Georgia Administrative Code

(1) Each ambulatory surgical treatment center shall be organized with an identifiable governing body that establishes the objectives, sets the policies and assumes full legal responsibilities for the overall conduct of the center and for compliance with all applicable laws and re…

Each ambulatory surgical center, when applying for a permit shall designate the type(s) or classification(s) of services to be provided in or by the center. These classifications may include, but are not necessarily limited to the following: general surgery; eye, ear, nose, and t…

(1) Any person or persons responsible for the operation of an ambulatory surgical treatment center as defined and classified in these regulations, or who may hereafter propose to establish and operate such an institution, shall submit an application to the Department for a permit…

(1) Following inspection and classification of the institution for which application for a permit has been made, the Department may issue a permit or a provisional permit or refuse to reissue or continue a permit or provisional permit. Each permit or provisional permit shall indi…

Provisional permits may be issued for a limited period specified by the Department based on an acceptable written plan for correcting one or more deficiencies (plan of correction) found during an inspection; provisional permits issued shall remain in force and effect for such lim…

(1) The ambulatory surgical treatment center shall be available at all reasonable and/or scheduled operating hours for observation and examination by properly identified representative of the Department. (2) The governing body shall notify the Department of the anticipated openin…

(1) All services provided by or in the center shall be provided by persons who are currently licensed to perform the services they render when such services require licensure or registration under the laws of the State of Georgia. There shall be a sufficient number of qualified s…

The following minimum physical plant and operational standards shall be met by an applicant or licensee as a prerequisite for the issuance and continuance of a permit to operate an ambulatory surgical treatment center. The failure of any licensee to comply with the minimum standa…

(1) The governing body shall appoint an administrator who is responsible for the day-today management and operation of the center. (2) The administrator shall designate an individual to act for him in his absence in order to provide the center with administrative direction at all…

(1) A full-time employee shall be designated responsible for establishing and maintaining medical records required to be kept by these rules and regulations. (2) Medical records containing sufficient information to validate the diagnosis and to establish the basis upon which trea…

(1) Each center shall provide administrative space and facilities for admitting patients and other service, such as telephone and information office files and supplies, patients' personal belongings, medical records and files. (2) A waiting room area shall be provided with a seat…

(1) Laboratory services utilized by an ambulatory surgical treatment center shall be consistent with requirements of the Clinical Laboratory Licensure Law, O.C.G.A. § 31-22-1et seq., and applicable amendments and regulations, which provide for clinical laboratory services to be e…

(1) Each center shall provide sufficient space and equipment and ensure that housekeeping and maintenance is sufficient to keep the center and equipment in a clean and tidy condition and state of good repair. Proper maintenance shall be provided as necessary to correct, prevent, …

Each center shall provide adequate space and equipment and staff to assure that drugs are stored and administered in compliance with State and Federal laws and regulations.

Each center which provides service for which blood is needed, shall provide separate refrigeration for the storage of blood and shall have a written agreement with a source for meeting its blood needs. If blood is retained overnight, such refrigeration shall be equipped with a te…

All X-Ray facilities in the center shall be registered with and meet the requirements of rules and regulations of governing radiological health as promulgated by the Department. X-Rays and x-ray reports shall be made a part of the patient's record.

(1) All electrical work and equipment shall be designed and installed in accordance with State and local laws and ordinances. (2) All areas of the center shall have sufficient artificial lighting for designated purpose. (3) Centers which utilize general anesthesia shall provide a…

(1) All centers shall provide facilities for maintaining sanitary standards throughout the premises, as well as for water supply, sewerage, garbage and refuse, disposal systems. Such facilities shall meet local and State regulations. (2) All garbage, trash and waste shall be stor…

Any advertising of the services provided in or by ambulatory surgical treatment center shall include the full name of the center and its Georgia license number, as shown on the face of the permit.

The Department may waive any rule for a stated period of time when it is shown that the specific rule is not applicable or when a waiver is needed to permit experimentation and demonstration of new and innovative approaches to the delivery of services which will not jeopardize th…

An ambulatory surgical treatment center which fails to comply with these rules and regulations shall be subject to revocation of its permit or provisional permit and/or other sanctions provided by law. The enforcement and administration of these rules and regulations shall be as …

These regulations are applicable only to ambulatory surgical treatment centers and the services provided therein, and expressly do not modify or revoke any of the provisions of the published rules of the Department of Community Health, Chapter 111-8-40 (Rules and Regulations for …

In the event that any rule, sentence, clause or phrase of any of these rules and regulations may be construed by any court of competent jurisdiction to be invalid, illegal, unconstitutional, or otherwise unenforceable, such determination or adjudication shall in no manner affect …

These rules shall be known as the Rules and Regulations for Hospitals. The purpose of these rules is to provide for the inspection and issuance of permits for hospitals and to establish minimum requirements for facilities operating under a hospital permit.

