902 KAR 28:020. Kentucky trauma system designation process

Section 1. Hospital Trauma Center Designation. A hospital shall receive designation as a trauma center by the Department for Public Health following successful completion of the verification and review process established in this administrative regulation and 902 KAR 28:030. (1) Each hospital seeking designation in the Kentucky trauma care system shall adhere to: (a) The criteria established by the American College of Surgeons Verification Review Committee that is available at https://www.facs.org/quality-programs/trauma/quality/verification-review-and-consultation-program/, if the facility is seeking designation as a Level I, II, or III trauma center; or (b) The standards for Level IV designation established in 902 KAR 28:030. (2) Each hospital in Kentucky that volunteers to become part of the trauma care system shall make application to the Commissioner of Public Health using the: (a) KYTAC-Application-1, Hospital Application for Level IV Verification and Kentucky Designation as a Trauma Center, if the facility is seeking designation as a Level IV trauma center; or (b) KYTAC-Application-2, Hospital Application for Kentucky Trauma Center Designation, if the facility is seeking designation as a Level I, II, or III trauma center. (3) Â (a) Â 1. Except as provided by subparagraph 2. of this paragraph, designation shall be for a three (3) year period following trauma center verification. 2. Designation shall be for less than a three (3) year period following trauma center verification if the facility received a shorter provisional designation to address a non-critical deficiency identified during the verification site visit by either ACS COT or a Kentucky verification team. (b) Each hospital shall be reverified to maintain trauma designation. (4) Only those hospitals that are designated trauma centers under the provisions of 902 KAR 28:010 through 28:060 shall be recognized by the commonwealth as belonging to the Kentucky Trauma Care System and may hold themselves out to the public as a trauma center. Section 2. Level I, II, or III Designation. (1) Upon being notified that the ACS COT has been requested to conduct a Level I, II, or III trauma center verification visit, and with the agreement of both the applying hospital and the ACS COT, the commissioner shall direct a representative of the department or the KyTAC to participate as an observer during the site visit. (2) The commissioner shall issue a certificate of designation in the Kentucky trauma care system concurrent with the recommendations and time period specified in the ACS COT documents upon receipt of the KYTAC-Application-2, the appropriate fees, and a copy of the ACS COT documents indicating satisfactory verification to their latest standards. (3) The state-issued designation certificate shall be posted in a public area of the hospital adjacent to the Kentucky facility licensure certificate. Section 3. Level IV Trauma Center Designation. (1) Designation process. (a) Once the facility has completed the Level IV verification and review process pursuant to Section 1 of this administrative regulation, the original completed KYTAC-Application-1 shall be forwarded to KyTAC. KyTAC shall conduct a review of the facility's compliance with this administrative regulation and 902 KAR 28:030 and make recommendations to the commissioner within sixty (60) days of receipt of the application. (b) Â 1. If the facility meets all the requirements of this administrative regulation and 902 KAR 28:030, a certificate of trauma center designation shall be: a. Issued by the commissioner for a three (3) year period following completion of the trauma center verification process except as provided by subparagraph 2. of this paragraph; and b. Posted in a public area of the hospital adjacent to the Kentucky facility licensure certificate. 2. If the facility has a deficiency that is not deemed critical to the effective functioning of the trauma center, the commissioner may issue a provisional designation certificate for a period of time less than three (3) years to provide time to address or correct the deficiency. The commissioner shall send a written notice informing the facility of that determination, and the facility may be subject to a subsequent audit or re-verification of the finding to confirm that it was satisfactorily addressed. The facility may appeal the decision in accordance with 902 KAR 28:060. 3. If the facility does not meet the requirements of this administrative regulation and 902 KAR 28:030, the commissioner shall send a written notice to the facility informing the facility of that determination. The facility may appeal the decision in accordance with 902 KAR 28:060. (c) Â 1. Except as provided by subparagraph 2. of this paragraph, designation shall be for a three (3) year period following satisfactory completion of the trauma center verification process. 2. Designation shall be for less than a three (3) year period following trauma center verification if the facility received a shorter provisional designation to address a non-critical deficiency identified during the verification site visit in accordance with paragraph (b)2. of this subsection. (2) Redesignation. At least four (4) months preceding the expiration of a designation certificate, the hospital shall initiate the process established in 902 KAR 28:030 for reverification and redesignation. Section 4. Designation Suspension or Revocation. (1) A designated trauma center hospital that is unable to meet the applicable minimum required criteria of a Level I, Level II, or Level III trauma center as established by ACS COT, or a Level IV trauma center as established in 902 KAR 28:030, shall notify the commissioner within five (5) business days of the event that caused the facility to fall below minimum criteria. (2) If the commissioner becomes aware of a significant change in the status of the trauma care program at a designated hospital that may potentially affect its designation status, the commissioner may: (a) Request confirmation of continued designation status from the hospital; or (b) Assign a representative of KyTAC or a designee to conduct a site visit to review the status of the trauma program and report the findings to the commissioner within thirty (30) days of assignment. (3) The commissioner may consult with KyTAC and the ACS COT on information received from the hospital and site visit, and may: (a) Suspend the hospital's designation; (b) Place the facility into a probationary status pending resolution within thirty (30) days of the disciplinary action; or (c) Revoke the hospital's designation. (4) If the designation is revoked, and if the facility seeks redesignation, the facility shall correct the identified problems, and request, at its expense, a focused review to demonstrate that each problem has been corrected. (5) Following the review required by subsection (4) of this section, the commissioner shall: (a) Reinstate the designation; (b) Request that the facility reapply for verification at a lower level; (c) Deny redesignation; or (d) Refer the matter to KyTAC for determination of other appropriate action. (6) A hospital not able to meet trauma center criteria at the initial designation level shall not hold designation as a trauma center until reverified at an appropriate level and redesignated. Section 5. Incorporation by Reference. (1) The following material is incorporated by reference: (a) KYTAC-Application-1, "Hospital Application for Level IV Verification and Kentucky Designation as a Trauma Center", January 2024; and (b) KYTAC-Application-2, "Hospital Application for Kentucky Trauma Center Designation", January 2024. (2) This material: (a) May be inspected, copied, or obtained, subject to applicable copyright law, at the Kentucky Department for Public Health, Commissioner's Office, 275 East Main Street, Frankfort, Kentucky 406012, Monday through Friday, 8 a.m. to 4:30 p.m.; and (b) Is available online at https://www.kyha.com/kentucky-trauma-system/.