The purpose of this section is to manage environmental hazards and risks, prevent accidents and injuries, and maintain safe conditions for patients, visitors, and staff.

(1) An ambulatory surgical facility must create and follow an environment of care management plan that addresses safety, security, hazardous materials and waste, emergency preparedness, fire safety, medical equipment, utility systems and physical environment.

(2) An ambulatory surgical facility must assure the environment of care management plan contains the following items:

(a) Safety:

(i) Policies and procedures on safety-related issues such as but not limited to physical hazards and injury prevention;

(ii) Method to educate and periodically review with staff the safety policies and procedures;

(iii) Process to investigate, correct and report safety-related incidents; and

(iv) Process to keep the physical environment free of hazards.

(b) Security:

(i) Policies and procedures to protect patients, visitors, and staff while in the facility including preventing patient abduction;

(ii) Method to educate and periodically review security policies and procedures with staff; and

(iii) When the facility has security staff, train the security staff to a level of skill and competency for their assigned responsibility.

(c) Hazardous materials and waste:

(i) Establish and implement a program to safely control hazardous materials and waste according to federal, state, and local regulations;

(ii) Provide space and equipment for safe handling and storage of hazardous materials and waste;

(iii) Process to investigate all hazardous material or waste spills, exposures, and other incidents, and report as required to appropriate authority; and

(iv) Method to educate staff on hazardous materials and waste policies and procedures.

(d) Emergency preparedness:

(i) Establish, implement and periodically review a disaster plan for internal and external disasters that is specific to the facility and community;

(ii) Process to educate and train staff on the disaster plan;

(iii) Process to periodically conduct drills to test the plan.

(e) Fire safety:

(i) Policies and procedures on fire prevention and emergencies including an evacuation plan; and

(ii) Process to orient, educate, and conduct drills with staff fire prevention, emergency and evacuation policies and procedures.

(f) Medical equipment:

(i) Method to operate and maintain medical equipment properly, safely and according to manufacturer's recommendations;

(ii) Perform and document preventive maintenance; and

(iii) Process to investigate, report, and evaluate procedures in response to equipment failures.

(g) Utility systems:

(i) Policies and procedures to operate and maintain a safe and comfortable environment; and

(ii) Process to investigate and evaluate utility systems problems, failures, or user errors and report incidents.

(h) Physical environment:

(i) Process to keep the physical environment clean including cleaning the operating room between surgical procedures;

(ii) Provide hot and cold running water under pressure;

(iii) Assure hot water for handwashing does not exceed 120°F;

(iv) Assure cross connection controls meet the requirements of the state plumbing code; and

(v) Operate and maintain ventilation to prevent objectionable odors and excessive condensation.