| (C) A current therapeutic diet manual approved by the
dietitian and medical staff shall be readily available to all medical,
nursing, and food service personnel. The therapeutic manual shall:
(i) be revised as needed, not to exceed 5 years;
(ii) be appropriate for the diets routinely ordered
in the facility;
(iii) have standards in compliance with the RDA;
(iv) contain specific diets which are not in compliance
with RDA; and
(v) be used as a guide for ordering and serving diets.
(c) Governing body.
(1) Legal responsibility. There shall be a governing
body responsible for the organization, management, control, and operation
of the facility, including appointment of the medical staff. For facilities
owned and operated by an individual or by partners, the individual
or partners shall be considered the governing body.
(2) Organization. The governing body shall be formally
organized in accordance with a written constitution or bylaws which
clearly set forth the organizational structure and responsibilities.
(3) Meeting records. Records of governing body meetings
shall be maintained.
(4) Responsibilities relating to the medical staff.
The governing body shall:
(A) ensure that the medical staff has current bylaws,
rules, and regulations which are implemented and enforced;
(B) approve medical staff bylaws and other medical
staff rules and regulations;
(C) determine, in accordance with state law and with
the advice of the medical staff, which categories of practitioners
are eligible candidates for appointment to the medical staff;
(D) ensure that criteria for selection include individual
character, competence, training, experience, and judgment;
(E) ensure that under no circumstances is the accordance
of staff membership or professional privileges in the facility dependent
solely upon certification, fellowship or membership in a specialty
body or society;
(F) ensure the process for considering applications
for medical staff membership and privileges affords each candidate
for appointment procedural due process;
(G) ensure in granting or refusing medical staff membership
or privileges, the facility does not differentiate on the basis of
the academic medical degree;
(H) ensure that equal recognition is given to training
programs accredited by the Accreditation Council on Graduate Medical
Education and by the American Osteopathic Association if graduate
medical education is used as a standard or qualification for medical
staff membership or privileges for a physician;
(I) ensure that equal recognition is given to certification
programs approved by the American Board of Medical Specialties and
the Bureau of Osteopathic Specialists if board certification is used
as a standard or qualification for medical staff membership or privileges
for a physician;
(J) ensure that the medical staff is accountable to
the governing body for the quality of care provided to patients;
(K) ensure that a facility's credentials committee
acts expeditiously and without unnecessary delay when a candidate
for appointment submits a completed application, as defined by each
hospital, for medical staff membership or privileges, in accordance
with the following:
(i) The credentials committee shall take action on
the completed application not later than the 90th day after the date
on which the application is received;
(ii) The governing body shall take final action on
the application for medical staff membership or privileges not later
than the 60th day after the date on which the recommendation of the
credentials committee is received; and
(iii) The facility must notify the applicant in writing
of the facility's final action, including a reason for denial or restriction
of privileges, not later than the 20th day after the date on which
final action is taken;
(L) ensure the facility complies with the requirements
for reporting to the Texas Medical Board the results and circumstances
of any professional review action in accordance with the Medical Practice
Act, Occupations Code, §160.002 and §160.003.
(5) Facility administration. The governing body shall
appoint a chief executive officer or administrator who is responsible
for managing the facility.
(6) Patient care. In accordance with facility policy,
the governing body shall ensure that:
(A) every patient is under the care of a physician.
This provision is not to be construed to limit the authority of a
physician to delegate tasks to other qualified health care personnel
to the extent recognized under state law;
(B) patients are admitted to the facility only by
members of the medical staff who have been granted admitting privileges;
and
(C) a physician is on duty or on-call at all times.
(7) Contracted services. The governing body shall be
responsible for services furnished in the facility whether or not
they are furnished directly or under contracts. The governing body
shall ensure that a contractor of services (including one for shared
services and joint ventures) furnishes services in a safe and effective
manner that permits the facility to comply with all applicable rules
and standards for contracted services.
(8) Nurse staffing. The governing body shall adopt,
implement and enforce a written nurse staffing policy to ensure that
an adequate number and skill mix of nurses are available to meet
the level of patient care needed. The governing body policy shall
require that hospital administration adopt, implement and enforce
a nurse staffing plan and policies that:
(A) require significant consideration be given to the
nurse staffing plan recommended by the hospital's nurse staffing committee
and the committee's evaluation of any existing plan;
(B) are based on the needs of each patient care unit
and shift and on evidence relating to patient care needs;
(C) ensure that all nursing assignments consider client
safety, and are commensurate with the nurse's educational preparation,
experience, knowledge, and physical and emotional ability;
(D) require use of the official nurse services staffing
plan as a component in setting the nurse staffing budget;
(E) encourage nurses to provide input to the nurse
staffing committee relating to nurse staffing concerns;
(F) protect from retaliation nurses who provide input
to the nurse staffing committee; and
(G) comply with subsection (j) of this section.
(d) Infection control. The facility shall provide a
sanitary environment to avoid sources and transmission of infections
and communicable diseases. There shall be an active program for the
prevention, control, and investigation of infections and communicable
diseases.
(1) Organization and policies. A person shall be designated
as infection control coordinator. The facility shall ensure that policies
governing prevention, control and surveillance of infections and communicable
diseases are developed, implemented and enforced.
(A) There shall be a system for identifying, reporting,
investigating, and controlling nosocomial infections and communicable
diseases between patients and personnel.
(B) The infection control coordinator shall maintain
a log of all reportable diseases and nosocomial infections designated
as epidemiologically significant according to the facility's infection
control policies.
(C) There shall be a written policy for reporting all
reportable diseases to the local health authority or the Infectious
Disease Epidemiology and Surveillance Division, Department of State
Health Services, Mail Code 2822, P.O. Box 149347, Austin, TX 78714-9347,
in accordance with Chapter 97 of this title (relating to Communicable
Diseases).
(2) Responsibilities of the chief executive officer
(CEO), medical staff, and chief nursing officer (CNO). The CEO, the
medical staff, and the CNO shall be responsible for the following.
(A) The facility-wide quality assurance program and
training programs shall address problems identified by the infection
control coordinator.
(B) Successful corrective action plans in affected
problem areas shall be implemented.
(3) Universal precautions. The facility shall adopt,
implement, and enforce a written policy to monitor compliance of the
facility and its personnel and medical staff with universal precautions
in accordance with Health and Safety Code, Chapter 85, Subchapter
I (relating to the Prevention of Transmission of HIV and Hepatitis
B Virus by Infected Health Care Workers).
(e) Laboratory services. The facility shall provide
directly, or have available adequate laboratory services to meet the
needs of its patients.
Cont'd... |
