(a)

1. (1) Each institution shall have an administrator responsible for the management of the institution.
2. (2) In the absence of the administrator, an alternate with authority to act shall be designated.

3. (3) The responsibilities of the administrator shall include:

   1. (A) Keeping the governing body fully informed of the conduct of the hospital by:

(i) Submitting periodic written reports; or

1. (ii) Attending meetings of the governing body;

   1. (B) Conducting interdepartmental meetings at regular intervals and maintaining minutes of the meetings;
   2. (C) Preparing an annual operating budget of anticipated income and expected expenditures; and
   3. (D) Preparing a capital expenditure plan for at least a three-year period.

(b)

1. (1) Policies and procedures shall be provided for:

   1. (A) The general administration of the institution; and
   2. (B) Each department, section, or service in the facility.
2. (2) All policies and procedures for departments or services shall have evidence of ongoing review and/or revision.

3. (3) The first page of each 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.

      1. (c) An accurate daily patient census sheet as of midnight shall be available to the Department of Health at all times.
      2. (d)

4. (1) The facility shall have visitation policies determined by the medical staff, governing body, and administration that shall include:

   1. (A) Development by the governing body, with guidance from the medical staff and Infection Prevention and Control Committee, regarding persons under the age of twelve (12) who visit critical care areas of the hospital; and
   2. (B) Provisions that comply with Acts 202, No. 311, known as the No Patient Left Alone Act, Arkansas Code § 20-6-401 et seq.
5. (2) See Appendix A.

(f)

1. (1)

   1. (A) Animals such as cats, dogs, birds, and fish and aquatic animals shall not be permitted in healthcare facilities.

   2. (B) Exceptions shall be made for:

      1. (i) Service animals;
      2. (ii) Animals that participate in pet therapy; and
      3. (iii) Fish and aquatic animals in approved aquariums.
   3. (C) See 20 CAR § 43-124, pet therapy program.
   4. (D) All exceptions shall be approved by the Division of Health Facilities Services.

2. (2) Service animals shall be permitted only under the following guidelines:

   1. (A) Only animals specifically trained as service animals shall be allowed into the facility;

   2. (B) Service animals shall not be allowed into the facility if they are:

      1. (i) Unhealthy;
      2. (ii) Feverish; or
      3. (iii) Suffering from:

(b) (b) Fleas; or

1. (c) (c) Skin lesions;

   1. (C)

      1. (i) Healthy, well-groomed animals shall be allowed to enter the facility into areas that are generally accessible to the public, i.e., lobbies, cafeteria, and nurses’ stations on unrestricted units.
      2. (ii) The owner of the animal shall be directed to inquire about the possibility of a visit before entering a patient's room.
      3. (iii) Authorization to visit shall be given by a unit supervisor;

   2. (D)

      1. (i) Service animals shall be:

(b) (b) Diapered in a manner to prevent contamination of the facility environment with excreta.

1. (ii) Service animals shall not be fed within the facility;

   1. (E) Petting or playing with service animals by hospital personnel or patients shall be prohibited;
   2. (F) Owners of service animals shall be instructed to wash their hands before having patient contact;

   3. (G) Visiting with service animals shall be restricted in the following circumstances:

      1. (i) The patient is in:

(b) (b) Protective isolation;

1. (ii) The patient, although not in protective isolation, is immunocompromised or has a roommate that is;

   1. (iii) The patient is in an intensive care unit, burn unit, or restricted access unit of the hospital;

      1. (iv) The patient or roommate:

(b) (b) Has a severe phobia; and

1. (v) The patient or roommate:

(b) (b) Has an altered perception of reality and is not amenable to rational explanation; and

1. (H) Animals that become loud, aggressive, or agitated shall be removed from the facility immediately.

2. (3)

   1. (A)

      1. (i) Fish and aquatic animals shall not be permitted in healthcare facilities without prior written approval by the division.
      2. (ii)

(a) (a) Aquariums shall be approved by the:

1. (1) (1) Medical staff; and
2. (2) (2) Infection Prevention and Control Committee.

(b) (b) Turtles will not be considered for approval.

1. (B) Aquariums shall meet the following requirements:

   1. (i) Aquariums shall be:

(b) (b) Shockproof;

1. (c) (c) Breakproof; and

   1. (d) (d) Quiet in operation;

      1. (ii) Aquariums shall be constructed or positioned in such a manner as to:

(b) (b) Be spillproof; and

1. (c) (c) Preclude patients or staff from having direct contact with the animals or water in the aquarium;

   1. (iii) Aquariums and associated equipment shall be cleaned frequently by appropriately trained personnel who do not have direct contact with patients or patient care items;

      1. (iv)

(b) (b) Aquariums shall not be placed in critical care areas, i.e., nursing stations, surgery, patient rooms, ICU, etc.; and

1. (v) Aquariums shall be kept in a state of good repair at all times.

   1. (C) There shall be written procedures for cleaning and caring for the aquarium.
   2. (D) There shall be written procedures for dealing with cleanup in the event there is a major accident concerning the aquarium.

   3. (E) Fish or aquatic animals shall be of varieties that:

      1. (i) Do not bite or sting; and
      2. (ii) Are considered nontoxic or nonpoisonous.

(g)

1. (1) Each facility shall develop and maintain a risk-assessed all-hazards-written disaster plan.

