| (D) Schedules, names, and telephone numbers of all
physicians and others on emergency call duty, including alternates,
shall be maintained. Schedules shall be retained for no less than
one year.
(3) Supplies and equipment. Adequate age appropriate
supplies and equipment shall be available and in readiness for use.
Equipment and supplies shall be available for the administration of
intravenous medications as well as facilities for the control of bleeding
and emergency splinting of fractures. Provision shall be made for
the storage of blood and blood products as needed. The emergency equipment
shall be periodically tested according to the policy adopted, implemented
and enforced by the hospital.
(4) Required emergency equipment. At a minimum, the
age appropriate emergency equipment and supplies shall include the
following:
(A) emergency call system;
(B) oxygen;
(C) mechanical ventilatory assistance equipment, including
airways, manual breathing bag, and mask;
(D) cardiac defibrillator;
(E) cardiac monitoring equipment;
(F) laryngoscopes and endotracheal tubes;
(G) suction equipment;
(H) emergency drugs and supplies specified by the medical
staff;
(I) stabilization devices for cervical injuries;
(J) blood pressure monitoring equipment; and
(K) pulse oximeter or similar medical device to measure
blood oxygenation.
(5) Participation in local emergency medical service
(EMS) system.
(A) General hospitals shall participate in the local
EMS system, based on the hospital's capabilities and capacity, and
the locale's existing EMS plan and protocols.
(B) The provisions of subparagraph (A) of this paragraph
do not apply to a comprehensive medical rehabilitation hospital or
a pediatric and adolescent hospital that generally provides care that
is not administered for or in expectation of compensation.
(6) Emergency services for sexual assault survivors.
This section does not affect the duty of a health care facility to
comply with the requirements of the federal Emergency Medical Treatment
and Active Labor Act of 1986 (42 U.S.C. §1395dd) that are applicable
to the facility. The hospital shall develop, implement, and enforce
policies and procedures to ensure that after a sexual assault survivor
presents to the hospital following a sexual assault, the hospital
shall provide the care specified under the Health and Safety Code,
Chapter 323.
(f) Governing body.
(1) Legal responsibility. There shall be a governing
body responsible for the organization, management, control, and operation
of the hospital, including appointment of the medical staff. For hospitals
owned and operated by an individual or by partners, the individual
or partners shall be considered the governing body.
(2) Organization. The governing body shall be formally
organized in accordance with a written constitution and bylaws which
clearly set forth the organizational structure and responsibilities.
(3) Meeting records. Records of governing body meetings
shall be maintained.
(4) Responsibilities relating to the medical staff.
(A) The governing body shall ensure that the medical
staff has current bylaws, rules, and regulations which are implemented
and enforced.
(B) The governing body shall approve medical staff
bylaws and other medical staff rules and regulations.
(C) In hospitals that provide obstetrical services,
the governing body shall ensure that the hospital collaborates with
physicians providing services at the hospital to develop quality initiatives,
through the adoption, implementation, and enforcement of appropriate
hospital policies and procedures, to reduce the number of elective
or nonmedically indicated induced deliveries or cesarean sections
performed at the hospital on a woman before the 39th week of gestation.
(D) In hospitals that provide obstetrical services,
the governing body shall ensure that the hospital implements a newborn
audiological screening program, consistent with the requirements of
Health and Safety Code, Chapter 47 (Hearing Loss in Newborns), and
performs, either directly or through a referral to another program,
audiological screenings for the identification of hearing loss on
each newborn or infant born at the facility before the newborn or
infant is discharged. These audiological screenings are required to
be performed on all newborns or infants before discharge from the
facility unless:
(i) a parent or legal guardian of the newborn or infant
declines the screening;
(ii) the newborn or infant requires emergency transfer
to a tertiary care facility prior to the completion of the screening;
(iii) the screening previously has been completed;
or
(iv) the newborn was discharged from the facility not
more than 10 hours after birth and a referral for the newborn was
made to another program.
(E) In hospitals that provide obstetrical services,
the governing body shall adopt, implement, and enforce policies and
procedures related to the testing of any newborn for critical congenital
heart disease (CCHD) that may present themselves at birth. The facility
shall implement testing programs for all infants born at the facility
for CCHD. In the event that a newborn is presented at the emergency
room following delivery at a birthing center or a home birth that
may or may not have been assisted by a midwife, the facility shall
ascertain if any testing for CCHD had occurred and, if not, shall
provide the testing necessary to make such determination. The rules
concerning the CCHD procedures and requirements are described in Chapter
37, Maternal and Infant Health Services, Subchapter E, Newborn Screening
for Critical Congenital Heart Disease, §§37.75 - 37.79 of
this title.
(F) The governing body shall determine, in accordance
with state law and with the advice of the medical staff, which categories
of practitioners are eligible candidates for appointment to the medical
staff.
(i) In considering applications for medical staff membership
and privileges or the renewal, modification, or revocation of medical
staff membership and privileges, the governing body must ensure that
each physician, podiatrist, and dentist is afforded procedural due
process.
(I) If a hospital's credentials committee has failed
to take action on a completed application as required by subclause
(VIII) of this clause, or a physician, podiatrist, or dentist is subject
to a professional review action that may adversely affect his medical
staff membership or privileges, and the physician, podiatrist, or
dentist believes that mediation of the dispute is desirable, the physician,
podiatrist, or dentist may require the hospital to participate in
mediation as provided in Civil Practice and Remedies Code (CPRC),
Chapter 154. The mediation shall be conducted by a person meeting
the qualifications required by CPRC §154.052 and within a reasonable
period of time.
(II) Subclause (I) of this clause does not authorize
a cause of action by a physician, podiatrist, or dentist against the
hospital other than an action to require a hospital to participate
in mediation.
(III) An applicant for medical staff membership or
privileges may not be denied membership or privileges on any ground
that is otherwise prohibited by law.
(IV) A hospital's bylaw requirements for staff privileges
may require a physician, podiatrist, or dentist to document the person's
current clinical competency and professional training and experience
in the medical procedures for which privileges are requested.
(V) In granting or refusing medical staff membership
or privileges, a hospital may not differentiate on the basis of the
academic medical degree held by a physician.
(VI) Graduate medical education may be used as a standard
or qualification for medical staff membership or privileges for a
physician, provided that equal recognition is given to training programs
accredited by the Accreditation Council for Graduate Medical Education
and by the American Osteopathic Association.
(VII) Board certification may be used as a standard
or qualification for medical staff membership or privileges for a
physician, provided that equal recognition is given to certification
programs approved by the American Board of Medical Specialties and
the Bureau of Osteopathic Specialists.
(VIII) A hospital's credentials committee shall act
expeditiously and without unnecessary delay when a licensed physician,
podiatrist, or dentist submits a completed application for medical
staff membership or privileges. The hospital's credentials committee
shall take action on the completed application not later than the
90th day after the date on which the application is received. The
governing body of the hospital shall take final action on the application
for medical staff membership or privileges not later than the 60th
day after the date on which Cont'd... |
