1. (a)

   1. (1) A facility in which surgical services are offered that require the use of general or intravenous anesthetics and where, in the opinion of the attending physician, hospitalization is unnecessary, shall be considered an ambulatory/outpatient surgery center (ASC).

   2. (2) Ambulatory/outpatient surgery center does not include:

      1. (A) A medical office owned and operated by a physician or more than one (1) physician licensed by the Arkansas State Medical Board if the medical office does not bill facility fees to a third-party payor; or
      2. (B) A dental office that has a Facility Permit for Moderate Sedation or a Facility Permit for General/Deep Sedation issued by the Arkansas State Board of Dental Examiners.

   3. (3) General or intravenous anesthetics include:

      1. (A)

2. (i) Deep sedation/analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation.

   1. (ii) The ability to independently maintain ventilatory function may be impaired.

      1. (iii) Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate.

         1. (iv) Cardiovascular function is usually maintained.
         2. (v) Source. 2009 American Society of Anesthesiologists’ Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia; and

      2. (B)

         1. (i) General anesthesia is a drug-induced loss of consciousness during which patients are not arousable even by painful stimulation.
         2. (ii) The ability to independently maintain ventilator function is often impaired.
         3. (iii) Patient often requires assistance in maintaining a patent airway, and positive pressure ventilation may be required because of:
3. (a) (a) Depressed spontaneous ventilation; or

4. (b) (b) Drug-induced depression of neuromuscular function.

   1. (iv) Cardiovascular function may be impaired.

      1. (v) Source. 2009 American Society of Anesthesiologists’ Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia.

5. (b) ASCs shall conform with the following sections:

   1. (1) 20 CAR § 41-102, definitions;
   2. (2) 20 CAR § 41-103, licensure and codes;
   3. (3) 20 CAR § 41-104, governing body;
   4. (4) 20 CAR § 41-105, medical staff;
   5. (5) 20 CAR § 41-106, general administration;
   6. (6) 20 CAR § 41-110, patient care service (nursing);
   7. (7) 20 CAR § 41-111, medications;
   8. (8) 20 CAR § 41-113, Health Information Services (excluding obstetrical and newborn records);
   9. (9) 20 CAR § 41-115, pharmacy;
   10. (10) 20 CAR § 41-117, infection prevention and control;
   11. (11) 20 CAR § 41-118(a), (c)(2) and (f), laboratory;
   12. (12) 20 CAR § 41-119, radiological services;
   13. (13) 20 CA § 41-125, specialized services — surgical services;
   14. (14) 20 CAR § 41-126, specialized services — postanesthesia care unit;
   15. (15) 20 CAR § 41-127, specialized services — outpatient surgical services;
   16. (16) 20 CAR § 41-128, specialized services — anesthesia services;
   17. (17) 20 CAR § 41-133, specialized services — central sterilization supply;
   18. (18) 20 CAR § 41-145, physical environment; and

   19. (19) 20 CAR § 41-178, physical facilities — freestanding ambulatory surgery centers.

       1. (c) Staffing.
   20. (1) There shall be an adequate number of registered nurses on duty at all times and available for bedside care of any patient when needed.
   21. (2) There shall be registered nurses to staff all patient care areas.

   22. (3) A registered nurse shall assign the nursing care of each patient to other nursing personnel in accordance with the:

       1. (A) Patient’s needs; and
       2. (B) Preparation and competence of the nursing staff.

   23. (4) There shall be written criteria to substantiate the assignment.

       1. (d) Discharge criteria shall be established and approved by the medical staff and governing body.

6. (e) Surgical records shall include documentation stating the patient:

   1. (1) Meets discharge criteria; and
   2. (2) Is discharged from the facility accompanied by a responsible adult.

7. (f)

   1. (1) Diagnostic and treatment services provided through contract shall be from a source approved by the Department.
   2. (2) Such services shall be monitored by the ambulatory surgery center.

8. (g) Surgical procedures performed in the ambulatory surgery center shall be those that are:

   1. (1) Commonly performed on an inpatient basis in hospitals but may be safely performed in an ambulatory surgery center;
   2. (2) Not of a type that are commonly performed or that may be safely performed in physicians’ offices; and
   3. (3) Limited to those requiring a dedicated operating room or suite and generally requiring a postoperative recovery room or short-term (not overnight) rooms.

9. (h) Surgical procedures shall not be:

   1. (1) Of a type that generally:

      1. (A) Results in extensive blood loss;
      2. (B) Requires major or prolonged invasion of body cavities; or
      3. (C) Directly involves major blood vessels; or

   2. (2) Generally emergency or life-threatening in nature.

