RULE §134.41 Facility Functions and Services

Published: 2015

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(a) Anesthesia services. If the hospital furnishes
anesthesia services, these services shall be provided in a well-organized
manner under the direction of a qualified physician. The anesthesia
service is responsible for all anesthesia administered in the hospital.
  (1) Organization and staffing. The organization of
anesthesia services shall be appropriate to the scope of the services
offered. Anesthesia shall be administered only by:
    (A) a qualified anesthesiologist;
    (B) a physician (other than an anesthesiologist);
    (C) a dentist, oral surgeon, or podiatrist who is qualified
to administer anesthesia under state law; or
    (D) a certified registered nurse anesthetist who is
under the supervision, as set forth in the Medical Practice Act, Texas
Occupations Code, Title 3, Subtitle B, and the Nursing Practice Act,
Texas Occupations Code, Chapter 301, of the operating physician or
of an anesthesiologist who is immediately available if needed.
  (2) Delivery of services. Anesthesia services shall
be consistent with needs and resources. Policies on anesthesia procedures
shall include the delineation of pre-anesthesia and post-anesthesia
responsibilities. The policies shall ensure that the following are
provided for each patient.
    (A) A pre-anesthesia evaluation by an individual qualified
to administer anesthesia under paragraph (1) of this subsection shall
be performed within 48 hours prior to the procedure.
    (B) An intraoperative anesthesia record shall be provided.
The record shall include any complications or problems occurring during
the anesthesia including time, description of symptoms, review of
affected systems, and treatments rendered. The record shall correlate
with the controlled substance administration record.
    (C) A post-anesthesia follow-up report shall be written
by the person administering the anesthesia before transferring the
patient from the recovery room and shall include evaluation for recovery
from anesthesia, level of activity, respiration, blood pressure, level
of consciousness, and patient color.
      (i) With respect to inpatients, a post-anesthesia evaluation
for proper anesthesia recovery shall be performed after transfer from
recovery and within 48 hours after the procedure by the person administering
the anesthesia, registered nurse (RN), or physician in accordance
with policies and procedures approved by the medical staff.
      (ii) With respect to outpatients, immediately prior
to discharge, a post-anesthesia evaluation for proper anesthesia recovery
shall be performed by the person administering the anesthesia, RN,
or physician in accordance with policies and procedures approved by
the medical staff.
(b) Dietary services. The facility shall have organized
dietary services that are directed and staffed by adequate qualified
personnel. However, a facility that has a contract with an outside
food management company or an arrangement with another facility may
meet this requirement if the company or other facility has a dietitian
who serves the facility on a full-time, part-time, or consultant basis,
and if the company or other facility maintains at least the minimum
requirements specified in this section, and provides for the frequent
and systematic liaison with the facility medical staff for recommendations
of dietetic policies affecting patient treatment. The facility shall
ensure that there are sufficient personnel to respond to the dietary
needs of the patient population being served.
  (1) Organization.
    (A) A facility shall have an employee who is qualified
by experience or training to serve as director of the food and dietetic
service, and be responsible for the daily management of the dietary
services. This employee shall be full-time in a hospital; the crisis
stabilization unit employee does not have to be full-time.
    (B) There shall be a qualified dietitian who works
full-time, part-time, or on a consultant basis. If by consultation,
such services shall occur at least once per month for not less than
eight hours. The dietitian shall:
      (i) be currently licensed under the laws of this state
to use the titles of licensed dietitian or provisional licensed dietitian,
or be a registered dietitian;
      (ii) maintain standards for professional practice;
      (iii) supervise the nutritional aspects of patient
      (iv) make an assessment of the nutritional status and
adequacy of nutritional regimen, as appropriate;
      (v) provide diet counseling and teaching, as appropriate;
      (vi) document nutritional status and pertinent information
in patient medical records, as appropriate;
      (vii) approve menus; and
      (viii) approve menu substitutions.
    (C) There shall be administrative and technical personnel
competent in their respective duties. The administrative and technical
personnel shall:
      (i) participate in established departmental or facility
training pertinent to assigned duties;
      (ii) conform to food handling techniques in accordance
with paragraph (2)(E)(vii) of this subsection;
      (iii) adhere to clearly defined work schedules and
assignment sheets; and
      (iv) comply with position descriptions which are job
  (2) Director. The director shall:
    (A) comply with a position description which is job
    (B) clearly delineate responsibility and authority;
    (C) participate in conferences with administration
and department heads;
    (D) establish, implement, and enforce policies and
procedures for the overall operational components of the department
to include, but not be limited to:
      (i) quality assurance;
      (ii) frequency of meals served;
      (iii) non-routine occurrences; and
      (iv) identification of patient trays;
    (E) maintain authority and responsibility for the following,
but not be limited to:
      (i) orientation and training;
      (ii) performance evaluations;
      (iii) work assignments;
      (iv) supervision of work and food handling techniques;
      (v) procurement of food, paper, chemical, and other
supplies, to include implementation of first-in first-out rotation
system for all food items;
      (vi) menu planning; and
      (vii) ensuring compliance with §§229.161
- 229.171 of this title (relating to Texas Food Establishments).
