(a) A facility shall have an identified governing body fully responsible for organization, management, control, and operation of the facility, including the appointment of the facility's medical director. The medical director shall be board certified or board eligible in emergency medicine, or board certified in primary care with at least two years emergency care experience.
(b) The governing body shall adopt, implement, and enforce written policies and procedures for the total operation and all services provided by the facility.
(c) The governing body is responsible for all services furnished in the facility, whether furnished directly or under contract. The governing body shall ensure services are provided in a safe and effective manner that permits the facility to comply with all applicable rules and standards.
(d) The governing body shall ensure the medical staff has on file current written bylaws, rules, and regulations that are adopted, implemented, and enforced.
(e) The governing body shall disclose all owners of the facility to the Texas Health and Human Services Commission (HHSC).
(f) The governing body shall meet at least annually and keep minutes or other records necessary for orderly conduct of the facility. Each meeting held by the facility governing body shall be a separate meeting with separate minutes from any other governing body meeting.
(g) If the governing body elects, appoints, or employs officers and administrators to carry out its directives, the governing body shall define the authority, responsibility, and functions of all such positions.
(h) The governing body shall develop a process for appointing or reappointing medical staff, and for assigning or curtailing medical privileges.
(i) The governing body shall provide (in a manner consistent with state law and based on evidence of education, training, and current competence) for the initial appointment, reappointment, and assignment or curtailment of privileges and practice for non-physician health care personnel and practitioners.
(j) The governing body shall encourage personnel to participate in continuing education that is relevant to their responsibilities within the facility.
(k) The governing body shall adopt, implement, and enforce written policies to ensure compliance with applicable state and federal laws.
(l) In accordance with Texas Health and Safety Code §254.157 (relating to Certain Advertising Prohibited), a facility may not advertise or hold itself out as a network provider, including by stating that the facility "takes" or "accepts" any insurer, health maintenance organization, health benefit plan, or health benefit plan network, unless the facility is a network provider of a health benefit plan issuer.
(m) A facility may not post the name or logo of a health benefit plan issuer in any signage or marketing materials if the facility is an out-of-network provider for all of the issuer's health benefit plans.
(n) A facility shall assess, and the governing body shall review, patient satisfaction with services and environment no less than annually.

Source Note: The provisions of this §509.41 adopted to be effective December 4, 2023, 48 TexReg 7064