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Title: Section 755.2 - Administrative requirements

Effective Date


755.2 Administrative requirements. When ambulatory surgery services are provided, the operator shall ensure that:

(a) there is a documented plan and procedure for the transfer of patients to a nearby hospital when hospitalization is indicated. Such plans shall include arrangements for an ambulance service and, when appropriate, escort of the patient to the hospital by clinical staff member of the ambulatory surgery service;

(b) the specific ambulatory surgical procedures which each physician and dentist is qualified and competent to perform are delineated in writing, reviewed on an ongoing basis by the medical staff and revised as necessary;

(c) the medical staff develops, maintains and reviews at least biannually a list of surgical procedures which may be performed in this service;

(d) each member of the medical staff practicing at the center with three or fewer physicians in any one specialty has an appointment with equivalent delineated privileges at one or more hospitals in the area. When there are four or more physicians in any one specialty practicing at the center, such appointments are not required;

(e) the medical staff adopts, with the operator's approval, bylaws which provide formal procedures for the evaluation of the application and credentials of registered physician's assistants and registered specialist's assistants applying for employment or privileges in the facility for the purpose of providing medical services under the supervision of a physician; and

(f) evidence of compliance with operational standards, as set forth in Section 751.11 of this Title, shall apply. New facilities shall obtain accreditation from an accreditation agency to which the Centers for Medicare and Medicaid Services has granted deeming status and which the Commissioner has determined has accrediting standards sufficient to assure the Commissioner that ambulatory surgery services so accredited are in compliance with ambulatory surgery services operational standards under this Chapter within two full years of operation.


VOLUME E (Title 10)