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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 §133.187Neonatal Designation Level II

(a) Level II (Special Care Nursery).

  (1) The Level II neonatal designated facility will:

    (A) provide care for mothers and their infants of generally >=32 weeks gestational age and birth weight >=1500 grams who have physiologic immaturity or who have problems that are expected to resolve rapidly and are not anticipated to require subspecialty services on an urgent basis; and

    (B) either provide care, including assisted endotracheal ventilation for less than 24 hours or nasal continuous positive airway pressure (NCPAP) until the infant's condition improves, or arrange for appropriate transfer to a higher level designated facility. If the facility performs neonatal surgery, the facility shall provide the same level of care that the neonate would receive at a higher level designated facility and shall, through the QAPI Program, complete an in depth critical review of the care provided; and

    (C) provide skilled personnel that have documented training, competencies and annual continuing education specific for the patient population served.

  (2) If a facility is located more than 75 miles from the nearest Level III or IV designated neonatal facility, and retains a neonate between 30 and 32 weeks of gestation having a birth weight of between 1250 - 1500 grams, the facility shall provide the same level of care that the neonate would receive at a higher level designated neonatal facility and shall, through the QAPI Program, complete an in depth critical review of the care provided.

(b) Neonatal Medical Director (NMD). The NMD shall be a physician who is:

  (1) a board eligible/certified neonatologist, with experience in the care of neonates/infants and demonstrates a current status on successful completion of the Neonatal Resuscitation Program (NRP); or

  (2) by the effective date of this rule, a pediatrician or neonatologist who:

    (A) has continuously provided neonatal care for the last consecutive two years; has experience and training in the care of neonates/infants including assisted endotracheal ventilation and NCPAP management;

    (B) maintains a consultative relationship with a board eligible/certified neonatologist;

    (C) demonstrates effective administrative skills and oversight of the QAPI Program;

    (D) demonstrates a current status on successful completion of the NRP; and

    (E) has completed continuing medical education annually specific to the care of neonates.

(c) Program Functions and Services.

  (1) Triage and assessment of all patients admitted to the perinatal service with the identification of pregnant women with a high likelihood of delivering a neonate requiring a higher level of care be transferred prior to delivery unless the transfer is unsafe.

  (2) Supportive and emergency care delivered by appropriately trained personnel, for unanticipated maternal-fetal problems that occur during labor and delivery through the disposition of the patient.

  (3) The ability to perform an emergency cesarean delivery.

  (4) The physician, advanced practice nurse and/or physician assistant with special competence in the care of neonates, whose credentials have been reviewed by the NMD and is on call, and:

    (A) shall demonstrate a current status on successful completion of the NRP;

    (B) shall have completed continuing education annually specific to the care of neonates;

    (C) shall arrive at the patient bedside within 30 minutes of an urgent request;

    (D) if not immediately available to respond or is covering more than one facility, appropriate back-up coverage shall be available, documented in an on call schedule and readily available to facility staff;

    (E) the physician, advanced practice nurse and/or physician assistant providing backup coverage shall arrive at the patient bedside within 30 minutes of urgent request; and

    (F) shall be on-site to provide ongoing care and to respond to emergencies when a neonate/infant is maintained on endotracheal ventilation.

  (5) Anesthesia services with pediatric experience will be provided in compliance with the requirements found in §133.41(a) of this title (relating to Hospital Functions and Services).

  (6) Dietitian or nutritionist with sufficient training and experience in neonatal and maternal nutrition, appropriate to meet the needs of the population served, shall be available and in compliance with the requirements found in §133.41(d) of this title.

  (7) Laboratory services shall be in compliance with the requirements found in §133.41(h) of this title and shall have:

    (A) personnel on-site at all times when a neonate/infant is maintained on endotracheal ventilation;

    (B) a blood bank capable of providing blood and blood component therapy; and

    (C) neonatal/infant blood gas monitoring capabilities.

  (8) Pharmacy services shall be in compliance with the requirements found in §133.41(q) of this title and shall have a pharmacist with experience in neonatal/perinatal pharmacology available at all times.

    (A) If medication compounding is done by a pharmacy technician for neonates/infants, a pharmacist will provide immediate supervision of the compounding process.

    (B) If medication compounding is done for neonates/infants, the pharmacist will develop checks and balances to ensure the accuracy of the final product.

    (C) Total parenteral nutrition appropriate for neonates/infants shall be available.

  (9) An occupational or physical therapist with sufficient neonatal expertise shall be available to meet the needs of the population served.

  (10) Medical Imaging. Radiology services shall be in compliance with the requirements found in §133.41(s) of this title and will incorporate the "As Low as Reasonably Achievable" principle when obtaining imaging in neonatal and maternal patients; and shall have:

    (A) personnel appropriately trained, in the use of x-ray and ultrasound equipment;

    (B) personnel at the bedside within 30 minutes of an urgent request;

    (C) appropriately trained personnel shall be available on-site to provide ongoing care and to respond to emergencies when an infant is maintained on endotracheal ventilation; and

    (D) interpretation capability of neonatal and perinatal x-rays and ultrasound studies available at all times.

  (11) A respiratory therapist, with experience and specialized training in the respiratory support of neonates/infants, whose credentials have been reviewed by the NMD, shall be immediately available on-site when:

    (A) a neonate/infant is on a respiratory ventilator to provide ongoing care and to respond to emergencies; or

    (B) a neonate/infant is on a Continuous Positive Airway Pressure (CPAP) apparatus.

  (12) Resuscitation. The facility shall have written policies and procedures specific to the facility for the stabilization and resuscitation of neonates based on current standards of professional practice.

    (A) Each birth shall be attended by at least one provider who demonstrates current status of successful completion of the NRP whose primary responsibility is the management of the neonate and initiating resuscitation.

    (B) At least one person must be immediately available on-site with the skills to perform a complete neonatal resuscitation including endotracheal intubation, establishment of vascular access and administration of medications.

    (C) Additional providers with current status of successful completion of the NRP shall be on-site and immediately available upon request.

    (D) Additional providers who demonstrate current status of successful completion of the NRP shall attend each neonate in the event of multiple births.

    (E) A full range of NRP equipment and supplies shall be immediately available for trained staff to perform resuscitation and stabilization on any neonate/infant.

  (13) Perinatal Education. A registered nurse with experience in neonatal care, including special care nursery, and/or perinatal care shall provide supervision and coordination of staff education.

  (14) Social services and pastoral care shall be provided as appropriate to the patient population served.

  (15) Ensure the timely evaluation of retinopathy of prematurity, monitoring, referral for treatment and follow-up, in the case of an at-risk infant.

  (16) Ensure the availability of support personnel with knowledge and expertise in lactation to meet the needs of new mothers while breastfeeding.

  (17) Ensure provisions for follow up care at discharge for infants at high risk for neurodevelopmental, medical or psychosocial complications.


Source Note: The provisions of this §133.187 adopted to be effective June 9, 2016, 41 TexReg 4011

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