26 Tex. Admin. Code § 509.41 - Operational Standards
(a) A facility
shall have an identified governing body fully responsible for organization,
management, control, and operation of the facility, including the appointment
of the facility's medical director. The medical director shall be board
certified or board eligible in emergency medicine, or board certified in
primary care with at least two years emergency care experience.
(b) The governing body shall adopt,
implement, and enforce written policies and procedures for the total operation
and all services provided by the facility.
(c) The governing body is responsible for all
services furnished in the facility, whether furnished directly or under
contract. The governing body shall ensure services are provided in a safe and
effective manner that permits the facility to comply with all applicable rules
and standards.
(d) The governing
body shall ensure the medical staff has on file current written bylaws, rules,
and regulations that are adopted, implemented, and enforced.
(e) The governing body shall disclose all
owners of the facility to the Texas Health and Human Services Commission
(HHSC).
(f) The governing body
shall meet at least annually and keep minutes or other records necessary for
orderly conduct of the facility. Each meeting held by the facility governing
body shall be a separate meeting with separate minutes from any other governing
body meeting.
(g) If the governing
body elects, appoints, or employs officers and administrators to carry out its
directives, the governing body shall define the authority, responsibility, and
functions of all such positions.
(h) The governing body shall develop a
process for appointing or reappointing medical staff, and for assigning or
curtailing medical privileges.
(i)
The governing body shall provide (in a manner consistent with state law and
based on evidence of education, training, and current competence) for the
initial appointment, reappointment, and assignment or curtailment of privileges
and practice for non-physician health care personnel and
practitioners.
(j) The governing
body shall encourage personnel to participate in continuing education that is
relevant to their responsibilities within the facility.
(k) The governing body shall adopt,
implement, and enforce written policies to ensure compliance with applicable
state and federal laws.
(l) In
accordance with Texas Health and Safety Code §
254.157
(relating to Certain Advertising Prohibited), a facility may not advertise or
hold itself out as a network provider, including by stating that the facility
"takes" or "accepts" any insurer, health maintenance organization, health
benefit plan, or health benefit plan network, unless the facility is a network
provider of a health benefit plan issuer.
(m) A facility may not post the name or logo
of a health benefit plan issuer in any signage or marketing materials if the
facility is an out-of-network provider for all of the issuer's health benefit
plans.
(n) A facility shall assess,
and the governing body shall review, patient satisfaction with services and
environment no less than annually.
Notes
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