Neonatal Rules Webinar

Neonatal Rules Webinar
Today is the Level II – Special Care Nursery Neonatal Rules Webinar. Power Point Presentation – which will be mailed out to participants, RACs and other stakeholders. Questions – will be answered at the end of the presentation. Welcome! Thank you everyone for taking the time out today to participate in this webinar. I have a short presentation to begin the webinar and then we will move into answering questions. We will provide a link to this webinar and a copy of the power point presentation to the participants today and to our stakeholder groups. The webinar will be posted on the Neonatal Designation website in the next few weeks.

How do I send questions? You may type your questions in the chat box and hit “enter”; Or You may your questions to be answered at a later time to:

Hospital Level of Care Designations for Neonatal Care
Elizabeth Stevenson, Manager Neonatal & Maternal Designation Department of State Health Services Debbie Lightfoot, Designation Coordinator Neonatal & Maternal Designation Department of State Health Services June 14 and 24, 2016

Objectives Review of Subchapter J Sections that pertain to Level II Neonatal Designation. Detailed review of Subchapter J Sections § and § Discuss deadlines for designation. Answer questions and next steps Today I am going to cover information in the rules that pertain specifically to the Level II designation. We will cover sections and in detail. I want to be sure that everyone is familiar with the requirements. We will discuss the deadlines, and answer your questions.

Subchapter J This is a snapshot of the Texas Administrative Code or TAC. Subchapter J – the Hospital Level of Care Designations for Neonatal and Maternal Care became effective June 9, There was a question last week about how quickly a facility needed to be compliant with the rules. The final rules were released for review on June 3rd in the Texas Register. Facilities may not be compliant with the rule immediately because changes were made to the last revision published. With this being a new program, it will take some time in order for facilities to meet some of the requirements set forth in the rule, especially if they were practicing in between two different levels. The rules may be effective, but there is a “grace” period for facilities to be compliant with the Level of Care designation in which they provide appropriate services to neonatal patients.

TAC § Purpose The purpose of this section is to implement Health and Safety Code, Chapter 241, Subchapter H, Hospital Level of Care Designations for Neonatal and Maternal Care, which requires a level of care designation of neonatal services to be eligible to receive reimbursement through the Medicaid program for neonatal services. Great reminder that designation is required to be eligible to receive reimbursement through the Medicaid program for neonatal services. August 31, 2018 is the deadline for being designated by the Executive Commissioner in order to receive Medicaid reimbursement. This is a firm date. There are no extensions or special circumstances for any facility.

TAC § Definitions The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.

TAC § Definitions (3) CAP--Corrective Action(s) Plan. A plan for the facility developed by the Office of EMS/Trauma Systems Coordination that describes the actions required of the facility to correct identified deficiencies to ensure compliance with the applicable designation requirements. (11) Immediate supervision--The supervisor is actually observing the task or activity as it is performed. If our office determines that the facility has deficiencies, we may require a Corrective Action Plan to meet the requirements. The corrective action plan may require that the facility report specified information to our office quarterly, have a site visit performed by our office staff, attend an educational opportunity, and/or another action that assists the facility in achieving compliance with the rule. Our goal is for facilities to be compliant with the requirements and provide best care to our babies born in Texas. Immediate supervision – Included in the pharmacy requirements for compounding any medication to be administered to a neonate/infant. Immediate supervision and other types of supervision or also defined in the Hospital Licensing section.

