Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 509 - FREESTANDING EMERGENCY MEDICAL CARE FACILITIES
Subchapter C - OPERATIONAL REQUIREMENTS
Section 509.65 - Patient Transfer Policy
Universal Citation: 26 TX Admin Code ยง 509.65
Current through Reg. 49, No. 38; September 20, 2024
(a) General.
(1) The governing body of each facility shall
adopt, implement, and enforce a policy relating to patient transfers that is
consistent with this section and contains each of the requirements in
subsection (b) of this section. The policies shall identify facility staff that
has authority to represent the facility and the physician regarding transfers
from the facility.
(2) The
governing body shall adopt the transfer policy after consultation with the
medical staff, and the transfer policy shall apply to transfers to hospitals
licensed under Texas Health and Safety Code Chapter 241 (relating to Hospitals)
and Chapter 577 (relating to Private Mental Hospitals and Other Mental Health
Facilities), as well as transfers to hospitals that are exempt from
licensing.
(3) The transfer policy
shall govern transfers not covered by a transfer agreement.
(4) The transfer policy shall include a
written operational plan to provide for patient transfer transportation
services if the facility does not provide its own patient transfer
transportation services.
(5) The
governing body, after consultation with the medical staff, shall implement its
transfer policy by adopting transfer agreements with hospitals in accordance
with §
509.66 of this subchapter
(relating to Patient Transfer Agreements).
(6) The transfer policy shall recognize and
comply with the applicable requirements of Texas Health and Safety Code Chapter
61 (relating to Indigent Health Care and Treatment Act).
(7) The transfer policy shall acknowledge
contractual obligations and comply with statutory or regulatory obligations
that may exist concerning a patient and a designated provider.
(8) The transfer policy shall require that
all reasonable steps are taken to secure the written informed consent of a
patient, or a person acting on a patient's behalf, when refusing a transfer or
related examination and treatment. Reasonable steps include:
(A) a factual explanation of the increased
medical risks to the patient reasonably expected from not being transferred,
examined, or treated at the transferring hospital;
(B) a factual explanation of any increased
risks to the patient from not effecting the transfer; and
(C) a factual explanation of the medical
benefits reasonably expected from the provision of appropriate treatment at
another hospital.
(9) The
informed refusal of a patient, or a person acting on a patient's behalf, to
examination, evaluation, or transfer shall be documented and signed if possible
by the patient or by a person acting on the patient's behalf, dated and
witnessed by the attending physician or facility employee, and placed in the
patient's medical record.
(10) The
transfer policy shall recognize the right of an individual to request a
transfer into the care of a physician and a hospital of the individual's own
choosing.
(b) Requirements for transfer of patients from facilities to hospitals.
(1) The transfer policy shall provide that
the transfer of a patient may not be predicated upon arbitrary, capricious, or
unreasonable discrimination based upon race, religion, national origin, age,
sex, physical condition, economic status, insurance status, or ability to
pay.
(2) The transfer policy shall
recognize the right of an individual to request transfer into the care of a
physician and hospital of the individual's own choosing; however, if a patient
requests or consents to transfer for economic reasons and the patient's choice
is predicated upon or influenced by representations made by the transferring
physician or facility administration regarding the availability of medical care
and hospital services at a reduced cost or no cost to the patient, physician or
facility administration shall fully disclose to the patient the eligibility
requirements established by the patient's chosen physician or
hospital.
(3) The transfer policy
shall provide that each patient who arrives at the facility is:
(A) evaluated by a physician at the time the
patient presents; and
(B)
personally examined and evaluated by the physician before an attempt to
transfer is made.
(4) The
policy of the transferring facility and receiving hospital shall provide that
licensed nurses and other qualified personnel are available and on duty to
assist with patient transfers. The policy shall provide that written protocols
or standing delegation orders are in place to guide facility personnel when a
patient requires transfer to another hospital.
(5) Special requirements related to the
transfer of patients who have emergency medical conditions:
(A) If a patient at a facility has an
emergency medical condition that has not been stabilized, or when stabilization
of the patient's vital signs is not possible because the facility does not have
the appropriate equipment or personnel to correct the underlying process, the
facility shall evaluate and treat the patient and transfer the patient as
quickly as possible.
(B) The
transfer policy shall provide that the facility may not transfer a patient with
an emergency medical condition that has not been stabilized unless:
(i) the individual or the individual's
legally authorized representative, after being informed of the facility's
obligations under this section and the risk of transfer, requests the transfer,
in writing, and indicates the reasons for the request, as well as that he or
she is aware of the risks and benefits of the transfer; or
(ii) a physician has signed a certification,
which includes a summary of the risks and benefits, that, based on the
information available at the time of transfer, the medical benefits reasonably
expected from the provision of appropriate medical treatment at a hospital
outweigh the increased risks to the patient and, in the case of labor, to the
unborn child from effecting the transfer.
