Minnesota Administrative Rules

CHAPTER 4640, HOSPITAL LICENSING AND OPERATION

DEPARTMENT OF HEALTH

4640.0100 DEFINITIONS.

Subpart 1.

Scope.

For the purpose of this chapter, the terms used in subparts 2 to 11 have the meanings given them in this part.

Subp. 2.

[Repealed by amendment, L 1977 c 305 s 39]

Subp. 3.

Chronic disease hospital.

A "chronic disease hospital" is a hospital, the primary purpose of which is to provide the services and facilities for the diagnosis, treatment, and rehabilitation of patients with chronic illness. "Chronic disease" refers to illness or disability which is either permanent or recurrent, which may require long periods of medical supervision or care as well as special rehabilitative services, as distinguished from acute illness which is usually of short duration and self-limiting in nature. Nursing homes and boarding care homes as classified and defined in parts 4655.0090 to 4655.1060, and hospitals devoted exclusively to the care of patients with mental illness are not "chronic disease hospitals."

Subp. 4.

General hospital.

A "general hospital" is a hospital providing community service for inpatient medical and surgical care of acute illness or injury and for obstetrics.

Subp. 5.

Hospital.

A "hospital" is an institution adequately and properly staffed and equipped; providing services, facilities, and beds for the reception and care for a continuous period longer than 12 hours for one or more nonrelated persons requiring diagnosis, treatment, or care for illness, injury, or pregnancy; and regularly making available clinical laboratory services, diagnostic X-ray services, and treatment facilities for surgery or obstetrical care or other definitive medical treatment of similar extent. Definitive medical treatment may include psychiatric care, physical medicine and rehabilitation, X-ray therapy, and similar specialized treatment. The following are not hospitals within the meaning of these rules: diagnostic or treatment centers, physicians' offices or clinics, and facilities for the foster care of children licensed by the commissioner of human services.

Subp. 6.

Licensee.

The "licensee" is the person or governing body to whom the license is issued. The licensee is responsible for compliance with all applicable rules and standards of the commissioner of health.

Subp. 7.

Maternity hospital.

A "maternity hospital" is a hospital, the primary purpose of which is to provide services and facilities for obstetrical care.

Subp. 8.

Mental hospital.

A "hospital for persons with mental illnesses" is a hospital for the diagnosis, treatment, and custodial care of persons with a mental illness.

Subp. 9.

Psychiatric hospital.

A "psychiatric hospital" is a type of hospital for persons with a mental illness where patients receive diagnosis and intensive treatment and where usually only a minimum of continuous long-term treatment facilities are afforded.

Subp. 10.

Specialized hospital.

A "specialized hospital" is a hospital providing primarily for one type of care, such as a hospital for persons with a mental illness, a psychiatric hospital, a chronic disease hospital, or a maternity hospital. The specialized hospital shall meet the applicable regulations for a general hospital of corresponding size and all regulations pertaining to such specialized services as are provided by the hospital.

Subp. 11.

Specialized unit.

When a general hospital provides ten or more beds in a segregated unit for a specialized type of care, such as psychiatric, chronic disease, or nursing home, such a unit is a "specialized unit" of the general hospital. The services provided in a nursing home unit are not hospital services. For licensing purposes, one license shall be issued to a general hospital having one or more specialized units, when such units are adjacent to or located on property adjoining that of the general hospital. Separate licenses shall be required for institutions which are maintained on separate premises even though they are under the same management. The total bed capacity, including bassinets, shall be used in determining the license fee.

Subp. 12.

[Repealed, 44 SR 371]

Statutory Authority:

MS s 14.05; 14.3895; 144.55; 144.56

History:

L 1977 c 305 s 39; L 1984 c 654 art 5 s 58; L 2013 c 59 art 3 s 21; 44 SR 371

Published Electronically:

September 16, 2019

4640.0200 LICENSING.

Subpart 1.

License fees.

