1. (a) Postanesthesia care unit (PACU) services shall be provided in a well-organized manner under the:

   1. (1) Direction of a qualified physician; and
   2. (2) Supervision of a registered nurse.

2. (b)

   1. (1) Policies and procedures shall have evidence of ongoing review and/or revision.

   2. (2) The first page of each manual shall have the:

      1. (A) Annual review date; and
      2. (B) Signature of the department supervisor and/or person or persons conducting the review.

   3. (3) Policies and procedures shall include:

      1. (A) Lines of authority and nursing supervision;
      2. (B) Transfer of patients from the operating room to the postanesthesia care unit;
      3. (C) Criteria for discharge of patients from the postanesthesia care unit; and
      4. (D) The care of patients in the event the postanesthesia care unit closes, including provisions of adequate nursing staff.
3. (c) There shall be adequate nursing staff in attendance with every patient during anesthesia recovery.
4. (d) A physician shall order the discharge of the patient from the postanesthesia care unit.
5. (e) Equipment shall be available in accordance with services provided.
6. (f) The registered nurse shall assess and document assessment of each PAC patient.

7. (g)

   1. (1) Clinically relevant educational programs shall be conducted on a regularly scheduled basis of not less than twelve (12) per year.

   2. (2) There shall be evidence of:

      1. (A) Program dates;
      2. (B) Attendance; and
      3. (C) Subject matter.
8. (h) There shall be an ongoing QA/PI program that is specific to the patient care administered.

Codification Notes: “PAC” means postanesthesia care. "QA/PI" means quality assurance/performance improvement.