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RULE §133.185Program Requirements

(a) Designated facilities shall have a family centered philosophy. Parents shall have reasonable access to their infants at all times and be encouraged to participate in the care of their infants. The facility environment for perinatal care shall meet the physiologic and psychosocial needs of the mothers, infants, and families.

(b) Program Plan. The facility shall develop a written plan of the neonatal program that includes a detailed description of the scope of services available to all maternal and neonatal patients, defines the neonatal patient population evaluated and/or treated, transferred, or transported by the facility, that is consistent with accepted professional standards of practice for neonatal and maternal care, and ensures the health and safety of patients.

  (1) The written plan and the program policies and procedures shall be reviewed and approved by the facility's governing body. The governing body shall ensure that the requirements of this section are implemented and enforced.

  (2) The written neonatal program plan shall include, at a minimum:

    (A) standards of neonatal practice that the program policies and procedures are based upon that are adopted, implemented and enforced for the neonatal services it provides;

    (B) a periodic review and revision schedule for all neonatal care policies and procedures;

    (C) written triage, stabilization and transfer guidelines for neonates and/or pregnant/postpartum women that include consultation and transport services;

    (D) ensure appropriate follow up for all neonates/infants;

    (E) provisions for disaster response to include evacuation of mothers and infants to appropriate levels of care;

    (F) a QAPI Program as described in §133.41(r) of this title (relating to Hospital Functions and Services). The facility shall demonstrate that the neonatal program evaluates the provision of neonatal care on an ongoing basis, identify opportunities for improvement, develop and implement improvement plans, and evaluate the implementation until a resolution is achieved. The neonatal program shall measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and is outcome based. Evidence shall support that aggregate patient data is continuously reviewed for trends and data is submitted to the department as requested;

    (G) requirements for minimal credentials for all staff participating in the care of neonatal patients;

    (H) provisions for providing continuing staff education; including annual competency and skills assessment that is appropriate for the patient population served;

    (I) a perinatal staff registered nurse as a representative on the nurse staffing committee under §133.41(o)(2)(F) of this title;

    (J) the availability of all necessary equipment and services to provide the appropriate level of care and support of the patient population served; and

    (K) the availability of personnel with knowledge and skills in breastfeeding.

(c) Medical Staff. The facility shall have an organized, effective neonatal program that is recognized by the medical staff and approved by the facility's governing body. The credentialing of the medical staff shall include a process for the delineation of privileges for neonatal care.

(d) Medical Director. There shall be an identified Neonatal Medical Director (NMD) and/or Transport Medical Director (TMD) as appropriate, responsible for the provision of neonatal care services and credentialed by the facility for the treatment of neonatal patients.

  (1) The NMD and/or TMD shall have the authority and responsibility to monitor neonatal patient care from admission, stabilization, operative intervention(s) if applicable, through discharge, inclusive of the QAPI Program.

  (2) The responsibilities and authority of the NMD and/or TMD shall include but are not limited to:

    (A) examining qualifications of medical staff requesting neonatal privileges and makes recommendations to the appropriate committee for such privileges;

    (B) assuring staff competency in resuscitation techniques;

    (C) participating in ongoing staff education and training in the care of the neonatal patient;

    (D) oversight of the inter-facility neonatal transport;

    (E) participating in the development, review and assurance of the implementation of the policies, procedures and guidelines of neonatal care in the facility including written criteria for transfer, consultation or higher level of care;

    (F) regular and active participation in neonatal care at the facility where medical director services are provided;

    (G) ensuring that the QAPI Program is specific to neonatal/infant care, is ongoing, data driven and outcome based; and regularly participates in the neonatal QAPI meeting; and

    (H) maintaining active staff privileges as defined in the facility's medical staff bylaws.

(e) Neonatal Program Manager (NPM). The NPM responsible for the provision of neonatal care services shall be identified by the facility and:

  (1) be a registered nurse:

  (2) have successfully completed and is current in the Neonatal Resuscitation Program (NRP) or an office-approved equivalent:

  (3) have the authority and responsibility to monitor the provision of neonatal patient care services from admission, stabilization, operative intervention(s) if applicable, through discharge, inclusive of the QAPI Program as defined in subsection (b)(2)(E) of this section.

  (4) collaborate with the NMD in areas to include, but not limited to: developing and/or revising policies, procedures and guidelines; assuring staff competency, education, and training; the QAPI Program; and regularly participates in the neonatal QAPI meeting; and

  (5) develop collaborative relationships with other NPM(s) of designated facilities within the applicable Perinatal Care Region.

Source Note: The provisions of this §133.185 adopted to be effective June 9, 2016, 41 TexReg 4011

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