OB Labor and Delivery by wuu19113

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									                                                                                               FY 2007-2008 CMS/RPICC OB Program Compliance Review

 RPICC Standards                                                                         YES       NO            Response/Comments:

OB: Labor and Delivery
Area/space requirements
1.     Is there an observation area available for patients who are not in active labor
       or who are being observed for labor?
2.     Is there a room available and equipped for patients requiring obstetrical care?
       If “yes”, give location.
       number of triage rooms/beds
3.     Labor/Delivery rooms
       number of delivery rooms
       number of operating rooms
       number of delivery/operating rooms
       number of labor rooms
       number of labor beds
       number of recovery rooms
4.     Birthing Rooms
       number of labor, delivery, recovery (LDR) rooms
       number of labor, delivery, recovery, postpartum (LDRP) rooms
5.     number of fetal monitors
       Location of monitors:
6.     Does each delivery room have a minimum of 350 square feet?
       Does each LDR/LDRP room have a minimum of 250 square feet?
7.     Is one delivery room per 3,000 deliveries equipped for performing cesarean
       sections within 30 minutes?

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                                                                                             FY 2007-2008 CMS/RPICC OB Program Compliance Review

 RPICC Standards                                                                       YES       NO            Response/Comments:

8.     Are delivery rooms located close to the labor rooms but away from the labor
       and delivery entrance?
9.     Where are elective cesarean sections performed?
Equipment
1.     Each labor area contains:
       a.     Labor or birthing bed with adjustable side rails and a foot stool.
       b.     Sphygmomanometer and stethoscopes, both regular and fetal.
       c.     Oxygen and suction equipment.
2.     Each delivery area contains:
       a.     A delivery table allowing variation in position for delivery.
       b.     Sphygmomanometer and stethoscope, both regular and fetal.
       c.     Equipment for inhalation and regional anesthesia, including equipment
              for emergency resuscitation.
       d.     Oxygen and suction for mother and infant.
       e.     Instruments and equipment for normal or operative delivery and for the
              management of obstetrical emergencies.
       f.     Medications for mother and infant.
       g.     Heated infant examination and resuscitation unit, including
              laryngoscopes, endotracheal tubes, drugs, and suction catheters.
       h.     The necessary equipment for examination, immediate care, and the
              identification of the infant.
       i.     Wall clock with second hand.
3.     Labor and delivery area includes:
       a.     Equipment for continuous management of maternal electrocardiogram
              with printout capability.

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                                                                                             FY 2007-2008 CMS/RPICC OB Program Compliance Review

 RPICC Standards                                                                       YES       NO            Response/Comments:

       b.     Availability of equipment for obtaining intra-arterial blood pressure.
       c.     I.V. solutions and equipment located close to labor, delivery, and
              recovery rooms.
       d.     Emergency cart with drugs, syringes, needles, laryngoscopes,
              endotracheal tubes, airways, resuscitation bags, cardiac monitor,
              defibrillator, and emergency delivery set.
       e.     Equipment for fetal scalp sampling.
       f.     Equipment for continuous I.V. infusion of medications such as pitocin
              and magnesium sulfate, but not limited for use with such medication.
OB: Recovery Room
Area/space requirements
1.     Is there a separate OB recovery room available close to the delivery area?
2.     Recovery room includes:
       a.     Oxygen and suction equipment at each patient station.
       b.     Sphygmomanometers and stethoscopes.
       c.     Emergency drugs and resuscitation equipment.
       d.     EKG equipment.
3.     Number of recovery room beds?
OB: Antepartum and Postpartum Unit
Area/space requirements
1.     Number of antepartum beds?
2.     Number of postpartum beds?
3.     Is a separate bed area available for undelivered designated as “high risk”?
4.     Is “rooming in” permitted?