TAC § 133.182 Definitions (12) Immediately--Without delay.
(22) PCR--Perinatal Care Region. (24) POC--Plan of Correction. A report submitted to the office by the facility detailing how the facility will correct any deficiencies cited in the survey report or documented in the self-attestation. Immediately – without delay. Immediately is not defined as 15 minutes or 30 minutes. The response will be without delay. There may a situation in which the physician may be in the middle of a procedure on another neonate or unable to be at the bedside within minutes, but the response will be without delay. Not to be assumed as 5 minutes, 20 minutes or 60 minutes. PCR – Perinatal Care Region. This is the organization (committee, workgroup, etc.) that will be developed in each region based on the Trauma Service Areas, with the support of the Regional Advisory Councils (RACs). Facilities are required to participate in these meetings for designation. Facilities need to make sure that they are represented at these meetings and when making decisions about disaster and emergency preparedness plans. The Plan of Correction will be submitted if your facility has potential deficiencies identified on the survey report. The plan of correction will include the following: Identify the deficiency; state the corrective action to be taken; title of the person responsible for the action; how the plan will be monitored; and the date for completion of the action. Make sure that the appropriate person is identified to implement or be responsible for the action. The Neonatal Program Manager cannot be held responsible for the entire plan of correction. The Neonatal Medical Director generally will be responsible for many of the deficiencies that the NPM is. Especially if it is the quality assessment/performance improvement program, or the policies and procedures concerning standards of care. If the deficiency is related to financial decisions, increasing FTE’s, physician related issues, or physician recruitment, it may be a person in administration or the “C” suite that is responsible for these issues.

TAC § Definitions (28) RAC--Regional Advisory Council as described in § of this title (relating to Regional Emergency Medical Services/Trauma Systems). The RAC for trauma and stroke is the equivalent of the Perinatal Care Regions for neonatal and maternal. The Regional Advisory Council is made up stakeholders in the specified trauma service area or region. These stakeholders are responsible for making decisions for their region concerning their program which may be trauma or stroke. The RAC or the stakeholders may have developed transport protocols, a plan for responding to a disaster, or a regional inventory of emergency preparedness equipment. Many of the RACs have different committees in their programs that discuss issues in the region and share best practices. The stakeholders drive their own process, how they will operate and make decisions. This is why it is important for all designated facilities to be at the table when decisions are made. Many urban hospitals do not understand or realize the challenges that rural hospitals face. They don’t know what they don’t know.

TAC § 133.183 General Requirements
(a) The Office of Emergency Medical Services (EMS)/Trauma Systems Coordination (office) shall recommend to the Executive Commissioner of the Health and Human Services Commission (executive commissioner) the designation of an applicant/healthcare facility as a neonatal facility at the level for each location of a facility, which the office deems appropriate. Our office recommends the appropriate designation for a facility to the Executive Commissioner of HHSC. The actual process from recommendation of approval of designation takes approximately days. Our office makes recommendations for designation to the commissioner once a month. The recommendations follow a specific process of lower approvals before being sent to the commissioner for final approval. The commissioner then returns the approved designations and signed letters back to our office. It is important to understand the basics of this program so you can appreciate the deadlines for designation application submittal. The entire process will need to be completed before the facility is considered to be successfully designated. This is why we have placed the July 1, 2018 deadline for all initial designations to be into our office, so that we may complete this process and all facilities will be designated before the September 1st, 2018 deadline.

(b) A healthcare facility is defined under this subchapter as a single location where inpatients receive hospital services or each location if there are multiple buildings where inpatients receive hospital services and are covered under a single hospital license. Hospitals are the only healthcare facilities that are required to become designated. There are no requirements for birthing centers or other healthcare facilities that may deliver babies.

(c) Each location shall be considered separately for designation and the office will determine the designation level for that location, based on, but not limited to, the location's own resources and level of care capabilities; Perinatal Care Region (PCR) capabilities; compliance with Chapter 133 of this title, concerning Hospital Licensing. A stand-alone children's facility that does not provide obstetrical services is exempt from obstetrical requirements. The final determination of the level of designation may not be the level requested by the facility. Multiple locations under a single license requires that each location is separately designated. You may have four facilities that are under the same license number. One hospital may not provide OB services or care for babies, the largest hospital may be a Level IV nursery, and the other two facilities are both Level II nurseries. Each facility will need to apply for the appropriate designation for services provided.

(e) PCRs. Aligned with the Trauma Service Areas (TSAs) due to established infrastructure to support the functions of the PCRs. Established for regional planning purposes, including emergency and disaster preparedness. Not established for the purpose of restricting patient referral.

