La. Admin. Code tit. 48 § I-6769

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-6769 - Staffing Requirements

A. Administrative Staff. The following administrative staff is required for all FSBCs:

1. a qualified administrator at each licensed geographic location who shall meet the qualifications as established in these provisions; and

2. other administrative staff as necessary to operate the FSBC and to properly safeguard the health, safety, and welfare of the clients receiving services.

3. Repealed.

B. Administrator

1. Each FSBC shall have a qualified administrator who is a full-time on-site employee responsible for the dayto-day management, supervision, and operation of the FSBC.

2. Any current administrator employed by a licensed FSBC, at the time these licensing provisions are adopted and become effective, shall be deemed to meet the qualifications of the position of administrator as long as that individual holds his/her current position. If that individual leaves his/her current position, he/she shall be required to meet the qualifications stated in these licensing provisions to be reemployed into such a position.

3. The administrator shall meet the following qualifications:

a. possess a college degree from an accredited university; or

b. have three years of relevant work experience involving administrative duties in a healthcare facility.

4. Changes in the administrator shall be reported to the department within 10 days of the change on the appropriate form designated by the department.

C. The director of clinical midwifery services shall:

1. have a current, unrestricted Louisiana license as a physician, a CNM, or a licensed midwife;

2. be in good standing with the applicable state licensing board; and

3. shall have a minimum of one-year experience in a healthcare setting and possess the knowledge, skills and experience consistent with the complexity and scope of delivery services provided by the FSBC;

a. the director of clinical midwifery services holding dual administrative/midwifery director roles shall meet the qualifications of each role; and

b. changes in the director of clinical midwifery services shall be reported in writing to the department within 10 days of the change on the appropriate form designated by the department.

D. Responsibilities of the administrator and the director of clinical midwifery services. The administrator and the director of clinical midwifery services shall develop, adopt, implement, and monitor the policies and procedures of the FSBC and the professional services of the staff. The staff bylaws shall be maintained within the FSBC. The bylaws and rules shall contain provisions for at least the following:

1. developing the structure of the licensed healthcare practitioner staff, including qualified personnel and categories of membership;

2. developing, implementing, and monitoring policies and procedures to review credentials, at least every two years, and to delineate and recommend approval for individual privileges;

3. developing, implementing, and monitoring policies and procedures to ensure that all licensed healthcare practitioner staff possess current and unrestricted Louisiana licenses and that each member of the licensed practitioner staff is in good standing with his/her respective licensing board;

4. providing recommendations to the governing body for membership to the licensed healthcare practitioner staff with initial appointments and reappointments not to exceed two years;

5. developing, implementing, and monitoring policies and procedures for the suspension and/or termination of membership to the licensed healthcare practitioner staff;

6. developing, implementing, and monitoring criteria and frequency for review and evaluation of past performance of its individual staff members. This process shall include monitoring and evaluation of the quality of client care provided by each individual;

7. the appointment of committees as deemed appropriate;

8. reviewing and making recommendations for revisions to all policy and procedures at least annually; and

9. meeting at least semi-annually. One of these meetings shall be designated as the official annual meeting. A record of attendance and minutes of all licensed healthcare practitioner staff meetings shall be maintained within the FSBC.

E. Licensed Healthcare Practitioner Staff

1. The FSBC shall have an organized licensed healthcare practitioner staff, inclusive of one or more of the following, who shall attend each woman in labor from the time of admission through birth, and the immediate postpartum period:

a. a licensed obstetrician;

b. a certified nurse midwife; or

c. a licensed midwife.

2. A licensed obstetrician providing birthing services within the FSBC shall:

a. hold a current, unrestricted state license issued by the LSBME;

b. be actively engaged in a clinical obstetrical practice;

c. have hospital privileges in obstetrics in a hospital accredited by the Joint Commission; and

d. practice within the scope of practice of a licensed physician in accordance with applicable state statutes and regulations.

3. A CNM or LM providing birthing services within the FSBC shall be a licensed healthcare practitioner who is acting within the scope of practice of his/her respective licensing board(s) and/or certifications.

