Neonatal Program Plan

Neonatal Program Plan. The facility must develop a written neonatal operational plan for the neonatal program that includes a detailed description of the scope of services and clinical resources available for all neonatal patients, mothers, and families. The plan must define the neonatal patient population evaluated, treated, transferred, or transported by the facility consistent with clinical guidelines based on current standards of neonatal practice ensuring the health and safety of patients. The plan must identify the resources used to develop the facility’s neonatal policies and procedures for the neonatal services it provides. 1. The written Neonatal 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 the requirements of this section are implemented and enforced. 2. The written Neonatal Program Plan must include, at a minimum: a. Clinical guidelines based on current standards of neonatal practice, and policies and procedures that are adopted, implemented, and enforced by the neonatal program; b. A process to ensure and validate these clinical guidelines based on current standards of neonatal practice, policies, and procedures, are reviewed and revised a minimum of every three years; c. Written triage, stabilization, and transfer guidelines for neonatal patients that include consultation and transport services; d. 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 consultation, including appropriate situations, scope of care, and ii. documentation that is monitored through the neonatal Performance Improvement (PI) Plan and process; and iii. 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 variances; e. written guidelines for discharge planning instructions and appropriate follow-up appointments for all neonates/infants; f. provisions to facilitate continuity of care for high-risk neonatal patients from delivery to discharge; g. delineation of roles, responsibilities, and authority of the medical, nursing, and ancillary patient care directors; h. physician, advanced practice nurse, and/or other medical care provider staffing plan for neonatal coverage; i. plan for nurse staffing including provisions for flexibility and change in census and acuity; j. written guidelines for the hospital disaster response, including a defined neonatal 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 neonatal care can be sustained and adequate resources are available; k. written minimal education and credentialing requirements for all staff participating in the care of neonatal patients, which are documented and monitored by the managers who have oversight of staff; l. written requirements for providing continuing staff education, including annual educational needs assessment to evaluate the ongoing educational needs of all staff participating in the care of newborns, which are documented and monitored by the managers who have oversight of staff; m. annual education plan for all staff participating in the care of newborns that includes didactic, education, simulation, competency, and skills validation; n. measures to monitor the availability of all necessary equipment and services required to provide the appropriate level of care and support for the patient population served; o. documented guidelines for consulting support personnel with knowledge and skills in breastfeeding and lactation, which includes expected response times, defined roles, responsibilities, and expectations; p. Appropriate allocations for family-centered care including providing parents with reasonable access to their infants and encouraging advocacy, shared decision-making, and participation in their child’s care; and q. Assurance of equitable care for all neonatal patients and families and provisions for promoting an environment of cultural humility.