Ohio Administrative Code
Title 3701 - Department of Health - Administration and Director
Chapter 3701-83 - Licensing Provisions for Health Care Facilities
Section 3701-83-16 - Governing body - ambulatory surgical facilities

(1) At least every twenty-four months review, update, and approve the surgical procedures that may be performed at the facility and maintain an up-to-date listing of these procedures;

(2) Grant or deny clinical (medical-surgical and anesthesia) privileges, in writing and reviewed or re-approved at least every twenty-four months, to physicians and other appropriately licensed or certified health care professionals based on documented professional peer advice and on recommendations from appropriate professional staff. These actions shall be and based on documented evidence of the following:

(3) In the case of an ASF owned and operated by a single individual, provide for an external peer review by an unrelated person not otherwise affiliated or associated with the individual. The external peer review shall consist of a quarterly audit of a random sample of surgical cases.

(4) Designate a qualified professional trained in infection control to direct the infection control program required by paragraph (D) of rule 3701-83-09 of the Administrative Code. For the purpose of this rule, a qualified professional trained in infection control means a nurse or physician as defined in rule 3701-83-01 of Administrative Code, who has documentation of completion of training in infection control, including, but not limited to, continuing education units, in-service training, or academic or vocational course completion.