59A-5.0085. Departments and Services

Effective on Sunday, September 28, 2014
  • 1(1) Surgical department. This department shall be organized under written policies and procedures relating to surgical staff privileges, anesthesia, functioning standards, staffing patterns and quality maintenance of the surgical suite.

    31(a) A qualified person designated by the administrator shall be responsible for the daily functioning and maintenance of the surgical suite.

    52(b) A surgery record shall be maintained on a current basis that contains the following information:

    681. Patient’s name, patient number, pre-operative diagnosis, post-operative diagnosis, surgical procedure, anesthetic, and complications, if any; and,

    852. Name of each member of the surgical team, including the surgeon, first assistant, anesthesiologist, nurse anesthetist, anesthesiologist assistant, circulating nurse and operating room technician.

    110(c) Each center shall ensure, prior to any surgery being performed, that the signed informed consent for the procedure, verification of the identity of patient, operative site, and operative procedure to be performed are in the patient’s medical record.

    149(d) All infections of surgical cases shall be recorded and reported to the governing board or its designee and a procedure shall exist for the investigation of such cases.

    178(e) Emergency equipment shall be provided as needed commensurate with the services of the center, maintained in functional condition, and capable of providing 201and maintaining cardiorespiratory functioning.

    205(f) Written procedures in implementation of policies shall relate specifically to the functional activities of the surgical suite and include the following:

    2271. Surgical asepsis: preparation, handling, and maintenance of sterile equipment and supplies.

    2392. Medical asepsis: patients, staff, equipment, traffic, and equipment flow patterns.

    2503. Sterilization and disinfection standards and controls; equipment and supplies.

    2604. Housekeeping.

    262(2) Anesthesia service. This service shall be organized under written policies and procedures relating to anesthesia staff privileges, the administration of anesthesia, and the maintenance of strict safety controls.

    291(a) All anesthesia shall be administered by an anesthesiologist, a 301credentialed and privileged physician, 305certified registered nurse anesthetist 309or anesthesiologist assistant, 312except for local anesthesia administered by a podiatrist, and except for local anesthesia administered by a dentist, and such other anesthesia administered by a dentist in accordance with Section 341466.017, F.S. 343and Chapter 64B5-14, F.A.C.

    347(b) An anesthesiologist or other physician or a certified registered nurse anesthetist under the on-site medical direction of a licensed physician 368or an anesthesiologist assistant under the direct supervision of an anesthesiologist, 379shall be in the center during the anesthesia and post-anesthesia recovery period until all patients are cleared for discharge.

    398(c) At least one registered professional nurse shall be in the recovery area during the patient’s recovery period.

    416(d) Prior to the administration of anesthesia, patients shall have a history and physical examination including laboratory analysis when indicated.

    436(e) Written policies and procedures relative to the administration of anesthesia shall be developed by the anesthesia service, approved by the medical staff and the governing board, and be reviewed annually, dated at time of each review, revised as necessary, and enforced.

    478(f) Anesthetic safety regulations shall be developed, posted and enforced. Such regulations shall include the following requirements:

    4951. All operating room electrical and anesthesia equipment shall be inspected on no less than a semi-annual basis, and a written record of the results and corrective actions be maintained;

    5252. Flammable anesthetic agents shall not be employed in centers;

    5353. Electrical equipment in anesthetizing areas shall be on an audiovisual line isolation monitor, with the exception of radiologic equipment and fixed lighting more than 5 feet above the floor;

    5654. Each anesthetic gas machine shall have pin-index system or equivalent safety system and a minimum oxygen flow safety device; and,

    5865. All reusable anesthesia equipment in direct contact with the patient shall be cleaned or sterilized as appropriate after each use;

    6076. The following monitors shall be applied to all patients receiving conduction or general anesthesia:

    622a. Blood pressure cuff;

    626b. A continuous temperature device, readily available to measure the patient’s temperature;

    638c. Pulse Oximeter; and,

    642d. Electrocardiogram.

