OAR 333-076-0930: ESC Policies and Procedures

(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.