CHAPTER 241. HOSPITALS
HEALTH AND SAFETY CODE
TITLE 4. HEALTH FACILITIES
SUBTITLE B. LICENSING OF HEALTH FACILITIES
CHAPTER 241. HOSPITALS
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 241.001. SHORT TITLE. This chapter may be cited as the
Texas Hospital Licensing Law.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Sec. 241.002. PURPOSE. The purpose of this chapter is to
protect and promote the public health and welfare by providing
for the development, establishment, and enforcement of certain
standards in the construction, maintenance, and operation of
hospitals.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Sec. 241.003. DEFINITIONS. In this chapter:
(1) "Advanced practice nurse" means a registered nurse
recognized as an advanced practice nurse by the Texas Board of
Nursing.
(2) "Board" means the Texas Board of Health.
(3) "Comprehensive medical rehabilitation hospital" means a
general hospital that specializes in providing comprehensive
medical rehabilitation services, including surgery and related
ancillary services.
(4) "Department" means the Texas Department of Health.
(5) "General hospital" means an establishment that:
(A) offers services, facilities, and beds for use for more than
24 hours for two or more unrelated individuals requiring
diagnosis, treatment, or care for illness, injury, deformity,
abnormality, or pregnancy; and
(B) regularly maintains, at a minimum, clinical laboratory
services, diagnostic X-ray services, treatment facilities
including surgery or obstetrical care or both, and other
definitive medical or surgical treatment of similar extent.
(6) "Governmental unit" means a political subdivision of the
state, including a hospital district, county, or municipality,
and any department, division, board, or other agency of a
political subdivision.
(7) "Hospital" includes a general hospital and a special
hospital.
(8) "Medical staff" means a physician or group of physicians and
a podiatrist or a group of podiatrists who by action of the
governing body of a hospital are privileged to work in and use
the facilities of a hospital for or in connection with the
observation, care, diagnosis, or treatment of an individual who
is, or may be, suffering from a mental or physical disease or
disorder or a physical deformity or injury.
(9) "Pediatric and adolescent hospital" means a general hospital
that specializes in providing services to children and
adolescents, including surgery and related ancillary services.
(10) "Person" means an individual, firm, partnership,
corporation, association, or joint stock company, and includes a
receiver, trustee, assignee, or other similar representative of
those entities.
(11) "Physician" means a physician licensed by the Texas State
Board of Medical Examiners.
(12) "Physician assistant" means a physician assistant licensed
by the Texas State Board of Physician Assistant Examiners.
(13) "Podiatrist" means a podiatrist licensed by the Texas State
Board of Podiatric Medical Examiners.
(14) Repealed by Acts 2005, 79th Leg., Ch. 1286, Sec. 2, eff.
September 1, 2005.
(15) "Special hospital" means an establishment that:
(A) offers services, facilities, and beds for use for more than
24 hours for two or more unrelated individuals who are regularly
admitted, treated, and discharged and who require services more
intensive than room, board, personal services, and general
nursing care;
(B) has clinical laboratory facilities, diagnostic X-ray
facilities, treatment facilities, or other definitive medical
treatment;
(C) has a medical staff in regular attendance; and
(D) maintains records of the clinical work performed for each
patient.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Amended by Acts 1995, 74th Leg., ch. 965, Sec. 79, eff. Sept. 1,
1995; Acts 1997, 75th Leg., ch. 43, Sec. 1, eff. May 7, 1997;
Acts 1997, 75th Leg., ch. 623, Sec. 2, eff. Sept. 1, 1997; Acts
1999, 76th Leg., ch. 428, Sec. 1, eff. Sept. 1, 1999.
Amended by:
Acts 2005, 79th Leg., Ch.
1286, Sec. 2, eff. September 1, 2005.
Acts 2007, 80th Leg., R.S., Ch.
889, Sec. 67, eff. September 1, 2007.
Sec. 241.004. EXEMPTIONS. This chapter does not apply to a
facility:
(1) licensed under Chapter 242 or 577;
(2) maintained or operated by the federal government or an
agency of the federal government; or
(3) maintained or operated by this state or an agency of this
state.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Amended by Acts 1991, 72nd Leg., ch. 76, Sec. 16, eff. Sept. 1,
1991.
Sec. 241.005. EMPLOYMENT OF PERSONNEL. The department may
employ stenographers, inspectors, and other necessary assistants
in carrying out the provisions of this chapter.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Sec. 241.006. COORDINATION OF SIGNAGE REQUIREMENTS IMPOSED BY
STATE AGENCIES. (a) The department is authorized to review
current and proposed state rules issued by the department or by
other state agencies that mandate that a hospital place or post a
notice, poster, or sign in a conspicuous place or in an area of
high public traffic, concerning the rights of patients or others
or the responsibilities of the hospital, which is directed at
patients, patients' families, or others. The purpose of this
review shall be to coordinate the placement, format, and language
contained in the required notices in order to:
(1) eliminate the duplication of information;
(2) reduce the potential for confusion to patients, patients'
families, and others; and
(3) reduce the administrative burden of compliance on hospitals.
(b) Notwithstanding any other law, this section applies to all
notices, posters, or signs described in Subsection (a).
Added by Acts 1995, 74th Leg., ch. 965, Sec. 3, eff. June 16,
1995.
SUBCHAPTER B. HOSPITAL LICENSES
Sec. 241.021. LICENSE REQUIRED. A person or governmental unit,
acting severally or jointly with any other person or governmental
unit, may not establish, conduct, or maintain a hospital in this
state without a license issued under this chapter.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Sec. 241.022. LICENSE APPLICATION. (a) An application for a
license must be made to the department on a form provided by the
department.
(b) The application must contain:
(1) the name and social security number of the sole proprietor,
if the applicant is a sole proprietor;
(2) the name and social security number of each general partner
who is an individual, if the applicant is a partnership;
(3) the name and social security number of any individual who
has an ownership interest of more than 25 percent in the
corporation, if the applicant is a corporation; and
(4) any other information that the department may reasonably
require.
(c) The department shall require that each hospital show
evidence that:
(1) at least one physician is on the medical staff of the
hospital, including evidence that the physician is currently
licensed;
(2) the governing body of the hospital has adopted and
implemented a patient transfer policy in accordance with Section
241.027; and
(3) if the governing body has chosen to implement patient
transfer agreements, it has implemented the agreements in
accordance with Section 241.028.
