Basic Services

(1) Surgical Services. (a) Facilities restricted in services they provide, e.g. those that restrict services to radiation therapy or use of local anesthetics only, may be exempted from all or part of the requirements of this rule pertaining to laboratory services, food and dietetic services, surgical services, and anesthesia services. (b) If the facility provides surgical services, the services must be well-organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered, the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. (c) A hospital may choose to separately license a portion of the facility as an Ambulatory Surgical Treatment Center; the licensure fee for such is not required. (d) The organization of the surgical services must be appropriate to the scope of the services offered. (e) The operating rooms must be supervised by an experienced registered nurse or a doctor of medicine or osteopathy. (f) An ASTC may use scrub nurses in its operating rooms. For the purposes of this rule, a “scrub nurse” is defined as a registered nurse or either a licensed practical nurse STANDARDS FOR AMBULATORY SURGICAL TREATMENT CHAPTER 0720-20 CENTERS (L.P.N.) or a surgical technologist (operating room technician) supervised by a registered nurse who works directly with a surgeon within the sterile field, passing instruments, sponges, and other items needed during the procedure and who scrubs his or her hands and arms with special disinfecting soap and wears surgical gowns, caps, eyewear, and gloves, when appropriate. (g) Qualified registered nurses may perform circulating duties in the operating room. In accordance with applicable state laws and approved medical staff policies and procedures, LPNs and surgical technologists may assist in circulatory duties under the supervision of a qualified registered nurse who is immediately available to respond to emergencies. (h) Surgical privileges must be delineated for all practitioners performing surgery in accordance with the competencies of each practitioner. The surgical service must maintain a roster of practitioners specifying the surgical privileges of each practitioner. (i) Surgical services must be consistent with needs and resources. Policies covering surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. (j) The Health Facilities Commission shall publish an approved list of accredited surgical technology programs. 1. Surgical technologists must meet one (1) or more of the following: (i) Successfully completed a nationally accredited surgical technology program, and holds and maintains certification as a surgical technologist from a national certifying body that certifies surgical technologists and is recognized by the Health Facilities Commission; (ii) Successfully completed an accredited surgical technologist program; (I) Has not, as of the date of hire, obtained certification as a surgical technologist from a national certifying body that certifies surgical technologists and is recognized by the Health Facilities Commission; and (II) Obtains such certification no later than eighteen (18) months after completion of the program. (iii) Successfully completed a training program for surgical technology in the armed forces of the United States, the national guard, or the United States public health service; or (iv) Performed surgical technology services as a surgical technologist in a healthcare facility on or before May 21, 2007, and has been designated by the healthcare facility as being competent to perform surgical technology services based on prior experience or specialized training validated by competency in current practice. The healthcare facility employing or retaining such person as a surgical technologist under this subsection (a) obtains proof of such person’s prior experience, specialized training, and current continuing competency as a surgical technologist and makes the proof available to the Health Facilities Commission upon request of the commission. STANDARDS FOR AMBULATORY SURGICAL TREATMENT CHAPTER 0720-20 CENTERS 2. This section does not prohibit a person from performing surgical technology services if the person is acting within the scope of the person’s license, certification, registration, permit, or designation, or is a student or intern under the direct supervision of a healthcare provider. (k) An ASTC can petition the director of health care facilities of the department for a waiver from the provisions of 0720-20-.06(1)(j) if they are unable to employ a sufficient number of surgical technologists who meet the requirements. The facility shall demonstrate to the director that a diligent and thorough effort has been made to employ surgical technologists who meet the requirements. The director shall refuse to grant a waiver upon finding that a diligent and thorough effort has not been made. A waiver shall exempt a facility from meeting the requirements for not more than nine (9) months. Additional waivers may be granted, but all exemptions greater than twelve (12) months shall be approved by the Board for Licensing Health Care Facilities. (l) Surgical technologists shall demonstrate continued competence in order to perform their professional duties in