1. A. An administrator shall ensure that policies and procedures for providing medical emergency treatment to a patient are established, documented, and implemented and include:

   1. 1. A list of the medications, supplies, and equipment required on the premises for the medical emergency treatment provided by the outpatient surgical center;
   2. 2. A system to ensure medications, supplies, and equipment are available, have not been tampered with, and, if applicable, have not expired;
   3. 3. A requirement that a cart or a container is available for medical emergency treatment that contains medications, supplies, and equipment specified in policies and procedures;
   4. 4. A method to verify and document that the contents of the cart or container are available for medical emergency treatment; and
   5. 5. A method for ensuring a patient may be transferred to a hospital or other health care institution to receive treatment for a medical emergency that the outpatient surgical center is not authorized or not able to provide.
2. B. An administrator shall ensure that medical emergency treatment is provided to a patient admitted to the outpatient surgical center according to policies and procedures.

3. C. An administrator shall ensure that:

   1. 1. A disaster plan is developed, documented, maintained in a location accessible to medical staff and employees, and, if necessary, implemented that includes:

      1. a. Procedures to be followed in the event of a fire or threat to patient safety;
      2. b. Assigned personnel responsibilities;
      3. c. Instructions for the evacuation or transfer of patients;
      4. d. Maintenance of patient medical records; and
      5. e. A plan to provide any other services related to patient care to meet the patients’ needs;
   2. 2. The disaster plan required in subsection (C)(1) is reviewed at least once every 12 months;

   3. 3. Documentation of a disaster plan review required in subsection (C)(2) is created, is maintained for at least 12 months after the date of the disaster plan review, and includes:

      1. a. The date and time of the disaster plan review;
      2. b. The name of each personnel member, employee, medical staff member, or volunteer participating in the disaster plan review;
      3. c. A critique of the disaster plan review; and
      4. d. If applicable, recommendations for improvement;
   4. 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;
   5. 5. An evacuation drill for employees is conducted at least once every six months for employees on the premises;

   6. 6. Documentation of an evacuation drill is created, is maintained for at least 12 months after the date of the evacuation drill, and includes:

      1. a. The date and time of the evacuation drill;
      2. b. The amount of time taken for employees to evacuate the outpatient surgical center;
      3. c. Any problems encountered in conducting the evacuation drill; and
      4. d. Recommendations for improvement, if applicable; and
   7. 7. An evacuation path is conspicuously posted on each hallway of each floor of the outpatient surgical center and every room where patients may be present.
4. D. An administrator shall ensure that, if applicable, a sign is placed at the entrance to a room or area indicating that oxygen is in use.

5. E. An administrator shall:

   1. 1. Obtain a fire inspection conducted according to the time-frame established by the local fire department or the State Fire Marshal,
   2. 2. Make any repairs or corrections stated on the fire inspection report, and
   3. 3. Maintain documentation of a current fire inspection.

Historical Note

Adopted effective October 20, 1982 (Supp. 82-5). Section repealed, new Section adopted effective February 17, 1995 (Supp. 95-1). Section repealed; new Section made by final rulemaking at 9 A.A.R. 338, effective March 16, 2003 (Supp. 03-1). Section amended by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt rulemaking at 20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, § 13; effective July 1, 2014 (Supp. 14-2).