Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.
(b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee.
(c) Each facility shall establish and implement policies and procedures, including but not limited to:
(1) Physician services policies and procedures which include:
(A) Orientation of new physicians to the facility and changes in physician services and/or policies.
(B) Patient evaluation visits by the attending physician and documentation of alternate schedules for such visits.
(2) Nursing services policies and procedures which include:
(A) A current nursing procedure manual.
(B) Provision for the inventory and identification of patients' personal possessions, equipment and valuables.
(C) Screening of all patients for tuberculosis upon admission. These procedures shall be determined by the patient care policy committee. A tuberculosis screening procedure may not be required if there is satisfactory written evidence available that a tuberculosis screening procedure has been completed within 90 days of the date of admission to the facility. Subsequent tuberculosis screening procedures shall be determined by the attending physician.
(D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition.
(E) Conditions under which restraints are used, the application of restraints, and the mechanism used for monitoring and controlling their use.
(3) Infection control policies and procedures.
(4) Dietary services policies and procedures which include:
(A) Provision for safe, nutritious food preparation and service.
(B) A provision for maintaining a current dietetic service procedure manual.
(5) Pharmaceutical services policies and procedures.
(6) Activity program policies and procedures.
(7) Housekeeping services policies and procedures which include provision for maintenance of a safe, clean environment for patients, employees and the public.
1. Amendment of subsection (c)(2)(D) and NOTE filed 3-3-2010; operative 4-2-2010 (Register 2010, No. 10).
Note: Authority cited: Sections 1275, 100275 and 131200, Health and Safety Code. Reference: Sections 1276, 1316.5, 131050, 131051 and 131052, Health and Safety Code.