Unless a context otherwise requires, these identified terms mean the following when used in these rules: (a) Board certified means current certification of a licensed physician by a specialty board recognized by the American Board of Medical Specialties (ABMS) or American Osteopa…

No person, corporation, association, or other entity shall establish, operate, or maintain a hospital in Georgia without a permit or provisional permit. (a) A permit is required for each hospital. Multi-building hospitals may request a single permit to include all buildings provi…

The following classes of hospitals are exempt from these rules: (1) Federally owned and/or operated hospitals. Hospitals owned or operated by the federal government are exempt from these rules and the requirement for a Georgia hospital permit; and (2) Residential Mental Health Fa…

An application for a permit to operate a hospital shall be submitted on forms provided by the Department. The application submitted to the Department shall be an original document. No application shall be considered by the Department unless it is complete and accompanied by all r…

The Department may refuse to grant an initial permit, revoke a current permit, or impose other sanctions as described herein and in the rules for the "General Licensing and Enforcement Requirements," Chapter 111-8-25. (a) Denial of an Application for a Permit. The Department may …

(1) Inspections by the Department. The hospital shall be available during all hours of operation for observation and examination by properly identified representatives of the Department. (a) Initial Inspection. There shall be an initial inspection of a hospital prior to the openi…

There shall be full disclosure of hospital ownership to the Department at the time of the initial application and when requested. In the case of corporations and partnerships, the names of all corporate officers, partners, and all others owning five (5) percent or more of corpora…

The hospital shall have an established and functioning governing body that is responsible for the conduct of the hospital as an institution and that provides for effective hospital governance, management, and budget planning. (a) The governing body shall be organized under bylaws…

The hospital shall develop, implement, and enforce policies and procedures to ensure that each patient is: (a) Informed about the hospital's grievance process, including whom to contact to file a grievance or complaint with the hospital and that individual's telephone number, and…

Each hospital shall have an organized medical staff that operates under bylaws adopted by the medical staff and approved by the governing body. The bylaws may provide for the exercise of the medical staff's authority through committees. (a) Organization of the Medical Staff. The …

The hospital shall select and organize sufficient qualified and competent personnel to meet patients' needs and in a manner appropriate to the scope and complexity of the services offered. (a) The hospital shall establish and implement human resources policies and procedures to i…

The governing body shall establish and approve a plan for a hospital-wide quality management program, which includes the use of peer review committees. The purpose of the quality management program is to measure, evaluate, and improve the provision of patient care. (a) The scope …

The hospital shall be equipped and maintained to provide a clean and safe environment for patients, employees, and visitors. (a) Safety. The hospital shall develop and implement an effective hospital-wide safety program that includes the following components: 1. A fire safety pro…

The hospital shall prepare for potential emergency situations that may affect patient care by the development of an effective disaster preparedness plan that identifies emergency situations and outlines an appropriate course of action. The plan must be reviewed and revised annual…

The hospital shall have an effective infection control system to reduce the risks of nosocomial infections in patients, health care workers, volunteers, and visitors. (a) The hospital shall designate qualified infection control staff to coordinate the infection control program. (…

Each hospital shall designate a sterile processing service area designated for the decontamination, cleaning, sterilizing of reusable equipment, instruments, and supplies. (a) With the collaboration of the infection control program, the staff providing sterile processing services…

(1) Management of Patients' Medical Records. The hospital shall have an efficient and organized medical records service that establishes the policies and procedures for the maintenance of the medical records for all patients and that is administratively responsible for the manage…

All patient care services provided by the hospital shall be under the direction of a member of the medical staff or a licensed physician, dentist, osteopath, or podiatrist who has been granted hospital privileges. (a) Patient Assessment/Screening on Admission. The hospital shall …

The hospital shall utilize an effective and on-going discharge planning process that identifies post-hospital needs of inpatients and arranges for appropriate resource referral and follow-up care. (a) On admission, the nursing assessment shall identify patients who are likely to …

The hospital shall have an organized nursing service that provides twenty-four (24) hour nursing care to meet the needs of patients. Critical access hospitals are exempted from providing on-site twenty-four (24) hour nursing care when there are no hospitalized patients. (a) Organ…

The hospital shall provide or have access to effective pharmaceutical services to meet the needs of its patients in accordance with generally accepted standards of practice and applicable laws and regulations. (a) Pharmacy Director. All pharmaceutical services in the hospital sha…

The hospital shall have an organized food and dietary service that is directed and staffed by an adequate number of qualified personnel to meet the nutritional needs of hospital patients. All hospital food service areas and operations shall comply with current federal and state l…

(1) Imaging Services. The hospital shall maintain or arrange for effective imaging services to meet the needs of patients. The radiological imaging services shall be provided by the hospital in accordance with the rules under Chapter 111-8-90 Rules and Regulations for X-rays, whe…