Current through Reg. 50, No. 26; June 27, 2025
(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 Texas Health and Safety Code (HSC) Chapter
671.
(b) Organ and tissue donors.
The hospital shall adopt, implement, and enforce a written protocol to identify
potential organ and tissue donors which complies with HSC Chapter 692A. 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 §692A.015.
(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.
(c) Discrimination prohibited. A licensed
hospital shall not discriminate based on a patient's disability and shall
comply with HSC Chapter 161, Subchapter S.
(d) All-hazard disaster preparedness.
(1) Definitions.
(A) Adult intensive care unit (ICU)--Can
support critically ill or 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 or 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 Texas Health and Human Services Commission (HHSC), 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:
(i) National Fire
Protection Association 99, Standard for Health Care Facilities, 2002 edition,
Chapter 12, published by the National Fire Protection Association;
and
(ii) the State of Texas
Emergency Management Plan, which is available from the city or county emergency
management coordinator;
(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;
(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 Texas Department of
State Health Services (DSHS) approved process to update bed availability, as
follows:
(i) as requested by DSHS 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:
(IV) negative pressure/isolation;
(iii) for 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, which 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, which 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 or 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, which shall include at a
minimum:
(-a-) the patient's most recent
physician's assessment;
(-c-) medication
administration record (MAR);
(-d-)
patient history with physical documentation; and
(-e-) a weather-proof patient identification
wrist band (or equivalent identification), which must be intact on all
patients.
(5) Hospitals participating in an exercise or
responding to a real-life event under paragraph (4)(D) of this subsection shall
develop an after-action report (AAR) within 60 days. The hospital shall retain
the AARs for at least three years and make them available for review by the
local emergency management authority and HHSC.
(e) Voluntary paternity establishment
services. A hospital that handles the birth of newborns must provide voluntary
paternity establishment services in accordance with:
(2) the rules of the Office of the Attorney
General found at 1 Texas Administrative Code 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
§161.501.
(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) a list of the names, addresses, and phone
numbers of 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 §161.507(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;
(D) the appropriate schedule for follow-up
procedure for newborn screening;
(E) information regarding sudden infant death
syndrome, including current recommendations for infant sleeping conditions to
lower the risk of sudden infant death syndrome;
(F) educational information in both English
and Spanish on:
(i) pertussis disease and the
availability of a vaccine to protect against pertussis, including information
on the Centers for Disease Control and Prevention recommendation that parents
receive Tdap during the postpartum period to protect newborns from the
transmission of pertussis; and
(ii)
the incidence of cytomegalovirus, birth defects caused by congenital
cytomegalovirus, and available resources for the family of an infant born with
congenital cytomegalovirus; and
(G) the danger of heatstroke for a child left
unattended in a motor vehicle.
(2) If the woman is a recipient of medical
assistance under Texas Human Resources Code Chapter 32, the policy must require
the hospital to provide the woman and the father of the infant, if possible, or
another adult caregiver with a resource guide that includes information in both
English and Spanish relating to the development, health, and safety of a child
from birth until age five, including information relating to:
(A) selecting and interacting with a primary
health care practitioner and establishing a "medical home" for the
child;
(E) the importance of reading to a
child;
(F) expected developmental
milestones;
(G) health care
resources available in the state;
(H) selecting appropriate child care;
and
(I) other resources available
in the state;
(3) 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 Texas Occupations Code §
164.052(a)(19).
(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;
and
(2) include provisions that if
the vaccines requested by the elderly person under paragraph (1) of this
subsection are determined appropriate by the physician or other qualified
medical personnel, the elderly person shall receive the vaccines prior to
discharge from the hospital;
(3)
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;
(4) 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
(5) address required
documentation of the vaccination in the patient medical record.
(6) HHSC 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 HSC
§241.011.
(k) Prohibited
discharge of patients to certain group-centered facilities. A hospital shall
comply with HSC §256.003.
(1) Except as
provided by paragraph (2) of this subsection, a hospital may discharge or
release a patient to a group home, boarding home facility, or similar
group-centered facility only if the person operating the group-centered
facility holds a license or permit issued in accordance with applicable state
law.
(2) A hospital may discharge
or release a patient to a group home, boarding home facility, or similar
group-centered facility operated by a person who does not hold a license or
permit issued in accordance with applicable state law only if:
(A) there is no group-centered facility
operated in the county where the patient is discharged that is operated by a
person holding the applicable license or permit; or
(B) the patient voluntarily chooses to reside
in the group-centered facility operated by an unlicensed or unpermitted
person.
(l)
Basic sexual assault forensic evidence collection training. A hospital shall
develop, implement, and enforce policies and procedures to ensure a person who
performs a forensic medical examination on a survivor of sexual assault
completes the required forensic evidence collection training or equivalent
education required by HSC §323.0045.
(m) Basic sexual assault response policy and
training. A hospital shall develop, implement, and enforce policies and
procedures to provide basic sexual assault response training that meets the
requirements under HSC §323.0046 to facility employees who provide patient
admission functions, patient-related administrative support functions, or
direct patient care.
