise nursing care in the emergency unit. Nursing staff shall be available to cover average utilization. Provision shall be made for additional nursing personnel during unusual circumstances.
13.102	PROGRAMMATIC FUNCTIONS
(1)	11.1.4	POLICIES. Emergency patient care shall be guided by written policies, and shall be supported by appropriate procedure manuals and reference material.
(2)	11.1.7	DISCHARGES. Each patient shall be discharged from the emergency unit department only upon a physicians physician’s recorded authorization including instructions given to the patient for follow-up care.
11.1.8	MEDICAL RECORDS. Medical records shall be maintained on all patients presented or presenting themselves for treatment. The emergency room record shall contain:
1.	Patient identification
2.	History of disease or injury
3.	Physical findings
4.	Laboratory and X-Ray reports, if any
5.	Diagnosis
6.	Record of treatment
7.	Disposition of the case, including instructions given to the patient for follow-up care.
8.	Signature of a physician.
Medical records for patients treated in the emergency services shall be organized by a medical record administrator. Where appropriate, medical records of emergency services shall be integrated with those of the inpatient and outpatient services. A proper method of filing records shall be maintained. At a minimum, emergency service medical records are kept for as long a time as required in the state's statute of limitations.  {Addressed in Medical Records section}
(3)	11.1.10  POISON CONTROL. A poison control chart and the location and telephone number of the nearest poison control center shall be posted prominently in the emergency unit department.
13.103	EQUIPMENT & SUPPLIES
(1)	11.1.9	EQUIPMENT AND SUPPLIES. Equipment, supplies and drugs shall be provided commensurate with the scope of operation as defined in 13.102 (1) 11.1.4. 
(2)	The equipment and supplies shall include but not be limited to the administration of blood, plasma, plasma expanders, parenteral solutions; the administration of oxygen; tracheotomy; the control of bleeding; emergency splinting of fractures; and gastric lavage. X-Ray permeable stretchers intended for use as examining tables should be provided.
13.104	FACILITIES
(1)	11.1.2	EMERGENCY FACILITIES. Emergency facilities should be conveniently located with respect to radiological and laboratory services. Emergency facilities shall be separate and removed from surgical and obstetrical suites and shall consist, as a minimum of the following:
(a)	A well-marked ENTRANCE, separate from the main hospital entrance, at grade level and sheltered from the weather with provisions for ambulance and pedestrian service.
(b)	A RECEPTION AND CONTROL AREA with visual control of the entrance, waiting room and treatment area. (Required for hospitals of 50 beds or more).(1)
(c)	COMMUNICATIONS with appropriate nursing stations outside the emergency unit and connected to emergency power source.
(d)	PUBLIC WAITING SPACE with toilet facilities, telephone. drinking fountain, stretcher and wheelchair storage.(1)>
(e)	EMERGENCY ROOM equipped with clinical sink and handwashing facilities.(1)
(f)	NURSES STATION which may be combined with reception and control area, or it may be within the emergency room.(1)
(g)	STORAGE FOR CLEAN SUPPLIES,(1)
(1)	Required only in case of new hospital construction, or modification of an existing hospital facility.
(2)	11.2.3  FACILITIES 2.  Surgery. If provided, operating rooms located within the emergency unit shall meet the requirements specified in Section Part 23 surgical suite and recovery room(s).
(3)	11.2.3  FACILITIES 2.  Surgery. In addition to those areas required for surgery suites, the The following physically separated areas must be provided: 1) An adequate waiting room, 2) public toilet facilities, 3) public phone, 4) drinking fountain, 5) patient preparation area with adjacent toilet room, handwashing and provision for storing patient's clothing, 6) ' provisions within the patient preparation area for medication storage and preparation, 7) recovery room equipped as specified in Section 23.33 Part 33, Section 11. 

14	OUTPATIENT SERVICES {Reorganization and clarificaton.  No substantive changes intended.}
14.101	ORGANIZATION AND STAFFING
(1)	Hospitals shall provide outpatient services.
(11.2  OUTPATIENT SERVICES. Outpatient services is that service which is organized to provide facilities, equipment and personnel who are qualified by training, experience and ability to care for individuals who come to the hospital on an outpatient basis.
(2)	11.2.1  POLICIES. There shall be specific written policies for admissions and discharge of patients, physician responsibility, staffing, and procedures for individual patient care, and equipment and supplies.
(3)	11.2.2  PERSONNEL. The nursing service shall be under the supervision of a registered nurse qualified by training, experience and ability. There shall be such professional and non-professional personnel as required for efficient operation.
14.102	PROGRAMMATIC FUNCTIONS.  Reserved.
14.103	EQUIPMENT AND SUPPLIES.  Reserved.
14.104	FACILITIES  
(1)	11.2.3	FACILITIES. 2.  In addition to those areas required for surgery suites, the The following physically separated areas must shall be provided: 1) An adequate waiting room, 2) public toilet facilities, 3) public phone, 4) drinking fountain, 5) patient preparation area with adjacent toilet room, handwashing and provision for storing patient's clothing, 6) ' provisions within the patient preparation area for medication storage and preparation, 7) recovery room equipped as specified in Section 23.33 Part 23, Surgical and Recovery Services.
3.	X-Ray. See Section 24 Radiological Services.
11.2.4	MEDICAL RECORDS. Medical records are maintained, and correlated with other hospital medical records. Information contained in the medical record shall be complete and sufficiently detailed relative to the patient's history, physical examination, laboratory and other diagnostic tests, diagnosis, and treatment to facilitate continuity of care.
The outpatient medical record shall be integrated with the patient's overall hospital record. {Concept moved to Part 8, Medical Records}
The outpatient medical record should be accessible to the physicians, nurses, and other personnel of the department. { Concept moved to Part 8, Medical Records n}
11.3	ORDERS. See 19.23

15	COMMUNICABLE DISEASE INFECTION CONTROL SERVICES {Substantive changes intended.}
15.101	ORGANIZATION AND STAFFING
(1)	The facility shall have an infection control program responsible for reducing the risk of acquiring and transmitting nosocomial infections and infectious diseases in the facility.
(2)	12.1  INFECTIONS COMMITTEE. There shall be a multi-disciplinary infections control committee charged with the responsibility of investigation and recommendations:
(a)	 developing written policies and procedures regarding for the prevention, surveillance and control of nosocomial infections and infectious diseases. communicable diseases in the hospital.
(b)	Making findings and recommendations to prevent and control nosocomial infections and infectious diseases.
(3)	Infection control officer(s) shall implement the policies and procedures and the recommendations of the infection control committee. 
15.102	PROGRAMMATIC FUNCTIONS
(1)	12.2  COMMITTEE FUNCTIONS.  A.  POLICIES. There shall be written policies and procedures consistent with guidelines of the Centers for Disease Control and Prevention (CDC) regarding infection control.  The committee shall be responsible for all hospital policies and procedures related to communicable disease infection control including, the following:  Policies and procedures shall include, but not be limited to:
(a)	,  1) The admission and isolation of patients with specific communicable infectious diseases, and protective isolation of appropriate patients; 
(b)	2) The control of routine use of antibiotics and adrenocorticosteroids; 
(c)	3) The review and revision of policies and procedures for communicable disease prevention, surveillance and control; 
(d)	4) The inservice education programs on the control of communicable nosocomial and infectious diseases, including but not limited to handwashing and gloving; 
(e)	standards for sterilization of equipment used for direct patient care;
(f)	standards for cleaning and disinfecting all areas of the hospital;
(g)	standards for linen and laundry services;
(h)	the implementation of infection control measures during hospital renovations;
(i)	5) The reporting of diseases as required by laws and regulations, pertaining to disease control, Colorado Department of Health, 1968.
B.	The committee shall make findings and recommendations available promptly to a designated individual the infection control officer for action.
C.	The committee shall meet at least monthly and maintain minutes of the meetings.  For the committee to carry out its responsibilities the following are highly recommended standards: 1) Meet at least monthly, and more frequently if the surveillance committee so indicates. 2) Plan an agenda that includes: (a) review of significant features of the monthly report (b) review of one major control policy (and related procedures) area each month in the light of newest available information and the hospital's current practice.
12.3	PATIENT ISOLATION.Hospitals shall observe the rules pertaining to isolation of patients as required by laws and regulations, pertaining to disease control, Colorado Department of Health, 1968.
15.103	EQUIPMENT AND SUPPLIES.  Reserved.
15.104	FACILITIES
(1)	Required only in case of new hospital construction, or modification of an existing hospital facility.
(1)	12.3.1  ISOLATION ROOM(s) Rooms used for isolation of patients with infectious diseases should be: 1) Equipped with private toilet facilities; 2) Provided with an air supply and exhaust system that neither recirculates nor redistributes air from a central air system; 3) Designed to provide a negative or positive pressure in relation to adjacent areas.
In the case of new hospital construction, or modification of an existing hospital facility isolation room(s) shall be provided on the basis of one for each thirty (30) beds or major fraction thereof, if the hospital does not have a separate contagious disease unit. Each isolation room shall have:  
(a)	Handwashing facilities as required in Part 19 General Patient Care Services chapter IV, Par. 19.7
(b)	Separate toilet room with bath or shower
(c)	Mechanical ventilation shall be provided at the rate of six air changes per hour with no recirculation. Supply air shall be filtered using 80% efficient filters.  Rooms to be of negative pressure relative to adjacent areas.
(d)	An anteroom with lavatory should be provided (One anteroom may serve more than one isolation room.)
(e)	View window for nursing observation should be provided.
13 16	INHALATION THERAPY  RESPIRATORY CARE SERVICES {Reorganization only.  No substantive changes intended}
DEFINITION. Inhalation therapy is that service which is organized to provide facilities, equipment, and personnel who are qualified by training, experience and ability to treat conditions caused by deficiencies or abnormalities associated with respiration. {Moved to Part 2, Definitions}
16.101	ORGANIZATION AND STAFFING
(1)	The hospital may provide respiratory care services.  The following standards shall apply only if the hospital provides such services.  
(2)	13.1  The inhalation therapy respiratory care service should be under the direct supervision of a committee of the organized medical staff or a physician who has had special training in respiratory diseases and therapy. Where hospital usage warrants, it is recommended that the service be made a separate department.
16.102	PROGRAMMATIC FUNCTIONS
(1)	13.1  PERSONNEL. Inhalation therapy Respiratory care services shall be administered only by persons qualified by training, experience, and ability in inhalation therapy.
16.103	EQUIPMENT AND SUPPLIES
(1)	13.2  FACILITIES AND EQUIPMENT. The facilities and equipment for inhalation therapy respiratory care services shall be commensurate with the clinical procedures and programs of the hospital.
(2)	13.3 EQUIPMENT DISINFECTION. Inhalation therapy Respiratory care equipment shall be cleaned properly and disinfected after each use in accordance with written procedures. The disinfection process shall be bactericidal, tuberculocidal, and virucidal. Written procedures shall be developed for these processes.
16.104	FACILITIES
(1)	13.2  FACILITIES AND EQUIPMENT. The facilities for and equipment for inhalation therapy respiratory care services shall be commensurate with the clinical procedures and programs of the hospital.

