Ch. 14, § 7. Medical Staff

(a) The facility shall have a medical staff that includes at least one physician, and may also include one or more mid-level practitioners, and does the following: (i) Examines the credentials of candidates for medical staff membership and makes recommendations to the governing body on the appointment of the candidate; (ii) Adopts a collaborative plan containing the following, and enforces the collaborative plan after approval by the governing body; (A) A statement of the duties and privileges of each category of medical staff (e.g., physician and mid-level practitioner); and (B) A requirement that a physical examination be made and medical history taken of a patient by a member of the medical staff no more than 24 hours after the patient’s admission to the facility. (b) A physician on staff shall: (i) Provide medical direction for the facility’s health care activities and consultation for non-physician health care providers; (ii) In conjunction with the mid-level practitioner staff members, partici- pate in developing, executing, and periodically reviewing the facility’s written policies and the services provided to patients; (iii) Review and sign the records of each patient admitted and treated by a mid-level practitioner no later than fifteen (15) days after that patient’s discharge from the facility; (iv) Provide health care services to the patients in the facility, whenever needed and requested; (v) Prepare guidelines for the medical management of health problems, including conditions requiring medical consultation and/or patient referral; and (vi) At intervals no more than two weeks apart, be physically present in the facility for a sufficient time to provide the medical direction, medical care services, and staff consultation required by the collaborative plan; (A) When not present, either be available through direct telecommu- nication for consultation and assistance with medical emergencies, and patient referral, or ensure that another physician is available for the purpose; (B) However, the physical site visit for a given two week period is not required if, during that period, no inpatients have been treated in the facility. (c) A mid-level practitioner on staff shall: (i) Participate in the development, execution, and periodic review of the guidelines and written policies governing the services furnished by the facility; (ii) Participate with a physician in a review of each patient’s health records; (iii) Provide health care services to patients according to the facility’s policies; (iv) Arrange for, or refer patients to needed services that are not provided at the facility; and (v) Assure that adequate patient health records are maintained and trans- ferred as necessary when a patient is referred.