TAC § 133.184 Designation Process
Level II Statistics required on application: Total Live Births Annually Live Births <32 Weeks and <1500 grams, Not Transferred Transfers Out Total Multiple Births Total newborns on assisted endotracheal ventilation for >24 hours or nasal continuous positive airway pressure (NCPAP) until condition improves. Transfers In I wanted to share the statistics that would be required for the application for a Level II facility. The application will not be released until September 1, Currently, the facility should focus on becoming familiar with the rules and compiling evidence of how the facility is compliant with the rule. This process will be beneficial in preparing for the survey process also. If you compile other statistics that are tracked by the facility, continue to compile and report those statistics as you have done in the past.

(d) Non-refundable application fees for the three year designation period are as follows: (1) Level II neonatal facility applicants, the fees are as follows: (2) Level II neonatal facility applicants, the fee is $1, There were questions about the application fees last week so I wanted to include the fee for each level. This application fee is to fund the administration of the neonatal designation program by DSHS. The facility will also be responsible for any fees related to having a survey performed at the facility for compliance with the rule. These fees will be determined by approved agencies to provide a survey in the state of Texas. The two agencies that are preparing to perform the surveys are the American Academy of (AAP) and Texas EMS, Trauma and Acute Care Foundation (TETAF).

(A) All completed applications, received on or before July 1, 2018, including the application fee, evidence of participation in the PCR, an appropriate attestation if required, survey report, and that meet the requirements of the requested designation level, will be issued a designation for the full three-year term. If a facility has submitted the complete application packet, including a survey report, it will be issued a designation for the full three year term. Our office would like to minimize the financial impact to facilities for neonatal designation. Hence, the 3 year designation, for facilities that have paid for a survey.

(B) Any facility that has not completed an on-site survey to verify compliance with the requirements for a Level II, III or IV designation at the time of application must provide a self-survey and attestation and will receive a Level I designation. The office, at its sole discretion may recommend a designation for less than the full three-year term. A designation for less than the full three-year term will have a pro-rated application fee consistent with the one, two or three-year term length. This section serves as a safety net for facilities applying for Levels II, III and IV that may not undergo a survey prior to the required application deadline to successfully designate by September 1, The facility will apply for a Level I designation to ensure that they are eligible for the Medicaid reimbursement while waiting to have the survey performed to designate at the appropriate level for services provided to newborns. The Level I designation may be issued with less than a three year term and will have a pro-rated application fee. This will also assist our office in dispersing the designations evenly over the first three year cycle.

(C) A facility applying for Level I designation requiring an attestation may receive a shorter term designation at the discretion of the office. A designation for less than the full three-year term will have a pro-rated application fee. (D) The office, at its discretion, may designate a facility for a shorter term designation for any application received prior to September 1, 2018. (E) An application for a higher or lower level designation may be submitted at any time. These were included so that our office may disperse the workload involved with designation of facilities. We do not want every facility to expire in the same year. Therefore, your facility may receive a shorter term for designation. If you are a facility that may want to upgrade to a higher level, you may do this at any time. Upgrading or downgrading to a different levels require a new application and survey performed by an approved agency.

Guiding Principles If the rule does not specify the exact requirement (ex. Successful NRP completion), it is up to the facility to define the expectation appropriate for the population served. Medical Practice decisions are not regulated by the Department of State Health Services. Please keep these basic principles in mind when reviewing the rules and evaluating your program. Rules are not developed to be prescriptive or give specific directions on how your facility functions. Texas is a diverse state and so are the hospitals that provide care to our residents and visitors. Therefore, each facility will make decisions on how to function dependent on their location and their resources. We all know that Level I facilities will function much differently than a Level III. The rules provide the basic requirements and the facility decides how to meet compliance. My reference for this is cooking. We may all start out with chicken to make an entree, but we will all probably fix it differently. I used cooking as an example because it sounds better than 100 different ways to skin a cat! The DSHS not regulate medical practice. Therefore, the rules are not going to dictate how a physician practices at your facility. When your facility has a survey, the patient care will be reviewed by peers. These will be physicians that are in active practice in a facility that has a program with a higher designation. The peer review process is optimal when medical practice decisions are being reviewed for appropriateness and compliance with current standards of care.

