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007.05.10-7. General Administration.

AR ADC 007.05.10-7Arkansas Administrative CodeEffective: June 20, 2022

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)
Effective: June 20, 2022
Ark. Admin. Code 007.05.10-7
007.05.10-7. General Administration.
A. Each institution shall have an Administrator responsible for the management of the institution. In the absence of the Administrator, an alternate with authority to act shall be designated. The responsibilities of the Administrator shall include:
1. Keeping the Governing Body fully informed of the conduct of the hospital by submitting periodic written reports or by attending meetings of the Governing Body;
2. Conducting interdepartmental meetings at regular intervals and maintaining minutes of the meetings;
3. Preparing an annual operating budget of anticipated income and expected expenditures; and
4. Preparing a capital expenditure plan for at least a three-year period.
B. Policies and procedures shall be provided for the general administration of the institution and for each department, section or service in the facility. All policies and procedures for departments or services shall have evidence of ongoing review and/or revision. The first page of each manual shall have the annual review date signature of the department supervisor and/or person(s) conducting the review.
C. An accurate daily patient census sheet as of midnight shall be available to the Department at all times.
D. The facility shall have visitation policies determined by the Medical Staff, Governing Body and Administration which shall include:
1. Development by the Governing Body with guidance from the Medical Staff and Infection Prevention and Control Committee regarding persons under the age of 12 who visit critical care areas of the hospital.
2. Provisions that comply with Act 311 of 2021 known as “No Patient Left Alone Act” which is codified at A.C.A. § 20-6-401 et seq. See Appendix A.
E. Provisions shall be made for safe storage of patients' valuables.
F. Animals such as cats, dogs, birds and fish and aquatic animals shall not be permitted in health care facilities. Exceptions shall be made for service animals, animals that participate in pet therapy, fish and aquatic animals in approved aquariums. (See Section 25, Pet Therapy Program.) All exceptions shall be approved by Health Facility Services.
1. Service animals shall be permitted only under the following guidelines:
a. Only animals specifically trained as service animals shall be allowed into the facility.
b. Service animals shall not be allowed into the facility if they are unhealthy, feverish, or suffer from gastroenteritis, fleas or skin lesions.
c. Healthy, well-groomed animals shall be allowed to enter the facility into areas that are generally accessible to the public (i.e., lobbies, cafeteria, and nurses stations on unrestricted units). The owner of the animal shall be directed to inquire about the possibility of a visit before entering a patient's room. Authorization to visit shall be given by a unit supervisor.
d. Service animals shall be walked before entering the facility or shall be diapered in a manner to prevent contamination of the facility environment with excreta. Service animals shall not be fed within the facility.
e. Petting or playing with service animals by hospital personnel or patients shall be prohibited.
f. Owners of service animals shall be instructed to wash their hands before having patient contact.
g. Visiting with service animals shall be restricted in the following circumstances:
1) The patient is in isolation for respiratory, enteric or infectious diseases or is in protective isolation;
2) The patient, although not in protective isolation, is immunocompromised or has a roommate that is;
3) The patient is in an intensive care unit, burn unit or restricted access unit of the hospital;
4) The patient or roommate is allergic to animals or has a severe phobia; and
5) The patient or roommate is psychotic, hallucinating or confused or has an altered perception of reality and is not amenable to rational explanation.
h. Animals which become loud, aggressive or agitated shall be removed from the facility immediately.
2. Fish and aquatic animals shall not be permitted in health care facilities without prior written approval by Health Facility Services. Aquariums shall be approved by the Medical Staff and Infection Prevention and Control Committee. (Turtles will not be considered for approval.)
a. Aquariums shall meet the following requirements:
1) Aquariums shall be self-contained, shock proof, break proof and quiet in operation.
2) Aquariums shall be constructed or positioned in such a manner as to be leak-proof, spill proof and to preclude patients or staff from having direct contact with the animals or water in the aquarium.
3) Aquariums and associated equipment shall be cleaned frequently by appropriately trained personnel who do not have direct contact with patients or patient care items.
4) Aquariums shall be placed only in areas which are accessed by the general public. Aquariums shall not be placed in critical care areas (i.e., nursing stations, surgery, patient rooms, ICU, etc.)
5) Aquariums shall be kept in a state of good repair at all times.
