Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 133 - HOSPITAL LICENSING › Subchapter K - HOSPITAL LEVEL OF CARE DESIGNATIONS FOR MATERNAL CARE › Section 133.205 - Program Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) Maternal
				  Program Philosophy. Designated facilities must have a family centered
				  philosophy. The facility environment for perinatal care must meet the
				  physiologic and psychosocial needs of the mothers, infants, and families.
				  Parents must have reasonable access to their infants at all times and be
				  encouraged to participate in the care of their infants.
(b) Maternal Program Plan. The facility must
				  develop a written maternal operational plan for the maternal program that
				  includes a detailed description of the scope of services and clinical resources
				  available for all maternal patients and families. The plan will define the
				  maternal patient population evaluated, treated, transferred, or transported by
				  the facility consistent with clinical guidelines based on current standards of
				  maternal practice ensuring the health and safety of patients.
(1) The written Maternal Program Plan must be
				  reviewed and approved by Maternal Program Oversight and be submitted to the
				  facility's governing body for review and approval. The governing body must
				  ensure that the requirements of this section are implemented and
				  enforced.
(2) The written Maternal
				  Program Plan must include, at a minimum:
(A)
				  clinical guidelines based on current standards of maternal practice, and
				  policies and procedures that are adopted, implemented, and enforced by the
				  maternal program;
(B) a process to
				  ensure and validate that these clinical guidelines based on current standards
				  of maternal practice, policies, and procedures are reviewed and revised a
				  minimum of every three years;
(C)
				  written triage, stabilization, and transfer guidelines for pregnant and
				  postpartum patients that include consultation and transport services;
(D) written guidelines or protocols for
				  prevention, early identification, early diagnosis, and therapy for conditions
				  that place the pregnant or postpartum patient at risk for morbidity or
				  mortality;
(E) the role and scope
				  of telehealth/telemedicine practices if utilized, including:
(i) documented and approved written policies
				  and procedures that outline the use of telehealth/telemedicine for inpatient
				  hospital care, or for inpatient consultation, including appropriate situations,
				  scope of care, and documentation that is monitored through the QAPI Plan and
				  process; and
(ii) written and
				  approved procedures to gain informed consent from the patient or designee for
				  the use of telehealth/telemedicine, if utilized, that are monitored for
				  compliance;
(F) written
				  guidelines for discharge planning instructions and appropriate follow up
				  appointments for all mothers and infants;
(G) written guidelines for the hospital
				  disaster response, including a defined mother and infant evacuation plan and
				  process to relocate mothers and infants to appropriate levels of care with
				  identified resources, and this process must be evaluated annually to ensure
				  maternal care can be sustained and adequate resources are available;
(H) requirements for minimal credentials for
				  all staff participating in the care of maternal patients;
(I) provisions for providing continuing staff
				  education, including annual competency and skills assessment that is
				  appropriate for the patient population served;
(J) a perinatal staff registered nurse as a
				  representative on the nurse staffing committee under §
												133.41 of this title (relating to
				  Hospital Functions and Services); and
(K) the availability of all necessary
				  equipment and services to provide the appropriate level of care and support of
				  the patient population served.
(3) The facility must have a documented QAPI
				  Plan. The maternal program must measure, analyze, and track quality indicators
				  and other aspects of performance that the facility adopts or develops that
				  reflect processes of care and is outcome based.
(A) The Chief Executive Officer, Chief
				  Medical Officer, and Chief Nursing Officer must implement a culture of safety
				  for the facility and ensure adequate resources are allocated to support a
				  concurrent, data-driven maternal QAPI Plan.
(B) The facility must demonstrate that the
				  maternal QAPI Plan consistently assesses the provision of maternal care
				  provided. The assessment will identify variances in care, the impact to the
				  patient, and the appropriate levels of review. This process will identify
				  opportunities for improvement and develop a plan of correction to address the
				  variances in care or the system response. An action plan will track and analyze
				  data through resolution or correction of the identified variance.
(C) Maternal facilities must review their
				  incidence and management of placenta accreta spectrum disorder through the QAPI
				  Plan and report the incidence and outcomes through the Maternal Program
				  Oversight.
(D) The Maternal Medical
				  Director (MMD) must have the authority to make referrals for peer review,
				  receive feedback from the peer review process, and ensure maternal physician
				  representation in the peer review process for maternal cases.
(E) The MMD and the Maternal Program Manager
				  (MPM) must participate in the PCR meetings, QAPI regional initiatives, and
				  regional collaboratives, and submit requested data to assist with data analysis
				  to evaluate regional outcomes as an element of their maternal QAPI
				  Plan.
(F) The facility must have
				  documented evidence of maternal QAPI summary reports reviewed and reported by
				  Maternal Program Oversight that monitor and ensure the provision of services or
				  procedures through the telehealth and telemedicine, if utilized, is in
				  accordance with the standard of care applicable to the provision of the same
				  service or procedure in an in-person setting.
(G) The facility must have documented
				  evidence of maternal QAPI summary reports to support that aggregate maternal
				  data are consistently reviewed to identify developing trends, opportunities for
				  improvement, and necessary corrective actions. Summary reports must be provided
				  through Maternal Program Oversight, available for site surveyors, and submitted
				  to the department as requested.