Current through all regulations passed and filed through September 16, 2024
(A)
Each maternity
unit, newborn care nursery, or maternity home shall develop and follow policies
and procedures to effectively receive, investigate, and report findings of
complaints regarding the quality or appropriateness of care and services. The
documentation of complaints shall, at a minimum, include the following:
(1)
The date
complaint was received;
(2)
The identity, if provided, of the
complainant;
(3)
A description of the complaint
allegations;
(4)
The identity of persons, or provider of the services,
or both, involved;
(5)
The findings of the investigation; and
(6)
The resolution of
the complaint.
(B)
Each maternity unit, newborn care nursery, and
maternity home shall post the department's toll free complaint hotline in a
conspicuous place.
(C)
Each maternity unit or newborn care nursery shall
establish a quality assessment and improvement program designed to
systematically monitor and evaluate the quality of patient care provided in
each maternity unit or newborn care nursery. The quality assessment and
improvement program shall do all of the following:
(1)
Monitor and
evaluate all aspects of care including effectiveness, appropriateness,
accessibility, continuity, efficiency, patient outcome, and patient
satisfaction;
(2)
Establish expectations, develop plans, and implement
procedures to assess and improve the maternity unit and newborn care
nursery's:
(a)
Quality of care;
(b)
Resolution of identified problems;
(c)
Governance;
(d)
Management; and
(e)
Clinical and
support processes;
(3)
Establish
information systems and appropriate data management processes to facilitate the
collection, management, and analysis of data needed for quality
improvement;
(4)
Identify and resolve problems; including problems
resulting from a pattern or patterns of practices;
(5)
Internally
document and report findings, conclusions, actions taken, and the results of
any actions taken to the health care service's management and medical
director;
(6)
Within sixty days of an unexpected complication or
adverse event that arise during the provision of the service or during the
hospital stay, document, review and analyze those unexpected complications and
adverse events; and
(7)
Hold regular meetings that include a maternity unit
physician or newborn care nursery physician, as appropriate, but at least
within thirty days after the review required under paragraph (C)(6) of this
rule is completed, review the analysis and report findings.
(D)
Each
maternity unit, newborn care nursery, and maternity home shall, on a form
prescribed by the director, report to the department:
(1)
Fetal death,
other than the termination of a pregnancy, to include all fetuses of twenty
weeks gestation or greater that showed evidence of life at any point from the
mother's admission through delivery;
(2)
Neonatal death,
to include all liveborn neonates before twenty-eight days of age, from delivery
or admission through transfer or discharge;
(3)
Infant death, to
include all liveborn infants twenty-eight days of age through one year of age,
from delivery or admission through transfer or discharge;
(4)
Maternal death,
to include the death of a woman from any cause related to or aggravated by
pregnancy or its management, from the woman's admission and care at the
delivering hospital through transfer or discharge;
(5)
Neonatal or
infant abduction; and
(6)
Discharge of a neonate or infant to the wrong family or
organization.
Replaces: 3701-7-15
