reglab/statecodes huggingface dataset:
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 7 - ORGANIZATION AND STAFF › Rule 15-16-1-42.7.1 - Chief Executive Officer or Administrator

Current through June 25, 2024
1. The
					 governing authority shall appoint a qualified person as chief executive officer
					 of the facility to represent the governing authority and shall define his/her
					 authority and duties in writing. He/she shall be responsible for the management
					 of the facility, implementation of the policies of the governing authority and
					 authorized and empowered to carry out the provisions of these
					 regulations.
2. The chief executive
					 officer shall designate, in writing, a qualified person to act in his/her
					 behalf during his/her absence. In the absence of the chief executive officer,
					 the person on the grounds of the facility who is designated by the chief
					 executive officer to be in charge of the facility shall have reasonable access
					 to all areas in the facility related to patient care and to the operation of
					 the physical plant.
3. When there
					 is a planned change in ownership or in the chief executive officer, the
					 governing authority of the facility shall notify the Mississippi State
					 Department of Health. The chief executive officer shall be responsible for the
					 preparation of written facility policies and procedures.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 7 - ORGANIZATION AND STAFF › Rule 15-16-1-42.7.2 - Administrative Records

Current through June 25, 2024
The following essential documents and references shall
						be on file in the administrative office of the facility:
1. Appropriate documents evidencing control
					 and ownerships, such as deeds, leases, or corporation or partnerships
					 papers.
2. Bylaws and policies and
					 procedures of the governing authority and professional staff.
3. Minutes of the governing authority
					 meetings.
4. Minutes of the
					 facility's professional and administrative staff meetings.
5. A current copy of the ambulatory surgical
					 facility regulations.
6. Reports of
					 inspections, reviews, and corrective actions taken related to
					 licensure.
7. Contracts and
					 agreements for all services not provided directly by the facility.
8. All permits and certificates shall be
					 appropriately displayed.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 8 - PERSONNEL POLICIES AND PROCEDURES › Rule 15-16-1-42.8.1

Current through June 25, 2024
Personnel Records. A record of each employee should be
						maintained which includes the following to help provide quality assurance in
						the facility:
1. Application for
					 employment.
2. Written references
					 and/or a record of verbal references.
3. Verification of all training and
					 experience, and licensure, certification, registration and/or
					 renewals.
4. Performance
					 appraisals.
5. Initial and
					 subsequent health clearances.
6.
					 Disciplinary and counseling actions.
7. Commendations.
8. Employee incident reports.
9. Record of orientation to the facility, its
					 policies and procedures and the employee's position. Personnel records shall be
					 confidential. Representatives of the licensing agency conducting an inspection
					 of the facility shall have the right to inspect personnel records.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 8 - PERSONNEL POLICIES AND PROCEDURES › Rule 15-16-1-42.8.2 - Job Descriptions

Current through June 25, 2024
1. Every position
					 shall have a written description which adequately describes the duties of the
					 position.
2. Each job description
					 shall include position title, authority, specific responsibilities and minimum
					 qualifications. Qualifications shall include education, training, experience,
					 special abilities and license or certification required.
3. Job descriptions shall be kept current and
					 given to each employee when assigned to the position and whenever the job
					 description is changed.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 8 - PERSONNEL POLICIES AND PROCEDURES › Rule 15-16-1-42.8.3 - Health Examination

Current through June 25, 2024
As a minimum, each employee shall have a pre-employment
						health examination by a physician. The examination is to be repeated annually
						and more frequently if indicated to ascertain freedom from communicable
						diseases. The extent of the annual examinations shall be determined by a
						committee consisting of the medical director, administrator and director of
						nursing, and documentation of the health examination shall be included in the
						employee's personnel folder.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 9 - MEDICAL STAFF ORGANIZATION › Rule 15-16-1-42.9.1

