| (1) Level I and II facilities and all free-standing
children's facilities must request a survey through the ACS trauma
verification program.
(2) Level III facilities must request a survey through
the ACS trauma verification program or through a department-approved
survey organization.
(3) Level IV facilities must request a survey through
a department-approved survey organization, or by a department-credentialed
surveyor.
(4) The facility must notify the department of the
date of the planned survey and the composition of the survey team.
(5) The facility is responsible for any expenses associated
with the survey.
(6) The department, at its discretion, may appoint
a designation coordinator to accompany the survey team. In this event,
the cost for the designation coordinator is borne by the department.
(k) The survey team composition must be as follows.
(1) Level I or Level II facilities must be surveyed
by a team that is multidisciplinary and includes at a minimum: two
general surgeons, an emergency physician, and a trauma nurse all active
in the management of trauma patients.
(2) Free-standing children's facilities of all levels
must be surveyed by a team consistent with current ACS policy and
includes at a minimum: a pediatric surgeon, a general surgeon, a pediatric
emergency physician, and a pediatric trauma nurse coordinator or a
trauma nurse coordinator with pediatric experience.
(3) Level III facilities must be surveyed by a team
that is multidisciplinary and includes at a minimum: a trauma surgeon
and a trauma nurse (ACS or department-credentialed), both active in
the management of trauma patients.
(4) Level IV facilities must be surveyed by a department-credentialed
representative, registered nurse, or licensed physician. A second
surveyor may be requested by the facility or by the department.
(5) Department-credentialed surveyors must meet the
following criteria:
(A) have at least three years' experience in the care
of trauma patients;
(B) be currently employed in the coordination of care
for trauma patients;
(C) have direct experience in the preparation for and
successful completion of trauma facility verification or designation;
(D) have successfully completed a department-approved
trauma facility site surveyor course and be successfully re-credentialed
every four years; and
(E) have current credentials as follows:
(i) for nurses: Trauma Nurses Core Course (TNCC) or
Advanced Trauma Course for Nurses (ATCN); and Pediatric Advanced Life
Support (PALS) or Emergency Nurses Pediatric Course (ENPC);
(ii) for physicians: Advanced Trauma Life Support (ATLS);
and
(iii) have successfully completed a site survey internship.
(6) All members of the survey team, except department
staff, must come from a TSA outside the facility's location and at
least 100 miles from the facility. There must be no business or patient
care relationship or any potential conflict of interest between the
surveyor or the surveyor's place of employment and the facility being
surveyed.
(l) The survey team evaluates the facility's compliance
with the designation criteria, by:
(1) reviewing medical records; staff rosters and schedules;
process improvement committee meeting minutes; and other documents
relevant to trauma care;
(2) reviewing equipment and the physical plant;
(3) conducting interviews with facility personnel;
(4) evaluating compliance with participation in the
State Trauma Registry; and
(5) evaluating appropriate use of telemedicine capabilities
where applicable.
(m) The site survey report in its entirety must be
part of a facility's performance improvement program and subject to
confidentiality as articulated in the Texas Health and Safety Code §773.095.
(n) The surveyor must provide the facility with a written,
signed survey report regarding the evaluation of the facility's compliance
with trauma facility criteria. This survey report must be forwarded
to the facility within 30 calendar days of the completion date of
the survey. The facility is responsible for forwarding a copy of this
report to the department if it intends to continue the designation
process.
(o) The department must review the findings of the
survey report for compliance with trauma facility criteria.
(1) A recommendation for designation must be made to
the commissioner based on meeting the designation requirements.
(2) If a facility does not meet the criteria for the
level of designation deemed appropriate by the department, the department
must notify the facility of the requirements it must meet to achieve
the appropriate level of designation.
(3) If a facility does not meet the requirements, the
department must notify the facility of deficiencies and recommend
corrective action.
(A) The facility must submit to the department a report
that outlines the corrective action taken. The department may require
a second survey to ensure compliance with the criteria. If the department
substantiates action that brings the facility into compliance with
the criteria, the department recommends designation to the commissioner.
(B) If a facility disagrees with the department's decision
regarding its designation application or status, it may request a
secondary review by a designation review committee. Membership on
a designation review committee will:
(i) be voluntary;
(ii) be appointed by the EMS/Trauma Systems Section
director;
(iii) be representative of trauma care providers and
appropriate levels of designated trauma facilities; and
(iv) include representation from the department and
the Trauma Systems Committee of the Governor's EMS and Trauma Advisory
Council (GETAC).
(C) If a designation review committee disagrees with
the department's recommendation for corrective action, the records
must be referred to the associate commissioner for recommendation
to the commissioner.
(D) If a facility disagrees with the department's recommendation
at the end of the secondary review, the facility has a right to a
hearing, governed by the department's rules for a contested case hearing
and by Texas Administrative Procedure Act, Texas Government Code Chapter
2001, and the department's formal hearing procedures in §§1.21,
1.23, 1.25, and 1.27 of this title (relating to Formal Hearing Procedures).
(p) The facility has the right to withdraw its application
at any time before being recommended for trauma facility designation
by the department.
(q) If the associate commissioner concurs with the
recommendation to designate, the facility receives a letter and a
certificate of designation valid for three years. Additional actions,
such as a site review or submission of information/reports to maintain
designation, may be required by the department.
(r) It is necessary to repeat the designation process
as described in this section prior to expiration of a facility's designation
or the designation expires.
(s) A designated trauma facility must comply with the
provisions of this chapter; all current state and system standards
as described in this chapter; all policies, protocols, and procedures
as set forth in the system plan; and meet the following requirements.
(1) Continue its commitment to provide the resources,
personnel, equipment, and response as required by its designation
level.
(2) Participate in the State Trauma Registry. Data
submission requirements for designation purposes are as follows.
(A) Initial designation--Six months of data prior to
the initial designation survey must be uploaded. Subsequent to initial
designation, data should be uploaded to the State Trauma Registry
on at least a quarterly basis (with monthly submissions recommended)
as indicated in Chapter 103 of this title (relating to Injury Prevention
and Control).
(B) Re-designation--The facility's trauma registry
should be current with at least quarterly uploads of data to the State
Trauma Registry (monthly submissions recommended) as indicated in
Chapter 103 of this title.
(3) Notify the department, its RAC, and other affected
RACs of all changes that affect air medical access to designated landing
sites.
(A) Non-emergent changes must be implemented no earlier
than 120 days after a written notification process.
(B) Emergency changes related to safety may be implemented
immediately along with immediate notification to department, the RAC,
and appropriate air medical providers.
Cont'd... |