  (3) Diets. Menus shall meet the needs of the patients.
    (A) Therapeutic diets shall be prescribed by the physician(s)
responsible for the care of the patients. The dietary department of
the facility shall:
      (i) establish procedures for the processing of therapeutic
diets to include, but not be limited to:
        (I) accurate patient identification;
        (II) transcription from nursing to dietary services;
        (III) diet planning by a dietitian;
        (IV) regular review and updating of diet when necessary;
        (V) written and verbal instruction to patient and family.
It shall be in the patient's primary language, if practicable, prior
to discharge. What is or would have been practicable shall be determined
by the facts and circumstances of each case;
      (ii) ensure that therapeutic diets are planned in writing
by a qualified dietitian;
      (iii) ensure that menu substitutions are approved by
a qualified dietitian;
      (iv) document pertinent information about the patient's
response to a therapeutic diet in the medical record; and
      (v) evaluate therapeutic diets for nutritional adequacy.
    (B) Nutritional needs shall be met in accordance with
recognized dietary practices and in accordance with orders of the
physician(s) responsible for the care of the patients. The following
requirements shall be met.
      (i) Menus shall provide a sufficient variety of foods
served in adequate amounts at each meal according to the guidance
provided in the Recommended Dietary Allowances, as published by the
Food and Nutrition Board, National Academy of Sciences, National Research
Council, Tenth edition, 1989, which may be obtained by writing the
National Academy Press, 2101 Constitution Avenue, Box 285, Washington,
D.C. 20055, telephone (888) 624-8373.
      (ii) A maximum of 15 hours shall not be exceeded between
the last meal of the day (i.e. supper) and the breakfast meal, unless
a substantial snack is provided. The facility shall adopt, implement,
and enforce a policy on the definition of "substantial" to meet each
patient's varied nutritional needs.
    (C) A current therapeutic diet manual approved by the
dietitian and medical staff shall be readily available to all medical,
nursing, and food service personnel. The therapeutic manual shall:
      (i) be revised as needed, not to exceed 5 years;
      (ii) be appropriate for the diets routinely ordered
in the facility;
      (iii) have standards in compliance with the RDA;
      (iv) contain specific diets which are not in compliance
with RDA; and
      (v) be used as a guide for ordering and serving diets.
(c) Governing body.
  (1) Legal responsibility. There shall be a governing
body responsible for the organization, management, control, and operation
of the facility, including appointment of the medical staff. For facilities
owned and operated by an individual or by partners, the individual
or partners shall be considered the governing body.
  (2) Organization. The governing body shall be formally
organized in accordance with a written constitution or bylaws which
clearly set forth the organizational structure and responsibilities.
  (3) Meeting records. Records of governing body meetings
shall be maintained.
  (4) Responsibilities relating to the medical staff.
The governing body shall:
    (A) ensure that the medical staff has current bylaws,
rules, and regulations which are implemented and enforced;
    (B) approve medical staff bylaws and other medical
staff rules and regulations;
    (C) determine, in accordance with state law and with
the advice of the medical staff, which categories of practitioners
are eligible candidates for appointment to the medical staff;
    (D) ensure that criteria for selection include individual
character, competence, training, experience, and judgment;
    (E) ensure that under no circumstances is the accordance
of staff membership or professional privileges in the facility dependent
solely upon certification, fellowship or membership in a specialty
body or society;
    (F) ensure the process for considering applications
for medical staff membership and privileges affords each candidate
for appointment procedural due process;
    (G) ensure in granting or refusing medical staff membership
or privileges, the facility does not differentiate on the basis of
the academic medical degree;
    (H) ensure that equal recognition is given to training
programs accredited by the Accreditation Council on Graduate Medical
Education and by the American Osteopathic Association if graduate
medical education is used as a standard or qualification for medical
staff membership or privileges for a physician;
    (I) ensure that equal recognition is given to certification
programs approved by the American Board of Medical Specialties and
the Bureau of Osteopathic Specialists if board certification is used
as a standard or qualification for medical staff membership or privileges
for a physician;
    (J) ensure that the medical staff is accountable to
the governing body for the quality of care provided to patients;
    (K) ensure that a facility's credentials committee
acts expeditiously and without unnecessary delay when a candidate
for appointment submits a completed application, as defined by each
hospital, for medical staff membership or privileges, in accordance
with the following:
      (i) The credentials committee shall take action on
the completed application not later than the 90th day after the date
on which the application is received;
      (ii) The governing body shall take final action on
the application for medical staff membership or privileges not later
than the 60th day after the date on which the recommendation of the
credentials committee is received; and
      (iii) The facility must notify the applicant in writing
of the facility's final action, including a reason for denial or restriction
of privileges, not later than the 20th day after the date on which
final action is taken;
    (L) ensure the facility complies with the requirements
for reporting to the Texas Medical Board the results and circumstances
of any professional review action in accordance with the Medical Practice
Act, Occupations Code, §160.002 and §160.003.
  (5) Facility administration. The governing body shall
appoint a chief executive officer or administrator who is responsible
for managing the facility.
  (6) Patient care. In accordance with facility policy,
the governing body shall ensure that: