Section 640.60  Information for Facility Designation and Redesignation as Level I, Level II, Level II with Extended Capabilities, and Level III Perinatal Facilities and Assurances Required of Applicants

a)         Applicant facilities shall provide the Department the following information which may be included in its Maternity and Neonatal Service Plan or letter of agreement:

1)         A definition of the geographic area the facility currently serves or plans to serve.

2)         A description of the physical facility, compliance with Subpart O of 77 Ill. Adm. Code 250, and a description of the maternity and nursery units currently in place or in preparation for operation should the facility be designated.

3)         A description of the facility's staffing in accordance with those additional standards or designation described in the Regionalized Perinatal Health Care Code as follows:

A)        Social work and nutrition services shall be available through a hospital department for Level II and Level III designation.

B)        Names, titles and contact numbers shall be provided for the Director or Chairman of Maternal-Fetal Medicine, Neonatology, Obstetrics, Pediatrics and Neonatal Services, Chief Nursing Supervisor, Nursing Supervisor of Maternity Unit; names and contact number of medical staff members in maternal-fetal medicine, obstetrics and gynecology, neonatology, OB anesthesiology, family practice, anesthesiology; listing of anesthetists, staff for respiratory therapy, nurse-midwives, and involved house staff.

C)        A description of the current nurse/patient ratios in the nursery, delivery room, postpartum floor and intermediate or intensive care newborn nurseries for all shifts.

D)        A description of the qualifications of nursing personnel involved in the newborn nursery, delivery room and postpartum area.

E)         A description of the staff plans to assure that maternity/nursery staff are trained and prepared to stabilize infants prior to transfer, and are available 24 hours a day.

4)         A description giving evidence that the facility's laboratory, X-ray and respiratory therapy equipment and capabilities meet all the conditions described in 77 Ill. Adm. Code 250, Subpart O and are available 24 hours a day in-house.

A)        Evidence is required that continuous electronic maternal-fetal monitoring is available and staff knowledge in its use and interpretation is available 24 hours a day for Level I, Level II, Level II with Extended Capabilities, and Level III designation applicants.

B)        Level III and Perinatal Center shall provide Level II ultrasound available on the OB floor.

C)        Level I ultrasound and staff knowledgeable in its use and interpretation shall be available at Level II facilities on a 24 hour a day basis.

5)         A description of the capabilities for or capabilities planned for (giving the start-up time), emergency neonatology surgery, listing specialists such as surgeons, trained or support staff for neonates, and a description of the capabilities for caesarean section and start-up time.

6)         A description of the present plan for identification of high-risk maternity and neonatal patients and agreements for consultation with the Perinatal Center in cases of maternity and neonatal complications and neonates with handicapping conditions. This description shall include plans and agreements for providing:

A)        Management of acute surgical or cardiac difficulties;

B)        Genetic counseling should a genetically related condition be diagnosed in the neonate, or should a parent or a known carrier request such services;

C)        Information, counseling and referral for parents of neonates with handicapping conditions or developmental disabilities to ensure informed consent for treatment;

D)        Counseling and referral services to assist these patients in obtaining habilitation and rehabilitation services;

E)         A description of the types of patients the facility will care for and the types of patients it will refer to the Perinatal Center.

7)         A description of the history and current level of involvement with Continuous Quality Improvement activities as designed and implemented by the Perinatal Center.

8)         All of the information required for facility designation or redesignation to the Perinatal Center with which it is seeking affiliation.

b)         The following guidelines shall govern the review of perinatal facilities applying for designation or redesignation:

1)         Hospitals applying for perinatal designation or redesignation shall provide all the information contained in Standardized Perinatal Site Visit Protocol (Appendix A) and Outcome Oriented Data (Appendix B).

2)         The completed Standardized Perinatal Site Visit Protocol and Outcome Oriented Data shall be submitted to the Department, along with the site visit report, and the letter of agreement.

3)         The Standardized Perinatal Site Visit Protocol and Outcome Oriented Data shall be sent by the Department to PAC members, no less than one week in advance of the meeting, to facilitate their review of the applicant facility.

4)         A representative of the Perinatal Center shall be present at the PAC meeting to respond to questions or concerns of PAC members regarding the facility's application for designation or redesignation. The representative may also be asked to present an oral summary of the applicant facility and the Perinatal Center's reasons for recommending/not recommending designation or redesignation to the PAC.

5)         The Department shall ask the Perinatal Center to conduct a follow-up site visit to the facility if the initial site visit is more than 6 months prior to submission for review by PAC for designation or redesignation. In such cases, approval shall be contingent upon receiving the findings of the follow-up site visit.

(Source:  Amended at 24 Ill. Reg. 12574, effective August 4, 2000)