(d) The application must be accompanied by:
(1) a copy of the hospital's current patient transfer policy;
(2) a nonrefundable license fee;
(3) copies of the hospital's patient transfer agreements, unless
the filing of copies has been waived by the hospital licensing
director in accordance with the rules adopted under this chapter;
and
(4) a copy of the most recent annual fire safety inspection
report from the fire marshal in whose jurisdiction the hospital
is located.
(e) The department may require that the application be approved
by the local health authority or other local official for
compliance with municipal ordinances on building construction,
fire prevention, and sanitation. A hospital located outside the
limits of a municipality shall comply with corresponding state
laws.
(f) The department shall post on the department's Internet
website a list of all of the individuals named in applications as
required by Subsections (b)(1)-(3). The department may not post
on its Internet website a social security number of an individual
required to be named in an application under Subsections
(b)(1)-(3).
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Amended by Acts 1991, 72nd Leg., ch. 14, Sec. 82, eff. Sept. 1,
1991; Acts 1993, 73rd Leg., ch. 584, Sec. 1, eff. Sept. 1, 1993.
Amended by:
Acts 2005, 79th Leg., Ch.
1161, Sec. 1, eff. September 1, 2005.
Sec. 241.023. ISSUANCE OF LICENSE. (a) On receiving a license
application and the license fee, the department shall issue a
license if it finds that the applicant and the hospital comply
with this chapter and the rules or standards adopted under this
chapter.
(b) A license may be renewed annually after payment of the
required fee and submission of an application for license renewal
that contains the information required by Section 241.022(b).
(c) Except as provided by Subsection (c-1), the department may
issue a license only for the premises of a hospital and person or
governmental unit named in the application.
(c-1) The department may issue one license for multiple
hospitals if:
(1) all buildings in which inpatients receive hospital services
and inpatient services of each of the hospitals to be included in
the license are subject to the control and direction of the same
governing body;
(2) all buildings in which inpatients receive hospital services
are within a 30-mile radius of the main address of the applicant;
(3) there is integration of the organized medical staff of each
of the hospitals to be included in the license;
(4) there is a single chief executive officer for all of the
hospitals who reports directly to the governing body and through
whom all administrative authority flows and who exercises control
and surveillance over all administrative activities of the
hospital;
(5) there is a single chief medical officer for all of the
hospitals who reports directly to the governing body and who is
responsible for all medical staff activities of the hospital;
(6) each building of a hospital to be included in the license
that is geographically separate from other buildings of the same
hospital contains at least one nursing unit for inpatients,
unless providing only diagnostic or laboratory services, or a
combination of diagnostic or laboratory services, in the building
for hospital inpatients; and
(7) each hospital that is to be included in the license complies
with the emergency services standards:
(A) for a general hospital, if the hospital provides surgery or
obstetrical care or both; or
(B) for a special hospital, if the hospital does not provide
surgery or obstetrical care.
(c-2) The hospital licensing director may recommend a waiver of
the requirement of Subsection (c-1)(7) for a hospital if another
hospital that is to be included in the license:
(1) complies with the emergency services standards for a general
hospital; and
(2) is in close geographic proximity to the hospital.
(c-3) The executive commissioner of the Health and Human
Services Commission shall adopt rules to implement the waiver
provision of Subsection (c-2). The rules must provide for a
determination by the department that the waiver will facilitate
the creation or operation of the hospital seeking the waiver and
that the waiver is in the best interest of the individuals served
or to be served by the hospital.
(d) Subject to Subsection (e), a license issued under this
section for a hospital includes each outpatient facility that is
not separately licensed, that is located apart from the hospital,
and for which the hospital has submitted to the department:
(1) a copy of a fire safety survey that is dated not earlier
than one year before the submission date indicating approval by:
(A) the local fire authority in whose jurisdiction the
outpatient facility is located; or
(B) the nearest fire authority, if the outpatient facility is
located outside of the jurisdiction of a local fire authority;
and
(2) if the hospital is accredited by the Joint Commission on
Accreditation of Healthcare Organizations or the American
Osteopathic Association, a copy of documentation from the
accrediting body showing that the outpatient facility is included
within the hospital's accreditation.
(e) Subsection (d) applies only if the federal Department of
Health and Human Services, Health Care Financing Administration,
or Office of Inspector General adopts final or interim final
rules requiring state licensure of outpatient facilities as a
condition of the determination of provider-based status for
Medicare reimbursement purposes.
(f) A license may not be transferred or assigned without the
written approval of the department.
(g) A license shall be posted in a conspicuous place on the
licensed premises.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Amended by Acts 1999, 76th Leg., ch. 1411, Sec. 2.01, eff. Sept.
1, 1999.
Amended by:
Acts 2005, 79th Leg., Ch.
1161, Sec. 2, eff. September 1, 2005.
Acts 2005, 79th Leg., Ch.
1286, Sec. 1, eff. September 1, 2005.
Sec. 241.024. HOSPITAL LICENSING DIRECTOR. (a) The
commissioner of health shall appoint, with the advice and consent
of the board, a person to serve as hospital licensing director.
(b) A person appointed as the hospital licensing director must:
(1) have at least five years experience or training, or both, in
the field of hospital administration;
(2) be of good moral character; and
(3) have been a resident of this state for at least three years.
(c) The hospital licensing director shall administer this
chapter and is directly responsible to the department.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Sec. 241.025. LICENSE FEES. (a) The department shall charge
each hospital an annual license fee for an initial license or a
license renewal.
(b) The board by rule shall adopt the fees authorized by
Subsection (a) according to a schedule under which the number of
beds in the hospital determines the amount of the fee. The fee
may not exceed $15 a bed. A minimum license fee may be
established. The minimum fee may not exceed $1,000.
(c) A fee adopted under this chapter must be based on the
estimated cost to and level of effort expended by the department
to conduct the activity for which the fee is imposed.
(d) All license fees collected shall be deposited in the state
treasury to the credit of the department to administer and
enforce this chapter. These fees are hereby appropriated to the
department.