Each application for either an initial or renewal license to operate a hospital or a related institution within the meaning of Minnesota Statutes, sections 144.50 to 144.56 and these rules, shall be accompanied by a fee based upon the formula established in part 4735.0200. A bed must be licensed if it is available for use by patients. If the number of licensed beds in a nonaccredited hospital is increased during the term of the license, $25 for each additional bed shall be paid. There shall be no refund for a decrease in licensed beds.

Subp. 2.

License expiration date.

Initial and renewal licenses issued pursuant to Minnesota Statutes, sections 144.50 to 144.56 and these rules, shall be issued for the calendar year for which application is made and shall expire on December 31 of such year. License renewals shall be applied for on an annual basis. Applications for license renewal shall be submitted no later than December 31 of the year preceding the year for which application is made. Any application for an initial license submitted after November 1 shall be considered as an application for the following year; provided, however, that a license may be issued and be effective prior to January 1 of the year for which application is made without payment of fees for two years.

Subp. 3.

License to be posted.

The license shall be posted conspicuously in the hospital.

Statutory Authority:

MS s 144.55; 144.56

Published Electronically:

November 12, 1997

4640.0300 COMPLIANCE.

All hospitals licensed as of the effective date of these rules shall comply with the requirements contained in parts 4640.0100 to 4640.6400.

Statutory Authority:

MS s 144.55; 144.56

Published Electronically:

November 12, 1997

4640.0400 HOSPITAL PLANNING.

When any individual or group in a given locality believes a need exists for a hospital and would like to investigate the need for and the possibilities of such a hospital, the commissioner of health shall be so notified in writing. The commissioner of health shall thereupon make available to such body all of the latest information relative to hospital needs in that hospital area. Nothing in these rules shall prohibit the development of a hospital in any location, provided such hospital meets the standards of construction, equipment, licensing, maintenance, and operation as prescribed in these rules.

Statutory Authority:

MS s 144.55; 144.56

History:

L 1977 c 305 s 39

Published Electronically:

November 12, 1997

4640.0500 CROWDED CONDITIONS IN EXISTING HOSPITALS.

When the occupancy rates of a hospital are determined by the commissioner of health to be so excessively high as to thereby create serious overcrowding and interference with the provision of proper care for patients, the commissioner of health shall so inform the governing body which shall thereupon make provisions for expansion of the bed capacity and needed services or make other arrangements to alleviate such conditions.

Statutory Authority:

MS s 144.55; 144.56

History:

L 1977 c 305 s 39

Published Electronically:

November 12, 1997

4640.0600 CONVERSION.

On and after the effective date of these rules, any building or structure not then operating as a hospital but which is to be converted for use as a hospital shall be of fire-resistive construction and upon completion shall conform with parts 4645.0200 to 4645.5200 of these hospital rules entitled regulations for hospital construction and equipment. The commissioner of health shall be advised immediately in writing when the acquisition or purchase of a building or structure is contemplated for use as a hospital.

Statutory Authority:

MS s 144.55; 144.56

History:

L 1977 c 305 s 39

Published Electronically:

November 12, 1997

ADMINISTRATION, MEDICAL STAFF, PERSONNEL

4640.0700 ADMINISTRATION.

Subpart 1.

Standards.

It is recommended that the standards of the Joint Commission on Accreditation of Hospitals, 875 North Michigan, Chicago, Illinois 60611, be adopted.

Subp. 2.

Governing body.

The governing body or the person or persons designated as the governing authority in each institution shall be responsible for its management, control, and operation. It shall appoint a hospital administrator and the medical staff. It shall formulate the administrative policies for the hospital. The governing body should not employ an administrator until it is determined that the administrator qualifies for registration as a hospital administrator in Minnesota. It is recommended that the governing body officially appoint one or more assistants to the administrator who shall act in the administrator's absence.

Subp. 3.

Change in administrators.

Notification of the termination of service of the administrator as well as of the appointment of a new administrator shall be given promptly in writing by the governing body of the hospital to the commissioner of health. If a registered administrator is not available to assume the position immediately, such notification to the commissioner of health should include the name of the person temporarily in charge of the hospital. This temporary period should not exceed 90 days.

