25 TAC 135 8 Quality Assurance in a

25 TAC 135. 8. Quality Assurance in a licensed ASC 135. 8(g)(1) The quality assurance program shall be a well-defined organized program designed to enhance patient care through the ongoing objective assessment of important aspects of patient care and the associated or identified problems. The responsibilities for quality assurance activities shall be clearly delineated

25 TAC 135. 8. Quality Assurance in a licensed ASC • Quality assurance activities described in subsection (f) of this section shall encompass, but are not limited to: • (1) the clinical performance of health care practitioners • 2) the standards for medical records; • (3) quality controls for and the use of radiology, pathology, and medical laboratory services; ) • (4) other professional and technical services provided; • (5) studies of patient satisfaction.

25 TAC 135. 10. Facilities and Environment. • 135. 10(a)(1) • periodic instruction of all personnel in the proper use of safety, emergency, and fireextinguishing equipment • procedures, including adequate surveillance techniques, that minimize sources and transmission of infections;

135. 10(a)(A-G) (a) Anesthesia services. • (7) Patients who have received anesthesia shall be evaluated for proper anesthesia recovery by the operating surgeon or the person administering the anesthesia prior to discharge from the post anesthesia care unit using criteria approved by the medical staff.

25 TAC 135. 15. Facility Staffing and Training. • 135. 15(a)(1) • (a) Nursing services. • (1) There shall be an organized nursing service under the direction of a qualified registered nurse (RN). The ambulatory surgical center (ASC) shall be staffed to assure that the nursing needs of all patients are met.

25 TAC 135. 15. Facility Staffing and Training. • 135. 15(a)(2)(A-D) • (2) There shall be a written plan of administrative authority for all nursing services with responsibilities and duties of each category of nursing personnel delineated and a written job description for each category. The scope of nursing service shall include, but is not limited to, nursing care rendered to patients preoperatively, intraoperatively, and postoperatively. • (A) The responsible individual for nursing services shall be a qualified registered nurse (RN) whose responsibility and authority for nursing service shall be clearly defined and includes supervision of both personnel performance and patient care.

25 TAC 135. 15. Facility Staffing and Training. • (B) There shall be a written delineation of functions, qualifications, and patient care responsibilities for all categories of nursing personnel. • (C) Surgical technicians and licensed vocational nurses may be permitted to serve in the scrub nurse role under the direct supervision of an RN; they shall not be permitted to function as circulating nurses in the operating rooms. Licensed vocational nurses and surgical technicians may assist in circulatory duties under the direct supervision of a qualified RN. • (D) Nursing services shall be provided in accordance with current recognized standards or recommended practices.

25 TAC 135. 15. Facility Staffing and Training. • 135(15)(3)(A-B) • (3) There shall be an adequate number of RNs on duty to meet the following minimum staff requirements: director of the department (or designee), and supervisory and staff personnel for each service area to assure the immediate availability of an RN for emergency care or for any patient when needed. • (A) An RN shall assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the preparation and qualifications of the nursing staff available. • (B) There shall be other nursing personnel in sufficient numbers to provide nursing care not requiring the service of an RN.

25 TAC 135. 27. Patient Safety Program. 1) The governing body shall ensure that the PSP reflects the complexity of the ASC’s organization and services, including those services furnished under contract or arrangement, and focuses on the prevention and reduction of medical errors and adverse events.

Pharmaceutical services 416. 48 (a) Administration of drugs • Drugs must be prepared and administered according to established policies and acceptable standards of practice. • Use safe injection practices • Usingle dose vials for one patient only • Pre-filled medications should be initialed, dated and timed by the person who draws it. The label should also include the medication and expiration for use. ** • Avoid pre-drawing of meds to avoid loss of security, integrity, or stability

416. 47 (b) Form & content of record • Every record must be accurate, legible, and promptly completed **. Medical records must include at least the following: • (1) Patient identification. • (2) Significant medical history and results of physical examination. • (3) Pre-operative diagnostic studies (entered before surgery), if performed. • including a pathologist’s report on all tissues removed during surgery, • except those exempted by the governing body. • (5) Any allergies and abnormal drug reactions. • (6) Entries related to anesthesia administration. • (7) Documentation of properly executed informed patient consent. ** • (8) Discharge diagnosis. • (9) Post anesthesia recovery documentation **

416. 51 (a) sanitary environments • • • monitor house keeping, maintenance and construction activities food storage areas (food in the suite) ** disposal of regulated waste cleaning and disinfecting (how often in and out of the surgical suite) decontamination procedures for large amounts of blood or body fluids ** uncovered and over flowing dirty linen and red bags **

416. 44 (a) Physical environment • • Traffic patterns for patients Traffic patterns for supplies and waste Air vents in the suite Intended use of space

416. 51 Infection control • The ASC must maintain an ongoing program designed to prevent, control, and investigate infections and communicable diseases. • Must be directed by a designated healthcare professional with training in infection control • Must be integrated into the quality assessment process improvement (QAPI) program • Must ensure patient care personnel receive appropriate training • Must coordinate with physicians in tracking healthcare associated infections