(e) Notwithstanding Subsection (d), to the extent that money
received from the fees collected under this chapter exceeds the
costs to the department to conduct the activity for which the fee
is imposed, the department may use the money to administer
Chapter 324 and similar laws that require the department to
provide information related to hospital care to the public. The
department may not consider the costs of administering Chapter
324 or similar laws in adopting a fee imposed under this section.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Amended by Acts 1993, 73rd Leg., ch. 584, Sec. 3, eff. Sept. 1,
1993; Acts 1999, 76th Leg., ch. 1411, Sec. 2.02, eff. Sept. 1,
1999.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 4, eff. September 1, 2007.
Sec. 241.026. RULES AND MINIMUM STANDARDS. (a) The board shall
adopt and enforce rules to further the purposes of this chapter.
The rules at a minimum shall address:
(1) minimum requirements for staffing by physicians and nurses;
(2) hospital services relating to patient care;
(3) fire prevention, safety, and sanitation requirements in
hospitals;
(4) patient care and a patient bill of rights;
(5) compliance with other state and federal laws affecting the
health, safety, and rights of hospital patients; and
(6) compliance with nursing peer review under Subchapter I,
Chapter 301, and Chapter 303, Occupations Code, and the rules of
the Texas Board of Nursing relating to peer review.
(b) In adopting rules, the board shall consider the conditions
of participation for certification under Title XVIII of the
Social Security Act (42 U.S.C. Section 1395 et seq.) and the
standards of the Joint Commission on Accreditation of Healthcare
Organizations and will attempt to achieve consistency with those
conditions and standards.
(c) Upon the recommendation of the hospital licensing director
and the council, the board by order may waive or modify the
requirement of a particular provision of this Act or minimum
standard adopted by board rule under this section to a particular
general or special hospital if the board determines that the
waiver or modification will facilitate the creation or operation
of the hospital and that the waiver or modification is in the
best interests of the individuals served or to be served by the
hospital.
(d) The board shall adopt rules establishing procedures and
criteria for the issuance of the waiver or modification order.
The criteria must include at a minimum a statement of the
appropriateness of the waiver or modification against the best
interests of the individuals served by the hospital.
(e) If the board orders a waiver or modification of a provision
or standard, the licensing record of the hospital granted the
waiver or modification shall contain documentation to support the
board's action. The board's rules shall specify the type and
specificity of the supporting documentation that must be
included.
(f) A comprehensive medical rehabilitation hospital or a
pediatric and adolescent hospital shall have an emergency
treatment room but is not required to have an emergency
department.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Amended by Acts 1991, 72nd Leg., ch. 350, Sec. 1, eff. Aug. 26,
1991; Acts 1993, 73rd Leg., ch. 584, Sec. 4, eff. Sept. 1, 1993;
Acts 1997, 75th Leg., ch. 43, Sec. 2, eff. May 7, 1997; Acts
1997, 75th Leg., ch. 617, Sec. 2, eff. Sept. 1, 1997; Acts 1997,
75th Leg., ch. 623, Sec. 3, eff. Sept. 1, 1997; Acts 2001, 77th
Leg., ch. 1420, Sec. 14.786, eff. Sept. 1, 2001.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
889, Sec. 68, eff. September 1, 2007.
Sec. 241.0262. CIRCULATING DUTIES FOR SURGICAL SERVICES.
Circulating duties in the operating room must be performed by
qualified registered nurses. In accordance with approved medical
staff policies and procedures, licensed vocational nurses and
surgical technologists may assist in circulatory duties under the
direct supervision of a qualified registered nurse circulator.
Added by Acts 2005, 79th Leg., Ch.
966, Sec. 2, eff. September 1, 2005.
Sec. 241.0263. RECOMMENDATIONS RELATING TO MISSING INFANTS. (a)
The department shall recommend hospital security procedures to:
(1) reduce the likelihood of infant patient abduction; and
(2) aid in the identification of missing infants.
(b) In making recommendations, the department shall consider
hospital size and location and the number of births at a
hospital.
(c) The procedures recommended by the department under
Subsection (a)(1) may include:
(1) controlling access to newborn nurseries;
(2) expanding observation of newborn nurseries through the use
of video cameras; and
(3) requiring identification for hospital staff and visitors as
a condition of entrance to newborn nurseries.
(d) The procedures recommended by the department under
Subsection (a)(2) may include:
(1) footprinting, photographing, or writing descriptions of
infant patients at birth; and
(2) obtaining umbilical cord blood samples for infant patients
born at the hospital and storing the samples for genetic testing
purposes.
(e) Each hospital licensed under this chapter shall consider
implementing the procedures recommended under this section.
Added by Acts 1997, 75th Leg., ch. 314, Sec. 1, eff. Sept. 1,
1997.
Sec. 241.0265. STANDARDS FOR CARE FOR MENTAL HEALTH AND CHEMICAL
DEPENDENCY. (a) The care and treatment of a patient receiving
mental health services in a facility licensed by the department
under this chapter or Chapter 577 are governed by the standards
adopted by the Texas Department of Mental Health and Mental
Retardation to the same extent as if the standards adopted by
that department were rules adopted by the board under this
chapter or Chapter 577.
(b) The care and treatment of a patient receiving chemical
dependency treatment in a facility licensed by the department
under this chapter are governed by the same standards that govern
the care and treatment of a patient receiving treatment in a
treatment facility licensed under Chapter 464 and that are
adopted by the Texas Commission on Alcohol and Drug Abuse, to the
same extent as if the standards adopted by the commission were
rules adopted by the board under this chapter.
(c) The department shall enforce the standards provided by
Subsections (a) and (b). A violation of a standard is subject to
the same consequence as a violation of a rule adopted by the
board under this chapter or Chapter 577. The department is not
required to enforce a standard if the enforcement violates a
federal law, rule, or regulation.
Added by Acts 1993, 73rd Leg., ch. 573, Sec. 3.02, eff. Sept. 1,
1993.
Sec. 241.027. PATIENT TRANSFERS. (a) The board shall adopt
rules to govern the transfer of patients between hospitals that
do not have a transfer agreement and governing services not
included in transfer agreements.
