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RULE §133.45Miscellaneous Policies and Protocols

(a) Determination of death and autopsy reports. The hospital shall adopt, implement, and enforce protocols to be used in determining death and for filing autopsy reports which comply with Health and Safety Code (HSC), Title 8, Subtitle A, Chapter 671 (Determination of Death and Autopsy Reports).

(b) Organ and tissue donors. The hospital shall adopt, implement, and enforce a written protocol to identify potential organ and tissue donors which is in compliance with the Texas Anatomical Gift Act, HSC, Chapter 692. The hospital shall make its protocol available to the public during the hospital's normal business hours.

  (1) The hospital's protocol shall include all requirements in HSC, Chapter 692, §692.013 (Hospital Protocol).

  (2) A hospital which performs organ transplants shall be a member of the Organ Procurement and Transplantation Network in accordance with 42 United States Code, §274 (Organ Procurement and Transplantation Network).

(c) Discrimination prohibited. A licensed hospital shall not discriminate based on a patient's disability and shall comply with Texas Health and Safety Code Chapter 161, Subchapter S (relating to Allocation of Kidneys and Other Organs Available for Transplant).

(d) All-hazard disaster preparedness.

  (1) Definitions.

    (A) Adult intensive care unit (ICU)--Can support critically ill/injured patients, including ventilator support.

    (B) Burn or burn ICU--Either approved by the American Burn Association or self-designated. (These beds should not be included in other ICU bed counts.)

    (C) Medical/surgical--Also thought of as "ward" beds.

    (D) Negative pressure/isolation--Beds provided with negative airflow, providing respiratory isolation. Note: This value may represent available beds included in the counts of other types.

    (E) Operating rooms--An operating room that is equipped and staffed and could be made available for patient care in a short period.

    (F) Pediatric ICU--The same as adult ICU, but for patients 17 years and younger.

    (G) Pediatrics--Ward medical/surgical beds for patients 17 years and younger.

    (H) Physically available beds--Beds that are licensed, physically set up, and available for use. These are beds regularly maintained in the hospital for the use of patients, which furnish accommodations with supporting services (such as food, laundry, and housekeeping). These beds may or may not be staffed but are physically available.

    (I) Psychiatric--Ward beds on a closed/locked psychiatric unit or ward beds where a patient will be attended by a sitter.

    (J) Staffed beds--Beds that are licensed and physically available for which staff members are available to attend to the patient who occupies the bed. Staffed beds include those that are occupied and those that are vacant.

    (K) Vacant/available beds--Beds that are vacant and to which patients can be transported immediately. These must include supporting space, equipment, medical material, ancillary and support services, and staff to operate under normal circumstances. These beds are licensed, physically available, and have staff on hand to attend to the patient who occupies the bed.

  (2) A hospital shall adopt, implement, and enforce a written plan for all-hazard, natural or man-made, disaster preparedness for effective preparedness, mitigation, response, and recovery from disasters.

  (3) The plan, which may be subject to review and approval by the department, shall be sent to the local disaster management authority.

  (4) The plan shall:

    (A) be developed through a joint effort of the hospital governing body, administration, medical staff, hospital personnel and emergency medical services partners;

    (B) include the applicable information contained in the National Fire Protection Association 99, Standard for Health Care Facilities, 2002 edition, Chapter 12 (Health Care Emergency Management), published by the National Fire Protection Association (NFPA), and the State of Texas Emergency Management Plan. Information regarding the State of Texas Emergency Management Plan is available from the city or county emergency management coordinator. The NFPA document referenced in this section may be obtained by writing or calling the NFPA at the following address and telephone number: 1 Batterymarch Park, Post Office Box 9101, Quincy, Massachusetts 02269-9101, (800) 344-3555;

    (C) contain the names and contact numbers of city and county emergency management officers and the hospital water supplier;

    (D) be exercised at least annually and in conjunction with state and local exercises. Hospitals participating in an exercise or responding to a real-life event shall develop an after-action report (AAR) within 60 days. AARs shall be retained for at least three years and be available for review by the local emergency management authority and the department;

    (E) include the methodology for notifying the hospital personnel and the local disaster management authority of an event that will significantly impact hospital operations;

    (F) include evidence that the hospital has communicated prospectively with the local utility and phone companies regarding the need for the hospital to be given priority for the restoration of utility and phone services and a process for testing internal and external communications systems regularly;

    (G) include the use of a department approved process to update bed availability, as follows:

      (i) as requested by the department during a public health emergency or state declared disaster; and

      (ii) for the physically available beds and staffed beds that are vacant/available beds for the following bed types:

        (I) adult ICU;

        (II) burn or burn ICU;

        (III) medical/surgical;

        (IV) negative pressure/isolation;

        (V) operating rooms;

        (VI) pediatric ICU;

        (VII) pediatrics; and

        (VIII) psychiatric;

      (iii) emergency department divert status;

      (iv) for decontamination facility available; and

      (v) for ventilators available;

    (H) include at a minimum:

      (i) a component for the reception, treatment, and disposition of casualties that can be used in the event that a disaster situation requires the hospital to accept multiple patients. This component shall include at a minimum:

        (I) process, developed in conjunction with appropriate agencies, to allow essential healthcare workers and personnel to safely access their delivery care sites;

        (II) procedures for the appropriate provision of personal protection equipment for and appropriate immunization of staff, volunteers, and staff families; and

        (III) plan to provide food and shelter for staff and volunteers as needed throughout the duration of response;

      (ii) an evacuation component that can be engaged in any emergency situation necessitating either a full or partial evacuation of the hospital. The evacuation component shall address at a minimum:

        (I) activation, including who makes the decision to activate and how it is activated;

        (II) when within control of the hospital, patient evacuation destination, including protocol to ensure that the patient destination is compatible to patient acuity and health care needs, plan for the order of removal of patients and planned route of movement, train and drill staff on the traffic flow and the movement of patients to a staging area, and room evacuation protocol;

        (III) family/responsible party notification, including the procedure to notify patient emergency contacts of an evacuation and the patient's destination; and

        (IV) transport of records and supplies, including the protocol for the transfer of patient specific medications and records to the receiving facility. These records shall include at a minimum: the patient's most recent physician's assessment, order sheet, medication administration record (MAR), and patient history with physical documentation. A weather-proof patient identification wrist band (or equivalent identification) must be intact on all patients.

(e) Voluntary paternity establishment services. A hospital that handles the birth of newborns must provide voluntary paternity establishment services in accordance with:

  (1) the HSC, §192.012, Record of Acknowledgment of Paternity; and


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