44:76:04:01.  Administrative management. Each facility shall comply with §§ 44:76:04:02 to 44:76:04:12, inclusive.

          Source: 42 SDR 51, effective October 13, 2015.

          General Authority: SDCL 34-12-13(5).

          Law Implemented: SDCL 34-12-13(5).

          44:76:04:02.  Governing body. Each facility operated by limited liability partnership, a corporation, or political subdivision shall have an organized governing body legally responsible for the overall conduct of the facility. If the facility is operated by an individual or partnership, the individual or partnership shall carry out the functions in this chapter pertaining to the governing body. The governing body shall establish and maintain administration policies, procedures, or bylaws governing the operation of the facility. The governing body of a facility shall determine which categories of practitioners are eligible candidates for appointment to the medical staff and shall credential and grant admitting or patient care privileges to appointees to the medical staff. The governing body may appoint members to the medical staff only after considering the recommendations of the existing members of the medical staff. In addition, the governing body shall do the following:

          (1)  Appoint the medical staff and grant privileges in accordance with the bylaws of the medical staff and governing body;

          (2)  Maintain personnel records on each employee, including job application, professional licensing information, and health information;

          (3)  Establish procedures for transfer to a hospital of patients requiring immediate medical care beyond the capacity of the ambulatory surgery center;

          (4)  Assure that all patients admitted to the ambulatory surgery center are under the care of a physician who is a member of the medical staff;

          (5)  Assure the provision of equipment is in good repair within the ambulatory surgery center to provide efficient services and protection to the patients and staff;

          (6)  Provide for the patient all essential medical information, including diagnosis, if a patient is transferred to another health care facility; and

          (7)  Provide a written plan for the evacuation of patients, visitors, and personnel in the event of fire or other disaster within the ambulatory surgery center and an alarm system to notify personnel. Personnel shall be acquainted with the evacuation plan.

          Source: 42 SDR 51, effective October 13, 2015.

          General Authority: SDCL 34-12-13(5).

          Law Implemented: SDCL 34-12-13(5).

          Cross-Reference: Medical staff, § 44:76:04:03.

          44:76:04:03.  Medical staff. A facility shall have a medical staff organized under bylaws and rules approved by the governing body and responsible to the governing body for the quality of all medical care provided patients in the facility and for the ethical and professional practices of its members. The medical staff shall include physicians, but it may also include other practitioners appointed by the governing body. If the medical staff has an executive committee, a majority of the members of the committee shall be physicians. The responsibility for the conduct of medical staff affairs shall be assigned to an individual physician. The medical staff shall establish a credentials committee to review the qualifications of practitioners applying for admitting or patient care privileges and recommend to the governing body practitioners eligible for appointment to the medical staff by the governing body. The review shall include recommendations regarding delineation of admitting and patient care privileges. The medical staff shall conduct appraisals of its members at least every two years. The review shall include recommendations regarding delineation of privileges. In addition, the medical staff shall do the following:

          (1)  Hold at least quarterly meetings for which records of attendance and minutes are kept;

          (2)  At least biennially review and analyze the clinical experience of its members and the medical records of patients on sampling or another basis. All techniques and procedures involving diagnosis and treatment of patients shall be reviewed annually and shall be subject to change by the medical staff;

          (3)  Assure that all persons admitted to the ambulatory surgery center are under the care of a physician; and

          (4)  Assure that all medical orders are given by a practitioner and recorded in accordance with the medical staff bylaws and rules. All orders shall be signed or countersigned by the attending physician.

          Source: 42 SDR 51, effective October 13, 2015.

          General Authority: SDCL 34-12-13(5).

          Law Implemented: SDCL 34-12-13(5).

          Cross-Reference: Governing body, § 44:76:04:02.

          44:76:04:04.  Administrator. The governing body shall designate a qualified administrator to represent the owner or governing body and to be responsible for the daily overall management of the facility. The administrator shall designate a qualified person to represent the administrator during the administrator's absence. The governing body shall notify the department in writing of any change of administrator.

          Source: 42 SDR 51, effective October 13, 2015.

          General Authority: SDCL 34-12-13(5).

          Law Implemented: SDCL 34-12-13(5).

