333-077-0090 Policies and Procedures (1) A birthing center shall develop and implement written policies and procedures that include, but are not limited to, the following: (a) Types of services and procedures that may be performed in the birthing center; (b) Training requirements for clinical providers, clinical staff and other personnel that include, but are not limited to: (A) Infection control measures; and (B) Emergency procedures, including but not limited to: (i) Procedures for fire and other disasters; (ii) Procedures in life threatening situations including but not limited to cardiopulmonary resuscitation and other life saving techniques; and (iii) Threats against clients or newborns. (c) System for ensuring 24-hour coverage of the birthing center, consistent with the requirements in OAR 333-077-0080; (d) Client care and services activities; (e) Admission and discharge criteria; (f) Visitor conduct and control; (g) Client grievance procedures; (h) Assessment of risk status and consultation requirements in accordance with OAR 333-077-0125; (i) Content and form of medical records and release of medical information consistent with the requirements in OAR 333-077-0130; (j) Infection control requirements in accordance with OAR 333-077-0190; (k) Equipment storage, maintenance and sterilization in accordance with OAR 333-077-0180; (l) Provision of life saving measures within the clinical provider's scope of practice and arrangements for transfer to hospital-based care for the client or newborn; (m) Prompt availability of emergency transportation for transport of the client or newborn to hospital-based care with the capacity for emergency care of persons, in all the stages of labor, and emergency care of newborns; (n) Orientation and education of clients and family members or legal representatives registering for care including the services available, required disclosures, client rights, and exclusion, transfer, and consultation requirements; (o) Performance of appropriate laboratory services including tests required pursuant to ORS 433.017 and the rules adopted thereunder; (p) Procurement, storage and administration of drugs, including: (A) Timely administration of Rh immune globulin to the client, where applicable; and (B) Timely administration of Vitamin K to a newborn and prevention of ophthalmia neonatorum in a newborn in accordance with OAR 333-077-0170. If Vitamin K or gonococcal ophthalmia neonatorum prophylaxis cannot be administered by the clinical provider delivering the newborn, methods must be described to ensure that these services are arranged by referral; (q) Appropriate and timely collection of blood from a newborn for testing by the Oregon State Public Health Laboratory for metabolic diseases in accordance with OAR 333-077-0170; (r) Performance of pulse oximetry screening on every newborn in accordance with OAR 333-077-0170; (s) Systems to ensure that appropriate vital records are filed according to ORS 432.088; (t) Procedures for notifying clients orally and in writing of any financial interest as required by ORS 441.098; and (u) Procedures for providing health care interpreter services to clients who prefer to communicate in a language other than English in accordance with ORS 413.559 and OAR 950-050-0160. (2) Policies and procedures shall be evaluated annually and be amended or rewritten as needed. Documentation of the annual evaluation is required. Statutory/Other Authority: ORS 441.025 Statutes/Other Implemented: ORS 441.025 & ORS 433.017 History: PH 23-2025, amend filed 11/03/2025, effective 11/03/2025 PH 121-2024, renumbered from 333-076-0670, filed 12/24/2024, effective 12/24/2024 PH 18-2014, f. & cert. ef. 6-17-14 PH 18-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-29-14 PH 15-2006, f. & cert. ef. 6-27-06 HD 2-1990, f. 1-8-90, cert. ef. 1-15-90, Renumbered from 333-076-0420 HD 26-1985, f. & ef. 10-28-85