(1) The ASTC must have an effective governing
body legally responsible for the conduct of the ASTC. If an ASTC does not have
an organized governing body, the persons legally responsible for the conduct of
the ASTC must carry out the functions specified in this chapter.
(2) The governing body shall appoint a chief
executive officer or administrator who is responsible for managing the ASTC.
The chief executive officer or administrator shall designate an individual to
act for him or her in his or her absence, in order to provide the ASTC with
administrative direction at all times.
(3) The governing body, whether it be that of
the center alone or that of a parent organization, shall establish effective
mechanisms to ensure the accountability of the center's medical staff and other
governing body shall assure that the ASTC has the financial resources to
provide the services essential to the operation of the facility.
(5) Staffing shall be adequate to provide the
services essential to the operation of the ASTC.
(6) The ambulatory surgical treatment center
shall ensure a framework for addressing issues related to care at the end of
(7) The ambulatory surgical
treatment center shall provide a process that assesses pain in all patients.
There shall be an appropriate and effective pain management program.
(8) The ASTC shall perform only those
surgical procedures which can be safely and effectively carried out on an
(9) Each ASTC
shall have at all times a designated Medical Director who shall be a licensed
physician or dentist who shall be responsible for the direction and
coordination of medical programs.
(10) Staff education programs and training
sessions shall include life safety, medical equipment, utility systems,
infection control and hazardous waste practices. At least two (2) on duty
members of the facility shall be trained in emergency resuscitation.
(11) When licensure is applicable for a
particular job, a copy of the current license must be included as a part of the
personnel file. Each personnel file shall contain accurate information as to
the education, training, experience and personnel background of the employee.
Adequate medical screenings to exclude communicable disease shall be required
of each employee.
(12) Whenever the
rules and regulations of this chapter require that a licensee develop a written
policy, plan, procedure, technique, or system concerning a subject, the
licensee shall develop the required policy, maintain it and adhere to its
provisions. An ASTC which violates a required policy also violates the rule and
regulation establishing the requirement.
(13) Policies and procedures shall be
consistent with professionally recognized standards of practice.
(14) No ASTC shall retaliate against or, in
any manner, discriminate against any person because of a complaint made in good
faith and without malice to the board, the department, the Adult Protective
Services, or the Comptroller of the State Treasury. An ASTC shall neither
retaliate, nor discriminate, because of information lawfully provided to these
authorities, because of a person's cooperation with them, or because a person
is subpoenaed to testify at a hearing involving one of these
(15) When services
such as dietary, laundry or therapy services are purchased from others, the
governing body shall be responsible to assure the supplier(s) meet the same
local and state standards the facility would have to meet if it were providing
those services itself using its own staff.
(16) The governing body shall provide for the
appointment, reappointment or dismissal of members of the medical, dental, and
other health professions and provide for the granting of clinical
(17) The governing body
shall ensure that there is a written facility agreement with one or more acute
care general hospitals licensed by the state, which will admit any patient
referral who requires continuing care.
(18) Each ASTC shall specify the
classification of services to be provided in the facility and list authorized
(19) Where the
physician-owner-operator serves as the governing body, the articles of
incorporation or other written organizational plan shall describe the manner in
which the owner-operator executes the governing body responsibility.
(a) The ASTC must provide a sanitary
environment to avoid sources and transmission of infections and communicable
diseases. There must be an active performance improvement program for the
prevention, control, and investigation of infections and communicable
environment of the ambulatory surgical treatment center shall be maintained in
a safe, clean and sanitary manner.
condition on the ambulatory surgical treatment center site conducive to the
harboring or breeding of insects, rodents or other vermin shall be prohibited.
Chemical substances of a poisonous nature used to control or eliminate vermin
shall be properly identified. Such substances shall not be stored with or near
food or medications.