          44:76:04:05.  Personnel. The facility shall have a sufficient number of qualified personnel to provide effective and safe care. Staff members on duty shall be awake at all times. Any supervisor shall be 18 years of age or older. Written job descriptions and personnel policies and procedures shall be made available to personnel of all departments and services. The facility may not knowingly employ any person with a conviction for abusing another person. The facility shall establish and follow policies regarding special duty or staff members on contract.

          Source: 42 SDR 51, effective October 13, 2015.

          General Authority: SDCL 34-12-13(5).

          Law Implemented: SDCL 34-12-13(5).

          44:76:04:06.  Personnel training. The facility shall have a formal orientation program and an ongoing education program for all personnel. Ongoing education programs shall cover the required subjects annually. These programs shall include the following subjects:

          (1)  Fire prevention and response. The facility shall conduct fire drills quarterly for each shift to provide training for all staff;

          (2)  Emergency procedures and preparedness;

          (3)  Infection control and prevention;

          (4)  Accident prevention and safety procedures;

          (5)  Proper use of restraints;

          (6)  Patient rights;

          (7)  Confidentiality of patient information;

          (8)  Incidents and diseases subject to mandatory reporting and the facility's reporting mechanisms; and

          (9)  Care of patients with unique needs;

          Personnel whom the facility determines will have no contact with patients are exempt from training required by subdivisions (5) and (9) of this section.

          Additional personnel education shall be based on facility identified needs.

          Current professional and technical reference books and periodicals shall be made available for personnel.

          Source: 42 SDR 51, effective October 13, 2015.

          General Authority: SDCL 34-12-13(5).

          Law Implemented: SDCL 34-12-13(5).

          44:76:04:07.  Employee health program. The facility shall have an employee health program for the protection of the patients. All personnel shall be evaluated by a licensed health professional for freedom from reportable communicable disease which poses a threat to others before assignment to duties or within 14 days after employment including an assessment of previous vaccinations and a tuberculin skin tests or blood assay test. The facility may not allow anyone with a communicable disease, during the period of communicability, to work in a capacity that would allow spread of the disease. Any personnel absent from duty because of a reportable communicable disease which may endanger the health of patients and fellow employees may not return to duty until they are determined by a physician, physician’s designee, physician assistant, nurse practitioner, or clinical nurse specialist to no longer have the disease in a communicable stage.

          Source: 42 SDR 51, effective October 13, 2015.

          General Authority: SDCL 34-12-13(1), (5), and (14).

          Law Implemented: SDCL 34-12-13(1), (5), and (14).

          Cross-Reference: Reportable diseases, ch 44:20:01.

          44:76:04:08.  Admissions of patients. The governing body of the facility shall establish and maintain admission, assessment, transfer, and discharge policies, with written evidence to assure the patients admitted are within the licensure classification of the facility or its distinct part. The facility may admit, on the orders of a practitioner, only those patients for whom it can provide care safely and effectively.

          Source: 42 SDR 51, effective October 13, 2015.

          General Authority: SDCL 34-12-13(5).

          Law Implemented: SDCL 34-12-13(5).

          44:76:04:09.  Disease prevention. Each facility shall provide an organized infection control program for preventing, investigating and controlling infection. The facility shall establish written policies regarding visitation in the various services and departments of the facility. Any visitor who has an infectious disease, who has recently recovered from such a disease, or who has recently had contact with such a disease shall be discouraged from entering the facility.

          Source: 42 SDR 51, effective October 13, 2015.

          General Authority: SDCL 34-12-13(1), (5), and (14).

          Law Implemented: SDCL 34-12-13(1), (5), and (14).

          44:76:04:10.  Tuberculin screening requirements. Each facility shall develop criteria to screen healthcare workers for Mycobacterium tuberculosis (TB) based on the guidelines issued by Centers for Disease Control and Prevention. Each facility shall establish policies and procedures for conducting Mycobacterium tuberculosis risk assessment that include the key components of responsibility, surveillance, containment, and education. The frequency of repeat screening shall depend upon annual risk assessments conducted by the facility.

