Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 133 - HOSPITAL LICENSING › Subchapter J - HOSPITAL LEVEL OF CARE DESIGNATIONS FOR NEONATAL CARE › Section 133.185 - Program Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) Neonatal
				  Program Philosophy. Designated facilities must have a family-centered
				  philosophy. Parents must 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 must meet the physiologic and psychosocial needs
				  of the mothers, infants, and families.
(b) Neonatal Program Plan. The facility must
				  develop a written neonatal operational plan for the neonatal program that
				  includes a detailed description of the scope of services and clinical resources
				  available for all neonatal patients, mothers, and families. The plan must
				  define the neonatal patient population evaluated, treated, transferred, or
				  transported by the facility consistent with clinical guidelines based on
				  current standards of neonatal practice ensuring the health and safety of
				  patients.
(1) The written Neonatal Program
				  Plan must be reviewed and approved by Neonatal Program Oversight and be
				  submitted to the facility's governing body for review and approval. The
				  governing body must ensure the requirements of this section are implemented and
				  enforced.
(2) The written Neonatal
				  Program Plan must include, at a minimum:
(A)
				  clinical guidelines based on current standards of neonatal practice, and
				  policies and procedures that are adopted, implemented, and enforced by the
				  neonatal program;
(B) a process to
				  ensure and validate these clinical guidelines based on current standards of
				  neonatal practice, policies, and procedures, are reviewed and revised a minimum
				  of every three years;
(C) written
				  triage, stabilization, and transfer guidelines for neonatal patients that
				  include consultation and transport services;
(D) 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 consultation, including appropriate situations, scope of
				  care, and documentation that is monitored through the neonatal 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
				  variances;
(E) written
				  guidelines for discharge planning instructions and appropriate follow-up
				  appointments for all neonates/infants;
(F) written guidelines for the hospital
				  disaster response, including a defined neonatal 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 neonatal care
				  can be sustained and adequate resources are available;
(G) written minimal education and
				  credentialing requirements for all staff participating in the care of neonatal
				  patients, which are documented and monitored by the managers who have oversight
				  of staff;
(H) written requirements
				  for providing continuing staff education, including annual competencies and
				  skills assessment that is appropriate for the patient population served, which
				  are documented and monitored by the managers who have oversight of
				  staff;
(I) documentation of meeting
				  the requirement for a perinatal staff registered nurse to serve as a
				  representative on the nurse staffing committee under §
												133.41 of this title (relating to
				  Hospital Functions and Services);
(J) measures to monitor the availability of
				  all necessary equipment and services required to provide the appropriate level
				  of care and support for the patient population served; and
(K) documented guidelines for consulting
				  support personnel with knowledge and skills in breastfeeding and lactation,
				  which includes expected response times, defined roles, responsibilities, and
				  expectations.
(3) The
				  facility must have a documented and approved neonatal QAPI Plan.
(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 neonatal QAPI Plan.
(B) The facility must demonstrate that the
				  neonatal QAPI Plan consistently assesses the provision of neonatal care
				  provided. The assessment must identify variances in care, the impact to the
				  patient, and the appropriate levels of review. This process must 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) The neonatal program must measure,
				  analyze, and track performance through defined quality indicators, core
				  performance measures, and other aspects of performance that the facility adopts
				  or develops to evaluate processes of care and patient outcomes. Summary reports
				  of these findings are reported through the Neonatal Program
				  Oversight.
(D) All neonatal
				  facilities must participate in a neonatal data initiative. Level III and IV
				  neonatal facilities must participate in benchmarking programs to assess their
				  outcomes as an element of the neonatal QAPI Plan.
(E) The Neonatal Medical Director (NMD) must
				  have the authority to make referrals for peer review, receive feedback from the
				  peer review process, and ensure neonatal physician representation in the peer
				  review process for neonatal cases.
(F) The NMD and Neonatal Program Manager
				  (NPM) must participate in PCR meetings, regional QAPI initiatives, and regional
				  collaboratives, and submit requested data to assist with data analysis to
				  evaluate regional outcomes as an element of the facility's neonatal QAPI
				  Plan.
(G) The facility must have
				  documented evidence of neonatal QAPI summary reports reviewed and reported by
				  Neonatal Program Oversight that monitor and ensure the provision of services or
				  procedures through telehealth and telemedicine, if utilized, is in accordance
				  with the standards of care applicable to the provision of the same service or
				  procedure in an in-person setting.
(H) The facility must have documented
				  evidence of neonatal QAPI summary reports to support that aggregate neonatal
				  data are consistently reviewed to identify developing trends, opportunities for
				  improvement, and necessary corrective actions. Summary reports must be provided
				  through the Neonatal Program Oversight, available for site surveyors, and
				  submitted to the department as requested.