Current through Reg. 49, No. 38; September 20, 2024
(a)
Determination of death and autopsy reports. The hospital shall adopt,
implement, and enforce protocols to be used in determining death and for filing
autopsy reports which comply with Health and Safety Code (HSC), Title 8,
Subtitle A, Chapter 671 (Determination of Death and Autopsy Reports).
(b) Organ and tissue donors. The hospital
shall adopt, implement, and enforce a written protocol to identify potential
organ and tissue donors which is in compliance with the Texas Anatomical Gift
Act, HSC, Chapter 692. The hospital shall make its protocol available to the
public during the hospital's normal business hours.
(1) The hospital's protocol shall include all
requirements in HSC, Chapter 692, §692.013 (Hospital Protocol).
(2) A hospital which performs organ
transplants shall be a member of the Organ Procurement and Transplantation
Network in accordance with
42 United States
Code, §
274 (Organ Procurement and
Transplantation Network).
(c) Discrimination prohibited. A licensed
hospital shall not discriminate based on a patient's disability and shall
comply with Texas Health and Safety Code Chapter 161, Subchapter S (relating to
Allocation of Kidneys and Other Organs Available for Transplant).
(d) All-hazard disaster preparedness.
(1) Definitions.
(A) Adult intensive care unit (ICU)--Can
support critically ill/injured patients, including ventilator
support.
(B) Burn or burn
ICU--Either approved by the American Burn Association or self-designated.
(These beds should not be included in other ICU bed counts.)
(C) Medical/surgical--Also thought of as
"ward" beds.
(D) Negative
pressure/isolation--Beds provided with negative airflow, providing respiratory
isolation. Note: This value may represent available beds included in the counts
of other types.
(E) Operating
rooms--An operating room that is equipped and staffed and could be made
available for patient care in a short period.
(F) Pediatric ICU--The same as adult ICU, but
for patients 17 years and younger.
(G) Pediatrics--Ward medical/surgical beds
for patients 17 years and younger.
(H) Physically available beds--Beds that are
licensed, physically set up, and available for use. These are beds regularly
maintained in the hospital for the use of patients, which furnish
accommodations with supporting services (such as food, laundry, and
housekeeping). These beds may or may not be staffed but are physically
available.
(I) Psychiatric--Ward
beds on a closed/locked psychiatric unit or ward beds where a patient will be
attended by a sitter.
(J) Staffed
beds--Beds that are licensed and physically available for which staff members
are available to attend to the patient who occupies the bed. Staffed beds
include those that are occupied and those that are vacant.
(K) Vacant/available beds--Beds that are
vacant and to which patients can be transported immediately. These must include
supporting space, equipment, medical material, ancillary and support services,
and staff to operate under normal circumstances. These beds are licensed,
physically available, and have staff on hand to attend to the patient who
occupies the bed.
(2) A
hospital shall adopt, implement, and enforce a written plan for all-hazard,
natural or man-made, disaster preparedness for effective preparedness,
mitigation, response, and recovery from disasters.
(3) The plan, which may be subject to review
and approval by the department, shall be sent to the local disaster management
authority.
(4) The plan shall:
(A) be developed through a joint effort of
the hospital governing body, administration, medical staff, hospital personnel
and emergency medical services partners;
(B) include the applicable information
contained in the National Fire Protection Association 99, Standard for Health
Care Facilities, 2002 edition, Chapter 12 (Health Care Emergency Management),
published by the National Fire Protection Association (NFPA), and the State of
Texas Emergency Management Plan. Information regarding the State of Texas
Emergency Management Plan is available from the city or county emergency
management coordinator. The NFPA document referenced in this section may be
obtained by writing or calling the NFPA at the following address and telephone
number: 1 Batterymarch Park, Post Office Box 9101, Quincy, Massachusetts
02269-9101, (800) 344-3555;
(C)
contain the names and contact numbers of city and county emergency management
officers and the hospital water supplier;
(D) be exercised at least annually and in
conjunction with state and local exercises. Hospitals participating in an
exercise or responding to a real-life event shall develop an after-action
report (AAR) within 60 days. AARs shall be retained for at least three years
and be available for review by the local emergency management authority and the
department;
(E) include the
methodology for notifying the hospital personnel and the local disaster
management authority of an event that will significantly impact hospital
operations;
(F) include evidence
that the hospital has communicated prospectively with the local utility and
phone companies regarding the need for the hospital to be given priority for
the restoration of utility and phone services and a process for testing
internal and external communications systems regularly;
(G) include the use of a department approved
process to update bed availability, as follows:
(i) as requested by the department during a
public health emergency or state declared disaster; and
(ii) for the physically available beds and
staffed beds that are vacant/available beds for the following bed types:
(I) adult ICU;
(II) burn or burn ICU;
(III) medical/surgical;
(IV) negative pressure/isolation;
(V) operating rooms;
(VI) pediatric ICU;
(VII) pediatrics; and
(VIII) psychiatric;
(iii) emergency department divert
status;
(iv) for decontamination
