(a) The governing body of each limited services rural hospital (LSRH) shall adopt, implement, and enforce a policy relating to patient transfers consistent with this section and contains each of the requirements in subsection (b) of this section. The policy shall identify LSRH staff that has authority to represent the LSRH and the physician regarding transfers from the LSRH.
(b) The LSRH's governing body shall adopt the transfer policy after consultation with the medical staff. The policy shall apply to patient transfers to general and special hospitals licensed under Texas Health and Safety Code (HSC) Chapter 241 (relating to Hospitals) and private psychiatric hospitals licensed under HSC Chapter 577 (relating to Private Mental Hospitals and Other Mental Health Facilities), as well as transfers to general, special, and private psychiatric hospitals that are exempt from licensing.
(c) The LSRH's transfer policy shall govern transfers not covered by a transfer agreement.
(d) The LSRH's transfer policy shall include a written operational plan to provide for patient transfer transportation services if the LSRH does not provide its own patient transfer transportation services.
(e) The LSRH's governing body, after consultation with the medical staff, shall implement its transfer policy by adopting transfer agreements with hospitals in accordance with this section.
(f) The LSRH's transfer policy shall recognize and comply with the requirements HSC Chapter 61 §§61.030 - 61.032 and §§61.057 - 61.059 (relating to Indigent Health Care and Treatment Act).
(g) The LSRH's transfer policy shall acknowledge contractual obligations and comply with statutory or regulatory obligations that may exist concerning a patient and a designated provider.
(h) The LSRH's transfer policy shall require the LSRH to take all reasonable steps to secure the written informed consent of a patient, or a person acting on a patient's behalf, when refusing a transfer or related examination and treatment. Reasonable steps include:
  (1) providing a factual explanation regarding:
    (A) the increased medical risks to the patient reasonably expected from not being transferred, examined, or treated at the transferring hospital;
    (B) any increased risks to the patient from not effecting the transfer; and
    (C) the medical benefits reasonably expected from the provision of appropriate treatment at another hospital; and
  (2) documenting the informed refusal of a patient, or of a person acting on a patient's behalf, to examination, evaluation, or transfer and obtaining, if possible, the signature of the patient or the person acting on the patient's behalf, regarding the refusal that is dated and witnessed by the attending physician or facility employee, and placed in the patient's medical record.
(i) The LSRH's transfer policy shall recognize an individual's right to request a transfer into the care of a physician and a hospital of the individual's own choosing.
(j) The LSRH's transfer policy shall prohibit a patient transfer from being predicated upon arbitrary, capricious, or unreasonable discrimination based upon race, religion, national origin, age, sex, physical condition, economic status, insurance status, or ability to pay.
(k) The LSRH's transfer policy shall require, when a patient requests or consents to transfer for economic reasons and the patient's choice is based on or influenced by representations made by the transferring physician or LSRH administration regarding the availability of medical care and hospital services at a reduced cost or no cost to the patient, the physician or facility administration to fully disclose to the patient the eligibility requirements established by the patient's chosen physician or hospital.
(l) The LSRH's transfer policy shall provide that each patient who arrives at the facility is:
  (1) evaluated by a physician at the time the patient presents or is presented or evaluated by a physician on-call who is:
    (A) physically able to reach the patient within 30 minutes after being informed that a patient is present at the LSRH who requires immediate medical attention; or
    (B) accessible by direct, telephone, or radio communication within 30 minutes with a registered nurse, physician assistant, or other qualified medical personnel as established by the governing body at the LSRH under orders to assess and report the patient's condition to the physician; and
  (2) personally examined and evaluated by the physician before an attempt to transfer is made; however:
    (A) after receiving a report on the patient's condition from the LSRH's registered nurse, physician assistant, or other qualified medical personnel as established by the governing body by telephone or radio, if the physician on-call determines that an immediate transfer of the patient is medically appropriate and that the time required to conduct a personal examination and evaluation of a patient will unnecessarily delay the transfer to the detriment of the patient, the physician on-call may order the transfer by telephone or radio;
    (B) physician orders for the transfer of a patient which are issued by telephone or radio shall be reduced to writing in the patient's medical record, signed by the registered nurse, physician assistant, or other qualified medical personnel as established by the governing body receiving the order, and countersigned by the physician authorizing the transfer as soon as possible; and
    (C) patient transfers resulting from physician orders issued by telephone or radio shall be subject to automatic review by the medical staff pursuant to subsection (q)(6) of this section.
(m) The transfer policies of the transferring LSRH and receiving general or special hospital shall require the facilities to have licensed nurses and other qualified personnel available and on duty to assist with patient transfers. The policies shall require written protocols or standing delegation orders to be in place to guide facility personnel when a patient requires transfer to another hospital.
(n) If a patient at an LSRH has an emergency medical condition that has not been stabilized, or when stabilization of the patient's vital signs is not possible because the LSRH does not have the appropriate equipment or personnel to correct the underlying process, the LSRH shall evaluate and treat the patient, then transfer the patient as quickly as possible.