Statutory Authority:

MS s 144.55; 144.56

History:

L 1977 c 305 s 39; L 1980 c 567 s 2; 17 SR 1279

Published Electronically:

November 12, 1997

4640.0800 THE MEDICAL STAFF.

Subpart 1.

Responsibility.

The medical staff shall be responsible to the governing body of the hospital for the clinical and scientific work of the hospital. It shall be called upon to advise regarding professional problems and policies.

Subp. 2.

Organization and duties.

In any hospital used by two or more practitioners, the medical staff shall be an organized group which shall formulate and, with the approval of the governing body, adopt bylaws, rules, regulations, and policies for the proper conduct of its work. The medical staff shall: designate one of its members as chief of staff; hold regular meetings for which minutes and records of attendance shall be kept; and review and analyze at regular intervals the clinical experience in the hospital.

Subp. 3.

Professional care.

All persons admitted to the hospital shall be under the professional care of a member of the medical staff.

Subp. 4.

[Repealed, L 2012 c 247 art 4 s 51]

Subp. 5.

Emergency calls.

Provision shall be made for one or more members of the medical staff to be available at all times for emergency calls.

Statutory Authority:

MS s 144.55; 144.56

History:

L 2012 c 247 art 4 s 51

Published Electronically:

July 11, 2012

4640.0900 PERSONNEL.

Subpart 1.

Policies and procedures.

Written policies, procedures, rules, and regulations shall be established for the administrative and technical guidance of the personnel of the entire hospital. Employees shall be instructed in the requirements, policies, and procedures pertaining to their respective duties.

Subp. 2.

Number of personnel.

At all times there shall be enough qualified personnel on duty to provide the standard of care and maintenance in the hospital which is necessary for the well-being of the persons received for care. This includes night duty, vacation, and other relief periods. A record shall be kept of the length of service of each employee.

Subp. 3.

Nurses.

A registered nurse shall be responsible for the nursing care of patients and shall assign nursing duties to qualified personnel when he or she is off duty. Additional nursing personnel with training and experience commensurate with the responsibility of the specific assignments shall be employed to assure a high quality of nursing care to all patients both day and night.

It is recommended that nurses in the obstetrical department limit their services to maternity and clean surgical cases.

Subp. 4.

Practical nurses, auxiliary workers, and volunteers.

All practical nurses, auxiliary workers, and volunteers performing nursing service functions shall be under the supervision of a registered nurse. Their duties shall be clearly defined and they shall be instructed in all duties assigned to them.

Subp. 5.

Health of employees.

The governing body of the hospital upon recommendation of its organized medical staff shall provide in its rules and regulations measures to prevent the transmission of communicable diseases. Such regulations shall include provisions for an immunization program; for preemployment physical examinations including tuberculin tests, X-rays of the chest, and other indicated laboratory procedures; and for subsequent chest X-rays and periodic examinations of all hospital employees. Such regulations shall also include the procedures to be followed in the case of illness or absenteeism of any employee or in the case of the exposure of any employee to a communicable disease. All employees shall report any illness or exposure to communicable disease to the administrator and to a designated member of the medical staff.

Routine admission chest X-ray examination of patients is recommended.

Statutory Authority:

MS s 144.55; 144.56

History:

17 SR 1279

Published Electronically:

December 8, 2014

RECORDS AND REPORTS

4640.1000 MEDICAL RECORDS.

Subpart 1.

Personnel.

A trained medical record librarian or other authorized hospital employee shall be given the responsibility for the proper custody, supervision, indexing, and filing of the completed medical records of patients.

Subp. 2.

Facilities and equipment.

Space and equipment shall be provided for the recording and completion of the record by the physician as well as for indexing, filing, and safe storage of medical records.

Subp. 3.

Information to be included.