surgical technology. The employer shall maintain evidence of the continued competence of such individuals. Continued competence activities may include but are not limited to continuing education, in-service training, or certification renewal. Persons qualified to be employed as surgical technologists shall complete fifteen (15) hours of continuing education or contact hours annually. Current certification by the National Board of Surgical Technology and Surgical Assisting shall satisfy this requirement. (m) There must be a complete history and physical work-up in the chart of every patient prior to surgery, except in emergencies. If the history has been dictated, but not yet recorded in the patient’s chart, there must be a statement to that effect and an admission note in the chart by the practitioner who admitted the patient. (n) Properly executed informed consent, advance directive, if available, and organ donation forms, if available, must be in the patient’s chart before surgery, except in emergencies. The patient is not required to sign advance directive and organ donation forms. (o) Adequate equipment and supplies must be available as determined by the governing body and the medical staff, and must meet the current acceptable standards of practice in the ASTC industry. In conjunction with their governing body and the medical staff, the facility shall develop policies and procedures specifying the types of emergency equipment that are appropriate for the facility’s patient population, and shall make the items immediately available at the ASTC to handle inter- or post-operative emergencies. (p) At least one registered nurse shall be in the recovery area during the patient’s recovery period. (q) The operating room register must be complete and up-to-date. (r) An operative report describing techniques, findings, and tissues removed or altered must be written or dictated immediately following surgery and signed by the surgeon. (s) The ASTC shall provide one or more surgical suites which shall be constructed, equipped, and maintained to assure the safety of patients and personnel. (t) Surgical suites are required to meet the same standards as hospital operating rooms, including those using general anesthesia. STANDARDS FOR AMBULATORY SURGICAL TREATMENT CHAPTER 0720-20 CENTERS (u) The ASTC shall have separate areas for waiting rooms, recovery rooms, treatment and/or examining rooms. (2) Anesthesiology Services. Anesthesia shall be administered by: (a) A qualified anesthesiologist; (b) A doctor of medicine or osteopathy (other than an anesthesiologist); (c) A dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia under state law; (d) A certified registered nurse anesthetist (CRNA); or (e) A graduate registered nurse anesthetist under the supervision of an anesthesiologist who is immediately available if needed. (f) After the completion of anesthesia, patients shall be constantly attended by competent personnel until responsive and able to summon aid. Each center shall maintain a log of the inspections made prior to each day’s use of the anesthesia equipment. A record of all service and maintenance performed on all anesthesia machines, vaporizers and ventilators shall also be on file. (g) When inhaled general anesthesia known to trigger malignant hyperthermia and/or succinylcholine are maintained in the facility, there shall be thirty-six (36) ampules of Dantrolene for injection onsite. This requirement applies to anesthesia agents, current or future, that are shown to cause malignant hyperthermia. If Dantrolene is administered, appropriate monitoring must be provided post-operatively. (h) Written policies and procedures relative to the administration of anesthesia shall be developed and approved by the medical staff and governing body. (i) Any patient receiving conscious sedation shall receive: 1. Continuous EKG monitoring; 2. Continuous oxygen saturations; 3. Serial BP monitoring at intervals no less than every 5 minutes; and 4. Supplemental oxygen therapy and immediately available: (i) Ambubag; (ii) Suction; (iii) Endotracheal tube; and (iv) Crash cart. (3) Medical Staff. STANDARDS FOR AMBULATORY SURGICAL TREATMENT CHAPTER 0720-20 CENTERS (a) The ASTC shall have a medical staff organized under written by-laws that are approved by the governing body. The medical staff of the ASTC shall define a mechanism to: 1. Assure that an optimal level of professional performance is maintained; 2. Appoint independent practitioners through a defined credentialing process; 3. Apply credentialing criteria uniformly; 4. Utilize the current license, relevant training and experience, current competence and the ability to perform requested privileges in the credentialing process; and 5. Provide for participation in required committees of the facility to ensure that quality medical care is provided to the patients. (b) Each licensed independent practitioner shall provide care under the auspices of the facility in accordance with approved privileges. (c) Clinical privileges shall be granted based on the practitioners’ qualifications and the services provided by the facility, and shall be reviewed and/or revised at least every two (2) years. (4) Nursing