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TITLE 25HEALTH SERVICES
PART 1DEPARTMENT OF STATE HEALTH SERVICES
CHAPTER 133HOSPITAL LICENSING
SUBCHAPTER JHOSPITAL LEVEL OF CARE DESIGNATIONS FOR NEONATAL AND MATERNAL CARE
RULE §133.184Designation Process

(a) Designation application packet. The applicant shall submit the packet, inclusive of the following documents to the Office of EMS/Trauma Systems Coordination (office) within 120 days of the facility's survey date:

  (1) an accurate and complete designation application form for the appropriate level of designation, including full payment of the designation fee as listed in subsection (d) of this section;

  (2) any subsequent documents submitted by the date requested by the office;

  (3) a completed neonatal attestation and self-survey report for Level I applicants or a designation survey report, including patient care reviews if required by the office, for Level II, III and IV applicants;

  (4) a plan of correction (POC), detailing how the facility will correct any deficiencies cited in the survey report, to include: the corrective action; the title of the person responsible for ensuring the correction(s) is implemented; how the corrective action will be monitored; and the date by which the POC will be completed; and

  (5) evidence of participation in the applicable Perinatal Care Region (PCR).

(b) Renewal of designation. The applicant shall submit the documents described in subsection (a)(1) - (5) of this section to the office not more than 180 days prior to the designation expiration date and at least 60 days prior to the designation expiration date.

(c) If a facility seeking designation fails to meet the requirements in subsection (a)(1) - (5) of this section, the application shall be denied.

(d) Non-refundable application fees for the three year designation period are as follows:

  (1) Level I neonatal facility applicants, the fees are as follows:

    (A) <=100 licensed beds, the fee is $250.00; or

    (B) >100 licensed beds, the fee is $750.00.

  (2) Level II neonatal facility applicants, the fee is $1,500.00.

  (3) Level III neonatal facility applicants, the fee is $2,000.00.

  (4) Level IV neonatal facility applicants, the fee is $2,500.00.

    (A) All completed applications, received on or before July 1, 2018, including the application fee, evidence of participation in the PCR, an appropriate attestation if required, survey report, and that meet the requirements of the requested designation level, will be issued a designation for the full three-year term.

    (B) Any facility that has not completed an on-site survey to verify compliance with the requirements for a Level II, III or IV designation at the time of application must provide a self-survey and attestation and will receive a Level I designation. The office, at its sole discretion may recommend a designation for less than the full three-year term. A designation for less than the full three-year term will have a pro-rated application fee consistent with the one, two or three-year term length.

    (C) A facility applying for Level I designation requiring an attestation may receive a shorter term designation at the discretion of the office. A designation for less than the full three-year term will have a pro-rated application fee.

    (D) The office, at its discretion, may designate a facility for a shorter term designation for any application received prior to September 1, 2018.

    (E) An application for a higher or lower level designation may be submitted at any time.

(e) If a facility disagrees with the level(s) determined by the office to be appropriate for initial designation or re-designation, it may make an appeal in writing not later than 60 days to the director of the office. The written appeal must include a signed letter from the facility's governing board with an explanation of how the facility meets the requirements for the designation level.

  (1) If the office upholds its original determination, the director of the office will give written notice of such to the facility not later than 30 days of its receipt of the applicant's complete written appeal.

  (2) The facility may, not later than 30 days of the office's sending written notification of its denial, submit a written request for further review. Such written appeal shall then go to the Assistant Commissioner of the Division for Regulatory Services (assistant commissioner).

(f) The surveyor(s) shall provide the facility with a written, signed survey report regarding their evaluation of the facility's compliance with neonatal program requirements. This survey report shall be forwarded to the facility no later than 30 days of the completion date of the survey. The facility is responsible for forwarding a copy of this report to the office if it intends to continue the designation process.

(g) The office shall review the findings of the survey report and any POC submitted by the facility, to determine compliance with the neonatal program requirements.

  (1) A recommendation for designation shall be made to the executive commissioner based on compliance with the requirements.

  (2) A neonatal level of care designation shall not be denied to a facility that meets the minimum requirements for that level of care designation.

  (3) If a facility does not meet the requirements for the level of designation requested, the office shall recommend designation for the facility at the highest level for which it qualifies and notify the facility of the requirements it must meet to achieve the requested level of designation.

  (4) If a facility does not comply with requirements, the office shall notify the facility of deficiencies and required corrective action(s) plan (CAP).

    (A) The facility shall submit to the office reports as required and outlined in the CAP. The office may require a second survey to ensure compliance with the requirements. The cost of the survey will be at the expense of the facility.

    (B) If the office substantiates action that brings the facility into compliance with the requirements, the office shall recommend designation to the executive commissioner.

    (C) If a facility disagrees with the office's decision regarding its designation application or status, it may request a secondary review by a designation review committee. Membership on a designation review committee will:

      (i) be voluntary;

      (ii) be appointed by the office director;

      (iii) be representative of neonatal care providers and appropriate levels of designated neonatal facilities; and

      (iv) include representation from the office and the Perinatal Advisory Council.

    (D) If a designation review committee disagrees with the office's recommendation for corrective action, the records shall be referred to the assistant commissioner for recommendation to the executive commissioner.

    (E) If a facility disagrees with the office's recommendation at the end of the secondary review, the facility has a right to a hearing, in accordance with a hearing request referenced in §133.121(9) of this title (relating to Enforcement Action), and Government Code, Chapter 2001.


Source Note: The provisions of this §133.184 adopted to be effective June 9, 2016, 41 TexReg 4011

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