(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
Texas Health and Safety Code (HSC) Chapter 671.
(b) Organ and tissue donors. The hospital shall adopt,
implement, and enforce a written protocol to identify potential organ
and tissue donors which complies with HSC Chapter 692A. 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 §692A.015.
(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.
(c) Discrimination prohibited. A licensed hospital
shall not discriminate based on a patient's disability and shall comply
with HSC Chapter 161, Subchapter S.
(d) All-hazard disaster preparedness.
(1) Definitions.
(A) Adult intensive care unit (ICU)--Can support critically
ill or 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 or 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 Texas Health and Human Services Commission (HHSC), 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:
(i) National Fire Protection Association 99, Standard
for Health Care Facilities, 2002 edition, Chapter 12, published by
the National Fire Protection Association; and
(ii) the State of Texas Emergency Management Plan,
which is available from the city or county emergency management coordinator;
(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;
(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 Texas Department of State
Health Services (DSHS) approved process to update bed availability,
as follows:
(i) as requested by DSHS 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) for 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, which 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, which 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 or 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, which shall include at a minimum:
(-a-) the patient's most recent physician's assessment;
(-b-) order sheet;
(-c-) medication administration record (MAR);
(-d-) patient history with physical documentation;
and
(-e-) a weather-proof patient identification wrist
band (or equivalent identification), which must be intact on all patients.
(5) Hospitals participating in an exercise or responding
to a real-life event under paragraph (4)(D) of this subsection shall
develop an after-action report (AAR) within 60 days. The hospital
shall retain the AARs for at least three years and make them available
for review by the local emergency management authority and HHSC.
(e) Voluntary paternity establishment services. A hospital
that handles the birth of newborns must provide voluntary paternity
establishment services in accordance with:
(1) HSC §192.012; and
(2) the rules of the Office of the Attorney General
found at 1 Texas Administrative Code Chapter 55, Subchapter J (relating
to Voluntary Paternity Acknowledgment Process).
(f) Harassment and abuse. A hospital shall adopt, implement,
and enforce a written policy for identifying and addressing instances
of alleged verbal or physical abuse or harassment of hospital employees
or contracted personnel by other hospital employees or contracted
personnel or by a health care provider who has clinical privileges
at the hospital.
Cont'd... |