PART 1. DEPARTMENT OF STATE HEALTH SERVICES

CHAPTER 157. EMERGENCY MEDICAL CARE

The Executive Commissioner of the Texas Health and Human Services Commission (HHSC), on behalf of the Department of State Health Services (DSHS), proposes amendments to §157.2, concerning Definitions; §157.125, concerning Requirements for Trauma Facility Designation; and §157.128, concerning Denial, Suspension, and Revocation of Trauma Facility Designation; the repeal of §157.123, concerning Regional Emergency Medical Services/Trauma Systems; §157.130, concerning Emergency Medical Services and Trauma Care System Account and Emergency Medical Services, Trauma Facilities, and Trauma Care System Fund; and §157.131, concerning Designated Trauma Facility and Emergency Medical Services Account; and new §157.123, concerning Regional Advisory Councils; §157.126, concerning Trauma Facility Designation Requirements Effective on September 1, 2025; and §157.130, concerning Funds for Emergency Medical Services, Trauma Facilities, and Trauma Care Systems, and the Designated Trauma Facility and Emergency Medical Services Account.

BACKGROUND AND PURPOSE

The purpose of the proposal is to update the content and processes with the advances, evidence-based practices, and system processes that have developed since these rules were adopted and to align with American College of Surgeons (ACS) standards. The rules also require amendments to implement legislation passed since the rules were last adopted. Senate Bill (S.B.) 330, 79th Legislature, Regular Session, 2005, amends Texas Health and Safety Code Chapter 773, Subchapter H, §773.203, requiring the development of regional stroke plans. House Bill (H.B.) 15, 83rd Legislature, Regular Session, 2013, and H.B. 3433, 84th Legislature, Regular Session, 2015, amends Texas Health and Safety Code Chapter 241, §241.183, requiring the development of perinatal care regions. S.B. 984, 87th Legislature, Regular Session, 2021, amends Texas Health and Safety Code Chapter 81, §81.027, directing the Regional Advisory Councils (RACs) to collect specific health care data. S.B. 969, 87th Legislature, Regular Session, 2021, amends Texas Health and Safety Code Chapter 81, §81.0445, requiring the RACs provide public information regarding public health disasters to stakeholders. S.B. 1397, 87th Legislature, Regular Session, 2021, amends Texas Health and Safety Code Chapter 773, §773.1141, requiring a RAC with at least one county located on the international border of Texas and at least one county adjacent to the Gulf of Mexico to track all patient transfers and the reason for the transfer out of its region.

A previous rule proposal was published in the January 19, 2024, issue of the Texas Register. The formal comment period on that proposal ended on February 20, 2024. Nearly 4,000 public comments were received. The major themes identified in the formal public comments included the following: align the trauma facility designation with the ACS standards and processes, provide 12 to 18 months for trauma facilities to prepare for the new rules before implementing the proposed rules, decrease the overall burden of cost for trauma facility designation, and decrease cost burden for the rural trauma facilities to maintain their designation.

To effectively address the public comments including implementation timelines, DSHS was required to withdraw that rule proposal. The notice providing that the proposed rules are withdrawn was published in the May 10, 2024, issue of the Texas Register. DSHS now proposes these amendments, repeals, and new rules in response to public and stakeholder comments.

SECTION-BY-SECTION SUMMARY

The proposed amendment to §157.2, concerning Definitions, integrates terminology for the RACs, emergency medical systems, trauma facilities, stroke facilities and current national standards. The definitions reflect terms for the trauma and emergency health care system, emergency medical services (EMS), trauma center management, and stroke center management.

The proposed repeal of §157.123, concerning Regional Emergency Medical Services/Trauma Systems, is replaced with new §157.123, concerning Regional Advisory Councils. New §157.123 implements H.B. 15, H.B. 3433, S.B. 330, S.B. 969, S.B. 984, and S.B. 1397, and defines additional requirements and functions of the RACs; develops a system of stroke survival, creating a process for stroke designation and regional stroke system plans; develops perinatal care regions to develop perinatal systems of care; requires a specific RAC (Lower Rio Grande Valley RAC) to track all patient transfers out of the identified RAC and the reasons for the transfer; and requires all RACs to collect specific health care data to facilitate emergency response planning and preparedness and to provide public information regarding public health disasters to stakeholders. Figure 25 TAC §157.123(c) is deleted.

The proposed amendment to §157.125, concerning Requirements for Trauma Facility Designation, clarifies that all designation surveys conducted on or before August 31, 2025, will meet the requirements of §157.125, allows a facility under a multi-location license to not be designated, and includes other clarifying changes. The following figures are deleted.

Figure: 25 TAC §157.125(x)

Figure: 25 TAC §157.125(x)(1)

Figure: 25 TAC §157.125(x)(2)

Figure: 25 TAC §157.125(y)

Figure: 25 TAC §157.125(y)(1)

Figure: 25 TAC §157.125(y)(2)

The content from figures 25 TAC §157.125(x) and 25 TAC §157.125(y) have been updated and incorporated into the rule text of §157.125(x) and §157.125(y), respectively.

Proposed new §157.126, concerning Trauma Facility Designation Requirements Effective on September 1, 2025, will apply to all designation surveys conducted on or after September 1, 2025. The section defines the requirements hospitals must meet to achieve trauma facility designation aligning with the national standards for trauma centers as outlined by the ACS; requires Level IV facilities evaluating and admitting 101 or more patients meeting National Trauma Data Back (NTDB) registry inclusion criteria meet the most current ACS criteria in addition to the state trauma requirements; and requires Level IV facilities evaluating and admitting 100 or less trauma patients meeting NTDB registry inclusion criteria meet the state trauma requirements to achieve designation.

The proposed amendment to §157.128, concerning Denial, Suspension, and Revocation of Trauma Facility Designation, updates the reasons why a facility designation may be denied, suspended, or revoked and describes the appeal process.

The proposed repeal of §157.130, concerning Emergency Medical Services and Trauma Care System Account and Emergency Medical Services, Trauma Facilities, and Trauma Care System Fund, and the proposed repeal of §157.131, concerning Designated Trauma Facility and Emergency Medical Services Account, are necessary to integrate the rule text in new §157.130, concerning Funds for Emergency Medical Services, Trauma Facilities, and Trauma Care Systems, and the Designated Trauma Facility and Emergency Medical Services Account. New §157.130 integrates the subdivision of a fund under Texas Health and Safety Code Chapter 780; reorganizes all funding requirements specific to the EMS allocation; and describes how EMS providers may contribute funds for a specified purpose within a trauma service area (TSA).

FISCAL NOTE

Christy Havel Burton, DSHS Chief Financial Officer, has determined that for each year of the first five years that the rules will be in effect, enforcing or administering the rules will not have foreseeable implications relating to costs or revenues of state or local governments.

GOVERNMENT GROWTH IMPACT STATEMENT

DSHS has determined that during the first five years that the rules will be in effect:

(1) the proposed rules will not create or eliminate a government program;

(2) implementation of the proposed rules will not affect the number of DSHS employee positions:

(3) implementation of the proposed rules will result in no assumed change in future legislative appropriations;

(4) the proposed rules will not affect fees paid to DSHS;

(5) the proposed rules will create new regulations;

(6) the proposed rules will expand existing regulations;

(7) the proposed rules will not change the number of individuals subject to the rules; and

(8) the proposed rules will not affect the state's economy.

SMALL BUSINESS, MICRO-BUSINESS, AND RURAL COMMUNITY IMPACT ANALYSIS

Christy Havel Burton has determined that there may be an adverse economic effect on small businesses, micro businesses, or rural communities relating to hospitals meeting the designation requirements due to the advances in trauma care practices, advances in technology, and clinical resource needs since the adoption of the rule in 2004. Costs are associated with complying with requirements for designation; however, designation is voluntary.

LOCAL EMPLOYMENT IMPACT

The proposed rules will not affect a local economy.

COSTS TO REGULATED PERSONS

Texas Government Code §2001.0045 does not apply to these rules because the rules are necessary to protect the health, safety, and welfare of the residents of Texas and are necessary to implement legislation that does not specifically state that §2001.0045 applies to the rules.

PUBLIC BENEFIT AND COSTS

Timothy Stevenson has determined that for each year of the first five years the rules are in effect, the public benefit includes improved trauma care, improved data reflecting trauma outcomes, improved regional system development, and advancements in the EMS/Trauma Systems by aligning the Texas trauma system to current national standards, advances in clinical care, evidence-based practice for trauma care, data management, and regional coordination.

Christy Havel Burton has also determined that for the first five years the rules are in effect, any economic costs to the persons regarding the proposed rules are related to complying with the requirements that align the Texas system with current national standards. Trauma designation is voluntary and the choice of the facility.

TAKINGS IMPACT ASSESSMENT

DSHS has determined that the proposal does not restrict or limit an owner's right to his or her property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under Texas Government Code §2007.043.

PUBLIC COMMENT

Written comments on the proposal may be submitted to EMS/Trauma Systems Section, DSHS, Attn: Proposed Trauma Rules, P.O. Box 149347, Mail Code 1876, Austin, Texas 78714-3247; street address 1100 West 49th Street, Austin, Texas 78756; or by email to DSHS.EMS-Trauma@dshs.texas.gov.

To be considered, comments must be submitted no later than 31 days after the date of this issue of the Texas Register. Comments must be (1) postmarked or shipped before the last day of the comment period, (2) hand-delivered before 5:00 p.m. on the last working day of the comment period, or (3) emailed before midnight on the last day of the comment period. If the last day to submit comments falls on a holiday, comments must be postmarked, shipped, or emailed before midnight on the following business day to be accepted. When emailing comments, please indicate "Comments on Proposed Trauma Designation Rules 21R151" in the subject line.

SUBCHAPTER A. EMERGENCY MEDICAL SERVICES - PART A

25 TAC §157.2

STATUTORY AUTHORITY

The amendment is authorized by Texas Health and Safety Code Chapter 773 (Emergency Health Care Act), which authorizes the Executive Commissioner to adopt rules to implement emergency medical services and trauma care systems; Texas Health and Safety Code Chapter 773, Subchapter G, which provides for the authority to adopt rules related to emergency medical services and trauma services; and Texas Government Code §531.0055 and Texas Health and Safety Code §1001.075, which authorize the Executive Commissioner of HHSC to adopt rules necessary for the operation and provision of health and human services by DSHS and for the administration of Texas Health and Safety Code Chapter 1001.

The amendment is authorized by Texas Government Code Chapter 531 and Texas Health and Safety Code Chapters 773 and 1001.

§157.2.Definitions.

The following words and terms, when used in this chapter, [these sections, shall] have the following meanings, unless the context clearly indicates otherwise:

(1) Abandonment--[-]Leaving a patient without appropriate medical care once patient contact has been established, unless emergency medical services personnel are following the medical director's protocols, a physician directive, or the patient signs a release; or turning the care of a patient over to an individual of lesser education when advanced treatment modalities have been initiated.

(2) Accreditation--[-]Formal recognition by a national association of a provider's service or an education program based on standards established by that association.

(3) Act--[-]Emergency Health Care [Medical Services] Act, Texas Health and Safety Code[,] Chapter 773.

(4) Active pursuit of department designation as a trauma facility--An undesignated facility recognized by the department after applying for designation as a trauma facility and has met the requirement to be eligible for uncompensated trauma care funds.

(5) Acute Stroke-Ready Level IV stroke facility--A hospital reviewed by a department-approved survey organization and meeting the national stroke standards of care for an acute stroke-ready facility as described in §157.133 of this chapter (relating to Requirements for Stroke Facility Designation).

(6) [(4)] Administrator of record [of Record] (AOR)--[-]The administrator for an emergency medical services (EMS) [(EMS) ] provider who meets the requirements of Texas Health and Safety Code[,] §773.05712 [and §773.0415].

(7) [(5)] Advanced emergency medical technician [Emergency Medical Technician] (AEMT)--[-]An individual [who is] certified by the department and [is] minimally proficient in performing the basic life support skills required to provide emergency prehospital or interfacility care and initiating and maintaining under medical supervision, certain advanced life support procedures, including intravenous therapy and endotracheal or esophageal intubation.

(8) Advanced Level II stroke facility--A hospital that completes a designation survey with a department-approved survey organization, meets the national stroke standards for Non-Comprehensive Thrombectomy Stroke Center, and meets the requirements of an Advanced Level II stroke facility as defined by §157.133 of this chapter.

(9) Advanced Level III trauma facility--A hospital surveyed by a department-approved survey organization that meets the state requirements and American College of Surgeons (ACS) standards for a Level III trauma facility as described in §157.125 of this chapter (relating to Requirements for Trauma Facility Designation Effective Through August 31, 2025 and §157.126 of this chapter (relating to Trauma Facility Designation Requirements Effective on September 1, 2025).

(10) [(6)] Advanced life support (ALS)--[-]Emergency prehospital or interfacility care that uses invasive medical acts and [which] includes [would include]ALS assessment. The provision of advanced life support must [shall] be under the medical supervision and control of a licensed physician.

[(7) Advanced life support (ALS) vehicle - A vehicle that is designed for transporting the sick and injured and that meets the requirements of §157.11(j)(2) of this title (relating to Requirements for an EMS Provider License) as an advanced life support vehicle and has sufficient equipment and supplies for providing advanced level of care based on national standards and the EMS provider's medical director approved treatment protocols.]

(11) [(8)] Advanced life support [Life Support] assessment--[-]Assessment performed by an AEMT or paramedic that qualifies [qualify ] as advanced life support based upon initial dispatch information, when it could reasonably be believed [that]the patient was suffering from an acute condition that may require advanced skills.

(12) Advanced life support vehicle--A vehicle designed for transporting the sick and injured and meeting the requirements of §157.11 of this chapter (relating to Requirements for an EMS Provider License) as an ALS vehicle and having sufficient equipment and supplies for providing an advanced level of care based on national standards and the EMS provider's medical director-approved treatment protocols.

(13) Advanced practice provider (APP)--A nurse practitioner or physician assistant reviewed and credentialed by the facility and may have additional credentialing to participate in the designation program.

(14) [(9)] Air ambulance provider--[-]A person who operates, maintains, or leases [operates/leases] a fixed-wing or rotor-wing air ambulance aircraft, equipped and staffed to provide a medical care environment on-board appropriate to the patient's needs. The term air ambulance provider is not synonymous with and does not refer to the Federal Aviation Administration (FAA) air carrier certificate holder unless the air ambulance provider maintains and controls [they also maintain and control] the medical aspects [that are] consistent with EMS provider licensure.

(15) [(10)] Ambulance--[-]A vehicle for transportation of the sick or injured patient [person] to, from, or between places of treatment for an illness or injury[,] and that provides out-of-hospital [provide out of hospital] medical care to the patient.

(16) American College of Surgeons (ACS)--The organization that sets the national standards for trauma centers, trauma verification, the National Trauma Data Standards (NTDS), National Trauma Data Bank (NTDB), Trauma Quality Improvement Program (TQIP), and regional system standards.

(17) Approved survey organization--An organization that has received department authorization to conduct designation surveys, meeting the department's designation survey guidelines and expectations.

(18) [(11)] Authorized ambulance vehicle--[-]A vehicle authorized to be operated by the licensed provider and meeting [that meets] all criteria for approval as described [listed] in §157.11(e) of this chapter [title].

(19) Bad debt--The unreimbursed cost for patient care to a hospital providing trauma care.

(20) Basic Level IV trauma facility--A hospital surveyed by a department-approved survey organization evaluating and admitting 101 or more trauma patients annually meeting NTDB registry inclusion criteria and meeting the state requirements and ACS standards, or a hospital surveyed by the department that evaluates and admits 100 or less trauma patients annually meeting NTDB registry inclusion criteria and meeting the state designation requirements for a Level IV trauma facility as described in §157.125 and §157.126 of this chapter.

(21) [(12)] Basic life support (BLS)--[-]Emergency prehospital or interfacility care that uses noninvasive medical acts. The provision of basic life support will have sufficient equipment and supplies for providing basic-level [basic- level] care based on national standards and the EMS provider's medical director-approved [director- approved] treatment protocols.

(22) [(13)] Basic life support (BLS) vehicle--[-]A vehicle [that is] designed for transporting the sick or injured and having [that has]sufficient equipment and supplies for providing basic life support based on national standards and the EMS provider's medical director-approved [director approved] treatment protocols.

[(14) Basic trauma facility - A hospital designated by the department as having met the criteria for a Level IV trauma facility as described in §157.125 of this title (relating to Requirements for Trauma Facility Designation). Basic trauma facilities provide resuscitation, stabilization, and arrange for appropriate transfer of major and severe trauma patients to a higher level trauma facility, provide ongoing educational opportunities in trauma related topics for health care professionals and the public, and implement targeted injury prevention programs.]

(23) [(15)] Bypass--[-]Direction given to a prehospital emergency medical services unit[,] by direct on-line [direct/on-line] medical control, or predetermined triage criteria[,] to pass the nearest hospital for the most appropriate [hospital/trauma ] facility. Development of bypass protocols must [Bypass protocols should] have local physician input [into their development] and [should] be reviewed through the regional performance improvement process.

(24) Calculation of the costs of uncompensated trauma care--A calculation of a hospital's total costs of uncompensated trauma care for patients meeting the hospital's trauma activation guidelines and meeting NTDB registry inclusion criteria determined by summing its charges related to uncompensated trauma care as defined in §157.130 of this chapter (relating to Funds for Emergency Medical Services, Trauma Facilities, and Trauma Care Systems, and the Designated Trauma Facility and Emergency Services Account), then applying the cost-to-charge ratio derived in accordance with generally accepted accounting principles.

(25) [(16)] Candidate--[-]An individual [who is] requesting emergency medical services personnel certification,[or] licensure, recertification, or re-licensure from the department [Texas Department of State Health Services].

(26) [(17)] Certificant--[-]Emergency medical services personnel with current certification from the department [Texas Department of State Health Services].

(27) Charity care--The unreimbursed cost to a hospital providing health care services for an inpatient, emergency department, transferred, or expired person classified by the hospital as "financially indigent."

(28) Commissioner--The commissioner of the Texas Department of State Health Services.

(29) Comprehensive Level I stroke facility--A hospital surveyed by a department-approved survey organization meeting the national standards of care for a Comprehensive Stroke Center, participates in its local Regional Advisory Council (RAC), participates in the regional stroke plan, and submits data to the department, as requested as defined by §157.133 of this chapter.

(30) [(18)] Comprehensive Level I trauma facility--[-]A hospital surveyed by a department-approved survey organization meeting the state designation requirements and ACS standards [designated by the department as having met the criteria] for a Level I trauma facility as described in §157.125 and §157.126 of this chapter [§157.125 of this title]. [Comprehensive trauma facilities manage major and severe trauma patients, provide ongoing educational opportunities in trauma related topics for health care professionals and the public, implement targeted injury prevention programs, and conduct trauma research.]

(31) Concurrent performance improvement--Performance improvement reviews occurring from prehospital, trauma activation, or admission through to discharge. The primary level of review must be completed within 14 days of discharge, 80 percent of the time.

(32) Concurrent trauma registry abstraction--Trauma registry data abstraction and registry data entry occurring during the hospital evaluation and admission and completed within 60 days after the patient's discharge, 80 percent of the time.

(33) Consumer Protection Division (CPD)--A division within the Texas Department of State Health Services responsible for the oversight of EMS provider licensure, certification, education, and complaint investigation. The division is responsible for the hospital designation process for trauma, stroke, maternal, and neonatal facilities; the RAC system development and advances; and funding, grant management, and distribution of funding for the division.

(34) Contingent designation--A designation awarded to a facility with one to three unmet designation requirements. The department develops a corrective action plan (CAP) for the facility and the facility must complete this plan and meet requirements to remain designated. Contingent designations may require a focused survey to validate requirements are met. The facility must demonstrate requirements are met to maintain designation.

(35) Contingent probationary designation--A designation awarded to a facility with four or more unmet designation requirements. The department develops a CAP for the facility and the facility must complete this plan and meet requirements to remain designated. The facility may be required to submit documentation reflecting the CAP to the department at defined intervals. Contingent probationary designation may require a full survey within 12 to 18 months after the original survey date. The facility must demonstrate requirements are met to maintain designation.

(36) Corrective action plan (CAP)--A plan for the facility developed by the department describing the actions the facility is required to correct.

(37) Cost-to-charges ratio--A ratio covering all applicable hospital costs and charges relating to inpatient care determined by the Texas Health and Human Services Commission from the hospital's Medicaid cost report.

(38) County of licensure--The county in which the physical address of a licensed EMS provider is located, as indicated by the provider on the application for licensure that is filed with the department.

(39) [(19)] Course medical director--[-]A Texas-licensed [Texas licensed] physician, approved by the department, with experience in and current knowledge of emergency care who must [shall] provide direction over all instruction and clinical practice required in EMS training courses.

(40) [(20)]Credit hour--[-]Continuing education credit unit awarded for successful completion of a unit of learning activity as defined in §157.32 of this chapter [title] (relating to Emergency Medical Services [EMS] Education Program and Course Approval).

(41) [(21)]Critically injured person--An individual[-A person] suffering [major or severe trauma,] with multi-system [severe multi system] injuries or major single-system [unisystem ] injury; the extent of the injury may be difficult to ascertain[,] but [which] has the potential of producing mortality or major disability. Retrospectively, typically defined with an injury severity score (ISS) of 25 or greater.

[(22) Current - Within active certification or licensure period of time.]

(42) Definitive care--The phase of care in which therapeutic interventions, treatments, or procedures are performed to stop or control an injury, illness, or disease and promote recovery.

(43) [(23)] Department--[-]The Texas Department of State Health Services.

(44) Designated facility administrator--Administrator responsible for the oversight, funding, contracts, and leadership of designated programs.

(45) [(24)] Designated infection control officer--[-]A designated officer who serves as a liaison between the employer [employer's] and the employees who have been or believe to [they ] have been exposed to a potentially life-threatening infectious disease[,] through a person who was treated or [and/or] transported[,] by the EMS provider.