      1. (i) The ambulatory surgery center shall:
   3. (1) Have a written agreement with a local hospital for transfer of a patient in a medical emergency of a nature that cannot be handled in the ambulatory surgery center; or
   4. (2) Ensure that every physician performing surgeries at the ASC has admitting privileges at a local hospital.

10. (j) Extended recovery time.

    1. (1) Scope/limitations of services.

       1. (A) The extended recovery time service shall be approved by the Division of Health Facilities Services prior to implementation of the service.

       2. (B)

          1. (i) Ambulatory surgery centers shall have the capability to provide care for postsurgical patients requiring continued nursing or medical treatment, but whose condition does not warrant acute hospitalization.
          2. (ii) The extended recovery period shall not exceed twenty-three (23) hours and fifty-nine (59) minutes.
          3. (iii) The extended recovery period shall be limited to:
11. (a) (a) Observation;

12. (b) (b) Control of nausea/vomiting;

    1. (c) (c) Replacement of fluids; and

       1. (d) (d) Pain management.
       2. (C) Patients shall be screened prior to surgery and prior to admission to the overnight area to ascertain that established admission criteria is met.

       3. (D) Services shall not include:

          1. (i) Intensive nursing care;
          2. (ii) Continuous monitoring due to the instability of vital signs;
          3. (iii) Administration of IV cardiac or antihypertensive drugs; or
          4. (iv) Treatment of any unstable underlying medical condition.
       4. (E) If a question arises as to whether or not a patient is an appropriate candidate for extended stay, the decision shall be made by the medical director or administrator.

    2. (2) Admission criteria:

       1. (A) Physician’s order shall be obtained for transfer to extended stay;
       2. (B) Stable vital signs and O2 saturation level;
       3. (C) Oriented to person, place, and time (a return to preoperative mentation);
       4. (D) Presence of satisfactory airway;
       5. (E) Absence of significant bleeding;
       6. (F) Stabilized, or resolution of any acute problem;
       7. (G) Movement of extremities following regional anesthetic;
       8. (H) Level of consciousness that permits patient to call for nurse;
       9. (I) Recovery will require twenty-three (23) hours and fifty-nine (59) minutes or less prior to discharge;

       10. (J)

           1. (i) The surgeon and anesthesia provider or their designee of similar training and expertise shall be present or immediately available.
           2. (ii) “Immediately available” shall be determined by the:
13. (a) (a) Administrative staff;

14. (b) (b) Medical staff; and

    1. (c) (c) Governing body; and

       1. (K) Patient assessment and orientation shall be recorded in the medical record.

    2. (3) Discharge criteria.

       1. (A) Discharge shall be done in keeping with the same criteria established for the discharge of any patient from the ambulatory surgery center.

       2. (B) The patient shall be discharged within twenty-three (23) hours and fifty-nine (59) minutes of his or her admission to extended recovery by:

          1. (i) The surgeon or anesthesiologist; or
          2. (ii) His or her designee.
       3. (C) If the patient’s condition is such that discharge is deemed inappropriate, arrangements shall be made for hospital transfer.

       4. (D) Postoperative prescription orders and instructions shall be given to the patient and responsible adult with:

          1. (i) An understanding of instructions verbally by the person or persons receiving them; and
          2. (ii) A copy retained in the medical record.

    3. (4) Transfer requirements to an acute care facility:

       1. (A) Patients who require continuous monitoring due to the instability of vital signs;
       2. (B) Patients who require administration of IV cardiac or antihypertensive drugs;
       3. (C) Patients who require treatment of any unstable underlying medical condition;
       4. (D) Patients whose pain management or observation requires longer than twenty-three (23) hours and fifty-nine (59) minutes;
       5. (E) Patients who have a lowered level of consciousness than their preoperative status; and
       6. (F) Patients who exhibit current or potential airway complications.

    4. (5) Supervision of extended recovery care.

       1. (A) Ambulatory surgery centers shall provide adequate supervision of extended stay area to ensure quality patient care and safety.

       2. (B)

          1. (i) The extended stay area shall be staffed with a minimum of two (2) caregivers at all times.
          2. (ii) At least one (1) of the caregivers shall be a registered nurse.
          3. (iii) All caregivers shall be:
15. (a) (a) Basic cardiac life support certified; and

16. (b) (b) Fully oriented and trained.

    1. (iv) At least one (1) registered nurse on duty at all times shall be advanced cardiac life support certified.