Current through June 25, 2024
There shall be a single organized medical staff that has
						the overall responsibility for the quality of all clinical care provided to
						patients, and for the ethical conduct and professional practices of its
						members, as well as for accounting therefore to the governing authority. The
						manner in which the medical staff is organized shall be consistent with the
						facility's documented staff organization bylaws, rules and regulations, and
						pertain to the setting where the facility is located. The medical staff bylaws,
						rules and regulations, and the rules and regulations of the governing authority
						shall require that patients are admitted to the facility only upon the
						recommendation of a licensed physician and that a licensed physician be
						responsible for diagnosis and all medical care and treatment. The organization
						of the medical staff, and its bylaws, rules and regulations, shall be approved
						by the facility's governing authority. The medical staff shall strive to assure
						that each member is qualified for membership and shall encourage the optimal
						level of professional performance of its members through the
						appointment/reappointment procedure, the specific delineation of clinical
						privileges, and the periodic reappraisal of each staff member according to the
						established provisions.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 9 - MEDICAL STAFF ORGANIZATION › Rule 15-16-1-42.9.2 - Qualifications

Current through June 25, 2024
The appointment and reappointment of medical staff
						members shall be based upon well-defined, written criteria that are related to
						the goals and objectives of the facility as stated in the bylaws, rules and
						regulations of the medical staff of the governing authority., Upon application
						or appointment to the medical staff, each individual must sign a statement to
						the effect that he/she has read and agrees to be bound by the medical staff and
						governing authority bylaws, rules and regulations. The initial appointment and
						continued medical staff membership shall be dependent upon professional
						competence and ethical practice in keeping with the qualifications, standards,
						and requirements set forth in the professional staff and governing authority
						bylaws, rules and regulations.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 9 - MEDICAL STAFF ORGANIZATION › Rule 15-16-1-42.9.3 - Method of Selection

Current through June 25, 2024
Each facility is responsible for developing a process of
						appointment to the medical staff whereby it can satisfactorily determine that
						the person is appropriately licensed and qualified for the privileges and
						responsibilities he/she seeks.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 9 - MEDICAL STAFF ORGANIZATION › Rule 15-16-1-42.9.4 - Privilege Delineation

Current through June 25, 2024
Privileges shall be delineated for each member of the
						medical staff, regardless of the type and size of the facility. The delineation
						of privileges shall be based on all verified information available in the
						applicant's or staff member's credentials file. Whatever method is used to
						delineate clinical privileges for each medical staff applicant, there must be
						evidence that the granting of such privileges is based on the member's
						demonstrated current competence.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 9 - MEDICAL STAFF ORGANIZATION › Rule 15-16-1-42.9.5 - Clinical Privileges Shall Be Facility-Specific

Current through June 25, 2024
The medical staff shall delineate in its bylaws, rules
						and regulations, the qualifications, status, clinical duties, and
						responsibilities of consultant physicians who are not members of the medical
						and dental staff but whose services require that they be processed through the
						usual medical staff channels. The training, experience, and demonstrated
						competence of individuals in such categories shall be sufficient to permit
						their performing their assigned functions.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 9 - MEDICAL STAFF ORGANIZATION › Rule 15-16-1-42.9.6 - Reappointment

Current through June 25, 2024
The facility's medical staff bylaws, rules and
						regulations shall provide for review and reappointment of each medical staff
						member at least once every three years. The reappointment process should
						include a review of the individual's status by a designated medical staff
						committee, such as the credentials committee. When indicated, the credentials
						committee shall require the individual to submit evidence of his/her current
						health status that verifies the individual's ability to discharge his/her
						responsibility. The committee's review of the clinical privileges of a staff
						member for reappointment should include the individual's past and current
						professional performance as well as his/her adherence to the governing
						authority and professional staff bylaws, rules and regulations. The medical
						staff bylaws, rules and regulations shall limit the time within which the
						medical staff reappointment and privilege delineation processes must be
						completed.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 9 - MEDICAL STAFF ORGANIZATION › Rule 15-16-1-42.9.7 - Professional Staff

