1. A. An osteopathic physician who performs office-based surgery shall:

   1. 1. Establish, document, and implement written policies and procedures that cover:

      1. a. Patients’ rights,
      2. b. Informed consent,
      3. c. Care of patients in an emergency, and
      4. d. Transfer of patients to a local accredited or licensed acute-care hospital;

   2. 2. Ensure that a staff member who assists with or a health care professional who participates in office-based surgery:

      1. a. Has sufficient education, training, and experience to perform assigned duties;
      2. b. If applicable, has a current license or certification required to perform assigned duties; and
      3. c. Performs only those acts that are within the scope of practice established in the staff member’s or health care professional’s governing statutes;

   3. 3. Ensure that the office or other practice location where office-based surgery is performed has all equipment necessary for:

      1. a. The physician to perform the office-based surgery safely,
      2. b. The physician or health care professional to administer the sedation safely,
      3. c. The physician or health care professional to monitor the use of sedation, and
      4. d. The physician and health care professional administering the sedation to rescue a patient after the sedation is administered if the patient enters into a deeper state of sedation than was intended by the physician;
   4. 4. Ensure that a copy of the patients’ rights policy is provided to each patient before performing office-based surgery;

   5. 5. Obtain informed consent from the patient before performing office-based surgery that:

      1. a. Authorizes the office-based surgery, and
      2. b. Authorizes the office-based surgery to be performed at the specific practice location; and
   6. 6. Review all policies and procedures at least every 12 months and update as needed.

2. B. An osteopathic physician who performs office-based surgery shall comply with:

   1. 1. The local jurisdiction’s fire code;
   2. 2. The local jurisdiction’s building codes for construction and occupancy;
   3. 3. The bio-hazardous waste and hazardous waste standards in 18 A.A.C. 13, Article 14; and
   4. 4. The controlled substances administration, supply, and storage standards in 4 A.A.C. 23, Article 5.

Historical Note

New Section made by final rulemaking at 20 A.A.R. 2654, effective November 8, 2014 (Supp. 14-3).