| (a) A CEFDT shall be surveyed by a team, approved by
the office, which is multi-disciplinary and includes at a minimum
one board certified physician that is active in the management of
maternal-fetal patients and/or performs fetal interventions; and a
nurse active in the management of maternal-fetal patients, at a facility
providing the same level of maternal-fetal care. An additional surveyor
may be requested by the facility or at the discretion of the office.
(b) Office-credentialed surveyors must meet the following
criteria:
(1) have at least three years of experience in the
care of maternal-fetal patients and/or fetal interventions;
(2) be currently employed and clinically practicing
in the coordination of care for maternal-fetal patients and fetal
interventions;
(3) have direct experience in the preparation for and
successful completion of a Centers of Excellence for Fetal Diagnosis
and Therapy verification and/or designation;
(4) have successfully completed an office-approved
Centers of Excellence for Fetal Diagnosis and Therapy site surveyor
course and be successfully re-credentialed every four years; and
(5) have current credentials as:
(A) a registered nurse with maternal-fetal experience
who has successfully completed an office-approved site survey internship;
or
(B) a physician who is board certified in the respective
specialty, and has successfully completed an office-approved site
survey internship.
(c) All surveyors, except department staff, shall come
from a Perinatal Care Region outside the facility's location and at
least 100 miles from the facility. There shall be no business or patient
care relationship or any potential conflict of interest between the
surveyor or the surveyor's place of employment and the facility being
surveyed.
(d) The surveyors shall evaluate the facility's compliance
with the designation criteria by:
(1) reviewing medical records; staff rosters and schedules;
documentation of QAPI Program activities, including peer review; the
program plan; policies and procedures; and other documents relevant
to fetal diagnosis and therapy services;
(2) reviewing equipment and the physical plant; and
(3) conducting interviews with facility personnel;
surveyors may meet privately with individuals or groups of personnel.
|