(b) The rules must provide that patient transfers between
hospitals be accomplished through hospital policies that result
in medically appropriate transfers from physician to physician
and from hospital to hospital by providing:
(1) for notification to the receiving hospital before the
patient is transferred and confirmation by the receiving hospital
that the patient meets the receiving hospital's admissions
criteria relating to appropriate bed, physician, and other
services necessary to treat the patient;
(2) for the use of medically appropriate life support measures
that a reasonable and prudent physician exercising ordinary care
in the same or a similar locality would use to stabilize the
patient before the transfer and to sustain the patient during the
transfer;
(3) for the provision of appropriate personnel and equipment
that a reasonable and prudent physician exercising ordinary care
in the same or a similar locality would use for the transfer;
(4) for the transfer of all necessary records for continuing the
care for the patient; and
(5) that the transfer of a patient not be predicated on
arbitrary, capricious, or unreasonable discrimination because of
race, religion, national origin, age, sex, physical condition, or
economic status.
(c) The rules must require that if a patient at a hospital has
an emergency medical condition which has not been stabilized, the
hospital may not transfer the patient unless:
(1) the patient or a legally responsible person acting on the
patient's behalf, after being informed of the hospital's
obligations under this section and of the risk of transfer, in
writing requests transfer to another medical facility;
(2) a licensed physician has signed a certification, which
includes a summary of the risks and benefits, that, based on the
information available at the time of transfer, the medical
benefits reasonably expected from the provision of appropriate
medical treatment at another medical facility outweigh the
increased risks to the patient and, in the case of labor, to the
unborn child from effecting the transfer; or
(3) if a licensed physician is not physically present in the
emergency department at the time a patient is transferred, a
qualified medical person has signed a certification described in
Subdivision (2) after a licensed physician, in consultation with
the person, has made the determination described in such clause
and subsequently countersigns the certificate.
(d) The rules also shall provide that a public hospital or
hospital district shall accept the transfer of its eligible
residents if the public hospital or hospital district has
appropriate facilities, services, and staff available for
providing care to the patient.
(e) The rules must require that a hospital take all reasonable
steps to secure the informed refusal of a patient or of a person
acting on the patient's behalf to a transfer or to related
examination and treatment.
(f) The rules must recognize any contractual, statutory, or
regulatory obligations that may exist between a patient and a
designated or mandated provider as those obligations apply to the
transfer of emergency or nonemergency patients.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Amended by Acts 1991, 72nd Leg., ch. 14, Sec. 83, eff. Sept. 1,
1991; Acts 1993, 73rd Leg., ch. 584, Sec. 5, eff. Sept. 1, 1993.
Sec. 241.028. TRANSFER AGREEMENTS. (a) If hospitals execute a
transfer agreement that is consistent with the requirements of
this section, all patient transfers between the hospitals are
governed by the agreement.
(b) The hospitals shall submit the agreement to the department
for review for compliance with the requirements of this section.
The department shall complete the review of the agreement within
30 days after the date the agreement is submitted by the
hospitals.
(c) At a minimum, a transfer agreement must provide that:
(1) transfers be accomplished in a medically appropriate manner
and comply with Sections 241.027(b)(2) through (5) and Section
241.027(c);
(2) the transfer or receipt of patients in need of emergency
care not be based on the individual's inability to pay for the
services rendered by the transferring or receiving hospital;
(3) multiple transfer agreements be entered into by a hospital
based on the type or level of medical services available at other
hospitals;
(4) the hospitals recognize the right of an individual to
request transfer to the care of a physician and hospital of the
individual's choice;
(5) the hospitals recognize and comply with the requirements of
Chapter 61 (Indigent Health Care and Treatment Act) relating to
the transfer of patients to mandated providers; and
(6) consideration be given to availability of appropriate
facilities, services, and staff for providing care to the
patient.
(d) If a hospital transfers a patient in violation of Subsection
(c)(1), (2), (4), (5), or (6), relating to required provisions
for a transfer agreement, the violation is a violation of this
chapter.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Amended by Acts 1991, 72nd Leg., ch. 14, Sec. 84, eff. Sept. 1,
1991; Acts 1993, 73rd Leg., ch. 584, Sec. 6, eff. Sept. 1, 1993.
Sec. 241.029. POLICIES AND PROCEDURES RELATING TO WORKPLACE
SAFETY. (a) The governing body of a hospital shall adopt
policies and procedures related to the work environment for
nurses to:
(1) improve workplace safety and reduce the risk of injury,
occupational illness, and violence; and
(2) increase the use of ergonomic principles and ergonomically
designed devices to reduce injury and fatigue.
(b) The policies and procedures adopted under Subsection (a), at
a minimum, must include:
(1) evaluating new products and technology that incorporate
ergonomic principles;
(2) educating nurses in the application of ergonomic practices;
(3) conducting workplace audits to identify areas of risk of
injury, occupational illness, or violence and recommending ways
to reduce those risks;
(4) controlling access to those areas identified as having a
high risk of violence; and
(5) promptly reporting crimes committed against nurses to
appropriate law enforcement agencies.
Added by Acts 2003, 78th Leg., ch. 876, Sec. 13, eff. June 20,
2003.
SUBCHAPTER C. ENFORCEMENT
Sec. 241.051. INSPECTIONS. (a) The department may make any
inspection, survey, or investigation that it considers necessary.
A representative of the department may enter the premises of a
hospital at any reasonable time to make an inspection, a survey,
or an investigation to assure compliance with or prevent a
violation of this chapter, the rules adopted under this chapter,
an order or special order of the commissioner of health, a
special license provision, a court order granting injunctive
relief, or other enforcement procedures. The department shall
maintain the confidentiality of hospital records as applicable
under state or federal law.
(b) The department or a representative of the department is
entitled to access to all books, records, or other documents
maintained by or on behalf of the hospital to the extent
necessary to enforce this chapter, the rules adopted under this
chapter, an order or special order of the commissioner of health,
a special license provision, a court order granting injunctive
relief, or other enforcement procedures.
(c) By applying for or holding a hospital license, the hospital
consents to entry and inspection of the hospital by the
department or a representative of the department in accordance
with this chapter and the rules adopted under this chapter.