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                                                                                 FY 2007-2008 CMS/RPICC OB Program Compliance Review

 RPICC Standards                                                           YES       NO            Response/Comments:

       Is so, what are the hours?
6.     Antepartum/postpartum unit has the following equipment available:
       a.     Sphygmomanometers and stethoscopes.
       b.     Fetoscopes and/or external fetal monitoring equipment.
       c.     Sterile amniocentesis tray, available at all times.
       d.     Oxygen and suction at each patient station.
       e.     I.V. solutions and equipment.
       f.     Emergency drugs and resuscitation equipment.
       g.     An emergency delivery set.
OB: Outpatient Clinic
Area/space requirements
1.     Number of examining rooms:
2.     The outpatient area includes:
       a.     Waiting room adequate in size.
       b.     Assurance of privacy during examination.
       c.     Dressing area providing privacy to patients.
       d.     Toilet facilities located near examining rooms.
       e.     Area for displaying patient education materials.
       f.     Examination tables and stools.
       g.     Patient scale.
       h.     Sphygmomanometers and stethoscopes.
       I.     Fetoscopes/Doptonese.

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                                                                                   FY 2007-2008 CMS/RPICC OB Program Compliance Review

 RPICC Standards                                                             YES       NO            Response/Comments:

       j.     Microscope and slides.
       k.     Equipment for performing bacteriological & cytologic smears.
       l.     Emergency cart with drugs, syringes, needles, laryngoscopes,
              endotracheal tubes and airways.
       m.     Emergency delivery set and infant resuscitation equipment.
3.     When are OB clinics held for RPICC Program patients?
       a.     Number of patients usually scheduled for each clinic
       b.     Average “no show” rate per clinic
       c.     Is there a log book of OB referrals?
              What is included?
General Services
1.     The following services are available:
       a.     Amniocentesis
              Where is the sample drawn?
              Who does the chromosomal and AFP evaluation?
       b.     Who provides genetic counseling?
       c.     Ultrasound
              Where is it located?
       d.     Fetal monitoring (antepartum and intrapartum).
       e.     Fetal scalp sampling.
       f.     Non-stress and stress tests
              Where are these performed?
       g.     Intrauterine transfusions.
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                                                                                              FY 2007-2008 CMS/RPICC OB Program Compliance Review

 RPICC Standards                                                                        YES       NO            Response/Comments:

3.     Nursing services include:
       a.     Assessment of patient’s health status.
       b.     Oxytocin induction management and fetal monitoring interpretation.
       c.     Nursing management of complications.
       d.     Patient education including dietary and family planning counseling,
              postpartum instruction, and infant care.
       e.     Nursing skills and knowledge in:
              -      initiating fluid replacement per I.V.
              -      managing blood transfusions.
              -      administering oxygen.
              -      performing external cardiac massage.
              -      maintaining respiration.
              -      management of spontaneous delivery.
              -      newborn resuscitation.
4.     How are 24-hour in-house anesthesia services provided?
       Who provides coverage, e.g., CRNA, etc.?
5.     Ancillary health services include:
       a.     24-hour blood bank services
       b.     24-hour x-ray services, with capability for performing ultrasounds to
              determine placental position and fetal head biparietal diameter
              measurement.
       c.     24-hour laboratory services for amniotic fluid analysis; including
              studies of fetal maturity and determination of L/S ratio and fetal well
              being.


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                                                                                                 FY 2007-2008 CMS/RPICC OB Program Compliance Review

 RPICC Standards                                                                           YES       NO            Response/Comments:

       d.     24-hour respiratory therapy services, with capability for performing fetal
              scalp pH.
       e.     Nutrition services.
              How are these provided?
       f.     Social services.
              How are these provided?
       g.     Access to psychological services.
              How are these provided?
       h.     Prenatal classes.
              Indicate frequency and name of instructor.
6.     Do you staff interhospital maternal transports?
       a.     Is so, attach a description of the system
       b.     If not, how are interhospital maternal transports provided?
7.     Outreach education.
       a.     Is a needs assessment done for determination of outreach program
              content?
       b.     Who participates in programs?
       c.     What are the geographic boundaries of outreach education
              responsibilities?
       d.     Is there a fee schedule for programs?
       e.     How is program effectiveness evaluated?
       f.     Describe future topics for outreach education.
8.     Domestic Abuse/Substance Abuse.
       a.     Do you ask about domestic and substance abuse in the clinic setting?
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                                                                                                 FY 2007-2008 CMS/RPICC OB Program Compliance Review

