| (G) Non-department surveyors must meet the following criteria: (i) have at least three years experience in the care of trauma patients and active participation in a regional EMS/trauma system; (ii) be currently employed in the coordination of care for trauma patients; (iii) have direct experience in the preparation for and successful completion of regional EMS/trauma system designation; (iv) have successfully completed the department Regional EMS/Trauma System Site Surveyor Course; and (v) on-going bureau evaluation of survey reports for compliance with bureau reporting requirements. (H) All members of the survey team, except department staff, should come from a non-adjacent public health region and/or trauma service area (TSA). There shall be no business or patient care relationship between the surveyor and/or the surveyor's place of employment and regional EMS/trauma system being surveyed. (I) The survey team shall evaluate the regional EMS/trauma system by: (i) attendance records, performance improvement committee meeting minutes and other documents specifically relevant to regional EMS/trauma system development; (ii) visiting EMS provider stations and hospitals within the TSA; and (iii) conducting interviews with RAC members and non-members. (J) Findings of the survey team shall be forwarded to the RAC Executive Board within thirty calendar days of the date of the survey. If a RAC wants to continue the designation process, the complete survey report must be submitted to the bureau within three months after receipt of the survey or the application will expire. A request for an extension could be requested for extenuating circumstances. (K) The bureau shall review the findings for compliance with the criteria. If a regional EMS/trauma system does not meet the criteria for designation, the bureau shall notify the RAC executive board of the requirements it must meet to achieve designation. (L) A recommendation for designation shall be made to the commissioner based on compliance with the criteria. (M) In the event there is a problem area in which a regional EMS/trauma system does not comply with the criteria, the bureau shall notify the applicant of deficiencies and recommend corrective action. (N) The regional EMS/trauma system shall submit a report to the bureau which outlines the corrective action taken. The bureau may require a second survey to insure compliance with the criteria. If the regional EMS/trauma system and/or bureau report substantiates action that brings the regional EMS/trauma system into compliance with the criteria, the bureau shall recommend designation to the commissioner. (O) If a regional EMS/trauma system disagrees with a bureau decision regarding its designation application or status, it may request a secondary review by a designation review committee. Membership on the designation review committee will: (i) be voluntary; (ii) be appointed by the bureau chief; (iii) be representative of trauma care providers within a designated regional EMS/trauma system; and (iv) include representation from the department and the Trauma Systems Committee of the Governor's EMS and Trauma Advisory Council (GETAC). (P) If the designation review committee disagrees with the bureau recommendation for corrective action, the records shall be referred to the associate commissioner for consumer health protection for recommendation to the commissioner. (Q) The bureau shall provide a copy of the survey report, for surveys conducted by or contracted for by the department and results to the applicant regional EMS/trauma system. (R) At the end of the secondary review and final phases of the designation process, if a regional EMS/trauma system disagrees with the bureau recommendations, opportunity for an appeal in accordance with the Administrative Procedure Act, Government Code, Chapter 2001 shall be offered. (S) The bureau 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. (T) The applicant regional EMS/trauma system shall have the right to withdraw its application at any time prior to the department making a final decision on the application for designation. (U) If the commissioner concurs with the recommendation to designate, the RAC shall receive a letter of designation for two years. Site surveys will be required every six years, or more frequently at the bureau's discretion. Additional actions, such as a site review or submission of information, to maintain designation may be required by the department. (V) It shall be necessary to repeat the designation process as described in this section prior to expiration of a regional EMS/trauma system designation or the designation will be considered expired: (W) A designated regional EMS/trauma system shall: (i) notify the bureau within five days if temporarily unable to comply with the essential trauma system criteria; (ii) notify the bureau and RAC membership within five days if it is unable to provide the resources as required by its designation. (I) If the resources are not critical, the bureau will determine a 30-day to 90-day period from onset date of deficiency for the RAC to achieve compliance. (II) If the resources are critical, the bureau will determine a no greater than 30-day period from onset date of the deficiency for the RAC to achieve compliance. (iii) notify the bureau if the RAC will no longer provide services commensurate with designation. If the regional EMS/trauma system chooses to permanently relinquish its designation, it shall provide at least 30 days notice to the bureau. (iv) comply with the provisions within these sections, all current state and system standards as described in this chapter, and all policies, guidelines, and procedures as set forth in the system plan; (v) continue its commitment to provide the resources as required by its designation; and (vi) utilize the state trauma registry. (X) A regional EMS/trauma system may not use the terms "regional trauma system", "trauma system", or similar terminology in its signs or advertisements or in the printed materials and information it provides to the public unless the regional EMS/trauma system has been designated as a regional EMS/trauma system according to the process described in this section. This subsection also applies to regional EMS/trauma systems whose designation has lapsed. (Y) The bureau shall have the right to review, inspect, evaluate, and audit all RAC performance improvement committee minutes and other documents relevant to trauma care in any designated regional EMS/trauma system at any time to verify compliance with the statute and these rules, including the designation criteria. The bureau shall maintain confidentiality of such records to the extent authorized by the Public Information Act, (Government Code, Chapter 552), the Texas Health and Safety Code, Chapter 773 and/or any other relevant confidentiality law or regulation. Such inspections shall be scheduled by the bureau when appropriate. (c) Regional EMS/trauma system criteria. Attached Graphic |
