TITLE 7 HEALTH
CHAPTER 11 OUTPATIENT FACILITIES
PART 2 REQUIREMENTS
FOR FACILITIES PROVIDING OUTPATIENT MEDICAL
SERVICES
AND INFIRMARIES
7.11.2.1 ISSUING AGENCY: New
Mexico Department of Health, Public Health Division, Health Facility Licensing
and Certification Bureau.
[10/31/96; 7.11.2.1
NMAC - Rn, 7 NMAC 11.2.1, 02/28/06]
7.11.2.2 SCOPE:
A. These
regulations apply to the following:
(1) public, profit or
nonprofit outpatient facilities, ambulatory surgical centers, diagnostic and
treatment centers, or infirmaries, providing services as outlined by these
regulations; or
(2) any facility
providing services as outlined by these regulations which by federal regulation
must be licensed by the state of New Mexico to obtain or maintain full or
partial, permanent or temporary federal funding.
B. These
regulations do not apply to the following: offices and treatment rooms of
licensed private practitioners.
[9/1/56, 7/1/60,
6/27/90; 7.11.2.2 NMAC - Rn & A, 7 NMAC 11.2.2,
02/28/06]
7.11.2.3 STATUTORY AUTHORITY: The
regulations set forth herein are promulgated by the secretary of the New Mexico
department of health, pursuant to the general authority granted under Section
9-7-6 (E) of the Department of Health Act, NMSA 1978,
as amended; and the authority granted under Sections 24-1-2 (D), 24-1-3 (I) and
24-1-5 of the Public Health Act, NMSA 1978, as
amended.
[9/1/56, 7/1/60,
6/27/90, 10/31/96; 7.11.2.3 NMAC - Rn, 7 NMAC 11.2.3,
02/28/06]
7.11.2.4 DURATION: Permanent.
[10/31/96; 7.11.2.4
NMAC - Rn, 7 NMAC 11.2.4, 02/28/06]
7.11.2.5 EFFECTIVE DATE:
October 31, 1996, unless a later date is specified at the end of a
section.
[10/31/96; 7.11.2.5
NMAC - Rn & A, 7 NMAC 11.2.5, 02/28/06]
7.11.2.6 OBJECTIVE:
A. Establish
minimum standards for licensing of health facilities who
provide outpatient medical services and infirmaries.
B. Monitor
health facilities providing outpatient medical services and infirmaries with
these regulations through surveys to identify any areas which could be
dangerous or harmful to the patients or staff.
C. Encourage
the establishment and maintenance of health facilities to provide outpatient
medical services and infirmaries to the citizens of New Mexico that provide
quality services that maintains or improves the health and quality of life to
the patients.
[9/1/56, 7/1/60,
6/27/90; 7.11.2.6 NMAC - Rn & A, 7 NMAC 11.2.6,
02/28/06]
7.11.2.7 DEFINITIONS:
A. "Applicant" means the individual who, or organization which, applies for a license;
if the applicant is an organization, then the individual signing the
application on behalf of the organization must have authority from the
organization; the applicant must be the owner.
B. “Certified registered nurse
anesthetist” means an advanced
practice professional registered nurse permitted by law to provide anesthesia
care; in an interdependent role as a member of a health care team in which
medical care of the patient is directed by a medical physician, osteopathic
physician, dentist or podiatrist licensed in the state of New Mexico; the
certified registered nurse anesthetist shall collaborate with the medical
physician, osteopathic physician, dentist or podiatrist concerning the
anesthesia care or the patient; collaboration means the process in which each
health care provider contributes their respective expertise.
C. "Deficiency" means a violation of or failure to comply with a provision(s) of these
regulations.
D. "Dentist" means a person licensed to practice dentistry in the state of New
Mexico under the Dental Act, Sections 61-5-1 to 61-5-22 NMSA
1978.
E. "Department" means the New Mexico department of health.
F. "Facility" means a building or buildings in which outpatient medical services are
provided to the public and which is licensed pursuant to this rule.
G. "Governing body" means the governing authority of a facility
which has the ultimate responsibility for all planning, direction, control and
management of the activities and functions of a facility licensed pursuant to
these regulations.
H. "License" means the document issued by the licensing authority pursuant to these
regulations granting the legal right to operate for a specified period of time,
not to exceed one (1) year.
I. ”Licensed practical nurse" means a person licensed as a trained
practical nurse under the Nursing Practice Act, Section 61-3-19 NMSA 1978.
J. “Licensee" means the person(s) who, or organization which, has an ownership,
leasehold, or similar interest in the facility and in whose name a license for
a facility has been issued and who is legally responsible for compliance with
these regulations.
K. "Licensing authority" means the New Mexico department of health.
L. "NMSA" means the New Mexico Statutes Annotated,
1978 compilation, and all the revisions and compilations thereof.
M. "Physician" means a person licensed to practice medicine or osteopathy by the New
Mexico board of medical examiners, pursuant to Section 61-6-10 NMSA 1978 or the osteopathic medical examiners board
pursuant to Sections 61-10-1 through 61-10-21, NMSA
1978.
N. "Physician's assistant" means a person licensed as a physician's
assistant by the New Mexico board of medical examiners, in accordance with
Section 61-6-6 NMSA 1978.
O. "Plan of correction" means the plan submitted by the licensee or
representative of the licensee addressing how and when deficiencies identified
at time of a survey will be corrected.
P. "Policy" means a statement of principle that guides and determines present and
future decisions and actions.
Q. "Premises" means all parts of buildings, grounds, and equipment of a facility.
R. "Procedure" means the action(s) that must be taken in order to implement a policy.
S. "Registered nurse" means a person who holds a certificate of
registration as a registered nurse under the Nursing Practice Act, Sections
61-3-1 to 61-3-30 NMSA 1978.
T. "Resident" as defined in Section 3 (I) of the Resident Abuse and Neglect Act
means any person who receives treatment from a health facility.
U. "U/L approved" means approved for safety by the national
underwriters laboratory.
V. "Variance" means an act on the part of the licensing authority to refrain from
pressing or enforcing compliance with a portion or portions of these
regulations for an unspecified period of time where the granting of a variance
will not create a danger to the health, safety, or welfare of patients or staff
of a facility, and is at the sole discretion of the licensing authority.
W. "Waive or waiver"
means to refrain from pressing or enforcing compliance with a portion or
portions of these regulations for a limited period of time provided the health,
safety, or welfare of the patients and staff are not in danger; waivers are
issued at the sole discretion of the licensing authority.
