| (a) A facility shall have an identified governing body
fully responsible for organization, management, control, and operation
of the facility, including the appointment of the facility's medical
director. The medical director shall be board certified or board eligible
in emergency medicine, or board certified in primary care with at
least two years emergency care experience.
(b) The governing body shall adopt, implement, and
enforce written policies and procedures for the total operation and
all services provided by the facility.
(c) The governing body is responsible for all services
furnished in the facility, whether furnished directly or under contract.
The governing body shall ensure services are provided in a safe and
effective manner that permits the facility to comply with all applicable
rules and standards.
(d) The governing body shall ensure the medical staff
has on file current written bylaws, rules, and regulations that are
adopted, implemented, and enforced.
(e) The governing body shall disclose all owners of
the facility to the Texas Health and Human Services Commission (HHSC).
(f) The governing body shall meet at least annually
and keep minutes or other records necessary for orderly conduct of
the facility. Each meeting held by the facility governing body shall
be a separate meeting with separate minutes from any other governing
body meeting.
(g) 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.
(h) The governing body shall develop a process for
appointing or reappointing medical staff, and for assigning or curtailing
medical privileges.
(i) 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.
(j) The governing body shall encourage personnel to
participate in continuing education that is relevant to their responsibilities
within the facility.
(k) The governing body shall adopt, implement, and
enforce written policies to ensure compliance with applicable state
and federal laws.
(l) In accordance with Texas Health and Safety Code §254.157
(relating to Certain Advertising Prohibited), a facility may not advertise
or hold itself out as a network provider, including by stating that
the facility "takes" or "accepts" any insurer, health maintenance
organization, health benefit plan, or health benefit plan network,
unless the facility is a network provider of a health benefit plan
issuer.
(m) A facility may not post the name or logo of a health
benefit plan issuer in any signage or marketing materials if the facility
is an out-of-network provider for all of the issuer's health benefit
plans.
(n) A facility shall assess, and the governing body
shall review, patient satisfaction with services and environment no
less than annually.
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