(46) [(25)] Designation--[-]A formal recognition by the department of a hospital's [trauma care] capabilities, [and] commitment, care practices, and participation in the RAC to serve as a designated facility.

(47) Designation appeal--The process for a hospital that has been downgraded or denied a specific level of designation to appeal the designation decision.

(48) Designation survey--An on-site or virtual review of a facility applicant to determine if it meets the criteria for a particular level of designation.

(49) Dispatch--The sending of individuals and equipment by EMS for assessment, prompt efficient treatment, and transportation, if required, of a sick or injured patient.

(50) [(26)] Distance learning-- [-]A method of learning remotely without being in regular face-to-face contact with an instructor in the classroom.

(51) [(27)] Diversion--[ -]A procedure put into effect by a health care [trauma ] facility notifying EMS [to ensure appropriate patient care] when that facility is unable to provide the level of care demanded by a [trauma] patient's injuries or condition due to lack of capacity or capabilities, or when the facility has temporarily exhausted its resources and requesting patients be transported to another facility.

(52) [(28)] Emergency call--[-]A [new] call or other similar communication from a member of the public, as part of a 9-1-1 system or other emergency access communication system, made to obtain emergency medical services.

(53) [(29)] Emergency care attendant (ECA)--[-]An individual who is certified by the department as minimally proficient in performing [to provide] emergency prehospital care by providing initial aid that promotes comfort and avoids aggravation of an injury or illness.

(54) [(30)] Emergency medical services (EMS)--[-]Services used to respond to an individual's perceived need for medical care and to prevent death or aggravation of physiological or psychological illness or injury.

(55) EMS medical director--The licensed physician who provides medical supervision to the EMS personnel of a licensed EMS provider or a recognized first responder organization (FRO) under the terms of the Medical Practice Act (Texas Occupations Code Chapters 151 - 165) and rules promulgated by the Texas Medical Board; may also be called "off-line medical control."

(56) [(31)] Emergency medical services [(EMS)] operator--An individual[-A person] who, as an employee of a public or private agency, [as that term is defined by Health and Safety Code, §771.001,] receives emergency calls and may provide medical information or medical instructions to the public during those emergency calls.

[(32) Emergency medical services and trauma care system - An arrangement of available resources that are coordinated for the effective delivery of emergency health care services in geographical regions consistent with planning and management standards.]

(57) [(33)] Emergency medical services [(EMS)] personnel--[-]

(A) emergency care attendant (ECA);

(B) emergency medical technician (EMT);

(C) advanced emergency medical technician (AEMT);

[(D) emergency medical technician intermediate (EMT-I); or]

(D) [(E)] emergency medical technician-paramedic (EMT-P); or

(E) [(F)] licensed paramedic (LP).

(58) [(34)] Emergency medical services[(EMS)] provider--[-]A person who uses, operates, or maintains EMS vehicles and EMS personnel to provide emergency medical services [EMS. See §157.11 of this title regarding fee exemption].

(59) Emergency medical services times--

(A) Time of call--The date and time a phone rings at a public safety answering point (PSAP) or other designated entity, requesting EMS services.

(B) Dispatch time--The date and time a responding EMS provider is notified by dispatch.

(C) En route--The date and time the EMS vehicle starts moving to respond.

(D) On scene--The date and time a responding EMS vehicle stops moving when it arrives at the location of the response.

(E) At patient side--The date and time the EMS personnel of the responding EMS vehicle arrives at the patient's side.

(F) Transport--The date and time the responding EMS vehicle leaves the location of the response and starts moving toward the destination.

(G) Arrival time--The date and time the responding EMS vehicle arrives with the patient at the destination or transfer point.

(H) Transfer of care--The date and time patient care is transferred to the destination health care staff or transfer point of health care.

(I) Back in service--The date and time the EMS vehicle is back in service and available for another response.

(60) Emergency medical services vehicle--

(A) basic life support (BLS) vehicle;

(B) advanced life support (ALS) vehicle;

(C) mobile intensive care unit (MICU) vehicle;

(D) MICU rotor-wing and MICU fixed-wing air medical vehicles; or

(E) specialized emergency medical service vehicle.

[(35) Emergency medical services (EMS) volunteer provider--An EMS provider that has at least 75% of the total personnel as volunteers and is a nonprofit organization. See §157.11 of this title regarding fee exemption.]

(61) [(36)] Emergency medical services [(EMS)] volunteer--[-]EMS personnel who provide emergency prehospital or interfacility care in affiliation with a licensed EMS provider or a registered FRO [First Responder organization] without remuneration, except for reimbursement for expenses.

(62) Emergency medical services volunteer provider--An EMS provider with at least 75 percent of personnel as volunteers and is a nonprofit organization. See §157.11 of this chapter regarding fee exemption.

(63) [(37)] Emergency medical technician (EMT)--[-]An individual [who is] certified by the department as minimally proficient in performing [to perform] emergency prehospital care [that is] necessary for basic life support and [that] includes the control of hemorrhaging and cardiopulmonary resuscitation.

(64) [(38)] Emergency medical technician-paramedic (EMT-P)--[-] An individual [who is] certified by the department as minimally proficient in performing [to provide] emergency prehospital or interfacility care in health care facility's emergency or urgent care clinical setting, including a hospital emergency room and a freestanding emergency medical care facility, by providing advanced life support that includes initiation and maintenance under medical supervision of certain procedures, including intravenous therapy, endotracheal or esophageal intubation or both, electrical cardiac defibrillation or cardioversion, and drug therapy.

[(39) Emergency medical services vehicle-]

[(A) basic life support (BLS) vehicle;]

[(B) advanced life support (ALS) vehicle;]

[(C) mobile intensive care unit (MICU);]

[(D) MICU rotor wing and MICU fixed wing air medical vehicles; or]

[(E) specialized emergency medical service vehicle.]

[(40) Emergency Medical Task Force (EMTF) - A unit specially organized to provide coordinated emergency medical response operation systems during large scale EMS incidents.]

(65) [(41)] Emergency prehospital care--[-]Care provided to the sick and injured within a health care facility's emergency or urgent care clinical setting, including a hospital emergency room and [a] freestanding emergency medical care facility, before or during transportation to a medical facility, including any necessary stabilization of the sick or injured in connection with [that]transportation.

(66) Event--A variation from the established care management guidelines or system operations such as delays in response, delays in care, hospital event such as complications, or death. An event or variation in care creates a need for review of the care or system processes to identify opportunities for improvement.

(67) Event resolution--An event, as described in paragraph (66) of this section, that is identified and reviewed to determine the impact to the patient and if opportunities for improvement in care or the system exist, with a specific action plan tracked with data analysis to demonstrate the action plan created the desired change to achieve the desired goal, and improved outcomes are sustained.

(68) Extraordinary emergency--A serious, unexpected event or situation requiring immediate action to reduce or minimize disruption to established health care services within the EMS and trauma care system.

(69) [(42)] Field [Facility ] triage--[-]The process of determining which [assigning patients to an appropriate trauma] facility is most appropriate for patients based on injury severity, time-sensitive disease factors, and facility availability. Refer to paragraph (104) of this section.

(70) Financially indigent--An uninsured or underinsured patient unable to pay for the trauma services rendered based on the hospital's eligibility system.

(71) First responder organization (FRO)--A group or association of certified EMS personnel that work in cooperation with a licensed EMS provider.

(72) [(43)] Fixed location--[-]The address as it appears on the initial or [and/or ] renewal EMS provider license application in which the patient care records and administrative departments are [offices will be] located.

[(44) General trauma facility - A hospital designated by the department as having met the criteria for a Level III and Level IV trauma facility as described in §157.125 of this title. General trauma facilities provide resuscitation, stabilization, and assessment of injury victims and either provide treatment or arrange for appropriate transfer to a higher level trauma facility, provide ongoing educational opportunities in trauma related topics for health care professionals and the public, and implement targeted injury prevention programs.]

(73) [(45)] Governmental entity--[-]A county, a city or town, a school district, or a special district or authority created in accordance with the Texas Constitution, including a rural fire prevention district, an emergency services district, a water district, a municipal utility district, and a hospital district.

(74) Governor's EMS and Trauma Advisory Council (GETAC)--An advisory council appointed by the Governor of Texas that provides professional recommendations to the EMS/Trauma System Section regarding EMS and trauma system development and serves as a forum for stakeholder input.

[(46) Health care entity - A first responder, EMS provider, physician, nurse, hospital, designated trauma facility, or a rehabilitation program.]

(75) [(47)] Inactive EMS provider status--[-]The period of time when a licensed EMS provider is not able to respond [or response ready] to an EMS [an emergency or non-emergency medical] dispatch.

(76) [(48)] Industrial ambulance--[-]Any vehicle owned and operated by an industrial facility as defined in the Texas Transportation Code[,] §541.201[,] and used for initial transport or transfer of company employees who become urgently ill or injured on company premises to an appropriate health care [medical] facility.

(77) Injury severity score (ISS)--An anatomical scoring system providing an overall score for trauma patients. The ISS standardizes the severity of trauma injuries based on the three worst abbreviated injury scales (AIS) from the body regions. These regions are the head and neck, face, chest, abdomen, extremity, and external as defined by the Association for the Advancement of Automotive Medicine (AAAM). The highest abbreviated injury score in the three most severely injured body regions have the scores squared, then added together to define the patient's ISS.

(A) ISS of 1-9 is considered moderate trauma injury.

(B) ISS of 10-15 is a major trauma injury.

(C) ISS of 16-24 is a severe trauma injury.

(D) ISS of 25 or greater is a critical trauma injury.

(78) [(49)] Interfacility care-- [-]Care provided while transporting a patient between health care [medical] facilities.

[(50) Lead trauma facility - A trauma facility which usually offers the highest level of trauma care in a given trauma service area, and which includes receipt of major and severe trauma patients transferred from lower level trauma facilities. It also includes on-going support of the regional advisory council and the provision of regional outreach, prevention, and trauma educational activities to all trauma care providers in the trauma service area regardless of health care system affiliation.]

(79) [(51)] Legal entity name-- [-]The name of the lawful or legally standing association, corporation, partnership, proprietorship, trust, or individual. Has legal capacity to:

(A) enter into agreements or contracts;

(B) assume obligations;

(C) incur and pay debts;

(D) sue and be sued in its own right; and

(E) to be accountable for illegal activities.

(80) Level of harm--A classification system defining the impact of an event to the patient and assists in defining the urgency of review. There are five levels of harm used to define the impact to the patient as defined by the American Society for Health Care Risk Management:

(A) No harm--The patient was not symptomatic or no symptoms were detected, and no treatment or intervention was required.

(B) Mild harm--The patient was symptomatic, symptoms were mild, loss of function or harm was either minimal or intermediate but short-term, and no interventions or only minimal interventions were needed.

(C) Moderate harm--The patient was symptomatic, required intervention such as additional operative procedure, therapeutic treatment, or an increased length of stay, required a higher level of care, or may experience long-term loss of function.

(D) Severe harm--The patient was symptomatic, required life-saving or other major medical or surgical intervention, or may experience shortened life expectancy, and may experience major permanent or long-term loss of function.

(E) Death harm--The event was a contributing factor in the patient's death.

(81) Levels of review--Describes the levels of performance improvement review for an event in the designation program's quality improvement or performance improvement patient safety (PIPS) plan. There are four levels of review:

(A) Primary level of review--Initial investigation of identified events by the facility's designation program performance improvement personnel to capture the event details and to validate and document the timeline, contributing factors, and level of harm. The program manager usually addresses system issues with no level of harm, including identifying the opportunities for improvement and action plan appropriate for the event, and keeping the program medical director updated. This must be written in the facility's performance improvement plan.

(B) Secondary level of review--The level of review by the facility's designation program medical director in which the program personnel prepare the documentation and facts for the review. The program medical director reviews the documentation and either agrees or corrects the level of harm, defines the opportunities for improvement with action plans, or refers to the next level of review.

(C) Tertiary level of review--The third level of review by the facility's designation program to evaluate care practices and compliance to defined management guidelines, identify opportunities for improvement, and define a plan of correction (POC). Minutes capturing the event, discussion, and identified opportunities for improvement with action plans must be documented.

(D) Quaternary level of review--The highest level of review, which may be conducted by an entity external to the facility program as an element of the performance improvement plan. The event, review, and discussion of the event, and identified opportunities for improvement with action plans must be documented.

(82) [(52)] Licensee--[-]A person who holds a current paramedic license from the department, [Texas Department of State Health Services (department)] or a person who uses, maintains, or operates EMS vehicles and provides EMS personnel to provide emergency medical services, [EMS] and who holds an EMS provider license from the department.

(83) [(53)] Major Level II trauma facility--[-]A hospital surveyed [designated] by a department-approved survey organization meeting the state designation requirements and ACS standards [the department as having met the criteria] for a Level II trauma facility as described in §157.125 and §157.126 of this chapter [§157.125 of this title]. [Major trauma facilities provide similar services to the Level I trauma facility although research and some medical specialty areas are not required for Level II facilities, provide ongoing educational opportunities in trauma related topics for health care professionals and the public, and implement targeted injury prevention programs.]

(84) [(54)] Major trauma patient--An individual[-A person] with injuries, or potential injuries,[severe enough to] who benefits [benefit ] from treatment at a trauma facility. The patient [These patients] may or may not present with alterations in vital signs or level of consciousness, or with obvious, significant injuries [(see severe trauma patient)], but has [they have] been involved in an event [incident which results in] that produces a high index of suspicion for significant injury and [and/or] potential disability. Co-morbid factors such as age or [and/or] the presence of significant preexisting medical conditions [problems should] are also [be] considered. The patient initiates a system [These patients should initiate a system's or health care entity's trauma] response to[,] include field [including prehospital] triage to the most appropriate [a] designated trauma facility. For performance improvement purposes, the patient is [these patients are] also identified retrospectively by an ISS of 10-15 [injury severity score of 9 or above].

(85) [(55)] Medical control--[-]The supervision of prehospital EMS [emergency medical service] providers and FROs by a licensed physician. This encompasses on-line (direct voice contact) and off-line (written protocol and procedural review).

[(56) Medical Director - The licensed physician who provides medical supervision to the EMS personnel of a licensed EMS provider or a recognized First Responder Organization under the terms of the Medical Practices Act (Occupations Code, Chapters 151 - 165 and rules promulgated by the Texas Medical Board. Also may be referred to as off-line medical control.]

(86) [(57)] Medical oversight-- [-]The assistance and management given to health care providers and [and/or] entities involved in regional EMS/trauma systems planning by a physician or group of physicians designated to provide technical assistance to the EMS provider or FRO medical director.

(87) [(58)] Medical supervision--[-]Direction given to EMS [emergency medical services] personnel by a licensed physician under the terms of the Medical Practice Act[,] (Texas Occupations Code[,] Chapters 151 - 165) and rules promulgated by the Texas Medical Board[pursuant to the terms of the Medical Practice Act].

(88) [(59)] Mobile intensive care unit [(MICU)]--[-]A vehicle [that is] designed for transporting the sick or injured, [and that] meeting [meets] the requirements of the advanced life support vehicle, and [which] having [has] sufficient equipment and supplies to provide cardiac monitoring, defibrillation, cardioversion, drug therapy, and two-way communication with at least one paramedic on the vehicle when providing EMS.

(89) National EMS Compact--The agreement among states to allow the day-to-day movement of EMS personnel across state boundaries.

(90) National EMS Information System (NEMSIS)--A universal standard for how patient care information resulting from an EMS response is collected.

(91) National Trauma Data Bank (NTDB)--The national repository for trauma registry data, defined by the ACS with inclusion criteria and data elements required for submission.

(92) National Trauma Data Standards (NTDS)--The American College of Surgeons' standard data elements with definitions required for submission to the NTDB, as defined in paragraph (91) of this section.

(93) Non-contiguous emergency department--A hospital emergency department located in a separate building, not contiguous with the designated facility. May be referred to as a satellite emergency department.

(94) [(60)]Off-line medical director [direction]-- [-]The licensed physician who provides approved protocols and medical supervision to the EMS personnel of a licensed EMS provider under the terms of the Medical Practice [Practices] Act (Texas Occupations Code[,] Chapters 151 - 165) and [a] rules promulgated by the Texas Medical Board [(22 Texas Administrative Code, §197.3)].

(95) [(61)] On-line [Online] course--[-]A directed learning process[,] comprised of educational information (articles, videos, images, web links), communication (messaging, discussion forums) for virtual learning, [with a process] and [some way to] measures [measure] to evaluate the student's [students'] knowledge.

(96) [(62)] Operational name--[-]Name under which the business or operation is conducted and presented to the world.

(97) [(63)] Operational policies--[-]Policies and procedures that [which ] are the basis for the provision of EMS and that [which] include[, but are not limited to] such areas as vehicle maintenance;[,] proper maintenance and storage of supplies, equipment, medications, and patient care devices; complaint investigations [investigation];[,] multi-casualty [multicasualty] incidents;[,] and hazardous materials; but do not include personnel or financial policies.

(98) Operations Committee--Committee serving as the facility's trauma program administrative oversight for designation and responsible for the approval of trauma management guidelines, operational plan, and procedures within the program or system having the potential to impact care practices or designation.

(99) Operative or surgical intervention--Any surgical procedure provided to address trauma injuries for patients taken directly from the scene, emergency department, or other hospital location to an operating suite for patients meeting the hospital's trauma activation guidelines and meeting NTDB registry inclusion criteria.

(100) [(64)] Out of service vehicle --[-]The period of time when a licensed EMS [Provider] vehicle is unable to respond to [ or be response ready for] an emergency or non-emergency response.

(101) Performance improvement and patient safety (PIPS) plan--The written plan and processes for evaluating patient care, system response, and adherence to established patient management guidelines; defining variations from care or system response; assigning the level of harm and level of review; identifying opportunities for improvement; and developing the CAP. The CAP outlines data analysis and measures to track the action plan to ensure the desired changes are met and maintained to resolve the event. The medical director, program manager, and administrator have the authority and oversight over PIPS.

(102) Plan of correction (POC)--A report submitted to the department by the facility detailing how the facility will correct one or multiple requirements defined as "not met" during a trauma designation survey review that is reported in the survey summary or documented in the self-attestation.

(103) Practical exam--An evaluation that assesses the person's ability to perceive instructions and perform motor responses, also referred to as a psychomotor exam.

[(65) Person - An individual, corporation, organization, government, governmental subdivision or agency, business, trust, partnership, association, or any other legal entity.]

(104) [(66)] Prehospital triage--[-]The process of identifying medical or injury [medical/injury] acuity or the potential for severe injury based upon physiological criteria, injury patterns, and [and/or ] high-energy mechanisms and transporting patients to a facility appropriate for the [their] patient's medical or injury [medical/injury] needs. Prehospital triage for injured patients or time-sensitive disease events [injury victims] is guided by the approved prehospital triage [protocol adopted] guidelines adopted by the RAC [regional advisory council (RAC)] and approved by the department. May also be referred to as "field triage" or "prehospital field triage."

[(67) Practical exam - Sometime referred to as psychomotor, is an exam that assesses the subject's ability to perceive instructions and perform motor responses.]

(105) Primary EMS provider response area--The geographic area in which an EMS agency routinely provides emergency EMS as agreed upon by a local or county governmental entity or by contract.

(106) Primary Level III stroke facility--A hospital designated by the department and meets the department-approved national stroke standards of care for a primary stroke center, participates in its RAC, participates in the regional stroke plan, and submits data as requested by the department.

(107) [(68)] Protocols--[-]A detailed, written set of instructions by the EMS provider's [Provider] medical director, which may include delegated standing medical orders, to guide patient care or the performance of medical procedures as approved.

[(69) Primary EMS provider response area - The geographic area in which an EMS agency routinely provides emergency EMS as agreed upon by a local or county governmental entity or by contract.]

(108) [(70)] Public safety answering point (PSAP)--[-]The call center responsible for answering calls to an emergency telephone number for ambulance services; sometimes called "public safety access point[,]" or "dispatch center."

(109) [(71)] Quality management--[-]Quality assessment [assurance], quality improvement, and [and/or] performance improvement activities. See definition of PIPS in paragraph (101) of this section.

(110) Receiving facility--A health care facility to which an EMS vehicle may transport a patient requiring prompt continuous medical care, or a facility receiving a patient being transferred for definitive care.

(111) Recertification--The procedure for renewal of EMS certification.

(112) Reciprocity--The recognition of certification or privileges granted to an individual from another state or recognized EMS system.

(113) [(72)] Regional Advisory Council (RAC)--[-An]A nonprofit organization [serving as the Department of State Health Services] recognized by the department and responsible for system coordination [health care coalition responsible] for the development, implementation, and maintenance of the regional trauma and emergency health care system within its [the]geographic jurisdiction of the Trauma Service Area. A RAC [Regional Advisory Council] must maintain [§]501(c)(3) status.

[(73) Regional EMS/trauma system - A network of healthcare providers within a given trauma service area (TSA) collectively focusing on traumatic injury as a public health problem, based on the given resources within each TSA.]

(114) Regional Advisory Council Performance Improvement Plan--A written plan of the RAC's processes to review identified or referred events, identify opportunities for improvement, define action plans and data required to correct the event, and establish measures to evaluate the action plan through to event resolution.

(115) [(74)]Regional medical control--[-]Physician supervision for prehospital EMS [emergency medical services (EMS)] providers in a given trauma service area (TSA) or other geographic area intended to provide standardized oversight, treatment, and transport guidelines, which should, at minimum, follow the RAC's [regional advisory council's] regional EMS/trauma system plan components related to these issues and 22 Texas Administrative Code[,] §197.3 (relating to Off-line Medical Director).

[(75) Recertification - The procedure for renewal of emergency medical services certification.]

[(76) Receiving facility - A facility to which an EMS vehicle may transport a patient who requires prompt continuous medical care.]

[(77) Reciprocity - The recognition of certification or privileges granted to an individual from another state or recognized EMS system.]

