(a) The licensee shall be responsible for the conduct of the licensed abortion facility and shall assume full legal responsibility for developing, implementing, enforcing, and monitoring written policies governing the facility's total operation, and for ensuring that these policies comply with the Act and the applicable provisions of this chapter and are administered so as to provide health care in a safe and professionally acceptable environment. These written policies shall include at a minimum the following:
  (1) administrative policies governing the administration of the facility, covering at a minimum:
    (A) personnel;
    (B) employee orientation, training, and evaluation;
    (C) employee and patient record system;
    (D) auditing system for monitoring state or federal funds;
    (E) advertisements for the facility;
    (F) accuracy of public education information materials and activities in relation to abortion, birth control, and sexually-transmitted diseases;
    (G) patient education/information services and referral services;
    (H) reporting requirements; and
    (I) procedures for the resolution of complaints regarding care or services rendered by licensed health professionals and other members of the facility staff, including contract services or staff. The facility shall document the receipt and the disposition of the complaint. The investigation and documentation shall be completed within 30 calendar days after the facility receives the complaint, unless the facility has and documents reasonable cause for a delay.
  (2) clinical policies governing medical and clinical practices and procedures of the facility, covering at a minimum:
    (A) the provision of medical and clinical services;
    (B) the provision of laboratory services;
    (C) examination of fetal tissue;
    (D) disposition of medical waste;
    (E) emergency services;
    (F) condition on discharge procedures;
    (G) clinical records;
    (H) reporting and filing requirements; and
    (I) monitoring post-procedure infection(s).
  (3) a policy to ensure that the facility is in compliance with fire safety provisions as required by the local codes;
  (4) policies on decontamination, disinfection, and sterilization, and storage of sterile supplies;
  (5) policies for parental notice for unemancipated pregnant minors as stipulated in Family Code, Chapter 33;
  (6) policies for informed consent as stipulated in Health and Safety Code, Chapter 171, the Woman's Right to Know Act;
  (7) policies for reporting suspected abuse or neglect as stipulated in Family Code, Chapter 261; and
  (8) policies to ensure all women who present to obtain an abortion provide identification that includes the woman's date of birth.
    (A) If the woman does not have identification stating her date of birth, she shall be required to execute an affidavit on a form published by the department indicating that she does not have appropriate identification and indicating her date of birth on the affidavit.
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    (B) The facility shall keep a copy of the identification presented or the affidavit in its files.
(b) The licensee, in fulfilling its responsibility under subsection (a) of this section, shall review the facility's written policies and procedures periodically, but no less than once every two years; date to indicate time of last review; revise as necessary; and enforce.

Source Note: The provisions of this §139.41 adopted to be effective June 28, 2009, 34 TexReg 4125