[9/1/56, 7/1/60,
6/27/90, 10/31/96; 7.11.2.7 NMAC - Rn & A, 7 NMAC
11.2.7, 02/28/06]
7.11.2.8 STANDARD OF COMPLIANCE: The
degree of compliance required throughout these regulations is designated by the
use of the words "shall" or "must" or "may".
"Shall" or "must" means mandatory. "May" means
permissive. The use of the words "adequate", "proper", and
other similar words means the degree of compliance that is generally accepted
throughout the professional field by those who provide out-patient services to
the public in facilities governed by these regulations.
[6/27/90; 7.11.2.8
NMAC - Rn, 7 NMAC 11.2.8, 02/28/06]
7.11.2.9 TYPES OF FACILITIES AND SCOPE
OF SERVICES:
A. Ambulatory
surgical center: means any distinct entity that operates exclusively for the
purpose of providing surgical services without anticipation of overnight stay
of patients. This type of facility may be integrated with the surgical
department of an existing hospital and its outpatient department utilizing many
of their services and resources. Those facilities which are freestanding may
provide some services such as specialized diagnostic and laboratory by
agreement or contract with another health care provider.
B. Diagnostic and treatment center: means a facility which provides a service to
the public on an outpatient basis for the diagnosis and treatment of medical
conditions not requiring hospitalization. Services provided are those
diagnostic and therapeutic services commonly furnished in a physician's office
or at the entry point into the health care delivery system. These include
medical history, physical examination, assessment of health status and
treatment for a variety of medical conditions.
C. Limited
diagnostic and treatment center: means a facility which provides on an outpatient
basis a limited scope of services. This type of facility provides services
usually in only one or two areas of preventive health, such as family planning,
hypertension, child health, prenatal, dental health etc; their services rely
heavily on consultation, referral and counseling. Because of their limited
scope of services and amounts of medical supplies and equipment less stringent
standards in building and fire codes are permitted.
D. Rural health clinic: means a facility which provides services to the public in a rural area
where there is a limited population and a shortage of physicians and other
health care providers. Services are the same as those of a diagnostic and
treatment center which are normally provided by a physician, but in a rural
health clinic may be provided by a nurse practitioner or a physician's
assistant. Facilities licensed as a rural health clinic must be located in a
geographic area in which it has been determined by the New Mexico department of
health or federal government, through the use of indices and other standards
set by them, that a shortage of physicians and health care personnel exist to
provide primary health care to the citizens of that area.
E. Infirmary: is a short term emergency medical and nursing care facility of an
educational institution which in conjunction with providing diagnostic and
treatment services to the members, has on a continuing 24-hour basis, inpatient
facilities and resources for short-term emergency medical and nursing care.
F. New or innovative clinic: When a professional organization has shown a
need for a new or innovative type of outpatient service which does not fit into
one of the categories of Subsections A through E of 7.11.2.9 NMAC of these
regulations, it may be licensed at the sole discretion of the licensing
authority, if all requirements outlined in 7.11.2.10 NMAC below have been met.
[9/1/56, 7/1/60,
6/27/90; 7.11.2.9 NMAC - Rn & A, 7 NMAC 11.2.9,
02/28/06]
7.11.2.10 INITIAL LICENSURE PROCEDURES: To
obtain an initial license for a facility pursuant to these regulations the
following procedures must be followed by the applicant.
A. Initial Phase: These regulations should be thoroughly understood by the applicant and
used as a reference for design of a new building or renovation or addition to
an existing building for licensure as a facility pursuant to these regulations.
Prior to starting construction, renovations or additions to an existing
building the applicant of the proposed facility shall:
(1) advise the
licensing authority of intention to open a facility pursuant to these
regulations and depending on the type of facility submit the following:
(a) ambulatory
surgical centers, diagnostic and treatment centers, rural health clinics and
infirmaries will submit a complete set of construction documents (blueprints)
for the total building;
(b) limited
diagnostic and treatment centers will submit a set of floor plans for the
building which must be of professional quality, be on substantial paper of at
least 18" x 24", and be drawn to an accurate scale of 1/4" to
1'; these plans must include:
(i) proposed use of each room e.g., waiting room, examination
room, office, etc.;
(ii) interior
dimensions of all rooms;
(iii) one
building or wall section showing exterior and interior wall construction;
section must include floor, wall, ceiling, and the finishes, e.g., carpet,
tile, gyp board with paint, wood paneling;
(iv) door
types, swing, and sizes of all doors, e.g. solid core, hollow core, 3'0" x
6'8", 1 3/4" thick;
(v) if building is
air conditioned;
(vi) indicate
all sinks, tubs, showers;
(vii) indicate
furnaces, and hot water heaters and if fuel fired, or electric;
(viii) indicate
windows to include size and type;
(ix) indicate
any level changes within the building e.g. steps or ramps;
(x) indicate fire
extinguishers, heat and smoke detectors and alarm systems;
(xi) locate the building on a
site/plot plan to determine surrounding conditions, include all steps, ramps,
parking areas, walks, and any permanent structures;
(xii) indicate
on plans if building is new construction, remodeled or alteration, or an
addition; if remodeled or an addition indicate existing and new construction on
the plans;
(2) the proposed
facility must also submit to the licensing authority a functional program
outline that provides the following information:
(a) scope of services
to be provided by the proposed facility;
(b) projected
number of patients to be served daily;
(c) number of staff
and duties to be performed;
(d) services that
will be contracted or arranged with another health provider i.e.; x-ray,
laboratory, etc.;
(e) number of examination rooms, operating
rooms, treatment rooms, and other rooms for diagnostic use such as x-ray, laboratory,
etc.;
(3) new or innovative
outpatient services will also submit a proposal to the licensing authority for
review and approval; the proposal must include at least the following:
(a) information
supporting the need for a special type of outpatient service;
(b) explanation of
the special problems and needs of the patients who will be receiving services;
(c) specify portions
of these regulations with which the new or innovative outpatient services would
be in conflict;
(d) information on
how the proposed facility would resolve these conflicts with alternative
measures which would meet the intent of these regulations, e.g., increased
staffing or fire and safety precautions;
(4) if at its sole discretion the licensing
authority approves the proposal for the new or innovative outpatient services,
a license may be granted with variances for those portions of the regulations
with which the program would be in conflict;
(5) blueprints or
floor plans will be reviewed by the licensing authority for compliance with
current licensing regulations building and fire codes;
(6) if blueprints or
plans are approved the licensing authority will advise the applicant that
construction may begin.
B. Construction
phase: During the construction of a new building or renovations or
additions to an existing building the applicant must coordinate with the
licensing authority and submit any changes to the blueprints or plans for
approval before making such changes.
