12VAC5-410-200: Organization

A. The internal hospital organization shall be structured to include appropriate departments and services consonant with its statement of purpose.

B. Each hospital shall maintain clearly written definitions of its organization, authority, responsibility, and relationships.

C. Each hospital department and service shall maintain:

1. Clearly written definitions of its organization, authority, responsibility, and relationships; and

2. Written policies and procedures including:

a. Patient care where applicable;

b. Infection prevention;

c. Disaster preparedness; and

d. Facility security.