(116) [(78)] Relicensure--[-]The procedure for renewal of a paramedic license as described in §157.40 of this chapter [title] (relating to Paramedic Licensure); the procedure for renewal of an EMS provider license as described in §157.11 of this chapter [title].

(117) [(79)] Response pending status--[-]The status of an EMS vehicle that just delivered a patient to a final receiving facility[,] and for which the dispatch center has another EMS response waiting [that EMS vehicle].

(118) [(80)] Response ready--[-]When an EMS vehicle is equipped and staffed in accordance with §157.11 of this chapter [title (relating to Requirements for a Provider License)] and is immediately available to respond to any emergency call 24-hours [24 hours] per day, seven days per week (24/7).

(119) Rural county--A county with a population of less than 50,000 based on the latest estimated federal census population figures.

(120) [(81)] Scope of practice-- [-]The procedures, actions, and processes [that an] EMS personnel are authorized to perform as [permitted to undertake in keeping with the terms of their professional license or certification and] approved by the [their] EMS provider's medical director.

(121) Scope of services--The types of services and the resources to provide those services that a facility has available.

(122) [(82)] Severe trauma patient--[-]A person with injuries or potential injuries defined as high-risk for mortality or disability and meeting trauma activation guidelines and meeting NTDB registry inclusion criteria benefitting from definitive [that require] treatment at a designated [tertiary] trauma facility. These patients may be identified by an alteration in vital signs or [and/or] level of consciousness or by the presence of significant injuries and must [shall] initiate a [system's and/or health care entity's highest] level of trauma response [including prehospital triage to a designated trauma] defined by the facility, including prehospital triage to a designated trauma facility. For performance improvement purposes, these patients are also identified retrospectively by an ISS [injury severity score] of 16-24 [15 or above].

[(83) Shall - Mandatory requirements.]

[(84) Site survey - An on-site review of a trauma facility applicant to determine if it meets the criteria for a particular level of designation.]

(123) Simulation training--Training, typically scenario-based or skill-based, utilizing simulated patients or system events to improve or assess knowledge, competencies, or skills.

(124) [(85)] Sole provider--[-]The only licensed EMS [emergency medical service] provider in a geographically contiguous service area and in which the next closest provider is greater than 20 miles from the limits of the area.

(125) [(86)] Specialized EMS [emergency medical services] vehicle--[-]A vehicle [that is] designed for responding to and transporting sick or injured persons by any means of transportation other than by standard automotive ground ambulance or rotor or fixed-wing aircraft [fixed wing air craft] and that has sufficient staffing, equipment, and supplies to provide for the specialized needs of the patient transported. This category includes[, but is not limited to,] watercrafts [water craft], off-road vehicles, and specially designed, configured, or equipped vehicles used for transporting special care patients such as critical neonatal or burn patients.

(126) [(87)] Specialty resource centers--[-]Entities caring [that care] for specific types of patients such as [trauma,] pediatric, [stroke,] cardiac, [hospitals] and burn injuries [units] that have received certification, categorization, verification, or other forms [form] of recognition by an appropriate agency regarding the [their] capability to definitively treat these types of patients.

(127) [(88)] Staffing plan--[-]A document [which] indicating [indicates ] the overall working schedule patterns of EMS or hospital personnel.

(128) [(89)] Standard of care-- [-]Care equivalent to what any reasonable, prudent person of like education or certification level would have given in a similar situation, based on [locally, regionally and nationally] documented, evidence-based practices or adopted standard EMS [emergency medical services] curricula as adopted by reference in §157.32 of this chapter; [title (relating to Emergency Medical Services Training and Course Approval)] also refers to the documented standards of care reflecting evidence-based practice.

(129) State EMS Registry--State repository for the collection of EMS response data as defined in Chapter 103 of this title (relating to Injury Prevention and Control).

(130) State Trauma Registry--Statewide database housed within the department; responsible for the collection, maintenance, and evaluation of medical and system information related to required reportable events as defined in Chapter 103 of this title.

(131) Stroke--A time-sensitive medical condition occurring when the blood supply to the brain is reduced or blocked, caused by a ruptured blood vessel or clot, preventing brain tissue oxygenation.

(132) Stroke activation--The process of mobilizing the stroke care team when a patient screens positive for stroke symptoms; may be referred to as a "stroke alert" or "code stroke."

(133) Stroke facility--A hospital that has successfully completed the designation process and is capable of resuscitating and stabilizing, transferring, or providing definitive treatment to stroke patients and actively participates in its local RAC and system plan.

(134) Stroke medical director (SMD)--A physician meeting the department's requirements for the stroke medical director and having the authority and oversight for the stroke program, including the performance improvement process, data management, and outcome reviews.

(135) Stroke program manager (SPM)--A registered nurse meeting the requirements for the stroke program manager and having the authority and oversight for the stroke program, including the performance improvement process, data management, and outcome reviews.

(136) [(90)] Substation--[ -]An EMS provider station location, [that is] not the fixed station, and [which is] likely to provide rapid access to a location to which the EMS vehicle may be dispatched.

(137) Telemedicine medical service--A health care service delivered by a physician licensed in this state, or a health professional acting under the delegation and supervision of a physician licensed in this state, and acting within the scope of the physician's or health professional's license to a patient at a different physical location than the physician or health professional using telecommunications or technology as defined in Texas Occupations Code §111.001.

(138) Transport mode--As documented on the patient care record, the usage of emergency warning equipment when responding to an EMS dispatch and when transporting a patient to a receiving facility.

(139) [(91)] Trauma--[-]An injury or wound to a living body caused by the application of an external force or violence, including burn injuries, and meeting the trauma program's trauma activation guidelines[. Poisonings, near-drownings and suffocations, other than those due to external forces are to be excluded from this definition].

(140) Trauma activation guidelines--Established criteria identifying the potential injury risk to the human body and defining the resources and response times required to evaluate, resuscitate, and stabilize the trauma patient. The guidelines must meet the national recommendations, but each trauma program defines the activation guidelines for the facility. The facility may choose to have one activation level, two activation levels, or three activation levels.

(A) The highest level of trauma activation is commonly based on physiological changes in the patient's level of consciousness, airway or potential respiratory compromise, hypotension or signs of shock, significant hemorrhage, or evidence of severe trauma.

(B) The second level of trauma activation is commonly based on the patient's physiological stability with anatomical injuries or mechanisms of injury having the potential for serious injuries.

(C) The third level of trauma activation is designed for low-energy or single-system injuries that may require specialty service evaluation and intervention.

(141) Trauma administrator--Administrator responsible for the facility oversight, funding, contracts, and collaborative leadership of the program, and serves as an interface with the chief executive team as defined by the facility's organizational structure.

(142) Trauma and emergency health care system plan--The inclusive system that refers to the care rendered after a traumatic injury or time-sensitive disease or illness where the optimal outcome is the critical determinant. The system components encompass special populations, epidemiology, risk assessments, surveillance, regional leadership, system integration, business or finance models, prehospital care, definitive care facilities, system coordination for patient flow, prevention and outreach, rehabilitation, emergency preparedness and response, system performance improvement, data management, and research. These components are integrated into the regional self-assessment and system plan.

(143) Trauma care--Care provided to an injured patient meeting the hospital's trauma activation guidelines and meeting NTDB registry inclusion criteria and the continuum of care throughout the system, including discharge and follow-up care or transfer.

(144) Trauma Designation Review Committee--Committee responsible for reviewing trauma designation appeals, reviewing requirement exception and waiver requests, and outlining specific requirements not met in order to identify potential opportunities to improve future rule amendments.

(145) [(92)] Trauma facility--[-] A hospital that has successfully completed the designation process, is capable of resuscitating and stabilizing, transferring, or [stabilization and/or] providing definitive treatment to patients meeting trauma activation criteria, [of critically injured persons] and actively participates in its local RAC [a regional EMS/trauma] and the RAC system plan development.

(146) Trauma medical director (TMD)--A physician meeting the requirements and demonstrating the competencies and leadership for the oversight and authority of the trauma program as defined by the level of designation and having the authority and oversight for the trauma program, including the performance improvement and patient safety processes, trauma registry, data management, peer review processes, outcome reviews, and participation in the RAC and system plan development.

(147) Trauma patient--Any injured person who has been evaluated by a physician, a registered nurse, or EMS personnel, and found to require medical care in a trauma facility based on local or national medical standards.

(148) [(93)] Trauma [nurse coordinator/trauma] program manager (TPM)--[-]A registered nurse [with demonstrated interest, education, and experience in trauma care and] who[,] in partnership with the TMD [trauma medical director] and hospital administration[,] is responsible for oversight and authority [coordination] of the trauma program as defined by the level of designation, including [care at a designated trauma facility. This coordination should include active participation in] the trauma performance improvement and patient safety processes [program], trauma registry, data management, injury prevention, outreach education, outcome reviews, and research as appropriate to the level of designation [the authority to positively impact trauma care of trauma patients in all areas of the hospital, and targeted prevention and education activities for the public and health care professionals].

[(94) Trauma patient - Any critically injured person who has been evaluated by a physician, a registered nurse, or emergency medical services personnel, and found to require medical care in a trauma facility based on local, regional or national medical standards.]

(149) Trauma Quality Improvement Program (TQIP)--The ACS risk-adjusted benchmarking program using submitted data to evaluate specific types of injuries and events to compare cohorts' outcomes with other trauma centers; assisting in defining opportunities for improvement in specific patient cohorts.

(150) Trauma registrar--An individual meeting the requirements and whose job responsibilities include trauma patient data abstraction, trauma registry data entry, injury coding, and injury severity scoring, in addition to registry report writing and data management skills specific to the trauma registry and trauma program.

(151) [(95)] Trauma registry--[-]A trauma facility [statewide] database capturing required elements of trauma care for each patient. [which documents and integrates medical and system information related to the provision of trauma care by health care entities.]

(152) [(96)] Trauma service area [Service Area]--[-]Described in §157.122 of this subchapter (relating to Trauma Service Areas) [An organized geographical area of at least three counties administered by a regional advisory council for the purpose of providing prompt and efficient transportation and/or treatment of sick and injured patients].

(153) Uncompensated trauma care--The sum of "charity care" and "bad debt." Contractual adjustments in reimbursement for trauma services based upon an agreement with a payor (including Medicaid, Medicare, Children's Health Insurance Program (CHIP), or other health insurance programs) are not uncompensated trauma care.

(154) Urban county--A county with a population of 50,000 or more based on the latest estimated federal census population figures.

(155) Verification--Process used by the ACS to review a facility seeking trauma verification to validate the defined standards are met with documented compliance for successful trauma center verification. If a Level I or Level II facility is not verified by the ACS, the department cannot designate the facility.

(156) [(97)] When in service--[-]The period of time when an EMS vehicle is responding to an EMS dispatch, at the scene, or en route [when enroute] to a facility with a patient.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on July 18, 2024.

TRD-202403177

Cynthia Hernandez

General Counsel

Department of State Health Services

Earliest possible date of adoption: September 1, 2024

For further information, please call: (512) 535-8538

25 TAC §§157.123, 157.130, 157.131

STATUTORY AUTHORITY

The repeals are authorized by Texas Health and Safety Code Chapter 773 (Emergency Health Care Act), which authorizes the Executive Commissioner to adopt rules to implement emergency medical services and trauma care systems; Texas Health and Safety Code Chapter 773, Subchapter G, which provides for the authority to adopt rules related to emergency medical services and trauma services; and Texas Government Code §531.0055 and Texas Health and Safety Code §1001.075, which authorize the Executive Commissioner of HHSC to adopt rules necessary for the operation and provision of health and human services by DSHS and for the administration of Texas Health and Safety Code Chapter 1001.

The repeals are authorized by Texas Government Code Chapter 531 and Texas Health and Safety Code Chapters 773 and 1001.

§157.123.Regional Emergency Medical Services/Trauma Systems.

§157.130.Emergency Medical Services and Trauma Care System Account and Emergency Medical Services, Trauma Facilities, and Trauma Care System Fund.

§157.131.Designated Trauma Facility and Emergency Medical Services Account.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on July 18, 2024.

TRD-202403178

Cynthia Hernandez

General Counsel

Department of State Health Services

Earliest possible date of adoption: September 1, 2024

For further information, please call: (512) 535-8538

STATUTORY AUTHORITY

The amendments and new sections are authorized by Texas Health and Safety Code Chapter 773 (Emergency Health Care Act), which authorizes the Executive Commissioner to adopt rules to implement emergency medical services and trauma care systems; Texas Health and Safety Code Chapter 773, Subchapter G, which provides for the authority to adopt rules related to emergency medical services and trauma services; and Texas Government Code §531.0055 and Texas Health and Safety Code §1001.075, which authorize the Executive Commissioner of HHSC to adopt rules necessary for the operation and provision of health and human services by DSHS and for the administration of Texas Health and Safety Code Chapter 1001.

The amendments and new sections are authorized by Texas Government Code Chapter 531 and Texas Health and Safety Code Chapters 773 and 1001.

§157.123.Regional Advisory Councils.

(a) The department recognizes a Regional Advisory Council (RAC) as the coordinating entity for the development and advancement of the regional trauma and emergency health care system within the defined trauma service area (TSA) as described in §157.122 of this subchapter (relating to Trauma Service Areas).

(1) The department recognizes only one RAC for each TSA.

(2) Trauma, prehospital, perinatal, stroke, cardiac, disaster response, and emergency health care stakeholders in the TSA must be eligible for participation or membership in the RAC.

(b) A RAC must meet the following requirements to be recognized as a RAC:

(1) maintain incorporation as an entity exempt from federal income tax under §501(a) of the United States Internal Revenue Code of 1986, and its subsequent amendments, by being listed as an exempt organization under §501(c)(3) of the code, and to be eligible to receive, distribute, and utilize the emergency medical services (EMS), uncompensated care, and TSA allotments;

(2) submit required documentation to the department that includes, at a minimum, the following:

(A) a summary of regional trauma, prehospital, pediatric, geriatric, perinatal, stroke, cardiac, and emergency health care system activities;

(B) evidence of an annual summary of the EMS, trauma, and emergency health care system performance improvement plan; and

(C) a completed regional self-assessment by the end of each odd state fiscal year, and a current trauma and emergency health care system plan by the end of each even state fiscal year, with documented evidence the performance criteria are met;

(3) maintain external financial audits and financial statements as defined by the department; and

(4) maintain a current website to communicate with regional stakeholders.

(c) Each RAC must develop and maintain a regionally specific comprehensive trauma and emergency health care system plan. The plan must include all counties within the TSA and must be based on current industry standards and guidelines.

(1) The system plan must address the following elements:

(A) epidemiology data resources available;

(B) integration of regional stakeholders, identified coalitions, and community partners pertinent to the priorities and needs identified through the regional self-assessment;

(C) regional guidelines for prehospital field triage and destination, treatment, transport, and transfer of patients with time-sensitive health care injuries or illnesses;

(D) prevention and outreach activities guided by data available;

(E) system coordination and patient flow;

(F) meaningful participation in regional disaster preparedness, planning, response, recovery, after-action review, data tracking needs, and support of the hospital preparedness stakeholders, including the identified health care coalition and the department;

(G) identification of system-wide health care education sponsored or coordinated through the RAC;

(H) execution of a systems performance improvement plan that aligns with the state system performance improvement plan, and includes regional outcome data;

(I) current pediatric readiness capabilities that identifies opportunities to improve pediatric readiness within the region;

(J) integration of public health and business community stakeholders; and

(K) guidelines to support regional research projects.

(2) All health care entities and identified coalition partners should participate in the regional planning process.

(d) A RAC must collect from each hospital within the TSA continual data to facilitate emergency preparedness and response planning for a public health disaster, public health emergency, or outbreak of communicable disease, and report the data to the department at least monthly via the electronic reporting system specified by the department, consistent with Texas Health and Safety Code §§81.027, 81.0443, 81.0444, and 81.0445.

(1) Unless otherwise directed by the department, the data collected must include all adult and pediatric data specific to:

(A) general beds available and occupied;

(B) intensive care unit (ICU) beds available and occupied;

(C) emergency department visits in the last 24 hours;

(D) hospital admissions in the last 24 hours;

(E) ventilators available and in use; and

(F) hospital deaths in the last 24 hours.

(2) The department may request more or less frequent reporting or may request different information from individual RACs to adequately prepare and respond to any public health disaster, public health emergency, outbreak of communicable disease, or federal reporting requirement relating to emergency preparedness and response.

(3) RACs must make the collected data publicly available by posting the data on the RAC's internet website during any public health disaster or public health emergency and, when asked by the department, during outbreaks not associated with a public health disaster or emergency.

(e) A RAC with at least one county within the region located on the international border of Texas and at least one county within the region adjacent to the Gulf of Mexico must provide guidelines and protocols related to trauma patient transfer and related services meeting the following requirements.

(1) The RAC must develop an advisory committee composed of equal representation from designated trauma facilities within the RAC.

(2) The advisory committee must develop regional protocols for managing the dispatch, triage, transport, and transfer of patients.

(A) The advisory committee must periodically review patient transfers ensuring the applicable protocols are met.

(B) Each hospital and EMS provider operating within this TSA must collect and report to the RAC data on patients transferred outside of the TSA following the developed and approved regional protocols.

(C) The advisory committee and activities must be integrated into the regional trauma and health care system plan.

(f) A RAC must meet the defined performance criteria to ensure the mission of the regional system is maintained. A RAC must:

(1) notify the department and RAC membership within five days of the loss of capabilities to maintain the infrastructure to oversee and maintain the regional systems as required by the provisions within subsections (a) and (b) of this section or the department contract;

(2) provide the department with a plan of correction (POC) no more than 90 days from the onset of the deficiency for the RAC; and

(3) comply with the provisions of subsections (a) and (b) of this section, all current state and system standards as described in this chapter, and all guidelines and procedures as set forth in the regional trauma and emergency health care system plan.

(g) If a RAC chooses to relinquish services, it must provide at least a 30-day written advance notice to the department, all RAC membership, RAC coalition partners, and county judges within the impacted TSA.

(1) The RAC must submit a written plan to the department for approval before the 30-day notice to relinquish services.

(2) The RAC funding and assets must be dissolved in accordance with state and federal requirements.

(3) The department must consider options of realigning the TSA with another RAC to continue services.

(h) The department has the authority to schedule conferences, in-person or virtual, with 10-calendar days advanced notice, to review, inspect, evaluate, and audit all RAC documents to validate the department RAC performance criteria are met.

(i) RACs must maintain virtual options for stakeholder participation in committees or other activities.

§157.125.Requirements for Trauma Facility Designation Effective Through August 31, 2025.

(a) The [Office of] Emergency Medical Services (EMS)/Trauma Systems Section recommends [Coordination office) shall recommend] to the Commissioner of the Department of State Health Services (commissioner) the designation of an applicant [applicant/healthcare] facility (facility) as a trauma facility at the level [level(s)] for each location of a facility the department [office] deems appropriate. Trauma designation surveys conducted on or before August 31, 2025, are evaluated on the requirements of this section. For surveys conducted on or after September 1, 2025, see §157.126 of this subchapter (relating to Trauma Facility Designation Requirements Effective on September 1, 2025) for the requirements.

(1) Comprehensive (Level I) trauma facility designation--The facility, including a free-standing children's facility, meets the current American College of Surgeons (ACS) essential criteria for a verified Level I trauma center; meets the "Advanced Trauma Facility Criteria" in subsection (x) of this section; actively participates on the appropriate Regional Advisory Council (RAC); has appropriate services for dealing with stressful events available to emergency/trauma care providers; and submits data to the State Trauma [Texas EMS/Trauma] Registry.

(2) Major (Level II) trauma facility designation--The facility, including a free-standing children's facility, meets the current ACS essential criteria for a verified Level II trauma center; meets the "Advanced Trauma Facility Criteria" in subsection (x) of this section; actively participates on the appropriate RAC; has appropriate services for dealing with stressful events available to emergency/trauma care providers; and submits data to the State Trauma [Texas EMS/Trauma] Registry.

(3) Advanced (Level III) trauma facility designation--The facility meets the "Advanced Trauma Facility Criteria" in subsection (x) of this section; actively participates on the appropriate RAC; has appropriate services for dealing with stressful events available to emergency/trauma care providers; and submits data to the State Trauma [Texas EMS/Trauma] Registry. A free-standing children's facility, in addition to meeting the requirements listed in this section, must meet the current ACS essential criteria for a verified Level III trauma center.

(4) Basic (Level IV) trauma facility designation--The facility meets the "Basic Trauma Facility Criteria" in subsection (y) of this section; actively participates on the appropriate RAC; has appropriate services for dealing with stressful events available to emergency/trauma care providers; and submits data to the State Trauma [Texas EMS/Trauma] Registry.

(b) A health care [healthcare] facility is defined in this subchapter [under these rules] as a single location where inpatients receive hospital services or each location if there are multiple buildings where inpatients receive hospital services and are covered under a single hospital license.

[(1)] Each location is [shall be] considered separately for designation and the department [Department of State Health Services (department)] will determine the designation level for that location, based on, but not limited to, the location's own resources and levels of care capabilities; Trauma Service Area (TSA) capabilities; and the essential criteria and requirements outlined in subsection (a)(1) - (4) of this section. The final determination of the level [level(s)] of designation may not be the level [level(s)] requested by the facility.

[(2) A facility with multiple locations that is applying for designation at one location shall be required to apply for designation at each of its other locations where there are buildings where inpatients receive hospital services and such buildings are collectively covered under a single hospital's license.]

(c) The designation process consists [shall consist] of three phases.

(1) First phase--The application phase begins with submitting to the department [office] a timely and sufficient application for designation as a trauma facility and ends when the survey report is received by the department [office].

(2) Second phase--The review phase begins with the department's [office's] review of the survey report and ends with its recommendation to the commissioner whether [or not] to designate the facility and at what level [level(s)]. This phase also includes an appeal procedure governed by the department's rules for a contested case hearing and by Texas Administrative Procedure Act, Texas Government Code[,] Chapter 2001, and the department's formal hearing procedures in §§1.21, 1.23, 1.25, and 1.27 of this title (relating to Formal Hearing Procedures).

