This section guides the development of a plan for patient care. The ambulatory surgical facility accomplishes this by supervising staff, establishing, monitoring, and enforcing policies and procedures that define and outline the use of materials, resources, and promote the delivery of care.

An ambulatory surgical facility must:

(1) Provide personnel, space, equipment, reference materials, training, and supplies for the appropriate care and treatment of patients;

(2) Have a registered nurse available for consultation in the ambulatory surgical facility at all times patients are present;

(3) Adopt, implement, review and revise patient care policies and procedures designed to guide staff that address:

(a) Criteria for patient admission;

(b) Reliable method for personal identification of each patient;

(c) Conditions that require patient transfer to outside facilities;

(d) Patient safety measures;

(e) Staff access to patient care areas;

(f) Use of physical and chemical restraints or seclusion consistent with C.F.R. 42.482;

(g) Use of preestablished patient care guidelines or protocols. When used, these must be documented in the medical record and be preapproved or authenticated by an authorized practitioner or advanced registered nurse practitioner;

(h) Care and handling of patients whose condition require special medical consideration;

(i) Preparation and administration of blood and blood products; and

(j) Discharge planning.

(4) Have a system to plan and document care in an interdisciplinary manner, including:

(a) Development of an individualized patient plan of care, based on an initial assessment;

(b) Assessment for risk of falls, skin condition, pressure ulcers, pain, medication use, therapeutic effects and side or adverse effects.

(5) Complete and document an initial assessment of each patient's physical condition, emotional, and social needs in the medical record. Initial assessment includes:

(a) Dependent upon the procedure and the risk of harm or injury, a patient history and physical assessment including but not limited to falls, mental status and skin condition;

(b) Current needs;

(c) Need for discharge planning;

(d) When treating pediatric patients, the immunization status;

(e) Physical examination, if within thirty days prior to admission, and updated as needed if patient status has changed; and

(f) Discharge plans when appropriate, coordinated with:

(i) Patient, family or caregiver; and

(ii) Receiving agency, when necessary.