17 14	CRITICAL CARE AREAS SERVICES {Reorganization only.  No substantive changes intended.  Some deletions reflect changes to Life Safety Code requirements scheduled to be promulgated at the June 20, 2007 Board of Health Hearing.}
DEFINITION. Critical Care Unit means a designated area of the hospital containing a grouping of single bedrooms or enclosures accommodating not more than 6 beds each, and providing particularized facilities and services to care for patients who require continuing, acute observation and concentrated, highly proficient care. When such unit is provided the requirements listed herein shall be observed. {Moved to Part 2, Definitions} 
17.101	ORGANIZATION AND STAFFING
(1)	The hospital may provide critical care services in a critical care unit.  The following standards shall apply only if the hospital provides such services.  
17.102	PROGRAMMATIC FUNCTIONS
(1)	14.1  POLICIES. There shall be specific written policies for admission and discharge of patients, physician responsibility, staffing, and procedures for individual patient care. , and equipment and supplies,
(2)	14.2  NURSING. The nursing service shall be under the supervision of a registered nurse qualified by training, experience, and ability. At least a minimum of one registered nurse shall be on duty at all times to give direct patient care. Additional nursing personnel shall be available, consistent with the nursing care required by the different types of patients.
17.103	EQUIPMENT AND SUPPLIES
(1)	There shall be written policies regarding equipment and supplies.
(2)	14.7  EQUIPMENT. The equipment shall include: 1} Variable height beds with safety sides; 2) Bedside cabinets; 3) Sphygnomannometers; 4) Resuscitation apparatus; 5) Additional equipment as oxygen tents, pacemaker, defibrillator, and electrocaridiography apparatus; 6) Intravenous rods installed in ceilings or walls, or attached to beds; 7) Piped oxygen; 8) Suction outlets; 9) Emergency signal system at each bed and nurses station. 10) In case of new hospital construction or modification of an existing hospital facility, an emergency call from unit to outside the unit where additional personnel are available shall be provided.
17.104	FACILITIES
(1)	14.3  PERSONNEL FOR EMERGENCIES. A system shall be established for calling selected emergency personnel to the unit.
(2)	14.7  EQUIPMENT. The equipment shall include  The critical unit shall have: 1} Variable height beds with safety sides; 2) Bedside cabinets; 3) Sphygnomannometers; 4) Resuscitation apparatus; 5) Additional equipment as oxygen tents, pacemaker, defibrillator, and electrocaridiography apparatus; 6 1) Intravenous rods installed in ceilings or walls, or attached to beds; 7 2) Piped oxygen; 8 3) Suction outlets; 9 4) Emergency signal system at each bed and nurses station. 10 5) In case of new hospital construction or modification of an existing hospital facility, an emergency call from unit to outside the unit where additional personnel are available shall be provided.
(3)	14.4  FACILITIES AND SIZE. The area shall be sufficient in size to allow movable equipment to be placed on either side of the bed(s) and provide-at least 80 square feet per bed in multiple bedrooms and 100 square feet in single bedrooms. Space for storage of commonly used equipment and supplies shall be provided. (Storage carts are recommended). A patient care control center (nurses station), medicine preparation area, clean and soiled holding areas, and janitor's closet conforming to the requirements of Section 19, Patient Care Unit, shall be provided in proximity to the bedrooms or within the enclosures.  When more than one enclosure is provided within room, the size of these areas should be increased.
(4)	14.5  TOILET FACILITIES. A toilet complete with flushing attachments shall be provided in each room. In case of new hospital construction. or modification of an existing hospital facility the door to the toilet room shall be 2'8” wide, 3'0” recommended.
(5)	14.6  HANDWASHING FACILITIES. A lavatory complete with mixing faucet, blads controls, soap, and sanitary hand-drying accommodations shall be provided within each room.
(6)	14.8  ELECTRICAL. Two duplex convenience outlets shall be installed in proximity to the head of each bed. General lighting shall be uniform throughout the room and controlled by a dimmer. The electrical system shall be connected to the emergency power system. In the case of new hospital construction, or modification of an existing hospital facility, four duplex convenience outlets shall be installed in proximity to the head of each bed and the electrical installation shall meet the requirements of National Fire Protection Association, National Electrical Code, Bulletin No. 70, 1973.
14.9	VENTILITION. Ventilation shall meet the requirements specified in Chapter III, General Building and Fire Safety.
(7)	14.10  WATING ROOM.  A waiting room shall be provided. This may be shared with as adjacent patient care unit.

18	OCCUPATIONAL AND PHYSICAL THERAPY SERVICES {Reorganization only.  No substantive changes intended}
18.100	Occupational Therapy
18.200	Physical Therapy

18.100	Occupational Therapy
18.101	ORGANIZATION AND STAFFING
(1)	The hospital may provide occupational therapy services.  The following standards shall apply only if the hospital provides such services.  
(2)	18.1.1  Occupational therapy services shall be rendered only by individuals qualified by training and experience.
18.102	PROGRAMMATIC FUNCTIONS
(1)	18.1.1  When occupational therapy services are offered there There shall be written policies identifying the organization, administration, performance standards, and direction and supervision of patient care rendered. Occupational therapy services shall be rendered only by individuals qualified by training and experience.
18.1.2  Treatment records shall include a prescription and/or order for treatment signed by the physician, progress notes of the occupational therapist, and results of special tests and measurements. {Moved to Medical Records}
18.103	EQUIPMENT AND SUPPLIES
(1)	18.1.3  FACILITIES. There shall be adequate facilities, space, appropriate equipment and storage areas as determined by the professional staff to be essential to the requirements of care and treatment of referred patients.
18.104	FACILITIES
(1)	18.1.3  FACILITIES. There shall be adequate facilities, space, appropriate equipment and storage areas as determined by the professional staff to be essential to the requirements of care and treatment of referred patients.
18.200	Physical Therapy
18.2	PHYSICAL THERAPY.
18.201	ORGANIZATION AND STAFFING
(1)	The hospital may provide occupational therapy services.  The following standards shall apply only if the hospital provides such services.  
(2)	18.2.1  MEDICAL DIRECTION. The physical therapy services shall be under medical direction. This may be 1) A committee of the organized medical staff, or 2) A designated physician qualified by training and experience.
(3)	18.2.3  PERSONNEL. Physical therapy shall be rendered only by a physical therapist licensed to practice in the State of Colorado. All personnel assisting with the physical therapy of patients must be under the direct supervision of a licensed physical therapist.

18.202	PROGRAMMATIC FUNCTIONS
(1)	18.2.2  POLICIES. There shall be written policies governing physical therapy services.
18.2.4  Treatment records shall include a prescription and/or order for treatment signed by the physician, progress notes of the physical therapist, and results of special tests and measurements. {Moved to Part 8, Medical Records Department}
18.203	EQUIPMENT AND SUPPLIES
(1)	18.2.6  FACILITIES. There shall be adequate facilities, space, appropriate equipment, and storage areas as determined by the professional staff, to be essential to the requirements of care and treatment of referred patients.
18.204	FACILITIES
(1)	18.2.5  LOCATION. The physical therapy services shall be located in an area convenient for in and out patients.
(2)	18.2.6  FACILITIES. There shall be adequate facilities, space, appropriate equipment, and storage areas as determined by the professional staff to be essential to the requirements of care and treatment of referred patients.