(3) Third phase--The final phase begins with the commissioner reviewing the recommendation and ends with the commissioner's [his/her] final decision.

(d) For a facility seeking initial designation, a timely and sufficient application must [shall] include:

(1) the department's current "Complete Application" form for the appropriate level, with all fields correctly and legibly filled-in and all requested documents attached, hand-delivered, or sent by postal services to the department [office];

(2) full payment of the designation fee enclosed with the submitted "Complete Application" form;

(3) any subsequent documents submitted by the date requested by the department [office];

(4) a trauma designation survey completed within one year of the date of the receipt of the application by the department [office]; and

(5) a complete survey report, including patient care reviews, that is within 90 [180] days of the date of the survey and is submitted [hand-delivered or sent by postal services] to the department [office].

(e) If a hospital seeking initial designation fails to meet the requirements in subsection (d)(1) - (5) of this section, the application is [shall be] denied.

(f) For a facility seeking re-designation, a timely and sufficient application must [shall] include:

(1) the department's current "Complete Application" form for the appropriate level, with all fields correctly and legibly filled-in and all requested documents attached, submitted [hand-delivered or sent by postal services] to the department [office] one year before the expiration of the current designation [or greater from the designation expiration date];

(2) full payment of the designation fee enclosed with the submitted "Complete Application" form;

(3) any subsequent documents submitted by the date requested by the department [office]; and

(4) a complete survey report, including patient care reviews, that is within 90 [180] days of the date of the survey and is submitted [hand-delivered or sent by postal services] to the department [office ] and at least 60 days before the expiration of the current designation [no less than 60 days prior to the designation expiration date].

(g) If a health care [healthcare] facility seeking re-designation fails to meet the requirements outlined in subsection (f)(1) - (4) of this section, the original designation will expire on its expiration date.

(h) The department's [office's] analysis of the submitted "Complete Application" form may result in recommendations for corrective action when deficiencies are noted and must [shall also] include a review of:

(1) the evidence of current participation in RAC and regional [RAC/regional] system planning; and

(2) the completeness and appropriateness of the application materials submitted, including the submission of a non-refundable application fee as follows:

(A) for Level I and Level II trauma facility applicants, the fee is [will be] no more than $10 per licensed bed with an upper limit of $5,000 and a lower limit of $4,000;

(B) for Level III trauma facility applicants, the fee is [will be] no more than $10 per licensed bed with an upper limit of $2,500 and a lower limit of $1,500; and

(C) for Level IV trauma facility applicants, the fee is [will be] no more than $10 per licensed bed with an upper limit of $1000 and a lower limit of $500.

(i) When a "Complete Application" form for initial designation or re-designation from a facility is received, the department [office] will determine the level it deems appropriate for pursuit of designation or re-designation for each [of the] facility [facility's] location [locations ] based on [, but not limited to]: the facility's resources and levels of care capabilities [at each location], TSA resources, and the essential criteria for Levels I, II, III, and IV trauma facilities. In general, physician services capabilities described in the application must be in place 24-hours [24 hours] a day/7 days a week. In determining whether a physician services capability is present, the department may use the concept of substantial compliance that is defined as having said physician services capability at least 90% of the time.

(1) If a facility disagrees with the level [level(s)] determined by the department [office] to be appropriate for pursuit of designation or re-designation, it may make an appeal in writing within 60 days to the EMS/Trauma Systems Section director [of the office]. The written appeal must include a signed letter from the facility's governing board with an explanation as to why designation at the level determined by the department [office] would not be in the best interest of the citizens of the affected TSA or the citizens of the State of Texas.

[(2) The written appeal may include a signed letter (s) from the executive board of its RAC or individual healthcare facilities and/or EMS providers within the affected TSA with an explanation as to why designation at the level determined by the office would not be in the best interest of the citizens of the affected TSA or the citizens of the State of Texas.]

(2) [(3)] If the department [office] upholds its original determination, the EMS/Trauma Systems Section director [of the office] will give written notice of such to the facility within 30 days of its receipt of the applicant's complete written appeal.

(3) [(4)] The facility may, within 30 days of the department [office's] sending written notification of its denial, submit a written request for further review. Such written appeal is submitted [shall then go] to the associate commissioner [Assistant Commissioner], Consumer Protection Division [for Regulatory Services (assistant commissioner)].

(j) When the analysis of the "Complete Application" form results in acknowledgement by the department [office ] that the facility is seeking an appropriate level of designation or re-designation, the facility may then contract for the survey, as follows.

(1) Level I and II facilities and all free-standing children's facilities must [shall] request a survey through the ACS trauma verification program.

(2) Level III facilities must [shall] request a survey through the ACS trauma verification program or through a department-approved survey [comparable] organization [approved by the department].

(3) Level IV facilities must [shall] request a survey through [the ACS trauma verification program, through] a department-approved survey [comparable] organization [approved by the department], or by a department-credentialed surveyor [surveyor(s) active in the management of trauma patients].

(4) The facility must [shall] notify the department [office] of the date of the planned survey and the composition of the survey team.

(5) The facility is [shall be] responsible for any expenses associated with the survey.

(6) The department [office], at its discretion, may appoint a designation coordinator [an observer] to accompany the survey team. In this event, the cost for the designation coordinator [observer] is [shall be] borne by the department [office].

(k) The survey team composition must [shall ] be as follows.

(1) Level I or Level II facilities must [shall ] be surveyed by a team that is multidisciplinary [multi-disciplinary] and includes at a minimum: two [2] general surgeons, an emergency physician, and a trauma nurse all active in the management of trauma patients.

(2) Free-standing children's facilities of all levels must [shall] be surveyed by a team consistent with current ACS policy and includes at a minimum: a pediatric surgeon,[;] a general surgeon,[;] a pediatric emergency physician,[;] and a pediatric trauma nurse coordinator or a trauma nurse coordinator with pediatric experience.

(3) Level III facilities must [shall] be surveyed by a team that is multidisciplinary [multi-disciplinary ] and includes at a minimum: a trauma surgeon and a trauma nurse (ACS or department-credentialed), both active in the management of trauma patients.

(4) Level IV facilities must [shall] be surveyed by a department-credentialed representative, registered nurse, or licensed physician. A second surveyor may be requested by the facility or by the department.

(5) Department-credentialed surveyors must meet the following criteria:

(A) have at least three [3] years' experience in the care of trauma patients;

(B) be currently employed in the coordination of care for trauma patients;

(C) have direct experience in the preparation for and successful completion of trauma facility verification or designation [verification/designation];

(D) have successfully completed a department-approved trauma facility site surveyor course and be successfully re-credentialed every four [4] years; and

(E) have current credentials as follows:

(i) for nurses: Trauma Nurses Core Course (TNCC) or Advanced Trauma Course for Nurses (ATCN); and Pediatric Advanced Life Support (PALS) or Emergency Nurses Pediatric Course (ENPC);

(ii) for physicians: Advanced Trauma Life Support (ATLS); and

(iii) have successfully completed a site survey internship.

(6) All members of the survey team, except department staff, must [shall] come from a TSA outside the facility's location and at least 100 miles from the facility. There must [shall] be no business or patient care relationship or any potential conflict of interest between the surveyor or the surveyor's place of employment and the facility being surveyed.

(l) The survey team evaluates [shall evaluate] the facility's compliance with the designation criteria, by:

(1) reviewing medical records; staff rosters and schedules; process improvement committee meeting minutes; and other documents relevant to trauma care;

(2) reviewing equipment and the physical plant;

(3) conducting interviews with facility personnel;

(4) evaluating compliance with participation in the State Trauma [Texas EMS/Trauma] Registry; and

(5) evaluating appropriate use of telemedicine capabilities where applicable.

(m) The site survey report in its entirety must [shall] be part of a facility's performance improvement program and subject to confidentiality as articulated in the Texas Health and Safety Code[,] §773.095.

(n) The surveyor [surveyor(s)] must [shall] provide the facility with a written, signed survey report regarding the [their] evaluation of the facility's compliance with trauma facility criteria. This survey report must [shall] be forwarded to the facility within 30 calendar days of the completion date of the survey. The facility is responsible for forwarding a copy of this report to the department [office] if it intends to continue the designation process.

(o) The department [office] must [shall] review the findings of the survey report for compliance with trauma facility criteria.

(1) A recommendation for designation must [shall] be made to the commissioner based on meeting the designation requirements [compliance with the criteria].

(2) If a facility does not meet the criteria for the level of designation deemed appropriate by the department [office], the department [office] must [shall] notify the facility of the requirements it must meet to achieve the appropriate level of designation.

(3) If a facility does not meet the requirements [comply with criteria], the department [office] must [shall] notify the facility of deficiencies and recommend corrective action.

(A) The facility must [shall] submit to the department [office] a report that outlines the corrective action [action(s)] taken. The department [office] may require a second survey to ensure compliance with the criteria. If the department [office] substantiates action that brings the facility into compliance with the criteria, the department [Office] recommends [shall recommend] designation to the commissioner.

(B) If a facility disagrees with the department's [office's] decision regarding its designation application or status, it may request a secondary review by a designation review committee. Membership on a designation review committee will:

(i) be voluntary;

(ii) be appointed by the EMS/Trauma Systems Section director [office director];

(iii) be representative of trauma care providers and appropriate levels of designated trauma facilities; and

(iv) include representation from the department and the Trauma Systems Committee of the Governor's EMS and Trauma Advisory Council (GETAC).

(C) If a designation review committee disagrees with the department's [office's] recommendation for corrective action, the records must [shall] be referred to the associate [assistant] commissioner for recommendation to the commissioner.

(D) If a facility disagrees with the department's [office's] recommendation at the end of the secondary review, the facility has a right to a hearing, governed by the department's rules for a contested case hearing and by Texas Administrative Procedure Act, Texas [in accordance with the department's rules for contested cases, and] Government Code[,] Chapter 2001, and the department's formal hearing procedures in §§1.21, 1.23, 1.25, and 1.27 of this title (relating to Formal Hearing Procedures).

(p) The facility has [shall have] the right to withdraw its application at any time before [prior to] being recommended for trauma facility designation by the department [office].

(q) If the associate commissioner concurs with the recommendation to designate, the facility receives [shall receive] a letter and a certificate of designation valid for three [3] years. Additional actions, such as a site review or submission of information/reports to maintain designation, may be required by the department.

(r) It is [shall be] necessary to repeat the designation process as described in this section prior to expiration of a facility's designation or the designation expires.

(s) A designated trauma facility must [shall:]

[(1)] comply with the provisions of this chapter [within these sections]; all current state and system standards as described in this chapter; [and] all policies, protocols, and procedures as set forth in the system plan; and meet the following requirements.

(1) [(2)] Continue [continue] its commitment to provide the resources, personnel, equipment, and response as required by its designation level.[;]

(2) [(3)] Participate [participate] in the State Trauma [Texas EMS/Trauma] Registry. Data submission requirements for designation purposes are as follows.

(A) Initial designation--Six months of data prior to the initial designation survey must be uploaded. Subsequent to initial designation, data should be uploaded to the State Trauma [Texas EMS/Trauma] Registry on at least a quarterly basis (with monthly submissions recommended) as indicated in Chapter 103 of this title (relating to Injury Prevention and Control) [§103.19 of this title (relating to Electronic Reporting)].

(B) Re-designation--The facility's trauma registry should be current with at least quarterly uploads of data to the State Trauma [Texas EMS/Trauma] Registry (monthly submissions recommended) as indicated in Chapter 103 of this title. [§103.19 of this title;]

(3) [(4)] Notify [notify ] the department [office], its RAC, and [plus] other affected RACs of all changes that affect air medical access to designated landing sites.

(A) Non-emergent changes must [shall] be implemented no earlier than 120 days after a written notification process.

(B) Emergency changes related to safety may be implemented immediately along with immediate notification to department, the RAC, and appropriate air medical providers [Air Medical Providers].

(C) Conflicts relating to helipad air medical access changes must [shall] be negotiated between the facility and the EMS provider.

(D) Any unresolved issues must [shall] be managed [handled] utilizing the nonbinding alternative dispute resolution (ADR) process of the RAC in which the helipad is located.[;]

(4) [(5)] Within five [within 5] days, notify the department [office]; its RAC and [plus] other affected RACs; and the health care [healthcare] facilities to which it customarily transfers-out trauma patients or from which it customarily receives trauma transfers-in if temporarily unable to comply with a designation [criterion]. If the health care [healthcare] facility intends to meet [comply with] the requirements [criterion] and maintain current designation status, it must also submit to the department [office] a plan for corrective action and a request for a temporary exception to requirements [criteria] within five [5] days.

(A) If the requested essential requirements [criterion] exception is not critical to the operations of the health care [healthcare] facility's trauma program and the department [office] determines [that] the facility has intent to meet the requirements [comply], a 30-day to 90-day exception period from the onset date of the deficiency may be granted for the facility to meet requirements [achieve compliancy].

(B) If the requested essential requirements [criterion] exception is critical to the operations of the health care [healthcare] facility's trauma program and the department [office] determines [that] the facility has intent to meet requirements [comply], no greater than a 30-day exception period from the onset date of the deficiency may be granted for the facility to meet requirements [achieve compliancy]. Essential requirements [criteria ] that are critical include [such things as]:

(i) neurological surgery capabilities (Level I, II);

(ii) orthopedic surgery capabilities (Level I, II, III);

(iii) general/trauma surgery capabilities (Level I, II, III);

(iv) anesthesiology (Levels I, II, III);

(v) emergency physicians (all levels);

(vi) trauma medical director (all levels);

(vii) trauma program manager [nurse coordinator/program manager] (all levels); and

(viii) trauma registry (all levels).

(C) If the health care [healthcare] facility has not met the requirements [come into compliance ] at the end of the exception period, the department [office] may at its discretion elect one of the following.[:]

(i) Allow [allow] the facility to request designation at the level appropriate to its revised capabilities.[;]

(ii) Propose [propose] to re-designate the facility at the level appropriate to its revised capabilities.[;]

(iii) Propose [propose] to suspend the facility's designation status. If the facility is amenable to this action, the department [office] will develop a [plan for] corrective action plan for the facility and a specific timeline for [compliance by] the facility to meet the requirements.[; or]

(iv) Propose [propose] to extend the facility's temporary exception to criteria for an additional period not to exceed 90 days. The department will develop a [plan for] corrective action plan for the facility and a specific timeline for [compliance by] the facility to meet the requirements.

(I) Suspensions of a facility's designation status and exceptions to criteria for facilities are [will be] documented on the EMS Trauma Systems Section [office] website.

(II) If the facility disagrees with a proposal by the department [office,] or is unable or unwilling to meet the department-imposed [office-imposed] timelines for completion of specific actions plans, it may request a secondary review by a designation review committee as defined in subsection (o)(3)(B) of this section.

(III) The department [office] may at its discretion choose to activate a designation review committee at any time to solicit technical advice regarding criteria deficiencies.

(IV) If the designation review committee disagrees with the department's [office's] recommendation for corrective actions, the case is [shall be] referred to the associate [assistant] commissioner for recommendation to the commissioner.

(V) If a facility disagrees with the department's [office's] recommendation at the end of the secondary review process, the facility has a right to a hearing, governed by the department's rules for a contested case hearing and by Texas Administrative Procedure Act, Texas [in accordance with the department's rules for contested cases and] Government Code[,] Chapter 2001, and the department's formal hearing procedures in §§1.21, 1.23, 1.25, and 1.27 of this title (relating to Formal Hearing Procedures).

(VI) Designated trauma facilities seeking exceptions to essential criteria [shall] have the right to withdraw the request at any time prior to resolution of the final appeal process.[;]

(5) [(6)] Notify [notify ] the department [office]; its RAC and [plus] other affected RACs; and the health care [healthcare ] facilities to which it customarily transfers-out trauma patients or from which it customarily receives trauma transfers-in if [transfers-in, if] it no longer provides trauma services commensurate with its designation level.

(A) If the facility chooses to apply for a lower level of trauma designation, it may do so at any time; however, it is [shall be] necessary to repeat the designation process. There must [shall] be a [paper] review by the department [office] to determine if [and when] a full survey is [shall be] required.

(B) If the facility chooses to relinquish its trauma designation, it must [shall] provide at least 30 days' [days] notice to the RAC and the department. [office; and]

(6) [(7)] Within [within ] 30 days, notify the department [office]; its RAC and [plus] other affected RACs; and the health care [healthcare] facilities to which it customarily transfers-out trauma patients or from which it customarily receives trauma transfers-in, of the change [change(s)] if it adds capabilities beyond those that define its existing trauma designation level.

(A) It is [shall be] necessary to repeat the trauma designation process.

(B) There must [shall then] be a [paper] review by the department [office] to determine if [and when] a full survey is [shall be] required.

(t) Any facility seeking trauma designation must [shall] have measures in place that define the trauma patient population evaluated at the facility or [and/or] at each of its locations, and the ability to track trauma patients throughout the course of [their] care within the facility or [and/or] at each of its locations in order to maximize funding opportunities for uncompensated care.

(u) A health care [healthcare] facility may not use the terms "trauma facility," [facility", ] "trauma hospital," [hospital",] "trauma center," [center",] or similar terminology in its signs or advertisements or in the printed materials and information it provides to the public unless the health care [healthcare ] facility is currently designated as a trauma facility according to the process described in this section.

(v) The department [office] has [shall have] the right to review, inspect, evaluate, and audit all trauma patient records, trauma performance improvement committee minutes, and other documents relevant to trauma care in any designated trauma facility or applicant [applicant/healthcare ] facility at any time to verify meeting requirements in [compliance with] the statute and this section, [rule, ] including the designation requirements [criteria]. The department maintains [office shall maintain] confidentiality of such records to the extent authorized by the Texas Public Information Act, Texas Government Code[,] Chapter 552, and consistent with current laws and regulations related to the Health Insurance Portability and Accountability Act of 1996. Such inspections must [shall] be scheduled by the department [office] when deemed appropriate. The department provides [office shall provides] a copy of the survey report, for surveys conducted by or contracted for the department, and the results to the health care [healthcare] facility.

(w) The department [office] may grant an exception to this section if it finds [that] meeting requirements in [compliance with] this section would not be in the best interests of the persons served in the affected local system.

(x) Advanced (Level III) Trauma Facility Requirements [Criteria]. An advanced trauma facility (Level III) provides resuscitation, stabilization, and assessment of injured patients and either provides treatment or arranges for appropriate transfer to a higher level designated trauma facility.

[Figure: 25 TAC §157.125(x)]

(1) The facility must identify a trauma medical director (TMD) responsible for the provision of trauma care and must have a defined job description and organizational chart delineating the TMD's role and responsibilities. The TMD must be a physician who meets the following:

(A) is a general surgeon;

(B) is currently credentialed in ATLS or an equivalent department-approved course;

(C) is charged with overall management of trauma services provided by the facility;

(D) must have the authority and responsibility for the clinical oversight of the trauma program, including:

(i) credentialing of medical staff who provide trauma care;

(ii) recommending trauma team privileges;

(iii) providing trauma care;

(iv) developing trauma management guidelines;

(v) collaborating with nursing to address educational needs; and

(vi) developing, implementing, and maintaining the trauma performance improvement and patient safety (PIPS) plan with the trauma program manager (TPM);

(E) must be credentialed by the facility to participate in the resuscitation and treatment of trauma patients and must:

(i) have current board-certification or board-eligibility;

(ii) complete nine hours of trauma-related continuing medical education per year;

(iii) comply with trauma management guidelines; and

(iv) participate in the trauma PIPS program;

(F) must participate in a leadership role in the facility, community, and emergency management (disaster) response committee; and

(G) should participate in the development of the regional trauma system plan.

(2) An identified TPM is a registered nurse and must:

(A) successfully complete and remain current in the TNCC or ATCN or an equivalent department-approved course;

(B) successfully complete and remain current in a nationally recognized pediatric advanced life support course (e.g., PALS or ENPC);

(C) have the authority and responsibility to monitor trauma patient care from emergency department (ED) admission through operative intervention, intensive care unit (ICU) care, stabilization, rehabilitation care, and discharge, including the trauma PIPS program;

(D) have a defined job description and organizational chart delineating the TPM's role and responsibilities;

(E) participate in a leadership role in the facility, community, and regional emergency management (disaster) response committee;

(F) be full-time; and

(G) complete a course designed for their role that provides essential information on the structure, process, organization, and administrative responsibilities of a PIPS program to include a department-approved trauma outcomes and performance improvement course.

(3) The trauma program must have written trauma management guidelines, developed with approval by the trauma multidisciplinary committee and facility's medical staff with evidence of implementation, for:

(A) trauma team activation;

(B) trauma resuscitation guidelines for the roles and responsibilities of team members during a resuscitation;

(C) triage, admission, and transfer of trauma patients; and

(D) trauma management guidelines specific to the trauma population evaluated and admitted to the facility as defined by the State Trauma Registry.

(4) All major, severe, and critical trauma patients must be admitted to an appropriate surgeon and all multi-system trauma patients must be admitted to a general surgeon.

(5) A general surgeon participating in trauma-call coverage must:

(A) be credentialed in ATLS or an equivalent department-approved course at least one time if board-certification maintained; and

(B) be credentialed by the TMD to participate in the resuscitation and treatment of trauma patients and must maintain:

(i) current board-certification or board-eligibility, or must maintain current ATLS or an equivalent department-approved course;

(ii) nine hours of trauma-related continuing medical education per year;

(iii) compliance with trauma management guidelines;

(iv) participation in the trauma PIPS program; and

(v) attendance at 50 percent or more of multidisciplinary and peer review trauma committee meetings.

(6) A non-board-certified general surgeon desiring inclusion in a facility's trauma program must meet the ACS guidelines as specified in its most current version of the "Resources for Optimal Care of the Injured Patient," Alternate Criteria section.

(7) The general surgeon must be present in the ED at the time of arrival of the highest level of trauma activation or within 30 minutes of notification of the trauma activation. This must be continuously monitored by the trauma PIPS program.

