| (F) include a requirement that a physical examination
and medical history be done no more than 30 days before or 24 hours
after an admission for each patient by a physician or other qualified
practitioner who has been granted these privileges by the medical
staff. The medical history and physical examination shall be placed
in the patient's medical record within 24 hours after admission. When
the medical history and physical examination are completed within
the 30 days before admission, an updated examination for any changes
in the patient's condition must be completed and documented in the
patient's medical record within 24 hours after admission; and
(G) include procedures regarding DNR orders issued
in the hospital by an attending physician that comply with Health
and Safety Code, Chapter 166, Subchapter E (relating to Health Care
Facility Do-Not-Resuscitate Orders), including policies and procedures
regarding the rights of a patient and person authorized to make treatment
decisions regarding the patient's DNR status; notice and medical record
requirements for DNR orders and revocations; and actions the attending
physician and hospital must take pursuant to Health and Safety Code §166.206
when the attending physician or hospital and the patient or person
authorized to make treatment decisions regarding the patient's DNR
status are in disagreement about the execution of, or compliance with,
a DNR order. The procedures shall include that:
(i) Except in circumstances described by Health and
Safety Code §166.203(a)(2), a DNR order issued for a patient
is valid only if the patient's attending physician issues the order,
the order is dated, and the order is issued in compliance with:
(I) the written and dated directions of a patient who
was competent at the time the patient wrote the directions;
(II) the oral directions of a competent patient delivered
to or observed by two competent adult witnesses, at least one of whom
must be a person not listed under Health and Safety Code §166.003(2)(E)
(III) the directions in an advance directive enforceable
under Health and Safety Code §166.005 or executed in accordance
with Health and Safety Code §§166.032, 166.034, or 166.035;
(IV) the directions of a patient's legal guardian or
agent under a medical power of attorney acting in accordance with
Health and Safety Code, Chapter 166, Subchapter D (relating to Medical
Power of Attorney); or
(V) a treatment decision made in accordance with Health
Safety Code §166.039.
(ii) A DNR order that is not issued in accordance with
Health and Safety Code §166.203(a)(1) is valid only if the patient's
attending physician issues the order, the order is dated, and:
(I) the order is not contrary to the directions of
a patient who was competent at the time the patient conveyed the directions;
(II) in the reasonable medical judgment of the patient's
attending physician, the patient's death is imminent, regardless of
the provision of cardiopulmonary resuscitation; and
(III) in the reasonable medical judgment of the patient's
attending physician, the DNR order is medically appropriate.
(iii) A DNR order takes effect at the time the order
is issued, as provided by Health and Safety Code §166.203(b).
(iv) Before placing in a patient's medical record a
DNR order described by Health and Safety Code §166.203(a)(2),
the physician, physician assistant, nurse, or other person acting
on behalf of the hospital shall:
(I) notify the patient of the order's issuance; or
(II) if the patient is incompetent, make a reasonably
diligent effort to contact or cause to be contacted and inform of
the order's issuance the patient's known agent under a medical power
of attorney or legal guardian or, for a patient who does not have
a known agent under a medical power of attorney or legal guardian,
a person described by Health and Safety Code §166.039(b)(1),
(2), or (3).
(v) A physician providing direct care to a patient
for whom a DNR order is issued shall revoke the patient's DNR order
if the patient or the patient's agent under a medical power of attorney
or the patient's legal guardian if the patient is incompetent:
(I) effectively revokes an advance directive, in accordance
with Health and Safety Code §166.042, for which a DNR order is
issued under Health and Safety Code §166.203(a); or
(II) expresses to any person providing direct care
to the patient a revocation of consent to or intent to revoke a DNR
order issued under Health and Safety Code §166.203(a).
(vi) A person providing direct care to a patient under
the supervision of a physician shall notify the physician of the request
to revoke a DNR order under Health and Safety Code §166.205(a).
(vii) A patient's attending physician may at any time
revoke a DNR order executed under Health and Safety Code §166.203(a)(2).
(l) Mental health services.
(1) Mental health services unit. A hospital may not
admit patients to a mental health services unit unless the unit is
approved by the department as meeting the requirements of §133.163(q)
of this title.
(2) Admission criteria. A hospital providing mental
health services shall have written admission criteria that are applied
uniformly to all patients who are admitted to the service.
(A) The hospital's admission criteria shall include
procedures to prevent the admission of minors for a condition which
is not generally recognized as responsive to treatment in an inpatient
setting for mental health services.
(i) The following conditions are not generally recognized
as responsive to treatment in a hospital unless the minor to be admitted
is qualified because of other disabilities, such as:
(I) cognitive disabilities due to intellectual disability;
(II) learning disabilities.
(ii) A minor may be qualified for admission based on
other disabilities which would be responsive to mental health services.
(B) The medical record shall contain evidence that
admission consent was given by the patient, the patient's legal guardian,
or the managing conservator, if applicable.
(C) The hospital shall have a preadmission examination
procedure under which each patient's condition and medical history
are reviewed by a member of the medical staff to determine whether
the patient is likely to benefit significantly from an intensive inpatient
program or assessment.
(D) A voluntarily admitted patient shall sign an admission
consent form prior to admission to a mental health unit which includes
verification that the patient has been informed of the services to
be provided and the estimated charges.