(C) Except as is specifically provided in
subsection (a)(6) and (7) of this section, the transfer policy shall provide
that the transfer of patients who have emergency medical conditions, as
determined by a physician, shall be undertaken for medical reasons only. The
facility must provide medical treatment within its capacity that minimizes the
risks to the individual's health and, in the case of a woman in labor, the
health of the unborn child.
(6) The transfer policy shall provide for the
following physician's duties and standard of care requirements.
(A) The transferring physician shall
determine and order life support measures that are medically appropriate to
stabilize the patient before transfer and to sustain the patient during
transfer.
(B) The transferring
physician shall determine and order the utilization of appropriate personnel
and equipment for the transfer.
(C)
In determining the use of medically appropriate life support measures,
personnel, and equipment, the transferring physician shall exercise that degree
of care that a reasonable and prudent physician exercising ordinary care in the
same or similar locality would use for the transfer.
(D) Except as allowed under paragraph (5)(B)
of this subsection, before each patient transfer, the physician who authorizes
the transfer shall personally examine and evaluate the patient to determine the
patient's medical needs and to ensure that the proper transfer procedures are
used.
(E) Before transfer, the
transferring physician shall ensure that a receiving hospital and physician
that are appropriate to the medical needs of the patient have accepted
responsibility for the patient's medical treatment and hospital care.
(7) The facility's medical staff
shall review appropriate records of patients transferred from the facility to
determine that the appropriate standard of care has been met.
(8) A facility shall comply with the
following medical record requirements.
(A) The
facility's policy shall require that a copy of those portions of the patient's
medical record that are available and relevant to the transfer and to the
continuing care of the patient be forwarded to the receiving physician and
receiving hospital with the patient. If all necessary medical records for the
continued care of the patient are not available at the time the patient is
transferred, the records shall be forwarded to the receiving physician and
hospital as soon as possible.
(B)
The medical record shall contain at least:
(i)
a brief description of the patient's medical history and physical
examination;
(ii) a working
diagnosis and recorded observations of physical assessment of the patient's
condition at the time of transfer;
(iii) the reason for the transfer;
(iv) the results of all diagnostic tests,
such as laboratory tests;
(v)
pertinent radiological films and reports; and
(vi) any other pertinent
information.
(9) A facility shall comply with the
following memorandum of transfer requirements.
(A) The facility's policy shall require that
a memorandum of transfer be completed for every patient who is
transferred.
(B) The memorandum
shall contain the:
(i) patient's full name, if
known;
(ii) patient's race,
religion, national origin, age, sex, physical handicap, if known;
(iii) patient's address and next of kin,
address, and phone number, if known;
(iv) names, telephone numbers, and addresses
of the transferring and receiving physicians;
(v) names, addresses, and telephone numbers
of the transferring facility and receiving hospital;
(vi) time and date on which the patient first
presented or was presented to the transferring physician and transferring
facility;
(vii) time and date on
which the transferring physician secured a receiving physician;
(viii) name, date, and time hospital
administration was contacted in the receiving hospital;
(ix) signature, time, and title of the
transferring facility administration who contacted the receiving
hospital;
(x) certification
required by paragraph (5)(B)(ii) of this subsection, if applicable (the
certification may be part of the memorandum of transfer form or may be on a
separate form attached to the memorandum of transfer form);
(xi) time and date on which the receiving
physician assumed responsibility for the patient;
(xii) time and date on which the patient
arrived at the receiving hospital;
(xiii) signature and date of receiving
hospital administration;
(xiv) type
of vehicle and company used to transport the patient;
(xv) type of equipment and personnel needed
in the transfer;
(xvi) name and
city of hospital to which patient was transported;
(xvii) diagnosis by transferring physician;
and
(xviii) attachments by
transferring facility.
(C) A copy of the memorandum of transfer
shall be retained by the transferring facility. The memorandum shall be filed
separately from the patient's medical record and in a manner that will
facilitate its inspection by HHSC. All memorandum of transfer forms filed
separately shall be retained for at least five years.
(c) Violations. A facility violates the Act and this section if:
(1) the
facility fails to comply with the requirements of this section; or
(2) the governing body fails or refuses to:
(A) adopt a transfer policy that is
consistent with this section and contains each of the requirements in
subsection (b) of this section;
(B)
adopt a memorandum of transfer form that meets the minimum requirements for
content contained in this section; or
(C) enforce its transfer policy and the use
of the memorandum of transfer.
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