Oregon Administrative Rules › Chapter 333 - OREGON HEALTH AUTHORITY, PUBLIC HEALTH DIVISION › Division 76 - AMBULATORY SURGICAL CENTERS (ASC) AND EXTENDED STAY CENTERS (ESC) › Section 333-076-0670 - Policies and Procedures

Current through Register Vol. 63, No. 7, July 1, 2024
Each Center must have a detailed Policies and Procedures Manual
				in easily accessible form, that has been approved by the governing body or
				person. In order to be approved by the Division for licensing purposes, these
				policies and procedures must meet North American Registry of Midwives (NARM)
				standards. All the above noted policies must be made available to
				representatives of the Division on request, and subject to their approval.
				Failure of approval will be adequate reason for the finding of deficiencies
				that must be corrected for continuation of licensure. The policies must be
				implemented as applicable, and there must be documented evidence of
				implementation of the above noted policies. The policies and procedures that
				will be developed as applicable and implemented include:
(1) A detailed organizational chart that
			 shows the governing body or person, and clearly delineates lines of authority,
			 responsibility and accountability for each position included in the
			 organization, including volunteers.
(2) Staffing - The governing body or person
			 must ensure, through the policies and procedures, that there are adequate
			 numbers of qualified and, where required, licensed or registered personnel on
			 duty and immediately available to provide services intended for mothers and
			 families, and to provide for safe maintenance of the Center.
(3) Detail of procedures to be permitted, and
			 by whom, and method of determining the qualifications and privileges of all
			 personnel. Staff will be required to provide documented evidence of such
			 qualifications. Such evidence must be maintained by the Center.
(4) System for ensuring 24-hour coverage of
			 the Center, including constant attendance by qualified attendants while a
			 client is in the Center.
(5)
			 System for training and for continuing education for all personnel according to
			 their assigned duties and evaluation of skills consistent with the individual
			 practitioners' scopes of practice. All personnel providing direct client care
			 must be trained in cardiopulmonary resuscitation (CPR) and there must be a
			 record of current CPR certification. In addition there must be present at each
			 birth one practitioner trained in care and resuscitation of the newborn.
(6) System delineating how and
			 when the Center will seek consultation with clinical specialists in obstetrics
			 and pediatrics in order to ensure that all services, policies, and procedures
			 meet North American Registry of Midwives (NARM) standards.
(7) Protocol for referral or transfer to
			 appropriate health care facilities all clients whose risk status exceeds that
			 for "low risk pregnancy."
(8)
			 Procedures by which risk status will be assessed during the antepartal,
			 intrapartal, and post partum period, and the identification of medical and
			 social factors which exclude women, fetuses and newborns from the low-risk
			 group; and for the annual review of these methods. Documentation of such
			 assessments must be maintained in client's clinical records. Only those clients
			 for whom prenatal and intrapartum history, physical examination, and laboratory
			 screening procedures have demonstrated a low risk pregnancy and labor will be
			 accepted into the Center for childbirth.
(9) System by which the Center will ensure
			 the presence and continuing maintenance, as recommended by the manufacturer(s),
			 of equipment needed to provide low risk maternity care, and to initiate
			 emergency procedures in life-threatening events to the mother or baby.
(10) Plan and protocols for
			 ensuring that emergency situations in either the mother or newborn are
			 recognized in a timely fashion, and care is provided within the limits of the
			 practitioner's scope of practice.
(11) System delineating how emergency
			 transportation will be promptly available for transport of the mother and/or
			 newborn to a health care facility with the capacity for emergency care of
			 women, in all the stages of labor, and newborns. The written policy must
			 include a listing of situations for the mother and/or newborn that would have
			 the potential to necessitate emergency transfer. The policy must also include
			 the requirement that a transfer plan for each patient be developed.
(12) Systems for ensuring the orientation and
			 education of women and families registering for care at the Center so that they
			 will be informed as to the benefits and risks of the services available to them
			 at the Center and the qualifications and licensure status of practitioners at
			 the Center. They must be fully informed of the risk criteria as defined in OAR
			 333-076-0650  and provide written consent. The client, as a part of the informed consent,
			 must also agree in advance to transfer to another clinician or appropriate
			 health care facility, should the need occur due to the development of
			 unexpected risk factors after admission to the Center. The client must be
			 informed of the benefits and risks of such a transfer.
(13) System for the sterilization of
			 equipment and supplies, unless only pre-packaged and pre-sterilized items are
			 used.
(14) System to ensure the
			 performance of appropriate laboratory studies and to ensure that the results
			 are available in a timely manner.
(15) System for the storage and
			 administration of drugs. All medications must be prescribed and/or administered
			 within the individual practitioner's licensure and/or scope of practice.
(16) System to ensure the timely
			 administration of Rh immune globulin to the mother, where applicable.
(17) System to ensure the timely
			 appropriate administration of Vitamin K to the newborn, according to rules of
			 the Division.
(a) The purpose of ORS 433.303 to 433.314 is to protect newborn infants against hemorrhagic disease of the
			 newborn.
(b) The Vitamin K forms
			 suitable for use are forms of Vitamin K1 (Phytonadione), available in
			 injectable or oral forms: as Mephyton for oral use, or as aquamephyton or
			 konakion for injectable use. The Vitamin K dose is to be administered within
			 the first 24 hours of delivery. Menadione (Vitamin K3) is not recommended for
			 prophylaxis and treatment of hemorrhagic disease of the newborn.
(c) The dose of any of the Vitamin K1 forms
			 to be administered is one dose of 0.5 to 1.0 mg., if given by injection, or one
			 dose of 1.0 to 2.0 mg. if given orally.
(d) A parent may, after being provided a full
			 and clear explanation, decline to permit the administration of Vitamin K based
			 on religious tenets and practices. In this event, the parent must sign a form
			 acknowledging his/her understanding of the reason for administration of Vitamin
			 K and possible adverse consequences in the presence of a person who witnessed
			 the instruction of the parent, and who must also sign the form. The form must
			 become a part of the clinical record of the newborn infant.