| (a) The LSRH must have a professional health care staff
that includes one or more physicians, and may include one or more
physician assistants, or advanced practice registered nurses (APRN).
(b) Any ancillary personnel are supervised by the professional
staff.
(c) There shall be a written delineation of functions,
qualifications, and patient care responsibilities for all categories
of personnel.
(d) The LSRH shall maintain documentation of evidence
that all personnel are trained prior to treatment of services.
(e) The staff shall be sufficient to provide the services
essential to the operation of the LSRH.
(f) A nurse shall be on duty whenever the LSRH has
one or more patients receiving emergency care or observation care.
(g) If the LSRH provides outpatient services, the services
shall meet the needs of the patients in accordance with acceptable
standards of practice.
(1) The LSRH shall assign an individual to be responsible
for outpatient services.
(2) The LSRH shall have appropriate physicians on staff
and other professional and nonprofessional personnel available.
(3) The physician must:
(A) provide medical direction for the LSRH's health
care activities and consultation for, and medical supervision of,
the health care staff;
(B) participate, in conjunction with any physician
assistant or nurse practitioner members, in developing, executing,
and periodically reviewing the LSRH's written policies governing the
services it furnishes;
(C) review periodically, in conjunction with any physician
assistant or nurse practitioner members, the LSRH patient records,
provide medical orders, and provide medical care services to the patients
of the LSRH; and
(D) review periodically and sign a sample of outpatient
records of patients cared for by APRN or physician assistants only
to the extent where state law requires record reviews or co-signatures,
or both, by a collaborating physician.
(h) A physician must be present for sufficient periods
of time to provide medical direction, consultation, and supervision
for the services provided in the LSRH, and is available through direct
radio or telephone communication or electronic communication for consultation,
assistance with medical emergencies, or patient referral.
(i) The physician assistant, the nurse practitioner,
or clinical nurse specialist members of the LSRH staff shall:
(1) participate in the development, execution and periodic
review of the written policies governing the services the LSRH furnishes;
and
(2) participate with a physician in a periodic review
of the patients' health records.
(j) The physician assistant, nurse practitioner, or
clinical nurse specialist shall perform the following functions to
the extent they are not being performed by a physician:
(1) provides services in accordance with the LSRH's
policies; and
(2) arranges for, or refers patients to, needed services
that cannot be furnished at the LSRH, and assures that adequate patient
health records are maintained and transferred as required when patients
are referred.
(k) Whenever a patient is placed in observation care
at the LSRH by a nurse practitioner, physician assistant, or clinical
nurse specialist, a physician on the staff of the LSRH is notified
of the patient's status.
(l) When required by law, the quality and appropriateness
of the diagnosis and treatment furnished by nurse practitioners, clinical
nurse specialists, and physician assistants at the LSRH must be evaluated
by a member of the LSRH staff who is a physician or by another physician
under contract with the LSRH.
(m) The quality and appropriateness of the diagnosis
and treatment provided by a physician at the LSRH must be evaluated
by one of the following:
(1) One Quality Improvement Organization (QIO) or equivalent
entity;
(2) in the case of distant-site physicians and practitioners
providing telemedicine services to the LSRH's patient under an agreement
between the LSRH and a distant-site hospital, the distant-site hospital;
or
(3) in the case of distant-site physicians and practitioners
providing telemedicine services to the LSRH's patients under a written
agreement between the LSRH and a distant-site telemedicine entity,
one QIO or equivalent entity.
(n) The LSRH staff shall consider the findings of the
evaluation and make the necessary changes as specified in Code of
Federal Regulations Title 42 §485.528 (b) - (d) (relating to
Condition of participation: Staffing and staff responsibilities).
(o) There shall be an organized nursing service under
the direction of a qualified registered nurse (RN). The LSRH shall
be staffed to assure that the nursing needs of all patients are met.
(p) There shall be a written plan of administrative
authority for all nursing services with responsibilities and duties
of each category of nursing personnel delineated and a written job
description for each category. The scope of nursing service shall
include nursing care rendered to patients preoperatively, intraoperatively,
and postoperatively.
(1) The responsible individual for nursing services
shall be a qualified RN whose responsibility and authority for nursing
service shall be clearly defined and includes supervision of both
personnel performance and patient care.
(2) There shall be a written delineation of functions,
qualifications, and patient care responsibilities for all categories
of nursing personnel.
(3) Surgical technicians and licensed vocational nurses
may be permitted to serve in the scrub nurse role under the direct
supervision of an RN; they shall not be permitted to function as circulating
nurses in the operating rooms. Licensed vocational nurses and surgical
technicians may assist in circulatory duties under the direct supervision
of a qualified RN.
(4) Nursing services shall be provided in accordance
with current recognized standards or recommended practices.
(5) The LSRH shall adopt, implement and enforce policies
and procedures to comply with Texas Health and Safety Code Chapter
259 (relating to Surgical Technologists at Health Care Facilities).
(6) There shall be an adequate number of RNs on duty
to meet the following minimum staff requirements: director of the
department (or designee), and supervisory and staff personnel for
each service area to assure the immediate availability of an RN for
emergency care or for any patient when needed.
(7) An RN shall assign the nursing care of each patient
to other nursing personnel in accordance with the patient's needs
and the preparation and qualifications of the nursing staff available.
(8) There shall be other nursing personnel in sufficient
numbers to provide nursing care not requiring the service of an RN.
(9) An RN qualified, at a minimum, with current certification
in advanced cardiac life support and pediatric advanced life support
shall be on duty and on the premises at all times whenever patients
are present in the LSRH.
(q) All direct patient care staff must have current
certification in basic cardiac life support.
(r) In addition to meeting the requirements for nursing
staff under subsections (p) and (q) of this section, LSRHs shall comply
with the following staffing requirements.
(1) LSRHs that provide only topical anesthesia, local
anesthesia, or minimal sedation are required to have a second individual
on duty on the premises who is trained and currently certified in
basic cardiac life support until all patients have been discharged
from the facility.
(2) LSRHs that provide moderate sedation/analgesia
are required to have the following additional staff:
(A) a second individual on duty on the premises who
is trained and currently certified in basic cardiac life support until
all patients have been discharged from the facility; and
(B) an individual trained and currently certified in
advanced cardiac life support and, if surgery is performed on pediatric
patients, pediatric advanced life support shall be available until
all patients have been discharged from the post-anesthesia care unit.
(s) LSRHs that provide deep sedation/analgesia, general
anesthesia, or regional anesthesia shall have the following additional
staff:
(1) a second individual on duty on the premises who
is trained and currently certified in basic cardiac life support until
all patients have been discharged from the facility; and
(2) an individual who is trained and currently certified
in advanced cardiac life support and, if surgery is performed on pediatric
patients, pediatric advanced life support shall be on duty on the
premises and sufficiently free of other duties to enable the individual
to respond rapidly to emergency situations until all patients have
been discharged from the post-anesthesia care unit.
(t) As applicable, the LSRH shall establish a nursing
peer review committee to conduct nursing peer review, as required
by Texas Occupations Code Chapter 303 (relating to Nursing Peer Review).
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