La. Admin. Code tit. 48 § I-4531

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-4531 - Governing Body

A. An ASC shall have an identifiable governing body with responsibility for, and authority over, the policies and activities of the ASC, which shall include use agreements and all contracts. The governing body is the ultimate governing authority of the ASC and shall adopt bylaws which address its responsibilities. No contract or other arrangements, including use agreements, shall limit or diminish the responsibilities of the governing body.

B. An ASC shall have documents identifying the following information regarding the governing body:

1. names and addresses of all members;

2. terms of membership;

3. officers of the governing body; and

4. terms of office for any officers.

C. The governing body shall be comprised of one or more persons and shall hold formal meetings at least twice a year. There shall be written minutes of all formal meetings, and the bylaws shall specify the frequency of meetings and quorum requirements.

D. The governing body of an ASC shall:

1. ensure the ASCs continual compliance and conformity with all relevant federal, state, local and municipal laws and regulations;

2. ensure that the ASC is adequately funded and fiscally sound which entails:

a. verification of sufficient assets equal to $100,000 or the cost of three months of operation, whichever is less; or

b. a letter of credit issued from a federally insured, licensed lending institution in the amount of at least $100,000 or the cost of three months of operation, whichever is less;

3. review and approve the ASCs annual budget;

4. designate a person to act as the administrator and delegate sufficient authority to this person to manage the day-to-day operations of the ASC;

5. annually evaluate the administrators performance;

6. have the authority to dismiss the administrator;

7. formulate and annually review, in consultation with the administrator, written policies and procedures concerning the ASCs philosophy, goals, current services, personnel practices, job descriptions, fiscal management, contracts and use agreements:

a. the ASCs written policies and procedures shall be maintained within the ASC and made available to all staff at all times;

8. determine, in accordance with state law, which practitioners are eligible candidates for appointment to the medical staff and make the necessary appointments;

9. determine, in conjunction with the medical staff, whether the ASC will provide services beyond the customary hours of operation by allowing a patient to stay up to 23 hours. If permitted the ASC shall provide continuous physician (on call and available to be on-site as needed) and professional nursing services (registered nurse) on-site. In addition, the ASC shall provide for ancillary services to accommodate patient needs during this extended stay including but not limited to medication and nutrition;

10. ensure and maintain quality of care, inclusive of a quality assurance/performance improvement process that measures patient, process, and structural (e.g. system) outcome indicators to enhance patient care;

11. ensure that surgical or invasive procedures shall not be performed in areas other than the operating room or other designated and approved treatment rooms;

12. ensure that surgical or invasive procedures are initiated in accordance with acceptable standards of practice, which includes the use of standard procedures, such as a timeout to ensure proper identification of the patient and surgical site, in order to avoid wrong site, wrong person or wrong procedure errors;

13. meet with designated representatives of the department whenever required to do so;

14. inform the department, or its designee, prior to initiating any substantial changes in the services provided by the ASC; and

15. ensure that pursuant to R.S. 40:1191.2, prior to the final disposition of a miscarried child, but not more than 24 hours after a miscarriage occurs in an ASC, the ASC shall notify the patient, or if the patient is incapacitated, the spouse of the patient, both orally and in writing, of both of the following:

a. the parent's right to arrange for the final disposition of the miscarried child through the use of the notice of parental rights form as provided for in R.S. 40:1191.3; and

b. the availability of a chaplain or other counseling services concerning the death of the miscarried child, if such services are provided by the ASC.

La. Admin. Code tit. 48, § I-4531

Promulgated by the Department of Health, Bureau of Health Services Financing, LR 431740 (9/1/2017).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2131-2141.