59A-3.255. Emergency Care

(1) SIGNAGE REQUIREMENTS.

(a) Each hospital offering emergency services and care shall post, in a conspicuous place in the emergency service area, a sign clearly stating a patient’s right to emergency services and care as set forth in Section 395.1041, F.S. The sign shall be posted in both English and in Spanish.

(b) Each hospital offering emergency services and care shall post a sign identifying the service capability of the hospital. The categories of services listed on the sign may be general in nature if the sign refers patients to another location within that facility where a list of the subspecialties is available. The sign identifying the service capability of the hospital and the additional listing of subspecialties, if a separate subspecialty list is maintained, shall be in both English and in Spanish.

(c) The signs required by this rule section shall be posted in a location where individuals not yet admitted to the hospital would reasonably be expected to present themselves for emergency services and care.

(2) TRANSFER PROCEDURES. Each hospital providing emergency services and care shall establish policies and procedures which incorporate the requirements of Chapter 395, F.S., relating to emergency services. The policies and procedures shall incorporate:

(a) Decision protocols identifying the emergency services personnel within the hospital responsible for the arrangement of outgoing and incoming transfers;

(b) Decision protocols stating the conditions that must be met prior to the transfer of a patient to another hospital. These conditions are:

1. If a patient, or a person who is legally responsible for the patient and acting on the patient’s behalf, after being informed of the hospital’s obligation under Chapter 395, F.S., and of the risk of transfer, requests that the transfer be effected; or

2. If a physician has signed a certification that, based upon the reasonable risks and benefits to the patient, and based upon 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 individual’s medical condition from effecting the transfer; or

3. If a physician is not physically present in the emergency services area at the time an individual is transferred, a qualified medical person may sign a certification that a physician with staff privileges at the transferring hospital, in consultation with such personnel, has determined that the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual’s medical condition from effecting the transfer. The certification shall summarize the basis for such determination. The consulting physician must sign the certification within 72 hours of the transfer.

(c) A provision providing that all medically necessary transfers shall be made to the geographically closest hospital with the service capability, unless another prior arrangement is in place or the geographically closest hospital is at service capacity as stated in Section 395.1041(3)(e), F.S.

(d) Protocols for maintaining records of patient transfers made or received for a period of five years. Patient transfer information shall be incorporated separately in transfer logs and into the patient’s permanent medical record as stated in Section 395.1041(4)(a)1., F.S.

(e) Documentation of all current transfer arrangements that have been made with other hospitals and physicians.

(f) A copy of Section 395.1041, F.S., Access to Emergency Services and Care, and a copy of this rule.

(g) Provisions for informing hospital emergency services personnel and medical staff of the hospital’s emergency service policies and procedures, having at a minimum, the requirement to provide emergency services and care pursuant to Section 395.1041, F.S.

(3) INVENTORY REPORTING.

(a) Pursuant to Section 395.1041, F.S., the Agency is responsible for compiling an inventory of hospitals with emergency services. This inventory shall list all services within the service capability of the hospital. A copy of this inventory is available on the Agency’s website at: http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Hospital_Outpatient/hospital.shtml.

(b) Every hospital offering emergency services and care shall report to the Agency for inclusion in the inventory those services which are within the service capability of the hospital. The following services, when performed on an infrequent and short time limited basis, are not considered to be within the service capability of the hospital:

1. Services performed for investigative purposes under the auspices of a federally approved institutional review board; or

2. Services performed for educational purposes; or

3. Emergencies performed by physicians who are not on the active medical staff of the reporting hospital.

(c) Any addition of service shall be reported to the Agency prior to the initiation of the service. The Agency will act accordingly to include the service in the next publication of the inventory and to add the service on the face of the hospital license.

(d) If the Agency has reason to believe that a hospital offers a service and the service was not reported on the inventory, the Agency will notify the hospital and provide the hospital with an opportunity to respond. The Agency shall arrange for an on-site visit prior to the Agency’s determination of capability, with advance notice of the on-site visit. If, after investigation, the Agency determines that a service is offered by the hospital as evidenced by the patient medical records or itemized bills, the Agency shall amend the inventory and the face of the hospital license.

(4) EXEMPTIONS.

