Maternal Program Plan

Maternal Program Plan The facility must develop a written maternal operational plan for the maternal program that includes a detailed description of the scope of services and clinical resources available for all maternal patients and families. The plan will define the maternal patient population evaluated, treated, transferred, or transported by the facility consistent with clinical guidelines based on current standards of maternal practice ensuring the health and safety of patients. 1. The written Maternal Program Plan must be reviewed and approved by Perinatal Multidisciplinary Committee and be submitted to the facility's governing body for review and approval. The governing body must ensure that the requirements of this section are implemented and enforced. 2. The written Maternal Program Plan must include, at a minimum: a. Clinical guidelines based on current standards of maternal practice, and policies and procedures that are adopted, implemented, and enforced by the maternal program; b. A process to ensure and validate that these clinical guidelines based on current standards of maternal practice, policies, and procedures are reviewed and revised a minimum of every three years; c. Written triage, stabilization, and transfer guidelines for pregnant and postpartum patients that include consultation and transport services; d. Written guidelines or protocols for prevention, early identification, early diagnosis, and therapy for conditions that place the pregnant or postpartum patient at risk for morbidity or mortality; e. The role and scope of telehealth/telemedicine practices if utilized, including: i. Documented and approved written policies and procedures that outline the use of telehealth/telemedicine for inpatient hospital care, or for inpatient consultation, including appropriate situations, scope of care, and documentation that is monitored through the PI Plan and process; and ii. Written and approved procedures to gain informed consent from the patient or designee for the use of telehealth/telemedicine, if utilized, that are monitored for compliance; f. Written guidelines for discharge planning instructions and appropriate follow up appointments for all mothers and infants; g. Written guidelines for the hospital disaster response, including a defined mother and infant evacuation plan and process to relocate mothers and infants to appropriate levels of care with identified resources, and this process must be evaluated annually to ensure maternal care can be sustained and adequate resources are available; h. Requirements for minimal credentials for all staff participating in the care of maternal patients; i. Provisions for providing continuing staff education, including annual competency and skills assessment that is appropriate for the patient population served; j. A perinatal staff registered nurse as a representative on the nurse staffing committee; and k. The availability of all necessary equipment and services to provide the appropriate level of care and support of the patient population served.