Accurate and complete medical records shall be maintained on all patients from the time of admission to the time of discharge. The following additional information shall be obtained and recorded for all maternity patients: full and true name of patient and her husband, the place of residence of the patient prior to hospitalization, and place of residence following discharge. To be considered complete, a record should include:

A.

adequate identification data;

B.

admitting diagnosis, to be completed within 24 to 48 hours;

C.

history and physical examination, including history of pregnancy on maternity cases, to be completed within 24 to 48 hours;

D.

progress notes;

E.

signed doctors' orders;

F.

operative notes, where applicable to include course of delivery on maternity cases;

G.

special reports and examinations, including clinical and laboratory findings, X-ray findings, records of consultations, anesthesia reports, etc.;

H.

nurses' notes;

I.

discharge diagnosis; and

J.

autopsy report, where applicable.

Subp. 4.

Records on newborn infants.

A medical record shall be maintained on all newborn infants and shall include a physical examination performed and recorded by the physician and a statement relative to the physical condition of the infant at the time of discharge. When the child leaves the hospital with any person other than a parent, the hospital shall obtain and record the true name of the person or persons with whom the child leaves, and the place of residence where it is planned that the child is to be taken.

Subp. 5.

Completion of the record.

The medical staff shall have a policy requiring that the medical records shall be completed within a reasonable time following the discharge of the patient. The completion of the medical record shall be the responsibility of the attending physician.

Subp. 6.

Surgical cases.

The history and physical examination record shall be completed and signed by the attending staff member prior to the performance of any surgery except in case of emergency when an admission note including significant findings and diagnosis shall be written.

Statutory Authority:

MS s 144.55; 144.56

History:

17 SR 1279

Published Electronically:

November 12, 1997

4640.1100 HOSPITAL RECORDS.

The following hospital records shall be maintained in a form and manner acceptable to the commissioner of health:

A.

record of admissions and discharges, total patient days, average length of stay, and number of autopsies performed. Separate data shall be maintained for: adults and children excluding newborns, and newborn infants excluding stillbirths;

B.

register of births;

C.

register of deaths;

D.

register of operations; and

E.

register of outpatients.

Statutory Authority:

MS s 144.55; 144.56

History:

L 1977 c 305 s 39

Published Electronically:

October 3, 2013

4640.1200 NARCOTIC RECORD.

A record shall be maintained for all narcotics administered. This record shall contain the date, hour, name of patient, name of physician, kind of narcotic, dose, and name of person by whom administered. A federal permit is necessary for the purchase of narcotics for stock use. Application for this permit must be approved by the commissioner of health. This approval is based on the proper storage of narcotics and the maintenance of a record book of narcotics.

Statutory Authority:

MS s 144.55; 144.56

History:

L 1977 c 305 s 39

Published Electronically:

November 12, 1997

4640.1300 REPORTS.

Subpart 1.

Annual report to commissioner of health.

On or before January 31 of each year, there shall be filed with the commissioner of health, on a form provided by the commissioner of health, the annual hospital statistical report covering patient service data.

Subp. 2.

Hospital reports.

On or before the tenth of each month, the hospital administrator shall file with the commissioner of health, on a blank provided by or approved by the commissioner of health for the purpose, a report of all births and deaths or stillbirths occurring in such institution during the previous month. Subpart 2 is taken from part 4600.1200 relating to hospital reporting of vital records. It is here made of special application to hospital administrators. Part 4615.0800 should also be noted. It reads as follows: Any death associated with pregnancy, including abortion and extrauterine pregnancy, or the puerperium for a period of three months postpartum, whether or not it is the actual cause of death, shall be reported by mail within three days after death to the Minnesota Department of Health, Section of Maternal and Child Health, by the attending physician and by the hospital where the death occurred.

Statutory Authority:

MS s 144.55; 144.56

History:

L 1977 c 305 s 39; L 2015 c 21 art 1 s 109

Published Electronically:

September 30, 2015

4640.1400 CHILD WELFARE REPORTS.

Subpart 1.

Illegitimate birth reports.

Every illegitimate birth shall be reported to the commissioner of human services, on a form furnished by the commissioner, within 24 hours after the birth of the child.

Subp. 2.