C. Licensing
phase: Prior to completion of construction, renovation or addition to an existing
building the applicant will submit to the licensing authority the following:
(1) Application form:
(a) will be provided
by the licensing authority;
(b) all information
requested on the application must be provided;
(c) will be printed
or typed;
(d) will be dated and
signed;
(e) will be
notarized.
(2)
Fees: all applications for
licensure must be accompanied by the required fee.
(a) Current fee schedules will be provided by
the licensing authority.
(b) Fees must be in the form of a certified
check, money order, personal, or business check made payable to the state of
New Mexico.
(c) Fees are non refundable.
(3) Zoning and building approval:
(a)
All initial applications must be accompanied with written zoning
approval from the appropriate authority (city, county or municipality).
(b) All initial applications must be
accompanied with written building approval (certificate of occupancy) from the
appropriate authority (city, county, or municipality).
(4) Fire authority approval: all initial
applications must be accompanied with written approval of the fire authority
having jurisdiction.
(5) New Mexico environment department
approval: all initial applications must be accompanied by written approval of
the New Mexico environment department for the following:
(a) private water
supply, if applicable;
(b) private waste or
sewage disposal, if applicable;
(c) kitchen approval
for infirmaries if meals are prepared on site;
(d) x-ray
installation, if applicable.
(6) Copy of appropriate drug permit issued by
the state board of pharmacy.
D. Initial survey: Upon receipt of a properly completed application with all supporting
documentation as outlined above an initial survey of the proposed facility will
be scheduled by the licensing authority.
E. Issuance of license: Upon completion of the initial survey and determination that the
facility is in compliance with these regulations the licensing authority will issue
a license.
[9/1/56, 7/1/60,
7/1/64, 6/27/90; 7.11.2.10 NMAC - Rn, 7 NMAC 11.2.10,
02/28/06]
7.11.2.11 LICENSES:
A. Annual
license: An annual license is issued for a one (1) year period to a
facility which has met all requirements of these regulations.
B. Temporary
license: The licensing authority may, at its sole discretion, issue a
temporary license prior to the initial survey, or when it finds partial
compliance with these regulations.
(1) A temporary license shall cover a period
of time, not to exceed one hundred twenty (120) days, during which the facility
must correct all specified deficiencies.
(2) In accordance with Section 24-1-5 (D) NMSA 1978, no more than two (2) consecutive temporary
licenses shall be issued.
C. Amended
license: A licensee must apply to the licensing authority for an amended
license when there is a change of administrator/director or when there is a
change of name for the facility.
(1) Application must be on a form provided by
the licensing authority.
(2) Application must be accompanied by the
required fee for amended license.
(3) Application must be submitted within ten
(10) working days of the change.
[9/1/56, 7/1/60,
6/27/90, 10/31/96; 7.11.2.11 NMAC - Rn, 7 NMAC
11.2.11, 02/28/06]
7.11.2.12 LICENSE RENEWAL:
A. Licensee
must submit a renewal application on forms provided by the licensing authority,
along with the required fee at least thirty (30) days prior to expiration of
the current license.
B. Upon
receipt of renewal application and required fee prior to expiration of their
current license, the licensing authority will issue a new license effective the
day following the date of expiration of the current license if the facility is
in substantial compliance with these regulations.
C. If
a licensee fails to submit a renewal application with the required fee and the
current license expires, the facility shall cease operations until it obtains a
new license through the initial licensure procedures. Section 24-1-5 (A) NMSA 1978, as amended, provides that no health facility
shall be operated without a license.
[9/1/56, 7/1/60,
7/1/64, 6/27/90, 10/31/96; 7.11.2.12 NMAC - Rn, 7
NMAC 11.2.12, 02/28/06]
7.11.2.13 POSTING OF LICENSE: The
facility's license must be posted in a conspicuous place on the licensed
premises in an area visible to the public.
[9/1/56, 7/1/60,
6/27/90; 7.11.2.13 NMAC - Rn, 7 NMAC 11.2.13,
02/28/06]
7.11.2.14 NONTRANSFERABLE RESTRICTION ON
LICENSE:
A. A
license shall not be transferred by assignment or otherwise to other persons or
locations. The license shall be void and must be returned to the licensing
authority when any one of the following situations occurs:
(1) ownership of the
facility changes;
(2) the facility
changes location;
(3) licensee of the
facility changes;
(4) the facility
discontinues operation.
B. A
facility wishing to continue operation as a licensed facility under
circumstances Paragraphs (1) - (4) of Subsection A of 7.11.2.14 NMAC above must
submit an application for initial licensure in accordance with 7.11.2.10 NMAC
of these regulations at least thirty 30 days prior to the anticipated change.
[9/1/56, 7/11960,
6/27/90, 10/31/96; 7.11.2.14 NMAC - Rn, 7 NMAC
11.2.14, 02/28/06]
7.11.2.15 AUTOMATIC EXPIRATION OF LICENSE: A
license will automatically expire at midnight on the day indicated on the
license as the expiration date, unless sooner renewed, suspended, or revoked:
or
A. on
the day a facility discontinues operation; or
B. on
the day a facility is sold, leased, or otherwise changes ownership and/or
license; or
C. on
the day a facility changes location.
[9/1/56, 7/1/60,
7/1/64, 6/27/90, 10/31/96; 7.11.2.15 NMAC - Rn &
A, 7 NMAC 11.2.15, 02/28/06]
7.11.2.16 SUSPENSION OF LICENSE WITHOUT
PRIOR HEARING. In accordance with Section 24-1-5 (H) NMSA 1978, if immediate action is required to protect human
health and safety, the licensing authority may suspend a license pending a
hearing, provided such hearing is held within five (5) working days of the
suspension, unless waived by the licensee.
[9/1/56, 7/1/60,
6/27/90; 7.11.2.16 NMAC - Rn, 7 NMAC 11.2.16,
02/28/06]
7.11.2.17 GROUNDS FOR REVOCATION OR
SUSPENSION OF LICENSE, DENIAL OF INITIAL OR RENEWAL APPLICATION FOR LICENSE, OR
IMPOSITION OF INTERMEDIATE SANCTIONS OR CIVIL MONETARY PENALTIES: A
license may be revoked or suspended, an initial or renewal application for license
may be denied, or intermediate sanctions or civil monetary penalties may be
imposed after notice and opportunity for a hearing, for any of the following:
A. failure
to comply with any provision of these regulations;
B. failure
to allow survey by authorized representatives of the licensing authority;
C. any
person active in the operation of a facility licensed pursuant to these
regulations shall not be under the influence of alcohol or narcotics or
convicted of a felony;
D. misrepresentation
or falsification of any information on application forms or other documents
provided to the licensing authority;
E. discovery
of repeat violations of these regulations during surveys; or
F. failure
to provide the required care and services as outlined by these regulations for
the patients receiving care at the facility.
