Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 410 - REGULATIONS FOR THE LICENSURE OF HOSPITALS IN VIRGINIA › Part II - Organization and Operation of General and Special Hospitals › Article 3 - Special Services › Section 12VAC5-410-440 - Obstetric and newborn services general requirements

Current through Register Vol. 40, No. 24, July 15, 2024
A. Hospitals with licensed obstetric and
					 newborn services in operation prior to August 10, 1995, or revisions to thereof
					 shall comply with all of the requirements of this section with the exception of
					 specified sections of
					 12VAC5-410-442. Hospitals that
					 establish and organize obstetric and newborn services after August 10, 1995,
					 shall comply with all requirements of this section and
					 12VAC5-410-441 through
					 12VAC5-410-447 before licensure
					 approval is granted.
B. A hospital
					 with organized obstetric and newborn services shall comply with the following
					 general requirements:
1. The governing body of
					 the hospital or the chief executive officer shall appoint an administrative
					 manager for the obstetric and newborn services. The administrative manager may
					 serve as an administrator of another hospital service but must be available to
					 the obstetric and newborn services. The chief executive officer shall
					 designate, in writing, an individual to act in the administrative manager's
					 behalf during a temporary absence of the administrative manager.
2. The hospital is responsible for the
					 development, periodic review and revision of a service management plan. The
					 plan must include provisions to assure that the hospital complies with all
					 state and federal regulations and guidelines applicable to obstetric and
					 newborn care as well as the policies and procedures for obstetric and newborn
					 care adopted by the hospital's governing body and medical staff. The plan is to
					 be developed and maintained as follows:
a.
					 The plan shall be developed in cooperation with the medical directors and
					 nursing staffs assigned to each of the services.
b. The plan shall include the protocol,
					 required by § 32.1-127 of the Code of Virginia, for the admission or
					 transfer of any pregnant woman who presents in labor.
c. The plan shall be the responsibility of
					 the administrative manager who is to assure that the plan is developed, that it
					 complies with state and federal requirements and the hospital's policies and
					 procedures, and that it is periodically reviewed and revised.
d. A copy of the plan shall be readily
					 available at each nursing station within the obstetric and newborn services for
					 staff reference.
e. A copy of the
					 plan shall be made available, upon request, to the licensing inspector for
					 review.
3. The hospital
					 shall provide the following services in support of the obstetric and newborn
					 services units:
a. Clinical laboratory
					 services and blood bank services shall be available in the hospital on a
					 24-hour basis. Laboratory and blood bank personnel shall be available on-site
					 or on-call on a 24-hour basis. The blood bank shall have group O Rh negative
					 blood available at all times and be able to provide correctly matched blood in
					 45 minutes from request. The hospital's laboratory and blood bank personnel
					 must be capable of performing the following tests with less than 1.0 ml of
					 blood within one hour of request or less if specified:
(1) Blood group and Rh type
					 determination/cross matching
(2)
					 Arterial blood gases within 20 minutes
(3) Blood glucose within 20 minutes
(4) Complete blood count
(5) Total protein
(6) Total bilirubin
(7) Direct Coombs test
(8) Electrolytes
(9) Blood urea nitrogen
(10) Clotting profile (may require more than
					 one cc of blood).
b.
					 Portable radiological services for basic radiologic studies in each labor room,
					 delivery room, and nursery shall be available on call on a 24-hour
					 basis.
c. In addition to the
					 requirements specified in
					 12VAC5-410-240 anesthesia service
					 personnel shall be available on-site or on-call to begin anesthesia within 30
					 minutes of notification.