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007.05.10-35. Specialized Services: Respiratory Care.

AR ADC 007.05.10-35Arkansas Administrative Code

West's Arkansas Administrative Code
Title 007. Department of Health
Division 05. Health Facility Services
Rule 10. Rules for Critical Access Hospitals in Arkansas (Refs & Annos)
Ark. Admin. Code 007.05.10-35
007.05.10-35. Specialized Services: Respiratory Care.
A. Respiratory Care Services shall be under the direction of a physician member of the Medical Staff.
B. Respiratory Care Services, including equipment, shall be supervised by a qualified and trained respiratory therapist.
C. There shall be sufficient personnel qualified and trained in respiratory care to provide respiratory care services.
1. Services may be performed by an assistant only when a qualified and trained respiratory therapist is readily available for consultation; and
2. Personnel qualified and trained in respiratory care shall be on the premises whenever continuous ventilatory support is provided to patients.
D. All respiratory care personnel shall maintain competency in:
1. Life support measures;
2. Isolation techniques; and
3. Safety techniques for oxygen and oxygen equipment.
E. The policy and procedure manual shall have evidence of ongoing review and/or revision. The first page of the manual shall have the annual review date and signature of the department supervisor and/or person(s) conducting the review.
F. Policies and procedures shall include:
1. Job descriptions;
2. Documentation, verified by the physician director, of who may perform special procedures and give patient instructions;
3. Safety practices;
4. Handling, storage and dispensing of therapeutic gases;
5. Infection prevention and control measures;
6. Assembly and operation of equipment;
7. Respiratory care services provided and a list of services shall be available to the Medical Staff;
8. Steps to take in the event of an adverse reaction;
9. Cleaning, disinfecting and sterilizing procedures; and
10. Orientation policies for new employees.
G. Clinically relevant educational programs shall be conducted on a regularly scheduled basis not less than 12 per year. There shall be evidence of program dates, attendance, and subject matter.
H. If arterial blood gases are performed the Respiratory Care department shall subscribe to a nationally recognized proficiency testing program for blood gases and meet the quality control requirements for clinical laboratories.
I. The Respiratory Care Service shall have sufficient equipment and adequate facilities appropriate for safety and effective provision of care.
1. Equipment shall be serviced calibrated, and operated according to manufacturers' directions.
2. An approved safety system shall be used with therapeutic gases.
3. Resuscitation, ventilatory and oxygenation support equipment shall be available for patients of all sizes.
4. Ventilators for continuous assistance or controlled breathing shall be equipped with alarm systems.
5. A preventive maintenance program shall be implemented and records maintained for the life of the equipment.
J. All Respiratory Care prescription/work requests shall specify the type, frequency and duration of each treatment, and, as required, the type and dose of medication and the type of diluent and oxygen or medical air.
K. Respiratory Care reports of blood gas results shall be prepared in duplicate and signed by the therapist responsible for the procedure/test. The original shall be placed in the patient's medical record and the copy retained in the department file.
L. Accurate records shall be maintained regarding the type and duration of each treatment given. These records shall be correlated with the patient's medical record.
M. Respiratory Care documentation for each patient shall include:
1. Current written plan of care to include goals and objectives;
2. Instructions to patient or patient's family; and
3. Type and duration of the treatment given.
N. When oxygen is being administered to a patient:
1. Patients, visitors and personnel shall be apprised of the fire hazard; and
2. If the patient is in a tent, alcohol or rub-on lotion shall not be used.
O. Oxygen shall be humidified in accordance with physician's orders.
P. If reusable reservoirs are used to humidify the oxygen, the reservoirs shall be cleaned and disinfected to a high-level of disinfection. (A high-level disinfection can be expected to kill all microorganisms with the exception of high numbers of bacterial endospores. Only sterile solutions and diluents shall be used in humidification and nebulizing equipment. Nebulizers (in-line and hand-held), between treatments on the same patient, shall be disinfected to a high level and rinsed in sterile water or, if a small volume medication nebulizer, air dried. All other semicritical equipment shall be cleaned and disinfected in accordance with the Center for Disease Control and Prevention's Guidelines.
Q. After use, all equipment shall be returned to a central location for thorough cleaning, servicing and disinfecting before use on another patient.
R. There shall be an ongoing QA/PI program.
S. Contracted Respiratory Care Services shall be under current agreement and the contractor shall fulfill all requirements of this section.
NOTE: The National Fire Protection Association Vol. 99, Health Care Facilities, is a mandatory reference for developing safety regulations for Respiratory Care Services.


Amended Jan. 1, 2016.
<Statutory authority: Promulgated under the Authority of Ark. Code Ann. ยง 20-7-123, 20-9-201 et seq.>
Current with amendments received through May 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 007.05.10-35, AR ADC 007.05.10-35
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