(B) The governing body shall:
(1) At least every twenty-four months review, update, and approve the surgical procedures that may be performed at the facility and maintain an up-to-date listing of these procedures;
(2) Grant or deny clinical (medical-surgical and anesthesia) privileges, in writing and reviewed or re-approved at least every twenty-four months, to physicians and other appropriately licensed or certified health care professionals based on documented professional peer advice and on recommendations from appropriate professional staff. These actions shall be and based on documented evidence of the following:
(a) Current licensure and certification, if applicable;
(b) Relevant education, training, and experience; and
(c) Competence in performance of the procedures for which privileges are requested, as indicated in part by relevant findings of quality assessment and improvement activities and other reasonable indicators of current competency.
(3) In the case of an ASF owned and operated by a single individual, provide for an external peer review by an unrelated person not otherwise affiliated or associated with the individual. The external peer review shall consist of a quarterly audit of a random sample of surgical cases.
(4) Designate a qualified professional trained in infection control to direct the infection control program required by paragraph (D) of rule 3701-83-09 of the Administrative Code. For the purpose of this rule, a qualified professional trained in infection control means a nurse or physician as defined in rule 3701-83-01 of Administrative Code, who has documentation of completion of training in infection control, including, but not limited to, continuing education units, in-service training, or academic or vocational course completion.
Five Year Review (FYR) Dates: 02/16/2016 and 02/15/2021
Promulgated Under: 119.03
Statutory Authority: 3702.13, 3702.30
Rule Amplifies: 3702.12, 3702.13, 3702.30
Prior Effective Dates: 1/13/1996, 9/5/02, 6/1/06, 4/24/11