1. (a) Level IV. A Level IV hospital will provide emergency medical services with at least a licensed independent practitioner, registered nurse, licensed practical nurse, or an Intermediate, AdvancedEmergency Medical Technician (AEMT) or paramedic , as defined in OAC 310:641-1-7, on site 24 hours a day. A hospital must be classified at Level IV for emergency general medicine services if it complies with all of this subsection:

   1. (1) Clinical services and resources. Diagnostic, surgical, or medical specialty services are not required.
   2. (2) Personnel. A physician, licensed independent practitioner, registered nurse, licensed practical nurse, or an Intermediate, Advanced Emergency Medical Technician (AEMT) or paramedic, as defined in OAC 310:641-1-7, isrequired on site 24 hours a day. In the absence of a physician, licensed independent practitioner, registered nurse, or paramedic, then at least one of the practitioners on duty must have received training in advanced life support techniques and must be competent to initiate treatment of the emergency patient.
   3. (3) Supplies and equipment. The hospital must have equipment for use in the resuscitation of patients of all ages on site, functional, and immediately available, including at least the items specified in OAC 310:667-59-9(a)(3).
   4. (4) Policies on transfers. The hospital must have written policies defining the medical conditions and circumstances for emergency patients that may be retained for treatment in-house, and for those who require stabilizing treatment and transfer to another hospital.

2. (b) Level III. A Level III hospital will provide emergency medical services with an organized emergency department. A physician and nursing staff with special capability in emergency care arerequired on site 24 hours a day. General surgery and anesthesiology services will be available either on duty or on call. A hospital must be classified at Level III for emergency general medicine services if it complies with all of this subsection (b):

   1. (1) Clinical services and resources.

      1. (A) Emergency services. A physician competent in the care of the critically injured and credentialed by the hospital to provide emergency medical services and nursing personnel with special capability in emergency care must be on site 24 hours a day.
      2. (B) General surgery. A board certified, board eligible, or residency trained general surgeon must be on call 24 hours a day and promptly available in the emergency department.
      3. (C) Anesthesia. Anesthesia services must be on call 24 hours a day, promptly available, and administered in accordance with OAC 310:667-25-2.
      4. (D) Internal medicine. A physician board certified, board eligible, or residency trained in internal medicine must be on call 24 hours a day and promptly available in the emergency department.

      5. (E) Other specialties. The hospital will also have the following specialty services on call and promptly available:

         1. (i) Family/general medicine;
         2. (ii) Pathology; and
         3. (iii) Radiology.
      6. (F) Operating suite. An operating suite with thermal control equipment for patients and infusion of blood and fluids must be available 24 hours a day.
      7. (G) Post-anesthesia recovery unit. The hospital must have a post-anesthesia recovery room or intensive care unit that is in compliance with OAC 310:667-15-7 with nursing personnel and anesthesia services remaining in the unit until the patient is discharged from post-anesthesia care.

      8. (H) Intensive care unit. The hospital's intensive care unit must include:

         1. (i) Compliance with OAC 310:667-15-7;
         2. (ii) A registered nurse on duty in the intensive care unit when it has a patient;
         3. (iii) A registered nurse on call and immediately available when the unitdoes not have a patient;
         4. (iv) Written minimum staffing requirements for the intensive care unit thatare monitored through the quality improvement program; and
         5. (v) The equipment listed in OAC 310:667-59-9(b)(3)(C).
      9. (I) Diagnostic imaging. The hospital must have diagnostic x-ray services available 24 hours a day. A radiology technologist must be on duty or on call and immediately available 24 hours a day.

      10. (J) Clinical laboratory service. The hospital must have clinical laboratory services available 24 hours a day. All or part of these services may be provided by arrangements with certified reference laboratories that are available on an emergency basis 24 hours a day. These services include:

          1. (i) Comprehensive immunohematology services including blood typing and compatibility testing;
          2. (ii) A supply of blood and blood products on hand that is properly stored and adequate to meet expected patient needs;
          3. (iii) All blood and blood products are properly stored;
          4. (iv) Standard analysis of blood, urine, and other body fluids to include routine chemistry and hematology testing;
          5. (v) Coagulation studies;
          6. (vi) Blood gas/pH analysis;
          7. (vii) Comprehensive microbiology services or appropriate supplies for the collection, preservation, and transport of clinical specimens for aerobic and anaerobic bacterial, mycobacterial, and fungus cultures; and
          8. (viii) Drug and alcohol screening.
      11. (K) Social services. Social services must be available and provided in accordance with Subchapter 31 of this Chapter.
   2. (2) Personnel: Emergency services director. The medical staff will designate a physician credentialed to provide emergency medical care as emergency services director. The emergency services director may serve as the trauma service director.
   3. (3) Supplies and equipment: Emergency department. The emergency department must have equipment for use in the resuscitation of patients of all ages on site, functional, and available in the emergency department, including at least the items specified in OAC 310:667- 59-9(b)(3)(A).
   4. (4) Policies on transfers. A Level III hospital is subject to the same policies on transfers requirements as a Level IV hospital as set forth in (a)(4) of this Section.
   5. (5) Organ Procurement. The hospital, in association with an organ procurement organization certified by the CMS,will develop policies and procedures to identify and refer potential organ donors.