(8) In facilities with surgical residency programs, evaluation and treatment may be started by a team of surgeons that must include a post-graduate year four (PGY4) or more senior surgical resident who is a member of that facility's residency program. The attending surgeon must participate in major therapeutic decisions, be present in the emergency department for major resuscitations, be present in the emergency department for the highest and secondary trauma activations, and be present at operative procedures. These must be continuously monitored by the trauma PIPS program.

(9) When the attending surgeon is not activated initially and an urgent surgical consult is necessary, the maximum response time of the attending surgeon is 60 minutes from notification to physical presence at the patient's bedside. This must be continuously monitored by the trauma PIPS program.

(10) There must be a published on-call schedule for obtaining general surgery care. There must be a documented system for obtaining general surgical care for situations when the attending general surgeon on-call is not available. This must be continuously monitored by the trauma PIPS program.

(11) An orthopedic surgeon participating in trauma-call coverage must be credentialed by the TMD to participate in the resuscitation and treatment of trauma patients and must maintain:

(A) current board-certification, board-eligibility, or meet ACS standards as specified in its current addition of "Resources for Optimal Care of the Injured Patient," Alternate Criteria section;

(B) compliance with trauma management guidelines; and

(C) participation in the trauma PIPS program.

(12) An orthopedic surgeon providing trauma coverage must be promptly available (physically present) at the major, severe, or critical trauma patient's bedside within 30 minutes of request by the attending trauma surgeon or emergency physician, from inside or outside the facility. This must be continuously monitored by the trauma PIPS program.

(13) When the orthopedic surgeon is not activated initially and an urgent surgical consult is necessary, the maximum response time of the orthopedic surgeon is 60 minutes from notification to physical presence at the patient's bedside. This must be continuously monitored by the trauma PIPS program.

(14) There must be a published on-call schedule for obtaining orthopedic surgery care. There must be a documented system for obtaining orthopedic surgery care for situations when the attending orthopedic surgeon on-call is not available. This must be continuously monitored by the trauma PIPS program.

(15) The orthopedic surgeon representative to the multidisciplinary trauma committee maintains nine hours of trauma-related continuing medical education per year and attends 50 percent or more of multidisciplinary and peer review trauma committee meetings.

(16) When a Level III facility has either full-time, routine, or limited neurosurgical coverage, a neurosurgeon participating in trauma-call coverage must be credentialed by the TMD to participate in the resuscitation and treatment of trauma patients and must maintain:

(A) current board-certification, board-eligibility, or meet ACS standards as specified in its current addition of "Resources for Optimal Care of the Injured Patient," Alternate Criteria section;

(B) compliance with trauma management guidelines; and

(C) participation in the trauma PIPS program.

(17) A neurosurgeon providing trauma coverage must be promptly available (physically present) at the major, severe, or critical trauma patient's bedside within 30 minutes of an emergency request by the attending trauma surgeon or emergency physician, from inside or outside the facility. This must be continuously monitored by the trauma PIPS program.

(18) When the neurosurgeon is not notified of the initial activation or was not consulted by the evaluating team and it has been determined by the emergency physician or trauma surgeon that an urgent neurosurgical consult is necessary, the maximum response time of the neurosurgeon surgeon is 60 minutes from notification to physical presence at the patient's bedside. This must be continuously monitored by the trauma PIPS program.

(19) There must be a published on-call schedule for obtaining neurosurgical care.

(20) There must be a documented system for obtaining neurosurgical care for situations when the neurosurgeon on-call is not available. This must be continuously monitored by the trauma PIPS program.

(21) The neurosurgeon representative to the multidisciplinary trauma committee must have nine hours of trauma-related continuing medical education per year and attend 50 percent or more of multidisciplinary and peer review trauma committee meetings.

(22) An emergency physician must be available in the emergency department 24-hours a day and physicians providing trauma coverage must meet the following:

(A) be credentialed by the facility to provide emergency medical services; and

(B) be credentialed by the TMD to participate in the resuscitation and treatment of trauma patients of all ages and must maintain:

(i) current board-certification, board-eligibility, or maintain current ATLS or an equivalent department-approved course;

(ii) compliance with trauma management guidelines; and

(iii) participation in the trauma PIPS program.

(23) A board-certified emergency medicine physician providing trauma coverage must have successfully completed an ATLS Student Course or an equivalent department-approved ATLS course at least once.

(24) Current ATLS verification is required for all physicians who work in the emergency department and are not board-certified in Emergency Medicine.

(25) The emergency physician representative to the multidisciplinary trauma committee must have nine hours of trauma-related continuing medical education per year and attend 50 percent or more of multidisciplinary and peer review trauma committee meetings.

(26) The radiology physician on-call must respond within 30 minutes of request, from inside or outside the facility. This system must be continuously monitored by the trauma PIPS program.

(27) The anesthesiology physician on-call must respond within 30 minutes of request, from inside or outside the facility. This system must be continuously monitored by the trauma PIPS program.

(A) Requirements may be fulfilled by a member of the anesthesia care team credentialed by the TMD to participate in the resuscitation and treatment of trauma patients that may include:

(i) current board certification or board eligibility;

(ii) trauma continuing education;

(iii) compliance with trauma management guidelines; and

(iv) participation in the trauma PIPS program.

(B) The anesthesiology physician representative to the multidisciplinary trauma committee that provides trauma coverage to the facility must attend 50 percent or more of multidisciplinary and peer review trauma committee meetings.

(28) All nurses caring for trauma patients throughout the continuum of care have ongoing documented knowledge and skill in trauma nursing for patients of all ages to include trauma specific orientation, annual clinical competencies, and continuing education.

(29) Written guidelines for nursing care of trauma patients for all units (e.g.,ED, ICU, Operating Room (OR), Post Anesthesia Care Unit (PACU), Medical/Surgical Units) in the facility must be implemented.

(30) The facility must have a written plan, developed by the facility, for acquisition of additional staff on a 24-hour basis to support units with increased patient acuity, and multiple emergency procedures and admissions (i.e., a written disaster plan.)

(31) The facility must have emergency services available 24-hours a day.

(A) The ED must have a designated physician director.

(B) The ED must have physicians with special competence in the care of critically injured patients, designated as members of the trauma team, and physically present in the ED 24-hours per day. Neither a facility's telemedical capabilities nor the physical presence of advanced practice providers (APPs) satisfies this requirement.

(C) APPs and telemedicine-support physicians who participate in the care of major, severe, or critical trauma patients must be credentialed by the facility to participate in the resuscitation and treatment of trauma patients and must maintain:

(i) board-certification or board-eligibility in specialty, or current ATLS or an equivalent department-approved ATLS course;

(ii) nine hours of trauma-related continuing medical education per year;

(iii) compliance with trauma management guidelines; and

(iv) participation in the trauma PIPS program.

(D) The ED physician must be activated on EMS communication with the ED or after a primary assessment of patients who arrive to the ED by private vehicle for the highest level of trauma activation and must respond within 30 minutes from notification of the trauma activation. This must be monitored in the trauma PIPS program.

(E) A minimum of two registered nurses who have trauma nursing training must participate in the highest level trauma activations.

(F) All registered nursing staff responding to the highest levels of trauma activations must have successfully completed and hold current credentials in an advanced cardiac life support course (e.g., Advanced Cardiac Life Support (ACLS) or an equivalent department-approved course), a nationally recognized pediatric advanced life support course (e.g., PALS or ENPC), and TNCC or ATCN or an equivalent department-approved course. A free-standing children's facility is exempt from the ACLS requirement.

(G) Nursing documentation for trauma activation patients must be systematic and meet the trauma primary and secondary assessment guidelines.

(H) 100 percent of nursing staff must have successfully completed and hold current credentials in an advanced cardiac life support course (e.g., ACLS or an equivalent department-approved course), a nationally recognized pediatric advanced life support course (e.g., PALS or ENPC), and TNCC or ATCN or an equivalent department-approved course, within 18 months of date of employment in the ED.

(I) 100 percent of a free-standing children's facility nursing staff who care for trauma patients must have successfully completed and hold current credentials in a nationally recognized pediatric advanced life support course (e.g., PALS or ENPC) and TNCC or ATCN or an equivalent department-approved course, within 18 months of date of employment in the ED.

(J) Two-way communication with all pre-hospital emergency medical services vehicles must be available.

(K) Equipment and services for the evaluation and resuscitation of, and to provide life support for, critically or seriously injured patients of all ages must include:

(i) airway control and ventilation equipment including laryngoscope and endotracheal tubes of all sizes, bag-valve-mask devices (BVMs), pocket masks, advanced airway management devices, and oxygen;

(ii) mechanical ventilator;

(iii) pulse oximetry and capnography;

(iv) suction device;

(v) electrocardiograph, oscilloscope, and defibrillator;

(vi) internal age-specific paddles;

(vii) all standard intravenous fluids and administration devices, including large-bore intravenous catheters and a rapid infuser system;

(viii) sterile surgical sets for procedures standard for the emergency department such as thoracostomy, venous cutdown, central line insertion, thoracotomy, diagnostic peritoneal lavage (if performed at facility), airway control/cricothyrotomy, etc.;

(ix) drugs and supplies necessary for emergency care;

(x) cervical spine stabilization device;

(xi) length-based body weight and tracheal tube size evaluation system (e.g., a current Broselow tape) and resuscitation medications and equipment that are dose-appropriate for all ages;

(xii) long bone stabilization device;

(xiii) pelvic stabilization device;

(xiv) thermal control equipment for patients and a rapid warming device for blood and fluids; and

(xv) non-invasive continuous blood pressure monitoring devices.

(32) Imaging capability must be available, with an in-house technician 24-hours a day or on-call and responding within 30 minutes of request. This must be continuously monitored by the trauma PIPS program.

(33) Psychosocial support services must be available for staff, patients, and their families.

(34) Operating room services must be available 24-hours a day.

(A) With advanced notice, the operating room must be opened and ready to accept a patient within 30 minutes. This must be continuously monitored by the trauma PIPS program.

(B) Equipment for all trauma patient populations and anticipated special requirements must include:

(i) thermal control equipment for patient and for blood and fluids;

(ii) imaging capability including c-arm image intensifier with technologist available 24-hours a day;

(iii) endoscopes, all varieties, and bronchoscope;

(iv) equipment for long bone and pelvic fixation;

(v) rapid infuser system;

(vi) appropriate monitoring and resuscitation equipment;

(vii) capability to measure pulmonary capillary wedge pressure; and

(viii) capability to measure invasive systemic arterial pressure.

(35) A PACU or surgical ICU must be available for trauma patients following operative interventions and include the following.

(A) Registered nurses and other essential personnel 24-hours a day.

(B) Appropriate monitoring and resuscitation equipment.

(C) Pulse oximetry and capnography.

(D) Thermal control equipment for patients and a rapid warming device for blood and fluids.

(36) An ICU must be available for trauma patients 24-hours a day and include the following.

(A) Designated surgical director or surgical co-director responsible for setting policies and administration related to trauma ICU patients. A physician providing this coverage must be a surgeon credentialed by the TMD to participate in the resuscitation and treatment of trauma patients and must maintain:

(i) board-certification, board-eligibility, or current in ATLS or an equivalent department-approved course;

(ii) trauma continuing medical education;

(iii) compliance with trauma management guidelines; and

(iv) participation in the trauma PIPS program.

(B) Physician, credentialed in critical care by the TMD, on duty in ICU 24-hours a day or immediately available from in-facility. Arrangements for 24-hour surgical coverage of all trauma patients must be provided for emergencies and routine care. This must be continuously monitored by the trauma PIPS program.

(C) Registered nurse-patient minimum ratio of 1:2 on each shift for patients identified as critical acuity.

(D) Appropriate monitoring and resuscitation equipment.

(E) Pulse oximetry and capnography.

(F) Thermal control equipment for patients and a rapid warming device for blood and fluids.

(G) Capability to measure pulmonary capillary wedge pressure.

(H) Capability to measure invasive systemic arterial pressure.

(37) Respiratory services in-house and must be available 24-hours per day.

(38) Clinical laboratory services must be available 24-hours per day and provide the following.

(A) Standard analyses of blood, urine, and other body fluids, including microsampling.

(B) Blood typing and cross-matching, to include massive transfusion guidelines and emergency release of blood guidelines.

(C) Comprehensive blood bank or access to a community central blood bank and adequate facility storage.

(D) Coagulation studies.

(E) Blood gases and pH determinations.

(F) Microbiology.

(G) Drug and alcohol screening.

(H) Infectious disease standard operating procedures.

(I) Serum and urine osmolality.

(39) Special imaging capabilities must be available.

(A) Sonography is available 24-hours per day or on-call and if notified, responds within 30 minutes of notification.

(B) Computerized tomography (CT) is available on-call 24-hours per day and if notified, responds within 30 minutes. This must be continuously monitored by the trauma PIPS program.

(C) Angiography of all types is available 24-hours per day and if on-call, responds within 30 minutes.

(D) Nuclear scanning is available and responds as defined in the trauma management guidelines.

(40) Acute hemodialysis capability is available or transfer agreements are documented if not available.

(41) Established criteria for care of burn patients with a process to expedite the transfer of burn patients to a burn center or higher level of care.

(42) In circumstances where a designated spinal cord injury rehabilitation center exists in the region, early transfer should be considered and transfer agreements in effect.

(43) In circumstances where a moderate to severe head injury center exists in the region, transfer should be considered in selected patients and transfer agreements in effect.

(44) Physician-directed rehabilitation service, staffed by personnel trained in rehabilitation care and properly equipped for care of the injured patient, or transfer guidelines to a rehabilitation facility for patients needing a higher level of care or specialty services, including:

(A) physical therapy;

(B) occupational therapy; and

(C) speech therapy.

(45) Social services must be available to assist with management of trauma patients.

(46) The facility must have a defined trauma PIPS plan approved by the TMD, TPM, and the multidisciplinary committee.

(A) On initial designation, a facility must have completed at least six months of reviews on all qualifying trauma records with evidence of "loop closure" on identified variances. Compliance with internal trauma management guidelines must be evident.

(B) On re-designation, a facility must show continuous PIPS activities throughout its designation and a rolling current three-year period must be available for review at all times.

(C) Minimum PIPS inclusion criteria must include: all trauma team activations (including those discharged from the ED); all trauma deaths; all identified facility events; transfers-in and transfers-out; and readmissions within 48 hours after discharge.

(D) The trauma PIPS program must be organized and include a pediatric-specific component with trauma audit filters.

(i) Review of trauma medical records for appropriateness and quality of care.

(ii) Documented evidence of identification of all variances from trauma management guidelines and system response guidelines, with in-depth critical review.

(iii) Documented evidence of corrective actions implemented to address all identified variances with tracking of data analysis.

(iv) Documented evidence of secondary level of review and participation by the TMD.

(v) Morbidity and mortality review including decisions by the TMD as to whether the trauma management guidelines were followed.

(vi) Documented resolutions "loop closure" of all identified variance to prevent future recurrences.

(vii) Specific reviews of all trauma deaths and other specified cases, including complications, utilizing age-specific criteria.

(viii) Multidisciplinary hospital trauma PIPS committee structure in place.

(E) Multidisciplinary trauma committee meetings for PIPS activities must include department communication, data review, and measures for problem solving.

(F) Multidisciplinary trauma conferences must include all disciplines caring for trauma patients. This conference must be for the purpose of addressing PIPS activities and continuing education.

(G) Feedback regarding trauma patient transfers-in must be provided to all transferring facilities.

(H) Feedback regarding trauma patient transfers-out must be obtained from receiving facilities.

(I) The trauma program must maintain a trauma registry or utilize the State Trauma Registry for data entry of NTDB registry inclusion criteria patients. Trauma registry data must be submitted to the State Trauma Registry on at least a quarterly basis.

(J) The trauma program must participate in the RAC's performance improvement (PI) program, including adherence to regional guidelines, submitting data preapproved by the RAC membership such as summaries of transfer delays and transfers to facilities outside of the RAC.

(K) The trauma program must track the times and reasons for diversion must be documented and reviewed by the trauma PIPS program and multidisciplinary committee.

(L) The trauma program must maintain published on-call schedules must be maintained for general surgeons, orthopedic surgeons, neurosurgeons, anesthesia, radiology, and other major specialists, if available.

(M) The trauma program must have performance improvement personnel dedicated to and specific for the trauma program.

(47) The trauma program must participate in the regional trauma system per RAC requirements.

(48) The trauma program must have a process to expedite the transfer of major, severe, or critical trauma patients to include written management guidelines, written transfer agreements, and participation in a regional trauma system transfer plan for patients needing higher level of care or specialty services.

(49) The facility must have a system for establishing an appropriate landing zone near the facility (if rotor-wing services are available).

(50) The trauma program must provide education and consultations to physicians of the community and outlying areas.

(51) The trauma program must have an identified individual to coordinate the facility's community outreach programs for the public and professionals.

(52) The trauma program must have a public education program to address specific injuries identified by the facility's trauma registry. Documented participation in a RAC injury prevention program is acceptable.

(53) The trauma program must have formal programs in trauma continuing education provided by facility for staff or in collaboration with the RAC, based on needs identified from the trauma PIPS program for:

(A) staff physicians;

(B) nurses;

(C) allied health personnel, including advanced practice providers;

(D) community physicians; and

(E) pre-hospital personnel.

(54) The facility may participate in trauma-related research.

[(1) Advanced (Level III) Trauma Facility Criteria Standards.]

[Figure: 25 TAC §157.125(x)(1)]

[(2) Advanced (Level III) Trauma Facility Criteria Audit Filters.]

[Figure: 25 TAC §157.125(x)(2)]

(y) Basic (Level IV) Trauma Facility Requirements [Criteria]. A Basic Trauma Facility (Level IV) provides resuscitation, stabilization, and arranges for appropriate transfer of trauma patients requiring a higher level of definitive care.

[Figure: 25 TAC §157.125(y)]

(1) The facility must identify a TMD responsible for the provision of trauma care and must have a defined job description and organizational chart delineating the TMD's role and responsibilities. The TMD must be a physician who meets the following:

(A) is currently credentialed in ATLS or an equivalent department-approved course;

(B) is charged with overall management of trauma services provided by the facility;

(C) must have the authority and responsibility for the clinical oversight of the trauma program, including:

(i) credentialing of medical staff who provide trauma care;

(ii) providing trauma care;

(iii) developing trauma management guidelines;

(iv) collaborating with nursing to address educational needs; and

(v) developing and implementing the trauma PIPS plan with the TPM;

(D) must be credentialed by the facility to participate in the resuscitation and treatment of trauma patients and must:

(i) have current board-certification or board-eligibility in surgery, emergency medicine or family medicine, or must maintain current ATLS or an equivalent department-approved course;

(ii) complete nine hours of trauma-related continuing medical education per year;

(iii) comply with trauma management guidelines; and

(iv) participate in the trauma PIPS program;

(E) must participate in a leadership role in the facility, community, and emergency management (disaster) response committee; and

(F) should participate in the development of the regional trauma system plan.

(2) An identified TPM is a registered nurse and must:

(A) successfully complete and remain current in the TNCC or ATCN or an equivalent department-approved course;

(B) successfully complete and remain current in a nationally recognized pediatric advanced life support course (e.g., PALS or the ENPC);

(C) have the authority and responsibility to monitor trauma patient care from ED admission through operative intervention, ICU care, stabilization, rehabilitation care, and discharge, including the trauma PIPS program;

(D) have a defined job description and organizational chart delineating the TPM's role and responsibilities;

(E) participate in a leadership role in the facility, community, and regional emergency management (disaster) response committee;

(F) ensure the TPM hours dedicated to the trauma program maintains a concurrent PIPS process and trauma registry; and

(G) complete a course designed for their role that provides essential information on the structure, process, organization, and administrative responsibilities of a PIPS program to include a department-approved trauma outcomes and performance improvement course.

(3) An identified Trauma Registrar or TPM must have appropriate training (e.g., the Association for the Advancement of Automotive Medicine (AAAM) course) in injury severity scaling. Typically, one full-time equivalent (FTE) employee dedicated to the registry is required to process approximately 500 patients annually.

(4) Written trauma management guidelines must be developed with approval by the TMD, TPM, and the facility's medical staff with evidence of implementation, for:

(A) trauma team activation, including defined response times;

(B) trauma resuscitation, defining the roles and responsibilities of team members during a resuscitation;

(C) triage, admission, and transfer of trauma patients; and

(D) trauma management specific to the trauma population evaluated and admitted to the facility as defined by the trauma registry.

(5) The emergency department must have physician coverage 24-hours per day. The physician providing coverage in the ED must be credentialed by the facility to provide emergency medical services.

(A) A physician providing trauma coverage must be credentialed by the TMD to participate in the resuscitation and treatment of trauma patients of all ages and must maintain:

(i) current board-certification or board-eligibility in emergency medicine or family medicine, or current ATLS or an equivalent department-approved course;

(ii) nine hours of trauma-related continuing medical education per year;

(iii) compliance with trauma management guidelines; and

(iv) participation in the trauma PIPS program.

(B) A board-certified emergency medicine physician providing trauma coverage must have successfully completed an ATLS Student Course or an equivalent department-approved ATLS course, at least once.

(C) Current ATLS verification is required for all physicians who work in the ED and are not board-certified in emergency medicine.

(D) The emergency physician representative to the multidisciplinary committee that provides trauma coverage to the facility must attend 50 percent or more of multidisciplinary and peer review trauma committee meetings.

(6) Radiology physician services must be available.

(7) Anesthesiology may be fulfilled by a member of the anesthesia care team credentialed in assessing emergent situations in trauma patients and providing any indicated treatment if operative services are provided.

(8) All nurses caring for trauma patients throughout the continuum of care must have ongoing documented knowledge and skill in trauma nursing for patients of all ages to include trauma specific orientation, annual clinical competencies, and continuing education.

(9) Written guidelines for nursing care of trauma patients for all units (i.e., ED, ICU, OR, PACU, medical/surgical units) in the facility must be implemented.

