| (a) The survey team composition must be as follows:
(1) Level I facilities neonatal program staff must
conduct a self-survey, documenting the findings on the approved department
survey form. The department may periodically require validation of
the survey findings by an on-site review conducted by department staff.
(2) Level II facilities must be surveyed by a multidisciplinary
team that includes, at a minimum, one neonatologist and one neonatal
nurse who:
(A) have completed a department survey training course;
(B) have observed a minimum of one neonatal survey;
(C) are currently active in the management of neonatal
patients and active in the neonatal QAPI Plan and process at a facility
providing the same or a higher-level of neonatal care; and
(D) meet the criteria outlined in the department survey
guidelines.
(3) Level III facilities must be surveyed by a multidisciplinary
team that includes, at a minimum, one neonatologist, one neonatal
nurse, and a pediatric surgeon when neonatal surgery is performed
in the facility, who:
(A) have completed a survey training course;
(B) have observed a minimum of one neonatal survey;
(C) are currently active in the management of neonatal
patients and active in the neonatal QAPI Plan and process at a facility
providing the same or a higher-level of neonatal care; and
(D) meet the criteria outlined in the department survey
guidelines.
(4) Level IV facilities must be surveyed by a multidisciplinary
team that includes, at a minimum, one neonatologist, one neonatal
nurse, and one pediatric surgeon, who:
(A) have completed a survey training course;
(B) have observed a minimum of one neonatal survey;
(C) are currently active in the management of neonatal
patients and active in the neonatal QAPI Plan and process at a facility
providing the same level of neonatal care; and
(D) meet the criteria outlined in the department survey
guidelines.
(b) All members of the survey team, except department
staff, must come from a PCR outside the facility's region or a contiguous
region.
(c) Survey team members cannot have a conflict of interest:
(1) A conflict of interest exists when a surveyor has
a direct or indirect financial, personal, or other interest which
would limit or could reasonably be perceived as limiting the surveyor's
ability to serve in the best interest of the public. The conflict
of interest may include a surveyor who, within the past four years,
has personally trained a key member of the facility's leadership in
residency or fellowship, collaborated with a key member of the facility's
leadership professionally, participated in a designation consultation
with the facility, or conducted a designation survey for the facility.
(2) If a designation survey occurs with a surveyor
who has a conflict of interest, the department, in its sole discretion,
may refuse to accept the neonatal designation site survey summary
conducted by a surveyor with a conflict of interest.
(d) The survey team must follow the department survey
guidelines to evaluate and validate that the facility demonstrates
the designation requirements are met.
(e) The survey team must evaluate appropriate use of
telehealth/telemedicine utilization for neonatal care.
(f) All information and materials submitted by a facility
to the department and a survey organization under Texas Health and
Safety Code, §241.183(d) or this subchapter, are subject to confidentiality
as articulated in Texas Health and Safety Code, §241.184, Confidentiality;
Privilege, and are not subject to disclosure under Texas Government
Code, Chapter 552, or discovery, subpoena, or other means of legal
compulsion for release to any person.
|
