New Mexico Administrative Code
Title 7 - HEALTH
Chapter 27 - EMERGENCY MEDICAL SERVICES
Part 7 - TRAUMA CARE SYSTEM
Section 7.27.7.9 - TRAUMA CENTER DESIGNATION PROCESS

Universal Citation: 7 NM Admin Code 7.27.7.9

Current through Register Vol. 35, No. 18, September 24, 2024

A. Levels of trauma centers: the Bureau shall identify trauma centers by levels of care capability as defined in these regulations. The levels are as follows:

(1) level I trauma center

(2) level II trauma center

(3) level III trauma center

(4) level IV trauma center

B. Phases of Designation:

(1) phase one (1), letter of intent: the first phase of the designation process is an invitation issued by the Bureau to all hospitals/healthcare facilities in the State that applications for designations are initiated by a letter of intent.

(2) phase two (2), application: the hospital shall submit an application, that has been developed by the Bureau, to the Bureau identifying the desired level of trauma center designation.

(3) phase three (3), review: the third phase is the review phase which begins with the on-site review of the hospital/healthcare facility and ends with the Bureau's recommendation to the Secretary to designate the hospital/healthcare facility as a trauma center.

(4) phase four (4), final: the fourth phase is the final phase which begins with the Secretary reviewing the Bureau's recommendations and ends with a final decision as to the level of trauma center designation by the Department. This phase also includes an appeal procedure for the denial of a designation application in accordance with these regulations.

C. Application Process:

(1) the Bureau shall develop and issue an application packet to hospitals or healthcare facilities, which have submitted a letter of intent in seeking initial designation as a trauma center.

(2) the application packet shall describe the information required from an applicant to be considered for trauma center designation. Such information shall include:
(a) application requirements,

(b) system standards for the level at which the hospital/healthcare facility is applying together with the current status on each standard and category of designation sought,

(c) evaluation criteria,

(d) statement and documentation of attendance and participation in the area ReTrAC and a commitment to serve the trauma care needs of their desired trauma services area and as a partner in the Statewide Trauma System,

(e) geographic area proposed to be covered, and appropriate utilization of data, and

(f) evidence of financial viability compliance.

(3) if there is a designated trauma center or centers at the same or higher level of designation in the proposed geographical area to be served by the applicant, the applicant shall include in its application the following:
(a) a statement of the proposed role of the applicant hospital assuring that the applicant's trauma program and activities would not have a negative financial or operational impact on the existing designated trauma center(s) program or services, and

(b) a statement by the area ReTrAC that the proposed trauma program of the applicant is consistent with and addresses the needs of the regional trauma program as described in the approved regional trauma plan.

(4) the Bureau shall:
(a) conduct a review of each applicant's submitted proposal for completeness. If any proposal is incomplete, the applicant shall be notified by the Bureau and afforded the opportunity to complete the application at least within twenty (20) working days of the Bureau's notification; and,

(b) evaluate applications for potential multiple hospital designation following the same criteria as for a single-facility application. Applications for multiple hospital designation must demonstrate that the goals of these regulations are met as defined in their applications.

D. On-Site Review for Designation:

(1) the Bureau shall conduct an on-site review of an applicant hospital/healthcare facility for levels I, II, III, and IV trauma centers, prior to designation.

(2) the Bureau shall establish multi-disciplinary on-site review teams composed of individuals knowledgeable in trauma care and systems, appropriate to the level of designation requested.

(3) for the initial designation for a level I and II trauma center, the team shall include but not be limited to a:
(a) trauma surgeon,

(b) emergency physician, and

(c) trauma nurse coordinator.

(4) for the designation for a level III and IV trauma center, the team shall include a:
(a) trauma surgeon or emergency physician, and

(b) trauma nurse coordinator.

(5) the composition of subsequent survey teams shall be determined by the Bureau.

(6) such teams shall consist of professionals who do not live or work:
(a) in the same state as the applicant for the designation of levels I and II trauma centers, or,

(b) in the same county as the applicant for designation of level III or IV trauma centers.

(7) the Bureau will consider the allegation of conflict of interest of an on-site review team member if a hospital or healthcare facility can demonstrate a reasonable basis for concern as determined by the Department. Concerns accompanied by the proof upon which the hospital or healthcare facility relies on must be submitted in writing within ten (10) working days of the Bureau's announcements of proposed on-site review team members.

