Transcript 25 TAC 135.8. Quality Assurance in a licensed ASC

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
• Using single 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
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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
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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