HAR 11-95 — FREESTANDING SURGICAL OUTPATIENT FACILITIES (§ 11-95-1 to 11-95-100)

The purpose of this chapter is to establish minimum requirements for the protection of the health, welfare, and safety of patients, personnel, and the public in freestanding surgical outpatient facilities. This chapter shall not be construed as lowering standards, ordinances, or …

A consultive dietitian shall supervise the preparation and service of whatever special diets may be deemed necessary for the patients to meet the objectives of the facility. There shall be written policies covering whatever dietetic services are deemed necessary by the governing …

If any provision of this chapter or the application thereof to any person or circumstances is held invalid, the remainder of this chapter or the application of the provisions to other persons or circumstances shall not be affected thereby. Notes Haw. Code R. § 11-95-100 [Eff MAR …

Appropriate policies shall be written to provide for cooperation with civil and military authorities in the event of a disaster for disaster relief under chapter 127, HRS which would require use of the equipment and personnel of the facility staff. Notes Haw. Code R. § 11-95-11 […

(a) The facility shall have an appropriate written preventive maintenance program which documents compliance with all life safety codes of the state and county. (b) Inspection of all devices essential to the health and safety of patients, personnel, and visitors shall be carried …

(a) The governing body shall be the supreme authority of the facility, responsible for the management, control and operation of the facility, including the appointment of an administrator and the appointment of a medical director. (b) The governing body shall appoint the medical …

(a) Definitive policies and procedures governing sterilization techniques shall be developed. All equipment shall be sterilized either by pressurized steam sterilization or gas sterilization. The procedures shall be written and shall include: (1) The technique to be used for a pa…

There shall be an appropriate inservice education program. This shall include, but not be limited to, annual training in fire prevention, infection control, and accident prevention. There shall be adequate documentation of these educational procedures. Notes Haw. Code R. § 11-95-…

Sufficient laboratory facilities shall be made available to carry out the objectives of the facility. the laboratory procedures shall be carried out by qualified medical technologists, at least one of whom shall be available as long as a patient is in the facility. Such a laborat…

(a) Provision shall be made for the handling, storage, and transportation of soiled and clean laundry and for satisfactory cleaning procedures. (b) Infectious laundry shall be handled in accordance with section 325-7, HRS, relating to potentially infectious laundry. Notes Haw. Co…

(a) Facilities licensed under this chapter shall be inspected at least annually by appropriate fire authorities for compliance with state and county laws. (b) A written and posted fire control and evacuation plan shall be maintained and kept current. Notes Haw. Code R. § 11-95-18…

(a) It shall be the responsibility of the medical director to develop appropriate written policies and procedures to provide the necessary preventive, diagnostic, and therapeutic services to patients in order to achieve the objectives of the facility. (b) In cooperation with the …

as used in this chapter: "Administrator" is the person to whom is delegated the responsibility for the interpretation and implementation of the policies and programs established by the governing body. This person may or may not be the same as the medical director. The administrat…

(a) There shall be available sufficient, appropriate qualified staff and necessary supporting personnel to facilitate the accurate processing, checking, indexing, filing, and prompt retrieval of records and record data. (b) All patient records shall be considered confidential and…

(a) There shall be an organized medical staff that has overall responsibility for the quality of medical care provided to the patients and for the ethical conduct and professional practice of its members. (b) The facility shall not permit interns, residents, fellows, graduates of…

A nuclear medical service, when provided by the facility, shall be under the direction of an appropriately qualified physician. There shall be written policies covering procedures, and ongoing training, in handling radioactive materials. Where applicable, provisions of chapter 33…

(a) Each facility shall have a nursing staff which shall be directed by the director of nursing. The director of nursing shall be a qualified registered professional nurse who shall be appointed by the administrator with the approval of the governing body. The director of nursing…

Examination of all tissues removed at the time of operation shall be performed by a pathologist. A report of the examination shall be placed in the patient's medical record. Certain permitted procedures may be exempt from this examination at the discretion of the director. Notes …

(a) All patients admitted to the facility shall be under the care of a medical staff member. (b) An appropriate medical history and physical examination shall be obtained within seventy-two hours prior to admission of the patient. A record of these procedures shall be on the pati…

In addition to any other appropriate action to enforce this chapter, the director may initiate procedures for invoking penalties as provided in chapter 321, HRS. Notes Haw. Code R. § 11-95-26 [Eff MAR 3, 1986] (Auth: HRS §§ 321-9, 321-10) (Imp: HRS §§ 321-10, 321-18)

(a) Medicines shall not be administered to patients unless ordered by a physician. The orders shall be in writing or, if given orally, shall be promptly reduced to writing and signed by the physician prior to discharge of the patient. (b) Medicines maintained in the facility shal…

The radiology service shall be directed by a qualified radiologist and be staffed by qualified technical personnel. There shall be written policies governing all radiological procedures. Sufficient diagnostic and therapeutic radiological equipment shall be available to satisfy th…

At the time of discharge from the facility, each patient, or another suitable person, shall be provided with appropriate information concerning community services which are available for home care needs. Notes Haw. Code R. § 11-95-29 [Eff MAR 3, 1986] (Auth: HRS §§ 321-9, 321-10)…

(a) No person, or group of persons, shall operate a freestanding surgical outpatient facility unless it is licensed by the director. (b) Any person, or group of persons desiring to operate a freestanding surgical outpatient facility shall apply to the director for a license on fo…

(a) Each operating room and surgical suite shall be appropriately equipped and supplied for the types of procedures to be performed. (b) Each recovery area shall be appropriately equipped and supplied for the post-anesthetic recovery of surgical patients. (c) The following equipm…

The facility shall establish transfer agreements which will expedite the transfer of patients to hospitals when needed. There shall be documented evidence that a local hospital has agreed to admit without delay, patients from the facility, should the staff of the facility feel th…

Notes Haw. Code R. §§ 11-95-33 through 11-95-99

(a) The director, after due notice, and after suitable opportunity for a hearing, may suspend, revoke, or refuse to issue or renew a license to any governing body because of failure to meet: (1) The requirements of this chapter; or (2) The conditions under which the license was i…

(a) The administrative personnel under the direction of an administration shall develop and carry out such administrative procedures as are necessary to achieve the objectives and policies of the governing body. (b) The administrator shall establish policies and develop procedure…

(a) General, local, or regional anesthesia shall be administered to patients only by a certified registered nurse anesthetist or by a qualified physician. The anesthesia shall be administered only under the supervision of a licensed physician. (b) Flammable anesthetics shall be p…

Where the facility does not employ a qualified person to render a required and necessary service, it shall have a written contract with an appropriately qualified outside person or provider to perform such service. Notes Haw. Code R. § 11-95-7 [Eff MAR 3, 1986] (Auth: HRS §§ 321-…

(a) Arrangements shall be made to quickly summon additional personnel to any area when needed in an emergency situation. (b) There shall be sufficient telephones (not pay telephones) located in separate areas so that at least one is quickly accessible in any part of the facility …

(a) The facility shall be constructed and maintained in accordance with state and county zoning, building, fire safety, and sanitation laws, ordinances, and rules. New construction and remodeling shall be guided by "Minimum Requirements of Construction & Equipment for Hospital & …