The purpose of this section is to guide the development and management of surgical services.

An ambulatory surgical facility must:

(1) Adopt and implement policies and procedures that:

(a) Identify areas where surgery and invasive procedures may be performed;

(b) Define staff access to areas where surgery and invasive procedures are performed;

(c) Identify practitioner and advanced registered nurse practitioner's privileges for operating room staff; and

(d) Define staff qualifications and oversight.

(2) Use facility policies and procedures which define standards of care;

(3) Implement a system to identify and indicate the correct surgical site prior to beginning a surgical procedure;

(4) Provide emergency equipment, supplies, and services to surgical and invasive areas;

(5) Provide separate refrigerated storage equipment with temperature alarms, when blood is stored in the surgical department; and

(6) Assure a registered nurse qualified by training and experience functions as the circulating nurse in every operating room whenever deep sedation or general anesthesia are used during surgical procedures.