19	GENERAL PATIENT CARE SERVICES PATIENT CARE UNIT {Reorganization only.  No substantive changes intended.  Some substantive deletions reflect changes to Life Safety Code requirements scheduled to be promulgated at the June 20, 2007 Board of Health Hearing.}
19.101	ORGANIZATION AND STAFFING
(1)	There shall be patient care services commensurate with the services provided by the facility.
(2)	19.22  NURSING.  The nursing care required by different types of patients shall be the major consideration in determining the number, quality, and category of nursing personnel that are needed in any given situation.
19.102	PROGRAMMATIC FUNCTIONS
(1)	Admissions
(a)	6.2  IDENTIFICATION.  Each patient admitted to the hospital shall have a visible means of identification placed on his person.
(b)	6.3  PATIENT BEDROOM.  No patient shall be admitted for inpatient care to any room or area other than one regularly designated as a patient bedroom. There shall be no more patients admitted to a patient bedroom than the number for which the room is designed and equipped.  Emergencies are exceptions.
(2)	Patient Care Unit
(a)	19.22  NURSING.  At least one registered nurse shall be on duty at all times in each patient care unit. One registered nurse shall be designated in charge and shall be delegated the authority and responsibility for the nursing services on that patient care unit. Additional registered nurses, licensed practical nurses, or other auxiliary personnel shall be available.
(b)	19.33  WRITTEN POLICIES. Written policies for patient care shall be established for each patient care unit.
(3)	19.32  NURSING CARE PLANS.  A nursing care plan shall be prepared for each patient. The plan shall be reviewed and revised as needed.
(4)	Medications 
(a)	19.25  MEDICATION IDENTIFICATION. Medications shall be identified with at least the name, strength, dosage, and frequency and mode of administration of the medication; and the name of the patient for whom the medication is prescribed. This identification shall be verified not only when the medicine is prepared but also when it is administered.
19.27  INVESTITGATIONAL DRUGS.  When nurses administer investigational drugs, they shall have documented basic information available concerning such drugs including dosage forms, strengths available, actions and uses, side effects including methods to combat them, symptoms of toxicity, and contraindications for use.
	19.23  PHYSICIAN ORDERS. Orders
(a)	19.23  Medications and treatments shall be given only on the order of a physician or other practitioner authorized by law. 
(b)	19.23  Orders shall be received by a house physician or registered nurse; shall be written; and shall include the date, time, and specifications of the order. 
(c)	19.23  Physician orders for treatment may be received by members of the appropriate discipline as specified and approved by the medical staff, nursing services, and the governing board. 
(d)	19.23  Orders shall be transferred to the medical record by a member of the specific discipline responsible for implementing the order to the patient record. 
(e)	19.24	DANGEROUS DRUGS. Orders prescribing dangerous drugs, i.e., narcotics, sedatives, anticoagulants, antibiotics, etc., shall include a time limit. Such time limit shall be agreed upon by the medical staff and shall be so recorded in the rules and regulations of the organized medical staff.  
19.25	Unused prepared medications shall be disposed of in accordance with documented procedures.  {Moved to Part 21, Pharmaceutical Services}
19.26	MEDICATION RECORDING.All medications administered shall be recorded on the patient's medical record and include the name, strength, dosage, mode of administration of the medication; date, time, and signature of the person administering. {Moved to Part 8, Medical Records}
19.29	BLOOD TRANSFUSION.Before administering a blood transfusion the following shall be identified accurately and verified by two persons: 1) Patient; 2) Patient's blood specimen; 3) Type, crossmatch, and expiration date of donor blood; 4) Pilot tube and equipment used in the typing and crossmatching. {Moved to Subpart 10.200, Blood Banking Services}
19.30	THERMOMETER. A disinfected thermometer shall be used each time a patient's temperature is taken.
19.31	DRESSINGS. There shall be individual patient equipment and supplies for changing dressings.
19.103	EQUIPMENT/FURNITURE AND SUPPLIES
(1)	19.28  EMERGENCY EQUIPMENT AND SUPPLIES. The following shall be readily available at all times: 1) Oxygen; 2) Suction; 3) Portable emergency equipment, supplies and medications; 4) Compatible supplies and equipment for immediate intravenous therapy.
(2)	19.9  PATIENT EQUIPMENT. Patient bedrooms shall be equipped with movable furniture and equipment with the following for each patient: 1) Adjustable, washable bed with side rails; 2) Cabinet or bedside table; 3) Overbed table; 4) Incombustible waste paper receptacle either seamless or with removable impervious liner; 4) 5) Complete personal care equipment that is sterile sterilized before each patient's use, and including water carafe, mouth wash cups, emesis basin, wash basin, bedpan and urinal (when necessary).
19.104	FACILITIES 
(1)	Patient Rooms
a.	19.1  PATIENT ROOMS.  There shall be provisions for private and multiple bedrooms to meet the needs of patients and programs of the hospital. There shall be no more than four beds per patient bedroom. There should be no more than approximately 40 patient beds in a patient care unit.
b.	19.2  BEDROOM SIZE.  Each one-bed room shall contain a minimum floor area of 100 square feet. Each multiple-bed room shall contain a minimum floor area of 80 square feet per bed. This minimum floor area, may include built-ins not exceeding four feet in height.
c.	19.3  PRIVACY.  Privacy shall be provided for each patient in a multiple-bed room by the installation of approved cubicle curtains or partitions. In the case of new hospital construction, or modification of an existing hospital facility privacy shall be provided by the installation of fire resistant cubicle curtains.
d.	19.4  WINDOWS.  Each patient bedroom shall have a minimum window area equal to 1/8 of the floor area. The sills of such windows shall not be located below the finished ground level and shall not be more than 32 inches above the floor level. The ground level shall be maintained at or below the window sill for a distance of at least 8 feet measured perpendicular to the window. One-half of the window shall be openable. If a mechanical ventilation system is provided, a portion of the required window shall be openable. Privacy for the patient and control of light shall be provided at each window.
e.	19.5  ENTRIES.  Each patient bedroom shall have direct entry from a corridor. Such entry shall have a door at least equal in fire resistance to 1-3/4 inches thick solid core wood door. The door opening shall be at least 3 feet 8 inches in clear width (four feet of clear width is recommended) and shall not swing into the corridor. In the case of new hospital construction, or modification of an existing hospital facility, the door to each patient room may be no more than 120 feet from the nursing station or from the clean or soiled holding rooms.
f.	19.6  LIGHTING.  Artificial light shall be provided and include: 1) General illumination; 2) Other sources of sufficient illumination for reading, observations, examinations, and treatments; 3) Night light controlled at the door of the bedroom; 4) Quiet operating switches (not required in existing buildings.)
g.	19.7  HANDWASHING FACILITIES.  A lavatory complete with mixing faucet, blade controls, soap and sanitary hand drying accommodations shall be provided in each patient bedroom, except that the lavatory may be installed within the toilet room in private bedrooms.
h.	19.8  TOILET FACILITIES.  Toilet facilities shall be provided immediately adjacent to private or multiple-bed rooms in the ratio of one facility for not more than four patient beds and shall include: 1) Toilet with bedpan flushing equipment; 2) Incombustible waste paper receptacle, either seamless or with removable impervious liner; 3) Approved grab bars convenient for the safety of patients; 4) Nurse-call signal system. In new construction the door to the toilet shall be at least 2'8” in width and shall not swing into the toilet room unless provided with rescue hardware. Recommend 3'0” door.
i.	19.10  CLOSET.  Each patient shall be provided with separate closet space or locker. In the case of new hospital construction or modification of an existing hospital facility, the closet space or locker must open into the patient room.
j.	9.11  NURSE-CALL SIGNAL SYSTEM.  Each patient shall be furnished with a nurse-call signal system that registers a signal from the patient, at the corridor bedroom door, at the patient care control center (nurses station), and in service areas of the patient care unit.  A duplex unit may be used for 2 patients in multi-bed rooms, but a light should be provided to indicate the patient placing the call.
(2)	19.12  SERVICE FACILITIES. Services Areas
a.	The following service areas shall be provided and located conveniently for patient care: 1) Patient care control center (nurses station) accommodating a nurse call signal system from patients, a communication system with other hospital departments, and the outside; 2) Medical record recording facilities; 3) Medicine preparation area; 4) Clean holding area: 5) Soiled holding area; 6) Janitor's closet; 7) Stretcher and wheelchair storage area, 8) Nourishment station shall be provided in the case of new hospital construction, or modification of an existing hospital facility; 9) Clinical examination and treatment room: 10) Bathing facilities.
(3)	19.13  PATIENT CARE CONTROL CENTER (nurses Station)(1) The patient care control center (nurses station) shall be adequately designed and equipped.
(4)	19.14  MEDICATION PREPARATION AREA(1) The medication preparation area shall be equipped with: 1) Cabinets with suitable locking devices to protect drugs stored therein; 2) Refrigerator equipped with thermometer and used exclusively for pharmaceutical storage; 3) Counter work space; 4) Sink with approved handwashing facilities; 5) Antidote, incompatibility, and metri-apothecary conversion charts. Only medications, equipment, and supplies for their preparation and administration shall be stored in the medication preparation area. Test reagents, general disinfectants, cleaning agents, and other similar products shall not be stored in the medication area.
	(1)	Other approved facilities for patient services may be substituted to meet the requirements specified in 19.13 through 19.18
(5)	Linen and Laundry
a.	19.15  CLEAN HOLDING ROOM.(1) (Not required in hospitals of 25 beds or less if the CSR is conveniently located on the same floor). The clean supply holding room shall be equipped with: 1) Suitable counter sink with mixing faucet, blade controls, soap, and sanitary band drying facility; 2) Waste container with cover (foot controlled recommended), and impervious, disposable liner; 3) Cupboards or carts for supplies. In the case of new hospital construction, or modification of an existing hospital facility, 4) Mechanical fresh air supply to maintain positive pressure; and 5) Nurse call utility station must also be provided.
b.	19.16  CLEAN LINEN.(1) There shall be a separate closed area in the clean supply holding room, on a cart, or in a separate closet for clean linen supplies.
c.	19.17  SOILED HOLDING ROOM.(1) (Not required in hospitals of 25 beds or less if there is a CSR, and a soiled linen holding room or soiled linen chute conveniently located on the same floor). The soiled holding room shall be equipped with: 1) Suitable counter sink with mixing faucet, blade controls, soap, and sanitary hand-drying facility. In the case of new hospital construction, or modification of an existing hospital facility the sink must be 2-compartment. 2) Waste container with cover (foot controlled recommended) and impervious, disposable liner; 3) Soiled linen cart or hamper with impervious liner; 4) Accommodations and provisions for enclosed soiled articles; 5) Space for short-time holding of specimens awaiting delivery to laboratory; 6) Adequate shelf and counter space; and in the case of new hospital construction, or modification of an existing hospital facility, 7) Nurse call utility station; 8) A clinical flushing sink; and 9) Continuous mechanical exhaust ventilation to the outside.
(6)	19.18  JANITOR'S CLOSET.(1) The janitor's closet shall be equipped with: 1) Sink, preferably a floor receptor, with mixing faucets; 2) Hook strip for mop handles from which soiled mopheads have been removed; 3) Shelving for cleaning materials; 4) Approved handwashing facilities, in the case of new hospital construction, or modification of an existing hospital facility, the handwashing facility must be separate if a floor receptor is used; 5) Waste receptacle with impervious liner.
The floor area should be adequate to store mop buckets on a roller carriage, wet and dry vacuum machine, and floor scrubbing machine.
(7)	19.19  STORAGE SPACE.  In new construction, recessed storage space or rooms shall be provided for extra equipment, stretchers, and wheelchairs.
(8)	19.19  A NOURISHMENT STATION.  In new construction, the nourishment station shall contain a sink equipped for handwashing, equipment for serving nourishments between scheduled meals, refrigerator, and storage cabinets. Ice for patient service and treatment shall be provided only by ice maker - dispenser units.
(1)	Other approved facilities for patient services may be substituted to meet the requirements specified in 19.13 through 19.18.
(9)	19.20  BATHING FACILITIES.  Patient bathing facilities shall be provided in the ratio of one tub or shower for each ten patients. Approved grab bars, and in the case of new hospital construction, or modification of an existing hospital facility, a nurse call, shall be installed at each tub or shower convenient for the safety of patients using the tub or shower. The room shall be sufficiently large to provide space for wheelchair movement and provision for privacy. In the case of new hospital construction or modification of an existing hospital facility, on each patient floor at least one shower shall be provided which will accommodate a wheelchair.
There should be toilet and lavatory facilities in the bathroom with mixing faucet, blade controls, soap, and sanitary hand-drying accommodations.
(10)	19.21  PERSONNEL TOILET FACILITIES. Toilet facilities shall be provided for personnel on each patient care unit.

