Texas Register, Volume 22, Number 80, Pages 12189-12342, December 12, 1997 Page: 12,216
12189-12342 p. ; 28 cm.View a full description of this periodical.
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(3) the applicant's self-study for comparison with the
criteria.
{fl When the application phase results in a bureau recom-
mendation for a survey, the bureau shall notify the applicant as fol-
lows.
(1) The applicant shall contract with an approved non-
department surveyor.
(2) The applicant shall notify the bureau of the date of
the planned survey and composition of the survey team.
(3) The applicant shall be responsible for any costs
associated with the survey.
(4) The bureau may appoint an observer to accompany
the survey team. In this event, the cost for the observer shall be borne
by the bureau.
(g) Applicants shall be surveyed by a department represen-
tative, registered nurse or licensed physician. A second surveyor may
be requested by the applicant or the bureau. Non-department survey-
ors must meet the following criteria:
(1) have at least three years experience in the care of
trauma patients;
(2) be currently employed in the coordination of care for
trauma patients;
(3) have direct experience in the preparation for and
successful completion of trauma facility verification/designation;
(4) have successfully completed the department Trauma
Facility Site Surveyor Course;
(5) have current credentials of Trauma Nurse Core
Curriculum (TNCC) for nurses or Advanced Trauma Life Support
(ATLS) for physicians, and the following:
(A) Advanced Cardiac Life Support (ACLS); and
(B) a pediatric advanced life support course;
(6) have successfully completed a site survey internship
with department staff; and
(7j except department staff, come from a public health
region outside the applicant's location and at least 100 miles from
the applicant.
hi The survey team shall evaluate the quality an applicant's
compliance with the requirements set forth in the criteria, by:
(1) reviewing medical records, staff rosters and sched-
ules, quality improvement committee meeting minutes and other doc-
uments relevant to trauma care;
(2) reviewing equipment and the physical plant; and
(3) conducting interviews with applicant personnel.
(i) Findings of the survey team shall be forwarded to the
bureau within 90 days.
(11 The bureau shall review the findings for compliance
with the criteria.
{2 A recommendation for designation shall be made to
the commissioner based on compliance with the criteria.
(3 In the event there is a problem area in which an
applicant does not comply with the criteria, the bureau shall notify
the applicant of deficiencies and outline corrective action.(A) The applicant shall submit a report to the bureau
which outlines the corrective action taken. The bureau may require a
second survey to insure compliance with the criteria. If the applicant
and/or bureau report substantiates action that brings the applicant into
compliance with the criteria, the bureau shall recommend designation
to the commissioner.
@B4 If the applicant disagrees that there is need for
corrective action, the bureau shall refer the complete file to the trauma
subcommittee of the emergency health care advisory committee for
review.
(C) If the trauma subcommittee disagrees with the
bureau recommendation for corrective action, the records shall be
referred to the deputy commissioner of health for review.
j) The bureau shall provide a copy of the survey report, for
surveys conducted by department staff, and results to the applicant.
(kI At the end of the secondary review and final phases of
the designation process, if an applicant disagrees with the bureau
recommendations, opportunity for an appeal in accordance with the
department formal hearing procedures as described in Chapter 1 of
this title shall be offered.
(1) The department may grant an exception to this section
if it finds that compliance with this section would not be in the best
interests of the persons served in the affected local system.
(m) The applicant shall have the right to withdraw its
application at any time prior to being awarded trauma facility
designation by the department.
(n) If the commissioner concurs with the bureau recommen-
dation, the applicant shall receive a certificate of designation for three
years.
(ol Designation is granted for a period of up to three years
and it shall be necessary to repeat the designation process as described
in this section before the expiration date in order to prevent a lapse
of designation.
(p) A designated trauma facility shall:
(1) notify the department and the regional advisory
council (RAC) within five days if temporarily unable to comply with
designation standards;
(2) notify the department and the RAC if it chooses to
no longer provide trauma services commensurate with its designation
level with at least 30 days notice;
(3) comply with the provisions within these sections,
157.121 through 157.131 (relating to Emergency Medical Services
Trauma Systems), all current state and system standards as described
in this chapter, and all policies, protocols, and procedures as set forth
in the system plan;
(4) continue its commitment to provide the resources,
personnel, equipment, and response as required by its designation
level; and
(5) participate in the state trauma registry as described in
157.129 of this title (relating to State Trauma Registry).
(q) A facility may not use the terms "trauma facility",
"trauma center", or similar terminology in its signs or advertisements
or in the printed materials and information it provides to the public
unless the facility has been designated as a trauma facility according
to the process described in this section. This subsection of this section
also applies to facilities whose designation has lapsed.22 TexReg 12216 December 12, 1997 Texas Register
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Texas. Secretary of State. Texas Register, Volume 22, Number 80, Pages 12189-12342, December 12, 1997, periodical, December 12, 1997; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth176721/m1/30/: accessed July 18, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.