Current through Register Vol. 6, March 22, 2024
(1) A Montana
health care facility that is not currently verified by the American College of
Surgeons as meeting the American College of Surgeons' criteria to qualify for
verification as a trauma facility and that wishes a designation or renewal of
designation as a Montana trauma facility must submit to the department an
application for trauma facility designation, supplied by the
department.
(2) The application
must:
(a) specify the level of designation
for which the facility is applying; and
(b) provide information about the facility's
compliance with the Montana Trauma Facility Designation Criteria of the State
Trauma Plan that are required for that level of trauma facility.
(3) The department will review the
application for completeness and within 30 days after receiving the application
notify the health care facility that:
(a) the
application is complete; or
(b) the
application is incomplete and request additional information.
(4) When the application is
complete, the department will:
(a) select a
site review team; and
(b) with a
minimum of 60 days advance notice, notify the facility of the scheduled dates
for the site survey and of the site review team members.
(5) The health care facility must:
(a) notify the department in writing within
ten working days if it objects to one or more members of the site review team
due to a perceived conflict of interest, and provide documentation of clear and
convincing evidence for its concern including, but not limited to, the member's
past or potential financial or personal gain, past or potential employment, or
gain from the use of confidential information; and
(b) prohibit its administration, faculty,
medical staff, employees, and representatives from having any contact with site
review members prior to the site survey, except as directed by the
department.
(6) The site
review team will:
(a) review the commitment
and capabilities of the applicant health care facility to meet the resource
criteria described in the Montana Trauma Facility Designation Criteria of the
State Trauma Plan for the level of designation sought, based upon consideration
of all pertinent information, including:
(i)
review of the application for designation;
(ii) inspection of the facility and required
equipment;
(iii) interview with
appropriate individuals;
(iv)
review of medical records;
(v)
review of inpatient logs and hospital emergency department logs;
(vi) review of hospital trauma registry
entries and reports;
(vii) review
of documentation of trauma performance improvement;
(viii) review of call rosters, staffing
schedules, and meeting minutes;
(ix) review of injury prevention and
education programs; and
(x) other
documentation as necessary to assess the facility's compliance with these
rules;
(b) make a verbal
report of its findings through an exit interview to the applicant upon
completion of the site survey and prior to leaving the facility; and
(c) make a written report of its findings and
recommendations to the department within 30 days following the on-site survey
of the facility.
(7) The
department will review the report of the site review team and forward a copy to
the designation subcommittee.
(8)
The designation subcommittee will review the report of a site review team at
the next quarterly State Trauma Care Committee meeting and make a
recommendation to the department regarding the trauma designation of the
applicant facility.
(9) The
department must:
(a) determine the final
designation of the facility based on consideration of the application, the
recommendations of the site review team, and the recommendations of the
designation subcommittee; and
(b)
notify the applicant of its decision in writing within 30 days after receiving
the recommendation from the designation subcommittee.
(10) The department will take one of the
following actions:
(a) designate the
applicant as qualifying for the trauma facility level requested, providing
there is compliance with the trauma facility resource criteria in the Montana
Trauma Facility Designation Criteria of the State Trauma Plan;
(b) issue a provisional designation to the
applicant provided:
(i) there are
deficiencies noted but the facility is substantially compliant with the
resource criteria and any deficiencies will not have an immediate detrimental
impact on trauma patient care; and
(ii) the applicant has submitted to the site
review team a corrective action plan, acceptable to the team, for the
correction of the identified deficiencies;
(c) designate the applicant as a trauma
facility at a different level from that for which the applicant applied,
provided that:
(i) the applicant meets all of
the requirements of the alternative trauma facility designation level;
and
(ii) the applicant agrees to be
designated at the alternative trauma facility designation level; or
(d) deny any trauma facility
designation if:
(i) there is substantial
noncompliance with the requirements; or
(ii) the deficiencies are fundamental or may
have an immediate detrimental impact on trauma patient care.
50-6-402,
MCA; IMP,
50-6-402,
50-6-410,
MCA;