1. (1) Each licensee shall have a governing body referred to in this rule as the board.
2. (2) The board members are legally responsible for the conduct of the hospital staff. The board members are also responsible for the appointment of the medical staff and an administrator assigned to carry out the requirements of Section R432-100-6.

3. (3) The licensee shall ensure that the board is organized in accordance with the articles of incorporation or bylaws that specify:

   1. (a) the board's functional organization, including any standing committee;
   2. (b) the duties and responsibilities of each board member;
   3. (c) the duties and responsibilities of each officer and any standing committee;
   4. (d) the frequency of meetings;
   5. (e) the mechanism for formal approval of the organization, bylaws, rules of the medical staff, and hospital departments;
   6. (f) the method for election or appointment to the board;
   7. (g) the methods established by the board for holding such individuals responsible;

   8. (h) the methods for removal of board members and officers;

      1. (i) the numbers or percentages of members that constitute a quorum for board meetings;
   9. (j) the size of the board;

   10. (k) the terms of office of the board; and

       1. (l) to who responsibility for operation and maintenance of the hospital, including evaluation of hospital practices, may be delegated.

4. (4) The board members shall:

   1. (a) meet at least quarterly; and
   2. (b) keep written minutes of meetings and actions and distribute copies to members of the board.

5. (5)(a) The board members shall employ a competent administrator and vest this person with authority and responsibility for carrying out board policies.

   1. (b) The board shall define, in writing, the administrator's qualifications, responsibilities, authority, and accountability.

6. (6) The board, through officers, committees, medical, and other staff, shall:

   1. (a) appoint members of the medical staff and delineate clinical privileges;
   2. (b) approve organization, bylaws, and rules of medical staff and hospital departments;
   3. (c) develop and implement a long-range plan; and
   4. (d) maintain a list of the scope and nature of any contracted services.

KEY: health care facilities

Date of Last Change: June 5, 2026

Notice of Continuation: August 22, 2025

Authorizing, and Implemented or Interpreted Law: 26B-1-202; 26B-2-202; 26B-2-203