The governing body shall address and is fully responsible, either directly or by appropriate professional delegation, for operation and performance of the facility. Governing body responsibilities include:
  (1) determining the mission, goals, and objectives of the facility;
  (2) ensuring that facilities and personnel are adequate and appropriate to carry out the mission;
  (3) ensuring a physical environment that protects the health and safety of patients, personnel, and the public;
  (4) establishing an organizational structure and specifying functional relationships among the various components of the facility;
  (5) adopting, implementing, and enforcing bylaws or similar rules and regulations for the orderly development and management of the facility;
  (6) adopting, implementing, and enforcing policies or procedures necessary for orderly conduct of the facility;
  (7) reviewing and approving the facility's training program for staff;
  (8) ensuring that all equipment used by facility staff or patients is properly used and maintained per manufacturer recommendations;
  (9) adopting, implementing, and enforcing policies or procedures related to emergency planning and disaster preparedness, including reviewing the facility's disaster preparedness plan at least annually;
  (10) ensuring there is a quality assessment and performance improvement (QAPI) program to evaluate the provision of patient care, including quarterly review and monitoring of QAPI activities;
  (11) reviewing legal and ethical matters concerning the facility and its staff, when necessary, and responding appropriately;
  (12) maintaining effective communication throughout the facility;
  (13) establishing a system of financial management and accountability that includes an audit or financial review appropriate to the facility;
  (14) adopting, implementing, and enforcing policies for provision of radiological services;
  (15) adopting, implementing, and enforcing policies for provision of laboratory services;
  (16) adopting, implementing, and enforcing policies for provision of pharmacy services;
  (17) adopting, implementing, and enforcing policies for collection, processing, maintenance, storage, retrieval, authentication, and distribution of patient medical records and reports;
  (18) adopting, implementing, and enforcing a policy on the rights of patients and complying with all state and federal patient rights requirements;
  (19) adopting, implementing, and enforcing policies for provision of an effective procedure for the immediate transfer to a licensed hospital of patients requiring emergency care beyond the capabilities of the facility, including a transfer agreement with a hospital licensed in this state in accordance with §509.66 of this subchapter (relating to Patient Transfer Agreements);
  (20) adopting, implementing, and enforcing policies for all individuals that arrive at the facility to ensure they are provided an appropriate medical screening examination within the capability of the facility, including ancillary services routinely available to determine whether or not the individual needs emergency care as defined in §509.2 of this chapter (relating to Definitions), and that if emergency care is determined to be needed, the facility shall provide any necessary stabilizing treatment or arrange an appropriate transfer the individual as defined in §509.65 of this subchapter (relating to Patient Transfer Policy);
  (21) adopting, implementing, and enforcing protocols to be used in determining death and for filing autopsy reports that comply with Texas Health and Safety Code Chapter 671 (relating to Determination of Death and Autopsy Reports);
  (22) approving all major contracts or arrangements affecting the medical care provided under its auspices, including those concerning:
    (A) services of physicians and practitioners;
    (B) use of external laboratories; and
    (C) an effective procedure for obtaining emergency laboratory, radiology, and pharmaceutical services when these services are not immediately available due to system failure;
  (23) formulating long-range plans in accordance with the mission, goals, and objectives of the facility;
  (24) operating the facility without limitation because of color, race, age, sex, religion, national origin, or disability;
  (25) ensuring that all marketing and advertising concerning the facility does not imply that it provides care or services that the facility is not capable of providing; and
  (26) developing a system of risk management appropriate to the facility, including:
    (A) periodic review of all litigation involving the facility, its staff, physicians, and practitioners regarding activities in the facility;
    (B) periodic review of all incidents reported by staff and patients;
    (C) review of all deaths, trauma, or adverse reactions occurring on premises; and
    (D) evaluation of patient complaints.

Source Note: The provisions of this §509.42 adopted to be effective December 4, 2023, 48 TexReg 7064