 RPICC Standards                                                                           YES       NO            Response/Comments:

       b.     Do you ask about domestic and substance abuse in the hospital
              setting?
       c.     How do you deal with patient needs related to domestic violence?
       d.     How do you deal with patient needs related to substance abuse?
       e.     How do you deal with patient needs related to depression?
       f.     Are you aware that any pregnant woman who is found to use drugs
              during pregnancy must receive treatment within twenty-four hours of
              referral at drug treatment centers that accept federal funds?
       g.     Are all pregnant women assessed for alcohol and tobacco use?
9.     Are obstetrical staff aware of the RPICC Transport contract with ShandsCair
       that provides transport services for medically and financially eligible high-risk
       pregnant women who reside in Florida over 75 miles from the RPICC facility?
10.    What arrangements are made for non-English speaking women who need
       prenatal classes or other prenatal educational materials?

Comments:




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                                                                                         FY 2006-2007 CMS/RPICC OB Program Compliance Review
                              RPICC Contract Provider Quality Assurance Tool for Security of Information

 (Security questionnaire was modified but content was not changed.)
   Security Criteria
                                                           Yes              Not Applicable         For all answers that could not
                                                                                                    be checked “Yes” and non-
                                                                        or Additional Comments
                                                                                                    compliant answers, provide
                                                                                                       Corrective Action Plan
  1. All staff that access Department of Health (DOH) RPICC
     Data System or who has been classified as sensitive
     positions in the RPICC Program has read and signed
     the DOH CMS RPICC Confidentiality and Security
     Agreement.
 RPICC Program Security Coordinator:

  2.   The person who is responsible for information security
       for RPICC Program information:
  RPICC Hospital Security and Confidentiality Procedures:
  3.   RPICC hospital and staff are aware that each DOH
       contract where the contract provider has access to
       confidential or sensitive information shall include
       standard contract language which requires the
       contractor to comply with current departmental
       information security policies, protocols, and procedures.
  4.   Has your Security Program been approved by a Hospital
       Accreditation Authority such as JAHCO.
  If approved please provide a copy of the approval.
 If not explain why or who has approved it.
 Confidential Information/Confidentiality

  5.   The following confidential information is stored in secure
       areas:
      RPICC liaison records
 Maintaining Secured Areas:

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                                                                                            FY 2006-2007 CMS/RPICC OB Program Compliance Review
                              RPICC Contract Provider Quality Assurance Tool for Security of Information
   Security Criteria
                                                                 Yes           Not Applicable         For all answers that could not
                                                                                                       be checked “Yes” and non-
                                                                           or Additional Comments
                                                                                                       compliant answers, provide
                                                                                                          Corrective Action Plan
  6.   The room in which RPICC confidential information is
       stored is locked with a reliable locking system.
  7.   Doors to designated secure rooms have limited access
       and are routinely kept locked at all times when
       employees are not present.
  RPICC High-Risk Obstetrical Clinic
  8.   The client sign-in procedure in the high-risk OB clinic
       maintains confidentiality.
  9.   Patient sign-in logs do not use human immunodeficiency
       virus or auto-immune deficiency syndrome (HIV/AIDS)
       clinics.
  10. Human immunodeficiency virus or auto-immune
      deficiency syndrome (HIV/AIDS) clinics are labeled in
      such a way as to protect client confidentiality.
  11. Health information of minors is protected, especially
      when sexually transmitted diseases and family planning
      services are provided.
Name of person who completed DOH CMS RPICC Information Security Risk Assessment Questionnaire :

Additional comments:




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                                                                                              FY 2006-2007 CMS/RPICC OB Program Compliance Review

                                                              Staffing Overview
       Unit            Position        7-3 or 7a-7p Shift            3-11 Shift           11-7 or 7p-7a Shift      Total      % Turnover
                                              FTE                       FTE                       FTE              FTE        in past 12
                                     Allocated       Filled    Allocated        Filled   Allocated      Filled                  months
 LD/LDR/LDRP         Charge Nurse              /                            /                      /


                         RN                    /                            /                      /


                         LPN                   /                            /                      /


                         NA                    /                            /                      /


                     *Other                    /                            /                      /


  Antepartum/        Charge Nurse              /                            /                      /
   Postpartum
                         RN                    /                            /                      /


                         LPN                   /                            /                      /


                         NA                    /                            /                      /


                     *Other                    /                            /                      /


Identify positions




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