[9/1/56, 7/1/60,
7/1/64, 6/27/90, 10/31/96; 7.11.2.17 NMAC - Rn &
A, 7 NMAC 11.2.17, 02/28/06]
7.11.2.18 HEARING PROCEDURES:
A. Hearing
procedures for an administrative appeal of an adverse action taken by the
licensing authority against a facility's license as outlined in Sections 16 and
17 of 7.11.2 NMAC above will be held in accordance with adjudicatory hearings,
New Mexico department of health, 7.1.2 NMAC.
B. A
copy of the above regulations will be furnished to a facility at the time an
adverse action is taken against its license by the licensing authority. A copy may be requested at any time by
contacting the licensing authority.
[9/1/56, 7/1/60, 6/271990,
10/31/96; 7.11.2.18 NMAC - Rn, 7 NMAC 11.2.18,
02/28/06]
7.11.2.19 CURRENTLY LICENSED FACILITIES: Any
facility currently licensed on the date these regulations are promulgated and
which provides the services prescribed under these regulations, but which fails
to meet all building requirements, may continue to be licensed under the
appropriate type of outpatient facility.
A. Variance
may be granted for those building requirements the facility cannot meet
provided the variances granted will not create a hazard to the health, safety
and welfare of the patients and staff; and
B. the
building requirements for which variances are granted cannot be corrected
without an unreasonable expense to the facility; and
C. variances
granted will be recorded and made a permanent part of the facility file.
[7/1/60, 6/27/90;
7.11.2.19 NMAC - Rn, 7 NMAC 11.2.19, 02/28/06]
7.11.2.20 NEW FACILITY:
A. A
new facility may be opened in an existing building or a newly constructed building.
If opened in an existing building a variance may be granted for those building
requirements the facility cannot meet under the same criteria outlined in
Subsections A, B and C of 7.11.2.19 NMAC of these regulations, if not in
conflict with existing building and fire codes. This is at the sole discretion
of the licensing authority.
B. A
new facility opened in a newly constructed building must meet all requirements
of these regulations.
[6/27/90; 7.11.2.20
NMAC - Rn, 7 NMAC 11.2.20, 02/28/06]
7.11.2.21 FACILITY SURVEYS:
A. Application
for licensure, whether initial or renewal, shall constitute permission for
entry into and survey of a facility by authorized licensing authority
representatives at reasonable times during the pendency
of the application and, if licensed, during the licensure period.
B. Surveys
may be announced or unannounced at the sole discretion of the licensing
authority.
C. Upon
receipt of a notice of deficiency from the licensing authority the licensee or
his/her representative will be required to submit a plan of correction to the
licensing authority within ten (10) working days stating how the facility
intends to correct each violation noted and the expected date of completion.
D. The
licensing authority may at its sole discretion accept the plan of correction as
written or require modifications of the plan by the licensee.
[9/1/56, 7/1/64,
6/27/90; 7.11.2.21 NMAC - Rn, 7 NMAC 11.2.21,
02/28/06]
7.11.2.22 REPORTING OF INCIDENTS: All
facilities licensed pursuant to these regulations must report to the licensing
authority any serious incident or unusual occurrence which has, or could
threaten the health, safety, and welfare of the patients or staff, such as but
not limited to:
A. fire,
flood, or other natural disaster which creates structural damages to the
facility or poses health hazards;
B. any
serious outbreak of contagious diseases dangerous to the public health;
C. any
serious human errors by staff members of the facility which has resulted in the
death, serious illness, or physical impairment of a patient; or
D. in
accordance with Section 8A of the “Resident, Abuse, and Neglect Act”.
[6/27/90, 10/31/96;
7.11.2.22 NMAC - Rn & A, 7 NMAC 11.2.22,
02/28/06]
7.11.2.23 QUALITY ASSURANCE: All
facilities licensed pursuant to these regulations must have an ongoing,
comprehensive self-assessment of the services provided by the facility. The
assessment must include the total operation of the facility.
A. To
be considered comprehensive the assessment for quality assurance must include,
but is not limited to the following:
(1) condition of
patients and services rendered;
(2) completeness of
patient records;
(3) organization of
the facility;
(4)
administration;
(5) staff utilization
and training; and
(6) policies and
procedures.
B. Where
problems (or potential problems) are identified, the facility must act as soon
as possible to avoid any risks to patients such as, but not limited to the
following:
(1) changes in
policies and procedures;
(2) staffing and
assignment changes;
(3) additional
education and training for the staff;
(4) changes in
equipment or physical plant; or
(5) deletion or
addition of services.
C. The
governing body of the facility shall ensure that the effectiveness of the
quality assurance program is evaluated by medical and administrative staff at
least once a year. If the evaluation is not done all at once, no more than a
year must lapse between evaluations of the same parts.
D. Documentation
of the quality assurance program must be maintained by the facility.
[6/27/90; 7.11.2.23
NMAC - Rn & A, 7 NMAC 11.2.23, 02/28/06]
7.11.2.24 PATIENT RECORDS: Each
facility licensed pursuant to these regulations must maintain a medical record
for each patient. Every record must be accurate, legible and promptly completed.
Medical records must include at least the following:
A. ambulatory surgical centers:
(1) patient
identification;
(2) significant
medical history and results of physical examination;
(3)
pre-operative diagnostic studies (entered
before surgery), if performed;
(4) findings and
techniques of the operation, including a pathologist's report on all tissues
removed during surgery, except those exempted by the governing body;
(5) any allergies and
abnormal drug reactions;
(6) entries related
to anesthesia administration;
(7) documentation of
properly executed informed patient consent; and
(8) discharge
diagnosis;
B. diagnostic and treatment centers, rural
health clinics, limited diagnostic and treatment centers:
(1) patient
identification;
(2) patient consent
forms (if applicable);
(3) pertinent medical
history;
(4) assessment of the
health status and health care needs of the patient;
(5) brief summary of the episode for which the
patient is requiring care;
(6) disposition, and
instructions to the patient;
(7) reports of
physical examinations, diagnostic and laboratory test results, and consultative
findings; and
(8) all physician's
orders, reports of treatments and medication and other pertinent information
necessary to monitor the patient's progress;
C. infirmaries:
(1) same as
Paragraphs (1) through (8) of Subsection B of 7.11.2.24 NMAC above;
(2) nursing notes
(for those patients requiring overnight care or observation); and
(3) medication chart
(if applicable);
D. new or innovative outpatient service:
(1) same as Paragraphs (1) through (8) of
Subsection B of 7.11.2.24 NMAC] above;
(2) any other
information deemed necessary by the licensing authority after review and
approval of the new or innovative service.