20	PEDIATRIC PATIENT CARE SERVICES {Reorganization only.  No substantive changes intended}
20.101	ORGANIZATION AND STAFFING
(1)	The hospital shall provide pediatric patient care services.  The following requirements are in addition to those specified in Section Part 19, General Patient Care Unit Services.
(2)	A medical staff member with special training in pediatrics should be appointed chief of pediatric service.
(3)	20.2  NURSING. Pediatric nursing care shall be under the direction of a registered nurse qualified by training, experience, and ability to direct effective pediatric nursing. All nursing personnel, assigned to care for children, shall be oriented to the special care of children.
20.102	PROGRAMMATIC FUNCTIONS
(1)	20.3  PATIENT ROOMS. The hospital shall not routinely admit children to patient bedrooms where accommodations are shared with adults.
20.103	EQUIPMENT AND SUPPLIES
(1)	20.1  FACILITIES. When a pediatric patient care unit is established it shall provide; 2) 1) An examination and treatment room with equipment and supplies appropriate for the care of children; 3) Rooms designed and furnished to facilitate grouping patients according to condition and age groups; 4) 2) Cubicle partitions, when used, that permit visibility of patients by nurses and by patients in the same room and that are of shatterproof materials; 5) Space with adequate facilities for safe storing and warming of food. 1) A playroom with 3) washable tables and chairs of various sizes for the playroom, storage for equipment and supplies, and appropriate entertainment materials;
20.104	FACILITIES
(1)	A separate pediatric patient care unit is recommended when the annual average pediatric daily census requires 10-14 beds. The unit should contain no more than 24 beds.
(2)	20.1  FACILITIES. When a pediatric patient care unit is established it shall provide; 1) A playroom with washable tables and chairs of various sizes, storage for equipment and supplies, and appropriate entertainment materials; 2) An examination and treatment room with equipment and supplies appropriate for the care of children; 3) Rooms designed and furnished to facilitate grouping patients according to condition and age groups; 4) Cubicle partitions, when used, that permit visibility of patients by nurses and by patients in the same room and that are of shatterproof materials; 5) Space with adequate facilities for safe storing and warming of food.
(3)	20.4  NURSERY. Nursery facilities shall be provided for sick newborn infants transferred from the newborn nursery and admitted from outside.  The facility shall include:: 1) A minimum of 30 square feet of space for each bassinet or incubator; 2) At least one incubator approved by the Underwriters Laboratories; 3) Diaper containers with foot-controlled covers and impervious, disposable liners; 4) Baby scales and stand.
(4)	20.5  FACILITIES FOR ADOLESCENTS. Reasonable privacy, without limiting necessary observation, shall be available for adolescents. The following are highly recommended standards:
A.	Organized activity, play, and educational programs should be available for all children, within the limits of their ability to participate.
B.	Instructions and supervised experience should be available to parents.
C.	There should be referrals to public health nurses or other agencies for follow-up care as needed.

21	PHARMACEUTICAL SERVICES {Reorganization only.  No substantive changes intended}
21.101	ORGANIZATION AND STAFFING
(1)	21.1  ORGANIZATION. The pharmaceutical services of the hospital shall be organized and maintained primarily for the benefit of the hospital patients, and shall be operated in accordance with federal and state laws and regulations. 
(2)	21.1  The pharmacy service shall be under the direction or supervision of a pharmacist registered licensed to practice pharmacy in the State of Colorado. 
21.102	PROGRAMMATIC FUNCTIONS
(1)	21.1  Written policies shall be developed by the hospital and the supervising pharmacist to indicate his the pharmacist’s responsibility for periodic inspection of medications, dispensing, inventory control, and establishment of necessary records.
(2)	21.2  POLICIES.The pharmacist shall initiate and develop policies of the department service. There should be a hospital pharmacy and therapeutic committee to assist in the formulation of broad professional policies regarding the evaluation, selection, procurement, distribution, use, safety procedures, and other matters relating to drugs in hospitals. It is recommended that a formulary be adopted and operations be under the formulary system.
(3)	19.25  MEDICATION IDENTIFICATION.  Unused prepared medications shall be disposed of in accordance with documented procedures.
(4)	21.3  PHARMACIST RESPONSIBILITIES. A pharmacist's responsibilities shall include: 1) Preparation of pharmaceuticals; 2) Filling and labeling of all drug containers from which medications are to be administered; 3) Dispensing of drugs, antibiotics, biological, and pharmaceutical preparations which shall meet the standards established by the United States Pharmacopeia, National Formulary, or New and Non-official Drugs: 4) Dispensing of narcotics, hypnotics, amphetamines, alcohol preparations, and the maintenance of a perpetual inventory of them; 5) Maintenance of an approved stock of antidotes and emergency drugs; 6) Periodic inspection of all pharmaceuticals and biological supplies on all services; 7) Distribution of information concerning medications to physicians, dentists, and nurses; 8) Preparation, sterilization, and analysis of injectable medications when compounded in the pharmacy; 9) Establishment and maintenance of a system of records and accounting in accordance with hospital policies.
(5)	21.4	NARCOTICS.Only physicians, who are so authorized under the laws of the State of Colorado, and are registered with the Director of Internal Revenue, shall prescribe narcotics. In case of recurring shortages or loss of significant quantities of narcotics, a copy of report of investigation shall be forwarded to the District Supervisor of the Bureau of Narcotics, in accordance with Treasury Regulations No. 5, 1964.
21.5	  NVESTIGATIONAL DRUGS. Investigational drugs shall be used only under direct supervision of the principal investigator and with recorded evidence of full knowledge of and approval of the medical staff therapeutics committee and hospital administration. The principal investigator shall be a member of the medical staff and shall assume responsibility for securing the patient's necessary consent prior to administration of the drug.
21.103	EQUIPMENT.  Reserved.
21.104	FACILITIES
(1)	21.6  FACILITIES. Facilities shall be provided for the storage, safe-guarding, preparation, and dispensing of drugs with proper lighting, temperature control, ventilation, and sanitation facilities. In addition to adequate safeguards for all drugs, special safety precautions should be given to the storage of alcohol.
(2)	21.7  REFRIGERATION.  A refrigerator with thermometer and freezing compartment shall be provided for the proper storage of thermolabile products.
21.8	STANDARD REFERENCES.The latest revisions of U.S. Pharmacopeia,National Formulary, New and Non-official Drugs, and Toxicology and Therapeutics shall be available.
21.9	FIRE EXTINGUISHERS.Adequate fire extinguishers shall be installed in the pharmacy.

