37.104.3030    COMPLAINT INVESTIGATION, REVOCATION, OR EMERGENCY SUSPENSION

(1) The department may review, inspect, evaluate, and audit trauma patient medical records, inpatient logs, hospital emergency department logs, trauma performance improvement documentation, and any other documents relevant to trauma care by any trauma facility at any time to verify compliance with these rules.

(2) The confidentiality of such records will be maintained by the department in accordance with state and federal law.

(3) The department will investigate written complaints alleging violation of these rules in the following manner:

(a) The department will request and the designated facility shall provide information that the department determines necessary to the investigation of the complaint.

(b) The results of a department investigation will be reviewed with the designation subcommittee.

(4) Following the completion of the investigation and review, the department may:

(a) take no action;

(b) initiate an emergency suspension of the facility's trauma designation;

(c) require the designated facility to submit a corrective plan of action for any deficiencies that were noted;

(d) change the designation of a trauma facility to provisional; or

(e) revoke the designation of the designated facility.

(5) The department will suspend the designation of a designated trauma facility on an emergency basis if the violation of these rules creates a substantial threat to public health or if the designated facility ceases to be a health care facility. The designated facility may appeal the emergency suspension pursuant to 50-6-410 , MCA, but the emergency suspension shall remain in effect until a final decision is made by the department.

(6) The department may revoke a trauma facility designation if the facility:

(a) fails to comply with these rules;

(b) no longer is a health care facility;

(c) makes a false statement of a material fact in the application for designation, in any record required by these rules, or in a matter under investigation;

(d) prevents, interferes with, or attempts to impede in any way, the work of a department representative in the lawful enforcement of these rules; or

(e) falsely advertises or in any way misrepresents the facility's ability to care for trauma patients based on its trauma designation status.

(7) If a designated facility notifies the department that it will be temporarily noncompliant with its trauma facility designation criteria for longer than one week, the department, after consultation with the designation subcommittee, may take one or more of the following actions:

(a) conduct a focused review;

(b) modify the facility's designation status to provisional and require that a plan of correction be submitted to the department outlining how the deficiency will be corrected;

(c) change its designation level to be consistent with the trauma facility level for which it has the required resources; or

(d) suspend the trauma facility's designation on an emergency basis.

History: 50-6-402, MCA; IMP, 50-6-402, 50-6-410, MCA; NEW, 2006 MAR p. 1896, Eff. 7/28/06.