[9/1/56, 7/1/60,
6/27/90; 7.11.2.24 NMAC - Rn & A, 7 NMAC 11.2.24,
02/28/06]
7.11.2.25 REPORTS AND RECORDS REQUIRED TO
BE ON FILE IN THE FACILITY: Each facility licensed pursuant to these
regulations must keep the following reports and records on file and make them
available for review upon request of the licensing authority.
A. A
copy of the latest fire inspection report by the fire authority having
jurisdiction.
B. A
copy of the last survey conducted by the licensing authority and any variances
granted.
C. Record
of fire and emergency evacuation drills conducted by the facility.
D. Licensing
regulations: A copy of these regulations: Requirements For
Facilities Providing Outpatient Medical Services and Infirmaries, New Mexico
department of health, 7.11.2 NMAC.
E. Health
certificates of staff.
F. A
copy of the current license, registration or certificate, of each staff member
for which a license, registration, or certification is required by the state of
New Mexico.
G. Latest
inspection by New Mexico environment department of radiological equipment, if
applicable.
H. Valid
drug permit as required by the state board of pharmacy.
I. Agreements
or contracts with other health care providers to provide services not available
in the facility, if applicable.
J. Latest
inspection of drug room by state board of pharmacy.
K. New
Mexico environment department approval of private water system, if applicable.
L. New
Mexico environment department approval of private waste or sewage disposal, if
applicable.
[9/1/56, 7/1/60,
6/27/90, 10/31/96; 7.11.2.25 NMAC - Rn, 7 NMAC
11.2.25, 02/28/06]
7.11.2.26 PATIENT RIGHTS:
A. All
facilities licensed pursuant to these regulations shall support, protect and
enhance the rights of patients as shown below:
(1) the right to efficient and equal service,
regardless of their race, sex, religion, ethnic background, education, social
class, physical or mental handicap, or economic status;
(2) the right of
considerate, courteous and respectful care from all staff of the facility;
(3) the right of
complete information in terms the average patient can reasonably be expected to
understand;
(4) the right to
informed consent and full discussion of risks and benefits prior to any
invasive procedure, except in an emergency; alternatives to the proposed
procedure must be discussed with the patient;
(5) the right to
obtain assistance in interpretation for non-English speaking patients;
(6) the right to know
the names, titles, and professions of the facility staff to whom the patient’s
speaks and from whom services or information are received;
(7) the right to
refuse examination, discussion and procedures to the extent permitted by law
and to be informed of the health and legal consequences of this refusal;
(8) the right of
access to patient's personal health records;
(9) the right of
respect for the patient's privacy;
(10) the right of
confidentiality of the patient's personal health records as provided by law;
(11) the right to
expect reasonable continuity of care within the scope of services and staffing
of the facility;
(12) the right to
respect for the patient's civil rights and religious opinions;
(13) the right to
present complaints to the management of the facility without fear of reprisal;
(14) the right to
examine and receive a full explanation of any charges made by the facility
regardless of source of payment.
B. Facility
staff shall be informed of and demonstrate their understanding of the policies
on patient rights and responsibilities through orientation and in-service
training activities.
C. Patient
rights will be posted in the facility both in English and Spanish where they
may be readily seen by the public.
D. The
method by which a patient may register a complaint will be posted in the
facility where it may be readily seen by the public.
[6/27/90; 7.11.2.26
NMAC - Rn, 7 NMAC 11.2.26, 02/28/06]
7.11.2.27 STAFF RECORDS: Each
facility licensed pursuant to these regulations must maintain a complete record
on file for each staff member or volunteer working more than half-time. Staff
records will be made available for review upon request of the licensing
authority.
A. Staff
records will contain at least the following:
(1) name;
(2)
address and telephone number;
(3) position for
which employed;
(4) date of employment;
(5) health certificate stating that the
employee is free from tuberculosis in a transmissible form as required by New
Mexico department of health regulations, Control of Communicable Disease in
Health Facility Personnel, 7.4.4 NMAC.
B. A
daily attendance record of all staff must be kept in the facility.
C. The
facility must keep weekly or monthly schedules of all staff. These schedules
must be kept on file for at least six (6) months.
[9/1/56, 7/1/60,
6/27/90, 10/31/96; 7.11.2.27 NMAC - Rn, 7 NMAC
11.2.27, 02/28/06]
7.11.2.28 POLICIES AND PROCEDURES:
A. All
facilities licensed pursuant to these regulations must have written policies
and procedures for the following:
(1) quality assurance
program;
(2) maintenance of
building and equipment;
(3) fire and evacuation;
(4) staff development
and evaluation;
(5) administration
and preparation of drugs;
(6) referral of
patients.
B. Ambulatory Surgical Center: In addition to those policies and procedures
listed in Subsection A of 7.11.2.28 NMAC of these regulations, ambulatory
surgical centers must have the following policies and procedures:
(1) transfer of
patients to hospital for patients requiring emergency care;
(2) for ambulance
services if applicable;
(3) transfer of medical information;
(4) resuscitative
techniques;
(5) aseptic
techniques and scrub procedures;
(6) care of surgical specimens;
(7) protocols of
surgical procedures;
(8) cleaning of
operating room after each use;
(9) sterilization and
disinfection;
(10) operating room
attire;
(11) care of anesthesia equipment;
(12) special provision
for infected or contaminated patients; and
(13) inspection and
maintenance of emergency equipment in operating room.
C. Infirmaries: In addition to those policies and procedures listed in Subsection A of
7.11.2.28 NMAC of these regulations, infirmaries must have the following
policies and procedures:
(1) inpatient care;
(2) transfer of
patients to hospital.
D. New or Innovative Outpatient Services: In addition to those policies and procedures
listed in Subsection A of 7.11.2.28 NMAC of these regulations, may have others required
by the licensing authority after review of program and approval of the new or
innovative service.
[6/27/90; 7.11.2.28
NMAC - Rn & A, 7 NMAC 11.2.28, 02/28/06]
7.11.2.29 GENERAL BUILDING REQUIREMENTS:
A. New Construction, Additions and Alterations: When construction of new buildings,
additions, or alterations to existing buildings are contemplated, plans and
specifications covering all portions of the work must be submitted to the
licensing authority for plan review and approval prior to beginning actual
construction. When an addition or alteration is contemplated, plans for the
entire facility must be submitted.