Service. A licensed registered nurse (R.N.) shall be on duty at all times. Additional appropriately trained staff shall be provided as needed to ensure that the medical needs of the patients are fully met. (a) The ASTC shall be organized under written policies and procedures relating to patient care, establishment of standards for nursing care and mechanisms for evaluating such care and nursing services. (b) A qualified registered nurse designated by the administrator shall be responsible for coordinating and supervising all nursing services. (c) There shall be a sufficient staffing pattern of registered nurses to provide quality nursing care to each surgical patient from admission through discharge. Additional staff shall be on duty and available to assist the professional staff to adequately handle routine and emergency patient needs. (d) The ASTC shall establish written procedures for emergency services which will ensure that professional staff members who have been trained in emergency resuscitation procedures shall be on duty at all times when there is a patient in the ASTC and until the patient has been discharged. (e) Nursing care policies and procedures shall be consistent with professionally recognized standards of nursing practice and shall be in accordance with the Nurse Practice Act of the State of Tennessee and the Association of Operating Room Nurses Standards of Practice. (f) Staff development and training shall be provided to the nursing staff and other ancillary staff in order to maintain and improve knowledge and skills. The educational/training program shall be planned, documented and conducted on a continuing basis. There shall be at least appropriate training on equipment, safety concerns, infection control and emergency care on an annual basis. STANDARDS FOR AMBULATORY SURGICAL TREATMENT CHAPTER 0720-20 CENTERS (5) Pharmaceutical Services. The ASTC must provide drugs and biologicals in a safe and effective manner in accordance with accepted standards of practice. Such drugs and biologicals must be stored in a separate room or cabinet which shall be kept locked at all times. (6) Ancillary Services. All ancillary or supportive health or medical services, including but not limited to, radiological, pharmaceutical, or medical laboratory services shall be provided in accordance with all applicable state and federal laws and regulations. (7) Radiological Services. The ASTC shall provide within the facility, or through arrangement, diagnostic radiological services commensurate with the needs of the ambulatory surgical treatment center. (a) If radiological services are provided by facility staff, the services shall be maintained free of hazards for patients and personnel. (b) New installations of radiological equipment, and subsequent inspections for the identification of radiation hazards shall be made as specified in state and federal requirements. (c) Personnel monitoring shall be maintained for each individual working in the area of radiation. Readings shall be on at least a monthly basis and reports kept on file and available for review. 1. Personnel - The ASTC shall have a radiologist either full-time or part-time on a consulting basis, both to supervise the service and to discharge professional radiological services. 2. The use of all radiological apparatus shall be limited to personnel designated as qualified by the radiologist; and use of fluoroscopes shall be limited to physicians. (d) If provided under arrangement with an outside provider, the radiological services must be directed by a qualified radiologist and meet state and federal requirements. (8) Laboratory Services. (a) The ASTC shall provide on the premises or by written agreement with a laboratory licensed under T.C.A. § 68-29-105, a clinical laboratory to provide those services commensurate with the needs and services of the ASTC. (b) Any patient terminating pregnancy in an ASTC shall have an Rh type, documented prior to the procedure, performed on her blood. In addition, she shall be given the opportunity to receive Rh immune globulin after an appropriate crossmatch procedure is performed within a licensed laboratory. (9) Food and Dietetic Services. If a patient will be in the facility for more than four (4) hours post- op, an appropriate diet shall be provided. (10) Environmental Services. (a) The facility shall provide a safe, accessible, effective and efficient environment of care consistent with its mission, service, law and regulation. (b) The facility shall develop policies and procedures that address: STANDARDS FOR AMBULATORY SURGICAL TREATMENT CHAPTER 0720-20 CENTERS 1. Safety; 2. Security; 3. Control of hazardous materials and waste; 4. Emergency preparedness; 5. Life safety; 6. Medical equipment; and, 7. Utility systems. (c) Staff shall have been oriented to and educated about the environment of care and possess knowledge and skills to perform responsibilities under the environment of care policies and procedures. (d) Utility systems, medical equipment, life safety elements, and safety elements of the environment of care shall be maintained, tested and inspected. (e) Safety issues shall be addressed and resolved. (f) Appropriate staff shall