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RULE §157.133Requirements for Stroke Facility Designation

exception, with a specific timeline based on the public interest, or deny the exception. If the facility is not granted an exception, or it is not compliant to the requirements at the end of the exception period, the department shall elect one of the following:

    (A) re-designate the facility at the level appropriate to its revised capabilities; or

    (B) accept the facility's surrender of its stroke facility designation certificate and designation award letter after the requirements in subsection (k) of this section have been completed.

(j) An application for a higher or lower level of stroke facility designation may be submitted to the department at any time.

  (1) A designated stroke facility that is increasing its stroke capabilities may choose to apply for a higher level of designation at any time. The facility must follow the designation process as described in subsection (g)(1) of this section to apply for the higher level.

  (2) A designated stroke facility that is unable to maintain compliance with the facility's current level of stroke designation may choose to apply for a lower level of designation at any time.

(k) If the facility chooses to relinquish its stroke facility designation, the facility shall provide a 30 days written, advance notice prior to the relinquishment of the designation to the department, the applicable RACs, EMS providers, and health care facilities it customarily transfers-out or transfers-in stroke patients. The facility is responsible to continue providing stroke care services and ensure that stroke care continuity for the region remains in place for the 30 days following the notice of relinquishing its stroke designation.

(l) A hospital shall not use or authorize the use of any public communication or advertising containing false, misleading, or deceptive claims regarding its stroke designation status. Public communication or advertising shall be deemed false, misleading, or deceptive if the facility uses these terms:

  (1) "stroke facility," "stroke hospital," "stroke center," or similar terminology and the facility is not currently designated as a stroke facility in accordance with this section; or

  (2) "comprehensive Level I stroke center," "advanced Level II stroke center," "primary Level III stroke center," "acute stroke ready Level IV center," or similar terminology in its signs, advertisements or in the printed materials the facility provides to the public, unless the hospital is currently designated at that defined level of stroke facility in accordance with this section.

(m) The department has the right to review, inspect, evaluate, and audit all stroke patient records, stroke multidisciplinary QAPI plan documents, and peer review activities, as well as, any other documents relevant to stroke care in a designated stroke facility or facility seeking stroke facility designation at any time to verify compliance with the Texas Health and Safety Code, Chapter 773 and this section.

(n) The department maintains confidentiality of such records to the extent authorized by Texas Government Code, Chapter 552.

(o) Stroke designation site review of the hospital applying for stroke facility designation will be scheduled with the department-approved survey organization and follow the department survey guidelines.

(p) The department may deny, suspend, or revoke a stroke facility designation if a designated stroke facility ceases to provide services to meet or maintain compliance with the requirements of this section or if it violates the Chapter 133 of this title, concerning requirements resulting in enforcement action.

Source Note: The provisions of this §157.133 adopted to be effective February 17, 2022, 47 TexReg 650

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