B. Access to the Handicapped: All outpatient facilities licensed pursuant
to these regulations must be accessible to and useable by handicapped
employees, staff, visitors, and patients.
C. Extent of a Facility: All buildings of the premises providing patient care and services will
be considered part of the facility and must meet all requirements of these
regulations. Where a part of the facility services are contained in another
facility, separation and access shall be maintained as described in current
building and fire codes.
D. Additional Requirements: A facility applying for licensure pursuant
to these regulations may have additional requirements not contained herein. The
complexity of building and fire codes and requirements of city, county, or
municipal governments may require these additional requirements. Any additional
requirements will be outlined by the appropriate building and fire authorities, and by the licensing authority through plan
review, consultation and on-site surveys during the licensing process.
[9/1/56, 7/1/60,
7/1/64, 6/27/90; 7.11.2.29 NMAC - Rn, 7 NMAC 11.2.29,
02/28/06]
7.11.2.30 MAINTENANCE OF BUILDING AND GROUNDS:
Facilities must maintain the building(s) in good repair at all times.
Such maintenance shall include, but is not limited to, the following.
A. All
electrical, signaling, mechanical, water supply, heating, fire protection, and
sewage disposal systems must be maintained in a safe and functioning condition,
including regular inspections of these systems.
B. All
equipment used for patient care shall be maintained clean and in good repair.
C. All
furniture and furnishings must be kept clean and in good repair.
D. The
grounds of the facility must be maintained in a safe and sanitary condition at
all times.
[9/1/56, 6/27/90;
7.11.2.30 NMAC - Rn, 7 NMAC 11.2.30, 02/28/06]
7.11.2.31 HOUSEKEEPING:
A. The
facility must be kept free from offensive odors and accumulations of dirt,
rubbish, dust, and safety hazards.
B. Examination
rooms, operating rooms, patient rooms, waiting areas and other areas of daily
usage must be cleaned daily.
C. Floors
and walls must be constructed of a finish that can be easily cleaned. Floor
polishes shall provide a slip resistant finish.
D. Bathrooms,
lavatories, and drinking fountains must be cleaned as often as necessary to
maintain a clean and sanitary condition.
E. Deodorizers
must not be used to mask odors caused by unsanitary conditions or poor
housekeeping practices.
F. Storage
areas must be kept free from accumulation of refuse, discarded equipment,
furniture, paper, and the like.
[9/1/56, 7/1/60,
6/27/90; 7.11.2.31 NMAC - Rn, 7 NMAC 11.2.31,
02/28/06]
7.11.2.32 WATER:
A. A
facility licensed pursuant to these regulations must be provided with an
adequate supply of water which is of a safe and sanitary quality suitable for
domestic use.
B. If
the water supply is not obtained from an approved public system, the private water
system must be inspected, tested, and approved by the New Mexico environment
department prior to licensure. It is the facility's responsibility to insure
that subsequent periodic testing or inspection of such private water systems be made at intervals prescribed by the New Mexico
environment department or recognized authority.
C. Hot
and cold running water under pressure must be distributed at sufficient
pressure to operate all fixtures and equipment during maximum demand periods.
D. Backflow
preventors (vacuum breakers) must be installed on
hose bibs, laboratory sinks, janitor's sinks, and on all other water fixtures
to which hoses or tubing can be attached.
E. Water
distribution systems are arranged to provide hot water at each hot water outlet
at all times. Hot water to hand washing facilities must not exceed 120 degrees
F.
[9/1/56, 7/1/60,
7/1/64, 6/27/90, 10/31/96; 7.11.2.32 NMAC - Rn &
A, 7 NMAC 11.2.32, 02/28/06]
7.11.2.33 SEWAGE AND WASTE DISPOSAL:
A. All
sewage and liquid wastes must be disposed of into a municipal sewage system
where such facilities are available.
B. Where
a municipal sewage system is not available, the system used must be inspected
and approved by the New Mexico environment department or recognized local
authority.
C. Where
municipal or community garbage collection and disposal service are not
available, the method of collection and disposal of solid wastes generated by
the facility must be inspected and approved by the New Mexico environment
department or recognized local authority.
D. Infectious
waste: Facilities licensed pursuant to these regulations which generate
infectious waste must insure that the method of disposal of such wastes meets
the requirements of the New Mexico environment department or recognized local
authority.
E. All
garbage and refuse receptacles must be durable, have tight fitting lids, must
be insect and rodent proof, washable, leak proof and constructed of materials
which will not absorb liquids. Receptacles must be kept clean.
[9/1/56, 7/1/60,
7/1/64, 6/27/90, 10/31/96; 7.11.2.33 NMAC - Rn, 7
NMAC 11.2.33, 02/28/06]
7.11.2.34 FIRE SAFETY COMPLIANCE: All
current applicable requirements of state and local codes for fire prevention
and safety must be met by the facility.
[9/1/56, 6/27/90; 7.11.2.34
NMAC - Rn & A, 7 NMAC 11.2.34, 02/28/06]
7.11.2.35 FIRE CLEARANCE AND INSPECTIONS: Each facility must request from the fire
authority having jurisdiction an annual fire inspection. If the policy of the
fire authority having jurisdiction does not provide for annual inspection of
the facility, the facility must document the date the request was made and to
whom. If the fire authorities do make annual inspections, a copy of the latest
inspection must be kept on file in the facility.
[9/1/56, 6/27/90;
7.11.2.35 NMAC - Rn, 7 NMAC 11.2.35, 02/28/06]
7.11.2.36 STAFF FIRE AND SAFETY TRAINING:
A. All
staff of the facility must know the location of and instructed in proper use of
fire extinguishers and other procedures to be observed in case of fire or other
emergencies. The facility should request the fire authority having jurisdiction
to give periodic instruction in fire prevention and techniques of evacuation.
B. Facility
staff must be instructed as part of their duties to constantly strive to detect
and eliminate potential safety hazards, such as loose handrails, frayed
electrical cords, faulty equipment, blocked exits or exit ways, and any other
condition which could cause burns, falls, or other personal injury to the
patients or staff.
C. Fire
and evacuation drills: The facility must conduct at least one (1) fire and
evacuation drill each month. A log must be maintained by the facility showing
the date, time, number of staff participating and outlining any problems noted
in the conduct of the drill.
[6/27/90; 7.11.2.36
NMAC - Rn, 7 NMAC 11.2.36, 02/28/06]
7.11.2.37 EVACUATION PLAN: Each
facility must have a fire evacuation plan conspicuously posted in each separate
area of the building showing routes of evacuation in case of fire or other
emergency.
