Current through 2024-38, September 18, 2024
The Ambulatory Surgical Facility must have a safe and
sanitary environment, properly constructed, equipped and maintained to protect
the health and safety of patients.
4.F.l. Physical Environment
The Ambulatory Surgical Facility must provide a functional
and sanitary environment for the provision of surgical services.
a. Each operating room must be designed and
equipped so that the types of surgery conducted can be performed in a manner
that protects the lives and assures the physical safety of all individuals in
the area.
b. The Ambulatory
Surgical Facility must have a separate recovery room and waiting
area.
c. The Ambulatory Surgical
Facility must establish a program for identifying and preventing infections,
maintaining a sanitary environment and reporting the results to appropriate
authorities.
4.F.2.
Safety From Fire
a. Except as provided in
paragraphs 4.E.2.b. and 4.E.2.c. of this section, the Ambulatory Surgical
Facility must meet the provisions of the 1985 edition of the Life Safety Code
of the National Fire Protection Association (which is incorporated by
reference) that are applicable to Ambulatory Surgical Facilities.
b. In consideration of a recommendation by
the State survey agency, HCFA may waive, for periods deemed appropriate,
specific provisions of the Life Safety Code which, if rigidly applied, would
result in unreasonable hardship upon an Ambulatory Surgical Facility, but only
if the waiver will not adversely affect the health and safety of the
patients.
c. Any Ambulatory
Surgical Facility that, on May 9, 1988, complies with the requirements of the
1981 edition of the Life Safety Code, with or without waivers, will be
considered to be in compliance with this standard, so long as the Ambulatory
Surgical Facility continues to remain in compliance with that edition of the
Life Safety Code.
4.F.3. Emergency Equipment
Emergency equipment available to the operating rooms must
include at least the following.
a.
Emergency call system
b. Oxygen
(both portable and stationary) to include oxygen delivery devices such as
tubing, masks and nasal cannulae
c.
Mechanical ventilator assistance equipment, including airways, manual breathing
bag and ventilator
d. Cardiac
monitoring equipment, including cardiac defibrillation equipment
e. Tracheostomy set
f. Laryngoscopes and endotracheal
tubes
g. Suction
equipment
h. Emergency medical
equipment and supplies specified by the medical staff.
4.F.4. Emergency Personnel
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.
