Utah Admin. Code R432-550-6 - Governing Body

(1) The licensee shall appoint in writing an individual or group to constitute the facility's governing body. The governing body shall:

(a) comply with federal, state and local laws, rules and regulations;

(b) adopt written policies and procedures which describe the functions and services of the birthing center and protect patient rights;

(c) adopt a policy prohibiting discrimination because of race, color, sex, religion, ancestry, or national origin in accordance with Title 13, Chapter 7, Sections 1 through 4.

(d) develop an organizational structure establishing lines of authority and responsibility;

(e) when the governing body is more than one individual, conduct meetings in accordance with facility policy, but at least annually, and maintain written minutes of the meetings;

(f) appoint by name and in writing a qualified administrator;

(g) appoint by name and in writing a qualified director of the clinical staff;

(h) appoint members of the clinical staff and delineate their clinical privileges;

(i) review and approve at least annually a quality assurance program for birthing center operation and patient care provided.

(j) establish a system for financial management and accountability;

(k) provide for resources and equipment to provide a safe working environment for personnel;

(l) act on findings and recommendations of facility-created committees relevant to compliance with these birthing center rules;

(m) ensure that facility patient admission eligibility criteria are strictly applied by clinical staff and are evaluated through quality assurance review in accordance with R432-550-11.

(2) Written policies and procedures shall:

(a) clearly, accurately and comprehensively define the methods by which the facility will be operated to protect the health and safety of patients;

(b) provide for meeting the patient's needs;

(c) provide for continuous compliance with federal, state and local laws, rules and regulations.

(d) Written policies and procedures shall include:

(i) defining the term "low risk maternal patient" which shall include eligibility criteria for birth services offered in the birthing center;

(ii) defining specific criteria, which shall in normally anticipated circumstances render a maternal patient ineligible for birth services or continued care at the birthing center;

(iii) identifying and outlining methods for transferring patients who, during the course of labor or recovery, are determined to be ineligible for birthing center services or continued care at the birthing center, including;

(A) information required for proper care and treatment of the individual(s) transferred, including patient records; and

(B) security and accountability of the personal effects of the individual being transferred.

(iv) planning for consultation, back-up services, transfer and transport of a newborn and maternal patient to a hospital where necessary care is available;

(v) documenting the maternal patient has been informed of the eligibility requirements of an out-of-hospital birthing center labor and birth;

(vi) providing instructions in postpartum and newborn care to the patient and any other family or support person designated by the patient;

(vii) registering birth, fetal death or death certificates in accordance with Title 26, Chapter 2, Sections 5, 13, 14, 23 and rules promulgated pursuant thereto in R436.

(viii) prescribing and instilling a prophylactic solution approved by the Department of Health in the eyes of the newborn in accordance with R386-702-8, Special Measures for the Control of Ophthalmia Neonatorum;

(ix) performing phenylketonuria (PKU) and other disease tests in accordance with Department of Health Laboratory rules developed pursuant to Section 6;

(x) verifying prenatal laboratory screening to include:

(A) blood type and Rh Factor and provision for appropriate use of Rh immunoglobulin;

(B) hematocrit or hemoglobin;

(C) antibody screen;

(D) rubella; and

(E) syphilis;

(xi) providing for infection control to include:

(A) housekeeping;

(B) cleaning, sterilization, sanitization and storage of supplies and equipment; and

(C) prevention of transmission of infection in personnel, patients and visitors.

Notes

Utah Admin. Code R432-550-6

Amended by Utah State Bulletin Number 2016-11, effective 5/16/2016 Amended by Utah State Bulletin Number 2016-18, effective 8/26/2016