1. (1) Each hospital shall be under the direction of a chief executive officer appointed by the governing board, who is responsible for the operation of the hospital in a manner commensurate with the authority conferred by the governing board.

2. (2) The chief executive officer shall take all reasonable steps to provide for:

   1. (a) Compliance with applicable laws and regulations; and,
   2. (b) The review of and prompt action on reports and recommendations of authorized planning, regulatory, and inspecting agencies.

3. (3) The chief executive officer shall provide for the following:

   1. (a) Establishment and implementation of organized management and administrative functions, including:

      1. Clear lines of responsibility and accountability within and between department heads and administrative staff;

      2. Effective communication mechanisms among departments, medical staff, the administration and the governing board;

      3. Internal controls;

      4. Coordination of services with the identified needs of the patient population;

      5. A policy on patient rights and responsibilities;

      6. A mechanism for receiving and responding to complaints concerning patient care;

      7. A policy on withholding resuscitative services;

      8. Policies and procedures on identification and referral of organ and tissue donors including notification of organ and tissue procurement agencies when organs and tissues become available as specified under Rule 59A-3.274, F.A.C.;

      9. Policies and procedures for meeting the communication needs of multicultural populations and persons with impaired hearing or speaking skills;

      10. Policies and procedures on discharge planning;

      11. A policy to assist in accessing educational services for children or adolescents when treatment requires a significant absence from school;

      12. Policies and procedures to assure that the treatment, education and developmental needs of neonates, children and adolescents transferred from one setting to another are assessed;

      13. Dissemination and enforcement of a policy prohibiting the use of smoking materials in hospital buildings and procedures for exceptions authorized for patients by a PA, APRN or physician’s written authorization;

      14. A policy regarding the use of restraints and seclusion; and,

      15. A comprehensive emergency management plan which meets the requirements of Section 395.1055(1)(c), F.S., and Rule 59A-3.078, F.A.C.

   2. (b) Personnel policies and practices which address:

      1. Non-discriminatory employment practices;

      2. Verification of credentials including current licensure and certification;

      3. Periodic performance evaluations; and,

      4. Provision of employee health services.

   3. (c) Financial policies and procedures;
   4. (d) An internal risk management program which meets the requirements of Section 395.0197, F.S., and Chapter 59A-10, F.A.C.;
   5. (e) Assurance of compliance with educational requirements on human immunodeficiency virus and acquired immune deficiency syndrome pursuant to Sections 381.0034 and 381.0035, F.S., and Chapter 64D-2, F.A.C., and;
   6. (f) Policies and procedures to ensure medical student training prioritization pursuant to section 395.1055, F.S. Documentation of compliance such as clinical placement agreements shall be made available for Agency review upon request.

Rulemaking Authority 395.1055 FS. Law Implemented 395.0197, 395.1055 FS. History–New 9-4-95, Formerly 59A-3.218, Amended 10-16-14, 6-1-25.