(8) the applicant's administration, faculty, medical staff, employees and representatives are prohibited from having any contact with any on-site review team member after the announcement of the team members and before the on-site review, except as authorized by the Bureau. A violation of this provision may be grounds for denying that applicant's proposal, as determined by the Bureau.

(9) the on-site review team shall evaluate the appropriateness and capabilities of the applicant to provide trauma care services, and validate the hospital/healthcare facility's ability to meet the responsibilities, equipment, and performance standards for the level of designation sought and to meet the overall needs of the trauma system in that region by:
(a) familiarizing themselves with the hospital or healthcare facility's proposal;

(b) inspecting the hospital or healthcare facility's physical plant and interviewing of key staff,

(c) examining hospital or healthcare facility trauma related documents, including patient care records;

(d) interviewing other appropriate individuals;

(e) reviewing past applicant or similar proposals for the regions; and, reviewing other materials as deemed appropriate by the Bureau.

(10) the on-site review team shall:
(a) make a verbal summary of preliminary findings to the applicant upon completion of the on-site review; and,

(b) make written recommendations to the Bureau of the on-site review.

(11) the Bureau and the members of the on-site review team shall maintain confidentiality of information, records, and reports developed pursuant to on-site reviews as permitted by state and federal laws. Information obtained by the on-site team, their oral and written reports, and deliberations shall be kept confidential by the Bureau.

(12) the applicant's application will become the property of the Bureau and shall be considered public information at the end of the designation process, subject to state and federal laws.

(13) hospitals applying for level I or level II may, at their discretion, request a verification site survey by representatives of the American College of Surgeons. The Bureau will accept the findings of the verification site visit and incorporate a copy of the findings in its report to the Secretary recommending or not recommending designation at the level applied for.

E. Designation of Trauma Center:

(1) as soon as practical, but no later than forty five (45) days after receipt of the on-site report survey document, the Bureau shall make recommendations to the Secretary based on:
(a) evaluation of pre-review documentation submitted as part of the application,

(b) recommendations from the on-site review team,

(c) ability of each applicant to comply with goals of the State and regional trauma plans, and,

(d) compliance with agreements with the Bureau, including compliance with regional review criteria as applicable during the previous designation period.

(2) after completion of the on-site review, the Bureau:
(a) may recommend to the Secretary approval at the level of designation proposed by the hospital or healthcare facility; or,

(b) may recommend to the Secretary a lower designation, if, according to the site surveyor's evaluation, the hospital or healthcare facility is unable to meet the standards of the designation for which the applicant applied; or,

(c) may require the hospital or healthcare facility to submit an application for the lower designation, to be followed by an on-site review.

(3) upon approval of the recommended level of designation by the Secretary, the Bureau shall require the hospital or healthcare facility, after receiving notification of the Secretary's decision, to respond within ten (10) working days to accept or decline the proposed designation.

(4) hospitals or healthcare facilities designated as a trauma center shall comply with applicable standards as set forth by the Bureau.

F. Categories of Designation:

(1) provisional: the Bureau may initially designate a trauma center as "provisional" for a term not to exceed one (1) year except for good cause shown as granted by the Bureau;
(a) shall require all provisional trauma centers to have a written work plan of objectives to rectify deficiencies and to demonstrate progress on the work plan throughout the twelve (12) month time period; and,

(b) shall, at the end of the provisional period, grant full designation, extend the provisional period, or suspend the trauma center for cause.

(2) full designation: the Bureau may grant full designation to any hospital or healthcare facility in full compliance with these regulations, subject to the review process described, for a period not to exceed three (3) years.

G. Agreement Process: the Bureau and the designated trauma center shall enter into a written agreement. The agreement shall:

(1) authorize the hospital or healthcare facility to function and identify itself as a designated trauma center for either provisional or full designation;

(2) identify the requirements and responsibilities of both the trauma center and the Bureau, including attendance requirements at local, regional, state and national meetings;

(3) allow the Bureau to monitor compliance with regulations and standards during the designation period, including access to:
(a) patient discharge summaries

(b) patient care logs

(c) patient care records

(d) hospital trauma process improvement program records, including minutes, and,

(e) other relevant documents as determined by the Bureau, and

(4) require confidentiality of information relating to individual patient, provider, and hospital/healthcare facility's care outcomes in accordance with state and federal laws.