    644e. An Inspired Oxygen Concentration Monitor and a Capnograph shall be applied to all patients receiving general anesthesia.

    662(3) Nursing service. This service shall be organized under written policies and procedures relating to patient care, establishment of standards for nursing care and mechanisms for evaluating such care, and nursing services.

    694(a) A registered professional nurse designated by the administrator shall be responsible for coordinating and supervising all nursing services.

    713(b) There shall be a sufficient staffing pattern of registered professional nurses to provide quality nursing care to each surgical patient from admission through discharge. Such additional trained nursing service personnel shall be on duty as may be needed commensurate with the service of the center.

    759(c) A registered professional nurse shall be assigned as the circulating nurse 771for one patient at a time for the duration of the surgical procedure for any procedure performed in the center791.

    792(d) A registered professional nurse shall be present in the recovery area at all times when a patient is present.

    812(e) A record shall be currently maintained of all nursing personnel and include regular and relief as well as full-time and part-time staff. The record shall include the current license number of each licensed person.

    847(f) A current job description delineating duties and responsibilities shall be maintained for each nursing service position.

    864(g) Written procedures in implementation of policies and to assure quality nursing care shall relate specifically to the functional activities of nursing service and include the following:

    8911. Patient admission;

    8942. Pre- and Post-Operative care;

    8993. Medical orders 902from physicians and other members of the medical staff;

    9114. Standing orders with required signatures;

    9175. Medications; storage and administration;

    9226. Treatments;

    9247. Surgical asepsis;

    9278. Medical asepsis;

    9309. Sterilization and disinfection;

    93410. Documentation: medical records and center records;

    94111. Patient discharge;

    94412. Patient transfer;

    94713. Emergency measures;

    95014. Isolation measures;

    95315. Incident reports;

    95616. Personnel orientation;

    95917. Inservice education record;

    96318. Equipment and supplies: availability and maintenance; and,

    97119. Visitors.

    973(4) Laboratories. Clinical Laboratory – Each center shall provide on the premises or by written agreement with a laboratory licensed under Chapter 483, F.S. and Chapter 59A-7, F.A.C., a clinical laboratory to provide those services commensurate with the center’s needs and which conform to the provisions of Chapter 483, F.S. and Chapter 59A-7, F.A.C.

    1027(5) Radiolocical services. Each center shall provide within the institution, or through arrangement, radiological services commensurate with the needs of the center.

    1049(a) If radiological services are provided by center staff, the service shall be maintained free of hazards for patients and personnel.

    1070(b) New installations of radiological equipment, and subsequent inspections for the identification of radiation hazards shall be made as required by Chapter 64E-5, F.A.C.

    1094(c) Personnel monitoring shall be maintained for each individual working in the area of radiation. Readings shall be on at least a monthly basis and reports kept on file and available for review.

    11271. Personnel – The center shall have a 1135licensed practitioner, as defined in Section 1141468.301(11), F.S., 1143to supervise the service and to discharge professional radiological services.

    11532. A technologist shall be on duty or on call at all times when there are patients within the center.

    11733. The use of all radiological apparatus shall be limited to 1184appropriately licensed 1186personnel; and use of fluoroscopes shall be limited to 1195appropriately licensed, credentialed and privileged personnel1201.

    1202(d) If provided under arrangement with an outside provider, the radiological services must be directed by a qualified radiologist and meet the standards as required by Chapter 64E-5, F.A.C.

    1231(6) Housekeeping service. The Housekeeping Service shall be organized under effective written policies and procedures relating to personnel, equipment, materials, maintenance, and cleaning of all areas of the center.

    1260Rulemaking Authority 1262395.1055 FS. 1264Law Implemented 1266395.009, 1267395.1055, 1268395.1011 FS. 1270History–New 12-12-96, Amended 9-28-14.


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