37.104.3022    DESIGNATION PROCEDURES FOR FACILITIES VERIFIED AS A TRAUMA FACILITY BY THE AMERICAN COLLEGE OF SURGEONS

(1) A health care facility with a current certificate of verification from the American College of Surgeons as a trauma facility qualifies as one of the following types of Montana trauma facility as set out in (2), providing it submits an application, department staff attend the on-site or virtual review conducted by the American College of Surgeons, and the facility demonstrates compliance with all requirements described in the Montana Trauma Facility Designation Criteria that may differ from the American College of Surgeons' standards in the college's document entitled "Resources for Optimal Care of the Injured Patient: 2022 standards." A copy of this document may be obtained as set forth in (8).

(2) A current certificate of verification for the following levels established by the American College of Surgeons qualifies a health care facility as the following type of Montana trauma facility:

(a) a level I trauma center qualifies as a comprehensive trauma center;

(b) a level II trauma center qualifies as a regional trauma center;

(c) a level III trauma center qualifies as an area trauma facility; and

(d) a level IV trauma center qualifies as a community trauma facility.

(3) A Montana health care facility that is seeking verification or reverification by the American College of Surgeons as a trauma center and wishes to be designated as a Montana trauma facility must submit to the department:

(a) an application for designation, on a form approved by the department, that:

(i) specifies the level of designation for which the facility is applying; and

(ii) includes a copy of the American College of Surgeons' prereview questionnaire;

(b) any additional information required by the department to verify compliance with any requirements described in the Montana Trauma Facility Designation Criteria that differ from the American College of Surgeons' standards;

(c) notification of the scheduled dates of the American College of Surgeons' site survey to allow for department participation in the site review; and

(d) upon receipt, a copy of the American College of Surgeons' letter indicating if the facility was successfully verified as a trauma facility.

(4) The department will review the application for completeness and within 30 days after receiving the application:

(a) notify the facility that the application is complete; or

(b) notify the facility that the application is incomplete and request additional information.

(5) When the application and the site review are complete, and the American College of Surgeons' letter is received that indicates whether the facility is verified as a trauma facility, the department will provide a copy of the application and the letter to the designation subcommittee at the next quarterly State Trauma Care Committee meeting.

(6) The designation subcommittee will review the application and American College of Surgeons' letter at the next quarterly State Trauma Care Committee meeting and make a recommendation to the department regarding the trauma designation of the applicant facility.

(7) Within 30 days after receiving a recommendation from the designation subcommittee, the department will take one of the following actions:

(a) designate the applicant at the trauma facility level requested providing there is compliance with these rules;

(b) issue a provisional designation to the applicant provided that:

(i) there are deficiencies noted but the facility is substantially compliant with the resource criteria and the deficiencies will not have an immediate detrimental impact on trauma patient care; and

(ii) the applicant has submitted to the department a corrective action plan, acceptable to the department, for the correction of the deficiencies;

(c) designate the applicant as a trauma facility at a different level from that for which the applicant applied, provided that:

(i) the applicant meets all of the requirements of the alternative trauma facility designation level; and

(ii) the applicant agrees to be designated at the alternative trauma facility designation level; or

(d) deny any designation if there is substantial noncompliance with the requirement, or the deficiencies may be a threat to public health and safety.

(8) The department adopts and incorporates by reference "Resources for Optimal Care of the Injured Patient: 2022 standards," published by the American College of Surgeons. The document contains the trauma facility criteria used by the American College of Surgeons in its process for verification of trauma facilities. A copy may be obtained from the Department of Public Health and Human Services, Public Health and Safety Division, Emergency Medical Services and Trauma Systems Section, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

 

History: 50-6-402, MCA; IMP, 50-6-402, 50-6-410, MCA; NEW, 2006 MAR p. 1896, Eff. 7/28/06; AMD, 2014 MAR p. 2792, Eff. 1/1/15; AMD, 2023 MAR p. 1622, Eff. 1/1/24.