participate in implementing safety recommendations and monitoring their effectiveness. (g) The building and grounds shall be suitable to services provided and patients served. (11) Infection Control. An Ambulatory Surgical Treatment Center shall have an annual influenza vaccination program which shall include at least: (a) The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The Ambulatory Surgical Treatment Center will encourage all staff and independent practitioners to obtain an influenza vaccination; (b) A signed declination statement on record from all who refuse the influenza vaccination for reasons other than medical contraindications (a sample form is available at https://www.tn.gov/content/dam/tn/health/documents/SampleIndividualFluForm.pdf); (c) Education of all employees about the following: 1. Flu vaccination, 2. Non-vaccine control measures, and 3. The diagnosis, transmission, and potential impact of influenza; (d) An annual evaluation of the influenza vaccination program and reasons for non- participation; and (e) A statement that the requirements to complete vaccinations or declination statements shall be suspended by the administrator in the event of a vaccine shortage as declared by the Commissioner or the Commissioner’s designee. STANDARDS FOR AMBULATORY SURGICAL TREATMENT CHAPTER 0720-20 CENTERS (12) Medical Records. (a) The ASTC shall comply with the Medical Records Act of 1974, T.C.A. §§ 68-11-301, et seq. (b) A medical record shall be maintained for each person receiving medical care provided by the ASTC and shall include: 1. Patient identification; 2. Name of nearest relative or other responsible agent; 3. Identification of primary source of medical care; 4. Dates and times of visits; 5. Signed informed consent; 6. Pertinent medical history; 7. Diagnosis; 8. Physician examination report; 9. Anesthesia records of pertinent pre-operative and post-operative reports including pre-anesthesia evaluation, type of anesthesia, technique and dosage used; 10. Operative report; 11. Discharge summary, including instructions for self-care and instructions for obtaining post-operative emergency care; 12. Reports of all laboratory and diagnostic procedures along with tests performed and the results authenticated by the appropriate personnel; and, 13. X-ray reports. (c) Medical records shall be current and confidential. Medical records and copies thereof shall be made available when requested by an authorized representative of the board or the department. (13) Invasive Procedures. (a) For purposes of interventional pain management, only a medical doctor, licensed pursuant to T.C.A. §§ 63-6-101 et seq., or an osteopathic physician, licensed pursuant to T.C.A. §§ 63-9-101 et seq., who meets the following qualifications will be permitted to perform invasive procedures of the spine, spinal cord, sympathetic nerves of the spine or block of major peripheral nerves of the spine. 1. Board certified through the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA) or the American Board of Physician Specialties (ABPS)/American Association of Physician Specialists (AAPS) in one of the following medical specialties: STANDARDS FOR AMBULATORY SURGICAL TREATMENT CHAPTER 0720-20 CENTERS (i) Anesthesiology; (ii) Neurological surgery, or neuromusculoskeletal medicine; (iii) Orthopedic surgery; (iv) Physical medicine and rehabilitation; (v) Radiology; or (vi) Any other board certified physician who had completed an ABMS subspecialty board in pain medicine or completed an ACGME accredited pain fellowship; 2. A recent graduate in a medical specialty listed in part 1. not yet eligible to apply for ABMS, AOA, or ABPS/AAPS board certification; provided, there is a practice relationship with a medical doctor or an osteopathic physician who meets the requirements of part 1.; 3. A licensee who is not board certified in one of the specialties listed in part 1., but is board certified in a different ABMS, AOA, or ABPS/AAPS specialty and has completed a post-graduate training program in interventional pain management approved by the board; 4. A licensee who serves as a clinical instructor in pain medicine at an accredited Tennessee medical training program; or 5. A licensee who has an active pain management practice in a clinic accredited in outpatient interdisciplinary pain rehabilitation by the Commission on Accreditation of Rehabilitation Facilities or any successor organizations. 6. This subparagraph (13)(a) shall not apply to a medical doctor, licensed pursuant to T.C.A. §§ 63-6-101 et seq., or an osteopathic physician, licensed pursuant to T.C.A. §§ 63-9-101 et seq., in the placement of medical devices used in the treatment of conditions not primarily related to pain. (b) An advanced practice nurse or physician assistant shall only perform invasive procedures involving any portion of the spine, spinal cord, sympathetic nerves of the spine or block of major peripheral nerves of the spine under the direct supervision of a medical doctor or an osteopathic physician who meets the qualifications of Rule 0720- 20-.06(12)(a)1. or 3. Direct supervision is defined as being physically present in the center at the time the invasive procedure is performed.