1. (a) Respiratory care services shall be under the direction of a physician member of the medical staff.
2. (b) Respiratory care services, including equipment, shall be supervised by a qualified and trained respiratory therapist.

3. (c) There shall be sufficient personnel qualified and trained in respiratory care to provide respiratory care services:

   1. (1) Services may be performed by an assistant only when a qualified and trained respiratory therapist is readily available for consultation; and
   2. (2) Personnel qualified and trained in respiratory care shall be on the premises whenever continuous ventilatory support is provided to patients.

4. (d) All respiratory care personnel shall maintain competency in:

   1. (1) Life support measures;
   2. (2) Isolation techniques; and
   3. (3) Safety techniques for oxygen and oxygen equipment.

5. (e)

   1. (1) The policy and procedure manual shall have evidence of ongoing review and/or revision.

   2. (2) The first page of the manual shall have the:

      1. (A) Annual review date; and
      2. (B) Signature of the department supervisor and/or person or persons conducting the review.

6. (f) Policies and procedures shall include:

   1. (1) Job descriptions;

   2. (2) Documentation verified by the physician director of who may:

      1. (A) Perform special procedures; and
      2. (B) Give patient instructions;
   3. (3) Safety practices;
   4. (4) Handling, storage, and dispensing of therapeutic gases;
   5. (5) Infection prevention and control measures;
   6. (6) Assembly and operation of equipment;
   7. (7) Respiratory care services provided and a list of services shall be available to the medical staff;
   8. (8) Steps to take in the event of an adverse reaction;
   9. (9) Cleaning, disinfecting, and sterilizing procedures; and
   10. (10) Orientation policies for new employees.

7. (g)

   1. (1) Clinically relevant educational programs shall be conducted on a regularly scheduled basis of not less than twelve (12) per year.

   2. (2) There shall be evidence of:

      1. (A) Program dates;
      2. (B) Attendance; and
      3. (C) Subject matter.

8. (h) If arterial blood gases are performed, the respiratory care department shall:

   1. (1) Subscribe to a nationally recognized proficiency testing program for blood gases; and
   2. (2) Meet the quality control requirements for clinical laboratories.

9. (i)

   1. (1) The respiratory care service shall have sufficient equipment and adequate facilities appropriate for safety and effective provision of care.
   2. (2) Equipment shall be serviced, calibrated, and operated according to manufacturers’ directions.
   3. (3) An approved safety system shall be used with therapeutic gases.
   4. (4) Resuscitation, ventilatory, and oxygenation support equipment shall be available for patients of all sizes.
   5. (5) Ventilators for continuous assistance or controlled breathing shall be equipped with alarm systems.
   6. (6) A preventive maintenance program shall be implemented and records maintained for the life of the equipment.

10. (j) All respiratory care prescription/work requests shall specify:

    1. (1) The type, frequency, and duration of each treatment; and

    2. (2) As required, the:

       1. (A) Type and dose of medication; and
       2. (B) Type of diluent and oxygen or medical air.

11. (k)

    1. (1) Respiratory care reports of blood gas results shall be:

       1. (A) Prepared in duplicate; and
       2. (B) Signed by the therapist responsible for the procedure/test.
    2. (2) The original shall be placed in the patient’s medical record and the copy retained in the department file.

12. (l)

    1. (1) Accurate records shall be maintained regarding the type and duration of each treatment given.
    2. (2) These records shall be correlated with the patient’s medical record.

13. (m) Respiratory care documentation for each patient shall include:

    1. (1) Current written plan of care to include goals and objectives;
    2. (2) Instructions to patient or patient’s family; and
    3. (3) Type and duration of the treatment given.

14. (n) When oxygen is being administered to a patient:

    1. (1) Patients, visitors, and personnel shall be apprised of the fire hazard; and
    2. (2) If the patient is in a tent, alcohol or rub-on lotion shall not be used.
15. (o) Oxygen shall be humidified in accordance with physician’s orders.

16. (p)

    1. (1) If reusable reservoirs are used to humidify the oxygen, the reservoirs shall be cleaned and disinfected to a high level of disinfection.
    2. (2) A high-level disinfection can be expected to kill all microorganisms with the exception of high numbers of bacterial endospores.
    3. (3) Only sterile solutions and diluents shall be used in humidification and nebulizing equipment.
    4. (4) Nebulizers, inline and hand-held, between treatments on the same patient shall be disinfected to a high level and rinsed in sterile water or, if a small-volume medication nebulizer, air-dried.
    5. (5) All other semicritical equipment shall be cleaned and disinfected in accordance with the Centers for Disease Control and Prevention’s guidelines.
17. (q) After use, all equipment shall be returned to a central location for thorough cleaning, servicing, and disinfecting before use on another patient.
18. (r) There shall be an ongoing QA/PI program.
19. (s) Contracted respiratory care services shall be under current agreement and the contractor shall fulfill all requirements of this section.
20. (t) Note. The National Fire Protection Association Vol. 99, Health Care Facilities, is a mandatory reference for developing safety rules for respiratory care services.

Codification Notes: “QA/PI” means quality assurance/performance improvement.