(A) Non-emergent changes shall be implemented no earlier
than 120 days after a written notification process.
(B) Emergency changes related to safety may be implemented
immediately along with immediate notification to department, the
RAC, and appropriate Air Medical Providers.
(C) Conflicts relating to helipad air medical access
changes shall be negotiated between the facility and the EMS provider.
(D) Any unresolved issues shall be handled utilizing
the nonbinding alternative dispute resolution (ADR) process of the
RAC in which the helipad is located;
(5) within 5 days, notify the office; its RAC plus
other affected RACs; and the healthcare facilities to which it customarily
transfers-out trauma patients or from which it customarily receives
trauma transfers-in if temporarily unable to comply with a designation
criterion. If the healthcare facility intends to comply with the
criterion and maintain current designation status, it must also submit
to the office a plan for corrective action and a request for a temporary
exception to criteria within 5 days.
(A) If the requested essential criterion exception
is not critical to the operations of the healthcare facility's trauma
program and the office determines that the facility has intent to
comply, a 30-day to 90-day exception period from the onset date of
the deficiency may be granted for the facility to achieve compliancy.
(B) If the requested essential criterion exception
is critical to the operations of the healthcare facility's trauma
program and the office determines that the facility has intent to
comply, no greater than a 30-day exception period from the onset
date of the deficiency may be granted for the facility to achieve
compliancy. Essential criteria that are critical include such things
as:
(i) neurological surgery capabilities (Level I, II);
(ii) orthopedic surgery capabilities (Level I, II,
III);
(iii) general/trauma surgery capabilities (Level I,
II, III);
(iv) anesthesiology (Levels I, II, III);
(v) emergency physicians (all levels);
(vi) trauma medical director (all levels);
(vii) trauma nurse coordinator/program manager (all
levels); and
(viii) trauma registry (all levels).
(C) If the healthcare facility has not come into compliance
at the end of the exception period, the office may at its discretion
elect one of the following:
(i) allow the facility to request designation at the
level appropriate to its revised capabilities;
(ii) propose to re-designate the facility at the level
appropriate to its revised capabilities;
(iii) propose to suspend the facility's designation
status. If the facility is amenable to this action, the office will
develop a plan for corrective action for the facility and a specific
timeline for compliance by the facility; or
(iv) propose to extend the facility's temporary exception
to criteria for an additional period not to exceed 90 days. The department
will develop a plan for corrective action for the facility and a specific
timeline for compliance by the facility.
(I) Suspensions of a facility's designation status
and exceptions to criteria for facilities will be documented on the
office website.
(II) If the facility disagrees with a proposal by the
office, or is unable or unwilling to meet the office-imposed timelines
for completion of specific actions plans, it may request a secondary
review by a designation review committee as defined in subsection
(o)(3)(B) of this section.
(III) The office may at its discretion choose to activate
a designation review committee at any time to solicit technical advice
regarding criteria deficiencies.
(IV) If the designation review committee disagrees
with the office's recommendation for corrective actions, the case
shall be referred to the assistant commissioner for recommendation
to the commissioner.
(V) If a facility disagrees with the office's recommendation
at the end of the secondary review process, the facility has a right
to a hearing, in accordance with the department's rules for contested
cases and Government Code, Chapter 2001.
(VI) Designated trauma facilities seeking exceptions
to essential criteria shall have the right to withdraw the request
at any time prior to resolution of the final appeal process;
(6) notify the office; its RAC plus other affected
RACs; and the healthcare facilities to which it customarily transfers-out
trauma patients or from which it customarily receives trauma transfers-in,
if it no longer provides trauma services commensurate with its designation
level.
(A) If the facility chooses to apply for a lower level
of trauma designation, it may do so at any time; however, it shall
be necessary to repeat the designation process. There shall be a paper
review by the office to determine if and when a full survey shall
be required.
(B) If the facility chooses to relinquish its trauma
designation, it shall provide at least 30 days notice to the RAC and
the office; and
(7) within 30 days, notify the office; its RAC plus
other affected RACs; and the healthcare facilities to which it customarily
transfers-out trauma patients or from which it customarily receives
trauma transfers-in, of the change(s) if it adds capabilities beyond
those that define its existing trauma designation level.
(A) It shall be necessary to repeat the trauma designation
process.
(B) There shall then be a paper review by the office
to determine if and when a full survey shall be required.
(t) Any facility seeking trauma designation shall have
measures in place that define the trauma patient population evaluated
at the facility and/or at each of its locations, and the ability to
track trauma patients throughout the course of their care within
the facility and/or at each of its locations in order to maximize
funding opportunities for uncompensated care.
(u) A healthcare facility may not use the terms "trauma
facility", "trauma hospital", "trauma center", or similar terminology
in its signs or advertisements or in the printed materials and information
it provides to the public unless the healthcare facility is currently
designated as a trauma facility according to the process described
in this section.
(v) The office shall have the right to review, inspect,
evaluate, and audit all trauma patient records, trauma performance
improvement committee minutes, and other documents relevant to trauma
care in any designated trauma facility or applicant/healthcare facility
at any time to verify compliance with the statute and this rule, including
the designation criteria. The office shall maintain confidentiality
of such records to the extent authorized by the Texas Public Information
Act, Government Code, Chapter 552, and consistent with current laws
and regulations related to the Health Insurance Portability and Accountability
Act of 1996. Such inspections shall be scheduled by the office when
deemed appropriate. The office shall provide a copy of the survey
report, for surveys conducted by or contracted for the department,
and the results to the healthcare facility.
(w) The office may grant an exception to this section
if it finds that compliance with this section would not be in the
best interests of the persons served in the affected local system.
(x) Advanced (Level III) Trauma Facility Criteria.
Attached Graphic
(1) Advanced (Level III) Trauma Facility Criteria Standards.
Attached Graphic
(2) Advanced (Level III) Trauma Facility Criteria Audit
Filters.
Attached Graphic
(y) Basic (Level IV) Trauma Facility Criteria.
Attached Graphic
(1) Basic (Level IV) Trauma Facility Criteria Standards.
Attached Graphic
(2) Basic (Level IV) Trauma Facility Criteria Audit
Filters.
Attached Graphic
|