1. (1) Legal Authority for Adoption of Rules. The following rules for Rural Emergency Hospitals are adopted by the Alabama State Board of Health pursuant to §22-21-20, et seq., Code of Ala. 1975.

2. (2) Definitions.

   1. (a) "Administrator" means a natural person who is the governing authority of the rural emergency hospital (REH) or a natural person who is designated by the governing authority of the REH and who is delegated the responsibility and authority for the interpretation, implementation, and proper application of policies and programs established by the governing authority. The administrator is delegated responsibility for the establishment of safe and effective administrative management, control, and operation of the services provided.
   2. (b) "Anesthesiologist" means a person currently licensed by the Medical Licensure Commission of Alabama to practice medicine in Alabama pursuant to the provisions contained in current state statutes.
   3. (c) "Anesthesiologist Assistant" means a person currently licensed by the Alabama State Board of Medical Examiners to perform anesthesiology services in Alabama under the direct supervision of an Alabama licensed anesthesiologist pursuant to the provisions contained in current state statutes.
   4. (d) "Board" or "State Board of Health" means the Alabama State Board of Health.
   5. (e) "Certified Registered Nurse Anesthetist" (CRNA) means a registered nurse who is certified to provide advanced practice nursing as a nurse anesthetist and is presently licensed to practice nursing by the Alabama Board of Nursing under the provisions contained in current state statutes.
   6. (f) "Clinical Nurse Specialist" means a registered nurse who, through study and supervised practice at the graduate level and as evidenced by certification, has advanced knowledge and practice skills in a specialized area of practice, and is presently licensed to practice nursing by the Alabama Board of Nursing under the provisions contained in current state statutes.
   7. (g) "Critical Access Hospital" (CAH) means a hospital licensed by the Department that provides inpatient care for an average annual length of stay not to exceed 96 hours, complies with Alabama's Rural Health Plan and all requirements applicable to general hospitals, and has a maximum of 45 beds.
   8. (h) "Dentist" or doctor of dental surgery or dental medicine means a person currently licensed by the Board of Dental Examiners of Alabama to practice dentistry in Alabama pursuant to the provisions contained in current state statutes.
      
   9. (i) "Department" means the Alabama Department of Public Health.
   10. (j) "Governing Authority" means the owner(s), hospital association, county hospital board, board of directors, board of governors, board of trustees, or any other comparable designation of a body duly organized and constituted for the purpose of owning, acquiring, constructing, equipping, operating, and maintaining an REH, and exercising control over the affairs of said hospital.
   11. (k) "Hospital" means a health institution licensed in Alabama by the Board which is planned, organized, and maintained pursuant to the Board's Rules for Hospitals, Chapter 420-5-7, Ala. Admin. Code.
       
       
   12. (l) "License" means the legal authority to operate an REH and to offer and provide care as permitted under these rules. A license may only be granted by the Board through the actions of its authorized agents.
   13. (m) "License Certificate" means a document issued by the Department showing that the entity named on the document is licensed as an REH. A license certificate shall contain the signature of the State Health Officer and other seals and markings designed to demonstrate its authenticity. The license certificate shall be posted in a conspicuous place on the hospital premises.
   14. (n) "Licensed Practical Nurse" (LPN) means a person currently licensed by the Alabama Board of Nursing to assist physicians and registered nurses and to provide such services in Alabama under the provisions contained in current state statutes.
   15. (o) "Medical Director" means a physician currently licensed by the Medical Licensure Commission of Alabama to practice medicine and/or surgery and is responsible for planning, organizing, conducting, and directing the medical affairs of the REH.
   16. (p) "Nurse Practitioner" (NP) means a certified registered nurse practitioner (CRNP) who is certified to provide advanced practice nursing in the delivery of nursing services within a health care system that provides for consultation, collaborative management, or referral as indicated by the health status of the client and is presently licensed to practice nursing by the Alabama Board of Nursing under the provisions contained in current state statutes. CRNPs practice pursuant to a collaborative agreement with a physician licensed by the Medical Licensure Commission of Alabama.
   17. (q) "Physician" means a person currently licensed by the Medical Licensure Commission of Alabama to practice medicine in Alabama under the provisions contained in current state statutes. The term includes both doctors of medicine and doctors of osteopathy.
   18. (r) "Physician Assistant" (PA) means a person currently licensed by the Alabama State Board of Medical Examiners to perform medical services in Alabama under the supervision of a licensed physician pursuant to the provisions contained in current state statutes.
   19. (s) "Podiatrist" or doctor of podiatric medicine means a person currently licensed by the State of Alabama Board of Podiatry to practice podiatry in Alabama pursuant to the provisions contained in current state statutes.

