Oregon Administrative Rules › Chapter 333 - OREGON HEALTH AUTHORITY, PUBLIC HEALTH DIVISION › Division 76 - AMBULATORY SURGICAL CENTERS (ASC) AND EXTENDED STAY CENTERS (ESC) › Section 333-076-0930 - ESC Policies and Procedures

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 governing body of an ESC 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 that are
			 separate and distinct from the affiliated ASC.
(2) The clinical services of each ESC shall
			 be under the supervision of a manager who shall be an RN or a
			 physician.
(3) An ESC shall develop
			 and implement written policies and procedures including but not limited to:
(a) Admission and discharge criteria. Such
			 policies shall be evaluated annually and rewritten as needed. Documentation of
			 the policy evaluation is required;
(b) Patient care;
(c) Transfer criteria that meets the
			 requirements in OAR 333-076-0950;
(d) Patient notification requirements
			 including but not limited to:
(A) Oral and
			 written notification about financial interest as required by ORS
			 441.098;
(B) Oral and written notification that
			 services are not covered by Medicare;
(C) The manner in which care will be provided
			 in the event that complications occur beyond what the ESC has the capability to
			 provide; and
(D) The manner in
			 which patients may express concerns regarding the ESC and the services
			 provided. The information must include contact information for the
			 Authority;
(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 that
			 includes the requirements in OAR 333-076-1010;
(j) Release of medical record information
			 including patient access to his or her medical record;
(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 meets the requirements in OAR chapter 333, division
			 56;
(m) Procurement, storage and
			 dispensing of drugs;
(n) Provision
			 of dietary services that conforms to Food Sanitation Rules, OAR chapter 333,
			 division 150 and OAR 333-076-1000.
(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
			 disasters;
(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) 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
(s) Requirements for identifying persons
			 responsible for obtaining informed consent and other appropriate disclosures
			 and ensuring that the information provided is accurate.