[6/27/90; 7.11.2.37
NMAC - Rn, 7 NMAC 11.2.37, 02/28/06]
7.11.2.38 PROVISIONS FOR EMERGENCY CALLS:
A. An
easily accessible telephone for summoning help, in case of emergency, must be
available in the facility.
B. A
list of emergency numbers, including, but not limited to, fire department,
police department, ambulance services, and poison control center must be
prominently posted by the telephone(s).
[9-1-56, 7-1-60,
6-27-90; 7.11.2.38 NMAC - Rn, 7 NMAC 11.2.38, 02/28/06]
7.11.2.39 FIRE EXTINGUISHERS:
A. Fire
extinguishers as approved by the state fire marshal or fire prevention
authority having jurisdiction must be located in the facility.
B. Fire
extinguishers must be properly maintained as recommended by the manufacturer,
state fire marshal or fire authority having jurisdiction.
C. All
fire extinguishers must be inspected yearly and recharged as specified by the
manufacturer, state fire marshal, or fire authority having jurisdiction. All
fire extinguishers must be tagged, noting the date of inspection.
[9/1/56, 7/1/60,
7/1/64, 6/27/90; 7.11.2.39 NMAC - Rn, 7 NMAC 11.2.39,
02/28/06]
7.11.2.40 ALARM SYSTEM: A
manually operated, electrically supervised fire alarm system shall be installed
in each facility as required by national fire protection association 101 (life
safety code). Infirmaries, ambulatory surgical centers, and multiple story
facilities require manual alarm systems.
[7/1/60, 7/1/64, 6/27/90;
7.11.2.40 NMAC - Rn, 7 NMAC 11.2.40, 02/28/06]
7.11.2.41 FIRE DETECTION SYSTEM: The
facility must be equipped with smoke detectors as required by the NFPA 101 (life safety code) and approved in writing by the
fire authority having jurisdiction as to number type and placement.
[6/27/90; 7.11.2.41
NMAC - Rn, 7 NMAC 11.2.41, 02/28/06]
7.11.2.42 JANITORS CLOSET(S):
A. Each
facility shall have at least one (1) janitor's closet. If a facility is more
than one story there must be a janitor's closet on each floor.
B. Each
janitor's closet shall contain:
(1) a
service sink;
(2) storage
for housekeeping supplies and equipment.
C. Each
janitor's closet must be vented.
D. Janitor's
closet is a hazardous area and must be provided with one-hour fire separation
and 1 3/4" solid core door.
[7/1/60, 7/1/64,
6/27/90; 7.11.2.42 NMAC - Rn, 7 NMAC 11.2.42,
02/28/06]
7.11.2.43 EMERGENCY LIGHTING:
A. A
facility must be provided with emergency lighting which will activate
automatically upon disruption of electrical service.
B. The
emergency lighting must be sufficient to illuminate paths of egress and exits
of the facility.
C. Facilities
utilizing general anesthesia or life support equipment shall be provided
essential electrical services in accordance with national fire protection
association 99. Standard for health care facilities.
[9/1/56, 7/1/60,
7/1/64, 6/27/90; 7.11.2.43 NMAC - Rn, 7 NMAC 11.2.43,
02/28/06]
7.11.2.44 ELECTRICAL STANDARDS:
A. All
electrical installation and equipment must comply with all current state and
local codes.
B. Circuit
breakers or fused switches that provide electrical disconnection and over
current protection shall be:
(1) enclosed
or guarded to provide a dead front assembly;
(2) readily accessible for use and maintenance;
(3) set
apart from traffic lanes;
(4) located in a dry, ventilated space, free of corrosive fumes
or gases;
(5) able
to operate properly in all temperature conditions;
(6) panel
boards servicing lighting and appliance circuits shall be on the same floor and
in the same facility area as the circuits they serve;
(7) each panel board
will be marked showing the area each circuit breaker or fused switch services;
(8) the use of
jumpers or devices to bypass circuit breakers or fused switches is prohibited.
[9/1/56, 7/1/60,
7/1/64, 6/27/90; 7.11.2.44 NMAC - Rn, 7 NMAC 11.2.44,
02/28/06]
7.11.2.45 LIGHTING: The
facility must meet the following requirements for lighting:
A. all
spaces occupied by people, machinery, or equipment within buildings, approaches
to buildings, and parking lots shall have lighting;
B. lighting
will be sufficient to make all parts of the area clearly visible;
C. all
lighting fixtures must be shielded;
D. lighting
fixtures must be selected and located with the comfort and convenience of the
staff and patients in mind;
E. a
fixed or portable examination light must be provided for all examination and
treatment rooms.
[9/1/56, 7/1/60,
7/1/64, 6/27/90; 7.11.2.45 NMAC - Rn, 7 NMAC 11.2.45,
02/28/06]
7.11.2.46 ELECTRICAL CORDS AND ELECTRICAL
RECEPTACLES:
A. Electrical Cords and Extension Cords:
(1) Electrical cords and extension cords must
be U/L approved.
(2) Electrical cords and extension cords must
be replaced as soon as they show wear.
(3)
Under no circumstances shall extension cords be used as a general wiring
method.
(4) Extension cords must be plugged into an
electrical receptacle within the room where used and must not be connected in
one room and extended to some other room.
(5) Extension cords must not be used in
series.
B. Electrical Receptacles:
(1) Duplex grounded type electrical
receptacles (convenience outlets) must be installed in all areas in sufficient
quantities for tasks to be performed as needed. Each examination or work table
must have access to a minimum of two duplex receptacles. Exception: Limited diagnostic and treatment
centers are only required to have access to one duplex receptacle for
examination or work tables.
(2) The use of multiple sockets (gang plugs) in
electrical receptacles is strictly prohibited.
[9/1/56, 7/1/60,
7/1/64, 6/27/90; 7.11.2.46 NMAC - Rn, 7 NMAC 11.2.46,
02/28/06]
7.11.2.47 HEATING, VENTILATION AND AIR
CONDITIONING:
A. Heating,
air-conditioning, piping, boilers, and ventilation equipment must be furnished,
installed and maintained to meet all requirements of current state and local mechanical,
electrical, and construction codes.
B. The
heating method used by the facility must have a minimum
indoor-winter-design-capacity of seventy-five (75) degrees F with controls
provided for adjusting temperature as appropriate for patient and staff
comfort.
C. The
use of unvented heaters, open flame heaters or
portable heaters is prohibited.
D. An
ample supply of outside air must be provided in all spaces where fuel fired
boilers, furnaces, or heaters are located to assure proper combustion.
