Current through Register Vol. 50, No. 12, December 20, 2024
A. An
ASC shall have an identifiable governing body with responsibility for, and
authority over, the policies and activities of the ASC, which shall include use
agreements and all contracts. The governing body is the ultimate governing
authority of the ASC and shall adopt bylaws which address its responsibilities.
No contract or other arrangements, including use agreements, shall limit or
diminish the responsibilities of the governing body.
B. An ASC shall have documents identifying
the following information regarding the governing body:
1. names and addresses of all
members;
3. officers of the
governing body; and
4. terms of
office for any officers.
C. The governing body shall be comprised of
one or more persons and shall hold formal meetings at least twice a year. There
shall be written minutes of all formal meetings, and the bylaws shall specify
the frequency of meetings and quorum requirements.
D. The governing body of an ASC shall:
1. ensure the ASCs continual compliance and
conformity with all relevant federal, state, local and municipal laws and
regulations;
2. ensure that the ASC
is adequately funded and fiscally sound which entails:
a. verification of sufficient assets equal to
$100,000 or the cost of three months of operation, whichever is less;
or
b. a letter of credit issued
from a federally insured, licensed lending institution in the amount of at
least $100,000 or the cost of three months of operation, whichever is
less;
3. review and
approve the ASCs annual budget;
4.
designate a person to act as the administrator and delegate sufficient
authority to this person to manage the day-to-day operations of the
ASC;
5. annually evaluate the
administrators performance;
6. have
the authority to dismiss the administrator;
7. formulate and annually review, in
consultation with the administrator, written policies and procedures concerning
the ASCs philosophy, goals, current services, personnel practices, job
descriptions, fiscal management, contracts and use agreements:
a. the ASCs written policies and procedures
shall be maintained within the ASC and made available to all staff at all
times;
8. determine, in
accordance with state law, which practitioners are eligible candidates for
appointment to the medical staff and make the necessary appointments;
9. determine, in conjunction with the medical
staff, whether the ASC will provide services beyond the customary hours of
operation by allowing a patient to stay up to 23 hours. If permitted the ASC
shall provide continuous physician (on call and available to be on-site as
needed) and professional nursing services (registered nurse) on-site. In
addition, the ASC shall provide for ancillary services to accommodate patient
needs during this extended stay including but not limited to medication and
nutrition;
10. ensure and maintain
quality of care, inclusive of a quality assurance/performance improvement
process that measures patient, process, and structural (e.g. system) outcome
indicators to enhance patient care;
11. ensure that surgical or invasive
procedures shall not be performed in areas other than the operating room or
other designated and approved treatment rooms;
12. ensure that surgical or invasive
procedures are initiated in accordance with acceptable standards of practice,
which includes the use of standard procedures, such as a timeout to ensure
proper identification of the patient and surgical site, in order to avoid wrong
site, wrong person or wrong procedure errors;
13. meet with designated representatives of
the department whenever required to do so;
14. inform the department, or its designee,
prior to initiating any substantial changes in the services provided by the
ASC; and
15. ensure that pursuant
to R.S.
40:1191.2, prior to the final disposition of
a miscarried child, but not more than 24 hours after a miscarriage occurs in an
ASC, the ASC shall notify the patient, or if the patient is incapacitated, the
spouse of the patient, both orally and in writing, of both of the following:
a. the parent's right to arrange for the
final disposition of the miscarried child through the use of the notice of
parental rights form as provided for in
R.S.
40:1191.3; and
b. the availability of a chaplain or other
counseling services concerning the death of the miscarried child, if such
services are provided by the ASC.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
40:2131-2141.