(a) Every hospital providing emergency services shall ensure the provision of services within the service capability of the hospital, 24 hours per day, 7 days per week either directly or indirectly through:

1. An agreement with another hospital made prior to receipt of a patient in need of the service; or

2. An agreement with one or more physicians made prior to receipt of a patient in need of the service; or

3. Any other arrangement made prior to receipt of a patient in need of the service.

(b) If a hospital has determined that it is unable to provide a service on a 24 hour per day, 7 day per week basis, either directly or indirectly through arrangement with another hospital or physician(s), the hospital must file an application with the Agency to request a service exemption. The application must identify the service for which the hospital is requesting an exemption. This information shall be submitted to the Agency on the Emergency Services Exemption Request, AHCA Form 3000-1, November 2013, which is incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-04607 and available from the Agency at http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Hospital_Outpatient/hospital.shtml. The Agency will make a determination of exemption status pursuant to the procedures in subsection (5) of this rule and notify the hospital of the determination within 45 days of receipt of the request.

(c) Upon receipt of a hospital exemption request, the Agency must act to approve or deny the exemption request within 45 days, during which time deemed exemption status does not exist. If the Agency fails to notify the hospital of the status of the exemption request within the 45 day time frame, the hospital is deemed to be exempt from offering the service until such time that the Agency acts to deny the request.

(d) When a hospital has been providing 24 hour per day, 7 day per week coverage either directly or indirectly through an agreement with another hospital or physician(s) for a specialty service as evidenced by the inventory and hospital license, and the circumstances significantly change such that the hospital can no longer provide the service on a 24 hour per day, 7 day per week basis, the hospital must apply for an exemption from the Agency. The Agency will make a determination of exemption status pursuant to subsection (5) of this rule and notify the hospital of the determination within 45 days of receipt of the request.

(e) When a hospital has been granted an exemption from providing a specialty service 24 hours per day, 7 days per week, either directly or indirectly through an agreement with another hospital or physician(s), and the Agency has information to indicate that the circumstances forwarded by the hospital, and accepted by the Agency, as the basis for the granting of the exemption have changed, the Agency will notify the hospital of this information and shall provide the hospital with an opportunity to respond. If the change in circumstances is confirmed and the hospital failed to report the change, the Agency will amend the inventory accordingly and add the service capability to the face of the hospital license accordingly. Revocation of exemption status shall be effective upon the expiration of 21 days following the hospital’s receipt of the Agency decision or the entry of a final order if appealed.

(f) Each hospital shall immediately report any change in the conditions which led to the granting of an exemption.

(5) AGENCY REVIEW PROCESS. The review process for exemption requests shall be as follows:

(a) Upon receipt of application, the Agency shall schedule an on-site visit at the hospital when deemed necessary to verify the facts as set forth in the application. The hospital will be notified of the date of the visit in advance. The Agency shall have access to all records necessary for the confirmation and substantiation of the information submitted in the application and to any other records deemed necessary by the Agency to make a determination.

(b) Upon receipt of an application, the Agency shall publish, in the next available Florida Administrative Register, notice of receipt of the application, identifying the applicant and the service(s) for which exemption is requested. Comments submitted within 15 days of the date of publication will be considered by the Agency prior to making a determination of exemption status.

(c) Within 45 days of receipt of application, the Agency shall determine if the hospital has demonstrated that it meets the requirements for service exemption set forth in Section 395.1041, F.S. The Agency shall notify the applicant in writing of its decision, and shall provide the applicant with specific reasons in the event that the request is denied.

(d) If the Agency fails to notify the hospital of the status of the exemption request within the required 45 day time frame, pursuant to Section 395.1041(3)(d)4., F.S., the hospital is deemed to be exempt from offering the service until such time that the Agency acts to deny the request.

(6) SERVICE DELIVERY REQUIREMENTS.

(a) Every hospital offering emergency services and care shall provide emergency care available 24 hours a day within the hospital to patients presenting to the hospital. At a minimum:

1. Emergency services personnel shall be available to ensure that emergency services and care are provided in accordance with Section 395.002(10), F.S.

2. At least one physician shall be available within 30 minutes through a medical staff call roster; initial consultation through two-way voice communication is acceptable for physician presence.

3. Specialty consultation shall be available by request of the attending physician or by transfer to a designated hospital where definitive care can be provided.

(b) When a patient is transferred from one hospital to another, all pertinent medical information shall accompany the patient being transferred.