Current through June 25, 2024
Each facility shall have at all times a designated
						medical director who shall be a physician and who shall be responsible for the
						direction and coordination of all medical aspects of facility programs. Each
						members of the medical staff shall have like privileges in at least one local
						hospital. In the case of an abortion facility, the facility must comply with
						all state and federal laws and regulations, including , but not limited to,
						provisions of MS. Code Ann. §
											41-75-1.
						There shall be a minimum of one licensed registered nurse per six patients (at
						any one time) at the clinic when patients are present, excluding the director
						of nursing. All facility personnel, medical and others, shall be licensed to
						perform the services they render when such services require licensure under the
						laws of the State of Mississippi. Anesthetic agents shall be administered by an
						anesthesiologist, a physician, or a certified registered nurse anesthetist
						under the supervision of a board-qualified or certified anesthesiologist or
						operating physician, who is actually on the premises. After the administration
						of an anesthetic, patients shall be constantly attended by an M.D., D.O., R.N.,
						or a L.P.N. supervised directly by an R.N., until reacted and able to summon
						aid. All employees of the facility providing direct patient care shall be
						trained in emergency resuscitation at least annually. [Section
						41-75-1(f)].
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 9 - MEDICAL STAFF ORGANIZATION › Rule 15-16-1-42.9.8 - Reporting Requirements

Current through June 25, 2024
Each abortion facility shall report monthly to the
						Mississippi State Department of Health such information as may be required by
						the department in its rules and regulations for each abortion performed by such
						facility.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 10 - PATIENT TRANSFER › Rule 15-16-1-42.10.1 - Transfer Agreement

Current through June 25, 2024
1. The ASC must
					 have an effective procedure for the immediate transfer, to a hospital, of
					 patients requiring medical care beyond the capabilities of the ASC. The
					 hospital must be a local, Medicare participating hospital or a local
					 non-participating hospital that meets the requirements for payment of emergency
					 services. See Rule 42.2.1(16) for definition of "local hospital".
a. The ASC must have a transfer agreement
					 with a hospital that meets the requirements, as stated above, or
b. Ensure that all physicians performing
					 surgery in the ASC have admitting privileges at a hospital that meets the
					 regulatory requirements of above.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 11 - SAFETY › Rule 15-16-1-42.11.1

Current through June 25, 2024
The governing authority shall develop written policies
						and procedures designed to enhance safety within the facility and on its
						grounds and minimize hazards to patients, staff and visitors.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 11 - SAFETY › Rule 15-16-1-42.11.2

Current through June 25, 2024
The policies and procedures shall include establishment
						of the following:
1. Safety rules and
					 practices pertaining to personnel, equipment, gases, liquids, drugs;
2. Provisions for reporting and the
					 investigation of accidental events regarding patients, visitors and personnel
					 (incidents) and corrective action taken;
3. Provision for dissemination of
					 safety-related information to employees and users of the facility;
					 and
4. Provision for syringe and
					 needle storage, handling and disposal.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 12 - HOUSEKEEPING › Rule 15-16-1-42.12.1

Current through June 25, 2024
Operating rooms shall be appropriately cleaned in
						accordance with established written procedures after each operation. Recovery
						rooms shall be maintained in a clean condition. Adequate housekeeping staff
						shall be employed to fulfill the above requirement.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 13 - LINEN AND LAUNDRY › Rule 15-16-1-42.13.1

Current through June 25, 2024
An adequate supply of clean linen or disposable
						materials shall be maintained.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 13 - LINEN AND LAUNDRY › Rule 15-16-1-42.13.2

Current through June 25, 2024
Provisions for proper laundering of linen and washable
						goods shall be made. Soiled and clean linen shall be handled and stored
						separately.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 13 - LINEN AND LAUNDRY › Rule 15-16-1-42.13.3

Current through June 25, 2024
Sufficient supply of cloth or disposable towels shall be
						available so that a fresh towel can be used after each hand washing. Towels
						shall not be shared.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 14 - SANITATION › Rule 15-16-1-42.14.1

Current through June 25, 2024
All parts of the facility, the premises and equipment
						shall be kept clean and free of insects, rodents, litter and
						rubbish.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 14 - SANITATION › Rule 15-16-1-42.14.2

Current through June 25, 2024
All garbage and waste shall be collected, stored and
						disposed of in a manner designed to prevent the transmission of disease.
						Containers shall be washed and sanitized before being returned to work areas.
						Disposable type containers shall not be reused.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 15 - PREVENTIVE MAINTENANCE › Rule 15-16-1-42.15.1

