| (a) The survey team composition must be as follows:
(1) Level I facilities maternal 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 obstetrics and gynecology physician
and one maternal nurse who:
(A) have completed a survey training course;
(B) have observed a minimum of one maternal survey;
(C) are currently active in the management of maternal
patients and active in the maternal QAPI Plan and process at a facility
providing the same or higher level of maternal 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 obstetrics and gynecology physician
or maternal fetal medicine physician and one maternal nurse, who:
(A) have completed a survey training course;
(B) have observed a minimum of one maternal survey;
(C) are currently active in the management of maternal
patients and active in the maternal QAPI Plan and process at a facility
providing the same or higher level of maternal care; and
(D) meet the criteria outlined in the department survey
guidelines.
(4) Level III facilities that serve as referral centers
for placenta accreta spectrum disorder, must have a survey team that
includes a maternal fetal medicine physician and a maternal nurse
from a Level IV facility.
(5) Level IV facilities must be surveyed by a multidisciplinary
team that includes at a minimum, one obstetrics and gynecology physician,
a maternal fetal medicine physician, and one maternal nurse, who:
(A) have completed a survey training course;
(B) have observed a minimum of one maternal survey;
(C) are currently active in the management of maternal
patients and active in the maternal QAPI plan and process at a facility
providing Level IV maternal 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 Perinatal Care Region 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 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, had a previous working
relationship with the facility or facility leaders, or conducted a
designation survey for the facility within the past four years. Surveyors
cannot be from the same PCR or TSA region or a contiguous region of
the facility's location.
(2) If a designation survey occurs with a surveyor
who has an identified conflict of interest, the maternal designation
site survey summary and medical record reviews may not be accepted
by the department.
(d) The survey team must follow the department survey
guidelines to evaluate and validate that the facility demonstrates
the designation requirements are met.
(e) 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.
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