TAC § 133.185 Program Requirements
(a) Designated facilities shall have a family centered philosophy. Parents shall have reasonable access to their infants at all times and be encouraged to participate in the care of their infants. The facility environment for perinatal care shall meet the physiologic and psychosocial needs of the mothers, infants, and families. Overall expectation of the neonatal program. Most facilities are probably already compliant with this requirement.

(b) Program Plan. The facility shall develop a written plan of the neonatal program that includes a detailed description of the scope of services available to all maternal and neonatal patients, defines the neonatal patient population evaluated and/or treated, transferred, or transported by the facility, that is consistent with accepted professional standards of practice for neonatal and maternal care, and ensures the health and safety of patients. Generally, facilities have these program plans in place. They may be “department” specific plans and not titled as program plans. Many agencies that perform accreditation require these plans, as well as CMS. The plan is going to describe the patient population that is served, the services that are provided for this population and if the service is not provided, how the facility will ensure the patient receives the appropriate care. Usually, this is transferring patients to an appropriate facility that offers the necessary services and care.

(1) The written plan and the program policies and procedures shall be reviewed and approved by the facility's governing body. The governing body shall ensure that the requirements of this section are implemented and enforced. (2) The written neonatal program plan shall include, at a minimum: (A) standards of neonatal practice that the program policies and procedures are based upon that are adopted, implemented and enforced for the neonatal services it provides; (B) a periodic review and revision schedule for all neonatal care policies and procedures; The written plan, and the program policies and procedures, being reviewed and approved by the governing body have been included in a process that is usually followed by accrediting bodies for hospitals. Policies and procedures will be based up current standards of care and they will be reviewed and revised periodically in order to keep patient care with best practices. Healthcare is changing frequently and facilities need to be up to date with the care provided to patients.

(C) written triage, stabilization and transfer guidelines for neonates and/or pregnant/postpartum women that include consultation and transport services; (D) ensure appropriate follow up for all neonates/infants; (E) provisions for disaster response to include evacuation of mothers and infants to appropriate levels of care; Triage, stabilization and transfer guidelines for neonates will be in your policies and procedures. Pregnant women are included so that the decision about care is best for the mother and the fetus. Ensure appropriate follow up for all neonates/infants – making physician or specialist appointments, referrals for social programs, therapies, home care, nutrition, etc. Disaster response is not only possibly transferring patients out to other facilities, but if there is a fire how will you move the babies out of the unit quickly.

(F) a QAPI Program as described in §133.41(r) of this title (relating to Hospital Functions and Services). The facility shall demonstrate that the neonatal program evaluates the provision of neonatal care on an ongoing basis, identify opportunities for improvement, develop and implement improvement plans, and evaluate the implementation until a resolution is achieved. The neonatal program shall measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and is outcome based. Evidence shall support that aggregate patient data is continuously reviewed for trends and data is submitted to the department as requested; The facility or program will determine the model used for QA/PI. It may be PDCA, Six Sigma, Lean or RCA (Root Cause Analysis). Monitoring core measures for neonates is already a requirement. Other areas of monitoring will be determined by the facility. In the rule there are no required indicators for all facilities to monitor. Examples I have seen are for pain and sedation, patient education in newborn care, teaching of medication, newborn screening for metabolic or congenital disorders, hearing tests, readmission, Transfers, nosocomial infections and possibly admission of neonates that are less than 32 weeks gestation and less than 1500 grams. It is important to understand that the QA/PI process is the backbone of the program. This is where the facility identifies area for improvement in care and processes. In the Neonatal QA/PI committee, staff participating in the care of the neonate, will review cases that may have poor outcomes, or deviate from the standard of care. The committee will complete a critical review of the care provided and decide upon the corrective action so the deviation does not occur with any other newborns in the future. This is also a time to discuss if there may have been a better way to manage a patient. The care may have been appropriate without a bad outcome, but is there a different or better way to manage the patient? Evidence of a robust QA/PI program will be evident through case reviews, QA/PI minutes and peer review. These will be reviewed by the surveyors during the survey process. Once again, this supports the importance of having peers review the programs and processes.