(d) All information and materials obtained or compiled by the
department in connection with a complaint and investigation
concerning a hospital are confidential and not subject to
disclosure under Section 552.001 et seq., Government Code, and
not subject to disclosure, discovery, subpoena, or other means of
legal compulsion for their release to anyone other than the
department or its employees or agents involved in the enforcement
action except that this information may be disclosed to:
(1) persons involved with the department in the enforcement
action against the hospital;
(2) the hospital that is the subject of the enforcement action,
or the hospital's authorized representative;
(3) appropriate state or federal agencies that are authorized to
inspect, survey, or investigate hospital services;
(4) law enforcement agencies; and
(5) persons engaged in bona fide research, if all
individual-identifying and hospital-identifying information has
been deleted.
(e) The following information is subject to disclosure in
accordance with Section 552.001 et seq., Government Code:
(1) a notice of alleged violation against the hospital, which
notice shall include the provisions of law which the hospital is
alleged to have violated, and a general statement of the nature
of the alleged violation;
(2) the pleadings in the administrative proceeding; and
(3) a final decision or order by the department.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Amended by Acts 1993, 73rd Leg., ch. 584, Sec. 8, eff. Sept. 1,
1993; Acts 1999, 76th Leg., ch. 1444, Sec. 15, eff. Aug. 30,
1999.
Sec. 241.052. COMPLIANCE WITH RULES AND STANDARDS. (a) A
hospital that is in operation when an applicable rule or minimum
standard is adopted under this chapter must be given a reasonable
period within which to comply with the rule or standard.
(b) The period for compliance may not exceed six months, except
that the department may extend the period beyond six months if
the hospital sufficiently shows the department that it requires
additional time to complete compliance with the rule or standard.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Sec. 241.053. DENIAL OF APPLICATION, SUSPENSION, REVOCATION,
PROBATION, OR REISSUANCE OF LICENSE. (a) The department, after
providing notice and an opportunity for a hearing to the
applicant or license holder, may deny, suspend, or revoke a
hospital's license if the department finds that the hospital:
(1) failed to comply with:
(A) a provision of this chapter;
(B) a rule adopted under this chapter;
(C) a special license condition;
(D) an order or emergency order by the commissioner of health;
or
(E) another enforcement procedure permitted under this chapter;
(2) has a history of noncompliance with the rules adopted under
this chapter relating to patient health, safety, and rights which
reflects more than nominal noncompliance; or
(3) has aided, abetted, or permitted the commission of an
illegal act.
(b) A hospital whose license is suspended or revoked may apply
to the department for the reissuance of a license. The department
may reissue the license if the department determines that the
hospital has corrected the conditions that led to the suspension
or revocation of the hospital's license, the initiation of
enforcement action against the hospital, the assessment of
administrative penalties, or the issuance of a court order
enjoining the hospital from violations or assessing civil
penalties against the hospital. A hospital whose license is
suspended or revoked may not admit new patients until the license
is reissued.
(c) A hospital must apply for reissuance in the form and manner
required in the rules adopted under this chapter.
(d) Administrative hearings required under this section shall be
conducted under the board's formal hearing rules and the
contested case provisions of Chapter 2001, Government Code.
(e) Judicial review of a final decision by the department is by
trial de novo in the same manner as a case appealed from the
justice court to the county court. The substantial evidence rule
does not apply.
(f) If the department finds that a hospital is in repeated
noncompliance under Subsection (a) but that the noncompliance
does not endanger public health and safety, the department may
schedule the hospital for probation rather than suspending or
revoking the hospital's license. The department shall provide
notice to the hospital of the probation and of the items of
noncompliance not later than the 10th day before the date the
probation period begins. The department shall designate a period
of not less than 30 days during which the hospital will remain
under probation. During the probation period, the hospital must
correct the items that were in noncompliance and report the
corrections to the department for approval.
(g) The department may suspend or revoke the license of a
hospital that does not correct items that were in noncompliance
or that does not comply with the applicable requirements within
the applicable probation period.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Amended by Acts 1993, 73rd Leg., ch. 584, Sec. 9, eff. Sept. 1,
1993; Acts 1993, 73rd Leg., ch. 705, Sec. 3.01, eff. Sept. 1,
1993; Acts 1995, 74th Leg., ch. 76, Sec. 5.95(51), eff. Sept. 1,
1995; Acts 2003, 78th Leg., ch. 802, Sec. 1, 2, eff. June 20,
2003.
Sec. 241.0531. COMMISSIONER'S EMERGENCY ORDERS. (a) Following
notice to the hospital and opportunity for hearing, the
commissioner of health or a person designated by the commissioner
may issue an emergency order, either mandatory or prohibitory in
nature, in relation to the operation of a hospital licensed under
this chapter if the commissioner or the commissioner's designee
determines that the hospital is violating or threatening to
violate this chapter, a rule adopted pursuant to this chapter, a
special license provision, injunctive relief issued pursuant to
Section 241.054, an order of the commissioner or the
commissioner's designee, or another enforcement procedure
permitted under this chapter and the provision, rule, license
provision, injunctive relief, order, or enforcement procedure
relates to the health or safety of the hospital's patients.
(b) The department shall send written notice of the hearing and
shall include within the notice the time and place of the
hearing. The hearing must be held within 10 days after the date
of the hospital's receipt of the notice.
(c) The hearing shall not be governed by the contested case
provisions of Chapter 2001, Government Code but shall instead be
held in accordance with the board's informal hearing rules.
(d) The order shall be effective on delivery to the hospital or
at a later date specified in the order.
Added by Acts 1993, 73rd Leg., ch. 584, Sec. 10, eff. Sept. 1,
1993. Amended by Acts 1995, 74th Leg., ch. 76, Sec. 5.95(51),
eff. Sept. 1, 1995.
Sec. 241.054. VIOLATIONS; INJUNCTIONS. (a) The department
shall:
(1) notify a hospital of a finding by the department that the
hospital is violating or has violated this chapter or a rule or
standard adopted under this chapter; and
(2) provide the hospital an opportunity to correct the
violation.
(b) After the notice and opportunity to comply, the commissioner
of health may request the attorney general or the appropriate
district or county attorney to institute and conduct a suit for a
violation of this chapter or a rule adopted under this chapter.
(c) The department may petition a district court for a temporary
restraining order to restrain a continuing violation if the
department finds that the violation creates an immediate threat
to the health and safety of the patients of a hospital.
