Current through Reg. 49, No. 38; September 20, 2024
(a) The survey team
composition must be as follows:
(1) Level I
facilities maternal program staff must conduct a self-survey, documenting the
findings on the approved department survey form. The department may
periodically require validation of the survey findings, by an on-site review
conducted by department staff.
(2)
Level II facilities must be surveyed by a multidisciplinary team that includes
at a minimum one obstetrics and gynecology physician and one maternal nurse
who:
(A) have completed a survey training
course;
(B) have observed a minimum
of one maternal survey;
(C) are
currently active in the management of maternal patients and active in the
maternal QAPI Plan and process at a facility providing the same or higher level
of maternal care; and
(D) meet the
criteria outlined in the department survey guidelines.
(3) Level III facilities must be surveyed by
a multidisciplinary team that includes at a minimum, one obstetrics and
gynecology physician or maternal fetal medicine physician and one maternal
nurse, who:
(A) have completed a survey
training course;
(B) have observed
a minimum of one maternal survey;
(C) are currently active in the management of
maternal patients and active in the maternal QAPI Plan and process at a
facility providing the same or higher level of maternal care; and
(D) meet the criteria outlined in the
department survey guidelines.
(4) Level III facilities that serve as
referral centers for placenta accreta spectrum disorder, must have a survey
team that includes a maternal fetal medicine physician and a maternal nurse
from a Level IV facility.
(5) Level
IV facilities must be surveyed by a multidisciplinary team that includes at a
minimum, one obstetrics and gynecology physician, a maternal fetal medicine
physician, and one maternal nurse, who:
(A)
have completed a survey training course;
(B) have observed a minimum of one maternal
survey;
(C) are currently active in
the management of maternal patients and active in the maternal QAPI plan and
process at a facility providing Level IV maternal care; and
(D) meet the criteria outlined in the
department survey guidelines.
(b) All members of the survey team, except
department staff, must come from a Perinatal Care Region outside the facility's
region or a contiguous region.
(c)
Survey team members cannot have a conflict of interest:
(1) A conflict of interest exists when a
surveyor has a direct or indirect financial, personal, or other interest which
would limit or could reasonably be perceived as limiting the surveyor's ability
to serve in the best interest of the public. The conflict of interest may
include a surveyor personally trained a key member of the facility's leadership
in residency or fellowship, collaborated with a key member of the facility's
leadership professionally, participated in a designation consultation with the
facility, had a previous working relationship with the facility or facility
leaders, or conducted a designation survey for the facility within the past
four years. Surveyors cannot be from the same PCR or TSA region or a contiguous
region of the facility's location.
(2) If a designation survey occurs with a
surveyor who has an identified conflict of interest, the maternal designation
site survey summary and medical record reviews may not be accepted by the
department.
(d) The
survey team must follow the department survey guidelines to evaluate and
validate that the facility demonstrates the designation requirements are
met.
(e) All information and
materials submitted by a facility to the department and a survey organization
under Texas Health and Safety Code, §
241.183(d)
or this subchapter, are subject to confidentiality as articulated in Texas
Health and Safety Code, §
241.184,
Confidentiality; Privilege, and are not subject to disclosure under Texas
Government Code, Chapter 552, or discovery, subpoena, or other means of legal
compulsion for release to any person.