(G) requirements for minimal credentials for all staff participating in the care of neonatal patients; (H) provisions for providing continuing staff education; including annual competency and skills assessment that is appropriate for the patient population served; (I) a perinatal staff registered nurse as a representative on the nurse staffing committee under §133.41(o)(2)(F) of this title; Facility will determine the minimal credentials outside of the specified requirements in the rule (NRP). It is important to make sure that the staff caring for newborns are provided with education, and that their knowledge and skills are appropriate for the population served. The nurse staffing committee is a compromise for staffing ratios. We do not want to prescribe what the facility staffing ratios are because the facilities are varied and so are their resources. Therefore, requiring that a perinatal staff RN be member or representative on the committee allows a voice in the process of determining staffing neonatal and maternal areas in the hospital.

(J) the availability of all necessary equipment and services to provide the appropriate level of care and support of the patient population served; and (K) the availability of personnel with knowledge and skills in breastfeeding. The facility will also determine the equipment necessary to provide the services described in the neonatal program plan. If your program plan includes providing care for infants that may require assisted ventilation for less than 24 hours, then the equipment and qualified personnel must be available to provide these services. The availability of personnel with knowledge and skills in breastfeeding. These may be your OB nurses that support the breast-feeding moms or it may be a community member that is a lay person with expertise in breastfeeding. Personnel need to be available.

(c) Medical Staff. The facility shall have an organized, effective neonatal program that is recognized by the medical staff and approved by the facility's governing body. The credentialing of the medical staff shall include a process for the delineation of privileges for neonatal care.

(d) Medical Director. There shall be an identified Neonatal Medical Director (NMD) and/or Transport Medical Director (TMD) as appropriate, responsible for the provision of neonatal care services and credentialed by the facility for the treatment of neonatal patients.

(1) The NMD and/or TMD shall have the authority and responsibility to monitor neonatal patient care from admission, stabilization, operative intervention(s) if applicable, through discharge, inclusive of the QAPI Program. (2) The responsibilities and authority of the NMD and/or TMD shall include but are not limited to:

(A) examining qualifications of medical staff requesting neonatal privileges and makes recommendations to the appropriate committee for such privileges; (B) assuring staff competency in resuscitation techniques; (C) participating in ongoing staff education and training in the care of the neonatal patient; The Medical Director will review the qualifications of the neonatal medical staff requesting privileges in the program and makes recommendations to the appropriate committee for these privileges. The recommendation may be made to the section leader, the credentialing committee, or directly to the medical staff committee. This is all dependent on how your facility completes credentialing and the different levels involved. When the Medical Director is reviewing qualifications, they will consider competency in resuscitation, participating in staff education and training in neonatal care. The ongoing education may be viewing online programs such as Health Stream or it may be the Medical Director sending out journal articles and requiring the neonatal providers to review the articles. Meetings with the neonatal Medical Staff may include specific education topics or case reviews that will also provide ongoing education to the providers. There are many ways to meet compliance with educations requirements.

(D) oversight of the inter-facility neonatal transport; (E) participating in the development, review and assurance of the implementation of the policies, procedures and guidelines of neonatal care in the facility including written criteria for transfer, consultation or higher level of care; (F) regular and active participation in neonatal care at the facility where medical director services are provided; The Medical Director will be actively involved in developing policies, procedures and guidelines in neonatal care and participating in the care of newborns at the facility in which they serve as the Medical Director. In other programs we have had physicians that have been contracted to serve as the Medical Director of a program. This physician would come to the facility quarterly, review cases and attend the PI meeting. Consider how effective this Medical Director is in the program if they are not working side by side with all of the other providers and staff. They do not know how the processes work in the facility or how decision making is done. An effective Medical Director needs to be familiar with the staff, the physical facility and the processes involved for providing neonatal care.

(G) ensuring that the QAPI Program is specific to neonatal/infant care, is ongoing, data driven and outcome based; and regularly participates in the neonatal QAPI meeting; and (H) maintaining active staff privileges as defined in the facility's medical staff bylaws. Medical Director will be responsible for an effective QA/PI program and will participate in the neonatal meetings. Maintain active staff privileges speaks for itself.

