Section 133.45 - Miscellaneous Policies and Protocols(a) Determination of death and autopsy reports. The hospital shall adopt, implement, and enforce protocols to be used in determining death and for filing autopsy reports which comply with Texas Health and Safety Code (HSC) Chapter 671.(b) Organ and tissue donors. The hospital shall adopt, implement, and enforce a written protocol to identify potential organ and tissue donors which complies with HSC Chapter 692A. The hospital shall make its protocol available to the public during the hospital's normal business hours.(1) The hospital's protocol shall include all requirements in HSC §692A.015.(2) A hospital which performs organ transplants shall be a member of the Organ Procurement and Transplantation Network in accordance with 42 United States Code § 274.(c) Discrimination prohibited. A licensed hospital shall not discriminate based on a patient's disability and shall comply with HSC Chapter 161, Subchapter S.(d) All-hazard disaster preparedness. (1) Definitions. (A) Adult intensive care unit (ICU)--Can support critically ill or injured patients, including ventilator support.(B) Burn or burn ICU--Either approved by the American Burn Association or self-designated. (These beds should not be included in other ICU bed counts.)(C) Medical/surgical--Also thought of as "ward" beds.(D) Negative pressure/isolation--Beds provided with negative airflow, providing respiratory isolation. Note: This value may represent available beds included in the counts of other types.(E) Operating rooms--An operating room that is equipped and staffed and could be made available for patient care in a short period.(F) Pediatric ICU--The same as adult ICU, but for patients 17 years and younger.(G) Pediatrics--Ward medical/surgical beds for patients 17 years and younger.(H) Physically available beds--Beds that are licensed, physically set up, and available for use. These are beds regularly maintained in the hospital for the use of patients, which furnish accommodations with supporting services (such as food, laundry, and housekeeping). These beds may or may not be staffed but are physically available.(I) Psychiatric--Ward beds on a closed or locked psychiatric unit or ward beds where a patient will be attended by a sitter.(J) Staffed beds--Beds that are licensed and physically available for which staff members are available to attend to the patient who occupies the bed. Staffed beds include those that are occupied and those that are vacant.(K) Vacant/available beds--Beds that are vacant and to which patients can be transported immediately. These must include supporting space, equipment, medical material, ancillary and support services, and staff to operate under normal circumstances. These beds are licensed, physically available, and have staff on hand to attend to the patient who occupies the bed.(2) A hospital shall adopt, implement, and enforce a written plan for all-hazard, natural or man-made, disaster preparedness for effective preparedness, mitigation, response, and recovery from disasters.(3) The plan, which may be subject to review and approval by the Texas Health and Human Services Commission (HHSC), shall be sent to the local disaster management authority.(4) The plan shall: (A) be developed through a joint effort of the hospital governing body, administration, medical staff, hospital personnel and emergency medical services partners;(B) include the applicable information contained in the:(i) National Fire Protection Association 99, Standard for Health Care Facilities, 2002 edition, Chapter 12, published by the National Fire Protection Association; and(ii) the State of Texas Emergency Management Plan, which is available from the city or county emergency management coordinator;(C) contain the names and contact numbers of city and county emergency management officers and the hospital water supplier;(D) be exercised at least annually and in conjunction with state and local exercises;(E) include the methodology for notifying the hospital personnel and the local disaster management authority of an event that will significantly impact hospital operations;(F) include evidence that the hospital has communicated prospectively with the local utility and phone companies regarding the need for the hospital to be given priority for the restoration of utility and phone services and a process for testing internal and external communications systems regularly;(G) include the use of a Texas Department of State Health Services (DSHS) approved process to update bed availability, as follows:(i) as requested by DSHS during a public health emergency or state declared disaster; and(ii) for the physically available beds and staffed beds that are vacant/available beds for the following bed types: (IV) negative pressure/isolation;(iii) for emergency department divert status;(iv) for decontamination facility available; and(v) for ventilators available;(H) include at a minimum: (i) a component for the reception, treatment, and disposition of casualties that can be used in the event that a disaster situation requires the hospital to accept multiple patients, which shall include at a minimum:(I) process, developed in conjunction with appropriate agencies, to allow essential healthcare workers and personnel to safely access their delivery care sites;(II) procedures for the appropriate provision of personal protection equipment for and appropriate immunization of staff, volunteers, and staff families; and(III) plan to provide food and shelter for staff and volunteers as needed throughout the duration of response;(ii) an evacuation component that can be engaged in any emergency situation necessitating either a full or partial evacuation of the hospital, which shall address at a minimum: (I) activation, including who makes the decision to activate and how it is activated;(II) when within control of the hospital, patient evacuation destination, including protocol to ensure that the patient destination is compatible to patient acuity and health care needs, plan for the order of removal of patients and planned route of movement, train and drill staff on the traffic flow and the movement of patients to a staging area, and room evacuation protocol;(III) family or responsible party notification, including the procedure to notify patient emergency contacts of an evacuation and the patient's destination; and(IV) transport of records and supplies, including the protocol for the transfer of patient specific medications and records to the receiving facility, which shall include at a minimum:(-a-) the patient's most recent physician's assessment;(-c-) medication administration record (MAR);(-d-) patient history with physical documentation; and(-e-) a weather-proof patient identification wrist band (or equivalent identification), which must be intact on all patients.(5) Hospitals participating in an exercise or responding to a real-life event under paragraph (4)(D) of this subsection shall develop an after-action report (AAR) within 60 days. The hospital shall retain the AARs for at least three years and make them available for review by the local emergency management authority and HHSC.