(d) On his own initiative, the attorney general, a district
attorney, or a county attorney may maintain an action in the name
of the state for a violation of this chapter or a rule adopted
under this chapter.
(e) The district court shall assess the civil penalty authorized
by Section 241.055, grant injunctive relief, or both, as
warranted by the facts. The injunctive relief may include any
prohibitory or mandatory injunction warranted by the facts,
including a temporary restraining order, temporary injunction, or
permanent injunction.
(f) The department and the party bringing the suit may recover
reasonable expenses incurred in obtaining injunctive relief,
civil penalties, or both, including investigation costs, court
costs, reasonable attorney fees, witness fees, and deposition
expenses.
(g) Venue may be maintained in Travis County or in the county in
which the violation occurred.
(h) Not later than the seventh day before the date on which the
attorney general intends to bring suit on his own initiative, the
attorney general shall provide to the department notice of the
suit. The attorney general is not required to provide notice of a
suit if the attorney general determines that waiting to bring
suit until the notice is provided will create an immediate threat
to the health and safety of a patient. This section does not
create a requirement that the attorney general obtain the
permission of a referral from the department before filing suit.
(i) The injunctive relief and civil penalty authorized by this
section and Section 241.055 are in addition to any other civil,
administrative, or criminal penalty provided by law.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Amended by Acts 1993, 73rd Leg., ch. 705, Sec. 3.02, eff. Sept.
1, 1993.
Sec. 241.055. CIVIL PENALTY. (a) A hospital shall timely
adopt, implement, and enforce a patient transfer policy in
accordance with Section 241.027. A hospital may implement patient
transfer agreements in accordance with Section 241.028.
(b) A hospital that violates Subsection (a), another provision
of this chapter, or a rule adopted or enforced under this chapter
is liable for a civil penalty of not more than $1,000 for each
day of violation and for each act of violation. A hospital that
violates this chapter or a rule or order adopted under this
chapter relating to the provision of mental health, chemical
dependency, or rehabilitation services is liable for a civil
penalty of not more than $25,000 for each day of violation and
for each act of violation.
(c) In determining the amount of the penalty, the district court
shall consider:
(1) the hospital's previous violations;
(2) the seriousness of the violation, including the nature,
circumstances, extent, and gravity of the violation;
(3) whether the health and safety of the public was threatened
by the violation;
(4) the demonstrated good faith of the hospital; and
(5) the amount necessary to deter future violations.
(d) A penalty collected under this section by the attorney
general shall be deposited to the credit of the general revenue
fund. A penalty collected under this section by a district or
county attorney shall be deposited to the credit of the general
fund of the county in which the suit was heard.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Amended by Acts 1991, 72nd Leg., ch. 14, Sec. 86, eff. Sept. 1,
1991; Acts 1993, 73rd Leg., ch. 584, Sec. 11, eff. Sept. 1, 1993;
Acts 1993, 73rd Leg., ch. 705, Sec. 3.03, eff. Sept. 1, 1993.
Sec. 241.056. SUIT BY PERSON HARMED. (a) A person who is
harmed by a violation under Section 241.028 or 241.055 may
petition a district court for appropriate injunctive relief.
(b) Venue for a suit brought under this section is in the county
in which the person resides or, if the person is not a resident
of this state, in Travis County.
(c) The person may also pursue remedies for civil damages under
common law.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Amended by Acts 1991, 72nd Leg., ch. 14, Sec. 87, eff. Sept. 1,
1991; Acts 1993, 73rd Leg., ch. 584, Sec. 12, eff. Sept. 1, 1993.
Sec. 241.057. CRIMINAL PENALTY. (a) A person commits an
offense if the person establishes, conducts, manages, or operates
a hospital without a license.
(b) An offense under this section is a misdemeanor punishable by
a fine of not more than $100 for the first offense and not more
than $200 for each subsequent offense.
(c) Each day of a continuing violation constitutes a separate
offense.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.
Sec. 241.058. MINOR VIOLATIONS. (a) This chapter does not
require the commissioner of health or a designee of the
commissioner to report a minor violation for prosecution or the
institution of any other enforcement proceeding authorized under
this chapter, if the commissioner or a designee of the
commissioner determines that prosecution or enforcement is not in
the best interests of the persons served or to be served by the
hospital.
(b) For the purpose of this section, a "minor violation" means a
violation of this chapter, the rules adopted under this chapter,
a special license provision, an order or emergency order issued
by the commissioner of health or the commissioner's designee, or
another enforcement procedure permitted under this chapter by a
hospital that does not constitute a threat to the health, safety,
and rights of the hospital's patients or other persons.
Added by Acts 1993, 73rd Leg., ch. 584, Sec. 13, eff. Sept.
1,1993.
Sec. 241.0585. RECOVERY OF COSTS. If the attorney general
brings an action to enforce an administrative penalty assessed
under Section 241.058 and the court orders the payment of the
penalty, the attorney general may recover reasonable expenses
incurred in the investigation, initiation, or prosecution of the
enforcement suit, including investigative costs, court costs,
reasonable attorney fees, witness fees, and deposition expenses.
Added by Acts 1993, 73rd Leg., ch. 705, Sec. 3.041, eff. Sept. 1,
1993.
Sec. 241.059. ADMINISTRATIVE PENALTY. (a) The commissioner of
health may assess an administrative penalty against a hospital
that violates this chapter, a rule adopted pursuant to this
chapter, a special license provision, an order or emergency order
issued by the commissioner or the commissioner's designee, or
another enforcement procedure permitted under this chapter. The
commissioner shall assess an administrative penalty against a
hospital that violates Section 166.004.
(b) In determining the amount of the penalty, the commissioner
of health shall consider:
(1) the hospital's previous violations;
(2) the seriousness of the violation;
(3) any threat to the health, safety, or rights of the
hospital's patients;
(4) the demonstrated good faith of the hospital; and
(5) such other matters as justice may require.
(c) The penalty may not exceed $1,000 for each violation, except
that the penalty for a violation of Section 166.004 shall be
$500. Each day of a continuing violation, other than a violation
of Section 166.004, may be considered a separate violation.