22	PSYCHIATRIC PATIENT CARE SERVICES {Reorganization only.  No substantive changes intended}
22.101	ORGANIZATION AND STAFFING
(1)	The hospital may provide psychiatric patient care services.  The standards in this section shall apply only if the hospital provides such services.  The following requirements are in addition to those specified in Section 19, Patient Care Unit Part 19, General Patient Care Services.
(2)	22.2  A medical staff member with special training in psychiatry, preferably a Diplomate of the American Board of Psychiatry and Neurology, should be appointed chief of the psychiatric service.
(3)	22.2  MEDICAL CARE. A qualified psychiatric staff shall provide diagnostic and consultation services for the care and treatment of patients admitted for psychiatric disorders and for those patients who in the course of hospitalization experience a psychiatric illness.
(4)	22.3  NURSING.  The nursing care shall be under the direction of a registered nurse qualified by training, experience, and ability to direct effective psychiatric nursing.
22.102	PROGRAMMATIC FUNCTIONS
(1)	22.4  RESTRAINTS. Confinement of patients in psychiatrically secure rooms and physical restraints shall be used only when necessary to prevent injury to the patient or others, and only when other measures are not sufficient to accomplish the purpose. Written policies shall be established relative to the use of psychiatrically secure rooms and restraints.
22.103	EQUIPMENT.  Reserved. 
22.104	FACILITIES 
(1)	22.1  FACILITIES.  When a psychiatric patient care unit is established, the unit shall provide; 1) A day-room or solarium; 2) A dining room; 3) An occupational therapy and recreation room with storage facilities; 4) A conference and interview room; 5) two or more psychiatrically secure rooms.

23	SURGICAL SUITE AND RECOVERY ROOM(S) SERVICES {Reorganization only.  No substantive changes intended.  Substantive deletions reflect changes to Life Safety Code requirements scheduled to be promulgated at the June 20, 2007 Board of Health Hearing. }
23.101	ORGANIZATION AND STAFFING
(1)	The hospital shall provide emergency surgical services and may provide other surgical services.  
(2)	23.31  NURSING. The nursing service of the surgical suite shall be under the supervision of a registered nurse qualified by training and experience to direct operating room nursing. 
(3)	23.31  A registered nurse qualified by training and experience in operating room nursing shall be present as a circulating nurse during operative procedures.
(4)	23.32.3  NURSING. At least one registered nurse shall be on duty at all times in the surgical recovery room when patients are present. Nurses shall have been instructed in the care of post-anesthetic and post-surgical patients, shall have no other duties during the time they are caring for such patients, shall have facilities for immediate communications with the attending surgeon, anesthesiologist, or qualified substitute present in the hospital. Additional registered and licensed practical nurses, and auxiliary nursing personnel shall be available. The nursing care required by different types of patients shall be the major consideration in determining the number, quality, and category of nursing personnel that are needed in any given situation.
23.102	PROGRAMMATIC FUNCTIONS
(1)	23.3  WRITTEN POLICIES. Rules, regulations, and/or policies Policies related to the surgical suite shall be written and available for staff use. Policies shall include the admission of patients, personnel, and visitors.
(2)	23.32.4  POLICIES. Policies governing the authority and responsibilities of nursing personnel and the admission and length of stay of patients in the surgical recovery room shall be written.
23.9	CONDUCTIVE FOOTWEAR.All personnel entering anesthetizing location or storage areas for flammable anesthetics shall be in electrical contact with the conductive floor through the wearing of conductive footwear. Conductive footwear shall be tested through an approved resistance measuring device having a short circuit current not exceeding 0.5 milliamperes.
23.10	CLOTHING. Silk, wool, or synthetic textile materials not in close contact with the skin shall not be permitted in anesthetizing areas.
23.103	EQUIPMENT
(1)	23.6  EQUIPMENT.  Equipment in anesthetizing areas shall be constructed of metal or other electrically conductive material and equipped with rubber pads, leg tips, casters, or equivalent devices which are conductive.
(2)	23.7  X-RAY EQUIPMENT.  Only approved portable X-ray equipment shall be used in anesthetizing locations. In the case of new hospital construction, or modification of an existing hospital facility, permanently installed X-ray equipment must be in accordance with Standards For The Use of Inhalation Anesthetics National Fire Protection Association Bulletin No. 56A, 1972.
23.8  PHOTOGRAPHIC EQUIPMENT.  Only approved photographic equipment in ceiling lighting shall be used in anesthetizing locations.
(4)	23.28  STERILIZE. At least one pressurized steam sterilizer or equivalent shall be installed in the sub-sterilizing room, and provided with indirect waste connections and recording thermometer that indicates temperature in discharge line of sterilizer. In the case of new hospital construction, or modification of an existing hospital facility pressurized steam sterilizer or equivalent, shall be installed in each sub-sterilizing facility, and provided with an indirect waste connection and a recording thermometer that indicates temperature in the discharge line of the sterilizer.
23.104	FACILITIES
(1)	23.2  SIGNS.Signs identifying the surgical suite shall be posted at each entrance to the suite.
(2)	23.12  INTERIOR FINISHES. Interior finishes in the surgical suite shall be smooth, unbroken, and shall facilitate and withstand frequent cleaning and disinfecting.
(3)	23.1  LOCATION. The surgical suite shall be located so that traffic will not pass through the suite to any other part of the hospital and shall be separated physically from the delivery suite and emergency unit department.  23.1.1  EXCEPTION. However, in In hospitals of 30 beds or less, one operating suite may be used for surgical and delivery procedures, providing there is a labor room equipped for emergency delivery adjacent and accessible to the suite and with a minimum area of 180 sq. ft. See Section 9.3.1.
(4)	Operating Room
(a)	23.13  OPERATING ROOM(S).  The surgical suite shall be provided with at least one operating room.  There should be one operating room for each 50 beds or major fraction thereof up to and including 200 beds. Above 200 beds the number of operating rooms will be based on the expected average of daily operations.  
(b)	The operating room design, equipment, and functional layout should be commensurate to the surgical procedures performed.
(c)	Each operating room should not be less than 18 feet in any one dimension.
(d)	23.30  NURSE CALL SYSTEM. Operating room(s) shall be provided with an approved electrical nurse call system. In the case of new hospital construction, or modification of an existing hospital facility, this system must be to the operations and control station or nurses station where additional help is available.
(e)	23.27LIGHTING.  General and spot illumination shall be provided in each operating room.
23.4	ANESTHETIC IGNITION. Design and equipment of the surgical suite shall be in accordance with or equal to the Standards of the National Fire Protection Association, Code of the Use of Flammable Anesthetics, Bulletin No. 56, July 1962. In the case of new hospital construction, or modification of an existing hospital facility, the Standard For the Use of Inhalation Anesthetics, National Fire Protection Association Bulletin No. 56A, 1972 shall be met. The hospital shall recognize the dangers to patients from ignition of anesthetic gases and shall minimize this hazard in accordance with National Fire Protection Association Standards.
23.5	FLOORS. Floors in anesthetizing areas and in rooms used for storage of flammable anesthetic agents shall be conductive in accordance with or equal to the standards specified in the Code For The Use of Flammable Anesthetics, National Fire Protection Association Bulletin No. 56, July 1962. In the case of new hospital construction, or modification of an existing hospital facility, the Standard For The Use of Inhalation Anesthetics, National Fire Protection Association Bulletin No. 56A 1972 shall be met. The conductive flooring shall extend at least 10 feet beyond the immediate limits of the operating room(s). Conductivity shall be maintained.
23.5A	EXEMPTION WHEN NO FLAMMABLE ANESTHETICS ARE USED: Operating rooms may be exempt from the requirements of 23.4, 23.5, 23.6, 23.7, 23.8, 23.9, 23.10, and 23.16 (5) and 23.29 provided that a written resolution is signed by the hospital board that no flammable anesthetic agents will be used in these areas and that appropriate notices are permanently and conspicuously affixed to the wall in each area and room.
23 11	.All doorways shall meet the requirements specified in Chapter III.
(f)	23.14 CEILING HEIGHTS. The ceiling height shall not be less than 9 feet in operating rooms.
(g)	23.15   OXYGEN. Each operating room shall be provided with piped oxygen.  Nitrous oxide and vacuum are recommended.
(4)	23.16  AREAS. In addition to operating room(s) the following physically separated areas shall be provided within the suite. In the case of new hospital construction or modification of an existing hospital facility these areas shall be separated by doors and/or walls: 1) Sub-sterilizing facilities; 2) Scrubup area; 3) Cleanup room: 4) Instrument and supply storage; 5) Anesthesia storage; 6) Janitor's facilities: 7) Doctors' locker and dressing room; 8) Nurses' locker and dressing room; 9) Stretcher alcove. In the case of new hospital construction, or modification of an existing hospital facility, an anesthesia workroom must also be provided. Stretcher space must also be provided in the surgery suite.
(5)	23.17  SUB-STERILIZING. The sub-sterilizing room shall be physically separated from but adjacent to the operating room for service to the room without passing through contaminated areas. In the case of new hospital construction, or modification of an existing hospital facility, sub-sterilizing facilities shall be located to serve each operating room conveniently. More than one sub-sterilizing facility shall be provided if a suite of operating rooms is not compactly arranged
(1)	Not required in existing buildings.
(6)	23.19  SCRUBUP AREA. The scrubup area shall be adjacent to the operating room to permit immediate access to the room after scrubbing. Surgeon scrub sink(s) with knee or foot controls shall be installed in the scrubup area.
(7)	23.20  CLEANUP ROOM. A clinical sink with an integral fresh water trap seal, and a sink with wrist-blade or foot-action valves shall be installed in each cleanup room.
(8)	23.21  LOCKER ROOMS. Toilet, shower, and lavatory facilities shall be provided in the doctors' locker rooms and in the nurses' locker rooms.
(9)	23.21A  ANESTHESIA WORKROOM.  In the case of new hospital construction, or modification of an existing hospital facility, at least one anesthesia equipment workroom for the cleaning, testing and storage of anesthesia equipment shall be provided. It shall contain a work counter and sink. In hospitals of 30 beds or less, the anesthesia workroom may be combined with other spaces provided that the resulting plan will not compromise the best standards of safety and of medical and nursing practices.
(10)	Ventilation
(a)	23.22  VENTILATION. Operating rooms shall be provided with a minimum ventilation rate of 8 room volumes of outdoor air per hour with no recirculation, except when not in use, by mechanical supply and exhaust air systems. In the case of new hospital construction or modification of an existing hospital facility, operating rooms shall be provided with a minimum ventilation rate of twenty-five room volumes of air per hour by mechanical supply and exhaust air systems. (a) Outdoor air intakes shall be located as far as practical but not less than 25 feet from the exhausts from any ventilating system, combustion equipment, medical-surgical vacuum system, or plumbing vent or areas which may collect noxious fumes. The bottom of outdoor air intakes shall be located as high as practical but not less than three feet above ground level, or if installed through the roof, 3 feet above the roof level. (b) All air supplied to sensitive areas such as operating and delivery rooms and nurseries shall be delivered at or near the ceiling of the area served.
(b)	23.23	FILTERS.  Filters shall be installed down draft from blower and provide a minimum efficiency of 90% of 1-5 micron size particles. In the case of new hospital construction, or modification of an existing hospital facility: 1) All ventilation or air conditioning systems serving surgery and delivery suites shall have a minimum of two filter beds. Filter Bed No. 1 shall be located upstream of the air conditioning equipment and shall have a minimum efficiency of 25%. 2) Filter Bed No. 2 shall be downstream of the supply fan and air conditioning equipment and humidifying equipment. Filter Bed No. 2 shall have a minimum efficiency of 90% of 1-5 micron size particles. 3) Each filter bed serving sensitive areas shall have a manometer installed across each filter bed.
(c)	23.24  EXHAUST.  Exhaust outlets, at least two (2), shall be provided, not less than 4 inches above the floor. In the case of new hospital construction, or modification of an existing hospital facility, exhaust outlets, at least two (2), shall be provided in each operating room, not less than 4 inches above the floor.
(d)	23.25  PRESSURE.  The entire surgical suite shall have a balanced air pressure. The surgical suite shall be maintained at a positive air pressure relative to the air pressures of adjacent areas within the hospital. In the case of new hospital construction, or modification of an existing hospital facility, operating rooms shall have a positive air pressure relative to the air pressures of adjacent rooms within the suite. The surgical suite shall be maintained at a positive air pressure relative to the air pressures of adjacent areas within the hospital.
(e)	23.26  HUMIDITY. Relative humidity in anesthetizing areas shall be maintained at 50% plus or minus 2%. A humidistat and accurate sensing gauge shall be provided.
23.28	ELECTRICAL OUTLETS. All convenience outlets shall be explosion proof. All switches, if not explosion proof, shall be installed not less than five (5) feet above the floor in anesthetizing areas.
23.29	ISOLATION TRANSFORMERS. An ungrounded explosion proof electrical system with ground indicators shall be provided in each anesthetizing area. The isolation transformer for this system shall be located outside hazardous locations.
23.32	SURGICAL RECOVERY ROOM. Definition: Surgical recovery room means a Designated room(s) designed, equipped, staffed, and operated to provide close, individual surveillance of patients recovering from acute affects of anesthesia, surgery, and diagnostic procedures. {Moved to Definitions section}
(11)	Surgical Recovery Room
(a)	23.32.1  DESIGN. The design and equipment shall conform generally to the critical care unit. In the case of new hospital construction, or modification of an existing hospital facility, the surgical recovery room must provide for the visual observation of all patients, medicine dispensing facilities, charting facilities, clinical sink with a bedpan washer attachment, and storage space for supplies and equipment.
(b)	23.32.2  LOCATION. The surgical recovery room(s) shall be located in the surgical suite or adjacent thereto.
(c)	23.32.3  NURSING. At least one registered nurse shall be on duty at all times in the room when patients are present. Nurses shall have been instructed in the care of post-anesthetic and post-surgical patients, shall have no other duties during the time they are caring for such patients, the  The surgical recovery room shall have facilities for immediate communications with the attending surgeon, anesthesiologist, or qualified substitute present in the hospital.