(e) Neonatal Program Manager (NPM). The NPM responsible for the provision of neonatal care services shall be identified by the facility and: (1) be a registered nurse: (2) have successfully completed and is current in the Neonatal Resuscitation Program (NRP) or an office-approved equivalent: The Neonatal Program Manager is responsible for neonatal care services. This person may be the Director or Manager of the Nursery because they are probably already performing these responsibilities. The facility does have to identify a person that is responsible for the neonatal program. The requirements of an RN and NRP are self-explanatory.

(3) have the authority and responsibility to monitor the provision of neonatal patient care services from admission, stabilization, operative intervention(s) if applicable, through discharge, inclusive of the QAPI Program as defined in subsection (b)(2)(E) of this section. (4) collaborate with the NMD in areas to include, but not limited to: developing and/or revising policies, procedures and guidelines; assuring staff competency, education, and training; the QAPI Program; and regularly participates in the neonatal QAPI meeting; and (5) develop collaborative relationships with other NPM(s) of designated facilities within the applicable Perinatal Care Region.

TAC § 133.187 Level II Designation
(a) Level II (Special Care Nursery). (1) The Level II neonatal designated facility will: (A) provide care for mothers and their infants of generally >=32 weeks gestational age and birth weight >=1500 grams who have physiologic immaturity or who have problems that are expected to resolve rapidly and are not anticipated to require subspecialty services on an urgent basis; and (B) either provide care, including assisted endotracheal ventilation for less than 24 hours or nasal continuous positive airway pressure (NCPAP) until the infant's condition improves, or arrange for appropriate transfer to a higher level designated facility. If the facility performs neonatal surgery, the facility shall provide the same level of care that the neonate would receive at a higher level designated facility and shall, through the QAPI Program, complete an in depth critical review of the care provided; and (C) provide skilled personnel that have documented training, competencies and annual continuing education specific for the patient population served. A Level II Nursery is referred to as a Special Care Nursery. Generally has been included in the description because we realize that the hospital may have a patient present for delivery that has not received prenatal care and the gestational age may be unknown. It may be that the neonate is very close to 32 weeks and less than 1500 grams but the facility is capable of providing the appropriate level of care for a few days until 32 weeks is reached. A Level II provide care, which may include assisted endotracheal ventilation for less than 24 hours or nasal continuous positive airway pressure until the infant’s condition improves. The facility may transfer this patient to a higher of level of care also. If a Level II facility decides to perform neonatal surgery, the facility shall provide the same level of care that the neonate would receive at a higher level. These cases will all have a complete in depth critical review of the care provided through the QAPI process. If you facility is going perform surgeries on neonates, please be familiar with the standards for the higher level of care. Once again, the facility does not have to meet all of the requirements of the higher level, but must provide the same standard of care.

(2) If a facility is located more than 75 miles from the nearest Level III or IV designated neonatal facility, and retains a neonate between 30 and 32 weeks of gestation having a birth weight of between grams, the facility shall provide the same level of care that the neonate would receive at a higher level designated neonatal facility and shall, through the QAPI Program, complete an in depth critical review of the care provided. This section was included for hospitals that are located more than 75 miles from the nearest Level III or IV designated neonatal facility. If the Level II facility chooses to admit an infant between 30 and 32 weeks of gestation having a birth weight of between 1250 and 1500 grams, the facility will provide the same level of care that the neonate would receive at a higher level designated facility. The Level II facility will need to ensure that the infant is receiving appropriate screenings, consultations in the appropriate time frames, etc. Basically, this is doing the right thing for the patient. The facility will need to provide the level of care required by the patient. It does not mean that the facility will need to meet the requirements of the higher level. The facility must also complete an in depth critical review of the care provided. This is to ensure that the appropriate care was provided for the best outcome of this neonate. There will be times that admission to the facility will out weigh the risks of transferring the neonate. This will need to be determined by the physician. If a critical review is completed, this should clarify the decision making process and identify if there were any opportunities for improvement in care.

