Texas Administrative Code
Title 25 - HEALTH SERVICES
Part 1 - DEPARTMENT OF STATE HEALTH SERVICES
Chapter 133 - HOSPITAL LICENSING
Subchapter L - CENTERS OF EXCELLENCE FOR FETAL DIAGNOSIS AND THERAPY
Section 133.226 - Surveyors

Universal Citation: 25 TX Admin Code ยง 133.226

Current through Reg. 49, No. 38; September 20, 2024

(a) A CEFDT shall be surveyed by a team, approved by the office, which is multi-disciplinary and includes at a minimum one board certified physician that is active in the management of maternal-fetal patients and/or performs fetal interventions; and a nurse active in the management of maternal-fetal patients, at a facility providing the same level of maternal-fetal care. An additional surveyor may be requested by the facility or at the discretion of the office.

(b) Office-credentialed surveyors must meet the following criteria:

(1) have at least three years of experience in the care of maternal-fetal patients and/or fetal interventions;

(2) be currently employed and clinically practicing in the coordination of care for maternal-fetal patients and fetal interventions;

(3) have direct experience in the preparation for and successful completion of a Centers of Excellence for Fetal Diagnosis and Therapy verification and/or designation;

(4) have successfully completed an office-approved Centers of Excellence for Fetal Diagnosis and Therapy site surveyor course and be successfully re-credentialed every four years; and

(5) have current credentials as:
(A) a registered nurse with maternal-fetal experience who has successfully completed an office-approved site survey internship; or

(B) a physician who is board certified in the respective specialty, and has successfully completed an office-approved site survey internship.

(c) All surveyors, except department staff, shall come from a Perinatal Care Region outside the facility's location and at least 100 miles from the facility. There shall be no business or patient care relationship or any potential conflict of interest between the surveyor or the surveyor's place of employment and the facility being surveyed.

(d) The surveyors shall evaluate the facility's compliance with the designation criteria by:

(1) reviewing medical records; staff rosters and schedules; documentation of QAPI Program activities, including peer review; the program plan; policies and procedures; and other documents relevant to fetal diagnosis and therapy services;

(2) reviewing equipment and the physical plant; and

(3) conducting interviews with facility personnel; surveyors may meet privately with individuals or groups of personnel.

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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