3. (c) Level II. A Level II hospital will provide emergency medical services with an organized emergency department. A physician and nursing staff with special capability in emergency care will be on site 24 hours a day. General surgery and anesthesiology services will be available on site or on call 24 hours a day. Services from an extensive group of clinical specialties including infectious disease, internal medicine, nephrology, and orthopedics will be promptly available on call. A hospital must be classified at Level II for emergency general medicine services if it complies with all of this subsection (c):

   1. (1) Clinical services and resources.

      1. (A) Emergency services. A physician competent in the care of the emergent patient and credentialed by the hospital to provide emergency medical services and nursing personnel with special capability in emergency care must be on site 24 hours a day.
      2. (B) General surgery. A Level II hospital is subject to the same general surgery requirements as a Level III hospital as set forth in (b)(1)(B) of this Section.
      3. (C) Anesthesia. Anesthesia services must be on call 24 hours a day, promptly available, and administered in accordance with OAC 310:667-25-2.
      4. (D) Internal medicine. A physician board certified, board eligible, or residency trained in internal medicine must be on call 24 hours a day and promptly available in the emergency department.

      5. (E) Other specialties. The hospital must also have the following specialty services on call and promptly available:

         1. (i) Cardiology;
         2. (ii) Family/general medicine;
         3. (iii) Infectious disease.
         4. (iv) Neurology;
         5. (v) Obstetrics/gynecology;
         6. (vi) Ophthalmology;
         7. (vii) Orthopedics;
         8. (viii) Otolaryngology;
         9. (ix) Pathology;
         10. (x) Pediatrics;
         11. (xi) Psychiatry;
         12. (xii) Pulmonary medicine;
         13. (xiii) Radiology;
         14. (xiv) Urology; and
         15. (xv) Nephrology.
      6. (F) Operating suite. An operating suite with adequate staff and equipment must be immediately available 24 hours a day. The hospital will define and document in writing the minimum staffing requirements for the operating suite. The operating room will be equipped in accordance with OAC 310:667-59-9(c)(3)(B). An on call schedule for emergency replacement staff will be maintained.
      7. (G) Post-anesthesia recovery unit. The hospital must have a post-anesthesia recovery room or intensive care unit that is in compliance with OAC 310:667-15-7 with nursing personnel and anesthesia services remaining in the unit until the patient is discharged from post-anesthesia care. The post-anesthesia recovery unit will be equipped in accordance with OAC 310:667-59-9(c)(3)(C).

      8. (H) Intensive care unit. The hospital's intensive care unit must include:

         1. (i) Compliance with OAC 310:667-15-7 ;
         2. (ii) A registered nurse on duty in the intensive care unit whenever it has a patient;
         3. (iii) A registered nurse on call and immediately available when the unitdoes not have a patient;
         4. (iv) Written minimum staffing requirements for the intensive care unit that are monitored through the quality improvement program; and
         5. (v) Equipment in accordance with OAC 310:667-59-9(c)(3)(D).

      9. (I) Diagnostic Imaging. The hospital's diagnostic x-ray services must be available 24 hours a day. A radiologic technologist and computerized tomography technologist will be on duty or on call and immediately available 24 hours a day. A single technologist designated as qualified by the radiologist in both diagnostic x-ray and computerized tomography procedures may be used to meet this requirement if an on call schedule of additional diagnostic imaging personnel is maintained. The diagnostic imaging services include:

         1. (i) Angiography;
         2. (ii) Ultrasonography;
         3. (iii) Computed tomography;
         4. (iv) Magnetic resonance imaging;
         5. (v) Neuroradiology; and
         6. (vi) Nuclear medicine imaging.
         7. (vii) For a hospital licensed as a general medical surgical hospital or specialty hospital, diagnostic imaging services shall also comply with the applicable requirements in Subchapter 23 of this Chapter.
      10. (J) Clinical laboratory service. A Level II hospital is subject to the same clinical laboratory requirements as a Level III hospital as set forth in (b)(1)(J) of this Section.
      11. (K) Respiratory therapy. Routine respiratory therapy procedures and mechanical ventilators will be available 24 hours a day. Respiratory therapy services will comply with OAC 310:667-23-6.
      12. (L) Social services. Social services must be available and provided in accordance with Subchapter 31 of this Chapter.
   2. (2) Personnel: Emergency services director. The medical staff will designate a physician credentialed to provide emergency medical care as emergency services director.
   3. (3) Supplies and equipment: Emergency department. The emergency department must have equipment for use in the resuscitation of patients of all ages on site, functional, and available in the emergency department, including the items specified in OAC 310:667-59-9(c)(3)(A).
   4. (4) Policies on transfers. A Level II hospital is subject to the same policies on transfers requirements as a Level IV hospital as set forth in (a)(4) of this Section.
   5. (5) Organ Procurement. The hospital, in association with an organ procurement organization certified by CMS, will develop policies and procedures to identify and refer potential organ donors.

