Section 5-6 - Organization and Administration (a) Governing Body. The ambulatory surgical center shall have a governing body which has legal authority and responsibility to operate the ambulatory surgical center. The governing body shall: - (i) Appoint an administrator who is responsible for managing the ambulatory surgical center.
- (ii) Adopt, revise, and approve personnel policies; including:
- (A) Frequency of employee evaluations;
- (iii) Prepare an organizational chart that reflects the administrative control and lines of authority for the delegation of responsibility from management down to the patient care level.
- (iv) The governing body shall ensure that all services provided are consistent with accepted standards of practice.
- (v) The governing body shall ensure that all procedures do not exceed twenty-three (23) hours of combined operating and recovery and/or convalescent time.
- (vi) The governing body shall be accountable for the quality of care provided to the patient.
- (vii) Personnel Records.
- (A) There shall be one person designated responsible for maintaining the confidentiality.
- (viii) Employee Health.
- (A) Policies and procedures shall be developed to protect the employees health, and to prevent the spread of disease from employee to patient.
- (B) Policies shall include but not limited to:
- (I) Policies which are specific to blood borne pathogens as defined by OSHA;
- (II) Communicable disease vaccines as recommended by current CDC Prevention Guidelines for Health Care Workers and endorsed by the State Health Department, Division of Public Health.
- (C) Documentation shall be maintained on the communicable disease vaccine given to the employee.
- (ix) Notification.
- (A) Prior to admission all perspective patients shall be notified if the ambulatory surgical center is not Medicare/Medicaid certified.
- (x) Services.
- (A) Furnished services, including the contracted services, shall comply with all applicable licensure standards;
- (B) Medical and nursing staff shall be licensed, certified, or registered according to Wyoming laws and rules; and
- (C) Staff members shall provide health services only within the scope of their license, certification or registration.