Current through June 25, 2024
A schedule of preventive maintenance shall be developed
						for all of the surgical equipment in the surgical suite to assure satisfactory
						operation when needed.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 16 - DISASTER PREPAREDNESS › Rule 15-16-1-42.16.1

Current through June 25, 2024
The facility shall have a posted plan for evacuation of
						patients, staff, and visitors in case of fire or other
						emergency.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 16 - DISASTER PREPAREDNESS › Rule 15-16-1-42.16.2 - Fire drills

Current through June 25, 2024
1. At least one
					 drill shall be held every three months for every employee to familiarize
					 employees with the drill procedure. Reports of the drills shall be maintained
					 with records of attendance.
2. Upon
					 identification of procedural problems with regard to the drills, records shall
					 show that corrective action has been taken.
3. There shall be an ongoing training program
					 for all personnel concerning aspects of fire safety and the disaster
					 plan.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 17 - MEDICAL RECORD SERVICES › Rule 15-16-1-42.17.1 - Medical Record System

Current through June 25, 2024
A medical record is maintained in accordance with
						accepted professional principles for every patient admitted and treated in the
						facility. The medical record system shall be under the supervision of a
						designated person who has demonstrated through relevant experience the ability
						to perform the required functions.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 17 - MEDICAL RECORD SERVICES › Rule 15-16-1-42.17.2 - Facilities

Current through June 25, 2024
A room or area shall be designated within the facility
						for medical records. The area shall be sufficiently large and adequately
						equipped to permit the proper processing and storing of records. All medical
						records must be accessible and easily retrieved.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 17 - MEDICAL RECORD SERVICES › Rule 15-16-1-42.17.3 - Ownership

Current through June 25, 2024
Medical records shall be the property of the facility
						and shall not be removed except by subpoena or court order. These records shall
						be protected against loss, destruction and unauthorized use.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 17 - MEDICAL RECORD SERVICES › Rule 15-16-1-42.17.4 - Preservation of Records

Current through June 25, 2024
Medical records shall be preserved either in the
						original form or by microfilm for a period of not less than ten years. In the
						case of minor the record is to be retained until the patient becomes of age,
						plus seven years.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 17 - MEDICAL RECORD SERVICES › Rule 15-16-1-42.17.5 - Individual Patient Records

Current through June 25, 2024
Each patient's medical record shall include at least the
						following information:
1. Patient
					 identification, including the patient's full name, sex, address, date of birth,
					 next of kin and patient number.
2.
					 Admitting diagnosis.
3.
					 Preoperative history and physical examination pertaining to the procedure to be
					 performed.
4. Anesthesia
					 reports.
5. Operative
					 report.
6. Pertinent laboratory,
					 pathology and X-ray reports.
7.
					 Preoperative and postoperative orders.
8. Discharge note and discharge
					 diagnosis.
9. Informed
					 consent.
10. Nurses' notes:
a. Admission and preoperative.
b. Recovery and discharge.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 17 - MEDICAL RECORD SERVICES › Rule 15-16-1-42.17.6 - Completion of Medical Records

Current through June 25, 2024
All medical records shall be completed
						promptly.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 17 - MEDICAL RECORD SERVICES › Rule 15-16-1-42.17.7 - Indexes

Current through June 25, 2024
All medical records should be indexed according to
						disease, operation, physician, and patient name.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 18 - Patient Care: Nursing Service › Rule 15-16-1-42.18.1 - Nursing Staff

Current through June 25, 2024
The ambulatory surgical facility shall maintain an
						organized nursing staff to provide high quality nursing care for the needs of
						the patients and be responsible to the ambulatory surgical facility for the
						professional performance of its members. The ambulatory surgical facility
						nursing service shall be under the direction of a legally and professionally
						qualified registered nurse. There shall be a sufficient number of duly licensed
						registered nurses on duty at all times to plan, assign, supervise, and evaluate
						nursing care, as well as to give patients the nursing care that requires the
						judgment and specialized skills of a registered nurse.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 18 - Patient Care: Nursing Service › Rule 15-16-1-42.18.2 - Director of Nursing Service