(o) The LSRH's transfer policy shall prohibit the LSRH from transferring a patient with an emergency medical condition that has not been stabilized unless:
  (1) the individual (or a legally responsible person acting on the individual's behalf), after being informed of the LSRH's obligations under this section and of the risk of transfer, requests the transfer in writing, indicates the reasons for the request, and states the individual is aware of the risks and benefits of the transfer; or
  (2) a physician signs a certification, which includes a summary of the risks and benefits based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another hospital outweigh the increased risks to the patient and, in the case of labor, to the unborn child from effecting the transfer.
(p) except as specifically provided in subsection (o) of this section, the LSRH's policy shall provide that the transfer of patients who have emergency medical conditions, as determined by a physician, shall be undertaken for medical reasons only. The LSRH must provide medical treatment within its capacity that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child.
(q) The LSRH's transfer policy shall include the following information related to physicians' duties and standard of care. The policy shall require:
  (1) the transferring physician to determine and order life support measures that are medically appropriate to stabilize the patient before transfer and to sustain the patient during transfer;
  (2) the transferring physician to determine and order the utilization of appropriate personnel and equipment for the transfer;
  (3) the transferring physician, in determining the use of medically appropriate life support measures, personnel, and equipment, to exercise that degree of care which a reasonable and prudent physician exercising ordinary care in the same or similar locality would use for the transfer;
  (4) except as allowed under subsection (o) of this section, before each patient transfer, the physician who authorizes the transfer to personally examine and evaluate the patient to determine the patient's medical needs and to ensure that the proper transfer procedures are used;
Cont'd...
(5) before each patient transfer, the transferring physician to ensure the receiving general or special hospital and physician are appropriate to the patient's medical needs and have accepted responsibility for the patient's medical treatment and hospital care; and
  (6) the LSRH's medical staff review appropriate records of patients transferred from the LSRH to determine that the appropriate standard of care has been met.
(r) The LSRH's transfer policy shall comply with the following requirements related to medical records.
  (1) The policy shall require the LSRH to forward a copy of the portions of the patient's medical record, which are available and relevant to the transfer and to the continuing care of the patient, to the receiving physician and receiving hospital with the patient. When all necessary medical records for the continued care of the patient are not available at the time the patient is transferred, the transferring LSRH shall forward the records to the receiving physician and hospital as soon as possible.
  (2) The patient's medical record shall contain at least the following:
    (A) a brief description of the patient's medical history and physical examination;
    (B) a working diagnosis and recorded observations of physical assessment of the patient's condition at the time of transfer;
    (C) the reason for the transfer;
    (D) the results of all diagnostic tests, such as laboratory tests;
    (E) relevant radiological films and reports; and
    (F) any other relevant information.
(s) The LSRH's transfer policy shall require the LSRH to complete a memorandum of transfer for every transferred patient.
  (1) The memorandum shall contain the following information:
    (A) if known, the patient's:
      (i) full name;
      (ii) race, religion, national origin, age, sex, disability status;
      (iii) address and phone number; and
      (iv) next of kin address and phone number;
    (B) the transferring and receiving physicians' names, telephone numbers, and addresses;
    (C) the transferring LSRH's and receiving general or special hospital's names, addresses, and telephone numbers;
    (D) the time and date on which the patient first presented or was presented to the transferring physician and transferring LSRH;
    (E) the time and date on which the transferring physician secured a receiving physician;
    (F) the name of the hospital contact and date and time hospital administration was contacted in the receiving general or special hospital;
    (G) the transferring LSRH administrator's signature and title and time the administrator contacted the receiving hospital;
    (H) certification required by subsection (o)(2) of this section, if applicable (the certification may be part of the memorandum of transfer form or may be on a separate form attached to the memorandum of transfer form);
    (I) the time and date the receiving physician assumed responsibility for the patient;
    (J) the time and date the patient arrived at the receiving general or special hospital;
    (K) the signature and date of receiving hospital administration;
    (L) the type of vehicle and company used to transport the patient;
    (M) the type of equipment and personnel needed in transfers;
    (N) the name and city of hospital where the patient was transported;
    (O) the patient's diagnosis by the transferring physician; and
    (P) the attachments by the transferring LSRH.
  (2) The transferring LSRH shall retain a copy of the memorandum of transfer for five years and file the memorandum separately from the patient's medical record and in a manner facilitating its inspection by the Texas Health and Human Services Commission.
(t) An LSRH violates HSC Chapter 241 and this section if:
  (1) the LSRH fails to comply with the requirements of this section; or
  (2) the LSRH's governing body fails or refuses to:
    (A) adopt a transfer policy that complies with this section and contains all requirements listed in this section;
    (B) adopt a memorandum of transfer form that complies with the content requirements contained in this section; or
    (C) enforce its transfer policy and the use of the memorandum of transfer.

Source Note: The provisions of this §511.65 adopted to be effective October 5, 2023, 48 TexReg 5668