(d) When it is determined that a violation has occurred the
commissioner of health shall issue a report that states the facts
on which the determination is based and the commissioner's
recommendation on the imposition of a penalty, including a
recommendation on the amount of the penalty.
(e) Within 14 days after the date the report is issued, the
commissioner of health shall give written notice of the report to
the person, delivered by certified mail. The notice must include
a brief summary of the alleged violation and a statement of the
amount of the recommended penalty and must inform the person that
the person has a right to a hearing on the occurrence of the
violation, the amount of the penalty, or both the occurrence of
the violation and the amount of the penalty.
(f) Within 20 days after the date the person receives the
notice, the person in writing may accept the determination and
recommended penalty of the commissioner of health or may make a
written request for a hearing on the occurrence of the violation,
the amount of the penalty, or both the occurrence of the
violation and the amount of the penalty.
(g) If the person accepts the determination and recommended
penalty of the commissioner of health, the commissioner by order
shall impose the recommended penalty.
(h) If the person requests a hearing or fails to respond timely
to the notice, the commissioner of health shall set a hearing and
give notice of the hearing to the person. The hearing shall be
held by the department. The person conducting the hearing shall
make findings of fact and conclusions of law and promptly issue
to the commissioner a proposal for a decision about the
occurrence of the violation and the amount of the penalty. Based
on the findings of fact, conclusions of law, and proposal for a
decision, the commissioner by order may find that a violation has
occurred and impose a penalty or may find that no violation
occurred.
(i) The notice of the commissioner of health's order given to
the person under Chapter 2001, Government Code must include a
statement of the right of the person to judicial review of the
order.
(j) Within 30 days after the date the commissioner of health's
order is final as provided by Subchapter F, Chapter 2001,
Government Code, the person shall:
(1) pay the amount of the penalty;
(2) pay the amount of the penalty and file a petition for
judicial review contesting the occurrence of the violation, the
amount of the penalty, or both the occurrence of the violation
and the amount of the penalty; or
(3) without paying the amount of the penalty, file a petition
for judicial review contesting the occurrence of the violation,
the amount of the penalty, or both the occurrence of the
violation and the amount of the penalty.
(k) Within the 30-day period, a person who acts under Subsection
(j)(3) may:
(1) stay enforcement of the penalty by:
(A) paying the amount of the penalty to the court for placement
in an escrow account; or
(B) giving to the court a supersedeas bond that is approved by
the court for the amount of the penalty and that is effective
until all judicial review of the board's order is final; or
(2) request the court to stay enforcement of the penalty by:
(A) filing with the court a sworn affidavit of the person
stating that the person is financially unable to pay the amount
of the penalty and is financially unable to give the supersedeas
bond; and
(B) giving a copy of the affidavit to the commissioner of health
by certified mail.
(l) When the commissioner of health receives a copy of an
affidavit under Subsection (k)(2), he may file with the court,
within five days after the date the copy is received, a contest
to the affidavit. The court shall hold a hearing on the facts
alleged in the affidavit as soon as practicable and shall stay
the enforcement of the penalty on finding that the alleged facts
are true. The person who files an affidavit has the burden of
proving that the person is financially unable to pay the amount
of the penalty and to give a supersedeas bond.
(m) If the person does not pay the amount of the penalty and the
enforcement of the penalty is not stayed, the commissioner of
health may refer the matter to the attorney general for
collection of the amount of the penalty.
(n) Judicial review of the order of the commissioner of health:
(1) is instituted by filing a petition as provided by Subchapter
G, Chapter 2001, Government Code; and
(2) is under the substantial evidence rule.
(o) If the court sustains the occurrence of the violation, the
court may uphold or reduce the amount of the penalty and order
the person to pay the full or reduced amount of the penalty. If
the court does not sustain the occurrence of the violation, the
court shall order that no penalty is owed.
(p) When the judgment of the court becomes final, the court
shall proceed under this subsection. If the person paid the
amount of the penalty and if that amount is reduced or is not
upheld by the court, the court shall order that the appropriate
amount plus accrued interest be remitted to the person within 30
days after the judgment of the court becomes final. The rate of
the interest is the rate charged on loans to depository
institutions by the New York Federal Reserve Bank, and the
interest shall be paid for the period beginning on the date the
penalty was paid and ending on the date the penalty is remitted.
If the person gave a supersedeas bond and if the amount of the
penalty is not upheld by the court, the court shall order the
release of the bond. If the person gave a supersedeas bond and if
the amount of the penalty is reduced, the court shall order the
release of the bond after the person pays the amount.
(q) A penalty collected under this section shall be remitted to
the comptroller for deposit in the general revenue fund.
(r) All proceedings under this section are subject to Chapter
2001, Government Code.
Added by Acts 1993, 73rd Leg., ch. 584, Sec. 14, eff. Sept. 1,
1993. Amended by Acts 1995, 74th Leg., ch. 76, Sec. 5.95(51),
(53), (55), (60), eff. Sept. 1, 1995; Acts 1999, 76th Leg., ch.
450, Sec. 2.03, eff. Sept. 1, 1999.
Sec. 241.060. ADMINISTRATIVE PENALTY FOR MENTAL HEALTH, CHEMICAL
DEPENDENCY, OR REHABILITATION SERVICES. (a) The board may
impose an administrative penalty against a person licensed or
regulated under this chapter who violates this chapter or a rule
or order adopted under this chapter relating to the provision of
mental health, chemical dependency, or rehabilitation services.
(b) The penalty for a violation may be in an amount not to
exceed $25,000. Each day a violation continues or occurs is a
separate violation for purposes of imposing a penalty.
(c) The amount of the penalty shall be based on:
(1) the seriousness of the violation, including the nature,
circumstances, extent, and gravity of any prohibited acts, and
the hazard or potential hazard created to the health, safety, or
economic welfare of the public;
(2) enforcement costs relating to the violation;
(3) the history of previous violations;
(4) the amount necessary to deter future violations;
(5) efforts to correct the violation; and
(6) any other matter that justice may require.
(d) If the commissioner determines that a violation has
occurred, the commissioner may issue to the board a report that
states the facts on which the determination is based and the
commissioner's recommendation on the imposition of a penalty,
including a recommendation on the amount of the penalty.