24.	RADIOLOGICAL SERVICES  DIAGNOSTIC IMAGING SERVICES {Substantive changes intended}
24.101	ORGANIZATION AND STAFFING
(1)	The hospital shall provide diagnostic radiology services.   Radiological imaging shall be available at all times.  The hospital may provide other diagnostic imaging services, such as ultrasound and magnetic resonance imaging. 
(2)	24.2  ORGANIZATION.  The X-ray department Imaging services shall be under the direction of a qualified physician.  Radiology services shall be under the supervision of a full-time or consulting radiologist whose professional competence has been determined by the organized medical staff.  If radiotherapy is provided, physician-in-charge shall be qualified appropriately.  
24.102	PROGRAMMATIC FUNCTIONS
(1)	Radiological services involving the use of machines that produce ionizing radiation or the use of radioactive materials for diagnostic purposes shall be in compliance with 6 CCR 1007-1, Rules and Regulations Pertaining to Radiation Control.
(2)	The hospital shall be responsible for the formulation, implementation and periodic review of written policies and procedures governing the services offered and in addition include the management of patients with infectious diseases, critical care patients, and patients who experience medical emergencies.
24.4  RECORDS.  A written report of the findings and evaluation of each X-ray imaging examination or treatment shall be signed by the physician responsible for the procedure and shall be made a part of the patient's medical record. {Moved to Medical Records}
(3)	Diagnostic imaging services shall be ordered by a physician or other practitioner authorized by law.  The order shall include the name of the patient, the name of the ordering individual, and the radiological procedure ordered.  Services shall be provided in accordance with the order.
24.103	EQUIPMENT AND SUPPLIES.  Reserved.
24.104	FACILITIES
(1)	24.1  FACILITIES.  Hospitals shall provide within the facility adequate space and fixed equipment for diagnostic X-ray examinations, including facilities for development and storage of radiological film.  The facilities used to provide diagnostic imaging  services shall have adequate space, storage (including storage for radiological images), lighting and ventilation.

The following standards are being deleted because they are addressed in 6 CCR 1007-1, Rules and Regulations Pertaining to Radiation Control.  
24.3  SAFETY.  The hospital shall ensure that all X-ray equipment is operated under adequate professional supervision by competent personnel trained in the use of X-ray equipment and familiar with safety precautions as set forth by the National Bureau of Standards and Colorado Department of Health.  
24.5  MONITORING.  Personnel monitoring shall be maintained for each individual working in the area of radiation where there is a reasonable probability of receiving one-fourth of the maximum permissible dose. 
24.6  MONITORING RECORDS.  Personnel monitoring records resulting from the use of film badges or dosimeters shall be maintained.  Readings should be on at least a monthly basis.  Permanent records of exposure on all monitored personnel must be maintained. 
24.7  RADIOACTIVE ISOTOPES.  All radioactive isotopes shall be received, handled, used and disposed of in accordance with the requirements of the Atomic Energy Commission.  

25	Nuclear Medicine Services {Substantive changes intended}

25.100	Nuclear Medicine Services
25.101	ORGANIZATION AND STAFFING
(1)	The hospital may provide nuclear medicine services.  The following standards shall apply only if the hospital provides such services.
(2)	Nuclear medicine services shall be under the direction of a qualified physician.  
25.102	PROGRAMMATIC FUNCTIONS
(1)	Nuclear medicine services shall be in compliance with 6 CCR 1007-1, Rules and Regulations Pertaining to Radiation Control.
(2)	There shall be written policies and procedures for all services offered which shall additionally include:
(a)	steps to take in the event of an adverse reaction.
(b)	protection from non-therapeutic radiation exposure for patients and visitors while in the hospital.
(c)	information to be provided to patients who receive nuclear medicine therapy and still have radioactive particles in their bodies regarding how to prevent/minimize radiation exposure of others .
25.103	EQUIPMENT.  Reserved.  
25.104	FACILITIES.  Reserved.

