OAR 333-076-0130: ASC Policies and Procedures

(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.