La. Admin. Code tit. 48 § I-19707

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-19707 - Procedure for Trauma Program Recognition

A. A hospital must complete the LERN approved form, "Application for Recognition of Trauma Program".

B. The hospital CEO must complete and sign the LERN approved trauma program checklist/attestation for the applicable trauma program level.

1. By this attestation, the hospital CEO ensures 24/7/365 availability of the resources listed.

2. The attestation must be validated by a site visit by LERN staff.

3. Upon CEO attestation and/or site visit, if it is determined by the LERN executive committee in conjunction with the LERN trauma medical director, that the required benchmarks are not in place the hospital will not be eligible for trauma program verification.

C. After satisfying the requirements of A. and B. above, the hospital will be recognized as a trauma program and such recognition will be added to the LERN resource management screen for the purpose of routing trauma patients.

D. To maintain trauma program recognition, the hospital must request an ACS verification or consultation site visit at the time of the attestation or within 30 days thereafter, with the consultation or survey to occur within 12 months of the attestation or as close to 12 months as the ACS schedule allows. Written documentation of the request and scheduling must be submitted to LERN.

1. If an ACS verification or consultation site visit is not requested within 30 days and does not occur within 12 months or as close to 12 months as the ACS schedule allows, the trauma program indicator on LERN resource management screen will be removed.

E. After a consultation visit for the desired trauma level, the hospital has 30 days to schedule the verification survey by the ACS to occur within 12 months of the consultation or as close to 12 months as the ACS schedule allows. Written documentation of the request and scheduling must be submitted to LERN.

1. If documentation of scheduling per required parameters is not submitted to LERN and the ACS verification survey is not scheduled to occur within 12 months of the consultation or as close to 12 months as the ACS schedule allows, the trauma program indicator will be removed on the LERN resource management screen.

2. If the hospital fails the ACS verification visit and a focused review visit, the hospital will lose trauma program status. The trauma program indicator will be removed on the LERN resource management screen.

F. After loss of trauma program status for failing the ACS verification visit and focused review visit, trauma program status may be regained provided the following conditions are met:

1. a LERN designee and either the LERN trauma medical director or a trauma surgeon must review the deficiencies and findings of the ACS at a site visit;

2. the hospital must develop a remediation plan and apply to the LERN board for approval of trauma program status;

3. the LERN board will review the LERN team assessment of deficiencies and the hospitals remediation plan;

4. the LERN board must vote to approve the trauma program status request.

La. Admin. Code tit. 48, § I-19707

Promulgated by the Department of Health, Emergency Response Network, LR 421932 11/1/2016), Amended LR 4463 (1/1/2018), Amended LR 45436 (3/1/2019), Repromulgated LR 45573 (4/1/2019).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2846(A), R.S. 40:2845(A)(1) and R.S. 9:2798.5.