Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 135 - AMBULATORY SURGICAL CENTERS › Subchapter A - OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS › Section 135.4 - Ambulatory Surgical Center (ASC) Operation

Current through Reg. 49, No. 28; July 12, 2024
(a) The ASC shall have a governing body that
				  sets policy and assumes full legal responsibility for the total operation of
				  the ASC.
(b) The governing body
				  shall be responsible for assuring that medical staff bylaws are current and on
				  file.
(c) The governing body shall
				  address and is fully responsible, either directly or by appropriate
				  professional delegation, for the operation and performance of the ASC.
				  Governing body responsibilities include, but are not limited to:
(1) determining the mission, goals, and
				  objectives of the ASC;
(2) assuring
				  that facilities and personnel are adequate and appropriate to carry out the
				  mission;
(3) establishing an
				  organizational structure and specifying functional relationships among the
				  various components of the ASC;
(4)
				  adopting bylaws or similar rules and regulations for the orderly development
				  and management of the ASC;
(5)
				  adopting policies or procedures necessary for the orderly conduct of the
				  ASC;
(6) assuring that the quality
				  of care is evaluated and that identified problems are addressed;
(7) reviewing all legal and ethical matters
				  concerning the ASC and its staff and, when necessary, responding
				  appropriately;
(8) maintaining
				  effective communication throughout the ASC;
(9) establishing a system of financial
				  management and accountability that includes an audit appropriate to the
				  ASC;
(10) developing, implementing,
				  and enforcing a policy on the rights of patients;
(11) approving all major contracts or
				  arrangements affecting the medical care provided under its auspices, including,
				  but not limited to, those concerning:
(A) the
				  employment of health care practitioners;
(B) an effective procedure for the immediate
				  transfer to a hospital of patients requiring emergency care beyond the
				  capabilities of the ASC. The ASC shall have a written transfer agreement with a
				  hospital or all physicians performing surgery at the ASC shall have admitting
				  privileges at a local hospital;
(C)
				  the use of external laboratories;
(D) an effective procedure for obtaining
				  emergency laboratory, radiology, and pharmaceutical services if laboratory,
				  X-ray, and pharmacy services are not provided on site; and
(E) the provision of education to students
				  and postgraduate trainees if the ASC participates in such programs;
(12) formulating long-range plans
				  in accordance with the mission, goals, and objectives of the ASC;
(13) operating the ASC without limitation
				  because of race, creed, sex, or national origin;
(14) assuring that all marketing and
				  advertising concerning the ASC does not imply that it provides care or services
				  which it is not capable of providing; and
(15) developing a system of risk management
				  appropriate to the ASC including, but not limited to:
(A) periodic review of all litigation
				  involving the ASC, its staff, and health care practitioners regarding
				  activities in the ASC;
(B) periodic
				  review of all incidents reported by staff and patients;
(C) review of all deaths, trauma, or adverse
				  reactions occurring on premises; and
(D) evaluation of patient
				  complaints.