| (a) The survey team composition shall be as follows:
(1) Level I facilities neonatal program staff shall
conduct a self-survey, documenting the findings on the approved office
survey form. The office may periodically require validation of the
survey findings, by an on-site review conducted by department staff.
(2) Level II facilities shall be surveyed by a team
that is multi-disciplinary and includes at a minimum of one neonatologist
and one neonatal nurse, all approved in advance by the office and
currently active in the management of neonatal patients at a facility
providing the same or a higher level of neonatal care.
(3) Level III facilities shall be surveyed by a team
that is multi-disciplinary and includes at a minimum of one neonatologist
and one neonatal nurse, all approved in advance by the office and
currently active in the management of neonatal patients at a facility
providing the same or a higher level of neonatal care. An additional
surveyor may be requested by the facility or at the discretion of
the office.
(4) Level IV facilities shall be surveyed by a team
that is multi-disciplinary and includes at a minimum of one neonatologist,
a surgeon with pediatric expertise and one neonatal nurse, all approved
in advance by the office and currently active in the management of
neonatal patients at a facility providing the same level of neonatal
care. If the facility holds a current pediatric surgery verification
by the American College of Surgeons, the facility may be exempted
from having a pediatric surgeon as a member of the survey team.
(b) Office-credentialed surveyors must meet the following
criteria:
(1) have at least three years of experience in the
care of neonatal patients;
(2) be currently employed/practicing in the coordination
of care for neonatal patients;
(3) have direct experience in the preparation for and
successful completion of neonatal facility verification/designation;
(4) have successfully completed an office-approved
neonatal facility site surveyor course and be successfully re-credentialed
every four years; and
(5) have current credentials as follows:
(A) a registered nurse who is current in the NRP and
has successfully completed an office approved site survey internship;
or
(B) a physician who is board certified in the respective
specialty, current in the NRP, and has successfully completed an office
approved site survey internship; or
(C) a surgeon who is board certified, has demonstrated
expertise in pediatric surgery, and has successfully completed an
office approved site survey internship.
(c) All members of the survey team, 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 survey team 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 neonatal care;
(2) reviewing equipment and the physical plant;
(3) conducting interviews with facility personnel;
and
(4) evaluating appropriate use of telemedicine capabilities
where applicable.
(e) All information and materials submitted by a facility
to the office under Health and Safety Code, §241.183(d), are
subject to confidentiality as articulated in Health and Safety Code, §241.184,
Confidentially; Privilege, and are not subject to disclosure under
Government Code, Chapter 552, or discovery, subpoena, or other means
of legal compulsion for release to any person.
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