Header:
TEXAS ADMINISTRATIVE CODE
TITLE 25. HEALTH SERVICES
PART 1. DEPARTMENT OF STATE HEALTH SERVICES
CHAPTER 131. FREESTANDING EMERGENCY MEDICAL CARE FACILITIES
SUBCHAPTER C. OPERATIONAL REQUIREMENTS
Date:
08/31/2009
Document:
§ 131.41. Operational Standards
(a) The facility shall have an identified governing body fully responsible for the organization, management, control, and operation of the facility, including the appointment of the facility's medical director. The medical director shall be board certified or board eligible in emergency medicine, or board certified in primary care with a minimum of two years emergency care experience.
(b) The governing body shall adopt, implement, and enforce written polices and procedures for the total operation and all services provided by the facility.
(c) The governing body shall be responsible for all services furnished in the facility, whether furnished directly or under contract. The governing body shall ensure that services are provided in a safe and effective manner that permits the facility to comply with all applicable rules and standards.
(d) The governing body shall ensure that the medical staff has on file current written bylaws, rules, and regulations that are adopted, implemented, and enforced.
(e) The governing body shall address and is fully responsible, either directly or by appropriate professional delegation, for the operation and performance of the facility. Governing body responsibilities include, but are not limited to:
(1) determining the mission, goals, and objectives of the facility;
(2) ensuring that facilities and personnel are adequate and appropriate to carry out the mission;
(3) ensuring a physical environment that protects the health and safety of patients, personnel, and the public;
(4) establishing an organizational structure and specifying functional relationships among the various components of the facility;
(5) adopting, implementing, and enforcing bylaws or similar rules and regulations for the orderly development and management of the facility;
(6) adopting, implementing, and enforcing policies or procedures necessary for the orderly conduct of the facility;
(7) reviewing and approving the facility's training program for staff;
(8) ensuring that all equipment utilized by facility staff or by patients is properly used and maintained per manufacturer recommendations;
(9) adopting, implementing, and enforcing policies or procedures related to emergency planning and disaster preparedness. The governing body shall review the facility's disaster preparedness plan at least annually;
(10) ensuring there is a quality assessment and performance improvement (QAPI) program to evaluate the provision of patient care. The governing body shall review and monitor QAPI activities quarterly;
(11) reviewing legal and ethical matters concerning the facility and its staff when necessary and responding appropriately;
(12) maintaining effective communication throughout the facility;
(13) establishing a system of financial management and accountability that includes an audit or financial review appropriate to the facility;
(14) adopting, implementing, and enforcing policies for the provision of radiological services;
(15) adopting, implementing, and enforcing policies for the provision of laboratory services;
(16) adopting, implementing, and enforcing policies for the provision of pharmacy services;
(17) adopting, implementing, and enforcing policies for the collection, processing, maintenance, storage, retrieval, authentication, and distribution of patient medical records and reports;
(18) adopting, implementing, and enforcing a policy on the rights of patients and complying with all state and federal patient rights requirements;
(19) adopting, implementing, and enforcing policies for the provision of an effective procedure for the immediate transfer to a licensed hospital of patients requiring emergency care beyond the capabilities of the facility. All facilities must have a transfer agreement with a hospital licensed in this state as a requirement for licensure as defined in § 131.67 of this title (relating to Patient Transfer Agreements);
(20) adopting, implementing, and enforcing policies for all individuals that arrive at the facility to ensure they are provided an appropriate medical screening examination within the capability of the facility, including ancillary services routinely available to determine whether or not the individual needs emergency care as defined in § 131.2 of this title (relating to Definitions). If emergency care is determined to be needed, the facility shall provide any necessary stabilizing treatment or arrange an appropriate transfer the individual as defined in § 131.66 of this title (relating to Patient Transfer Policy);
(21) adopting, implementing, and enforcing a policy to ensure that the facility shall remain open when necessary to continue appropriate patient care or services. This policy shall apply to a patient who is under the care of the facility, and shall ensure that the patient's course of treatment at the facility is completed, regardless of the facility's hours of operation;
(22) approving all major contracts or arrangements affecting the medical care provided under its auspices, including, but not limited to, those concerning:
(A) the employment of physicians and practitioners;
(B) the use of external laboratories;
(C) an effective procedure for obtaining emergency laboratory, radiology, and pharmaceutical services when these services are not immediately available due to system failure;
(23) formulating long-range plans in accordance with the mission, goals, and objectives of the facility;
(24) operating the facility without limitation because of color, race, age, sex, religion, national origin, or disability;
(25) ensuring that all marketing and advertising concerning the facility does not imply that it provides care or services that the facility is not capable of providing;
(26) reviewing and approving the Patient Safety Program; and
(27) developing a system of risk management appropriate to the facility, including, but not limited to:
(A) periodic review of all litigation involving the facility, its staff, physicians, and practitioners regarding activities in the facility;
(B) periodic review of all incidents reported by staff and patients;
(C) review of all deaths, trauma, or adverse reactions occurring on premises; and
(D) evaluation of patient complaints.
(f) The governing body shall provide for full disclosure of ownership to the department.
(g) The governing body shall meet at least annually and keep minutes or other records necessary for the orderly conduct of the facility. Meetings held by the facility governing body shall be separate meetings with separate minutes from any other governing body meeting.
(h) If the governing body elects, appoints, or employs officers and administrators to carry out its directives, the authority, responsibility, and functions of all such positions shall be defined.
(i) The governing body shall develop a process for appointing or reappointing medical staff, and for assigning or curtailing medical privileges.
(j) The governing body shall provide (in a manner consistent with state law and based on evidence of education, training, and current competence) for the initial appointment, reappointment, and assignment or curtailment of privileges and practice for non-physician health care personnel and practitioners.
(k) The governing body shall encourage personnel to participate in continuing education that is relevant to their responsibilities within the facility.
(l) The governing body shall adopt, implement, and enforce written policies to ensure compliance with applicable state and federal laws.
(m) The facility shall assess and the governing body shall review patient satisfaction with services and environment no less than annually.
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