Current through June 25, 2024
The director of nursing service shall be qualified by
						education, medical-surgical nursing and surgery experience of one year each,
						and demonstrated ability to organize, coordinate, and evaluate the work of the
						service. He/she shall be qualified in the fields of nursing and administration
						consistent with the complexity and scope of operation of the ambulatory
						surgical facility and shall be responsible to the administrator for the
						developing and implementing policies and procedures of the service in the
						ambulatory surgical facility.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 18 - Patient Care: Nursing Service › Rule 15-16-1-42.18.3 - Staffing Pattern

Current through June 25, 2024
A staffing pattern shall be developed for each nursing
						care unit (preoperative unit, surgical suite, recovery and postoperative unit).
						The staffing pattern shall provide for sufficient nursing personnel and for
						adequate supervision and direction by registered nurses consistent with the
						size and complexity of the ambulatory surgical facility.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 18 - Patient Care: Nursing Service › Rule 15-16-1-42.18.4 - Nursing Care Plan

Current through June 25, 2024
There shall be evidence established that the ambulatory
						surgical facility nursing service provides safe, efficient and therapeutically
						effective nursing care through the planning of each patient's preoperative,
						operative, recovery and postoperative care and the effective implementation of
						the plans. A registered nurse must plan, supervise and evaluate the nursing
						care of each patient from admission to discharge.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 18 - Patient Care: Nursing Service › Rule 15-16-1-42.18.5 - Licensed Practical Nurse

Current through June 25, 2024
Licensed practical nurses who are currently licensed to
						practice within the state, as well as other ancillary nursing personnel, may be
						used to give nursing care that does not require the skill and judgment of a
						registered nurse. Their performance shall be supervised by one or more
						registered nurses.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 18 - Patient Care: Nursing Service › Rule 15-16-1-42.18.6 - Nursing Service Evaluation

Current through June 25, 2024
To develop better patterns of utilization of nursing
						personnel, periodic evaluation of the activities and effectiveness of the
						nursing staff should be conducted as a part of quality assurance. Evaluations
						should be done after the first 90-day probationary period, then annually
						thereafter.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 18 - Patient Care: Nursing Service › Rule 15-16-1-42.18.7 - Nursing Service Organization

Current through June 25, 2024
The ambulatory surgical facility nursing service shall
						have a current written organization plan that delineates its functional
						structure and its mechanisms for cooperative planning and decision making. This
						plan shall be an integral part of the overall ambulatory surgical facility plan
						and shall:
1. Be made available to all
					 nursing personnel.
2. Be reviewed
					 periodically (yearly) and revised as necessary.
3. Reflect the staffing pattern for nursing
					 personnel throughout the ambulatory surgical facility.
4. Delineate the functions for which nursing
					 service is responsible.
5. Indicate
					 all positions required to carry out such functions.
6. Contain job descriptions for each position
					 classification in nursing service that delineates the functions,
					 responsibilities, and desired qualifications of each classification, and should
					 be made available to nursing personnel at the time of employment.
7. Indicate the lines of communication within
					 nursing service.
8. Define the
					 relationships of nursing service to all other services and departments in the
					 ambulatory surgical facility.
9. In
					 ambulatory surgical facilities where the size of the nursing staff permits,
					 nursing committees shall be formally organized to facilitate the establishment
					 and attainment of goals and objectives of the nursing service.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 18 - Patient Care: Nursing Service › Rule 15-16-1-42.18.8 - Policies and Procedures

Current through June 25, 2024
Written nursing care and administrative policies and
						procedures shall be developed to provide the nursing staff with acceptable
						methods of meeting its responsibilities and achieving projected goals through
						realistic, attainable goals. In planning, decision making, and formulation of
						policies that affect the operation of nursing service, the nursing care of
						patients, or the patient's environment, the recommendations of representatives
						of nursing service shall be considered. Nursing care policies and procedures
						shall be consistent with professionally recognized standards of nursing
						practice and shall be in accordance with Nurse Practice Act of the State of
						Mississippi and AORN Standards of Practice. Policies shall include statements
						relating to at least the following:
1.
					 Noting diagnostic and therapeutic orders.
2. Assignment of preoperative and
					 postoperative care of patients.
3.
					 Administration of medications.
4.
					 Charting of nursing personnel.
5.
					 Infection control.
6. Patient and
					 personnel safety.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 18 - Patient Care: Nursing Service › Rule 15-16-1-42.18.9

