Policies and Procedures, Employee Training, and Best Practices Requirements

Section 264.1525  Policies and Procedures, Employee Training, and Best Practices Requirements a)         The birth center shall have written policies and procedures governing all operations of the birth center and all services provided by the birth center. b)         The written policies and procedures shall be formulated by the clinical director and approved by the governing body. c)         The written policies shall be followed by the birth center and shall be reviewed at least annually, unless specified otherwise in this Part. d)         The policies shall comply with all of the requirements in this Part, and shall address, at a minimum, the following subjects: 1)         Admission protocols defining the criteria to determine which pregnancies are accepted as normal, uncomplicated, and low-risk, incorporating both medical and social factors. 2)         Protocols for local anesthesia. 3)         Procedures and criteria for antepartum acceptance and transfer to a hospital, and intrapartum and postpartum transport to a referral hospital.  The criteria for acceptance and transport to hospital at any stage shall also comply with the transfer agreement between the birth center and the referral hospital in the Perinatal System, pursuant to the requirements of Section 264.2250. 4)         Discharge procedures for the postpartum person and infant, in accordance with requirements of Section 264.1950. 5)         Client rights, to ensure patient dignity, privacy, and safety, in accordance with the Medical Patient Rights Act. 6)         Employee health program that includes, at a minimum, the following: an assessment of the employee's health and immunization status at the time of employment; immunization requirements; and procedures for the periodic health assessment of all personnel, which specify the content of the health assessment and the interval between assessments in compliance with the Control of Tuberculosis Code. 7)         Identifying potential dangers to the health and safety of personnel providing services in the birth center and procedures for protecting agency personnel from identified dangers. 8)         Orientation program and procedures for new patients. 9)         Childbirth education program for new and returning patients. 10)       Prenatal care. 11)       Labor and delivery personnel requirements and clinical care. 12)       Emergency transfer services and procedures for the pregnant person and neonate. 13)       Post-delivery care of the pregnant person. 14)       Clinical care of the newborn, in accordance with the Guidelines for Perinatal Care and including the clinical care requirements outlined in Section 264.1800(h). 15)       Identification of the newborn as required in Section 264.1800(h)(2). 16)       Procedures performed at the birth center as identified in Section 264.1250. 17)       Infection control. 18)       Disposal of medical waste. 19)       Emergency services. 20)       Follow-up postnatal and postpartum care for the infant and postpartum person. 21)       Laboratory and pharmacy services. 22)       Clinical record requirements and retention, maintenance, and confidentiality. 23)       Food services. 24)       Quality Assurance and Improvement Program. 25)       Reporting requirements. 26)       Employee training policies that at a minimum: A) Define the acts and practices that are allowed or prohibited for birth center employees; B) Establish how training will be conducted ; and C) Illustrate how initial competency will be established. (Section 50 of the Act). 27)       Visitors. 28)       Emergency preparedness. e)         Staff Training and Continuing Education Requirements 1)         All staff members shall be oriented to existing policies and procedures and shall be promptly notified of changes in policies or procedures. 2)         All staff members shall receive initial competency training and be evaluated to determine whether they meet established competency requirements consistent with the Commission for the Accreditation of Birth Centers of the Joint Commission and consistent with the scope of practice for the staff members' professional license.  All personnel records shall demonstrate proof that initial competency standards have been met. 3)         All staff members shall receive annual training on infection control, following the standards set forth in the guidelines for Infection Control in Health Care Personnel. 4)         Birth centers shall have a written policy and conduct continuing education yearly for providers and staff of obstetric medicine and other staff that may care for pregnant or postpartum women.  The written policy and continuing education shall include management of severe maternal hypertension and obstetric hemorrhage, addressing airway emergencies experienced during childbirth, and management of other leading causes of maternal mortality for units that care for pregnant or postpartum women . (Section 2310-222(b) of the Department of Public Health Powers and Duties Law of the Civil Administrative Code of Illinois) f)         Birth centers shall utilize best practices made available by the Department in consultation with the Illinois Perinatal Quality Collaborative for timely identification and assessment of all pregnant and postpartum persons for common pregnancy or postpartum complications and for care provided by the birth center throughout the pregnancy and postpartum period.  These standards must be incorporated into the policy referenced in subsection (e).