(a)

1. (1) An institution shall have an organized governing body that shall be legally responsible for:

   1. (A) Maintaining quality patient care; and
   2. (B) Establishing policies for the facility.
2. (2) The governing body shall be legally responsible for the conduct of the institution.

(b) Governing body bylaws.

1. (1) The governing body shall adopt written bylaws that shall be available to all members of the governing body.

2. (2) The bylaws shall ensure:

   1. (A) Maintenance of proper standards of professional work in the hospital;
   2. (B) The medical staff functions in conformity with reasonable standards of competency;
   3. (C) The method of selecting members and officers with terms and responsibilities delineated;
   4. (D)

(i) The selection of an administrator or chief executive officer with responsibilities for operation and maintenance of the facility delineated.

1. (ii) In the absence of the administrator, an alternate with authority to act shall be designated;

   1. (E) Methods for establishing governing body committees with the duties of each committee delineated;
   2. (F) Coordination of activities and general policies of the departments and special committees;
   3. (G) Liaison between the governing body and medical staff with quarterly documentation;
   4. (H) Quarterly governing body meetings with maintenance of minutes signed by an officer;
   5. (I) Provision for formal approval of the organization, bylaws, rules, and regulations of the medical staff and their services;

   6. (J)

      1. (i) Admission of patients by a physician, patient choice of physician and/or dentist, and emergency care by a physician.
      2. (ii) All institutions governed by these standards shall arrange for one (1) or more persons duly licensed to practice medicine to be called in an emergency.
      3. (iii) All individuals, who are not hospital employees, who make entries into the medical record, shall be credentialed through the medical staff;
   7. (K) A method of credentialing or appointing members to the medical staff and other authorized staff;
   8. (L) Methods by which quality assurance/performance improvement (QA/PI) is established; and

   9. (M) Establishment of a quorum to be met in order to conduct business.

      1. (c) Governing body minutes. The governing body minutes shall include at least the following information:
2. (1) Review, approval, and revision of the governing body bylaws and the medical staff bylaws, rules, and regulations;
3. (2) Election of officers as indicated in the bylaws;
4. (3) Documentation that the liaison between the governing body and medical staff is maintained;
5. (4) Appointment and reappointment of the medical staff and other authorized staff as indicated in the bylaws;

6. (5) Review and approval of the hospital’s:

   1. (A) Annual operating budget; and
   2. (B) Capital expenditure plan;
7. (6) Review and approval of reports received from the medical staff and administration; and
8. (7) Review and approval of the quality assurance/performance improvement (QA/PI) plan of the facility at least annually and also documentation of the quarterly quality assurance/performance improvement (QA/PI) summaries.