CHAPTER XX
AMBULATORY SURGICAL CENTER

DEFINITION  DEFINITIONS: 
A. Ambulatory Surgical Center (ASC) means a facility which operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization.
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B.  “Plan review” means the review by the Department, or its designee, of new construction or remodeling plans to ensure compliance by the facility with the National Fire Protection Association (NFPA) Life Safety Code, NFPA 99 Health Care Facilities, and with this Chapter XX.  Plan review consists of the examination of new construction or remodeling plans and onsite inspections, where warranted.  In reference to the National Fire Protection Association requirements, the Department is the authority having jurisdiction for state licensure.  {Explanation:  New language defines the term plan review.  Plan review is one of the Department oversight tasks for which a fee is being proposed.} 
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IX.	ANESTHESIA
A 	The use of flammable anesthetics in ambulatory surgical centers is prohibited. The design, equipment and storage for anesthetics shall meet “The Use of Inhalation Anesthetics in Ambulatory Care Facilities”, National Fire Protection Association Bulletin No. 56G, 1980. {Explanation:  Existing language is deleted because it is an outdated reference}
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XIII.	SURGICAL SERVICES
A.	Location: The ambulatory surgical center shall have at least one operating room that has the capability of administering general anesthesia to patients and is located in a sterile environment within the facility. The operating room(s) and accessory areas shall be located so that in and out traffic is properly controlled. The ambulatory surgical center may have additional, appropriately equipped treatment and/or procedures rooms for surgical procedures not requiring general anesthesia.
1.	If an ambulatory surgical center generally provides only surgical services that do not require general anesthesia, the facility may make application to the department for an appropriate modification of the requirements for a surgical suite provided that the facility can demonstrate the ability to implement a functional, sterile operating room whenever such use would be necessitated by patient needs.
2.	The requirements provisions of paragraph A.1. Shall not apply to ambulatory surgical centers licensed prior to the January 30, 1995 effective date of such paragraph. {Explanation:  January 30, 1995 was the date this regulatory provision was made effective.}
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E.	Interior Finishes: Interior finishes will be in accordance with Section XXII of the regulations. {Explanation:  This language is being deleted because it is already addressed by the NFPA standards references, for example:  NFPA 101, Sections 20.3.3 and 21.3.3.  Succeeding paragraphs will be  renumbered accordingly}
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H.	Oxygen: Medical Gases and Medical Gas Systems.  A supply of oxygen shall be available and stored in accordance with the National Fire Protection Association 99-1993 1999 Standards for Health Care Facilities, Chapter 4, Gas and Vacuum Systems.  Piped medical gas systems shall meet the requirements of NPFA 99-1999 chapter 4, Gas and Vacuum Systems.  {Explanation:  updating of outdated reference and codification of an existing requirement for facilities that are Medicare/Medicaid certified.}
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O.	Exhaust: At least two (2) exhaust outlets shall be provided in each operating room, not less than 4 inches above the floor. with the lower perimeter of the outlet situated between three to four inches off the floor.  {Explanation:  clarification of this requirement based on provisions under NFPA 90A.}
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Q.	Isolation Transformers: Each power circuit within or partially within an anesthetizing location shall be isolated from any distribution system supplying other than anesthetizing locations by means of one or more transformers consistent with Section XXII of the regulations (Building and Fire Safety).  Anesthetizing Locations.  Anesthetizing locations shall meet the requirements of NFPA 99-1999, Chapter 3 Electrical Systems.  {Explanation:  clarification of this requirement based on provisions under NFPA 99, Chapter 3, Electrical Systems.  Proposed language allows options other than isolation transformers.}
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XIV-A	PATIENT CARE UNIT
A.	An ambulatory surgical center shall maintain a distinct patient care area if the ambulatory surgical center provides surgical services for persons needing longer periods of care and/or observation beyond the recovery period and prior to discharge, but not to exceed 23 hours. Patient room window sills shall be located at a minimum of 12 inches above grade or ground level and a maximum of 36 inches above the floor. The grade or the ground level shall be maintained at or below the window sill for a distance of at least 8 feet measured perpendicular to the window. The window shall provide sufficient illumination to be consistent with patient needs. {Explanation: obsolete requirement.}  Patient rooms shall have direct exit to the corridor or exit way or discharge and shall have a maximum of two beds per room.
