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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 2336 (April 27, 2024).

Pennsylvania Code




105.1.    Principle.


105.11.    Access.
105.12.    Admission criteria.
105.13.    Alternate admissions arrangements.
105.14.    Admission diagnosis.
105.15.    Patient identification.


105.21.    [Reserved].
105.22.    Discharge planning.
105.23.    Transfer agreements.
105.24.    Discharge by transfer.
105.25.    Discharge of minor or incompetent patient.
105.26.    [Reserved].

Cross References

   This chapter cited in 55 Pa. Code §  6100.2 (relating to applicability).


§ 105.1. Principle.

 The hospital shall have written policies for the admission, discharge, and proper referral of all patients who present themselves for care. Criteria should specify additional approaches to assure appropriate utilization of hospital resources such as preadmission testing, ambulatory care programs and short-term procedure units.


§ 105.11. Access.

 (a)  No person seeking necessary medical care from the hospital shall be denied such care for reasons not based on sound medical practice or the hospital’s charter and, particularly, no such person shall be denied such care on account of race, creed, color, religion, sex or sexual preference, in accordance with the provisions of the Pennsylvania Human Relations Act (43 P.S. § §  951—963).

 (b)  When the hospital does not provide the services required by a patient or a person seeking necessary medical care, an appropriate referral shall be made. No hospital shall be required to make any referral which is contrary to its stated ethical policy promulgated in accordance with 16 Pa. Code §  51.31 (relating to adoption and substance of a stated ethical policy).

 (c)  Care shall be provided in a nondiscriminatory manner.

 (d)  Those facilities having an obligation under 42 U.S.C.A. §  291 shall comply with the provisions of that Act as it relates to free and low-cost care.

§ 105.12. Admission criteria.

 The governing body, with the advice of and in conjunction with the medical staff, shall establish medical criteria for admissions to ensure provision of care based on medical necessity and appropriateness.

Cross References

   This section cited in 28 Pa. Code §  141.23 (relating to medical appraisal of dental patients); and 28 Pa. Code §  143.4 (relating to medical appraisal of a podiatric patient).

§ 105.13. Alternate admissions arrangements.

 When, according to established criteria and the opinion of the attending physician, a patient requires inpatient care but, for any reason, cannot be admitted to the hospital, the hospital or attending physician, or both, should assist the patient in making arrangements for care in an alternate facility so as not to jeopardize the health and safety of the patient.

Cross References

   This section cited in 28 Pa. Code §  141.23 (relating to medical appraisal of dental patients); and 28 Pa. Code §  143.4 (relating to medical appraisal of a podiatric patient).

§ 105.14. Admission diagnosis.

 Each patient who is admitted shall be given a provisional diagnosis, entered on the clinical record, at the time of admission.

Cross References

   This section cited in 28 Pa. Code §  141.23 (relating to medical appraisal of dental patients); and 28 Pa. Code §  143.4 (relating to medical appraisal of a podiatric patient).

§ 105.15. Patient identification.

 At the time of admission or as soon as possible thereafter, each patient shall be fitted with an identification band or other visible means of identification.


§ 105.21. [Reserved].


   The provisions of this §  105.21 reserved September 19, 1980, effective September 20, 1980, 10 Pa.B. 3761. Immediately preceding text appears at serial page (37790).

§ 105.22. Discharge planning.

 (a)  Discharge planning shall be an integral part of the hospitalization of each patient and shall commence as soon as possible after admission. When the hospital determines no discharge planning is necessary in a particular case, that conclusion shall be noted on the medical record of the patient.

 (b)  The hospital shall have written policies governing discharge planning. These shall include but need not be limited to the following:

   (1)  Appropriate referral and transfer plans.

   (2)  Methods to facilitate the provision of follow-up care.

   (3)  Information to be given to the patient or his family or other persons involved in caring for the patient on matters such as the patient’s condition; his health care needs; the amount of activity he should engage in; any necessary medical regimens including drugs, diet, or other forms of therapy; sources of additional help from other agencies; and procedures to follow in case of complications. This information should be provided by the attending physician.

   (4)  Procedures for assisting the patient and his family in gaining information regarding financial assistance in paying bills incurred as a result of the hospitalization. The procedures shall specify how the patient is to be informed where relevant information can be obtained, how relevant hospital information is to be made available in a timely and useful manner, and how the hospital will affirmatively inquire into the eligibility of the patient for assistance from the various Federal and State government programs, for example, Medicare, Medicaid, Hill-Burton.

§ 105.23. Transfer agreements.

 (a)  Any hospital which does not provide extended care, subacute care, long-term care, or intermediate care shall maintain, to the extent possible, written agreements with institutions offering these kinds of care. Such agreements shall provide for the prompt transfer and admission of patients who no longer require the services of the hospital but do require one of the aforementioned kinds of institutional care.

 (b)  The hospital shall have written policies, adopted by the governing body, prohibiting transfer agreements which violate the provisions of §  103.9 (relating to conflicts of interest) or which could jeopardize the health of patients.

§ 105.24. Discharge by transfer.

 A patient shall not be transferred to another medical care facility unless prior arrangements for admission have been made. Clinical records of sufficient content to insure continuity of care shall accompany the patient.

§ 105.25. Discharge of minor or incompetent patient.

 Any individual who cannot legally consent to his own care shall be discharged only to the custody of parents, legal guardian, person standing in loco parentis, or another responsible party unless otherwise directed by the parent or guardian or court of competent jurisdiction. If the parent or guardian directs that discharge be made otherwise, he shall so state in writing, and the statement shall become a part of the permanent medical record of the patient.


   The provisions of this §  105.25 issued under 67 Pa.C.S. § §  6101—6104; and Reorganization Plan No. 2 of 1973 (71 P. S. §  755-2).


   The provisions of this §  105.25 amended September 19, 1980, effective September 20, 1980, 10 Pa.B. 3761. Immediately preceding text appears at serial page (37791).

§ 105.26. [Reserved].


   The provisions of this §  105.26 reserved December 3, 1982, effective December 4, 1982, 12 Pa.B. 4129. Immediately preceding text appears at serial page (52755).

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