       1. (v)
17. (a) (a) The anesthesiologist or designee and the surgeon or designee shall be present or immediately available.

18. (b) (b) “Immediately available” shall be determined by the:

    1. (1) (1) Administrative staff;
    2. (2) (2) Medical staff; and
    3. (3) (3) Governing body.

    4. (6) Emergency procedures.

       1. (A) Any emergency or life-threatening situation shall be handled in a manner that provides the most appropriate and rapid care to best meet patient needs.
       2. (B) Local emergency medical services shall be notified that regular hours are being extended on the days patients require extended recovery care.
       3. (C) Appropriate drugs, supplies, and equipment shall be immediately available to the area, including a fully stocked “crash cart” with defibrillator and oxygen tank.
       4. (D) Transfer agreements to a local acute care hospital and ambulance transportation covering the ambulatory surgery center shall include the extended stay area.

    5. (7) Medications.

       1. (A) The ambulatory surgery center shall have provisions for obtaining prescribed drugs and biologicals to meet the needs of the population served.
       2. (B) In addition, policies and procedures shall be developed and implemented for the handling of medications brought into the facility by patients.
       3. (C) Should it be necessary to administer a patient’s own medications, a signed physician’s order shall be in the medical record identifying the medication or medications along with the route and directions for use.

    6. (8) Medical records.

       1. (A) Ambulatory surgery centers shall have an expanded medical record for patients in extended stay.
       2. (B) The same medical record shall be utilized that was initiated upon admission for surgery.
       3. (C) A discharge note shall be written upon discharge from acute recovery care.
       4. (D) An admission note, to include a patient assessment by a registered nurse, shall be included when the patient is received in the extended care area.
       5. (E) Pertinent observations, treatments, and medications shall be documented in the nurses’ notes.

       6. (F) A closing entry or discharge summary shall include information/observations regarding the:

          1. (i) Patient’s condition; and
          2. (ii) Care provided throughout the extended care.

       7. (G)

          1. (i) Patient food allergies and preferences shall be documented.
          2. (ii) Meal intake and toleration of diet shall be documented by nursing personnel in the nurses’ notes.

    7. (9) Patient nutrition.

       1. (A)

          1. (i) If meals are prepared onsite, the food and nutrition services shall be supervised by a qualified individual on the days the facility is open.
          2. (ii) A qualified individual shall be at a minimum a certified dietary manager.

       2. (B) The food preparation area shall include at a minimum:

          1. (i) Refrigerator/freezer;
          2. (ii) Microwave oven;
          3. (iii) Hand hygiene sink with towel and soap dispensers;
          4. (iv) Counter space;
          5. (v) Garbage cans with cover;
          6. (vi) Storage area for food, food preparation equipment, and tableware; and
          7. (vii) A three-compartment sink if disposables are not utilized at all times.
       3. (C) If meals are not prepared onsite, the food served to the patient shall be obtained from a food service establishment that operates in accordance with the department’s Rules Pertaining to Retail Food Establishments, 20 CAR pts. 190 – 197.
       4. (D) Leftover foods shall not be stored for future patient use.
    8. (10) Physical facilities. Extended stay may permit patient sleeping accommodations in the postanesthesia recovery area.

    9. (11) Staffing.

       1. (A) At least one (1) registered nurse shall be on duty at all times while the center is in operation, with supportive personnel as needed.
       2. (B) Nonnursing personnel, i.e., aides, housekeeping, etc., shall be assigned in sufficient numbers and with sufficient training to meet the patient’s needs.

    10. (12) Security procedures.

        1. (A) Measures shall be employed to ensure the security of patients, families, physicians, and employees while at the center after normal working hours.
        2. (B) The parking lot shall be well-lit.
        3. (C) At least two (2) employees shall be present inside the facility when patients are present.

    11. (13) Quality assurance/performance improvement/risk management plan.

        1. (A) Ambulatory surgery centers shall ensure the same QA/PI plan is followed for extended recovery care patients as general patients.
        2. (B) Each extended recovery patient shall receive the same patient satisfaction questionnaire as general surgical patients upon discharge from the facility.

        3. (C)

           1. (i) Each extended recovery care patient shall receive a postoperative call if they are discharged to home.
           2. (ii) If they are discharged to an alternate healthcare facility (i.e., rehab) a discharge summary shall be obtained upon discharge from that facility.
        4. (D) During the first year of extended recovery services, a quarterly report of the plan review shall be sent to the division.

Codification Notes: “QA/PI” means quality assurance/performance improvement.