LAC 48:I.4575. General Provisions

A. The ASC shall have policies and procedures, approved and implemented by the medical staff and governing body, that address provisions for: 1. sanitizing, disinfecting and sterilizing supplies, equipment and utensils; 2. the safe use of cleaning supplies and solutions that are to be used and the directions for use, including: a. terminal cleaning of the OR/procedure rooms; and b. cleaning of the OR/procedure rooms between surgical and nonsurgical procedures; and 3. surgical smoke plume evacuation to mitigate and remove surgical smoke plume during a surgical procedure that uses heat-producing equipment, including but not limited to electrosurgery and lasers. B. Policies and procedures shall be developed, implemented and approved by the ASC’s governing body for the types and numbers of sterilizing equipment and autoclaves sufficient to meet the surgical sterilization needs of the ASC. 1. Procedures for the proper use of sterilizing equipment for the processing of various materials and supplies shall be in writing, according to manufacturer’s recommendations, and readily available to personnel responsible for the sterilizing process. 2. All sterilization monitoring logs shall be maintained within the ASC for a minimum of 18 months. C. All steam sterilizing equipment shall have live bacteriological spore monitoring performed at a frequency according to the manufacturer’s instructions. 1. If tests are positive, a system shall be in place to recall supplies that have tested substandard in accordance with the ASC’s policies and procedures set forth by the ASC’s governing body. D. All ethylene oxide sterilizing equipment shall have live bacteriological spore monitoring performed with each load and according to manufacturer’s recommendation. There shall be ventilation of the room used for this sterilization to the outside atmosphere. There shall be a system in place to monitor trace gases of ethylene oxide with a working alert system which is tested and documented daily.