The governing body shall address and is fully responsible,
either directly or by appropriate professional delegation, for operation
and performance of the facility. Governing body responsibilities include:
(1) determining the mission, goals, and objectives
of the facility;
(2) ensuring that facilities and personnel are adequate
and appropriate to carry out the mission;
(3) ensuring a physical environment that protects the
health and safety of patients, personnel, and the public;
(4) establishing an organizational structure and specifying
functional relationships among the various components of the facility;
(5) adopting, implementing, and enforcing bylaws or
similar rules and regulations for the orderly development and management
of the facility;
(6) adopting, implementing, and enforcing policies
or procedures necessary for orderly conduct of the facility;
(7) reviewing and approving the facility's training
program for staff;
(8) ensuring that all equipment used by facility staff
or patients is properly used and maintained per manufacturer recommendations;
(9) adopting, implementing, and enforcing policies
or procedures related to emergency planning and disaster preparedness,
including reviewing the facility's disaster preparedness plan at least
annually;
(10) ensuring there is a quality assessment and performance
improvement (QAPI) program to evaluate the provision of patient care,
including quarterly review and monitoring of QAPI activities;
(11) reviewing legal and ethical matters concerning
the facility and its staff, when necessary, and responding appropriately;
(12) maintaining effective communication throughout
the facility;
(13) establishing a system of financial management
and accountability that includes an audit or financial review appropriate
to the facility;
(14) adopting, implementing, and enforcing policies
for provision of radiological services;
(15) adopting, implementing, and enforcing policies
for provision of laboratory services;
(16) adopting, implementing, and enforcing policies
for provision of pharmacy services;
(17) adopting, implementing, and enforcing policies
for collection, processing, maintenance, storage, retrieval, authentication,
and distribution of patient medical records and reports;
(18) adopting, implementing, and enforcing a policy
on the rights of patients and complying with all state and federal
patient rights requirements;
(19) adopting, implementing, and enforcing policies
for provision of an effective procedure for the immediate transfer
to a licensed hospital of patients requiring emergency care beyond
the capabilities of the facility, including a transfer agreement with
a hospital licensed in this state in accordance with §509.66
of this subchapter (relating to Patient Transfer Agreements);
(20) adopting, implementing, and enforcing policies
for all individuals that arrive at the facility to ensure they are
provided an appropriate medical screening examination within the capability
of the facility, including ancillary services routinely available
to determine whether or not the individual needs emergency care as
defined in §509.2 of this chapter (relating to Definitions),
and that if emergency care is determined to be needed, the facility
shall provide any necessary stabilizing treatment or arrange an appropriate
transfer the individual as defined in §509.65 of this subchapter
(relating to Patient Transfer Policy);
(21) adopting, implementing, and enforcing protocols
to be used in determining death and for filing autopsy reports that
comply with Texas Health and Safety Code Chapter 671 (relating to
Determination of Death and Autopsy Reports);
(22) approving all major contracts or arrangements
affecting the medical care provided under its auspices, including
those concerning:
(A) services of physicians and practitioners;
(B) use of external laboratories; and
(C) an effective procedure for obtaining emergency
laboratory, radiology, and pharmaceutical services when these services
are not immediately available due to system failure;
(23) formulating long-range plans in accordance with
the mission, goals, and objectives of the facility;
(24) operating the facility without limitation because
of color, race, age, sex, religion, national origin, or disability;
(25) ensuring that all marketing and advertising concerning
the facility does not imply that it provides care or services that
the facility is not capable of providing; and
(26) developing a system of risk management appropriate
to the facility, including:
(A) periodic review of all litigation involving the
facility, its staff, physicians, and practitioners regarding activities
in the facility;
(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.
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