2. (2) The plan shall:

   1. (A) Be tailored to meet specific disaster risks present in the area such as earthquakes, tornadoes, floods, nuclear reactor failures, etc.;
   2. (B) Include widespread disasters as well as disasters occurring within the local community and hospital facility;
   3. (C) Provide for complete evacuation of the facility;

   4. (D) Provide for:

      1. (i) Care of mass casualties; and
      2. (ii) Increased patient volume;
   5. (E) Provide for transfer of patients, including those with hospital equipment, to an alternate site;

   6. (F) Contain two (2) rehearsals a year, preferably as part of a coordinated drill in which other community emergency agencies participate, and:

      1. (i) One (1) drill shall simulate a disaster of internal nature and the other external;
      2. (ii) One (1) drill shall be planned and one (1) shall be "no notice"; and
      3. (iii) Written reports and evaluation of all drills shall be maintained;
   7. (G) Contain specific provisions to supply food, water, generator fuel, and other essential items for seventy-two (72) hours (applies to inpatient facilities only);
   8. (H) Develop, maintain, and exercise redundant communication systems; and
   9. (I) Facilities with AWIN (Arkansas Wireless Information Network) issued equipment shall include regular maintenance and personnel training for its use.

(h)

1. (1) There shall be a posted list of names, telephone numbers, and addresses available for emergency use.

2. (2) The list shall include the:

   1. (i) Key hospital personnel and staff;

      1. (ii) Local police department;
      2. (iii) Fire department;
      3. (iv) Ambulance service;
      4. (v) American Red Cross; and
      5. (vi) Other available emergency units.

3. (3) The list shall be reviewed and updated at least every six (6) months.

   1. (i) There shall be rules governing the routine methods of handling and storing flammable and explosive agents, particularly in:
4. (1) Operating rooms;
5. (2) Delivery rooms;
6. (3) Laundries; and
7. (4) Areas where oxygen therapy is administered.

(k) The facility shall provide access to appropriate educational references to meet the professional and technical needs of hospital personnel.

1. (l)
2. (1) A safety committee shall develop written procedures for the reporting and prevention of safety hazards.
3. (2) The safety committee shall meet at least quarterly or more frequently if necessary to fulfill safety objectives.

4. (3) Minutes of the meeting shall be maintained.

   1. (m) All departments and/or services shall receive annual education on:
5. (1) Safety;
6. (2) Fire safety;
7. (3) Back safety;
8. (4) Infection prevention and control;
9. (5) Universal/standard precautions;
10. (6) Disaster preparedness; and
11. (7) Confidential information.

(n)

1. (1) Any hospital or related institution that closes shall meet the requirements for new construction in order to be eligible for relicensure.
2. (2) Once a facility closes, it is no longer licensed.
3. (3) The license shall be immediately returned to the division.
4. (4) To be eligible for licensure all the latest life, safety, and health rules shall be met.
5. (5) Refer to 20 CAR § 43-104(d) and (j).

(o)

1. (1) The facility administrator shall ensure the development of policies and procedures in accordance with Arkansas Code § 20-9-307 that, upon request of the patient, an itemized statement of all services shall be provided within thirty (30) days after discharge or thirty (30) days after request, whichever is later.
2. (2) The policy shall include a statement advising the patient in writing of his or her right to receive the itemized statement of all services.

(p) The facility shall establish a process for prompt resolution of patient grievances to include the following:

1. (1) The facility shall inform each patient whom to contact to file a grievance;
2. (2) The governing body shall approve and be responsible for the effective operation of the grievance process unless delegated in writing to another responsible individual;
3. (3) The facility shall establish a clearly explained procedure for the submission of a patient's written or verbal grievance to the facility;

4. (4) The grievance process shall specify timeframes for:

   1. (A) Review of the grievance; and
   2. (B) The provisional response; and
5. (5) The grievance process shall include a mechanism for timely referral of patient concerns regarding quality of care to the Quality Assurance/Performance Improvement Committee.

(q) A physician shall:

1. (1) Pronounce the patient dead; and
2. (2) Document the date, time, and cause of death.

(s)

1. (1) Pursuant to Arkansas Code § 20-9-302 hospitals shall not perform an abortion unless the abortion is to save the life of the pregnant woman in a medical emergency.
2. (2) An abortion shall only take place in a hospital or an emergency room.

3. (3) A physician that refers a pregnant woman for an abortion shall:

   1. (A) Perform an obstetric ultrasound on the pregnant woman using a method that the physician and the pregnant woman agree is best under the circumstances;

   2. (B)

      1. (i) Provide a simultaneous verbal explanation of what the ultrasound is depicting that includes the:

(b) (b) Number of unborn children depicted.

1. (ii) If the ultrasound image indicates that the unborn child has died, the physician or qualified technician shall inform the pregnant woman of that fact;

   1. (C) Display the ultrasound images so that the pregnant woman may view them and document in the pregnant woman’s medical record that the images were displayed to the pregnant woman;
   2. (D) Provide a medical description of the ultrasound images, including the dimensions of the unborn child and the presence of external members and internal organs if present and viewable; and
   3. (E) Retain the ultrasound image with the date that the ultrasound occurred in the pregnant woman’s medical record.

(u) A healthcare provider shall not mislead any patient regarding the healthcare provider’s licensure status.

1. (v) Hospitals must be in compliance with Acts 2023, No. 482, Arkansas Code § 20-9-314 by February 1, 2024:
2. (1) Hospitals are required to notify the division upon receipt of a CMS notice of noncompliance with Centers for Medicare & Medicaid Enforcement, 45 C.F.R. pt. 180;
3. (2) Hospitals are to notify the division upon receipt of CMS notification of return to compliance with Centers for Medicare & Medicaid Enforcement, 45 C.F.R. pt. 180; and
4. (3) Hospitals shall be issued fines of two hundred fifty dollars ($250) per day for noncompliance with Centers for Medicare & Medicaid Enforcement, 45 C.F.R. pt. 180, in accordance with Arkansas Code § 20-9-314.