25 Tex. Admin. Code § 117.41 - Governing Body
(a) There shall be
an identified governing body responsible for the organization, management,
control, and operation of the facility, including the appointment of the
facility's medical director as defined in §
117.2(48) of
this title (relating to Definitions).
(1) A
qualified medical director is a physician who is board certified in internal
medicine by the American Board of Internal Medicine or pediatrics by the
American Board of Pediatrics or is board certified in nephrology or pediatric
nephrology, and has at least 12 months of experience providing care to patients
receiving dialysis.
(2) A facility
may request a waiver to appoint or retain as medical director a physician who
does not meet one or more of the qualifications in paragraph (1) of this
subsection. The waiver shall explain why a physician meeting the board
certification requirement is not available and include a resume of the
physician the facility seeks to appoint or retain. A written request for waiver
shall be made through the Texas Department of State Health Services, Health
Facility Compliance Group, Mail Code 1979, P.O. Box 149347, Austin, Texas,
78714-9347 for transmission to CMS.
(b) The governing body shall develop,
implement, and enforce policies and procedures for all services provided by the
facility.
(c) The governing body
shall ensure that the medical staff has current bylaws, rules and regulations
that are adopted, implemented, and enforced.
(d) The governing body shall ensure that
effective administrative rules, regulations, and policies designed to protect
the health and safety of patients are implemented and reviewed
annually.
(e) The governing body
shall ensure that there is a quality assessment and performance improvement
(QAPI) program to evaluate the provision of patient care. The governing body
shall review and monitor QAPI activities quarterly.
(f) The governing body shall ensure that all
facility staff are qualified (i.e., advanced practice registered nurse,
physician assistant, registered nurse, licensed vocational nurse, licensed
master social worker, registered dietitian, patient care technician, and other
technical staff) to serve the complex needs of dialysis patients and deliver
dialysis services. The registered nurse, licensed vocational nurse, patient
care technician and other technical staff must demonstrate and sustain the
skills needed to perform the specific duties of their positions.
(g) The governing body shall ensure adequate
numbers of qualified personnel are present whenever patients are undergoing
dialysis so that the patient/staff ratio is appropriate to the level of
dialysis care given and meets the needs of patients.
(h) The governing body shall review and
approve the facility's training program for staff, patients, and/or patient's
caregiver.
(i) The governing body
shall develop, implement, and enforce policies and procedures relating to the
facility's disaster preparedness plan, to meet the requirements of §
117.45(b) of
this title (relating to Provision and Coordination of Treatment and Services).
The plan shall address the continuity of essential building systems including
emergency power and water, or a contract with another licensed ESRD facility to
provide emergency contingency care to patients to meet the requirements of
§
117.91(h) of
this title (relating to Fire Prevention, Protection, and Emergency Contingency
Plan).
(j) The governing body shall
ensure that all equipment utilized by facility staff and/or patients is
properly maintained in accordance with the manufacturer's direction for
use.
(k) The governing body shall
ensure a physical environment that protects the health and safety of patients,
personnel, and the public. The physical premises of the facility and those
areas of the facility's surrounding physical structure that are used by the
patients (including stairwells, corridors, and passageways) shall meet the
local building and fire safety codes as they relate to design and space
requirements for safe access and patient privacy.
(l) The governing body shall develop,
implement, and enforce policies and procedures regarding disruptive patients or
family members to ensure the health and safety of patients, personnel and the
public.
(m) The governing body
shall ensure that personnel shall be assigned to assist a social worker(s) with
ancillary tasks (e.g., assistance with financial services, transportation,
administrative, clerical, etc.), when the patient load, including all
modalities, exceeds 100 patients per facility. The maximum patient load,
including all modalities, per full-time equivalent qualified social worker,
with assigned personnel assistance, is 125 patients.
Notes
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No prior version found.