| (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
Cont'd... |