(10) The facility must have a written plan, developed by the facility, for acquisition of additional staff on a 24-hour basis to support units with increased patient acuity, multiple emergency procedures, and admissions (i.e., written disaster plan.)

(11) The facility must have emergency services available 24-hours a day.

(A) Physician on-call schedule must be published.

(B) Physicians with special competence in the care of critically injured patients, designated as members of the trauma team and on-call (if not in-house 24/7) must be promptly available within 30 minutes of request from inside or outside the facility. Neither a facility's telemedicine medical service capabilities nor the physical presence of APPs satisfy this requirement with the exception of the following:

(i) A health care facility located in a county with a population of less than 30,000 may satisfy a Level IV trauma facility designation requirement relating to physicians through the use of telemedicine medical service in which an on-call physician who has special competence in the care of critically injured patients provides patient assessment, diagnosis, consultation, or treatment, or transfers medical data to a physician, advanced practice registered nurse, or physician assistants located at the facility; and

(ii) APPs and telemedicine-support physicians who participate in the care of major, severe, or critical trauma patients must be credentialed by the facility to participate in the resuscitation and treatment of trauma patients, to include requirements such as current board-certification or board-eligibility in surgery or emergency medicine, nine hours of trauma-related continuing medical education per year, compliance with trauma management guidelines, and participation in the trauma PIPS program.

(C) The ED physician must be activated on EMS communication with the ED or after a primary assessment of patients who arrive to the ED by private vehicle for the highest level of trauma activation and must respond within 30 minutes from notification. This must be continuously monitored in the trauma PIPS program.

(D) A minimum of one and preferably two registered nurses who have trauma nursing training must participate in initial resuscitation of the highest level of trauma activations.

(E) All registered nursing staff responding to the highest levels of trauma activations must have successfully completed and hold current credentials in an advanced cardiac life support course (e.g., ACLS or an equivalent department-approved course ), a nationally recognized pediatric advanced life support course (e.g., PALS or ENPC), and TNCC or ATCN or an equivalent department-approved course.

(F) 100 percent of nursing staff must have successfully completed and hold current credentials in an advanced cardiac life support course (e.g., ACLS or an equivalent department-approved course ), a nationally recognized pediatric advanced life support course (e.g., PALS or ENPC), and TNCC or ATCN or an equivalent department-approved course, within 18 months of date of employment in the ED.

(G) Nursing documentation for trauma activation patients must be systematic and meet the trauma primary and secondary assessment guidelines.

(H) Two-way communication with all pre-hospital emergency medical services vehicles must be available.

(I) Equipment and services for the evaluation and resuscitation of, and to provide life support for, critically or seriously injured patients of all ages must include:

(i) airway control and ventilation equipment including laryngoscope and endotracheal tubes of all sizes, BVMs, pocket masks, advanced airway management devices, and oxygen;

(ii) mechanical ventilator;

(iii) pulse oximetry and capnography;

(iv) suction device;

(v) electrocardiograph, oscilloscope, and defibrillator;

(vi) all standard intravenous fluids and administration devices, including large-bore intravenous catheters and a rapid infuser system;

(vii) sterile surgical sets for procedures standard for the ED such as thoracostomy, central line insertion, thoracotomy if surgeons participate in trauma care, airway control/cricothyrotomy, etc.;

(viii) drugs and supplies necessary for emergency care;

(ix) cervical spine stabilization device;

(x) length-based body weight & tracheal tube size evaluation system (e.g., a current Broselow tape) and resuscitation medications and equipment that are dose-appropriate for all ages;

(xi) long bone stabilization device;

(xii) pelvic stabilization device;

(xiii) thermal control equipment for patients and a rapid warming device for blood and fluids; and

(xiv) non-invasive continuous blood pressure monitoring devices.

(12) Clinical laboratory services must be available 24-hours per day and provide the following.

(A) Call-back process for trauma activations available within 30 minutes. This must be continuously monitored in the trauma PIPS program.

(B) Standard analyses of blood, urine, and other body fluids, including microsampling.

(C) Blood-typing and cross-matching with a minimum of two units of universal packed red blood cells (PRBCs) immediately available.

(D) Capability for immediate release of blood for a transfusion and measures to obtain additional blood supply.

(E) Coagulation studies.

(F) Blood gases and pH determinations.

(G) Drug and alcohol screening.

(13) Imaging capabilities must be available 24-hours per day. Call-back process for trauma activations must be available within 30 minutes. This must be continuously monitored in the trauma PIPS program.

(14) The trauma program must have a defined trauma PIPS plan approved by the TMD, TPM, and the trauma multidisciplinary committee.

(A) On initial designation, a facility must have completed at least six months of reviews on all qualifying trauma records with evidence of "loop closure" on identified variances. Compliance with internal trauma management guidelines must be evident.

(B) On re-designation, a facility must show continuous PIPS activities throughout its designation and a rolling current three-year period must be available for review at all times.

(C) Minimum PIPS inclusion criteria includes: all trauma team activations (including those discharged from the ED); all trauma deaths; all identified facility events; transfers-in and transfers-out; and readmissions within 48-hours after discharge.

(D) The trauma PIPS program must be organized and include a pediatric-specific component with trauma audit filters.

(i) Review of trauma medical records for appropriateness and quality of care.

(ii) Documented evidence of identification of all variances from trauma management guidelines and system response guidelines, with in-depth critical review.

(iii) Documentation of corrective actions implemented to address all identified variances with tracking of data analysis.

(iv) Documented evidence of secondary level of review and participation by the TMD.

(v) Morbidity and mortality review including decisions by the TMD as to whether the trauma management guidelines were followed.

(vi) Documented resolutions "loop closure" of all identified issues to prevent future recurrences.

(vii) Specific reviews of all trauma deaths and other specified cases, including complications, utilizing age-specific criteria.

(viii) Multidisciplinary facility trauma PIPS committee structure must be in place and include department communication, data review, and measures for problem solving.

(E) Feedback regarding trauma patient transfers-out must be obtained from receiving facilities.

(F) Facility must maintain a trauma registry or utilize the State Trauma Registry for data entry of patients meeting NTDB registry inclusion criteria. Trauma registry data must be submitted to the State Trauma Registry on at least a quarterly basis.

(G) Participation with the RAC's PI program, including adherence to regional guidelines, submitting data preapproved by the membership to the RAC such as summaries of transfer delays and transfers to facilities outside of the RAC.

(H) Times and reasons for diversion must be documented and reviewed by the trauma PIPS program and multidisciplinary committee.

(15) The trauma program must participate in the regional trauma system per RAC requirements.

(16) The trauma program must have processes in place to expedite the transfer of major, severe, or critical trauma patients to include written management guidelines, written transfer agreements, and participation in a regional trauma system transfer plan for patients needing higher level of care or specialty services.

(17) The facility must have a system in place for establishing an appropriate landing zone in close proximity to the facility (if rotor-wing services are available).

(18) Facility may participate in a RAC injury prevention program.

(19) Formal programs in trauma continuing education must be provided by the facility or coordinated through the RAC for staff, based on needs identified from the trauma PIPS program for:

(A) staff physicians;

(B) nurses; and

(C) allied health personnel, including APPs.

[(1) Basic (Level IV) Trauma Facility Criteria Standards.]

[Figure: 25 TAC §157.125(y)(1)]

[(2) Basic (Level IV) Trauma Facility Criteria Audit Filters.]

[Figure: 25 TAC §157.125(y)(2)]

§157.126.Trauma Facility Designation Requirements Effective on September 1, 2025.

(a) The department designates hospital applicants as trauma facilities, which are part of the trauma and emergency health care system. Hospitals must meet the designation requirements specific to the level of designation requested by September 1, 2025. Trauma designation surveys conducted on or after September 1, 2025, are evaluated on the requirements in this section.

(b) The facility seeking trauma designation submits a completed designation application packet to the department. The department reviews the facility application documents for the appropriate level of designation. The complete designation application packet must include the following:

(1) a trauma designation application for the requested level of trauma designation;

(2) a completed department designation assessment questionnaire;

(3) the documented trauma designation survey summary report that includes findings of requirements met and medical record reviews;

(4) evidence of documented data validation and quarterly submission to the State Trauma Registry and National Trauma Data Bank (NTDB) (if applicable) for the past 12 months;

(5) evidence of the facility's trauma program participation at Regional Advisory Council (RAC) meetings throughout the designation cycle; and

(6) full payment of the non-refundable, non-transferrable designation fee.

(c) The department reviews the designation application packet to determine and approve the facility's level of trauma designation. The department defines the final trauma designation level awarded to the facility and this designation may be different than the level requested based on the designation site survey summary. If the department determines the facility meets the requirements for trauma designation the department provides the facility with a designation award letter and a designation certificate. The facility must display its trauma designation certificate in a public area of the licensed premises that is readily visible to patients, employees, and visitors.

(d) Eligibility requirements for trauma designation.

(1) Health care facilities eligible for trauma designation include:

(A) a hospital in Texas, licensed or otherwise, in accordance with Texas Health and Safety Code Chapter 241;

(B) a hospital owned and operated by the State of Texas; or

(C) a hospital owned and operated by the federal government, in Texas.

(2) Each hospital must demonstrate the capability to stabilize and transfer or treat an acute trauma patient, have written trauma management guidelines for the hospital, have a written operational plan, and have a written trauma performance improvement and patient safety (PIPS) plan.

(3) Each hospital operating on a single hospital license with multiple locations (multi-location license) may apply for trauma designation separately by physical location for each designation.

(A) Hospital departments or services within a hospital must not be designated separately.

(B) Hospital departments located in a separate building not contiguous with the designated facility must not be designated separately.

(C) Each non-contiguous emergency department of a hospital operating on a single hospital license must have trauma patient care and transfers monitored through the main hospital's trauma program.

(e) A facility is defined under subsection (d) of this section as a single location where inpatients receive hospital services and inpatient care.

(1) Each facility location must meet the requirements for designation. The department defines the designation level based on the facility's ability to demonstrate designation requirements are met.

(2) Each facility must submit a separate trauma designation application based on its resources and the level of designation the facility is seeking.

(3) If there are multiple hospitals covered under a single hospital license, each hospital or physical location where inpatients receive hospital services and care may seek designation.

(4) Trauma designation is issued for the physical location and to the legal owner of the operations of the designated facility and is non-transferable.

(f) Facilities seeking trauma designation must meet department-approved requirements and have them validated by a department-approved survey organization.

(g) The four levels of trauma designation are as follows.

(1) Comprehensive trauma facility designation (Level I). The facility, including a free-standing children's facility, must:

(A) meet the current American College of Surgeons (ACS) trauma verification standards for Level I and receive a letter of verification from the ACS;

(B) meet the state trauma designation requirements;

(C) meet the participation requirements for the local RAC;

(D) have appropriate services for dealing with stressful events available to emergency and trauma care providers; and

(E) submit quarterly trauma data to the State Trauma Registry, defined in Chapter 103 (relating to Injury Prevention and Control).

(2) Major trauma facility designation (Level II). The facility, including a free-standing children's facility, must:

(A) meet the current ACS trauma verification standards for Level II and receive a letter of verification from the ACS;

(B) meet the state trauma designation requirements;

(C) meet the participation requirements for the local RAC;

(D) have appropriate services for dealing with stressful events available to emergency and trauma care providers; and

(E) submit quarterly trauma data to the State Trauma Registry, defined in Chapter 103 of this title (relating to Injury Prevention and Control).

(3) Advanced trauma facility designation (Level III). The facility, including a free-standing children's facility, must:

(A) meet the current ACS trauma verification standards for Level III and receive a letter of verification from the ACS, or complete a designation survey conducted by a department-approved survey organization;

(B) meet the state trauma designation requirements;

(C) meet the participation requirements for the local RAC;

(D) have appropriate services for dealing with stressful events available to emergency and trauma care providers; and

(E) submit quarterly trauma data to the State Trauma Registry, defined in Chapter 103 of this title (relating to Injury Prevention and Control).

(4) Basic trauma facility designation (Level IV). The facility, including a free-standing children's facility:

(A) Level IV facilities evaluating and admitting 101 or more trauma patients annually meeting NTDB registry inclusion criteria must:

(i) meet the current ACS trauma verification standards for Level IV and complete a designation survey conducted by a department-approved survey organization;

(ii) meet the state trauma designation requirements;

(iii) meet the participation requirements for the local RAC;

(iv) have appropriate services for dealing with stressful events available to emergency and trauma care providers; and

(v) submit quarterly trauma data to the State Trauma Registry, defined in Chapter 103 of this title (relating to Injury Prevention and Control).

(B) Level IV facilities evaluating and admitting 100 or less trauma patients annually meeting NTDB registry inclusion criteria must:

(i) meet the defined state trauma designation requirements and complete a designation survey with the department or with a department-approved survey organization;

(ii) meet the participation requirements for the local RAC;

(iii) have appropriate services for dealing with stressful events available to emergency and trauma care providers; and

(iv) submit quarterly trauma data to the State Trauma Registry, defined in Chapter 103 of this title (relating to Injury Prevention and Control).

(h) All facilities seeking trauma designation must meet the following requirements.

(1) Facilities must have documented evidence of participation in the local RAC.

(2) Facilities must have evidence of quarterly trauma data submissions to the State Trauma Registry for patients that meet NTDB registry inclusion criteria, following the National Trauma Data Standards (NTDS) definitions and state definitions.

(3) Facilities must have emergency medical services (EMS) communication capabilities.

(4) Facilities must have provisions to capture the EMS wristband number or measures for patient tracking in resuscitation documentation.

(5) Facilities must have provisions to provide and document EMS hand-off.

(6) Facilities must have landing zone capabilities or system processes to establish a landing zone (when rotor-wing capabilities are available) with appropriate staff safety training.

(7) Facilities must have a process to provide feedback to EMS providers.

(8) All levels of trauma facilities must have written trauma management guidelines specific to the hospital that align with evidence-based practices and current national standards, which must be reviewed a minimum of every three years. These guidelines must be specific to the trauma patient population evaluated and admitted by the facility. Guidelines must be established for the following:

(A) trauma activation and response time based on national recommendations;

(B) trauma resuscitation and documentation;

(C) consultation services requests and response;

(D) admission and transfer;

(E) screening, management, and appropriate interventions or referral for both suspected and confirmed abuse of all patient populations; and

(F) massive transfusion.

(9) Facilities must have defined documentation of trauma management guidelines pertinent to the care of trauma patients in all nursing units providing care to the trauma patient.

(10) The written trauma management guidelines must be monitored though the trauma PIPS process.

(11) The trauma program must have provisions for the availability of all necessary equipment and services to administer the appropriate level of care and support for the injured patient meeting the hospital's trauma activation guidelines and meeting NTDB registry inclusion criteria through the continuum of care to discharge or transfer.

(12) All levels of adult trauma facilities must meet and maintain the Emergency Medical Services for Children's Pediatric Readiness Criteria, as evidenced by the following:

(A) annual completion of the on-line National Pediatric Readiness Project assessment (https://pedsready.org), including a written plan of correction (POC) for identified opportunities for improvement that is monitored through the trauma PIPS plan until resolution;

(B) pediatric equipment and resources immediately available at the facility, and staff with defined and documented competency skills and training on the pediatric equipment;

(C) education and training requirements for Emergency Nursing Pediatric Course (ENPC) or Pediatric Advanced Life Support (PALS) for the nurses responding to pediatric trauma activations;

(D) assessments and documentation include Glasgow Coma Score (GCS); complete vital signs to include temperature, heart rate, respirations, and blood pressure; pain assessment; and weight recorded in kilograms;

(E) serial vital signs, GCS, and pain assessments are completed and documented for the highest level of trauma activations or when shock, a traumatic brain injury, or multi-system injuries are identified;

(F) pediatric imaging guidelines and processes addressing pediatric age or weight-based appropriate dosing for studies imparting radiation consistent with the ALARA (as low as reasonably achievable) principle; and

(G) documented evidence the trauma facility has completed a pediatric trauma resuscitation simulation with medical staff participation every six months, including a completed critique identifying opportunities for improvement integrated into the trauma performance improvement initiatives and tracked until the identified opportunities are corrected. An adult trauma facility evaluating and managing 200 or more patients less than 15 years of age with an injury severity score (ISS) of 9 or greater is exempt from this requirement of pediatric trauma simulations. If the facility has responded to an actual pediatric trauma resuscitation event during a six-month period, the facility is exempt from this training but must have documented evidence of participation in the after-action-review.

(13) Free-standing children's trauma facilities must have resources and equipment immediately available for adult trauma resuscitations, adherence to the nursing requirements for Trauma Nurse Core Course (TNCC) or Advanced Trauma Care for Nurses (ATCN), documented evidence the trauma program has completed an adult trauma resuscitation simulation with medical staff participation every six months, including a completed critique identifying opportunities for improvement integrated into the trauma performance improvement initiatives and tracked until the identified opportunities are corrected. Free-standing children's trauma facilities evaluating and managing 200 adult patients 15 years or older with an ISS of 9 or greater are exempt from this requirement for adult trauma simulations.

(14) Rural Level IV trauma facilities in a county with a population less than 30,000 may utilize telemedicine resources with an Advanced Practice Provider (APP) available to respond to the trauma patient's bedside within 15 minutes of notification, with written resuscitation and trauma management guidelines monitored through the trauma performance improvement and patient safety processes.

(A) The APP must be current in Advance Trauma Life Support (ATLS) training, annually maintain an average nine hours of trauma-related continuing medical education, and demonstrate adherence to the trauma patient management guidelines and documentation standards.

(B) The facility must have a documented telemedicine physician credentialing process.

(C) All assessments, physician orders, and interventions initiated through telemedicine must be documented in the patient's medical record.

(15) Telemedicine in trauma facilities in a county with a population of 30,000 or more, if utilized, must have a documented physician credentialing process, written trauma protocols for utilization of telemedicine including physician response times, and measures to ensure the trauma management guidelines and evidence-based practice are monitored through the trauma performance improvement and patient safety processes.

(A) Telemedicine cannot replace the requirement for the trauma on-call physician to respond to the trauma activations in-person, to conduct inpatient rounds, or to respond to the inpatient units, when requested.

(B) All telemedicine assessments, physician orders, and interventions initiated through telemedicine must be documented in the patient's medical record.

(C) Telemedicine services or the telemedicine physician may be requested to assist in trauma performance improvement committee reviews.

(16) The trauma medical director (TMD) must define the role and expectations of the hospitalist or intensivist in providing care to the admitted injured patient meeting trauma activation guidelines and meeting NTDB registry inclusion criteria.

(17) A trauma program manager (TPM) or designee must be a participating member of the nurse staffing committee.

(18) The facility must maintain medical records facilitating the documentation of trauma patient arrival, level of activation, physician response and team response times, EMS hand-off, resuscitation, assessments, vital signs, GCS, serial evaluation of needs, interventions, patient response to interventions, reassessments, and re-evaluation through all phases of care to discharge or transfer out of the facility.

(19) Level I, II, and III facilities, and Level IV facilities evaluating and admitting 101 or more trauma patients annually meeting NTDB registry inclusion criteria must have an organized, effective trauma service recognized in the medical staff bylaws or rules and regulations and approved by the governing body. Medical staff credentialing must include a process for requesting and granting delineation of privileges for the TMD to oversee the providers participating in trauma call coverage, the trauma panel, and trauma management through all phases of care.

(20) Level I, II, and III facilities, and Level IV facilities evaluating and admitting 101 or more trauma patients annually meeting NTDB registry inclusion criteria must have a TMD with requirements aligned with the current ACS standards specific to the level of designation requested. The TMD must complete a trauma performance improvement course approved by the department.

(21) Level I, II, and III facilities, and Level IV facilities evaluating and admitting 101 or more trauma patients annually meeting NTDB registry inclusion criteria must have an identified TPM responsible for monitoring trauma patient care throughout the continuum of care, from pre-hospital management to trauma activation, inpatient admission, and transfer or discharge, to include transfer follow-up as appropriate. The TPM must be a registered nurse with clinical background in trauma care and must have completed a trauma performance improvement course approved by the department and the Association for the Advancement of Automotive Medicine (AAAM) Injury Scaling Course. It is recommended to complete courses specific to the TPM role. The role must be only for that facility and cannot cover multiple facilities. The TPM authority and responsibilities are aligned with the current ACS standards for the specific level of designation.

(22) The facility must have an organizational structure that facilitates the TPM's review of trauma care from admission to discharge, allowing for recommendations to improve care through all phases of care, and a reporting structure to an administrator having the authority to recommend and monitor facility system changes and oversee the trauma program.

(23) All levels of trauma facilities must maintain a continuous trauma PIPS plan. The plan must be data-driven and must:

(A) identify variances in care or system response events for review, including factors that led to the event, delays in care, hospital events such as complications, and all trauma deaths;

(B) define the levels of harm;

(C) define levels of review;

(D) identify factors that led to the event;

(E) identify opportunities for improvement;

(F) establish action plans to address the opportunities for improvement;

(G) monitor the action plan until the desired change is met and sustained;

(H) establish a concurrent PIPS process;

(I) meet staffing standards that align with the ACS standards for performance improvement personnel; and

(J) utilize terminology for classifying morbidity and mortality with the terms:

(i) morbidity or mortality without opportunity;

(ii) morbidity or mortality with opportunity for improvement; and

(iii) morbidity or mortality with regional opportunity for improvement.

(24) The trauma PIPS plan must be approved by the TMD, TPM, and the trauma operations committee and be disseminated to all departments providing care to the trauma patient. The departments must ensure staff are knowledgeable of the responsibilities in the trauma PIPS plan and the requested data and information to be presented at the trauma operations committee.

(25) The Level I, II, and III facilities, and Level IV facilities evaluating and admitting 101 or more trauma patients annually meeting NTDB registry inclusion criteria must demonstrate that the TMD chairs the secondary level of performance review, chairs the trauma multidisciplinary peer review committee, and co-chairs the trauma operations committee with the TPM.

(26) The trauma PIPS plan must outline the roles and responsibilities of the trauma operations committee and its membership.

