La. Admin. Code tit. 48 § I-4533

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

Section I-4533 - Policy and Procedures

A. An ASC, through collaboration by the administrator, medical staff, director of nursing, pharmacist, and other professional persons deemed appropriate by the ASC, shall develop, implement and maintain written policies and procedures governing all services rendered at the ASC. The ASC shall comply with all federal and state laws, rules and regulations in the development and implementation of its policies and procedures.

B. All policies and procedures shall be reviewed at least annually and revised as needed.

C. Direct care and medical staff shall have access to information concerning patients that is necessary for effective performance of the employees assigned tasks.

D. The ASC shall have written policies and procedures for the maintenance and security of records specifying who shall supervise the maintenance of records, who shall have custody of records and to whom records may be released.

E. The ASC shall allow designated representatives of the department, in the performance of their mandated duties, to:

1. inspect all aspects of an ASCs operations which directly or indirectly impact patients; and

2. interview any physician, staff member or patient.

F. An ASC shall make any required information or records, and any information reasonably related to assessment of compliance with these provisions, available to the department.

G. An ASC shall, upon request by the department, make available the legal ownership documents, use agreements and any other legal contracts or agreements in place.

H. The ASC shall have written policies and procedures approved by the governing body, which shall be implemented and followed, that address, at a minimum, the following:

1. confidentiality and confidentiality agreements;

2. security of files;

3. publicity and marketing, including the prohibition of illegal or coercive inducement, solicitation and kickbacks;

4. personnel;

5. patient rights;

6. grievance procedures;

7. emergency preparedness;

8. abuse and neglect;

9. incidents and accidents, including medical emergencies;

10. universal precautions;

11. documentation, whether electronic or in paper form;

12. admission and discharge procedures;

13. hours outside of stated usual and customary operation, including but not limited to early closures, extended business hours and holidays; and

14. conditions for coverage, if applicable.

I. An ASC shall have written personnel policies, which shall be implemented and followed, that include:

1. written job descriptions for each staff position, including volunteers;

2. policies which provide for staff, upon offer of employment, to have a health assessment as defined by the ASC and in accordance with LAC Title 51, Public Health-Sanitary Code guidelines;

3. policies which verify that all physicians, clinic employees, including contracted personnel and personnel practicing under a use agreement, prior to, and at the time of employment and annually thereafter, shall be free of tuberculosis in a communicable state, in accordance with the current LAC Title 51, Public Health-Sanitary Code;

4. an employee grievance procedure;

5. abuse reporting procedures that require all employees to report any incidents of abuse or mistreatment, whether that abuse or mistreatment is done by another staff member, a family member, a patient or any other person;

6. a written policy to prevent discrimination; and

7. a written policy to address prohibited use of social media. The policy shall ensure that all staff, either contracted or directly employed, receive training relative to the restrictive use of social media and include, at a minimum, ensuring confidentiality of patient information and preservation of patient dignity and respect, including protection of patient privacy and personal and property rights.

J. The ASC shall maintain, in force at all times, the requirements for financial viability under this Chapter

La. Admin. Code tit. 48, § I-4533

Promulgated by the Department of Health, Bureau of Health Services Financing, LR 431741 (9/1/2017).

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