2. Cats, dogs
or other animals shall not be allowed in any part of the ambulatory surgical
treatment center except for specially trained animals for the handicapped and
except as addressed by ambulatory surgical treatment center policy for pet
therapy programs. The ambulatory surgical treatment center shall designate in
its policies and procedures those areas where animals will be excluded. The
areas designated shall be determined based upon an assessment of the ambulatory
surgical treatment center performed by medically trained personnel.
3. The layout of patient care areas of the
ASTC, as well as the personal items offered to the patient, shall be outlined
in the ASTC's policy and be based on the type of procedure performed on the
4. Bath basin water
service, emesis basin, bedpan and urinal shall be individually
5. Water pitchers,
glasses, thermometers, emesis basins, douche apparatus, enema apparatus,
urinals, mouthwash cups, bedpans and similar items of equipment coming into
intimate contact with patients shall be disinfected or sterilized after each
use unless individual equipment for each is provided and then sterilized or
disinfected between patients and as often as necessary to maintain them in a
clean and sanitary condition. Single use, patient disposable items are
acceptable but shall not be reused.
The chief executive officer or
administrator shall assure that an infection control committee including
members of the medical staff, nursing staff and administrative staff develops
guidelines and techniques for the prevention, surveillance, control and
reporting of facility infections. Duties of the committee shall include the
1. Written infection control
2. Techniques and systems
for identifying, reporting, investigating and controlling infections in the
governing the use of aseptic techniques and procedures in all areas of the
facility, including adoption of a standardized central venous catheter
insertion process which shall contain these key components:
(i) Hand hygiene (as defined in
Maximal barrier precautions to include the use of sterile gowns, gloves, mask
and hat, and large drape on patient;
(iii) Chlorhexidine skin
(iv) Optimal site
(v) Daily review of line
(vi) Development and
utilization of a procedure checklist;
4. Written procedures concerning food
handling, laundry practices, disposal of environmental and patient wastes,
traffic control and visiting rules in high risk areas, sources of air
pollution, and routine culturing of autoclaves and sterilizers;
5. A log of incidents related to infectious
and communicable diseases;
method of control used in relation to the sterilization of supplies and water,
and a written policy addressing reprocessing of sterile supplies;
7. Formal provisions to educate and orient
all appropriate personnel in the practice of aseptic techniques such as
handwashing and scrubbing practices, proper grooming, masking and dressing care
techniques, disinfecting and sterilizing techniques, and the handling and
storage of patient care equipment and supplies; and,
8. Continuing education provided for all
facility personnel on the cause, effect, transmission, prevention, and
elimination of infections, as evidenced by front line employees verbalizing
understanding of basic techniques.
(d) The chief executive officer, the medical
staff and the chief nursing officer must ensure that the facility-wide
performance improvement program and training programs address problems
identified by the infection control committee and must be responsible for the
implementation of successful corrective action plans in affected problem
(e) The facility shall
develop policies and procedures for testing a patient's blood for the presence
of the hepatitis B virus and the HIV (AIDS) virus in the event that an employee
of the facility, a student studying at the facility, or other health care
provider rendering services at the facility is exposed to a patient's blood or
other body fluid. The testing shall be performed at no charge to the patient,
and the test results shall be confidential.
The facility shall have an annual
influenza vaccination program which shall include at least:
1. The offer of influenza vaccination to all
staff and independent practitioners or accept documented evidence of
vaccination from another vaccine source or facility;
2. A signed declination statement on record
from all who refuse the influenza vaccination for other than medical
all direct care personnel about the following:
(i) Flu vaccination,
(ii) Non-vaccine control measures,
(iii) The diagnosis,
transmission, and potential impact of influenza;
4. An annual evaluation of the influenza
vaccination program and reasons for non-participation; and
5. The requirements to complete vaccinations
or declination statements are suspended by the Medical Director in the event of
a vaccine shortage.