H. Denial, Revocation or Suspension of Designation:

(1) the Bureau may deny the application for designation if it finds that the hospital/healthcare facility:
(a) is not the most qualified applicant within a geographic area;

(b) is unable to meet the requirements of these regulations for the level of designation sought;

(c) makes a false statement of a material fact in the hospital/healthcare facility's application for designation;

(d) refuses to allow representatives of the Bureau to inspect any part of the hospital/healthcare facility, records, documentation, or files pertaining to the designation process;

(e) is unable to meet or comply with the requirements as stated in Paragraph (5) of Subsection C of 7.27.7.8 NMAC for participation in the activities of an area ReTrAC and the requirements of an approved regional trauma plan.

(f) engages in unauthorized contact with any on-site review team member.

(2) the Bureau may revoke or suspend a trauma center designation if the trauma center:
(a) fails, refuses to comply or violates the provisions of the State hospital licensure requirements of the State trauma regulations or provisions of applicable federal law; or the trauma center agreement;

(b) fails to provide data to the Trauma Registry;

(c) makes a false statement of a material fact in the application for designation, or in any record required by these regulations, or in a matter under investigation;

(d) prevents, interferes with, or attempts to impede in any way, the work of a representative of the Bureau in the lawful enforcement of these regulations or any other applicable state law;

(e) uses false, fraudulent, or misleading advertising, or makes any public claims regarding the hospital/healthcare facility's ability to care for non-trauma patients based on its trauma center designation status;

(f) misrepresents or is fraudulent in any aspect of conducting business;

(g) is substantially out of compliance with the requirements of these regulations, and has been unable or refused to comply as required by the Bureau.

(3) the following procedures will be used for any investigation of a designated trauma center by the Bureau:
(a) any person or entity may communicate a complaint or knowledge of an incident of any alleged violation of these regulations to the Bureau. Complaints shall be submitted in signed written form to the Bureau. The Bureau may begin an investigation without a signed written complaint if there is sufficient cause.

(b) trauma centers being investigated shall receive written notification within ten (10) working days after a decision is made to begin a preliminary investigation.

(c) at the conclusion of the Bureau's preliminary investigation, the Bureau shall report its findings to the trauma center in written form, including any requirements for corrective action.

(d) if the trauma center does not respond, the corrective action is insufficient, or if the complaint is of such serious nature as to warrant suspension or revocation of designation, as determined by the Bureau, the Bureau shall proceed to the procedure as outlined in Paragraph (4) of Subsection H of 7.27.7.9 NMAC below.

(4) preliminary and further investigations shall be conducted by the Bureau.
(a) preliminary investigations shall be initiated when the Bureau receives information, which might form the basis for action against a trauma center. This fact finding/information gathering investigation will determine for the Bureau whether justification exists to initiate an action or to conduct a further investigation.

(b) further investigations shall be undertaken when additional information is required to allow the Bureau to determine if it will initiate an action. Notice will be given to the trauma center, which is the subject of the investigation unless extenuating circumstances exist which would reasonably preclude notification.

(c) the Bureau will take every precaution to ensure that preliminary and further investigations are conducted in a confidential manner.

(d) an official record is maintained for every designated trauma center in New Mexico under these regulations. If the Bureau begins a preliminary or further investigation, a confidential record will be created containing all investigatory material. If the Bureau initiates an action, all records not exempt from disclosure under the Inspection of Public Records Act, Section 14-2-1, et seq, NMSA 1978, will be placed in the designated trauma center's official record. Any request for records maintained by the Bureau will be processed in accordance with the Inspection of Public Records Act.

(5) the following process shall be used when designation is contemplated to be denied, revoked, or suspended:
(a) the Bureau shall notify a hospital/healthcare facility in writing of contemplated denial of designation, revocation, or suspension of designation by issuing a Notice of Contemplated Action (NCA). Such NCA shall include:
(i) the reasons for the action, and,

(ii) rights of the hospital/healthcare facility, which include a right to a hearing, and may, for contemplated suspension or revocation actions, at the discretion of the Bureau, include authorization to submit a plan of correction.

