1. (a) Each ASC shall have a governing body whose duties include:

   1. (1) Management and control of the operation of the ASC;
   2. (2) Assessment and improvement of the quality of care and services;
   3. (3) Appointment of the ASC administrator;
   4. (4) Adoption of policies and procedures defining responsibilities for the operation of the ASC and the establishment of a medical staff;
   5. (5) Approval of medical staff policies and procedures establishing the medical staff responsibilities;
   6. (6) Responsibility for management of the overall operation and fiscal viability of the ASC;
   7. (7) Responsibility for determination of the qualifications for appointment for all managers, medical staff, and personnel; and
   8. (8) Ensuring compliance with all relevant health and safety requirements of federal, state, and local laws rules and regulations.
2. (b) If the ASC is a sole proprietorship, the duties in (a)(1) above shall pertain to the individual in ownership status.

3. (c) Each ASC shall have a full-time administrator who:

   1. (1) Meets one of the following qualifications:

      1. a. The administrator shall have a master’s degree from an accredited institution in business administration or a health-related field;
      2. b. The administrator shall have a bachelor’s degree from an accredited institution and at least 2 years of experience working in a health-related field; or
      3. c. The administrator shall be a registered nurse and have at least 3 years of experience working in a health-related field;

   2. (2) Shall be responsible to the governing body for the daily management and operation of the ASC including:

      1. a. Management and fiscal matters;
      2. b. Implementing the policies and procedures adopted by the governing body;
      3. c. The employment and termination of personnel necessary for the efficient operation of the ASC;
      4. d. The designation of an alternate, in writing, who shall be responsible for the daily management and operation of the ASC in the absence of the administrator;
      5. e. Attendance at meetings of the governing body, medical staff, and personnel, to serve as a liaison to the governing body;
      6. f. The planning, organizing, and directing of such other activities as may be delegated by the governing body;
      7. g. The delegation of responsibility to subordinates as appropriate;

      8. h. Ensuring development and implementation of ASC policies and procedures on:

         1. 1. Patient’s rights as required by RSA 151:20-21;
         2. 2. Advanced directives as required by RSA 137-J;
         3. 3. Discharge planning as required by RSA 151:26;
         4. 4. Organ and tissue donor identification and procurement, as applicable;
         5. 5. Withholding of resuscitative services from patients pursuant to RSA 137-J; and
         6. 6. Adverse event reporting; and
      9. i. Notifying the department, directly or through delegation, as specified in He-P 812.15, of any adverse event involving a patient; and
   3. (3) May hold more than one position within the ASC provided the individual meets the qualifications of each position.
4. (d) Each ASC shall have a medical staff in accordance with the policies and procedures established under (a)(4) above.

5. (e) There shall be a full-time director of nursing services who:

   1. (1) Is currently licensed in the state of New Hampshire pursuant to RSA 326-B, or licensed pursuant to the multi-state compact;
   2. (2) Has a minimum of 4 years’ relevant experience;

   3. (3) Is responsible for:

      1. a. Establishment of standards of nursing practice used in the ASC;
      2. b. Ensuring that the admission process and patient assessment process coordinates patient requirements for nursing care with available nursing resources;
      3. c. Participating with the governing body, administrator, and medical staff to improve the quality of nursing care at the ASC; and
      4. d. Nursing care as authorized by their nurse practice act and according to RSA 326-B; and
   4. (4) May hold more than one position within the ASC provided the director of nursing meets the qualifications of each position.

Source. #9727-A, eff 6-18-10, EXPIRED: 6-18-18 New. #12557, INTERIM, eff 6-26-18, EXPIRED: 12-24-18 New. #12926, eff 11-26-19; ss by #14042, eff 8-6-24 (formerly He-P 812.16)