105 CMR 130.810
Birth Center Services Written Policies and Procedures
An applicant to add birth center services to its license shall develop, through an
interdisciplinary team, written policies and procedures to ensure the safe operation of the birth
center prior to submitting an application for approval. A birth center shall implement, and
review and revise through an interdisciplinary team as needed but not less than once a year, its
written policies and procedures. A birth center shall ensure that all staff, including any
temporary staff and volunteers, are trained and determined to be competent as needed for their
duties on the policies and procedures developed by the facility. A birth center’s policies shall
include at a minimum, but not be limited to:
(A) Patient admission criteria including specific information by which a pregnant person’s risk
status will be established.
(B) Off-hour coverage.
(C) Consultation and referral for obstetric and pediatric care.
(D) Specific patient transfer criteria.
(E) Emergency procedures, including adult and neonatal cardiopulmonary resuscitation.
(F) Standards for medication procurement, storage and administration.
(G) Protocols for screening newborns for critical congenital heart disease with pulse oximetry
or another test approved by the Department in accordance with Department guidelines.