The facility and its employees shall adopt and utilize standard precautions
(per CDC) for preventing transmission of infections, HIV, and communicable
diseases, including adherence to a hand hygiene program which shall include:
1. Use of alcohol-based hand rubs or use of
non-antimicrobial or antimicrobial soap and water before and after each patient
contact if hands are not visibly soiled;
2. Use of gloves during each patient contact
with blood or where other potentially infectious materials, mucous membranes,
and non-intact skin could occur and gloves changed before and after each
3. Use of either a
non-antimicrobial soap and water or an antimicrobial soap and water for visibly
soiled hands; and
worker education programs which may include:
(i) Types of patient care activities that can
result in hand contamination;
Advantages and disadvantages of various methods used to clean hands;
(iii) Potential risks of health care workers'
colonization or infection caused by organisms acquired from patients;
(iv) Morbidity, mortality, and
costs associated with health care associated infections.
(h) All ASTC's shall adopt
appropriate policies regarding the testing of patients and staff for human
immunodeficiency virus (HIV) and any other identified causative agent of
acquired immune deficiency syndrome.
Performance Improvement. The ASTC shall
have a planned, systematic, organization-wide approach to process design and
redesign, performance measurement, assessment and improvement which is approved
by the designated medical staff committee of the facility, the owner and/or the
governing body. This plan shall address and/or include, but is not limited to:
(a) Infection control, including
Complications arising after the patient was admitted;
(c) Documentation of periodic review of the
data collected and follow-up actions;
(d) A system which identifies appropriate
plans of action to correct identified quality deficiencies;
(e) Documentation that the above policies are
being followed and that appropriate action is taken whenever
(f) The facility shall
develop and implement a system for measuring improvements in adherence to the
hand hygiene program, central venous catheter insertion process, and influenza
(22) The ASTC shall ensure a framework for
addressing issues related to care at the end of life.
(23) The ASTC shall provide a process that
assesses pain in all patients. There shall be an appropriate and effective pain
care facilities licensed pursuant to T.C.A. §§
seq. shall post the following in the main public entrance:
(a) Contact information including statewide
toll-free number of the division of adult protective services, and the number
for the local district attorney's office;
(b) A statement that a person of advanced age
who may be the victim of abuse, neglect, or exploitation may seek assistance or
file a complaint with the division concerning abuse, neglect and exploitation;
A statement that any
person, regardless of age, who may be the victim of domestic violence may call
the nationwide domestic violence hotline, with that number printed in boldface
type, for immediate assistance and posted on a sign no smaller than eight and
one-half inches (8½") in width and eleven inches (11") in height.
Postings of (a) and (b) shall be on a sign no smaller than
eleven inches (11") in width and seventeen inches (17") in height.
(25) "No smoking" signs
or the international "No Smoking" symbol, consisting of a pictorial
representation of a burning cigarette enclosed in a red circle with a red bar
across it, shall be clearly and conspicuously posted at every
(26) The facility shall
develop a concise statement of its charity care policies and shall post such
statement in a place accessible to the public.
Any ambulatory surgical treatment center
in which abortions, other than abortions necessary to prevent the death of the
pregnant female, are performed shall conspicuously post a sign in a location
defined below so as to be clearly visible to patients, which reads:
Notice: It is against the law for anyone, regardless of the
person's relationship to you, to coerce you into having or to force you to have
an abortion. By law, we cannot perform an abortion on you unless we have your
freely given and voluntary consent. It is against the law to perform an
abortion on you against your will. You have the right to contact any local or
state law enforcement agency to receive protection from any actual or
threatened criminal offense to coerce an abortion.
(b) The sign shall be printed in languages
appropriate for the majority of clients of the facility with lettering that is
legible and that is Arial font, at least 40-point bold-faced type.
(c) A facility in which abortions are
performed that is an ambulatory surgical treatment center shall post the
required sign in each patient waiting room and patient consultation room used
by patients on whom abortions are performed.
An ambulatory surgical treatment center
shall be assessed a civil penalty by the board for licensing health care
facilities of two thousand five hundred dollars ($2,500.00) for each day of
violation in which:
1. The sign required above
was not posted during business hours when patients or prospective patients are
2. An abortion other
than an abortion necessary to prevent the death of the pregnant female was
performed in the ambulatory surgical treatment center.