(1) As used in this section, "institution" means every hospital or related facility or institution having in excess of fifty beds and required to be licensed under part 1 of article 3 of this title or required to be certified pursuant to section 25-1.5-103 (1)(a)(II), except skilled nursing facilities and intermediate care facilities which are subject to the provisions of section 25-1-120. (2) The department shall require every institution to submit to the department a plan for a patient grievance mechanism and a policy statement with respect to the obligations of the institution to patients using the facilities of such institution. The plan and policy statement must meet with the approval of the department prior to certification of compliance or issuance or renewal of a license. (3) A patient grievance mechanism plan shall include, but not be limited to: (a) A provision for a patient representative to serve as a liaison between the patient and the institution; (b) A description of the qualifications of the patient representative; (c) An outline of the job description of the patient representative; (d) A description of the amount of decision-making authority given to the patient representative; (e) A method by which each patient will be made aware of the patient representative program and how the representative of the program may be contacted. (4) The policy statement with respect to the obligations of the institution to patients using facilities of such an institution shall be posted conspicuously in a public place on its premises and made available to each patient upon admission. Such policy statement shall include, but need not be limited to, a clarification of a physician's duty to provide informed consent, admission procedures, staff identification, privacy, medical records, billing procedures, and the obligation of the physician to provide information regarding research, experimental, or educational projects relating to the patient's own case. Nothing in this section shall apply to any nursing institution conducted by or for the adherents of any well-recognized church or religious denomination for the purpose of providing facilities for the care and treatment of the sick who depend exclusively upon spiritual means through prayer for healing in the practice of the religion of such church or denomination.
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