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Title: Section 405.20 - Outpatient services

Effective Date


405.20 Outpatient services. Outpatient services, including ambulatory care services and extension clinics, shall be provided in a manner which safely and effectively meets the needs of the patients.

(a) General requirements. As a minimum when provided, outpatient services shall comply with the rules and regulations set forth in this Part as well as the outpatient care provisions of Part 751, sections 752.1 and 753.1 and Parts 756, 757 and 758 of Subchapter C of this Title.

(1) The provision of this section shall apply to hospital-sponsored ambulatory services, including part-time and off-site clinics, which accept primary responsibility for health supervision and medical care of patients.

(2) The hospital shall ensure that all care provided by its ambulatory services is in accordance with prevailing standards of professional practice.

(3) The hospital shall conduct periodic reviews of the care rendered by its ambulatory services as part of its overall quality assurance program.

(b) The hospital shall assign a physician to be responsible for the professional services of the outpatient department. Either this physician or an administrator qualified by training and experience shall be responsible for administration of the outpatient services.

(c) Patient care. The hospital shall effectively meet outpatient patient care needs by:

(1) the provision of patient care in a continuous manner by the same health care practitioner, whenever possible;

(2) the appropriate referral to other health care facilities or health care practitioners for services not available;

(3) the identification, assessment, reporting and referral of cases of suspected child abuse or neglect as required by section 405.9(d) of this Part;

(4) compliance with the domestic violence provisions of section 405.9(e) of this Part;

(5) identification, assessment, and referral of individuals with documented substance use disorders or who appear to have or be at risk for substance use disorders, as that term is defined in section 1.03 of the Mental Hygiene Law, as described in subdivision (f) of section 405.9 of this Part;

(6) compliance with the human trafficking provisions pertaining to the identification, assessment, and appropriate treatment or referral of individuals who are suspected to be human trafficking victims, as described in subdivision (g) of section 405.9 of this Part; and

(7) the development of a written plan of treatment. When treatment is provided it is revised, as necessary, in consultation with other health care professionals.

(d) Hospital-based ambulatory surgery service. In a hospital maintaining an on-site hospital-based ambulatory surgery service, the following requirements supplement existing applicable requirements of sections 405.12 (Surgical services) and 405.13 (Anesthesia services) of this Part. (Hospital-based ambulatory surgery services) shall mean a service organized to provide surgical procedures which shall be performed for reasons of safety in an operating room on anesthetized patients requiring a stay of less than 24 hours duration. These procedures do not include outpatient surgical procedures which can be performed safely in a private physician's office or in an outpatient treatment room.

(1) The hospital-based ambulatory surgery service shall be directed by a physician found qualified by the governing body to perform such duties.

(2) The governing body and the medical staff shall develop, maintain and periodically review a list of surgical procedures which may be performed in the service. The medical staff shall assure that procedures performed in the service conform with generally accepted standards of professional practice, in accordance with the competencies of the medical and professional staff that have privileges in the hospital-based ambulatory surgery service, and are appropriate in the facilities and consistent with the equipment necessary to meet the needs of all patients. The medical staff shall, based upon its review of individual medical staff qualifications, recommend to the governing body specific surgical procedures which each practitioner is qualified to perform in the hospital-based ambulatory surgery service.

(3) Hospital-based ambulatory surgery services may be located at the same site as the hospital (on-site) or apart from the hospital (off-site), pursuant to section 709.5 of this Title.

(i) Recovery rooms adequate for the needs of hospital-based ambulatory surgery patients, conveniently located to the operating room, shall be provided.

(ii) Waiting rooms adequate for the needs of patients and responsible persons accompanying patients shall be provided.

(4) Prior to surgery, each patient shall have a timely history and physical examination, appropriate to the patient's physical condition and the surgical procedure to be performed, which shall be recorded in the patient medical record.

(5) Each post surgery patient shall be observed for post-operative complications for an adequate time period as determined by the attending practitioner and the anesthesiologist. The service shall have written policies for hospital admission of patients whose post-operative status prevents discharge and necessitates inpatient admission to a hospital capable of providing the appropriate level of care.

(6) Detailed verbal instructions understandable to the patient, or the patient's parent, legal guardian, or health care agent, confirmed by written instructions, and approved by the medical staff of the hospital-based ambulatory surgery service shall be provided to each patient, or the patient's parent, legal guardian, or health care agent, at discharge, to include at least the following:

(i) information about complications that may arise;

(ii) telephone number(s) to be used by the patient should complications or questions arise;

(iii) directions for medications prescribed, if any;

(iv) date, time and location of followup visit or return visit; and

(v) designated place to go for treatment in the event of emergency.

(7) The hospital-based ambulatory surgery service staff shall develop written policies, approved by the medical staff, for documentation of the patient's postoperative course of treatment. The policies must be reviewed and adopted by the governing body of the hospital prior to implementation. The policies must provide a mechanism to assure that complications of surgery or anesthesia, which occur before and after discharge, are identified and documented in the patient's medical record.

(8) The hospital-based ambulatory surgery service shall have an organized system of quality assurance approved by the medical staff and the governing body which undertakes investigations into operative results of surgical procedures performed on the service and maintains statistics on operative failures and complications.

(9) Notwithstanding anything herein to the contrary, an off-site hospital-based ambulatory surgery service shall be operated in accordance with the provisions of Part 755 of this Title.


VOLUME C (Title 10)