Oregon Administrative Rules › Chapter 333 - OREGON HEALTH AUTHORITY, PUBLIC HEALTH DIVISION › Division 76 - AMBULATORY SURGICAL CENTERS (ASC) AND EXTENDED STAY CENTERS (ESC) › Section 333-076-0130 - ASC Policies and Procedures

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The governing body of an ASC shall have a
			 formal organizational plan with written policies, procedures and by-laws that
			 are enforced and that clearly set forth the organizational plan with written
			 responsibilities, accountability and relationships of professional and other
			 personnel including volunteers.
(2)
			 The clinical services of each ASC shall be under the supervision of a manager
			 who shall be an RN or a physician.
(3) The following are written policies and
			 procedures that the ASC shall develop and implement:
(a) Types of procedures that may be performed
			 in the facility;
(b) Types of
			 anesthesia that may be used including storage procedures. Where inhalation
			 anesthetics and medical gases are used there shall be procedures to assure
			 safety in storage and use;
(c)
			 Criteria for evaluating patient before admission and before discharge or
			 transfer;
(d) Patient
			 care;
(e) Nursing service
			 activities;
(f) Infection
			 control;
(g) Visitor's conduct and
			 control;
(h) Criteria and
			 procedures for credentialing of physicians, dentists, or other individuals
			 within the scope of his or her license, to the staff;
(i) Content and form of medical
			 records;
(j) Release of medical
			 record information;
(k) Storage and
			 dispensing of clean and sterile supplies and equipment and the processing and
			 sterilizing of all supplies, instruments and equipment used in procedures
			 unless disposable sterile packs are used;
(l) Disposal of pathological and other
			 potentially infectious waste and contaminated supplies that meet the
			 requirements in OAR chapter 333, division 56;
(m) Procurement, storage and dispensing of
			 drugs;
(n) If the program calls for
			 the serving of snacks or other foods procedures shall be written covering
			 space, equipment and supplies. Arrangements may be made for outside services.
			 All food services shall meet the requirements of the Food Sanitation Rules, OAR
			 chapter 333, division 150;
(o)
			 Cleaning, storage and handling of soiled linen and the storage and handling of
			 clean linen;
(p) Routine laboratory
			 testing;
(q) Annual training, at a
			 minimum, in emergency procedures, including, but not limited to:
(A) Procedures for fire and other
			 disaster;
(B) Infection control
			 measures; and
(C) For staff
			 involved in direct patient care, procedures for life threatening situations
			 including, but not limited to, cardiopulmonary resuscitation and the life
			 saving techniques for choking;
(r) Essential life saving measures and
			 stabilization of a patient and arrangements for transfer to an appropriate
			 facility;
(s) Procedures for
			 notifying patients orally and in writing of any financial interest as required
			 by ORS 441.098;
(t) Requirements for informed consent signed
			 by the patient or legal representative of the patient for diagnostic and
			 treatment procedures; such policies and procedures shall address informed
			 consent of minors in accordance with provisions in ORS
			 109.640,
			 109.670, and
			 109.675; and
(u) Requirements for identifying persons
			 responsible for obtaining informed consent and other appropriate disclosures
			 and ensuring that the information provided is accurate.