SECTION 133.210. Survey Team

(a) The survey team composition must be as follows:

(1) Level I facilities maternal program staff must conduct a self-survey, documenting the findings on the approved department survey form. The department may periodically require validation of the survey findings, by an on-site review conducted by department staff.

(2) Level II facilities must be surveyed by a multidisciplinary team that includes at a minimum one obstetrics and gynecology physician and one maternal nurse who:

(A) have completed a survey training course;

(B) have observed a minimum of one maternal survey;

(C) are currently active in the management of maternal patients and active in the maternal QAPI Plan and process at a facility providing the same or higher level of maternal care; and

(D) meet the criteria outlined in the department survey guidelines.

(3) Level III facilities must be surveyed by a multidisciplinary team that includes at a minimum, one obstetrics and gynecology physician or maternal fetal medicine physician and one maternal nurse, who:

(A) have completed a survey training course;

(B) have observed a minimum of one maternal survey;

(C) are currently active in the management of maternal patients and active in the maternal QAPI Plan and process at a facility providing the same or higher level of maternal care; and

(D) meet the criteria outlined in the department survey guidelines.

(4) Level III facilities that serve as referral centers for placenta accreta spectrum disorder, must have a survey team that includes a maternal fetal medicine physician and a maternal nurse from a Level IV facility.

(5) Level IV facilities must be surveyed by a multidisciplinary team that includes at a minimum, one obstetrics and gynecology physician, a maternal fetal medicine physician, and one maternal nurse, who:

(A) have completed a survey training course;

(B) have observed a minimum of one maternal survey;

(C) are currently active in the management of maternal patients and active in the maternal QAPI plan and process at a facility providing Level IV maternal care; and

(D) meet the criteria outlined in the department survey guidelines.

(b) All members of the survey team, except department staff, must come from a Perinatal Care Region outside the facility's region or a contiguous region.

(c) Survey team members cannot have a conflict of interest:

(1) A conflict of interest exists when a surveyor has a direct or indirect financial, personal, or other interest which would limit or could reasonably be perceived as limiting the surveyor's ability to serve in the best interest of the public. The conflict of interest may include a surveyor personally trained a key member of the facility's leadership in residency or fellowship, collaborated with a key member of the facility's leadership professionally, participated in a designation consultation with the facility, had a previous working relationship with the facility or facility leaders, or conducted a designation survey for the facility within the past four years. Surveyors cannot be from the same PCR or TSA region or a contiguous region of the facility's location.

(2) If a designation survey occurs with a surveyor who has an identified conflict of interest, the maternal designation site survey summary and medical record reviews may not be accepted by the department.

(d) The survey team must follow the department survey guidelines to evaluate and validate that the facility demonstrates the designation requirements are met.

(e) All information and materials submitted by a facility to the department and a survey organization under Texas Health and Safety Code, §241.183(d) or this subchapter, are subject to confidentiality as articulated in Texas Health and Safety Code, §241.184, Confidentiality; Privilege, and are not subject to disclosure under Texas Government Code, Chapter 552, or discovery, subpoena, or other means of legal compulsion for release to any person.

Source Note: The provisions of this §133.210 adopted to be effective March 1, 2018, 43 TexReg 875; amended to be effective January 8, 2023, 47 TexReg 8986