Designation and Redesignation of Non-Birthing Center, Level I, Level II, Level II with Extended Neonatal Capabilities, Level III Perinatal Hospitals and Administrative Perinatal Centers

Section 640 Section 640.50  Designation and Redesignation of Non-Birthing Center, Level I, Level II, Level II with Extended Neonatal Capabilities, Level III Perinatal Hospitals and Administrative Perinatal Centers a)         The hospital shall declare by means of a letter of intent to the Department and the affiliated APC that it seeks designation as a hospital with no OB services, or as a Level I, Level II, Level II with Extended Neonatal Capabilities, or Level III in a Regional Perinatal Network. b)         The Department will acknowledge the letter of intent. c)         The APC shall arrange a site visit to the applicant hospital. The hospital shall prepare the designation/redesignation documents in accordance with Section 640.60.  The site visit team for Level I, II, II with Extended Neonatal Capabilities, and III perinatal hospitals shall consist of six members: three from the APC of the hospital's Regional Perinatal Network, including the Directors of Neonatology and Maternal-Fetal Medicine or their designees and the Perinatal Network Administrator; a representative of nursing; one representative from the PAC; and one representative of the Department. When travel is not feasible, regardless of the reason, the PAC representative shall be permitted to participate in the site visit from a remote location via telephone, Voice over Internet Protocol (VoIP), or video conferencing.  The site visit team shall review the capabilities of the applicant hospital based on the requirements outlined in the letter of agreement between the applicant hospital and the APC. The site visit team shall complete the Standardized Perinatal Site Visit Protocol (see Appendix A) and submit these materials to the medical directors of the hospital visited for their review and comment within 30 days after the date of the site visit. The APC shall collaborate with the Department to develop a summary site visit report within 60 days after the site visit. This report shall be sent to the hospital within 90 days after the site visit. d)         The Department will coordinate the site visit for APCs. The team shall consist of five members: one Director of Neonatology, one Director of Maternal-Fetal Medicine and one Perinatal Network Administrator from a non-contiguous Center; one representative from the PAC; and one representative of the Department. When travel is not feasible, regardless of the reason, the PAC representative shall be permitted to participate in the site visit from a remote location via telephone, Voice over Internet Protocol (VoIP), or video conferencing.  The Department shall collaborate with the site visit team to develop a summary site visit report within 60 days after the site visit. This report shall be forwarded to the hospital within 90 days after the site visit. e)         The Department will review the submitted materials, any other documentation that clearly substantiates a hospital's compliance with particular provisions or standards for perinatal care, and the recommendation of the PAC. f)         The Department will make the final decision and inform the hospital of the official determination regarding designation. The Department's decision will be based upon the recommendation of the PAC and the hospital's compliance with this Part, and may be appealed in accordance with Section 640.45. A 12-month to 18-month follow-up review will be scheduled for any increase in hospital designation to assess compliance with the requirements of this Part that are applicable to the new level of designation.  The Department shall consider the following criteria to determine if a hospital is in compliance with this Part: 1)         Maternity and Neonatal Service Plan (Subpart O of the Hospital Licensing Requirements); 2)         Proposed letter of agreement between the applicant hospital and its APC in accordance with Section 640.70; 3)         Appropriate outcome information contained in Appendix A and the Resource Checklist (Appendices L, M, N and O); 4)         Other documentation that substantiates a hospital's compliance with particular provisions or standards of perinatal care set forth in this Part; and 5)         Recommendation of Department program staff. g)         The Department will review all designations at least every three years to assure that the designated hospitals continue to comply with the requirements of the perinatal plan. Circumstances that may influence the Department to review a hospital's designation more frequently than every three years could include: 1)         A hospital's desire to expand or reduce services; 2)         Poor perinatal outcomes; 3)         Change in APC or Network affiliation; 4)         Change in resources that would have an impact on the hospital's ability to comply with the required resources for the level of designation; or 5)         An APC finds and the Department concurs or determines that a hospital is not appropriately participating in and complying with CQI programs. h)         Existing designations shall be effective until redesignation is accomplished.