26  25	CENTRAL MEDICAL-SURGICAL SUPPLY SERVICES {Reorganization only.  No substantive changes intended.}
26.101	ORGANIZATION AND STAFFING
(1)	25.1  SERVICES.  All hospitals shall provide central medical-surgical supply services with facilities for processing, sterilizing, storing, and dispensing supplies and equipment for all units departments/services of the hospital.
(2)	25.10  ORGANIZATION. The central medical-surgical supply services shall be organized as a unit service under the immediate supervision of a person who is competent in management, asepsis, supply processing, and control methods. 
(3)	25.10  ORGANIZATION. Sufficient supporting personnel shall be assigned to the service unit and properly trained in central medical-surgical supply services.
26.102	PROGRAMMATIC FUNCTIONS
(1)	25.11  STERILIZATION CONTROLS.  Continuous supervision shall be maintained throughout receiving, cleaning, processing, sterilizing, and storing. A combination of controls or indicators shall be used to determine the effectiveness of the sterilization process. Bacteriological methods shall be used to evaluate the effectiveness of sterilization, by at least monthly cultures with records maintained.
(2)	25.12  WRITTEN PROCEDURES.  Written policies and procedures shall be established for all functions of central medical-surgical supply services. Such written procedures shall include, but not be limited to, obtaining, cleaning, processing, sterilizing, storing and issuing supplies.  These policies and procedures shall be periodically reviewed by the Infection Control Committee, as applicable.
(3)	25.13  TRAINING PROGRAMS. Policies shall be established to provide supervision and training programs for all personnel involved in central medical-surgical supply operations and services.
(4)	25.8  STERILE SOLUTIONS. Water used for sterile solutions shall be distilled and sterilized in flasks which are resistant to heat, chemical, and electrical action.
(6)	25.6  DRY HEAT AND CHEMICALS. Dry heat and special chemical methods are available and acceptable for sterilization of materials which would be damaged by pressurized steam.
26.103	EQUIPMENT
(1)	25.5  PRESSURIZED STEAM. Pressurized steam sterilizers, or equivalent, and water stills, of approved type and necessary capacity for adequate sterilization, shall be provided and maintained.  Pressurized steam sterilizers shall be installed and provided with indirect waste connections and a recording thermometer that indicates temperature in discharge line of the sterilizer. All sterilizers that emit steam exhaust shall be vented. Such vents shall be installed in such a manner as to avoid recirculation.
26.104	FACILITIES
(1)	25.2  FACILITIES. This service shall be separated physically from other areas of the hospital and shall include areas designated for the following: 1) Receiving; 2) Cleaning and processing; 3) Sterilizing; 4) Storing clean and sterile supplies; 5) Storing bulk supplies and equipment.
(2)	25.3  CLEANING AREA.  A two-compartment sink, with counter or drainboard and knee-or-wrist action valves, shall be provided in the cleaning area.
(3)	25.4  PROCESSING AREA.  Adequate cabinets, cupboards, and other suitable equipment shall be provided for the processing of materials and for the storage of equipment and supplies in a clean and orderly manner.
(4)	25.5  PRESSURIZED STEAM. Pressurized steam sterilizers, or equivalent, and water stills, of approved type and necessary capacity for adequate sterilization, shall be provided and maintained. Pressurized steam sterilizers shall be installed and provided with indirect waste connections and recording thermometer that indicates temperature in discharge line of the sterilizer. All sterilizers that emit steam exhaust shall be vented.  Vents used for sterilizers that emit steam exhaust Such vents shall be installed in such a manner as to avoid recirculation.
25.7	BOILING WATER. Boiling water is prohibited as a method of sterilization.
(5)	Ventilation
(a)	25.9  VENTILATION.  Ventilation to this area may be supplied from the general ventilation system, if properly filtered.
(b)	The flow of air should be from the clean areas toward the exhaust in the soiled area. Exhausts should be installed over sterilizers to prevent condensation on walls and ceilings. In the case of new hospital construction or the modification of a hospital facility, the flow of air shall be from the clean areas toward the exhaust in the soiled area. 
(c)	Exhausts shall be installed over sterilizers to prevent condensation on walls and ceilings.

27  26	HOUSEKEEPING SERVICES  {Substantive changes intended}
27.101	ORGANIZATION AND STAFFING
(1)	26.1  ORGANIZATION. Each hospital shall establish organized housekeeping services planned, operated, and maintained to provide a pleasant, safe and sanitary environment.  The hospital environment shall be clean and sanitary.
(2)	26.1  The services should be shall under the supervision of a person competent in environmental sanitation and management.
27.102	PROGRAMMATIC FUNCTIONS
(1)	26.2  WRITTEN POLICIES. Written policies and procedures shall be established and implemented for cleaning the physical plant and equipment.  The policies and procedures shall be designed to prevent and control infection.  At minimum, the policies and procedures shall address:  cleaning schedules, cleaning methods, the proper use and storage of cleaning supplies, hand washing, and the supervision and training of housekeeping personnel. These policies and procedures shall be periodically reviewed by the Infection Control Committee, as applicable. 
26.3  WRITTEN PROCEDURES. There shall be specific written procedures for appropriate cleaning of all service areas in the hospital, giving special emphasis to procedures applying to infection control.
26.4  CLEANING METHODS. Cleaning shall be performed in a manner to minimize the spread of pathogenic organisms in the hospital atmosphere.
26.8	CRITICAL AREAS. Emergency, delivery, nursery, and surgical suites and intensive care and recovery units shall be maintained at a particularly high level of cleanliness at all times.
(2)	26.9 DRY DUSTING AND SWEEPING.  Dry dusting and sweeping are prohibited.
26.12	WASTE DISPOSAL. The hospital shall make provision for proper and safe disposal of all types of waste products. {Moved to Waste Disposal Section}
(4)	26.13  HANDWASHING. All personnel shall wash their hands thoroughly after handling waste products.
(5)	26.11  RUBBISH AND REFUSE CARTS. Accumulated waste material shall be removed at least daily.
26.14  TRAINING PROGRAMS. Policies shall be established to provide supervision and training programs for housekeeping personnel.
27.103	EQUIPMENT AND SUPPLIES
(1)	26.5  EQUIPMENT AND SUPPLIES. Suitable equipment and supplies shall be provided for cleaning of all surfaces. Such equipment shall be maintained in a safe, sanitary condition.
(2)	26.6	GERMICIDES. Selection of germicides shall be under the supervision of competent individual(s).
(3)	26.7 STORAGE. Solutions, cleaning compounds, and hazardous substances shall be labeled properly and stored in safe places. Paper towels, tissues, and other supplies shall be stored in a manner to prevent their contamination prior to use.
(4)	26.10  RUBBISH AND REFUSE CONTAINERS. All rubbish and refuse containers shall be impervious and tightly covered.
(5)	26.11  RUBBISH AND REFUSE CARTS. Carts used to transport rubbish and refuse shall be constructed of impervious materials, shall be enclosed, and shall be used solely for this purpose. 
27.104	FACILITIES.  Reserved.

28  27	LINEN AND LAUNDRY SERVICES {Substantive changes intended}
28.101	ORGANIZATION AND STAFFING
(1)	The hospital shall provide linen and laundry services.  There shall be proper laundering of washable goods and a sufficient supply of clean linen.  
(2)	Linen and laundry services shall be under the supervision of a person qualified by education, training and experience.
28.102	PROGRAMMATIC FUNCTIONS
(1)	There shall be written policies and procedures for the collection, processing, distribution and storage of linen.  These policies and procedures shall be periodically reviewed by the infection control committee, as applicable.
(2)	Clean linen shall be stored and distributed to the point of use in a way that minimizes microbial contamination from surface contact or airborne particles.
(3)	Soiled linen shall be collected at the point of use and transported to the soiled linen holding room in a manner that minimizes microbial dissemination.
28.103	EQUIPMENT
(1)	The hospital shall only use commercial laundry equipment to process hospital linen and laundry.
208.104	FACILITIES
(1)	27.13 Laundry Facilities Area.  Where a total laundry service is provided within the hospital, the laundry shall have a sufficient capacity, to process a continuous seven days' supply: 1) At least two washers with a combined rated capacity of not less than twelve pounds of dry laundry per day per patient bed when operating not more than 40 hours a week. 2) At least one extractor with a daily capacity equal to that given to the washer.  3) At least one tumbler with a rated capacity equal to twenty-five percent of one of the washers when operating forty hours per week. 5) At least one flat ironer with a capacity equal to seventy percent of the washer capacity operating forty hours per week.  The laundry equipment shall be provided with all safety appliances and sanitary requirements.  The equipment shall be designed and installed to comply with all local and state code laws.  There should be proper spacing and placing of the equipment to minimize material transportation and operation, to avoid all cross operations, and to provide storage between operations.  {Language seems too specific, and is more specific than AIA – see 7.23, p. 61}  Handwashing facilities and a toilet should be available in the laundry area.  27.12  VENTILATION.  In the laundry serving the hospital, the soiled linen holding and sorting area shall be a separate, well-ventilated room with negative pressures relative to adjacent areas.  Recirculation of air from this room shall not be permitted.  (Addressed in soiled linen storage and sorting section above.)  The air in the washing area shall be vented away from the area of extracting, ironing and finishing.  {Language is more specific than AIA}  The general air movement shall be from the cleanest areas to the most contaminated areas.  A minimum ventilation rate of ten room volumes of outside air per hour with no recirculation is recommended for the laundry proper.  Eight room volumes of outside air per hour is recommended for the sorting area.  Laundry exhaust should be carried to a point above the roof or 50 feet away from any window and shall should not discharge near any fresh air inlet.
(2)	Soiled Linen Storage and Sorting Area
	(a)	27.11  Soiled Linen Storage and sorting area. If a laundry is not provided in the hospital, a soiled linen storage room and a clean linen storage room shall be provided. 
	(b)	Soiled linen storage room shall be enclosed, designed and used solely for that purpose, and provided with exhaust ventilation direct to the outside.  Recirculation of air from this room shall not be permitted.  27.12  VENTILATION.  In the laundry serving the hospital, the soiled linen holding and sorting area shall be a separate, well-ventilated room with The room shall have negative pressures relative to adjacent areas.  Eight room volumes of outside air per hour is recommended for the sorting area.  27.11  In the case of new hospital construction, or modification of an existing hospital facility, a soiled linen storage and sorting room shall be enclosed, designed and used solely for that purpose, and the room shall also be mechanically ventilated to the outside air.  
(3)	Clean Linen Storage
27.16  Clean Linen Storage ROOM
	(a)	A clean linen storage and sewing room shall be provided separate from the laundry room.
	(b)	27.19  CLEAN LINEN STORAGE.  Clean linen stored on patient care units shall be in closets, shelves, conveyances, or rooms used only for clean linen storage.

