PURPOSE: This rule establishes the requirements for emergency services in a hospital.

1. (1) A hospital shall have a written plan that details the hospital’s criteria and process for diversion. Diversion may be due to the emergency department being overwhelmed with significantly critically ill or injured patients, or an overwhelming number of minor emergency patients, to the extent that the hospital is unable to provide quality care or protect the health or welfare of the patients it serves. A diversion also may be implemented if the hospital has resource limitations, such as, no available beds in specialty care units or general acute care, no surgical suites or shortages of equipment or personnel. The plan must be reviewed and approved by the Missouri Department of Health and Senior Services prior to being implemented by the hospital. A hospital may continue to operate under a plan in existence prior to the effective date of this section while awaiting approval of its plan by the department.

   1. (A) The diversion plan shall:

      1. 1. Identify the individuals by title who are authorized by

the hospital to implement the diversion plan;

1. 2. Define the process by which the decision to divert will

be made;

1. 3. Specify that the hospital will not implement the

diversion plan until the authorized individual has reviewed and documented the hospital’s ability to obtain additional staff, open existing beds that may have been closed, or take any other actions that might prevent a diversion from occurring;

1. 4. Include that all ambulance services within a defined

service area will be notified of the intent to implement the diversion plan upon the actual implementation. Ambulances that have made contact with the hospital before the hospital has declared itself to be on diversion shall not be redirected to other hospitals. In areas served by a real time, electronic reporting system, notification through such system shall meet the requirements of this provision so long as such system is available to all EMS agencies and hospitals in the defined service area;

1. 5. Include procedures for assessment, stabilization,

and transportation of patients in the event that services, including but not limited to, ICU beds or surgical suites become unavailable or overburdened. These procedures must also include the evaluation of services and resources of the facility that can still be provided to patients even with the implementation of the diversion plan;

1. 6. Include procedures for implementation of a resource

diversion in the event that specialized services are overburdened or temporarily unavailable; and

1. 7. Include that all other acute care hospitals within

a defined service area will be notified upon the actual implementation of the diversion plan. For defined service areas with more than two (2) hospitals, if more than one-half (1/2) of the hospitals implement their diversion plans, no hospital will be considered on diversion. For a defined service area with two (2) hospitals, if both hospitals implement their diversion plans, neither will be considered on diversion. Participation in a real time, electronic reporting system shall meet the notification requirements of this section. If a hospital participates in an approved community-wide plan, the community-wide plan may set the requirement for the number of hospitals to remain open.

1. (B) Each incident of diversion plan implementation must be reviewed by the hospital’s existing quality assurance committee. Minutes of these review meetings must be made available to the Missouri Department of Health and Senior Services upon request.
2. (C) The hospital shall assure compliance with screening, treatment, and transfer requirements as required by the Emergency Medical Treatment and Active Labor Act (EMTALA).
3. (D) A hospital or its designee shall report to the department, by phone or electronically, upon actual implementation of the diversion plan. This implementation report shall contain the time the plan will be implemented. The hospital or its designee shall report to the department, by phone or electronically, within eight (8) hours of the termination of the diversion. This termination report shall contain the time the diversion plan was implemented, the reason for the diversion, the name of the individual who made the determination to implement the diversion plan, the time the diversion status was terminated, and the name of the individual who made the determination to terminate the diversion. In areas served by real time, electronic reporting system, reporting through such system shall meet the requirements of this provision so long as such system generates reports as required by the department.
4. (E) Each hospital shall implement a triage system within its emergency department. The triage methodology shall continue to apply during periods when the hospital diversion plan is implemented.
5. (F) Any hospital that has a written approved policy, which states that the hospital will not go on diversion or resource diversion, except as defined in the hospital’s disaster plan in the event of a disaster, is exempt from the requirements of this section.
6. (G) If a hospital chooses to participate in a community-wide plan, the requirement of the number of hospitals to remain open, defined service areas, as well as community notification may be addressed within the community plan. Community plans must be approved by the department. Community plans must include that each hospital has a policy addressing diversion and the criteria used by each hospital to determine the necessity of implementing a diversion plan. Participation in a community plan does not exempt a hospital of the requirement to notify the department of a diversion plan implementation.

AUTHORITY: sections 192.006 and 197.154, RSMo 2016, and section 197.080, RSMo Supp. 2019.* This rule previously filed as 19 CSR 30-20.021(3)(C). Original rule filed June 27, 2007, effective Feb. 29, 2008. Amended: Filed March 20, 2019, effective Nov. 30, 2019. ** *Original authority: 192.006, RSMo 1993, amended 1995; 197.080, RSMo 1953, amended 1993, 1995, 2017; and 197.154, RSMo 2004. **Pursuant to Executive Order 21-09, 19 CSR 30-20.092 was suspended from March 19, 2020 through December 31, 2021.