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XXII	BUILDING AND FIRE SAFETY
A.	An ambulatory surgical center shall comply with the Life Safety Code, National Fire Protection Association 101, 1991 as it relates to new and existing ambulatory health facilities and the corresponding national fire protection association standards as they pertain to the particular service or system installed. {Explanation: outdated reference}
A.	Facilities shall be compliant with NFPA 99, Health Care Facilities (1999 Edition), Chapter 13, “Other” Health care occupancies and the National Fire Protection Association (NFPA) 101, Life Safety Code (2000) or in the case of facilities licensed before April 30, 1994, NFPA 101 Life Safety Code (1981).  {Explanation: adherence to the NFPA 101 (2000) is a codification of existing practice and is required for all Medicare/Medicaid certified facilities.  Compliance with NFPA 99 Chapter 13 is a codification of existing practice.}
1.	Facilities licensed on or before September 30, 2003 shall meet Chapter 21, New Ambulatory Health Care Occupancies.
2.	Facilities licensed on or after October 1, 2003 or portions of facilities that undergo remodeling shall meet Chapter 20, Existing Ambulatory Health Care Occupancies.    
B.	Notwithstanding the requirements of Section XXII, A above, facilities licensed before April 30, 1994 may meet the Uniform building Code (B occupancy, Division 2), 1982 and NFPA 101 Life safety code (1981 Edition), Section 12-6 “New ambulatory Health Care Centers.”   Ambulatory surgical centers licensed prior to the effective date of these regulations and If such facilities were lawfully constructed and in compliance with the regulations at the time of initial licensure and found to be in continuing compliance during any subsequent inspections, they may continue to utilize existing, approved life safety systems provided that they present no hazard to life, health, or property and that there are no changes in the scope of services and utilization patterns in the ambulatory surgical center. The ambulatory surgical center shall, in the event of any renovation to the facility of 25 percent or greater of the total interior of the physical plant on or after April 30, 1994 after the effective date of these regulations, comply with the requirements herein established in Section XXII, A above. {Explanation:  the proposed new language explicitly states the standards that facilities licensed prior to 04/30/94 must adhere to.  However, compliance with NFPA 101 (2000) is required for all Medicare/Medicaid certified facilities, irrespective of the date of initial licensure.}  
C.	Ambulatory surgical centers shall also demonstrate compliance with all other building and fire safety requirements of local governments and other state agencies, including but not limited to structural, mechanical, plumbing, and electrical requirements.
D.	The publication “Guidelines for Construction and Equipment of Hospitals and Medical Facilities, 1992-1993” from the American Institute of Architects and the U.S. Department of Health and Human Services may be used by the Department in resolving building and fire safety issues that relate to the services provided or systems installed on or before February 29, 2008, and are necessary to protect patient health, safety, and welfare.  On or after March 1, 2008, the American Institute of Architects “Guidelines for Design and Construction for Health Care Facilities,” (2006 Edition) may be used by the Department in resolving building and fire safety issues that relate to the services provided or systems installed on or after March 1, 2007, and are necessary to protect patient health, safety, and welfare. {Explanation:  updating of existing reference.}
XXIII	Department Oversight {Explanation:  an analysis of the fee structure is provided in the Basis and Purpose and Regulatory Analysis}
A.  Licensure Fees.  Fees shall be submitted to the Department as specified below.
1.	Initial license (when such initial licensure is not a change of ownership).  A license applicant shall submit with an application for licensure a nonrefundable fee of $6,600.  
2.	Renewal license.  A license applicant shall submit with an application for licensure a nonrefundable fee of $2,200.
3.	Change of Ownership.  A license applicant shall submit with an application for licensure a nonrefundable fee of $4,100.
4.	Provisional License.  The license applicant may be issued a provisional license upon submittal of a nonrefundable fee of $2,500.  If a provisional license is issued, the provisional license fee shall be in addition to the initial or renewal license fee.
5.	Conditional License.  A facility that is issued a conditional license by the Department shall submit a nonrefundable fee ranging from 10 to 25 percent of its applicable renewal fee.  The percentage shall be determined by the Department.  If the conditional license is issued concurrent with the initial or renewal license, the conditional license fee shall be in addition to the initial or renewal license fee.
b. Plan Review and Plan Review Fee.  Fees shall be submitted to the Department as specified below.  Fees are nonrefundable and shall be submitted prior to the Department initiating a plan review for a facility. 
1.	Initial license (when such initial licensure is not a change of ownership).  A license applicant shall submit with construction plans a nonrefundable fee of $5,000.  
2.	Remodeling.  A facility shall submit the following nonrefundable fees upon submission of plans
A.	Desk review only:  $500
B.	Desk and onsite review:  $1,500
3.	Replacement Building or New Location.  A facility shall submit a nonrefundable fee of $5,600.