(b) the Bureau shall notify the recognized ReTrAC (if applicable) of the action taken.

(c) should a plan of correction be authorized by the Bureau pending contemplated revocation or suspension of designation of a trauma center, the following procedure shall be followed:
(i) the Bureau shall specify a deadline for submission of the plan of correction in the NCA. The plan shall include steps, which the trauma center intends to take in order to correct deficiencies and projected date of completion.

(ii) the Bureau shall approve or disapprove the plan within fifteen (15) calendar days of receipt. If the plan is disapproved by the Bureau, the hospital/healthcare facility shall have twenty (20) days to request a hearing in accordance with Paragraph (6) of Subsection H of 7.27.7.9 NMAC below.

(iii) upon notification that the plan of correction is approved by the Bureau, the trauma center shall begin implementation of the plan immediately and notify the Bureau upon completion of the plan.

(iv) upon satisfactory evidence of compliance, which may include an on-site review, the trauma center shall retain the designation status.

(6) the following process of appeal will be available to any hospital/healthcare facility which has received a Notice of Contemplated Action (NCA) to deny, suspend or revoke a trauma center designation.
(a) within twenty (20) calendar days of receipt of the contemplated action to deny, suspend or revoke a trauma center designation,

(b) a hospital/healthcare facility may formally appeal by requesting a hearing in writing, by certified return receipt letter to the Secretary of the Department, PO Box 26110, Santa Fe, New Mexico, 87502-6110.

(c) upon receipt of a timely appeal, and request for a hearing, the Secretary shall appoint a Hearing Officer and schedule a hearing, to be held in Santa Fe, New Mexico within forty five (45) working days. If no timely request for hearing is received, the Bureau will take the action contemplated in the NCA.

(d) the Department shall notify the hospital/healthcare facility of the date, time, and place of the hearing, the identity of the Hearing Officer, and the subject matter of the hearing, not less than thirty (30) days prior to the date of the hearing.

(e) the Hearing Officer shall preside over the hearing, administer oaths, take evidence and decide evidentiary objections and rule on any motions or other matters that arise prior to the hearing.

(f) the hearing is open to the public unless requested to be closed by the hospital or the Department.

(g) the Hearing Officer shall make a written report and recommendation(s) to the Secretary containing a statement of the issue raised at the hearing, proposed findings of fact, conclusions of law, and a recommended determination.

(h) The Hearing Officer, or designee, shall record the hearing by means of mechanical sound recording device provided by the Department.

(i) The Hearing Officer's written report shall be submitted to the Secretary no later than thirty (30) working days after the close of the hearing.

(j) the Secretary shall render a final determination within ten (10) working days of the submission of the Hearing Officer's report. A copy of the final decision shall be mailed to the appealing hospital/healthcare facility by certified mail, and a copy shall be provided to the Office of General Counsel of the Department of Health.

I. Change in Trauma Center Designation Status:

(1) a designated trauma center shall have the right, with ninety (90) days notice, to withdraw as a trauma center or to request a designation lower than their current designated level.

(2) a designated trauma center shall:
(a) notify the Bureau and the approved ReTrAC within five (5) calendar days if temporarily unable to comply, and the reasons, with designation standards;

(b) notify the Bureau and the ReTrAC if it chooses to no longer provide trauma services commensurate with its designation level; and,

(c) if the trauma center chooses to apply for a lower level of designation, the Bureau, at its discretion, may repeat all or part of the designation process as described in these regulations.

J. Renewal of Trauma Centers Designation:

(1) all trauma centers shall repeat the designation process as described in these regulations every three (3) years prior to the trauma center's expiration of designation. The trauma center shall apply to the Bureau for re-designation for a period of three (3) years. A designated trauma center, in good standing, shall remain designated until the application process is completed.

(2) each level I, II, and III trauma center shall be resurveyed as described in the designation process in Section M of these regulations. Each level IV trauma center may be resurveyed, at the discretion of the Bureau.

(3) at the discretion, and for good cause, the Bureau may extend for up to one year the current designation status of any trauma center.

K. Trauma System Fees: the Bureau shall establish and publish a fee structure for trauma centers applicants for designation as a trauma center to help defray the costs associated with review of the application, the on-site review process and ongoing trauma system management.

