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This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Rule 3701-83-18 | Personnel and staffing requirements - ambulatory surgical facilities.


(A) Each ASF shall maintain qualified nursing and physician staff, and qualified dental staff, as appropriate for the services provided. Each ASF shall, based on the services provided and the number of patients served, maintain a sufficient number of staff and other personnel and an appropriate schedule of staff time to meet the needs of its patients in a timely manner.

(B) Each ASF shall have a medical director and an administrator as defined in rule 3701-83-01 of the Administrative Code. If the ASF limits its services:

(1) To dental/oral and maxillofacial surgery, a dentist may serve as the medical director; or

(2) To podiatric surgery, a podiatrist may serve as the medical director.

(C) Each ASF shall have a director of nursing who is an RN with experience in surgical and recovery room nursing care. The director of nursing shall be responsible for the management of nursing services.

(D) Each ASF shall only grant privileges to physicians, podiatrists, dentists, and CRNAs:

(1) Whose professional license or certification is maintained in good standing; and

(2) Who meet other guidelines as determined by the governing body.

(E) At all times when patients are receiving treatment or recovering from treatment until they are discharged from post anesthesia care, the ASF shall have present and on duty in the ASF at least one member of the physician staff, podiatry staff, or dental staff, as applicable.

(F) At all times when patients are receiving treatment or recovering from treatment until they are discharged, the ASF shall:

(1) Have at least two nurses present and on duty in the ASF, at least one of whom shall be an RN and at least one of whom is currently certified in advanced cardiac life support who shall be present and on duty in the recovery room when patients are present;

(2) In addition to the requirement of paragraph (F)(1) of this rule, have at least one RN shall be readily available on an on-call basis; and

(3) Have sufficient and qualified additional staff present to attend to the needs of the patients shall be present.

(G) Each ASF shall maintain the following:

(1) An established system of records sufficient for the director to ascertain that all individuals employed at the ASF in a professional capacity meet the standards applicable to that profession, including, but not limited to, possessing a current Ohio license, registration, or other certification required by law; and

(2) Staffing schedules, time-worked schedules, on-call schedules, and payroll records for at least two years.

(H) Each ASF shall provide an ongoing training program for its personnel. The program shall provide both orientation and continuing training to all staff members.

(1) The orientation shall be appropriate to the tasks that each staff member will be expected to perform; and

(2) The continuing training shall be designed to assure appropriate skill levels are maintained and that staff are informed of changes in techniques, philosophies, goals, and similar matters. The continuing training may include attending and participating in professional meetings and seminars.

(I) Each ASF shall require that each physician who practices at the facility complies with any provision of the Revised Code related to the obtaining of informed consent from a patient.

Supplemental Information

Authorized By: 3702.13, 3702.30
Amplifies: 3702.12, 3702.13, 3702.30
Five Year Review Date: 8/14/2021
Prior Effective Dates: 1/13/1996, 6/27/1996, 9/5/2002, 6/1/2006, 4/24/2011