(27) The trauma facility must document and include in its trauma PIPS plan the external review of the trauma verification and designation assessment questionnaire, designation survey documents, the designation survey summary report, including the medical record reviews, and all communication with the department.

(28) Trauma facilities must submit required trauma registry data every 90 days or quarterly to the State Trauma Registry and have documented evidence of data validation and correction of identified errors or blank fields.

(A) All levels of trauma facilities must demonstrate the current ACS standards for staffing requirements for the trauma registry are met.

(B) Trauma facilities utilizing a pool of trauma registrars must have an identified trauma registrar from the pool assigned to the facility to ensure data requests are addressed in a timely manner.

(29) All levels of trauma facilities must demonstrate the registered nurses assigned to care for arriving patients meeting trauma activation guidelines have current TNCC or ATCN, ENPC or PALS, and Advanced Cardiac Life Support certifications. Those new to the facility or the facility's trauma resuscitation area must meet these requirements within 18 months.

(30) Level I, II, and III facilities, and Level IV facilities evaluating and admitting 101 or more trauma patients annually meeting NTDB registry inclusion criteria must have evidence the trauma program surgeons, trauma liaisons, trauma program personnel, operating suite leaders, and critical care medical director and nursing leaders complete a mass casualty response training on their roles, potential job functions, and job action sheets, to ensure competency regarding actions required for surge capacity, capabilities, and patient flow management from resuscitation to inpatient admission, operative suite, and critical care units or intensive care units during a multiple casualty or mass casualty event. If the facility has responded to an actual mass casualty event during a 12-month period, the facility is exempt from this training but must have documented evidence of participation in the after-action review.

(31) Level IV facilities evaluating and admitting 101 or more patients annually meeting NTDB registry inclusion criteria must:

(A) meet the current ACS Level IV standards and defined state requirements;

(B) have 24-hour on-site coverage by an emergency physician credentialed by the hospital and approved by the TMD to participate in the resuscitation and treatment of trauma patients of all ages and respond to trauma activation patients within 30 minutes of request;

(C) have documented guidelines for trauma activations, resuscitation guidelines, documentation standards, and patient transfers, and measures to monitor the guidelines through the trauma performance improvement process. Transfer reviews must include the time of arrival, transfer decision time, transfer acceptance time, transport arrival time, and time transferred;

(D) have documented management guidelines specific to the trauma patients admitted at the facility based on trauma registry data;

(E) have a written trauma PIPS plan that, at minimum, monitors:

(i) trauma team activations;

(ii) trauma team member response times;

(iii) trauma resuscitation guidelines;

(iv) documentation standards;

(v) trauma management guidelines;

(vi) pediatric trauma resuscitation guidelines;

(vii) transfer guidelines; and

(viii) all trauma deaths; and

(F) have provisions for a multidisciplinary trauma peer review committee and a trauma operations committee.

(32) Level IV facilities evaluating and admitting 100 or less trauma patients annually meeting NTDB registry inclusion criteria must:

(A) have 24-hour emergency services coverage by a physician credentialed by the hospital and approved by the TMD to participate in the resuscitation and treatment of trauma patients of all ages and respond to trauma activation patients within 30 minutes of request;

(B) have a TMD overseeing and monitoring the trauma care provided and who is current in ATLS;

(C) have a TPM who is a registered nurse or have the TPM job functions integrated into the chief nursing officer (CNO) job functions and the TPM must:

(i) complete a trauma performance improvement course approved by the department;

(ii) complete a registry AAAM Injury Scoring Course; and

(iii) oversee and monitor trauma care provided;

(D) have documented guidelines for trauma team activation with response times, resuscitation guidelines, and documentation standards for resuscitation through admission, transfer, or discharge;

(E) have documented management guidelines specific for the trauma patients admitted to the facility;

(F) have documented transfer guidelines that are monitored to identify the arrival time, decision to transfer time, time of transfer acceptance, time of transport arrival, and time of transfer;

(G) have a trauma PIPS plan that, at minimum, monitors:

(i) trauma team activations;

(ii) trauma team member response times;

(iii) trauma resuscitation guidelines;

(iv) documentation standards;

(v) trauma management guidelines;

(vi) pediatric trauma resuscitation guidelines;

(vii) transfer guidelines; and

(viii) all trauma deaths;

(H) have provisions for a trauma multidisciplinary peer review process and operational oversight integrated into the hospitals performance review or quality review processes;

(I) have provisions for a trauma registry and submit the NTDB data to the State Trauma Registry quarterly to include each patient's ISS;

(J) have conventional radiology available 24-hours per day;

(K) have laboratory services available 24-hours per day for standard analysis of blood, urine, and other body fluids, including microbiologic sampling when appropriate;

(L) have blood bank capabilities including typing and cross-matching and have a minimum of two universal packed red blood cell units available; and

(M) participate in the local RAC.

(i) A facility seeking trauma designation or renewal of designation must submit the completed designation application packet, have the required documents available at the time of the designation survey, and submit the designation survey summary report and medical record reviews following the completed designation survey.

(1) A complete application packet contains the following:

(A) a trauma designation application for the requested level of trauma designation;

(B) a completed department designation assessment questionnaire;

(C) the documented trauma designation survey summary report that includes findings of requirements met and medical record reviews;

(D) evidence of documented data validation and quarterly submission to the State Trauma Registry and NTDB (if applicable) for the past 12 months;

(E) evidence of the facility's trauma program participation at RAC meetings throughout the designation cycle;

(F) full payment of the non-refundable, non-transferrable designation fee and department remit form submitted to the department Cash Branch per the designation application instructions; and

(G) the documentation in subparagraphs (A), (B), (D), and (E) of this paragraph must be submitted to the department and department-approved survey organization no less than 45 days before the facility's scheduled designation survey.

(2) The facility must have the required documents available and organized for the actual designation survey, including:

(A) documentation of a minimum of 12 months of trauma performance improvement and patient safety reviews, including minutes and attendance of the trauma operations meetings and the trauma multidisciplinary peer review committee meetings, all trauma-documented management guidelines or evidence-based practice guidelines, and all trauma-related policies, procedures, and diversion times;

(B) evidence of 12 months of trauma registry submissions to the State Trauma Registry;

(C) documentation of all injury prevention, outreach education, public education, and research activities (if applicable); and

(D) documentation to reflect designation requirements are met.

(3) Not later than 90 days after the trauma designation survey, the facility must submit to the department the following documentation:

(A) the documented trauma designation survey summary report that includes the requirements met and not met, and the medical record reviews; and

(B) a POC, if required by the department, which addresses all designation requirements defined as "not met" in the trauma designation survey summary report, which must include:

(i) a statement of the cited designation requirement not met;

(ii) a statement describing the corrective actions taken by the facility seeking trauma designation to meet the requirement;

(iii) the title of the individuals responsible for ensuring the corrective actions are implemented and monitored;

(iv) the date the corrective actions are implemented;

(v) a statement on how the corrective actions will be monitored and what data are measured to identify change;

(vi) documented evidence the POC is implemented within 60 days of the survey date; and

(vii) any subsequent documents requested by the department.

(4) The application includes full payment of the appropriate non-refundable, non-transferrable designation fee.

(A) For Level I and Level II trauma facility applicants, the fee is no more than $10 per licensed bed with an upper limit of $5,000 and a lower limit of $4,000.

(B) For Level III trauma facility applicants, the fee is no more than $10 per licensed bed with an upper limit of $2,500 and a lower limit of $1,500.

(C) For Level IV trauma facility applicants, the fee is no more than $10 per licensed bed with an upper limit of $1000 and a lower limit of $500.

(5) All application documents except the designation fee are submitted electronically to the department.

(j) Facilities seeking initial trauma designation must complete a scheduled conference call with the department and include the facility's chief executive officer (CEO), CNO, chief operating officer (COO), trauma administrator or executive leader, TMD, and TPM before scheduling the designation survey. The following information must be provided to the department before the scheduled conference call with the department:

(1) job descriptions for the TMD, TPM, and trauma registrar;

(2) trauma operational plan;

(3) trauma PIPS plan;

(4) trauma activation and trauma management guidelines; and

(5) trauma registry procedures.

(k) Facilities seeking designation renewal must submit the required documents described in subsection (i) of this section to the department no later than 90 days before the facility's current trauma designation expiration date.

(l) The application will not be processed if a facility seeking trauma designation fails to submit the required application documents and designation fee.

(m) A facility requesting designation at a different level of care or experiencing a change in ownership or a change in physical address must notify the department and submit a complete designation application packet and application fee.

(n) Level I, II, and III facilities, and Level IV facilities evaluating and admitting 101 or more trauma patients annually meeting NTDB registry inclusion criteria must schedule a designation survey with a department-approved survey organization. All aspects of the designation survey process must follow the department designation survey guidelines. All initial designation surveys must be performed in person unless approval for virtual review is given by the department.

(1) Facilities requesting Level I and II trauma facility designation must request a verification survey through the ACS trauma verification program. This includes pediatric stand-alone facilities.

(2) Level III facilities must request a designation survey through either the ACS trauma verification program or through a department-approved survey organization.

(3) Level IV facilities evaluating and admitting 101 or more trauma patients annually meeting NTDB registry inclusion criteria must schedule a designation survey with a department-approved survey organization.

(4) Level IV facilities evaluating and admitting 100 or less trauma patients annually meeting the NTDB registry inclusion criteria must schedule a designation survey with the department. The facility's executive officers may request, in writing, a designation survey with a department-approved survey organization.

(5) The facility must notify the department of the date of the scheduled designation survey a minimum of 60 days before the survey.

(6) The facility is responsible for any expenses associated with the designation survey.

(7) The department, at its discretion, may appoint a designation coordinator to participate in the survey process. The designation coordinator's costs are borne by the department.

(o) The survey team composition must be as follows:

(1) Level I or Level II facilities must be reviewed by a team consistent with the current ACS standards, currently participating in the management or oversight of trauma patients at a verified/designated Level I or II trauma facility and practicing outside of Texas. The facility's executive officers may request additional survey team members through the ACS.

(2) Level III facilities must be reviewed by a team consistent with the ACS current standards, currently participating in the management or oversight of trauma patients at a verified or designated Level I, II, or III trauma facility. The facility's executive officers may request additional survey team members through the survey organization.

(3) Level IV facilities must be reviewed by surveyors determined by the facility's number of trauma patients meeting NTDB registry inclusion criteria that are evaluated and admitted to the facility.

(A) Level IV facilities evaluating and admitting 101 or more trauma patients annually meeting NTDB registry inclusion criteria must be reviewed by a surgeon and a trauma program manager currently participating in trauma patient management or oversight at a Level I, II, or III designated facility. The facility's executive officers may request additional surveyor team members through the department-approved survey organization.

(B) Level IV facilities evaluating and admitting 100 or less trauma patients annually meeting NTDB registry inclusion criteria complete a designation survey with the department. The facility's executive officers may request, in writing, a designation survey with a department-approved survey organization. If a department-approved survey is requested, an emergency medicine physician or family practice physician, or surgeon currently serving in the role of a trauma medical director or trauma liaison, must complete the designation survey.

(p) Trauma facilities seeking designation or redesignation and department-approved survey organizations must follow the department survey guidelines and ensure all surveyors follow these guidelines.

(1) All members of the survey team for Level III or IV, except department staff, must not be from the same TSA or a contiguous TSA of the facility's location without the written approval from the department. There must be no business or patient care relationship or any known conflict of interest between the surveyor or the surveyor's place of employment and the facility being surveyed.

(2) The facility must not accept surveyors with any known conflict of interest. If a conflict of interest is present, the facility seeking trauma designation must decline the assigned surveyor through the survey organization.

(A) A conflict of interest exists when the surveyor has a direct or indirect financial, personal, or other interest which would limit or could reasonably be perceived as limiting the surveyor's ability to serve in the best interest of the public.

(B) The conflict of interest may include a surveyor who, in the past four years:

(i) has trained or supervised key hospital or medical staff in residency or fellowship;

(ii) collaborated professionally with key members of the facility's leadership team;

(iii) was employed in the same health care system in state or out of state;

(iv) participated in a designation consultation with the facility;

(v) had a previous working relationship with the facility or facility leader;

(vi) conducted a designation survey for the facility; or

(vii) is the EMS medical director for an agency that routinely transports trauma patients to the facility.

(3) If a designation survey occurs with a surveyor who has a known conflict of interest, the trauma designation survey summary report and medical record review may not be accepted by the department.

(4) A survey organization must complete an application requesting to perform designation surveys in Texas and be approved by the department. Each organization must renew its application every four years.

(q) Level I and II facilities using the ACS verification program who receive a Type I or three or more Type II standards not met, and Level III facilities surveyed by a department-approved survey organization with four or more requirements not met, must schedule a conference call with the department.

(r) If a health care facility seeking re-designation fails to meet the requirements outlined in subsection (j) of this section, the original designation expires on its expiration date. The facility must wait six months and begin the process again to continue as a designated trauma facility.

(s) If a facility disagrees with the designation level awarded by the department, the CEO, CNO, or COO may request an appeal, in writing, sent to the EMS/Trauma Systems Section director not later than 30 days after the issuance date of a designation award.

(1) All written appeals are reviewed quarterly by the EMS/Trauma Systems Section director in conjunction with the Trauma Designation Review Committee.

(A) The Trauma Designation Review Committee consists of the following individuals for trauma designation appeals, exception requests, or contingent designation survey summaries:

(i) chair of Governor's EMS and Trauma Advisory Council (GETAC);

(ii) chair of the GETAC Trauma System Committee;

(iii) current president of the Texas Trauma Coordinators Forum;

(iv) two individuals who each have a minimum of 10 years of trauma facility oversight as an administrator, medical director, program manager, or program liaison, all selected by the current chair of GETAC and approved by the EMS/Trauma Systems Section director and Consumer Protection Division (CPD) associate commissioner; and

(v) three department representatives from the EMS/Trauma Systems Section.

(B) The Trauma Designation Review Committee meetings are closed to maintain confidentiality for all reviews.

(C) The GETAC chair and the chair of the Trauma System Committee are required to attend the Trauma Designation Review Committee, in addition to a minimum of three of the other members, to conduct meetings with the purpose of reviewing trauma facility designation appeals, exception requests, and contingent designation survey summaries that identify requirements not met. Agreement from a majority of the members present is required.

(2) If the Trauma Designation Review Committee supports the department's designation determination, the EMS/Trauma Systems Section director gives written notice of the review and determination to the facility not later than 30 days after the committee's recommendation.

(3) If the Trauma Designation Review Committee recommends a different level of designation, it will provide the recommendation to the department. The department reviews the recommendation and determines the approved level of designation. Additional actions, such as a focused review, re-survey, or submission of information and reports to maintain designation, may be required by the department for identified designation requirements not met or only partially met.

(4) If a facility disagrees with the department's awarded level of designation, the facility may request a second appeal review with the department's CPD associate commissioner. The appeal must be submitted to the EMS/Trauma Systems Section no later than 15 days after the issuance date of the department's designation. If the CPD associate commissioner disagrees with the Trauma Designation Review Committee's recommendation, the CPD associate commissioner decides the appropriate level of designation awarded. The department sends a notification letter of the second appeal decision within 30 days of receiving the second appeal request.

(5) If the facility continues to disagree with the second level of appeal, the facility may request a hearing, governed by the department's rules for a contested case hearing and by Texas Administrative Procedure Act, Texas Government Code Chapter 2001, and the department's formal hearing procedures in §§1.21, 1.23, 1.25, and 1.27 of this title (relating to Formal Hearing Procedures).

(t) All designated facilities must follow the exceptions and notifications process outlined in the following paragraphs.

(1) A designated trauma facility must provide written or electronic notification of any significant change to the trauma program impacting the capacity or capabilities to manage and care for a trauma patient. The notification must be provided to:

(A) all EMS providers that transfer trauma patients to or from the designated trauma facility;

(B) the hospitals to which it customarily transfers out or from which it transfers in trauma patients;

(C) applicable RACs; and

(D) the department.

(2) If the designated trauma facility is unable to meet the requirements to maintain its current designation, it must submit to the department a documented POC and a request for a temporary exception to the designation requirements. Any request for an exception must be submitted in writing from the facility's CEO and define the facility's timeline to meet the designation requirements. The department reviews the request and the POC and either grants the exception with a timeline based on access to care, including geographic location, other levels of trauma facilities available, transport times, impact on trauma outcomes, and the regional trauma system, or denies the exception. If the facility is not granted an exception or it does not meet the designation requirements at the end of the exception period, the department elects one of the following:

(A) review the exception request with the Trauma Designation Review Committee with consideration of geographic location, access to trauma care in the local area of the facility, and impact on the regional system;

(B) re-designate the facility at the level appropriate to its revised capabilities;

(C) outline an agreement with the facility to satisfy all designation requirements for the level of care designation within a time specified under the agreement, which may not exceed the first anniversary of the effective date of the agreement; or

(D) accept the facility's relinquishing of its trauma designation certificate.

(3) If the facility is relinquishing its trauma designation, the facility must provide 30 day written advance notice of the relinquishment to the department. The facility informs the applicable RACs, EMS providers, and facilities to which it customarily transfers out or from which it transfers in trauma patients. The facility is responsible for continuing to provide trauma care services or ensuring a plan for trauma care continuity for 30 days following the written notice of relinquishment of its trauma designation.

(u) A designated trauma facility may choose to apply for a higher level of designation at any time. The facility must follow the initial designation process described in subsection (i) of this section to apply for a higher level of trauma designation. The facility must not claim or advertise the higher level of designation until the facility has received written notification of the award of the higher level of designation.

(v) A hospital providing trauma services must not use or authorize the use of any public communication or advertising containing false, misleading, or deceptive claims regarding its trauma designation status. Public communication or advertising is deemed false, misleading, or deceptive if the facility uses these, or similar, terms:

(1) trauma facility, trauma hospital, trauma center, functioning as a trauma center, serving as a trauma center, or similar terminology if the facility is not currently designated as a trauma center or designated trauma center at that level; or

(2) comprehensive Level I trauma center, major Level II trauma center, advanced Level III trauma center, basic Level IV trauma center, or similar terminology in its signs, website, advertisements, social media, or in the printed materials and information it provides to the public that are different than the current designation level awarded by the department.

(w) During a virtual, on-site, or focused designation review conducted by the department or a department-approved survey organization, the department or surveyor has the right to review and evaluate the following documentation to validate designation requirements are met in this section and the Texas Health and Safety Code Chapter 773:

(1) trauma patient medical records;

(2) trauma PIPS plan and process documents;

(3) appropriate committee documentation for attendance, meeting minutes, and documents demonstrating why the case was referred, the date reviewed, pertinent discussion, and any actions taken specific to improving trauma care and outcomes; and

(4) documents relevant to trauma care in a designated trauma facility or facility seeking trauma facility designation to validate evidence designation requirements are met.

(x) The department and department-approved survey organizations must comply with all relevant laws related to the confidentiality of such records.

§157.128.Denial, Suspension, and Revocation of Trauma Facility Designation.

(a) A [An applicant/healthcare] facility's application for designation may be denied or a [healthcare ] facility's [trauma] designation may be suspended or revoked for failure to meet designation requirements, or for any of [, but not limited to,] the following reasons:

(1) failure to comply with the statute and this chapter [these sections];

(2) willful preparation or filing of false reports or records;

(3) fraud or deceit in obtaining or attempting to obtain designation status;

(4) failure to submit data to the State Trauma [Texas EMS/Trauma] Registry;

(5) failure to maintain required licenses, designations, and accreditations or when disciplinary action has been taken against the health care [healthcare] facility by a state or national licensing agency;

(6) failure to have appropriate staff, [or ] equipment, or resources required for designation routinely available [as described in §157.125 of this title (relating to Requirements for Trauma Facility Designation)];

[(7) abuse or abandonment of a patient;]

(7) [(8)] unauthorized disclosure of medical or other confidential information;

(8) [(9)] alteration or inappropriate destruction of medical records; or

(9) [(10)] refusal to render care because of a patient's race, color, sex, pregnancy, [creed,] national origin, religion, sexual preference, age, disability, [handicap,] medical condition, [problem,] or inability to pay.[; or]

[(11) criminal conviction(s) as described in the Occupations Code, Chapter 53, Subchapter B.]

(b) Intermittent [Occasional] failure of a [healthcare] facility to meet designation criteria is [shall] not [be] grounds for denial, suspension, or revocation by the department [Office of EMS/Trauma Systems Coordination (office)], if the circumstances under which the failure occurred:

(1) do not reflect an overall deterioration in quality of trauma care; and

(2) are corrected within a reasonable timeframe by the [healthcare] facility.

(c) If the department [office] proposes to deny, suspend, or revoke a designation, the department [office] must [shall] notify the [healthcare ] facility at the address shown in [the] current department records [of the department]. The notice must [shall] state the alleged facts that warrant the proposed action and state [that] the [healthcare] facility has an opportunity to appeal the proposed action through the Trauma Designation Review Committee as described in §157.126(s) of this subchapter (relating to Trauma Facility Designation Requirements Effective on September 1, 2025) or request a hearing in the manner referenced for contested cases [accordance with] in Texas Government Code[,] Chapter 2001.

(1) A request for a hearing must [shall] be in writing and submitted to the department [Office of EMS/Trauma Systems Coordination and postmarked] within 15 days of the issuance date [the notice was sent].

(2) If the [healthcare] facility fails to [timely] submit a written request for a hearing, it will be deemed to have waived the opportunity for a hearing and the proposed action will be ordered.

(d) Six months after the denial of an applicant [applicant/healthcare] facility's designation, the applicant [applicant/healthcare] facility may reapply for [trauma] facility designation [as described in §157.125 of this title].

(e) One year after the revocation of a [healthcare] facility's designation, the [healthcare] facility may reapply for designation [as described in §157.125 of this title]. The department [office] may deny designation if the department [office] determines [that] the reason for the revocation continues to exist or if the facility otherwise does not continuously meet the designation requirements.

