SECTION 511.42. Governing Body Responsibilities

(a) A limited services rural hospital's (LSRH's) governing body shall address and is fully responsible, either directly or by appropriate professional delegation, for the operation and performance of the LSRH.

(b) The governing body is responsible for all services furnished in the LSRH, whether furnished directly or under contract. The governing body shall ensure:

(1) services, including any contracted services, are provided in a safe and effective manner that permits the LSRH to comply with all applicable rules and standards, including the federal conditions of participation at Code of Federal Regulations Title 42 (42 CFR) Part 485, Subchapter E and this chapter;

(2) the LSRH maintains a list of all contracted services, including the scope and nature of the services provided;

(3) the medical staff is accountable to the governing body for the quality of care provided to patients as required by 42 CFR §485.510; and

(4) the provision of education to students and postgraduate trainees if the LSRH participates in such programs.

(c) An LSRH's governing body shall adopt, implement, and enforce written policies and procedures for the total operation and all services the LSRH provides, with the policies for the LSRH's services being developed, reviewed, and updated in accordance with §511.51 of this subchapter (relating to Provision of Services). The policies and procedures shall include at least the following:

(1) bylaws or similar rules and regulations for the orderly development and management of the LSRH;

(2) policies or procedures necessary for the orderly conduct of the LSRH;

(3) policies or procedures related to emergency planning and disaster preparedness that shall require the governing body to review the LSRH's disaster preparedness plan at least annually;

(4) policies for the provision of the following services:

(A) emergency services;

(B) radiological services;

(C) laboratory services;

(D) pharmacy services; and

(E) any outpatient services the LSRH provides;

(5) policies for the collection, processing, maintenance, storage, retrieval, authentication, and distribution of patient medical records and reports;

(6) policy on the rights of patients and complying with all state and federal patient rights requirements;

(7) policies for the provision of an effective procedure for the immediate transfer to a licensed hospital of patients requiring emergency care beyond the capabilities of the LSRH, including a transfer agreement with a hospital licensed in this state as defined in §511.66 of this subchapter (relating to Patient Transfer Agreements);

(8) policies for all individuals that arrive at the LSRH to ensure they are provided an appropriate medical screening examination within the capability of the LSRH, including:

(A) ancillary services routinely available to determine whether or not the individual needs emergency care as defined in §511.2 of this chapter (relating to Definitions); and

(B) if emergency care is determined to be needed, the LSRH shall provide any necessary stabilizing treatment or arrange an appropriate transfer for the individual as defined in §511.65 of this subchapter (relating to Patient Transfer Policy);

(9) a policy that complies with the requirements under Texas Health and Safety Code §241.009 to require employees, physicians, contracted employees, and individuals in training who provide direct patient care at the LSRH to wear a photo identification badge during all patient encounters, unless precluded by adopted isolation or sterilization protocols; and

(10) policies to ensure compliance with applicable state and federal laws.

(d) The governing body's responsibilities shall include:

(1) determining the LSRH's mission, goals, and objectives;

(2) ensuring that facilities and personnel are sufficient and appropriate to carry out the LSRH's mission;

(3) determining, in accordance with state law, which categories of practitioners are eligible candidates for appointment to the medical staff;

(4) appointing members of the medical staff after considering the recommendations of the existing members of the medical staff;

(5) ensuring that the medical staff is accountable to the governing body for the quality of care provided to patients;

(6) ensuring the criteria for medical staff selection are individual character, competence, training, experience, and judgment;

(7) ensuring a physical environment that protects the health and safety of patients, personnel, and the public;

(8) establishing an organizational structure and specifying functional relationships among the various components of the LSRH;

(9) reviewing and approving the LSRH's training program for staff;

(10) ensuring all equipment utilized by LSRH staff or by patients is properly used and maintained per manufacturer recommendations;

(11) ensuring there is a quality assessment and performance improvement (QAPI) program to evaluate the provision of patient care;

(12) reviewing and monitoring QAPI activities quarterly;

(13) consulting directly at least periodically throughout the fiscal or calendar with medical director or their designee, and include discussion of matters related to the quality of medical care provided to patients of the LSRH;

(14) consulting directly with the individual responsible for the organized medical staff (or their designee) of each hospital or LSRH within its system as applicable for a multi-facility system, including a multi-hospital or multi-LSRH system, using a single governing body;

(15) reviewing legal and ethical matters concerning the LSRH and its staff when necessary and responding appropriately;

(16) ensuring that under no circumstances is the accordance of staff membership or professional privileges in the LSRH dependent solely upon certification, fellowship, or membership in a specialty body or society;

(17) maintaining effective communication throughout the LSRH;

(18) establishing a system of financial management and accountability that includes an audit or financial review appropriate to the LSRH;

(19) formulating long-range plans in accordance with the mission, goals, and objectives of the LSRH;

(20) operating the LSRH without limitation because of color, race, age, sex, religion, national origin, or disability;

(21) ensuring that all marketing and advertising concerning the LSRH does not imply that it provides care or services that the LSRH is not capable of providing;

(22) developing a system of risk management appropriate to the LSRH, including:

(A) periodic review of all litigation involving the LSRH, its staff, physicians, and practitioners regarding activities in the LSRH;

(B) periodic review of all incidents reported by staff and patients;

(C) review of all deaths, trauma, or adverse reactions occurring on premises; and

(D) evaluation of patient complaints;

(23) ensuring that when telemedicine services are furnished to the LSRH's patients through an agreement with a distant-site hospital, the agreement meets the requirements of 42 CFR §485.510; and

(24) ensuring that when telemedicine services are furnished the services meet all federal and state laws, rules, and regulations.

(e) The governing body shall ensure the medical staff has current written bylaws, rules, and regulations that are adopted, implemented, and enforced by the LSRH on file.

(f) The governing body shall approve medical staff bylaws and other medical staff rules and regulations.

(g) The governing body, with input from the medical staff, shall periodically review the scope of procedures performed in the LSRH and amend as appropriate.

(h) The governing body shall provide for full disclosure of ownership to the Texas Health and Human Services Commission.

(i) The governing body shall meet at least annually and maintain minutes or other records necessary for the orderly conduct of the LSRH. Meetings the LSRH's governing body holds shall be separate meetings with separate minutes from any other governing body meeting.

(j) 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.

(k) 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.

(l) The governing body shall develop a process for appointing or reappointing medical staff, and for assigning or curtailing medical privileges and shall periodically reappraise medical staff privileges.

(m) The governing body shall encourage personnel to participate in continuing education that is relevant to their responsibilities within the LSRH.

(n) The governing body shall review patient satisfaction with services and environment at least annually.

Source Note: The provisions of this §511.42 adopted to be effective October 5, 2023, 48 TexReg 5668