Information confidential.

No member of the hospital staff, or employee of the hospital, shall give information regarding a maternity patient or her child where there is any question relative to the legitimacy of such birth except to a duly authorized representative of the commissioner of health or to the commissioner of human services or the duly authorized representatives.

Subp. 3.

Boarding infants in hospital.

No infant shall be retained in the hospital for care for more than 29 days following discharge of the mother except for prematurity, illness, or other physical reason which requires specialized hospital care.

Subp. 4.

Placement of children.

No member of the hospital staff or employee of the hospital shall place or participate in the placement of any child born in the hospital with any person other than a birth parent or member of the immediate family except in cooperation with an authorized child-placing agency.

Statutory Authority:

MS s 144.55; 144.56

History:

L 1977 c 305 s 39; L 1984 c 654 art 5 s 58; L 1987 c 403 art 3 s 96; 17 SR 1279; L 1994 c 465 art 1 s 62; L 1994 c 631 s 31

Published Electronically:

November 12, 1997

LABORATORY AND X-RAY SERVICES

4640.1500

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.1600

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

ACCOMMODATIONS, FURNISHINGS, AND EQUIPMENT FOR CARE

4640.1700

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.1800

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.1900

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.2000

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.2100

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.2200

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.2300

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.2400

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.2500

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.2600

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.2700

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

FOOD SERVICE AND FOOD SANITATION

4640.2800

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.2900

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.3000

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.3100

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.3200

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

PHYSICAL PLANT

4640.3300

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.3400

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.3500

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

MENTAL AND PSYCHIATRIC HOSPITALS

4640.3600

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.3700

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.3800

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.3900

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.4000

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.4100

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.4200

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.4300

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.4400

[Repealed, 44 SR 371]

Published Electronically:

September 16, 2019

4640.4500

[Repealed, 44 SR 371]

Published Electronically:

September 16, 2019

4640.4600

[Repealed, 44 SR 371]

Published Electronically:

September 16, 2019

4640.4700

[Repealed, 44 SR 371]

Published Electronically:

September 16, 2019

4640.4800

[Repealed, 44 SR 371]

Published Electronically:

September 16, 2019

4640.4900

[Repealed, 44 SR 371]

Published Electronically:

September 16, 2019

4640.5000

[Repealed, 44 SR 371]

Published Electronically:

September 16, 2019

4640.5100

[Repealed, 44 SR 371]

Published Electronically:

September 16, 2019

4640.5200

[Repealed, 44 SR 371]

Published Electronically:

September 16, 2019

4640.5300

[Repealed, 44 SR 371]

Published Electronically:

September 16, 2019

4640.5400

[Repealed, 44 SR 371]

Published Electronically:

September 16, 2019

4640.5500

[Repealed, 44 SR 371]

Published Electronically:

September 16, 2019

4640.5600

[Repealed, 44 SR 371]

Published Electronically:

September 16, 2019

4640.5700

[Repealed, 44 SR 371]

Published Electronically:

September 16, 2019

4640.5800

[Repealed, 44 SR 371]

Published Electronically:

September 16, 2019

4640.5900

[Repealed, 44 SR 371]

Published Electronically:

September 16, 2019

4640.6000

[Repealed, 44 SR 371]

Published Electronically:

September 16, 2019

CHRONIC DISEASE HOSPITALS

4640.6100

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.6200

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.6300

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.6400

[Repealed, L 2023 c 70 art 3 s 83]

Published Electronically:

November 30, 2023

4640.6500

[Repealed, L 1980 c 567 s 2]

Published Electronically:

November 12, 1997

4640.6600

[Repealed, L 1980 c 567 s 2]

Published Electronically:

November 12, 1997

4640.6700

[Repealed, L 1980 c 567 s 2]

Published Electronically:

November 12, 1997

4640.6800

[Repealed, L 1980 c 567 s 2]

Published Electronically:

November 12, 1997

4640.6900

[Repealed, L 1980 c 567 s 2]

Published Electronically:

November 12, 1997