Maternal and Neonatal Survey FAQs

Texas’ Most Frequently Chosen Perinatal Surveying Organization

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Maternal Verification Surveys and Designation Rules

The following are questions that the Texas Perinatal Services team has received from Texas hospitals, with responses from the Texas Department of State Health Services (DSHS). If you have questions, please contact us and we will answer them.

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In the neonatal rules, there were definitive patients, such as surgical and gestation, that helped to define where patients were to receive care. However, in the maternal rules, there is room for interpretation. For example: Are all hypertensive patients required to be cared for in Level II and above facilities due to “medical, surgical, or obstetrical conditions that present a significant risk of maternal morbidity or mortality”?
The determination of what patients will be treated at a hospital is based on the hospital’s scope of practice and the physician’s medical decision. The Texas Department of State Health Services (DSHS) does not regulate medical practice.
What are the expectations for the written protocol addressing when each level should stabilize and transfer (Rule 133.206, Rule 133.207, Rule 133.208)? And what is the recommendation from the Texas Department of State Health Services (DSHS) on how facilities can define the appropriate place for patients to receive pregnancy related care?

The hospital should define its scope of practice in policy based on resources, capabilities, and medical providers. This policy should be well-vetted through committee with medical direction.

Does the Texas Department of State Health Services (DSHS) have a list of diagnoses for specific levels of care for the maternal patient population, or an exclusion or inclusion list of maternal patients/diagnosis by level of facility available to use as a guide?
The facility may refer to the Society for Maternal-Fetal Medicine and ACOG Obstetric Consensus of Care document for a general description of patient types.
To determine compliance to the state’s rule regarding sepsis guidelines or protocols, can a facility provide its maternal sepsis, chorioamnionitis, and Group Beta Strep policies/procedures that are consistent with current standards of practice and then have its medical records demonstrate compliance to the internal policies?

Yes.

Can you provide clarity on the state’s rules regarding sepsis guidelines or protocols?
For all levels, the rule requires the following: The facility shall have written guidelines or protocols for various conditions that place the pregnant or postpartum patient at risk for morbidity and/or mortality, including promoting prevention, early identification, early diagnosis, therapy, stabilization, and transfer.

The guidelines or protocols must address a minimum of sepsis and/or systemic infection in the pregnant or postpartum patient. The determination of the scoring tool is made internally by hospitals. Determining which tool is a hospital’s decision. The key to success is ensuring the use of the right tool.

Will the state accept only an electronic scoring system for sepsis? And, if that is the expectation, what scoring system is acceptable?

There are many ways to be compliant with requirements. If a facility can demonstrate compliance without an electronic scoring system, and it meets current practice, it would be considered compliant.

The surveyors will review what the facility has provided and determine if it is congruent with current practice and that it is reflected in practice through case reviews.

For example:

MEWS (Modified Early Warning System)

SIRS (Systemic Inflammatory Response Syndrome)

MEWT (Maternal Early Warning Trigger)

MEOWS (Modified Early Obstetric Warning Score)

MEWS (Maternal Early Warning System)

When should a hospital submit a request for re-designation survey?
Request your survey as early as 10 to 12 months before your designation expiration date. The expiration dates are on your original letter and the Texas Department of State Health Services (DSHS) website. Request your Maternal Care Survey here.
How soon will Texas Perinatal Services schedule the survey?

A member of the Texas Perinatal Services survey team will notify you when the maternal survey request is received. The request will be placed in the queue for scheduling.

What should be included in my plan of correction?

List the potential deficiencies, corrective actions, person responsible, date of completion, and how they will be monitored.

Can’t find the answer you’re looking for?

Please direct any questions to the Texas Perinatal Services survey team:

Jessica Phillips, MAS, BSN, RNC-OB, C-EFM, C-ONQS

Perinatal Program Director
Email Jessica

Aaron Rogers

Survey Operations Manager
Email Aaron

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