4. (d) Level I. A Level I hospital will provide emergency medical services with an organized emergency department. A physician and nursing staff with special capability in emergency care will be on site 24 hours a day. General surgery and anesthesiology services will be available on site or on call 24 hours a day. Additional clinical services and specialties such as nuclear diagnostic imaging, dermatology, endocrinology, and hematology/oncology specialists must also be promptly available. A hospital must be classified at Level I for emergency general medicine services if it complies with all of this subsection:

   1. (1) Clinical services and resources.

      1. (A) Emergency services. A Level I hospital is subject to the same emergency services requirements as a Level II hospital as set forth in (c)(1)(A) of this Section.
      2. (B) General surgery. A Level I hospital is subject to the same general surgery requirements as a Level III hospital as set forth in (b)(1)(B) of this Section.
      3. (C) Anesthesia. Anesthesia services must be on call 24 hours a day, promptly available, and administered in accordance with OAC 310:667-25-2.
      4. (D) Internal medicine. A physician board certified, board eligible, or residency trained in internal medicine must be on call 24 hours a day and promptly available in the emergency department.

      5. (E) Other specialties. The hospital must also have services from the following specialties on call and promptly available:

         1. (i) All the specialty services listed for Level II classification [see (c)(1)(E) in this Section];
         2. (ii) Critical care medicine;
         3. (iii) Dermatology;
         4. (iv) Emergency medicine;
         5. (v) Endocrinology;
         6. (vi) Gastroenterology;
         7. (vii) Hematology/oncology; and
         8. (viii) Rheumatology.
      6. (F) Operating suite. A Level I hospital is subject to the same operating suite requirements as a Level II hospital as set forth in (c)(1)(F) of this Section.
      7. (G) Post-anesthesia recovery unit. A Level I hospital is subject to the same post-anesthesia recovery unit requirements as a Level II hospital as set forth in (c)(1)(G) of this Section.
      8. (H) Intensive care unit. A Level I hospital is subject to the same intensive care unite requirements as a Level II hospital as set forth in (c)(1)(H) of this Section. A physician with privileges in critical care must be on duty in the unit or immediately available in the hospital 24 hours a day.
      9. (I) Diagnostic Imaging. A Level I hospital is subject to the same diagnostic imaging requirements as a Level II hospital as set forth in (c)(1)(I) of this Section.
      10. (J) Clinical laboratory service. A Level I hospital is subject to the same clinical laboratory requirements as a Level III hospital as set forth in (b)(1)(J) of this Section.
      11. (K) Respiratory therapy. Routine respiratory therapy procedures and mechanical ventilators will be available 24 hours a day. Respiratory therapy services will comply with OAC 310:667-23-6.
      12. (L) Acute hemodialysis. The hospital will have the capability to provide acute hemodialysis services 24 hours a day. All staff providing hemodialysis patient care will have documented hemodialysis training and experience.
      13. (M) Social services. Social services must be available and providedin accordance with Subchapter 31 of this Chapter.
   2. (2) Personnel: Emergency services director. The medical staff will designate a physician credentialed to provide emergency medical care as emergency services director.
   3. (3) Supplies and equipment: Emergency department. The emergency department must have equipment for use in the resuscitation of patients of all ages on site, functional, and available in the emergency department, including the items specified in OAC 310:667-59-9(d)(3)(A).
   4. (4) Policies on transfers. The hospital shall have written policies defining the medical conditions and circumstances for those emergency patients which may be retained for treatment in-house, and for those who require stabilizing treatment and transfer to another facility. A Level I hospital is subject to the same policies on transfers requirements as a Level IV hospital as set forth in (a)(4) of this Section.
   5. (5) Organ Procurement. The hospital, in association with an organ procurement organization certified by CMS, will develop policies and procedures to identify and refer potential organ donors.

Added at 17 Ok Reg 2992, eff 7-13-00

Amended at 20 Ok Reg 1664, eff 6-12-03

Amended at 39 Ok Reg 1392, eff 9-11-22