Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 509 - FREESTANDING EMERGENCY MEDICAL CARE FACILITIES › Subchapter C - OPERATIONAL REQUIREMENTS › Section 509.42 - Governing Body Responsibilities

Current through Reg. 49, No. 28; July 12, 2024
The governing body shall address and is fully responsible,
					 either directly or by appropriate professional delegation, for operation and
					 performance of the facility. Governing body responsibilities include:
(1) determining the mission, goals, and
				  objectives of the facility;
(2)
				  ensuring that facilities and personnel are adequate and appropriate to carry
				  out the mission;
(3) ensuring a
				  physical environment that protects the health and safety of patients,
				  personnel, and the public;
(4)
				  establishing an organizational structure and specifying functional
				  relationships among the various components of the facility;
(5) adopting, implementing, and enforcing
				  bylaws or similar rules and regulations for the orderly development and
				  management of the facility;
(6)
				  adopting, implementing, and enforcing policies or procedures necessary for
				  orderly conduct of the facility;
(7) reviewing and approving the facility's
				  training program for staff;
(8)
				  ensuring that all equipment used by facility staff or patients is properly used
				  and maintained per manufacturer recommendations;
(9) adopting, implementing, and enforcing
				  policies or procedures related to emergency planning and disaster preparedness,
				  including reviewing the facility's disaster preparedness plan at least
				  annually;
(10) ensuring there is a
				  quality assessment and performance improvement (QAPI) program to evaluate the
				  provision of patient care, including quarterly review and monitoring of QAPI
				  activities;
(11) reviewing legal
				  and ethical matters concerning the facility and its staff, when necessary, and
				  responding appropriately;
(12)
				  maintaining effective communication throughout the facility;
(13) establishing a system of financial
				  management and accountability that includes an audit or financial review
				  appropriate to the facility;
(14)
				  adopting, implementing, and enforcing policies for provision of radiological
				  services;
(15) adopting,
				  implementing, and enforcing policies for provision of laboratory
				  services;
(16) adopting,
				  implementing, and enforcing policies for provision of pharmacy
				  services;
(17) adopting,
				  implementing, and enforcing policies for collection, processing, maintenance,
				  storage, retrieval, authentication, and distribution of patient medical records
				  and reports;
(18) adopting,
				  implementing, and enforcing a policy on the rights of patients and complying
				  with all state and federal patient rights requirements;
(19) adopting, implementing, and enforcing
				  policies for provision of an effective procedure for the immediate transfer to
				  a licensed hospital of patients requiring emergency care beyond the
				  capabilities of the facility, including a transfer agreement with a hospital
				  licensed in this state in accordance with §
										509.66 of this subchapter
				  (relating to Patient Transfer Agreements);
(20) adopting, implementing, and enforcing
				  policies for all individuals that arrive at the facility to ensure they are
				  provided an appropriate medical screening examination within the capability of
				  the facility, including ancillary services routinely available to determine
				  whether or not the individual needs emergency care as defined in §
										509.2 of this chapter (relating to
				  Definitions), and that if emergency care is determined to be needed, the
				  facility shall provide any necessary stabilizing treatment or arrange an
				  appropriate transfer the individual as defined in §
										509.65 of this subchapter
				  (relating to Patient Transfer Policy);
(21) adopting, implementing, and enforcing
				  protocols to be used in determining death and for filing autopsy reports that
				  comply with Texas Health and Safety Code Chapter 671 (relating to Determination
				  of Death and Autopsy Reports);
(22)
				  approving all major contracts or arrangements affecting the medical care
				  provided under its auspices, including those concerning:
(A) services of physicians and
				  practitioners;
(B) use of external
				  laboratories; and
(C) an effective
				  procedure for obtaining emergency laboratory, radiology, and pharmaceutical
				  services when these services are not immediately available due to system
				  failure;