27.1	PATIENT LINEN.  In removing and handling soiled linen from a patient's bed, there shall be minimum shaking of the linen.  Soiled linen, including blankets, shall be placed in bags enclosed immediately in the patient's room.  Clean non-used linen also shall be placed in bags enclosed before removal from a patient's room.  The bags shall remain closed during transportation to soiled linen holding area and laundry.
27.2	INFECTIOUS DISEASE LINEN.  All linens and blankets from  patients with infectious disease shall be placed in special bags identified “contaminated” and transported in these enclosed bags to soiled linen holding area and laundry.
27.3	NURSERY LINEN.  All nursery linen shall be placed in bags identified “nursery” and transported in the enclosed bags to soiled linen holding area and laundry.
27.4	OTHER SOILED LINEN.  All other soiled linen shall be placed in bags enclosed in the immediate area of contamination and transported enclosed to soiled linen holding area and laundry.
27.5	SORTING AND PRE-RINSING.  Soiled linen shall be neither sorted nor pre-rinsed on patient care units.  Bathtubs, showers, and lavatories shall not be used to launder nor store linens.  No laundry operations shall be carried out in patient care areas nor in areas where food is prepared, served, or stored.
27.6	HANDWASHING.  All personnel shall wash their hands thoroughly after handling any soiled linen.
27.7	SOILED LINEN TRANSPORTATION.  Soiled linen, though enclosed in a bag, shall be removed from patient care units at least every 8 hours and transported to an enclosed storage area designated solely for that purpose.
27.8	SOILED LINEN CARTS.  Carts and hampers used to transport soiled linen shall be constructed of impervious materials, cleaned and disinfected after each use.
27.9	LINEN CHUTES.  If linen chutes are used, all soiled linen shall be in enclosed bags before placing them in chute.  Laundry chutes shall be cleaned regularly and by approved methods.
27.10	LINEN PROCESSING.  The hospital shall provide for proper handling, cleaning, and disinfecting of linen and other washable materials in its own laundry or in a commercial laundry.
27.14	SOILED LINEN SORTING.  Soiled linen shall be sorted only in the sorting area.
27.15	WASHING TEMPERATURE.  The temperature of water during the washing process shall be controlled to provide minimum temperature of 165° F (74° C) for 25 minutes.
27.16	CLEAN LINEN STORAGE ROOM.  A clean linen storage and sewing room shall be provided separate from the laundry room.
27.17	COMMERCIAL LAUNDRY SERVICES.  A contract for laundry services performed by commercial laundries for hospitals, shall provide for these standards.
27.18	CLEAN LINEN TRANSPORTATION.  Clean linen shall be returned to storage areas separate for the laundry, in clean enclosed conveyances used only for transporting clean linen.

29  28	MAINTENANCE SERVICES {Substantive changes intended}
29.101	ORGANIZATION AND STAFFING
(1)	The hospital shall provide facility maintenance services which shall be responsible for the upkeep of the hospital’s grounds, physical plant, equipment and furnishings.  The grounds, physical plant, equipment and furnishings shall be hazard free and in good repair.
(2)	28.2  SUPERVISION.  The building and mechanical programs shall be under the direction of a qualified person informed in the operations of the facility and in the building structures, their component parts and facilities.
(3)	30.1  INSECT, PEST, AND RODENT CONTROL.  The pesticides shall not be stored in patient or food areas and shall be kept under lock, and Oonly properly trained responsible personnel shall be allowed to apply insecticides and rodentcides.  
29.102	PROGRAMMATIC FUNCTIONS
(1)	28.1 WRITTEN POLICIES AND PROCEDURES.  There shall be The hospital shall implement written policies and procedures for an organized maintenance program to keep the entire facility in good repair and to provide for the safety, welfare, and comfort of the occupants of the building(s).
(2)	Physical Plant Maintenance
	(a)	Inspections and maintenance shall be conducted, in accordance with written maintenance schedules, of physical plant systems including but not limited to the electrical system, emergency power generators, water supply, and ventilation.  
	(b)	Records shall be maintained showing the date of maintenance and action taken to correct any deficiencies.
(3)	Equipment Maintenance
	(a)	Inspections and preventive maintenance shall be conducted in accordance with written maintenance schedules of equipment, including equipment used for direct patient care, to ensure that it is in good working order.  Preventive maintenance includes, but is not limited to, routine inspections, cleaning, testing and calibrating in accordance with manufacturer’s instructions or if there are not manufacturers’ instructions, as specified by the hospital’s written policies and procedures.
	(b)	Records shall be maintained showing the date of maintenance and action taken to correct any deficiencies.
(4)	Insect, Pest, and Rodent Control
	(a)	30.1  INSECT, PEST, AND RODENT CONTROL.  Written policies and procedures shall provide for The facility shall develop and implement written policies and procedures for the effective control and eradication of insects, pests, and rodents.  In the case of new hospital construction, or modification of an existing hospital facility, the facility shall have a pest control program provided by maintenance personnel or by contract with a pest control company using the least toxic and least flammable effective pesticides.  
	(b)	30.1  INSECT, PEST, AND RODENT CONTROL.  The pPesticides shall not be stored in patient or food areas and shall be kept under lock, and only properly trained responsible personnel shall be allowed to apply insecticides and rodentcides.  Screens or other approved methods shall be provided on all exterior openings and the structure so maintained as to prevent entry of rats or mice through cracks in foundations, holes in walls, around service pipes, etc.  Written policies and procedures shall be developed for these control measures
29.103	EQUIPMENT.  Reserved.
29.104	FACILITIES
(1)	30.1  INSECT, PEST, AND RODENT CONTROL.  Screens or other effective approved methods shall be provided on all exterior openings and the structure so maintained as to prevent entry of rats or mice through cracks in foundations, holes in walls, around service pipes, etc.  

30 29	WASTE DISPOSAL SERVICES  INCINERATOR  {Substantive changes intended.}
30.101	ORGANIZATION AND STAFFING
(1)	The hospital shall provide for the safe disposal of all types of waste products.  26.12  The hospital shall make provision for proper and safe disposal of all types of waste products.
(2)	Infectious waste disposal shall be directed by a person qualified by education, training, and experience in the principles of infectious waste management.  
30.102	PROGRAMMATIC FUNCTIONS
(1)	The hospital shall implement written policies and procedures to ensure the safe disposal of waste products.  The policies and procedures shall address:
	(a)	31.1  SEWAGE AND SEWER SYSTEMS.  Sewage.  All sewage shall be discharged into a public sewer system., or if such is not available, shall be disposed of in a manner approved by the State Health Department. The State Health Department shall determine the availability of the public sewer system.
	(b)	garbage and refuse.  31.2  All garbage and refuse, not treated as sewage, shall be collected in approved and stored in covered containers in such a manner as not to become a nuisance, and shall be removed from the hospital premises as frequently as necessary to prevent nuisance or health hazards or incinerated once a day.
	(c)	31.3  PATHOLOGICAL.  Pathological and bacteriological wastes, dressings, and other contaminated wastes must be incinerated at the hospital or disposed of by other methods approved by the State Department of Health  infectious waste.  Infectious waste shall be handled and disposed of in accordance with the requirements of C.R.S. 25-15-401, et seq.
	(d)	biological non-infectious waste.
(2)	31.2  Refuse or garbage shall not be burned on the premises except in an approved incinerator.  29.1  PATHOLOGICAL WASTE. (1)n case of new hospital construction or modification of an existing hospital facility, as such construction or modification relates to pathological waste, an incinerator shall be provided on-site or by off-site shared services for the complete destruction of pathological waste.  Off-site shared services shall be approved by the Colorado Department of Health.  Incinerators shall comply with federal, Sstate and local air Ppollution regulations and be so constructed as to prevent insect and rodent breeding and harborage. 
1) Facilities existing prior to April 1, 1979 may dispose of pathological waste by other methods approved by the State Department of Health.

29.2  INCINERATOR, RUBBISH.  In the case of new hospital construction or modification of an existing hospital facility, as such construction or modification relates to rubbish incineration, incinerators shall comply with State and local air pollution regulations and be so constructed as to prevent insect and rodent breeding and harborage.
29.3  SAFETY.  Incinerators with capacities up to 500 pounds shall have the enclosing walls of combustion chambers lined with fire brick not less than 42 inches thick, and incinerators of greater capacity shall have not less than 9-inch brick lining or equivalent.
30.103	EQUIPMENT
(1)	31.2  Incinerators shall comply with state and local air pollution regulations and be so constructed as to prevent insect and rodent breeding and harborage.
(2)	31.4  FACILITIES.  A sufficient number of sound water-tight containers with tight fitting lids, to hold all refuse that accumulates between collections, shall be provided. Lids must be kept on the containers. Racks or stands must be kept in good repair. Garbage containers shall be cleaned each time emptied. (Single service container liners are recommended).
30.104	FACILITIES.  
(1)	31.1  SEWAGE AND SEWER SYSTEMS.  All sewage shall be discharged into a public sewer system, or if such is not available, shall be disposed of in a manner approved by the State Health Department. The State Health Department shall determine the availability of the public sewer system. No exposed sewer line shall be located directly above working, storing, or eating surfaces in kitchens, dining rooms, pantries, or food storage rooms, or where medical or surgical supplies are prepared, processed, or stored.
(2)	31.4  FACILITIES.  A sufficient number of sound water-tight containers with tight fitting lids, to hold all refuse that accumulates between collections, shall be provided. Lids must be kept on the containers. Racks or stands for garbage containers shall must be kept in good repair. Garbage containers shall be cleaned each time emptied. (Single service container liners are recommended).  A paved storage area for the containers should be provided.