(e) Voluntary paternity establishment services. A hospital that handles the birth of newborns must provide voluntary paternity establishment services in accordance with: (2) the rules of the Office of the Attorney General found at 1 Texas Administrative Code Chapter 55, Subchapter J (relating to Voluntary Paternity Acknowledgment Process).(f) Harassment and abuse. A hospital shall adopt, implement, and enforce a written policy for identifying and addressing instances of alleged verbal or physical abuse or harassment of hospital employees or contracted personnel by other hospital employees or contracted personnel or by a health care provider who has clinical privileges at the hospital.(g) Information for parents of newborn children. A hospital that provides prenatal care to a pregnant woman during gestation or at delivery of an infant, shall adopt, implement, and enforce written policies to ensure compliance with HSC §161.501.(1) The policy shall require that the woman and the father of the infant, if possible, or another adult caregiver for the infant, be provided with a resource pamphlet which includes: (A) a list of the names, addresses, and phone numbers of professional organizations providing counseling and assistance relating to postpartum depression and other emotional trauma associated with pregnancy and parenting;(B) information regarding the prevention of shaken baby syndrome, as specified under HSC §161.507(a)(1)(B)(i) - (iv);(C) a list of diseases for which a child is required by state law to be immunized and the appropriate schedule for the administration of those immunizations;(D) the appropriate schedule for follow-up procedure for newborn screening;(E) information regarding sudden infant death syndrome, including current recommendations for infant sleeping conditions to lower the risk of sudden infant death syndrome;(F) educational information in both English and Spanish on: (i) pertussis disease and the availability of a vaccine to protect against pertussis, including information on the Centers for Disease Control and Prevention recommendation that parents receive Tdap during the postpartum period to protect newborns from the transmission of pertussis; and(ii) the incidence of cytomegalovirus, birth defects caused by congenital cytomegalovirus, and available resources for the family of an infant born with congenital cytomegalovirus; and(G) the danger of heatstroke for a child left unattended in a motor vehicle.(2) If the woman is a recipient of medical assistance under Texas Human Resources Code Chapter 32, the policy must require the hospital to provide the woman and the father of the infant, if possible, or another adult caregiver with a resource guide that includes information in both English and Spanish relating to the development, health, and safety of a child from birth until age five, including information relating to: (A) selecting and interacting with a primary health care practitioner and establishing a "medical home" for the child;(E) the importance of reading to a child;(F) expected developmental milestones;(G) health care resources available in the state;(H) selecting appropriate child care; and(I) other resources available in the state;(3) The policy shall include a requirement that it be documented in the woman's record that the information was provided, and that the documentation be maintained for at least five years.(h) Abortion. A hospital that performs abortions shall adopt, implement, and enforce policies to:(1) ensure compliance with HSC Chapter 171;(2) ensure compliance with Texas Occupations Code § 164.052(a)(19).(i) Influenza and pneumococcal vaccine for elderly persons. The hospital shall adopt, implement, and enforce a policy for providing influenza and pneumococcal vaccines for elderly persons. The policy shall:(1) establish that an elderly person, defined as 65 years of age older, who is admitted to the hospital for a period of 24 hours or more, is informed of the availability of the influenza and pneumococcal vaccines, and, if they request the vaccine, is assessed to determine if receipt of the vaccine is in their best interest; and(2) include provisions that if the vaccines requested by the elderly person under paragraph (1) of this subsection are determined appropriate by the physician or other qualified medical personnel, the elderly person shall receive the vaccines prior to discharge from the hospital;(3) include provisions that the influenza vaccine shall be made available in October and November, and if available, December, and pneumococcal vaccine shall be made available throughout the year;(4) require that the person administering the vaccine ask the elderly patient if they are currently vaccinated against influenza or pneumococcal disease, assess potential contraindications, and then, if appropriate, administer the vaccine under approved hospital protocols; and(5) address required documentation of the vaccination in the patient medical record.(6) HHSC may waive requirements related to the administration of the vaccines based on established shortages of the vaccines.(j) Human trafficking signage required. A licensed hospital shall comply with human trafficking signage requirements in accordance with HSC §241.011.(k) Prohibited discharge of patients to certain group-centered facilities. A hospital shall comply with HSC §256.003. (1) Except as provided by paragraph (2) of this subsection, a hospital may discharge or release a patient to a group home, boarding home facility, or similar group-centered facility only if the person operating the group-centered facility holds a license or permit issued in accordance with applicable state law.(2) A hospital may discharge or release a patient to a group home, boarding home facility, or similar group-centered facility operated by a person who does not hold a license or permit issued in accordance with applicable state law only if: (A) there is no group-centered facility operated in the county where the patient is discharged that is operated by a person holding the applicable license or permit; or(B) the patient voluntarily chooses to reside in the group-centered facility operated by an unlicensed or unpermitted person.(l) Basic sexual assault forensic evidence collection training. A hospital shall develop, implement, and enforce policies and procedures to ensure a person who performs a forensic medical examination on a survivor of sexual assault completes the required forensic evidence collection training or equivalent education required by HSC §323.0045.(m) Basic sexual assault response policy and training. A hospital shall develop, implement, and enforce policies and procedures to provide basic sexual assault response training that meets the requirements under HSC §323.0046 to facility employees who provide patient admission functions, patient-related administrative support functions, or direct patient care.25 Tex. Admin. Code § 133.45
The provisions of this §133.45 adopted to be effective June 21, 2007, 32 TexReg 3587; amended to be effective September 14, 2014, 39 TexReg 7140; Amended by Texas Register, Volume 46, Number 53, December 31, 2021, TexReg 9304, eff. 1/6/2022; Amended by Texas Register, Volume 49, Number 52, December 27, 2024, TexReg 10647, eff. 12/31/2024