L. Prohibition of the Use, Advertising or Marketing of Terms: to protect against public misconception of the capabilities of individual institutions and the usage of misleading terms, the following are prohibited:

(1) after January 1, 1996, no person, emergency medical service, hospital/healthcare facility shall, by any means, advertise, assert, represent, offer, provide or imply that such person, service, clinic or facility is a trauma center or use the terms; "trauma center", "trauma facility", trauma hospital", "trauma care hospital" or similar terminology or state in any manner that the person, organization or facility has the capabilities for providing treatment to major trauma patients except as permitted within the scope of the trauma center designation as provided herein.

(2) no trauma center shall, in any manner, advertise or publicly assert that its trauma designation affects the hospital/healthcare facility's care for non-trauma patients, nor that the designation should influence the referral of non-trauma system patients.

M. Trauma Center Fiscal Viability Requirement: in order to assure that each designated trauma center has adequate financial and facility resources and a qualified medical workforce to provide optimal care to the injured patient and to meet the requirements of these regulations, each designated trauma center shall:

(1) establish a trauma program fee and charge schedule for services rendered to qualifying trauma patients that accurately reflect the cost of services rendered to qualifying trauma patients and the financial risk associated with rendering trauma services as a designated trauma center;

(2) enter into reimbursement agreements or contracts with all third party payer organizations including, but not limited to, managed care organizations, Blue Cross and Blue Shield and preferred provider organizations. These reimbursement agreements are intended to:
(a) adequately reimburse the designated trauma center the cost for rendering emergency and in-hospital care to qualifying trauma patients, and

(b) adequately reimburse the hospital employed or contracted trauma team physicians the cost of rendering care to qualified trauma patients and the cost of trauma team alerting and trauma team activation.

(3) the designated trauma center, or an organization acting in its behalf such as the New Mexico Trauma Foundation, with the contractual authority to negotiate payment and reimbursement agreements and/or to perform other financial and collection services for the designated trauma center shall not discount or otherwise attempt to collect charges and fee less than the trauma program fee and charge schedule developed by the designated trauma center.

(4) a designated trauma center hospital may request from the Bureau a waiver of the financial viability requirements enumerated in this Section. The waiver request shall specify that the applicant's trauma program generates sufficient revenue to cover the cost of the trauma program and the financial risk associated with trauma center designation.

N. Trauma Team Physician Fiscal Viability Requirement: in order to assure that each trauma team physician participating on the trauma teams at the designated trauma centers has the financial resources needed to provide optimal care to the injured patient and to meet the requirements of these regulations, each trauma team participating physician shall:

(1) establish a trauma fee and charge schedule for physician services rendered to qualifying trauma patients that accurately reflect the cost of physician services rendered to qualifying trauma patients and the financial risk associated with rendering trauma care services as a trauma team physician; and

(2) enter into reimbursement agreements or contracts with all third party payer organizations including, but not limited to, managed care organizations, Blue Cross and Blue Shield and preferred provider organizations. These reimbursement agreements shall adequately reimburse the physician for physician services rendered to qualifying trauma patients.

(3) the trauma team physician or, an organization acting in his or her behalf such as the New Mexico Trauma Foundation, with the authority to negotiate payment and reimbursement agreements and/or to perform other financial and collection services for the physician shall not discount or otherwise attempt to collect charges and fee less than the trauma fee and charge schedule developed by the physician.

(4) a physician participating on the trauma team at a designated trauma center hospital may request from the Bureau a waiver of the financial viability requirements enumerated in this Section. The waiver request shall specify that the physician generates sufficient revenue to cover the cost of the trauma program participation. "

O. Trauma Managed Care Patients: each designated trauma center shall:

(1) facilitate the transfer of a member of a health maintenance organization or system when the medical condition of the patient permits as defined by the patient's attending trauma physician and trauma center's trauma protocols.

(2) develop written policies, in cooperation with managed care healthcare systems and hospitals owned or contracted to provide care to the managed care providers, to:
(a) notifying the healthcare plan within forty-eight (48) hours of a trauma patient's admission,

(b) coordinate discharge planning of plan patients, and,

(c) facilitate transfer of patients.

Disclaimer: These regulations may not be the most recent version. New Mexico may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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