4. All licensed practitioner staff shall be accountable to the governing body for the quality of all perinatal care provided to clients and newborns, and for the ethical and professional practices of its members.

5. The licensed healthcare practitioner staff shall be legally and professionally qualified for the positions to which they are appointed and for the performance of privileges granted.

6. A licensed healthcare practitioner staff shall remain within the FSBC until all clients are assessed as stable.

7. The client's attending licensed healthcare practitioner staff, or designated on-call licensed healthcare practitioner staff, shall be available by telephone for consultation and evaluation of the client, and available to be on-site within 30 minutes if needed, until the client is discharged from the FSBC.

8. Each client admitted to the FSBC shall be under the professional supervision of a member of the FSBC's licensed healthcare practitioner staff who shall assess, supervise, and evaluate the care of the client.

9. Credentialing files for each staff shall be kept current and maintained within the FSBC at all times.

F. Delivery Services Staff. The staffing pattern shall provide for sufficient qualified personnel and for adequate supervision and direction by licensed healthcare practitioners consistent with the number of deliveries performed and throughout the length of any client stay in the FSBC.

1. Delivery services shall be under the direction of a licensed healthcare practitioner that includes a plan of administrative authority with written delineation of responsibilities and duties for each category of staff members.

2. The FSBC shall ensure that the delivery services are directed under the leadership of licensed healthcare practitioner(s) sufficient in number, to plan, assign, supervise, and evaluate delivery services, as well as to give clients the high-quality care that requires the judgment and specialized skills of licensed healthcare practitioners.

a. There shall be sufficient staff with the appropriate qualifications to assure ongoing assessment of clients' needs and that these identified needs are addressed. The number and types of staff is determined by the volume and types of delivery the FSBC performs.

3. All licensed healthcare practitioners employed, contracted, or working with the FSBC shall have a current, unrestricted, and valid Louisiana license to practice. Nonprofessional or unlicensed qualified personnel employed, contracted, and performing delivery care services shall be under the supervision of a licensed healthcare practitioner.

4. A formalized program on in-service training shall be developed and implemented for all categories of the FSBC. Training shall be required on a quarterly basis related to required job skills.

a. Documentation of such in-service training shall be maintained on-site in the FSBC's files. Documentation shall include the:

i. training content;

ii. date and time of the training;

iii. names and signatures of personnel in attendance; and

iv. name of the presenter(s).

5. General staffing provisions for the delivery rooms shall be the following:

a. each delivery procedure shall be performed by a licensed healthcare practitioner; and

i. - iv. Repealed.

b. appropriately trained qualified personnel may perform assistive functions during each delivery procedure.

6. - 6.b. Repealed.

G. General Personnel Requirements

1. All licensed qualified personnel and FSBC employees, including contracted personnel shall meet and comply with these personnel requirements.

2. All licensed qualified personnel and FSBC employees, including contracted personnel, prior to and at the time of employment and annually thereafter, shall be verified to be free of tuberculosis in a communicable state in accordance with the FSBC's policies and procedures and the current Centers for Disease Control and Prevention (CDC) and the OPH recommendations.

3. All unlicensed qualified personnel involved in direct client care and/or services shall be supervised by a licensed healthcare practitioner.

4. A personnel file shall be maintained within the FSBC on every employee, including contracted employees.

Policies and procedures shall be developed to determine the contents of each personnel file. At a minimum, all personnel files shall include the following:

a. an application;

b. current verification of professional licensure;

c. healthcare screenings as defined by the FSBC;

d. orientation and competency verification;

e. annual performance evaluations;

f. criminal background checks for unlicensed staff, prior to offer of direct or contract employment, after the effective date of this Rule, as applicable and in accordance with state law. The criminal background check shall be conducted statewide by the Louisiana State Police or its authorized agent; and

g. any other screenings required of new applicants by state law.

La. Admin. Code tit. 48, § I-6769

Promulgated by the Department of Health, Bureau of Health Services Financing, LR 482120 (8/1/2022), Amended LR 49484 (3/1/2023).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and R.S. 40:2180.21-2180.28.