(c) Every hospital offering emergency services and care shall maintain a transfer manual, which shall include in addition to the requirements in subsection (2) of this rule:

1. Decision protocols for when to transfer a patient;

2. A list of receiving hospitals with special care capabilities, including the telephone number of a contact person;

3. A list of all “on-call” critical care physicians available to the hospital, including their telephone numbers; and

4. Protocols for receiving a call from a transferring hospital, including:

a. Requirements for specific information regarding the patient’s problem;

b. Estimated time of patient arrival;

c. Specific medical requirements;

d. A request to transfer the patient’s medical record with the patient; and

e. The name of the transporting service.

(d) Both transferring and receiving hospitals shall assign a specific person on each shift who shall have responsibility for being knowledgeable of the transfer manual and maintaining it.

(e) Each hospital offering emergency services and care shall maintain written policies and procedures specifying the scope and conduct of emergency services to be rendered to patients. Such policies and procedures must be approved by the organized medical staff, reviewed at least annually, revised as necessary, dated to indicate the time of last review, and enforced. Such policies shall include requirements for the following:

1. Direction of the emergency department by a designated physician who is a member of the organized medical staff.

2. A defined method of providing for a physician on call at all times.

3. Supervision of the care provided by all nursing service personnel with the emergency department by a designated registered nurse who is qualified by relevant training and experience in emergency care.

4. A written description of the duties and responsibilities of all other health personnel providing care within the emergency department.

5. A planned formal training program on emergency access laws, and participation, by all health personnel working in the emergency department.

6. A control register adequately identifying all persons seeking emergency care be established, and that a medical record be maintained on every patient seeking emergency care that is incorporated into the patient’s permanent medical record and that a copy of the Patient Care Record, in accordance with Rules 64J-1.001 and 64J-1.014, F.A.C., be included in the medical record, if the patient was delivered by ambulance. The control register must be continuously maintained and shall include at least the following for every individual seeking care:

a. Identification to include patient name, age and sex;

b. Date, time and means of arrival;

c. Nature of complaint;

d. Disposition; and

e. Time of departure.

(f) Every hospital offering emergency services and care shall have a method for assuring that a review of emergency patient care is performed and documented at least monthly, using the medical record and preestablished criteria.

(g) Every hospital offering emergency services and care shall insure the following:

1. That clinical laboratory services with the capability of performing all routine studies and standard analyses of blood, urine, and other body fluids are readily available at all times to the emergency department.

2. That an adequate supply of blood is available at all times, either in-hospital or from an outside source approved by the organized medical staff, and that blood typing and cross-matching capability and blood storage facilities are readily available to the emergency department.

3. That diagnostic radiology services within the service capability of the hospital are readily available at all times to the emergency department.

4. That the following are available for immediate use to the emergency department at all times:

a. Oxygen and means of administration;

b. Mechanical ventilatory assistance equipment, including airways, manual breathing bag, and ventilator;

c. Cardiac defibrillator with synchronization capability;

d. Respiratory and cardiac monitoring equipment;

e. Thoracentises and closed thoracostomy sets;

f. Tracheostomy or cricothyrotomy set;

g. Tourniquets;

h. Vascular cutdown sets;

i. Laryngoscopes and endotracheal tubes;

j. Urinary catheters with closed volume urinary systems;

k. Pleural and pericardial drainage set;

l. Minor surgical instruments;

m. Splinting devices;

n. Emergency obstetrical pack;

o. Standard drugs as determined by the facility, common poison antidotes, syringes and needles, parenteral fluids and infusion sets, and surgical supplies;

p. Refrigerated storage for biologicals and other supplies requiring refrigeration, within the emergency department; and

q. Stable examination tables.

(h) Hospital personnel and physicians shall report any apparent violations of emergency access requirements under Section 395.1041, F.S., to the Agency. Reports shall be made within 30 days following the occurrence. Violations include failure to report when on-call or intentionally misrepresenting the patient’s condition in cases of medically necessary transfers or in determining the presence or absence of an emergency medical condition or rendering appropriate emergency services and care, or failure or refusal to sign a certificate of transfer as required by this section.

(7) Each hospital offering emergency services and care shall have the capability to communicate via two-way radio with licensed EMS providers, as required by Section 395.1031, F.S.

Rulemaking Authority 395.1041, 395.1055 FS. Law Implemented 395.1031, 395.1041, 395.1055 FS. History–New 9-4-95, Formerly 59A-3.207, Amended 10-16-14.