Current through Reg. 49, No. 38; September 20, 2024
(a) A limited
services rural hospital's (LSRH's) governing body shall address and is fully
responsible, either directly or by appropriate professional delegation, for the
operation and performance of the LSRH.
(b) The governing body is responsible for all
services furnished in the LSRH, whether furnished directly or under contract.
The governing body shall ensure:
(1)
services, including any contracted services, are provided in a safe and
effective manner that permits the LSRH to comply with all applicable rules and
standards, including the federal conditions of participation at Code of Federal
Regulations Title 42 (42 CFR) Part 485, Subchapter E and this
chapter;
(2) the LSRH maintains a
list of all contracted services, including the scope and nature of the services
provided;
(3) the medical staff is
accountable to the governing body for the quality of care provided to patients
as required by 42 CFR §
485.510; and
(4) the provision of education to students
and postgraduate trainees if the LSRH participates in such programs.
(c) An LSRH's governing body shall
adopt, implement, and enforce written policies and procedures for the total
operation and all services the LSRH provides, with the policies for the LSRH's
services being developed, reviewed, and updated in accordance with §
511.51 of this subchapter
(relating to Provision of Services). The policies and procedures shall include
at least the following:
(1) bylaws or similar
rules and regulations for the orderly development and management of the
LSRH;
(2) policies or procedures
necessary for the orderly conduct of the LSRH;
(3) policies or procedures related to
emergency planning and disaster preparedness that shall require the governing
body to review the LSRH's disaster preparedness plan at least
annually;
(4) policies for the
provision of the following services:
(A)
emergency services;
(B)
radiological services;
(C)
laboratory services;
(D) pharmacy
services; and
(E) any outpatient
services the LSRH provides;
(5) policies for the collection, processing,
maintenance, storage, retrieval, authentication, and distribution of patient
medical records and reports;
(6)
policy on the rights of patients and complying with all state and federal
patient rights requirements;
(7)
policies for the provision of an effective procedure for the immediate transfer
to a licensed hospital of patients requiring emergency care beyond the
capabilities of the LSRH, including a transfer agreement with a hospital
licensed in this state as defined in §
511.66 of this subchapter
(relating to Patient Transfer Agreements);
(8) policies for all individuals that arrive
at the LSRH to ensure they are provided an appropriate medical screening
examination within the capability of the LSRH, including:
(A) ancillary services routinely available to
determine whether or not the individual needs emergency care as defined in
§
511.2 of this chapter (relating to
Definitions); and
(B) if emergency
care is determined to be needed, the LSRH shall provide any necessary
stabilizing treatment or arrange an appropriate transfer for the individual as
defined in §
511.65 of this subchapter
(relating to Patient Transfer Policy);
(9) a policy that complies with the
requirements under Texas Health and Safety Code §
241.009 to
require employees, physicians, contracted employees, and individuals in
training who provide direct patient care at the LSRH to wear a photo
identification badge during all patient encounters, unless precluded by adopted
isolation or sterilization protocols; and
(10) policies to ensure compliance with
applicable state and federal laws.
(d) The governing body's responsibilities
shall include:
(1) determining the LSRH's
mission, goals, and objectives;
(2)
ensuring that facilities and personnel are sufficient and appropriate to carry
out the LSRH's mission;
(3)
determining, in accordance with state law, which categories of practitioners
are eligible candidates for appointment to the medical staff;
(4) appointing members of the medical staff
after considering the recommendations of the existing members of the medical
staff;
(5) ensuring that the
medical staff is accountable to the governing body for the quality of care
provided to patients;
(6) ensuring
the criteria for medical staff selection are individual character, competence,
training, experience, and judgment;
(7) ensuring a physical environment that
protects the health and safety of patients, personnel, and the
public;
(8) establishing an
organizational structure and specifying functional relationships among the
various components of the LSRH;
(9)
reviewing and approving the LSRH's training program for staff;
(10) ensuring all equipment utilized by LSRH
staff or by patients is properly used and maintained per manufacturer
recommendations;
(11) ensuring
there is a quality assessment and performance improvement (QAPI) program to
evaluate the provision of patient care;
(12) reviewing and monitoring QAPI activities
quarterly;
(13) consulting directly
at least periodically throughout the fiscal or calendar with medical director
or their designee, and include discussion of matters related to the quality of
medical care provided to patients of the LSRH;
(14) consulting directly with the individual
responsible for the organized medical staff (or their designee) of each
hospital or LSRH within its system as applicable for a multi-facility system,
including a multi-hospital or multi-LSRH system, using a single governing
body;
(15) reviewing legal and
ethical matters concerning the LSRH and its staff when necessary and responding
appropriately;
(16) ensuring that
under no circumstances is the accordance of staff membership or professional
privileges in the LSRH dependent solely upon certification, fellowship, or
membership in a specialty body or society;
(17) maintaining effective communication
throughout the LSRH;
(18)
establishing a system of financial management and accountability that includes
an audit or financial review appropriate to the LSRH;
(19) formulating long-range plans in
accordance with the mission, goals, and objectives of the LSRH;
(20) operating the LSRH without limitation
because of color, race, age, sex, religion, national origin, or
disability;
(21) ensuring that all
marketing and advertising concerning the LSRH does not imply that it provides
care or services that the LSRH is not capable of providing;
(22) developing a system of risk management
appropriate to the LSRH, including:
(A)
periodic review of all litigation involving the LSRH, its staff, physicians,
and practitioners regarding activities in the LSRH;
(B) periodic review of all incidents reported
by staff and patients;
(C) review
of all deaths, trauma, or adverse reactions occurring on premises;
and
(D) evaluation of patient
complaints;
(23) ensuring
that when telemedicine services are furnished to the LSRH's patients through an
agreement with a distant-site hospital, the agreement meets the requirements of
42 CFR §
485.510; and
(24) ensuring that when telemedicine services
are furnished the services meet all federal and state laws, rules, and
regulations.
(e) The
governing body shall ensure the medical staff has current written bylaws,
rules, and regulations that are adopted, implemented, and enforced by the LSRH
on file.
(f) The governing body
shall approve medical staff bylaws and other medical staff rules and
regulations.
(g) The governing
body, with input from the medical staff, shall periodically review the scope of
procedures performed in the LSRH and amend as appropriate.
(h) The governing body shall provide for full
disclosure of ownership to the Texas Health and Human Services
Commission.
(i) The governing body
shall meet at least annually and maintain minutes or other records necessary
for the orderly conduct of the LSRH. Meetings the LSRH's governing body holds
shall be separate meetings with separate minutes from any other governing body
meeting.
(j) If the governing body
elects, appoints, or employs officers and administrators to carry out its
directives, the governing body shall define the authority, responsibility, and
functions of all such positions.
(k) The governing body shall provide (in a
manner consistent with state law and based on evidence of education, training,
and current competence) for the initial appointment, reappointment, and
assignment or curtailment of privileges and practice for non-physician health
care personnel and practitioners.
(l) The governing body shall develop a
process for appointing or reappointing medical staff, and for assigning or
curtailing medical privileges and shall periodically reappraise medical staff
privileges.
(m) The governing body
shall encourage personnel to participate in continuing education that is
relevant to their responsibilities within the LSRH.
(n) The governing body shall review patient
satisfaction with services and environment at least annually.