(b) Neonatal Medical Director (NMD). The NMD shall be a physician who: (1) a board eligible/certified neonatologist, with experience in the care of neonates/infants and demonstrates a current status on successful completion of the Neonatal Resuscitation Program (NRP); or (2) by the effective date of this rule, a pediatrician or neonatologist who:

(A) has continuously provided neonatal care for the last consecutive two years; has experience and training in the care of neonates/infants including assisted endotracheal ventilation and NCPAP management; (B) maintains a consultative relationship with a board eligible/certified neonatologist; (C) demonstrates effective administrative skills and oversight of the QAPI Program; (D) demonstrates a current status on successful completion of the NRP; and (E) has completed continuing medical education annually specific to the care of neonates.

(c) Program Functions and Services. (1) Triage and assessment of all patients admitted to the perinatal service with identification of pregnant women with a high likelihood of delivering a neonate requiring a higher level of care be transferred prior to delivery unless the transfer is unsafe. (2) Supportive and emergency care delivered by appropriately trained personnel for unanticipated maternal-fetal problems that occur during labor and delivery through the disposition of the patient. (3) The ability to perform an emergency cesarean delivery.

(4) The physician, advanced practice nurse and/or physician assistant with special competence in the care of neonates, whose credentials have been reviewed by the NMD and is on call, and: (A) shall demonstrate a current status on successful completion of the NRP; (B) shall have completed continuing education annually, specific to the care of neonates; States continuing education annually, which could include CMEs, articles sent our by the NMD, online courses, etc.

(C) shall arrive at the patient bedside within 30 minutes of an urgent request; (D) if not immediately available to respond or is covering more than one facility, appropriate backup coverage shall be available, documented in an on call schedule and readily available to facility staff; (E) the physician, advanced practice nurse and/or physician assistant providing backup coverage, shall arrive at the patient bedside within 30 minutes of an urgent request; and If a physician lives out in the country or on the opposite side of town, there may need to be another provider on call to respond within the 30 minutes if it will take longer for the primary on call to arrive. There is no excuse for the physician lives an hour away and could not arrive in 30 minutes, or the physician was at her daughter’s sporting event and could not make it in time. Yes, there may be times that it is impossible to make the 30 minutes response because of an unexpected event, but the back up should be utilized in this situation. Our goal is to insure that newborns receive the best care possible. If the physician is covering two facilities and cannot leave one facility to respond to the other, the back up provider will need to respond within 30 minutes to the bedside for an urgent request.

(F) shall be on-site to provide ongoing care and to respond to emergencies when a neonate/infant is maintained on endotracheal ventilation. (5) Anesthesia services with pediatric experience will be provided in compliance with the requirements found in §133.41(a) of this title (relating to Hospital Functions and Services). If a neonate/infant is maintained on endotracheal ventilation, there will be a physician or advanced practitioner on-site to provide the ongoing care and to respond to emergencies. There may be very capable nurses and respiratory therapist that manage these newborns, but the ultimate responsibility lies with the physician. What happens in the situation when you do not have your star staff members available to manage the patient? You will not have to place yourself or your physician in this dilemma because they will already be onsite to provide the appropriate care. Anesthesia requirements are found in the licensing rules. A Level II facility will need to provide anesthesia services with pediatric experience.

Here is a snapshot of the anesthesia section in Hospital Licensing. This is very small print, but you will need to know how to find these rules for reference.

(6) Dietitian or nutritionist with sufficient training and experience in neonatal and maternal nutrition, appropriate to meet the needs of the population served, shall be available and in compliance with the requirements found in §133.41(d) of this title. (7) Laboratory services shall be in compliance with the requirements found in §133.41(h) of this title and shall have: (A) personnel on-site at all times when a neonate/infant is maintained on endotracheal ventilation; (B) a blood bank capable of providing blood and blood component therapy; and (C) neonatal/infant blood gas monitoring capabilities.