          Tuberculin screening requirements for healthcare workers are as follows:

          (1)  Each new healthcare worker shall receive the two-step method of tuberculin skin test or a TB blood assay test to establish a baseline within 14 days of employment. Any two documented tuberculin skin tests completed within a 12 month period prior to the date of employment can be considered a two-step or one blood assay TB test completed within a 12 month period prior to the date of employment can be considered an adequate baseline test. Skin testing or TB blood assay tests are not necessary if a new employee transfers from one licensed healthcare facility to another licensed healthcare facility within the state if the facility received documentation of the last skin testing completed within the prior 12 months. Skin testing or TB blood assay test are not necessary if documentation is provided of a previous positive reaction to either test. Any new healthcare worker who has a newly recognized positive reaction to the skin test or TB blood assay test shall have a medical evaluation and a chest X-ray to determine the presence or absence of the active disease;

          (2)  A new healthcare worker who provides documentation of a positive reaction to the tuberculin skin test or TB blood assay test shall have a medical evaluation and chest X-ray to determine the presence or absence of the active disease; and

          (3)  Each healthcare worker with a history of a positive reaction to the tuberculin skin test or blood assay shall be evaluated annually by a physician, physician assistant, nurse practitioner, clinical nurse specialist, or a nurse and a record maintained of the presence or absence of symptoms of Mycobacterium tuberculosis. If this evaluation results in suspicion of active tuberculosis, the person shall be referred for further medical evaluation to confirm the presence or absence of tuberculosis.

          Source: 42 SDR 51, effective October 13, 2015.

          General Authority: SDCL 34-12-13(1), (5), and (14), 34-22-9.

          Law Implemented: SDCL 34-12-13(1), (5), and (14).

          Reference: Reference: Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Facilities, 2005. "Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report," December 30, 2005 (RR17).

          44:76:04:11.  Care policies. Each facility shall establish and maintain policies, procedures, and practices that follow accepted standards of professional practice to govern care, and related medical or other services necessary to meet the patients' needs.

          Source: 42 SDR 51, effective October 13, 2015.

          General Authority: SDCL 34-12-13(5).

          Law Implemented: SDCL 34-12-13(5).

          44:76:04:12.  Transfer agreements. Each ambulatory surgery center shall have in effect a transfer agreement with one or more hospitals to provide services not available on site. The agreement shall provide for an interchange of medical and other necessary information. The facility shall have an effective procedure for the immediate transfer to a hospital of patients requiring emergency medical care beyond the capabilities of the facility. The hospital shall be a local Medicare participating or local nonparticipating hospital that meets the requirements for payment for emergency services. The facility shall have a written transfer agreement with a hospital or all physicians performing surgery in the facility have admitting privileges at a hospital.

          Source: 42 SDR 51, effective October 13, 2015.

          General Authority: SDCL 34-12-13(5).

          Law Implemented: SDCL 34-12-13(5).

          44:76:04:13.  Quality assessment. Each licensed facility shall provide for on-going evaluation of the quality of services provided to patients that includes any contract services. Components of the quality assessment evaluation shall include establishment of facility standards; interdisciplinary review of patient services to identify deviations from the standards and actions taken to correct deviations; patient satisfaction surveys; utilization of services provided; and documentation of the evaluation and report to the governing body.

          Source: 42 SDR 51, effective October 13, 2015.

          General Authority: SDCL 34-12-13(5) and (14).

          Law Implemented: SDCL 34-12-13(5) and (14).

          44:76:04:14.  Discharge planning. A facility shall have policies and procedures for discharge planning including the person responsible, members of the discharge planning team, a list of all area agencies and resources, and a description of the process. Outside caregivers may be included in discharge planning conferences.

          The facility shall initiate planning with applicable agencies to meet identified needs, and patients shall be offered assistance to obtain needed services upon discharge. Information necessary for coordination and continuity of care shall be made available to whomever the patient is discharged and to referral agencies as required by the discharge plan.

          The facility shall ensure each has a discharge order signed by the physician who performed the surgery or procedure. All patients shall be discharged in the company of a responsible adult, except those patients exempted by the attending physician as outlined by the facility policy. Each patient shall be provided written discharge instructions.

          Source: 42 SDR 51, effective October 13, 2015.

          General Authority: SDCL 34-12-13(5) and (14).

          Law Implemented: SDCL 34-12-13(5) and (14).