Policies and Procedures

Policies and Procedures The facility will have written: 1. neonatal, medical, and ancillary care guidelines, policies, and procedures that are established on evidence-based literature, and best-practice standards, that are monitored and tracked for adherence, reviewed at least every 3 years, and revised as needed; 2. a policy that mandates the escalation of concern and the urgent presence of a privileged care provider at the bedside, including a method to track adherence; 3. policies and procedures that define the criteria for neonatal team presence at a delivery and identify a method to track adherence, if applicable; 4. policies and procedures for the triage, stabilization, and transfer of obstetrical patients to the appropriate level of care, if applicable; 5. policies and procedures for consultation by telehealth and telephone, if applicable; 6. policies and procedures for intrafacility and interfacility neonatal transport; 7. policies and procedures for transfer to a higher level of neonatal care or for services not available at the facility, if applicable; 8. policies and procedures for car seat safety observation before discharge; and 9. policies and procedures for disaster response, including evacuation of obstetrical and neonatal patients to the appropriate level(s) of care.