b. There shall be written procedures for cleaning and caring for the aquarium.
c. There shall be written procedures for dealing with clean up in the event there is a major accident concerning the aquarium.
d. Fish or aquatic animals shall be of varieties that do not bite, sting and are considered non-toxic or non-poisonous.
G. Each facility shall develop and maintain a risk-assessed all hazards written disaster plan. The plan shall:
1. be tailored to meet specific disaster risks present in the area, such as earthquakes, tornados, floods, nuclear reactor failures, etc.;
2. include widespread disasters as well as disasters occurring within the local community and hospital facility;
3. provide for complete evacuation of the facility;
4. provide for care of mass casualties and increased patient volume;
5. provide for transfer of patients, including those with hospital equipment, to an alternate site;
6. contain two rehearsals a year, preferably as part of a coordinated drill in which other community emergency agencies participate; and
a. one drill shall simulate a disaster of internal nature and the other external;
b. one drill shall be planned and one shall be “no notice;” and
c. written reports and evaluation of all drills shall be maintained;
7. contain specific provisions to supply food, water, generator fuel and other essential items for 72 hours (applies to inpatient facilities only);
8. develop, maintain and exercise redundant communication systems; and
9. facilities with AWIN (Arkansas Wireless Information Network) issued equipment shall include regular maintenance and personnel training for its use.
H. There shall be a posted list of names, telephone numbers and addresses available for emergency use. The list shall include the key hospital personnel and staff, the local police department, the fire department, ambulance service, Red Cross and other available emergency units. The list shall be reviewed and updated at least every six months.
I. There shall be rules and regulations governing the routine methods of handling and storing flammable and explosive agents, particularly in operating rooms, delivery rooms, laundries and in areas where oxygen therapy is administered.
J. All refrigerated areas, including freezers, shall be provided with thermometers and records maintained to document the temperatures checked on a daily or weekly basis, as required.
K. The facility shall provide access to appropriate educational references to meet the professional and technical needs of hospital personnel.
L. A safety committee shall develop written procedures for the reporting and prevention of safety hazards. The committee shall meet at least quarterly or more frequently if necessary to fulfill safety objectives. Minutes of the meeting shall be maintained.
M. All Departments and/or Services shall receive annual education on safety, fire safety, back safety, infection prevention and control, universal/standard precautions, disaster preparedness and confidential information.
N. Any hospital or related institution that closes shall meet the requirements for new construction in order to be eligible for re-licensure. Once a facility closes, it is no longer licensed. The license shall be immediately returned to Health Facility Services. To be eligible for licensure all the latest life safety and health regulations shall be met. Refer to Section 4, Licensure and Codes, item B., Application for License and item H., Revocation of Licenses.
O. The facility Administrator shall assure the development of policies and procedures in accordance with Ark. Code Ann. § 20-9-307 that, upon request of the patient, an itemized statement of all services shall be provided within 30 days after discharge or 30 days after request, whichever is later. The policy shall include a statement advising the patient in writing of his/her right to receive the itemized statement of all services.
P. The facility shall establish a process for prompt resolution of patient grievances to include the following:
1. The facility shall inform each patient whom to contact to file a grievance.
2. The Governing Body shall approve and be responsible for the effective operation of the grievance process unless delegated in writing to another responsible individual.
3. The facility shall establish a clearly explained procedure for the submission of a patient's written or verbal grievance to the facility.
4. The grievance process shall specify timeframes for review of the grievance and the provisional response.
5. The grievance process shall include a mechanism for timely referral of patient concerns regarding quality of care to the Quality Assurance/Performance Improvement Committee.
Q. A physician shall pronounce the patient dead and document the date, time and cause of death.
R. Patient care providers not employed by the hospital, who are involved in direct patient care, shall follow hospital policies and procedures.
S. Pursuant to A.C.A § 20-9-302 hospitals shall not perform an abortion unless the abortion is to save the life of the pregnant woman in a medical emergency.


Amended Jan. 1, 2016; Feb. 5, 2021; June 20, 2022.
<Statutory authority: Promulgated under the Authority of Ark. Code Ann. § 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 007.05.10-7, AR ADC 007.05.10-7
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