Missouri Code of State Regulations › Title 19 - DEPARTMENT OF HEALTH AND SENIOR SERVICES › Division 30 - Division of Regulation and Licensure › Chapter 30 - Ambulatory Surgical Centers and Abortion Facilities › Section 19 CSR 30-30.020 - Administration Standards for Ambulatory Surgical Centers

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: The Division of Regulation and Licensure,
				  Department of Health and Senior Services has the authority to establish
				  standards for the operation of ambulatory surgical centers. This rule provides
				  standards for the administration, medical staff, nursing staff and supporting
				  services to ensure high quality services to users of ambulatory surgical
				  centers.
PUBLISHER'S NOTE: The secretary of state has
				  determined that the publication of the entire text of the material which is
				  incorporated by reference as a portion of this rule would be unduly cumbersome
				  or expensive. This material as incorporated by reference in this rule shall be
				  maintained by the agency at its headquarters and shall be made available to the
				  public for inspection and copying at no more than the actual cost of
				  reproduction. This note applies only to the reference material. The entire text
				  of the rule is printed here.
(1) Organization, Administration, Medical
				Staff, Nursing Staff and Supporting Services.
(A) Governing Body.
1. The governing body is to establish and
				adopt bylaws by which it shall abide in conducting all business of the
				facility. Bylaws so adopted and changes are to be submitted to the Department
				of Health for its records.
2.
				Bylaws of the governing body shall provide for the selection and appointment of
				medical staff members based upon defined criteria and in accordance with an
				established procedure for processing and evaluating applications for
				membership. Applications for appointment and reappointment shall be in writing
				and shall signify agreement of the applicant to conform with bylaws of both the
				governing body and medical staff and to abide by defined professional ethical
				standards. Initial appointments to the medical staff shall not exceed twelve
				(12) months. Reappointments, which may be processed and approved at the
				discretion of the governing body on a monthly or other cyclical pattern, shall
				not exceed two (2) years.
3. The
				governing body shall select and employ an administrator who is a physician
				licensed in Missouri, a registered nurse (RN) licensed in Missouri or an
				individual who has at least one (1) year of administrative experience in health
				care; and shall notify the Department of Health of any change of administration
				within thirty (30) days after change has been made.
4. The governing body shall require in its
				bylaws that the ambulatory surgical center and medical staff abide by
				acceptable professional ethical standards.
5. Representatives of the Department of
				Health shall have access to inspect the ambulatory surgical center during
				normal working hours.
6. A written
				plan shall provide for the evacuation of patients, visitors and personnel in
				the event of fire or other disaster within the facility and for an alarm system
				to notify personnel. Personnel are to be acquainted with the evacuation plan to
				properly perform their duties in the event of a fire or disaster.
7. All fires occurring on the ambulatory
				surgical center premises shall be reported to the Department of Health within
				one (1) week giving the cause, location and extent of damage and personal
				injury, if any.
8. The
				administrator shall be responsible for the development and enforcement of
				written policies which prohibit smoking throughout the ambulatory surgical
				center except specific designated areas where smoking may be permitted. Each
				designated area shall have one hundred percent (100%) of the air supplied to
				the room exhausted.
9. Written
				smoking control policies shall be posted throughout the ambulatory surgical
				center.
10. Smoking shall be
				prohibited in any room or compartment where flammable liquids, combustible
				gases or oxygen are used or stored and in any other hazardous location. Those
				areas shall be posted with NO SMOKING signs.
11. The administrator shall assure that all
				patients admitted to the facility are under the care of a physician who is a
				member of the staff.
12. The
				administrator shall develop written procedures for receiving and investigating
				complaints regarding the facility, its physicians, dentists, podiatrists and
				employees practicing or working in the facility.
13. The administrator shall designate an
				individual duly qualified to act in his/her capacity during his/her
				absence.
14. The administrator
				shall assure the provision of adequate equipment in good repair within the
				facility to provide efficient services and protection to the patient and
				staff.
15. Personnel records shall
				be maintained on each employee and shall include job application, professional
				licensing information and health information.
16. If a patient is transferred to another
				health facility, essential medical information, including diagnosis, is to be
				transmitted with the patient to insure continuity of care.