Current through June 25, 2024
Written copies of the procedure manual shall be
						available to the nursing staff in every nursing care unit and service area and
						to other services and departments in the ambulatory surgical facility. The
						nursing procedure manual should be used to:
1. Provide a basis for staff development to
					 enable new nursing personnel to acquire local knowledge and current skills
					 through established orientation programs.
2. Provide a ready reference or procedures
					 for all nursing personnel.
3.
					 Standardize procedures and equipment.
4. Provide a basis for evaluation and study
					 to ensure continued improvements in techniques.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 18 - Patient Care: Nursing Service › Rule 15-16-1-42.18.10

Current through June 25, 2024
The ambulatory surgical facility nursing policies and
						procedures shall be developed, periodically reviewed, and revised as necessary
						by nursing representatives in cooperation with administration, the medical
						staff, and other facility services and departments concerned. All revisions
						shall be dated to indicate the date of the latest review.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 18 - Patient Care: Nursing Service › Rule 15-16-1-42.18.11 - In-Service Education and Meetings

Current through June 25, 2024
An in-service education programs and meetings of the
						nursing staff shall be provided for the improvement of existing aseptic and
						nursing practices; obtaining new knowledge and skills applicable to operating
						room nursing; keep personnel informed of changes in policies and procedures and
						discuss nursing service problems in the ambulatory surgical facility. The
						in-service program shall be planned, scheduled, documented and held on a
						continuing or monthly basis. There should be provisions for participation in
						appropriate training programs for the safe and effective use of diagnostic and
						therapeutic equipment for CPR and for other aspects of critical
						care.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 19 - SURGERY › Rule 15-16-1-42.19.1

Current through June 25, 2024
The ambulatory surgical facility shall have effective
						policies and procedures regarding surgical privileges, maintenance of the
						operating rooms and evaluation of the surgical patient.
1. Surgical privileges according to covered
					 surgical procedures shall be delineated for all physicians doing surgery in
					 accordance with the competencies of each physician. A roster shall be kept in
					 the confidential files of the operating room supervisor and in the files of the
					 administrator.
2. The operating
					 room register shall be complete and up-to-date.
3. There shall be a complete history and
					 physical work-up in the chart of every patient prior to surgery plus
					 documentation of a properly executed informed patient consent.
4. There shall be adequate provision for
					 immediate postoperative care.
5. An
					 operative report describing techniques and findings shall be written or
					 dictated immediately following surgery and signed by the surgeon.
6. A procedure shall exist in establishing a
					 program for identifying and preventing infections, maintaining a sanitary
					 environment, and reporting results to appropriate authorities. The operating
					 surgeon shall be required to report back to the facility an infection for
					 infection control follow-up.
7. The
					 operating rooms shall be supervised by an experienced registered professional
					 nurse.
8. The following equipment
					 shall be available to the operating suite: emergency call system, oxygen,
					 mechanical ventilatory assistance equipment, including airways and manual
					 breathing bag, cardiac defibrillator, cardiac monitoring equipment, thoracotomy
					 set, tracheotomy set, laryngoscopes and endotracheal tubes, suction equipment,
					 emergency drugs and supplies specified by the medical staff. Personnel trained
					 in the use of emergency equipment and in cardiopulmonary resuscitation must be
					 available whenever there is a patient in the ambulatory surgical
					 facility.
9. Precautions shall be
					 taken to eliminate shock hazards, including use of shoe covers.
10. Rules and regulations or policies related
					 to the operating room shall be available for ambulatory surgical facility
					 personnel and physicians.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 20 - ANESTHESIA › Rule 15-16-1-42.20.1