(f) The department informs the facility of the potential funding implications related to the designation denial, suspension, or revocation as outlined in:

(1) 1 Texas Administrative Code §355.8052 and §355.8065; and

(2) Section 157.130 of this subchapter (relating to Funds for Emergency Medical Services, Trauma Facilities, and Trauma Care Systems, and the Designated Trauma Facility and Emergency Medical Services Account).

§157.130.Funds for Emergency Medical Services, Trauma Facilities, and Trauma Care Systems, and the Designated Trauma Facility and Emergency Medical Services Account.

(a) Allocations determination under Texas Health and Safety Code §773.122 and Health and Safety Code Chapter 780.

(1) Department determination. The department determines each year:

(A) eligibility criteria for emergency medical services (EMS), trauma service area (TSA), and hospital allocations; and

(B) the amount of EMS, TSA, and hospital allocations based on language described in Texas Health and Safety Code §773.122 and Chapter 780.

(2) Eligibility requirements. To be eligible for funding from the accounts, all potential recipients must maintain the regional participation requirements.

(3) Extraordinary emergency funding.

(A) To be eligible to receive extraordinary emergency funding, an entity must meet the following requirements:

(i) be a licensed EMS provider, a designated trauma facility, or a recognized first responder organization (FRO);

(ii) submit a completed application and any additional documentation requested by the department; and

(iii) provide documentation of active participation in its local Regional Advisory Council (RAC).

(B) Incomplete applications will not be considered for extraordinary emergency funding.

(4) EMS allocation.

(A) The department contracts with each eligible RAC to distribute the county funds to eligible EMS providers based within counties aligned with the relevant TSA.

(i) The department evaluates submitted support documents per the contract statement of work. Awarded funds must be used in addition to current operational EMS funding of eligible recipients and must not supplant the operational budget.

(ii) Funds are allocated by county to be awarded to eligible providers in each county. Funds are non-transferable to other counties within the RAC if there are no eligible providers in a county.

(B) Eligible EMS providers may contribute funds for a specified purpose within the TSA when:

(i) all EMS providers received communication regarding the intent of the contributed funds;

(ii) the EMS providers voted and approved by majority vote to contribute funds; and

(iii) all EMS providers that did not support contributing funds, receive the eligible funding.

(C) To be eligible for funding from the EMS allocation, providers must:

(i) maintain and comply with all licensure requirements as described in §157.11 of this chapter (relating to Requirements for an EMS Provider License);

(ii) follow RAC regional guidelines regarding patient destination and transport in all TSAs where EMS is provided and verified by each RAC;

(iii) notify the RACs of any potential eligibility to receive funds and meet the RACs' participation requirements, if a provider is contracted to provide EMS within a county of any one TSA and whose county of licensure is another county not in or contiguous with that TSA; and

(iv) provide the department evidence of a contract or letter of agreement with each additional county government or taxing authority in which EMS is provided in any county beyond its county of licensure.

(D) Inter-facility transfer letters of agreement and contracts or mutual aid letters of agreement and contracts do not meet the requirement of a county contract.

(E) Contracts or letters of agreement must be submitted to the department on or before the stated department contract deadline of the respective year and provide evidence of continued coverage throughout the effective contract dates for which the eligibility of the EMS provider is being considered.

(F) EMS providers with contracts or letters of agreement on file with the department meeting the effective contract dates do not need to resubmit a copy of the contract or letter of agreement unless it has expired or will expire before the effective date of the next contract.

(G) The submitted contracts or letters of agreement must include effective dates to determine continued eligibility.

(H) EMS providers are responsible for ensuring all contracts or letters of agreement have been received by the department on or before the listed deadline to be considered for eligibility.

(I) Air ambulance providers must meet the same requirements as ground transport EMS providers to be eligible to receive funds from a specific county other than the county of licensure.

(J) If an EMS provider is licensed in a particular county for a service area considered a geo-political subdivision and whose boundary lines cross multiple county lines, it will be considered eligible for the EMS Allocation for all counties overlapped by that geo-political subdivision's boundary lines. Verification from local jurisdictions will be requested for every county that comprises the geo-political subdivision to determine funding eligibility for each county. The eligibility of EMS providers whose county of licensure is in a geo-political subdivision other than those listed in clauses (i) - (v) of this subparagraph will be evaluated on a case-by-case basis. Geo-political subdivisions include:

(i) municipalities;

(ii) school districts;

(iii) emergency service districts (ESDs);

(iv) utility districts; or

(v) prison districts.

(5) TSA allocation.

(A) The department contracts with eligible RACs to distribute the funds for the operation of the 22 TSAs and for equipment, communications, education, and training for the areas.

(B) To be eligible to distribute funding on behalf of eligible recipients in each county to the TSA, a RAC must be:

(i) officially recognized by the department as described in §157.123 of this subchapter (relating to Regional Advisory Councils);

(ii) in compliance with all RAC performance criteria, have a current RAC self-assessment, and have a current regional trauma and emergency health care system plan; and

(iii) incorporated as an entity exempt from federal income tax under Section 501(a), Internal Revenue Code of 1986, and its subsequent amendments by being listed as an exempt organization under Section 501(c)(3).

(C) The TSA allocation distributed under this paragraph is based on the relative geographic size and population of each TSA and on the relative amount of trauma care provided.

(6) Hospital allocation. The department distributes funds to designated trauma facilities to subsidize a portion of uncompensated trauma care provided or to enhance the facility's delivery of trauma care.

(A) Funds distributed from the hospital allocations are made based on:

(i) the hospital being designated as a trauma facility by the department as defined in Texas Health and Safety Code Chapter 773;

(ii) the percentage of the hospital's uncompensated trauma care cost for patients meeting the National Trauma Data Bank (NTDB) registry inclusion criteria relative to the total uncompensated trauma care cost reported for the identified patient population by qualified facilities that year;

(iii) availability of funds; and

(iv) submission of a complete application to the department within the stated time frame. Incomplete applications will not be considered.

(B) Additional information may be requested by the department to determine eligibility for funding.

(C) A designated trauma facility in receipt of funding from the hospital allocation that fails to maintain its designation as required in §157.125 of this subchapter (relating to Requirements for Trauma Facility Designation Effective Through August 31, 2025) and §157.126 of this subchapter (relating to Trauma Facility Designation Requirements Effective on September 1, 2025), must return to the department all hospital allocation funds received in the prior 12 months within 90 days of failure to maintain trauma designation.

(D) The department may grant an exception to subparagraph (C) of this paragraph if it finds compliance with this section would not be in the best interest of the persons served in the affected local system.

(E) A facility must have no outstanding balance owed to the department or other state agencies before receiving any future disbursements from the hospital allocation.

(7) Department allocations. The department's process for funding allocations defined in this subsection applies to the account defined in Texas Health and Safety Code Chapter 780 and includes designated trauma facilities and those in active pursuit of trauma designation in the funding allocation.

(8) Department unawarded designation. An undesignated facility in active pursuit of designation but that has not been awarded a trauma designation by the department pursuant to Texas Health and Safety Code §780.004 must return to the department all funds received from the hospital allocation, plus a penalty of 10 percent of the awarded amount.

(b) Calculation methods. Calculation of county portions of the EMS allocation, the RAC portions of the TSA allocation, and the hospital allocation are:

(1) EMS allocation.

(A) EMS allocation is derived by adjusting the weight of the statutory criteria to ensure, as closely as possible:

(i) 40 percent of the funds go to urban counties; and

(ii) 60 percent of the funds go to rural counties.

(B) An individual county's portion of the EMS allocation is based on its geographic size, population, and the number of emergency health care runs, multiplied by adjustment factors determined by the department, so the distribution approximates the required percentages for urban and rural counties.

(C) The formula is:

(i) the county's population multiplied by an adjustment factor;

(ii) plus, the county's geographic size multiplied by an adjustment factor;

(iii) plus, the county's total emergency health care runs multiplied by an adjustment factor;

(iv) divided by 3; and

(v) multiplied by the total EMS allocation.

(D) The adjustment factors are manipulated so the distribution approximates the required percentages for urban and rural counties.

(E) Total emergency health care runs are the number of emergency patient care records electronically transmitted to the department in a given calendar year by EMS providers.

(2) TSA allocation.

(A) The TSA allocation is based on its relative geographic size, population, and trauma care provided as compared to all other TSAs.

(B) The formula is:

(i) the TSA's percentage of the state's total population;

(ii) plus, the TSA's percentage of the state's total geographic size;

(iii) plus, the TSA's percentage of the state's total trauma care;

(iv) divided by 3; and

(v) multiplied by the total TSA allocation.

(C) Total trauma care is the number of trauma patient records electronically transmitted to the department in a given calendar year by EMS providers and hospitals.

(3) Hospital allocation.

(A) Distributions, including unexpended portions of the EMS and TSA allocations, are determined by an annual application process.

(B) An annual application must be submitted each state fiscal year. Incomplete applications will not be considered for the hospital allocation calculation.

(C) Based on the information provided in the approved application, each facility will receive allocations as follows.

(i) An equal amount, not to exceed 20 percent of the available hospital allocation, to reimburse designated trauma facilities and those facilities in active pursuit of designation under the program.

(ii) Any funds not allocated in paragraphs (1) and (2) of this subsection are included in the distribution formula in subparagraph (E) of this paragraph.

(D) If the total cost of uncompensated trauma care for patients meeting NTDB registry inclusion criteria exceeds the amount appropriated from the account, minus the amount referred to in subparagraph (C)(i) of this paragraph, the department allocates funds based on a facility's percentage of uncompensated trauma care costs in relation to the total uncompensated trauma care cost reported by qualified hospitals for the funding year.

(E) The hospital allocation formula for trauma designated facilities is:

(i) the facility's reported costs of uncompensated trauma care;

(ii) minus any collections received by the facility for any portion of the facility's uncompensated trauma care previously reported for the purposes of this section;

(iii) divided by the total reported costs of uncompensated trauma care by eligible facilities; and

(iv) multiplied by the total money available after reducing the amount to be distributed in subparagraph (C)(i) of this paragraph.

(F) The reporting period of a facility's uncompensated trauma care must apply to costs incurred during the preceding calendar year.

(c) Loss of funding eligibility. If the department finds an EMS provider, RAC, or hospital has violated Texas Health and Safety Code Chapter 773 or fails to comply with this chapter, the department may withhold account monies for a period of one to three years, depending upon the seriousness of the infraction.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on July 18, 2024.

TRD-202403179

Cynthia Hernandez

General Counsel

Department of State Health Services

Earliest possible date of adoption: September 1, 2024

For further information, please call: (512) 535-8538

The Executive Commissioner of the Texas Health and Human Services Commission (HHSC), on behalf of the Department of State Health Services (DSHS), proposes an amendment to §181.22, concerning Fees Charged for Vital Records Services; and the repeal of §181.35, concerning Parental Consent of Underage Applicants to Marriage.

BACKGROUND AND PURPOSE

The purpose of the proposal is to clarify and enhance the transparency of Vital Statistics fees in rule and to repeal outdated rules identified during the rule review process.

The amendment to §181.22 consolidates fees charged for vital records services to clearly state each fee amount. Currently, the public must add together separate fees to get the total fee for a vital record. There is no fee increase with this consolidation.

The expedited service fee, which shortens processing time, is available if the applicant chooses to pay the extra sum. The expedited service fee will increase from $5 to $25 per application. The current fee has not increased in 33 years and does not cover the costs for the service. The public does not need to pay this fee to obtain a vital record.

The amendment includes longstanding services being provided but were not listed in rule.

Section 181.35 is being repealed to comply with Senate Bill 1705, 85th Legislature, Regular Session, 2017, that repealed the statutory authority in the Texas Family Code §2.102.

SECTION-BY-SECTION SUMMARY

The proposed amendment to §181.22 1) clarifies the fee for a copy or research copy of a birth, death, or fetal death record; 2) deletes the surcharge fee for searching and issuing each certified copy of a birth certificate because it was consolidated in the service fee; 3) renumbers and simplifies language of the fee for an heirloom birth certificate, the fee for a heirloom wedding anniversary certificate, the fee for a search of a vital record, and the fee for a birth verification, marriage verification, divorce verification, or death verification; 4) adds the fees for existing services which were not previously included in rule; 5) renumbers and simplifies language of the fee for an identification of the court that granted an adoption and for an amendment to a birth, death, or fetal death record; 6) renumbers and simplifies language of the fee for a new birth record based on adoption or parentage determination, the fee for a delayed record of birth, the fee for an inquiry of the paternity registry, the fee for an inquiry of the Acknowledgment of Paternity Registry, and the fee for enrolling in the Central Adoption Registry; 7) increases the fee and simplifies language of the fee for expedited service; 8) renumbers and simplifies language of the disinterment permit, waived fee for an applicant obtaining an election identification certificate, and the waived fee for applicants who are a victim, or child of a victim, of dating or family violence.

The proposed repeal of §181.35 deletes the rule as the rule is no longer necessary.

FISCAL NOTE

Christy Havel Burton, DSHS Chief Financial Officer, has determined for each year of the first five years §181.22 will be in effect, there will be an estimated increase in revenue to state government as a result of enforcing and administering the rule as proposed. Enforcing or administering the rule does not have foreseeable implications relating to costs or revenues of local governments.

The effect on state government for each year of the first five years the proposed §181.22 is in effect is an estimated increase in revenue of $75,000 in fiscal year (FY) 2025, $150,000 in FY 2026, $150,000 in FY 2027, $150,000 in FY 2028, and $150,000 in FY 2029.

Christy Havel Burton has determined for each year of the first five years the repeal of §181.35 will be in effect, enforcing or administering the rule does not have foreseeable implications relating to costs or revenues of state or local governments.

GOVERNMENT GROWTH IMPACT STATEMENT

DSHS has determined during the first five years the rules will be in effect:

(1) the proposed rules will not create or eliminate a government program;

(2) implementation of the proposed rules will not affect the number of DSHS employee positions;

(3) implementation of the proposed rules will result in no assumed change in future legislative appropriations;

(4) the proposed rules will require an increase in fees paid to DSHS;

(5) the proposed rules will not create a new regulation;

(6) the proposed rules will repeal an existing regulation;

(7) the proposed rules will not change the number of individuals subject to the rules; and

(8) the proposed rules will not affect the state's economy.

SMALL BUSINESS, MICRO-BUSINESS, AND RURAL COMMUNITY IMPACT ANALYSIS

Christy Havel Burton has also determined there will be no adverse economic effect on small businesses, micro-businesses, or rural communities. The rules do not apply to small or micro-businesses, and rural communities.

LOCAL EMPLOYMENT IMPACT

The proposed rules will not affect a local economy.

COSTS TO REGULATED PERSONS

Texas Government Code §2001.0045 does not apply to these rules because the rules do not impose a cost on regulated persons and are necessary to implement legislation that does not specifically state that §2001.0045 applies to the rules.

PUBLIC BENEFIT AND COSTS

Dr. Manda Hall, Associate Commissioner, has determined for each year of the first five years the rules are in effect, the public benefit will be clearer and more transparent Vital Statistics fees in rule. Additionally, increasing the fee for expedited service will allow Vital Statistics to effectively provide this service for customers.

Christy Havel Burton, Chief Financial Officer, has also determined for the first five years the rules are in effect, there are no anticipated economic costs to persons who are required to comply with the proposed rules because the one fee increase is a voluntary fee for expedited service, not in the fees required to pay to obtain vital records.

TAKINGS IMPACT ASSESSMENT

DSHS has determined the proposal does not restrict or limit an owner's right to the owner's property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under Texas Government Code §2007.043.

PUBLIC COMMENT

Written comments on the proposal may be submitted to Rules Coordination Office, P.O. Box 13247, Mail Code 4102, Austin, Texas 78711-3247, or street address 701 W. 51st Street, Austin, Texas 78751; or emailed to HHSRulesCoordinationOffice@hhs.texas.gov.

To be considered, comments must be submitted no later than 31 days after the date of this issue of the Texas Register. Comments must be (1) postmarked or shipped before the last day of the comment period; (2) hand-delivered before 5:00 p.m. on the last working day of the comment period; or (3) emailed before midnight on the last day of the comment period. If the last day to submit comments falls on a holiday, comments must be postmarked, shipped, or emailed before midnight on the following business day to be accepted. When emailing comments, please indicate "Comments on Proposed Rule 24R032" in the subject line.

SUBCHAPTER B. VITAL RECORDS

25 TAC §181.22

STATUTORY AUTHORITY

The amendment is authorized by Texas Government Code §531.0055 and Texas Health and Safety Code §1001.075, which authorize the Executive Commissioner of HHSC to adopt rules for the operation and provision of health and human services by DSHS and for the administration of Texas Health and Safety Code Chapter 1001; and Texas Health and Safety Code §191.0045, which authorizes rules necessary to prescribe fees for vital statistics services.

The amendment implements Texas Government Code §531.0055 and Texas Health and Safety Code, Chapters 191, 192, 193, and 1001.

§181.22.Fees Charged for Vital Records Services.

(a) The fee for a certified copy or research copy of a birth record is $22.00 [shall be $10.00. Additional copies shall be $10.00 for each copy requested].

(b) The fee for a certified copy or research copy of a death or fetal death record is $20.00. The fee [certificate shall be $10.00 for the first or only copy requested, and $3.00] for each additional copy of the same record requested in the same order is $3.00 [request].

[(c) A surcharge of $2.00 shall be added to the fee for searching and issuing each certified copy of a certificate of birth, or conducting a search for a certificate of birth, as mandated by the Texas Health and Safety Code, §191.0045.]

(c) [(d)] The fee for an [issuing each] heirloom birth certificate is [, or gift certificate for such, shall be] $50.00. [If a record is not found, $38.00 of the fee shall be returned to the applicant.]

(d) [(e)] The fee for an heirloom [issuing each] wedding anniversary certificate is [or gift certificate for such shall be] $50.00.

(e) [(f)] The fee for a [to] search of a vital [for any] record or information on file within the Vital Statistics Section is [shall be] $10.00 [, regardless of whether a certified copy is issued or not].

(f) [(g)] The fee for a verification [search to verify the existence] of a birth [or death] record is $22.00 [shall be $10.00].

(g) [(h)] The fee for a verification of [search to verify] a marriage, [or] divorce, or death record is $20.00 [shall be $10.00].

(h) The fee for a photocopy of a marriage license application is $20.00.

(i) The fee for a certificate of birth resulting in stillbirth is $20.00.

(j) The fee for a file sealed by adoption or parentage determination is $10.00.

(k) The fee for a non-certified copy of an original birth certificate to an adult adoptee is $10.00.

(l) [(i)] The fee for an [ a search and] identification of the court that granted an adoption is [shall be] $10.00.

(m) [(j)] The fee for [filing] an amendment to a birth, death, or fetal death record is [ an existing certificate of birth or death on file with the Vital Statistics Section shall be] $15.00. [An amendment to a certificate includes adding information to a record to make it complete and changing information on a record to make it correct. An additional fee is required to issue a certified copy of the amended record.]

[(k) The fee for filing an amendment based on a court ordered name change shall be $15.00.]

(n) [(l)] The fee for a new birth record based on [upon] adoption or parentage determination is [shall be] $25.00.

(o) [(m)] The fee for [filing] a delayed record of birth is [shall be] $25.00.

(p) [(n)] The fee for a [search of the] Paternity Registry inquiry is [shall be] $10.00. [The fee includes a certification stating whether or not the requested information is located in the Registry.]

(q) [(o)] The fee for an [a search of the] Acknowledgment of Paternity Registry inquiry is [shall be] $10.00. The fee includes a certified copy of the Acknowledgement of Paternity, if found.

(r) [(p)] The fee for enrolling in [Each person applying to] the Central Adoption Registry is [shall pay a registration fee of] $30.00 [, which includes the $5.00 fee for determining if an agency that operates its own registry was involved in the adoption]. [(Also see §181.44 of this title (relating to the Inquiry Through the Central Index).)]

(s) [(q)] The fee [charged] for [an] expedited service is $25.00 for each application submission, in addition to required application fees [shall be $5.00 per request in addition to any other fee required. Expedited service is any service requested via fax or overnight mail service. The expedited fee is nonrefundable if a record or the information requested is not found.].

(t) [(r)] The fee for [the processing and issuance of] a disinterment permit is [shall be] $25.00. [The fee is to be paid by the applicant for the permit, and must be submitted with the application.]

[(s) A Texas Online fee of $10.00 shall be added to all requests for birth, death, marriage, and divorce record searches and document production.]

(u) [(t)] The [Except as provided in subsection (c) of this section, the] fee for a certified birth record [that otherwise is required under this section] is waived for an applicant who appears in person to obtain a certified copy from the department or a Local Registrar and states [represents that] the certified record is required for the purpose of obtaining an election identification certificate issued pursuant to Transportation Code[,] Chapter 521A.

(v) [(u)] The fee for a certified copy of a birth record is waived for an applicant who states [represents] the applicant is a victim, or child of a victim, of dating or family violence, pursuant to Texas Health and Safety Code §191.00491, who is fleeing a living situation due to dating or family violence and does not have personal identification documents.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on July 17, 2024.

TRD-202403149

Cynthia Hernandez

General Counsel

Department of State Health Services

Earliest possible date of adoption: September 1, 2024

For further information, please call: (512) 776-7646

STATUTORY AUTHORITY

The repeal is authorized by Texas Government Code §531.0055 and Texas Health and Safety Code §1001.075, which authorize the Executive Commissioner of HHSC to adopt rules for the operation and provision of health and human services by DSHS and for the administration of Texas Health and Safety Code Chapter 1001; and Texas Health and Safety Code §191.0045, which authorizes rules necessary to prescribe fees for vital statistics services.

The repeal implements Texas Government Code §531.0055 and Texas Health and Safety Code, Chapters 191, 192, 193, and 1001.

§181.35.Parental Consent of Underage Applicants to Marriage.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on July 17, 2024.

TRD-202403150

Cynthia Hernandez

General Counsel

Department of State Health Services

Earliest possible date of adoption: September 1, 2024

For further information, please call: (512) 776-7646