New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 370 - OVERSIGHT OF LICENSED HEALTHCARE FACILITIES AND COMMUNITY BASED WAIVER PROGRAMS › Part 17 - REQUIREMENTS FOR FREESTANDING BIRTH CENTERS › Section 8.370.17.23 - QUALITY ASSURANCE, QUALITY IMPROVEMENT SYSTEM, INTERNAL QUALITY COMMITTEE, EXTERNAL QUALITY COMMITTEE AND POLICIES AND PROCEDURES

Current through Register Vol. 35, No. 13, July 16, 2024
Each facility shall establish and maintain policies and
				  procedures for quality assurance and quality improvement systems, as well as an
				  internal quality committee and an external quality committee.
A. Policies and procedures: The administrator
				shall establish written policies and procedures which govern the facility's
				complete operation. The facility shall ensure that these policies are adopted,
				administered and enforced to provide quality health services in a safe
				environment. At a minimum, the facility's written policies and procedures shall
				include how the facility intends to comply with all requirements of these
				regulations and address:
(1) the facility
				organization including the legal entity or organization which owns the
				facility, any management companies or managers which manage the facility, the
				identity and credentials of the administrator responsible for establishing
				lines of responsibility and accountability for both licensed and non-licensed
				staff, and the administrator's responsibility to direct employees or
				contractually retain qualified individuals providing fiscal management and all
				operations in the facility, as well as maintaining records of disclosure of
				conflicts of interest and all ownership interests and controlling
				parties;
(2) the facility
				administration including designation of an administrator with authority,
				responsibility, and accountability for overall administration and operation,
				including plans for the administrator's absence;
(3) the maintenance of the facility,
				equipment and supplies including sterilization and disinfection of supplies,
				equipment and instruments; cleaning of birthing room after each use; inspection
				and maintenance of emergency equipment; maintenance of emergency supplies;
				maintenance, upkeep and cleaning of the building(s) and equipment; fire and
				emergency evacuation procedures; and proper disposal of waste liquids used for
				cleaning contaminated areas;
(4)
				quality of care and services including appropriate and inappropriate admission
				criteria; client rights; client risk assessment; administration and preparation
				of drugs; quality assurance and performance improvement programs; referral of
				clients for additional services including, but not limited to,, laboratory and
				sonography; transfer of clients to a hospital; ambulance transfer services;
				emergency procedures and resuscitative techniques; aseptic techniques;
				infectious waste and biohazard disposal in accordance with all applicable
				statutes and regulations; and safe handling of the placenta for families
				requesting to keep the placenta;
(5) staffing and personnel including written
				job descriptions for all staff with necessary qualifications consistent with
				these rules; minimum staffing and staff qualifications; and staff development
				and evaluation;
(6) maintenance of
				the client health record including protection of client confidentiality and
				privacy as required by law; secure release of medical information and records;
				and safe handling and storage of client records including appropriate document
				destruction procedures; and
(7)
				research procedures for any research being conducted at the facility in
				compliance with these regulations.