Section 28. Policies And Procedures

A. All facilities licensed pursuant to these regulations must have written policies and procedures for the following: (1) quality assurance program; (2) maintenance of building and equipment; (3) fire and evacuation; (4) staff development and evaluation; (5) administration and preparation of drugs; (6) referral of patients. B. Ambulatory surgical center: In addition to those policies and procedures listed in Subsection A of 8.370.18.28 NMAC of these regulations, ambulatory surgical centers must have the following policies and procedures: (1) transfer of patients to hospital for patients requiring emergency care; (2) for ambulance services if applicable; (3) transfer of medical information; (4) resuscitative techniques; (5) aseptic techniques and scrub procedures; (6) care of surgical specimens; (7) protocols of surgical procedures; (8) cleaning of operating room after each use; (9) sterilization and disinfection; 8.370.18 NMAC 10 (10) operating room attire; (11) care of anesthesia equipment; (12) special provision for infected or contaminated patients; and (13) inspection and maintenance of emergency equipment in operating room. C. Infirmaries: In addition to those policies and procedures listed in Subsection A of 8.370.18.28 NMAC of these regulations, infirmaries must have the following policies and procedures: (1) inpatient care; (2) transfer of patients to hospital. D. New or innovative outpatient services: In addition to those policies and procedures listed in Subsection A of 8.370.18.28 NMAC of these regulations, may have others required by the licensing authority after review of program and approval of the new or innovative service.