facility available; and
(v) for
ventilators available;
(H) include at a minimum:
(i) a component for the reception, treatment,
and disposition of casualties that can be used in the event that a disaster
situation requires the hospital to accept multiple patients. This component
shall include at a minimum:
(I) process,
developed in conjunction with appropriate agencies, to allow essential
healthcare workers and personnel to safely access their delivery care
sites;
(II) procedures for the
appropriate provision of personal protection equipment for and appropriate
immunization of staff, volunteers, and staff families; and
(III) plan to provide food and shelter for
staff and volunteers as needed throughout the duration of response;
(ii) an evacuation component that
can be engaged in any emergency situation necessitating either a full or
partial evacuation of the hospital. The evacuation component shall address at a
minimum:
(I) activation, including who makes
the decision to activate and how it is activated;
(II) when within control of the hospital,
patient evacuation destination, including protocol to ensure that the patient
destination is compatible to patient acuity and health care needs, plan for the
order of removal of patients and planned route of movement, train and drill
staff on the traffic flow and the movement of patients to a staging area, and
room evacuation protocol;
(III)
family/responsible party notification, including the procedure to notify
patient emergency contacts of an evacuation and the patient's destination;
and
(IV) transport of records and
supplies, including the protocol for the transfer of patient specific
medications and records to the receiving facility. These records shall include
at a minimum: the patient's most recent physician's assessment, order sheet,
medication administration record (MAR), and patient history with physical
documentation. A weather-proof patient identification wrist band (or equivalent
identification) must be intact on all patients.
(e) Voluntary paternity
establishment services. A hospital that handles the birth of newborns must
provide voluntary paternity establishment services in accordance with:
(1) the HSC, §192.012, Record of
Acknowledgment of Paternity; and
(2) the rules of the Office of the Attorney
General found at 1 TAC Chapter 55, Subchapter J (relating to Voluntary
Paternity Acknowledgment Process).
(f) Harassment and abuse. A hospital shall
adopt, implement and enforce a written policy for identifying and addressing
instances of alleged verbal or physical abuse or harassment of hospital
employees or contracted personnel by other hospital employees or contracted
personnel or by a health care provider who has clinical privileges at the
hospital.
(g) Information for
parents of newborn children. A hospital that provides prenatal care to a
pregnant woman during gestation or at delivery of an infant, shall adopt,
implement and enforce written policies to ensure compliance with HSC, Chapter
161, Subchapter T, §161.501 (relating to Parenting and Postpartum
Counseling Information).
(1) The policy shall
require that the woman and the father of the infant, if possible, or another
adult caregiver for the infant, be provided with a resource pamphlet which
includes:
(A) information on professional
organizations providing counseling and assistance relating to postpartum
depression and other emotional trauma associated with pregnancy and
parenting;
(B) information
regarding the prevention of shaken baby syndrome, as specified under HSC,
§167.501(a)(1)(B)(i) - (iv);
(C) a list of diseases for which a child is
required by state law to be immunized and the appropriate schedule for the
administration of those immunizations; and
(D) the appropriate schedule for follow-up
procedure for newborn screening.
(2) The policy shall include a requirement
that it be documented in the woman's record that the information was provided,
and that the documentation be maintained for at least five years.
(h) Abortion. A hospital that
performs abortions shall adopt, implement and enforce policies to:
(1) ensure compliance with HSC, Chapter
171;
(2) ensure compliance with
Occupations Code, §
164.052(a)(19)
(relating to Parental Consent for Abortion).
(i) Influenza and pneumococcal vaccine for
elderly persons. The hospital shall adopt, implement and enforce a policy for
providing influenza and pneumococcal vaccines for elderly persons. The policy
shall:
(1) establish that an elderly person,
defined as 65 years of age older, who is admitted to the hospital for a period
of 24 hours or more, is informed of the availability of the influenza and
pneumococcal vaccines, and, if they request the vaccine, is assessed to
determine if receipt of the vaccine is in their best interest. If determined
appropriate by the physician or other qualified medical personnel, the elderly
person shall receive the vaccines prior to discharge from the
hospital;
(2) include provisions
that the influenza vaccine shall be made available in October and November, and
if available, December, and pneumococcal vaccine shall be made available
throughout the year;
(3) require
that the person administering the vaccine ask the elderly patient if they are
currently vaccinated against influenza or pneumococcal disease, assess
potential contraindications, and then, if appropriate, administer the vaccine
under approved hospital protocols; and
(4) address required documentation of the
vaccination in the patient medical record.
(5) The department may waive requirements
related to the administration of the vaccines based on established shortages of
the vaccines.
(j) Human
Trafficking Signage Required. A licensed hospital shall comply with human
trafficking signage requirements in accordance with Texas Health and Safety
Code §
241.011
(relating to Human Trafficking Signs Required).
