PURPOSE: This rule specifies the duties of the chief executive officer of a hospital.

1. (1) The chief executive officer shall be the direct representative of the governing body and shall be responsible for management of the hospital commensurate with the authority delegated by the governing body in its bylaws.
2. (2) The chief executive officer shall be responsible for maintaining liaison among the governing body, medical staff and all departments of the hospital.
3. (3) The chief executive officer shall organize the administrative functions of the hospital through appropriate departmentalization and delegation of duties and shall establish a system of authorization, record procedures and internal controls.
4. (4) The chief executive officer shall be responsible for the recruitment and employment of qualified personnel to staff the various departments of the hospital and shall insure that written personnel policies and job descriptions are available to all employees.
5. (5) The chief executive officer shall be responsible for the development and enforcement of written policies and procedures governing visitors to all areas of the hospital.
6. (6) The chief executive officer shall be responsible for establishing effective security measures to protect patients, employees and visitors.

7. (7) The chief executive officer shall maintain policies protecting children admitted to or discharged from the hospital. Policies shall provide for at least the following:

   1. (A) A child shall not be released to anyone other than the child’s parent(s), legal guardian or custodian;
   2. (B) The social work service personnel shall have knowledge of available social services for unmarried mothers and for the placement of children;
   3. (C) Adoption placements shall comply with section 453.010, RSMo; and
   4. (D) The reporting of suspected incidences of child abuse shall be made to the Division of Family Services as established under section 210.120, RSMo.
8. (8) The chief executive officer shall be responsible for developing a written emergency preparedness plan. The plan shall include procedures which provide for safe and orderly evacuation of patients, visitors and personnel in the event of fire, explosion or other internal disaster. The plan shall also include procedures for caring for mass casualties resulting from any external disaster in the region.
9. (9) The emergency plan in section (8) of this rule shall be readily available to all personnel. The chief executive officer is responsible for ensuring all employees shall be instructed regarding their responsibilities during an emergency. Drills for internal disasters, such as fires, shall be held at least quarterly for each shift and shall include the simulated use of fire alarm signals and simulation of emergency fire conditions. Annual drills for external disasters shall be held in coordination with representatives of local emergency preparedness offices. The movement of hospital patients is not required as a part of the drills.
10. (10) The chief executive officer shall be responsible for carrying out policies of the governing body to ensure that patients are admitted to the hospital only by members of the medical staff and that each patient’s general medical condition shall be the primary responsibility of a physician member of the medical staff.
11. (11) The chief executive officer shall bring to the attention of the chief of the medical staff and governing body failure by members of that staff to conform with established hospital policies regarding administrative matters, professional standards or the timely preparation and completion of each patient’s clinical record.
12. (12) The chief executive officer shall be responsible for developing and maintaining a hospital environment which provides for efficient care and safety of patients, employees and visitors.
13. (13) The chief executive officer shall be responsible for the development and enforcement of written policies and procedures which prohibit the use of tobacco products throughout the hospital and its facilities. At a minimum, such policies and procedures shall include a description of the area encompassed by the tobacco-free policy; how employees, patients and visitors will be educated and informed about the tobacco-free policy; who is responsible for enforcing the tobacco-free policy and how the tobacco-free policy will be enforced; how the hospital will address an employee’s, patient’s, or visitor’s failure to comply with the tobacco-free policy; and how the hospital, if subject to Medicare Conditions of Participation for Long- Term Care Facilities, will comply with 42 CFR 483.15(b)(3). The chief executive officer shall enforce compliance with the written policies and procedures prohibiting the use of tobacco products throughout the hospital and its facilities beginning one (1) year from the effective date of this amendment.
14. (14) An annual licensing survey for each fiscal year shall be filed with the department on the survey document provided by the Department of Health and Senior Services. The survey shall be due within two (2) months after the hospital’s receipt of the survey.
15. (15) The chief executive officer shall be responsible for establishing and implement- 19 CSR 30-20

ing a mechanism which will assure that patient services provide care or an appropriate referral that is commensurate with the patient’s needs. If services are provided by contract, the contractor shall furnish services that permit the hospital to comply with all applicable hospital licensing requirements.

1. (16) The chief executive officer shall be responsible for establishing and implementing a mechanism to assure that all equipment and physical facilities used by the hospital to provide patient services, including those services provided by a contractor, comply with applicable hospital licensing requirements.

AUTHORITY: sections 192.006 and 197.080, RSMo 2000.* This rule previously filed as 19 CSR 30-20.021(2)(B). Original rule filed June 27, 2007, effective Feb. 29, 2008.

*Original authority: 192.006, RSMo 1993, amended 1995 and 197.080, RSMo 1953, amended 1993, 1995.