(8) Pharmacy services shall be in compliance with the requirements found in §133.41(q) of this title and shall have a pharmacist with experience in neonatal/perinatal pharmacology available at all times. (A) If medication compounding is done by a pharmacy technician for neonates/infants, a pharmacist will provide immediate supervision of the compounding process. (B) If medication compounding is done for neonates/infants, the pharmacist will develop checks and balances to ensure the accuracy of the final product. (C) Total parenteral nutrition (TPN) appropriate for neonates/infants shall be available. (9) An occupational or physical therapist with sufficient neonatal expertise shall be available to meet the needs of the population served.

(10) Medical Imaging. Radiology services shall be in compliance with the requirements found in §133.41(s) of this title and will incorporate the "As Low as Reasonably Achievable“ (ALARA) principle when obtaining imaging in neonatal and maternal patients; and shall have: (A) personnel appropriately trained, in the use of x-ray and ultrasound equipment; (B) personnel at the bedside within 30 minutes of an urgent request; (C) appropriately trained personnel shall be available on-site to provide ongoing care and to respond to emergencies when an infant is maintained on endotracheal ventilation; and (D) interpretation capability of neonatal and perinatal x-rays and ultrasound studies available at all times. Appropriate personnel trained in the use of ultrasound equipment, includes your physicians, and advanced practitioners. This does not mean that the Imaging Department needs to have a person trained for ultrasound on call 24 hours. The OB or FP physician may provide this service and also interpret the images. A person trained in the use of x-ray will need to be available.

(11) A respiratory therapist, with experience and specialized training in the respiratory support of neonates/infants, whose credentials have been reviewed by the NMD, shall be immediately available on-site when: (A) a neonate/infant is on a respiratory ventilator to provide ongoing care and to respond to emergencies; or (B) a neonate/infant is on a Continuous Positive Airway Pressure (CPAP) apparatus. If a neonate is on a ventilator or a CPAP, a respiratory therapist with appropriate credentials must be onsite and immediately available.

(12) Resuscitation. The facility shall have written policies and procedures specific to the facility for the stabilization and resuscitation of neonates based on current standards of professional practice. (A) Each birth shall be attended by at least one provider who demonstrates current status of successful completion of the NRP whose primary responsibility is the management of the neonate and initiating resuscitation. (B) At least one person must be immediately available on-site with the skills to perform a complete neonatal resuscitation including endotracheal intubation, establishment of vascular access and administration of medications. At least one provider may be a nurse, physician, PA or NP. (B) This is to ensure that a provider is present that can actually direct and perform the resuscitation. There may be providers available that have completed NRP, but are not capable of running the resuscitation by themselves. This is a clarification.

(C) Additional providers with current status of successful completion of the NRP shall be on-site and immediately available upon request. (D) Additional providers who demonstrate current status of successful completion of the NRP shall attend each neonate in the event of multiple births. (E) A full range of NRP equipment and supplies shall be immediately available for trained staff to perform resuscitation and stabilization on any neonate/infant.

(13) Perinatal Education. A registered nurse with experience in neonatal care, including special care nursery, and/or perinatal care shall provide supervision and coordination of staff education. (14) Social services and pastoral care shall be provided as appropriate to the patient population served. (15) Ensure the timely evaluation of retinopathy of prematurity (ROP), monitoring, referral for treatment and follow-up, in the case of an at-risk infant. (16) Ensure the availability of support personnel with knowledge and expertise in lactation to meet the needs of new mothers while breastfeeding. (17) Ensure provisions for follow up care at discharge for infants at high risk for neurodevelopmental, medical or psychosocial complications.

Designation Deadline Dates
Each hospital that provides neonatal care will need to be designated by September 1, to receive Medicaid funds. Applications must be received in our office before July 1, 2018 to be approved for designation by the Executive Commissioner before September 1, 2018.

DSHS Website The DSHS website is now available. Yay!
The website will be updated with this webinar, the rule, educational opportunity dates and a Frequently Asked Questions (FAQ) section.

DSHS Website

Neonatal Designation Coordinator
Debbie Lightfoot, RN (512) ext. 2032

Contact Information Please send your name, title, facility name, address and phone number to: or

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