The purpose of this section is to guide the development and management of surgical services. Hospitals are not required to provide surgery and interventional care in order to be licensed.

If providing surgical services, hospitals must:

(1) Adopt and implement policies and procedures that:

(a) Identify areas where surgery and invasive procedures may be performed;

(b) Define staff access to areas where surgery and invasive procedures are performed;

(c) Identify practitioner's privileges for operating room staff; and

(d) Define staff qualifications and oversight;

(2) Use hospital policies and procedures which define standards of care;

(3) Implement a system to identify and indicate the correct surgical site prior to beginning a surgical procedure;

(4) Timely provide emergency equipment, supplies, and services to surgical and invasive areas;

(5) Provide separate refrigerated storage equipment with temperature alarms, when blood is stored in the surgical department; and

(6) Assure that a registered nurse qualified by training and experience functions as the circulating nurse in every operating room during surgical procedures.