(e) Within 14 days after the date the report is issued, the
commissioner shall give written notice of the report to the
person. The notice may be given by certified mail. The notice
must include a brief summary of the alleged violation and a
statement of the amount of the recommended penalty and must
inform the person that the person has a right to a hearing on the
occurrence of the violation, the amount of the penalty, or both
the occurrence of the violation and the amount of the penalty.
(f) Within 20 days after the date the person receives the
notice, the person in writing may accept the determination and
recommended penalty of the commissioner or may make a written
request for a hearing on the occurrence of the violation, the
amount of the penalty, or both the occurrence of the violation
and the amount of the penalty.
(g) If the person accepts the determination and recommended
penalty of the commissioner, the board by order shall approve the
determination and impose the recommended penalty.
(h) If the person requests a hearing or fails to respond timely
to the notice, the commissioner shall set a hearing and give
notice of the hearing to the person. The administrative law judge
shall make findings of fact and conclusions of law and promptly
issue to the board a proposal for a decision about the occurrence
of the violation and the amount of a proposed penalty. Based on
the findings of fact, conclusions of law, and proposal for a
decision, the board by order may find that a violation has
occurred and impose a penalty or may find that no violation
occurred.
(i) The notice of the board's order given to the person under
Chapter 2001, Government Code must include a statement of the
right of the person to judicial review of the order.
(j) Within 30 days after the date the board's order is final as
provided by Subchapter F, Chapter 2001, Government Code, the
person shall:
(1) pay the amount of the penalty;
(2) pay the amount of the penalty and file a petition for
judicial review contesting the occurrence of the violation, the
amount of the penalty, or both the occurrence of the violation
and the amount of the penalty; or
(3) without paying the amount of the penalty, file a petition
for judicial review contesting the occurrence of the violation,
the amount of the penalty, or both the occurrence of the
violation and the amount of the penalty.
(k) Within the 30-day period, a person who acts under Subsection
(j)(3) may:
(1) stay enforcement of the penalty by:
(A) paying the amount of the penalty to the court for placement
in an escrow account; or
(B) giving to the court a supersedeas bond that is approved by
the court for the amount of the penalty and that is effective
until all judicial review of the board's order is final; or
(2) request the court to stay enforcement of the penalty by:
(A) filing with the court a sworn affidavit of the person
stating that the person is financially unable to pay the amount
of the penalty and is financially unable to give the supersedeas
bond; and
(B) giving a copy of the affidavit to the commissioner by
certified mail.
(l) The commissioner on receipt of a copy of an affidavit under
Subsection (k)(2) may file with the court within five days after
the date the copy is received a contest to the affidavit. The
court shall hold a hearing on the facts alleged in the affidavit
as soon as practicable and shall stay the enforcement of the
penalty on finding that the alleged facts are true. The person
who files an affidavit has the burden of proving that the person
is financially unable to pay the amount of the penalty and to
give a supersedeas bond.
(m) If the person does not pay the amount of the penalty and the
enforcement of the penalty is not stayed, the commissioner may
refer the matter to the attorney general for collection of the
amount of the penalty.
(n) Judicial review of the order of the board:
(1) is instituted by filing a petition as provided by Subchapter
G, Chapter 2001, Government Code; and
(2) is under the substantial evidence rule.
(o) If the court sustains the occurrence of the violation, the
court may uphold or reduce the amount of the penalty and order
the person to pay the full or reduced amount of the penalty. If
the court does not sustain the occurrence of the violation, the
court shall order that no penalty is owed.
(p) When the judgment of the court becomes final, the court
shall proceed under this subsection. If the person paid the
amount of the penalty and if that amount is reduced or is not
upheld by the court, the court shall order that the appropriate
amount plus accrued interest be remitted to the person. The rate
of the interest is the rate charged on loans to depository
institutions by the New York Federal Reserve Bank, and the
interest shall be paid for the period beginning on the date the
penalty was paid and ending on the date the penalty is remitted.
If the person gave a supersedeas bond and if the amount of the
penalty is not upheld by the court, the court shall order the
release of the bond. If the person gave a supersedeas bond and if
the amount of the penalty is reduced, the court shall order the
release of the bond after the person pays the amount.
(q) A penalty collected under this section shall be remitted to
the comptroller for deposit in the general revenue fund.
(r) All proceedings under this section are subject to Chapter
2001, Government Code.
Added by Acts 1993, 73rd Leg., ch. 705, Sec. 3.04, eff. Sept. 1,
1993. Amended by Acts 1995, 74th Leg., ch. 76, Sec. 5.95(49),
(53), (59), eff. Sept. 1, 1995. Renumbered from Health &
Safety Code Sec. 241.058 by Acts 1995, 74th Leg., ch. 76, Sec.
17.01(22), eff. Sept. 1, 1995.
SUBCHAPTER E. STAFF, RECORDS, AND PLAN REVIEWS
Sec. 241.101. HOSPITAL AUTHORITY CONCERNING MEDICAL STAFF. (a)
Except as otherwise provided by this section and Section 241.102,
this chapter does not change the authority of the governing body
of a hospital, as it considers necessary or advisable, to:
(1) make rules, standards, or qualifications for medical staff
membership; or
(2) grant or refuse to grant membership on the medical staff.
(b) This chapter does not prevent the governing body of a
hospital from adopting reasonable rules and requirements in
compliance with this chapter relating to:
(1) qualifications for any category of medical staff
appointments;
(2) termination of appointments; or
(3) the delineation or curtailment of clinical privileges of
those who are appointed to the medical staff.
(c) The process for considering applications for medical staff
membership and privileges or the renewal, modification, or
revocation of medical staff membership and privileges must afford
each physician, podiatrist, and dentist procedural due process
that meets the requirements of 42 U.S.C. Section 11101 et seq.,
as amended.
(d) If a hospital's credentials committee has failed to take
action on a completed application as required by Subsection (k),
or a physician, podiatrist, or dentist is subject to a
professional review action that may adversely affect his medical
staff membership or privileges, and the physician, podiatrist, or
dentist believes that mediation of the dispute is desirable, the
physician, podiatrist, or dentist may require the hospital to
participate in mediation as provided in Chapter 154, Civil
Practice and Remedies Code. The mediation shall