Current through June 25, 2024
The department of anesthesia shall have effective
						policies and procedures regarding staff privileges, the administration of
						anesthetics, and the maintenance of strict safety control.
1. A preoperative evaluation of the patient
					 within 24 hours of surgery shall be done by a physician to determine the risk
					 or anesthesia and of the procedure to be performed.
2. Before discharge from the ambulatory
					 surgical facility, each patient shall be evaluated by an anesthesiologist or
					 certified registered nurse anesthetist for proper anesthesia recovery and
					 discharged in the company of a responsible adult unless otherwise specified by
					 the physician.
3. Anesthetic agents
					 shall be administered by only a qualified anesthesiologist, a physician
					 qualified to administer anesthetic agents or a certified registered nurse
					 anesthetist.
4. The department of
					 anesthesia shall be responsible for all anesthetic agents administered in the
					 ambulatory surgical facility.
5. In
					 the ambulatory surgical facility where there is no department of anesthesia,
					 the department of surgery shall assume the responsibility of establishing
					 general policies and supervising the administration of anesthetic
					 agents.
6. Safety precautions shall
					 be in accordance with N.F.P.A. Bulletin 56-A, 1981.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 21 - DEPARTMENT OF DENTISTRY › Rule 15-16-1-42.21.1

Current through June 25, 2024
According to the procedure established for the
						appointment of the medical staff, one or more licensed dentists may be
						appointed to the staff. If this service is organized, its organization is
						comparable to that of other services or departments.
1. The above members shall be qualified
					 legally, professionally, and ethically for the positions to which they are
					 appointed.
2. Patients admitted for
					 the above services shall be admitted by a physician.
3. There shall be medical history done and
					 recorded by a member of the medical staff before surgery is done and a
					 physician in attendance who is responsible for the medical care of the
					 patient.
4. There shall be specific
					 bylaws concerning dentists and combined with the medical staff
					 by-laws.
5. The staff bylaws and
					 regulations shall specifically delineate the rights and privileges of the
					 dentists.
6. Complete records, both
					 medical and surgical, shall be required on each patient and shall be a part of
					 the ambulatory surgical facility records.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 22 - SANITARY ENVIRONMENT › Rule 15-16-1-42.22.1

Current through June 25, 2024
The ambulatory surgical facility shall provide a safe
						and sanitary environment, properly constructed, equipped, and maintained to
						protect the health and safety of patients.
1. An infection committee, or comparable
					 arrangement, composed or members of the medical staff, nursing staff,
					 administration and other services of the ambulatory surgical facility, shall be
					 established and shall be responsible for investigating, controlling and
					 preventing infections, documentation of such meetings and an attendance
					 roster.
2. There shall be written
					 procedures to govern the use of aseptic techniques and procedures in all areas
					 of the ambulatory surgical facility.
3. To keep infections at a minimum, such
					 procedures and techniques shall be regularly by the infection committee
					 annually.
4. Continuing education
					 shall be provided to all ambulatory surgical facility personnel on causes,
					 effects, transmission, prevention, and elimination of infection on an annual
					 basis.
5. A continuing process
					 shall be enforced for inspection and reporting of any ambulatory surgical
					 facility employee with an infection who may be in contact with patients on the
					 patient's environment.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 23 - CENTRAL STERILE SUPPLY › Rule 15-16-1-42.23.1

Current through June 25, 2024
Policies and procedures shall be maintained for method
						of control used in relation to the sterilization of supplies and water and a
						written policy requiring sterile supplies to be reprocessed at specific time
						periods. These areas shall be separated:
1. Receiving and clean-up area, to contain a
					 two-compartment sink with two drainboards.
2. Pack make-up shall have autoclaves, work
					 counter and unsterile storage.
3.
					 Sterile storage area should have pass-through to corridor.
Miss. Code Ann.
						§
												41-75-13
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 42 - MINIMUM STANDARDS OF OPERATION FOR AMBULATORY SURGICAL FACILITIES › Subchapter 24 - PHARMACEUTICAL SERVICES › Rule 15-16-1-42.24.1 - Administering Drugs and Medicines

Current through June 25, 2024
Drugs and medicines shall not be administered to
						patients unless ordered by a physician duly licensed to prescribe drugs. Such
						orders shall be in writing and signed personally by the physician who
						prescribes the drug or medicine.
Miss. Code Ann.
						§
												41-75-13