1. (a) The LHR facility must ensure that operations are being conducted in accordance with the protocols established by the contract specified in §118.10. The consulting physician must conduct audits of the LHR facility to verify compliance with the protocol.
2. (b) The audits must be unannounced, must be conducted at the physical site of the LHR facility, and must be conducted at least quarterly.
3. (c) The audits may be scheduled in advance if the consulting physician determines that advance notice does not compromise the ability to determine that operations are being conducted in accordance with established protocols.
4. (d) The audits may be conducted by the consulting physician, another alternate consulting physician or an advanced practice nurse or physician's assistant acting under the consulting physician's delegated authority.
5. (e) If the audit is conducted by an advanced practice nurse or physician's assistant, the consulting physician must sign the audit.
6. (f) The consulting physician must make records of audits conducted under the terms of the contract and maintain those records in accordance with the requirements of this chapter. The consulting physician audit records must be maintained in accordance with this chapter.

7. (g) The record of the audit must include at least the following:

   1. (1) date audit was performed;
   2. (2) name of the LHR facility audited;
   3. (3) assessment of the LHR facility's performance of the protocols established by the written contract; and
   4. (4) signature of the consulting physician, the LHR facility operator, and any other alternate consulting physician or advanced practice nurse or physician's assistant acting under the consulting physician's delegated authority to conduct the audit.

Source Note:The provisions of this §118.14 adopted to be effective October 1, 2025, 50 TexReg 6315.