(3) Compliance. A hospital providing mental health
services shall comply with the following rules administered by the
department. The rules are:
(A) Chapter 411, Subchapter J of this title (relating
to Standards of Care and Treatment in Psychiatric Hospitals);
(B) Chapter 404, Subchapter E of this title (relating
to Rights of Persons Receiving Mental Health Services);
(C) Chapter 405, Subchapter E of this title (relating
to Electroconvulsive Therapy (ECT));
(D) Chapter 414, Subchapter I of this title (relating
to Consent to Treatment with Psychoactive Medication--Mental Health
(E) Chapter 415, Subchapter F of this title (relating
to Interventions in Mental Health Programs).
(m) Mobile, transportable, and relocatable units. The
hospital shall adopt, implement and enforce procedures which address
the potential emergency needs for those inpatients who are taken to
mobile units on the hospital's premises for diagnostic procedures
(n) Nuclear medicine services. If the hospital provides
nuclear medicine services, these services shall meet the needs of
the patients in accordance with acceptable standards of practice and
be licensed in accordance with §289.256 of this title (relating
to Medical and Veterinary Use of Radioactive Material).
(1) Policies and procedures. Policies and procedures
shall be adopted, implemented, and enforced which will describe the
services nuclear medicine provides in the hospital and how employee
and patient safety will be maintained.
(2) Organization and staffing. The organization of
the nuclear medicine services shall be appropriate to the scope and
complexity of the services offered.
(A) There shall be a medical director or clinical director
who is a physician qualified in nuclear medicine.
(B) The qualifications, training, functions, and responsibilities
of nuclear medicine personnel shall be specified by the medical director
or clinical director and approved by the medical staff.
(3) Delivery of services. Radioactive materials shall
be prepared, labeled, used, transported, stored, and disposed of in
accordance with acceptable standards of practice and in accordance
with §289.256 of this title.
(A) In-house preparation of radiopharmaceuticals shall
be by, or under, the direct supervision of an appropriately trained
licensed pharmacist or physician.
(B) There shall be proper storage and disposal of radioactive
(C) If clinical laboratory tests are performed by the
nuclear medicine services staff, the nuclear medicine staff shall
comply with CLIA 1988 in accordance with the requirements specified
in 42 CFR Part 493.
(D) Nuclear medicine workers shall be provided personnel
monitoring dosimeters to measure their radiation exposure. Exposure
reports and documentation shall be available for review.
(4) Equipment and supplies. Equipment and supplies
shall be appropriate for the types of nuclear medicine services offered
and shall be maintained for safe and efficient performance. The equipment
shall be inspected, tested, and calibrated at least annually by qualified
(5) Records. The hospital shall maintain signed and
dated reports of nuclear medicine interpretations, consultations,
(A) The physician approved by the medical staff to
interpret diagnostic procedures shall sign and date the interpretations
of these tests.
(B) The hospital shall maintain records of the receipt
and disposition of radiopharmaceuticals until disposal is authorized
by the department's Radiation Safety Licensing Branch in accordance
with §289.256 of this title.
(C) Nuclear medicine services shall be ordered only
by an individual whose scope of state licensure and whose defined
staff privileges allow such referrals.
(o) Nursing services. The hospital shall have an organized
nursing service that provides 24-hour nursing services as needed.
(1) Organization. The hospital shall have a well-organized
service with a plan of administrative authority and delineation of
responsibilities for patient care.
(A) Nursing services shall be under the administrative
authority of a chief nursing officer (CNO) who shall be an RN and
comply with one of the following:
(i) possess a master's degree in nursing;
(ii) possess a master's degree in health care administration
or business administration;
(iii) possess a master's degree in a health-related
field obtained through a curriculum that included courses in administration
and management; or
(iv) be progressing under a written plan to obtain
the nursing administration qualifications associated with a master's
degree in nursing. The plan shall:
(I) describe efforts to obtain the knowledge associated
with graduate education and to increase administrative and management
skills and experience;
(II) include courses related to leadership, administration,
management, performance improvement and theoretical approaches to
delivering nursing care; and
(III) provide a time-line for accomplishing skills.
(B) The CNO in hospitals with 100 or fewer licensed
beds and located in counties with a population of less than 50,000,
or in hospitals that have been certified by the Centers for Medicare
and Medicaid Services as critical access hospitals in accordance with
the Code of Federal Regulations, Title 42, Volume 3, Part 485, Subpart
F, §485.606(b), shall be exempted from the requirements in subparagraph
(A)(i) - (iv) of this paragraph.
(C) The CNO shall be responsible for the operation
of the services, including determining the types and numbers of nursing
personnel and staff necessary to provide nursing care for all areas
of the hospital.
(D) The CNO shall report directly to the individual
who has authority to represent the hospital and who is responsible
for the operation of the hospital according to the policies and procedures
of the hospital's governing board.
(E) The CNO shall participate with leadership from
the governing body, medical staff, and clinical areas, in planning,
promoting and conducting performance improvement activities.
(2) Staffing and delivery of care.
(A) The nursing services shall adopt, implement and
enforce a procedure to verify that hospital nursing personnel for
whom licensure is required have valid and current licensure.