| (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.
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