   20. (t) "Principal" means an individual associate with a governing authority or a license applicant in any of the following capacities:
       

       1. 1. Administrator, or equivalent;
       2. 2. Chief Executive Officer, or equivalent;
       3. 3. Owner of a controlling interest in the governing authority, or, if the governing authority is a subsidiary of another business entity, owner of a controlling interest in the parent business entity; or
       4. 4. If no person has a controlling interest in the governing authority or in a parent corporation of the governing authority, then an owner of 10 percent or more of the governing authority or of any business entity of which the governing authority is a subsidiary.
   21. (u) "Registered Nurse" (RN) means a person who provides nursing services and holds an active license issued by the Alabama Board of Nursing.

   22. (v) "Rural Emergency Hospital" (REH) means a licensed hospital that, as of December 27, 2020, was previously licensed by the Board as a critical access hospital or a general acute care hospital, as defined in Section 1886(d)(l)(B) of the Social Security Act, with no more than 50 beds, that is considered rural, as defined in Section 1886(d)(2)(D)of the Social Security Act; or that, as of December 27, 2020, was treated as being located in a rural area that has had an active reclassification from urban to rural status; and has elected to convert to a hospital that:

       1. 1. Is enrolled as an REH with the Centers for Medicare and Medicaid Services (CMS) until:

          1. (i) Such time as the facility elects to convert back to its prior designation as a CAH or a subsection (d) hospital, as defined in Section 1886(d)( 1)(B) of the Social Security Act, as codified at 42 U.S.C. §1395ww; or
          2. (ii) The facility does not meet the requirements applicable to an REH, as determined by the Secretary of the U.S. Department of Health and Human Services.
       2. 2. Has no more than 50 beds as of December 27, 2020. For purposes of conversion to an REH, the bed count will be determined by calculating the number of available bed days during the most recent cost reporting period divided by the number of days in the most recent cost reporting period;
       3. 3. Is restricted to the provision of outpatient services, as defined in paragraph (l) herein;
       4. 4. Has in effect a transfer agreement with a Medicare-certified hospital, either in the state of Alabama, or in a bordering state, that is designated as a Level I or Level II trauma center;
       5. 5. Meets all current licensure requirements set forth by the Board;
       6. 6. Meets the requirements of a staffed emergency department, as set forth herein;
       7. 7. Meets the federal conditions of participation applicable to REHs under CMS regulations; and

       8. 
          8. Submits a detailed transition plan that lists the specific services that the REH will retain, modify, add, and/or discontinue upon conversion and a description of the services that it intends to furnish on an outpatient basis as an REH.

          Facilities that were enrolled as critical access hospitals or rural hospitals with not more than 50 beds as of December 27, 2020, and then subsequently closed after that date, would also be eligible to seek REH designation if they re-enroll in Medicare and meet all of the conditions of participation and licensure requirements for REHs, including an initial onsite survey by the Department.

   23. (w) "Rural Emergency Hospital Services" means the following services furnished by an REH that do not exceed an annual per patient average of 24 hours in the REH:

       1. 
          1. Emergency department services, observation care, and other outpatient and medical services in which the average length of patient stay does not exceed 24 hours. The time calculation for this determination begins with the registration, check-in or triage of the patient (whichever occurs first) and ends with the discharge of the patient from the REH (which occurs when the physician or other appropriate clinician has signed the discharge order or at the time the outpatient service is completed and documented in the medical record).
       2. 2. The services provided shall not include any acute care inpatient services, except for the furnishing of post-REH or post-hospital extended care services in the case where the REH includes a distinct part unit of the facility that is licensed as a skilled nursing facility.

   24. (x) "Staffed Emergency Department" means:

       1. 1. At a minimum, the emergency department (ED) is physically staffed 24 hours a day, 7 days a week by a physician, an NP, or a PA competent in the skills needed to address emergency medical care and able to receive patients and activate the appropriate medical resources to meet the care needed by the patient.

       2. 2. The REH must have a professional health care staff consisting of one or more physicians, and may include one or more PAs, NPs, or Clinical Nurse Specialists. Applicable staffing and staffing responsibilities under CMS regulations are met.

          1. 
             (i) An RN, Clinical Nurse Specialist, or LPN must be on duty whenever the REH has one or more patients receiving emergency care or observation care.
          2. (ii) A physician must be present for sufficient periods of time to provide medical direction, consultation, and supervision for the services provided in the REH, and is available through direct telephone or electronic communication for consultation, assistance with medical emergencies, or patient referral.
          3. (iii) The REH must have a physician, a PA, or NP with training or experience in emergency care on call at all times and immediately available by telephone and available onsite within 30 minutes.
          4. (iv) Whenever a patient is placed in observation care at the REH by an NP or PA, a physician on the staff of the REH is notified of the patient's status.
       3. 3. An REH shall be in compliance with the CAH conditions of participation, as they relate to emergency services provided by CAHs, as well as the hospital emergency services requirements, as determined by CMS to be applicable.

Author: Dana H. Billingsley

Statutory Authority: Code of Ala. 1975, §§22-21-20, et seq.

History: New Rule: Published August 31, 2023; effective October 15, 2023.