E. All
fuel fired boilers, furnaces, or heaters must be connected to an approved
venting system to take the products of combustion directly to the outside air.
F. A
facility must be adequately ventilated at all times to provide fresh air and
the control of unpleasant odors.
G. All
gas-fired heating equipment must be provided with a one-hundred (100) percent
automatic cutoff control valve in event of pilot failure.
H. The
facility must be provided with a system for maintaining patients and staff's
comfort during periods of hot weather.
I. All
boiler, furnace or heater rooms shall be protected from other parts of the
building by construction having a fire resistance rating of not less than one
hour. Door must be self-closing with 3/4 hour fire resistance.
J. Operating
room supply air shall be provided from ceiling outlets near the center of the
work area. Return air from floor level with at least two return inlets located
as remote as possible shall be provided.
K. All
central ventilation and air condition systems shall be provided filters having
efficiencies greater than twenty-five (25) percent. Operating rooms shall have
ninety (90) percent filter efficiencies.
[9/1/56, 7/1/60,
7/1/64, 6/27/90; 7.11.2.47 NMAC - Rn, 7 NMAC 11.2.47,
02/28/06]
7.11.2.48 WATER HEATERS:
A. Must
be able to supply hot water to all hot water taps within the facility at full
pressure during peak demand periods and maintain a maximum temperature of
one-hundred and twenty (120) degrees F.
B. Fuel
fired hot water heaters must be enclosed and separated from other parts of the
building by construction as required by current state and local building codes.
C. All
water heaters must be equipped with a pressure relief valve (pop-off-valve).
[7/1/60, 6/27/90;
7.11.2.48 NMAC - Rn, 7 NMAC 11.2.48, 02/28/06]
7.11.2.49 RADIOLOGY:
A. All
facilities licensed pursuant to these regulations which provide radiological
services to include portable and dental units must meet the requirements of the
New Mexico environment department for installation and use of the radiological
equipment.
B. For
those facilities providing radiological services the following is required:
(1) radiographic room
meeting the requirements as stated in Subsection A of 7.11.2.49 NMAC above;
(2) film processing
facilities;
(3) storage
facilities for exposed film;
(4) toilet room with
hand washing facilities accessible to fluoroscopy room(s), if fluoroscopic
procedures are part of the services; and
(5) dressing rooms or
booths, as required by services provided with convenient toilet access.
[6/27/90, 10/31/96;
7.11.2.49 NMAC - Rn & A, 7 NMAC 11.2.49,
02/28/06]
7.11.2.50 TOILETS, LAVATORIES AND BATHING
FACILITIES:
A. All
fixtures and plumbing must be installed in accordance with current state and
local plumbing codes.
B. All
toilets must be enclosed and vented.
C. All
toilet rooms must be provided with a lavatory for hand washing.
D. All
toilets must be kept supplied with toilet paper.
E. All
lavatories for hand washing, except those for scrub purposes in ambulatory
surgical centers, must be kept supplied with disposable towels for hand drying
or provided with mechanical blower.
F. Hand
washing lavatories for staff in patient care areas shall be trimmed with valves
that can be operated without hands (single-level devices may be used if they
meet this requirement).
G. Where
blade handles are used, they shall not exceed 4 1/2 inches, except that handles
on clinical sinks shall not be less than six (6) inches.
H. The
number of and location of toilets, lavatories and bathing facilities will be
mandated by requirements for each type facility. Such factors as extent of
services provided and size of facility will also dictate requirements.
[9/1/56, 7/1/60,
7/1/64, 6/27/90; 7.11.2.50 NMAC - Rn, 7 NMAC 11.2.50,
02/28/06]
7.11.2.51 EXITS:
A. Each
facility and each floor of a facility shall have exits as required/permitted by
national fire protection association 101 (life safety code).
B. Each
exit must be marked by illuminated signs having letters at least six (6) inches
high whose principle strokes are at least three-fourths (3/4) of an inch
wide. Exception: Limited diagnostic and
treatment centers may in some cases not be required to have the illuminated
exit signs but may use non-illuminated signs meeting the requirements as shown
above.
C. Illuminated
exit signs must be maintained in operable condition at all times.
D. Exit
ways must be kept free from obstructions at all times.
E. Exit
doors:
(1) Exit doors to all exit or exit access
doors must be at least 36" wide.
(2) Ambulatory surgical centers that use
general anesthesia or have patients on life support equipment must have exit
doors 44" in width.
[9/1/56, 7/1/60,
7/1/64, 6/27/90; 7.11.2.51 NMAC - Rn & A, 7 NMAC
11.2.51, 02/28/06]
7.11.2.52 CORRIDORS:
A. Ambulatory Surgical Centers:
(1) Minimum corridor width shall be six (6)
feet.
(2) In operating room and surgical suites
where patients are transported on stretchers or beds, corridors will have a
width of eight (8) feet.
B. All
other facilities: minimum corridor width shall be five (5) feet except work
corridors less than six (6) feet in length may be four (4) feet in width.
C. Facilities
will often be contained within existing commercial or residential buildings and
less stringent corridor widths may be allowed other than those contained in
Subsection B of 7.11.2.52 NMAC above if not in conflict with building or fire
codes and approved by the licensing authority prior to occupying the facility.
[9/1/56, 7/1/60,
7/1/64, 6/27/90; 7.11.2.52 NMAC - Rn, 7 NMAC 11.2.52,
02/28/06]
7.11.2.53 DOORS:
A. The
minimum door width for patient's use shall be 34" in width.
B. Patient
room doors in infirmaries shall be 44" in width 1 3/4" solid core.
C. Operating
rooms and recovery rooms shall have a minimum door width of 44".
D. Examination
and treatment rooms shall have a minimum door width of 36".
[9/1/56, 7/1/60,
7/1/64, 6/27/90; 7.11.2.53 NMAC - Rn, 7 NMAC 11.2.53,
02/28/06]
7.11.2.54 COMMON ELEMENTS FOR OUTPATIENTS
FACILITIES: The following shall apply to each outpatient
facility, with additions and/or modifications as noted for each specific type
of outpatient facility in other sections of these regulations or not applicable
based on scope of services provided by the facility. Administration and public areas:
A. Entrance
shall be able to accommodate wheelchairs.
B. Public
services shall include:
(1) conveniently
accessible wheelchair storage;
(2) a reception and
information counter or desk;
(3) waiting areas:
where an organized pediatric service is provided by the outpatient facility,
provisions shall be made for separating pediatric and adult patients;
(4) conveniently
accessible public toilets;
(5) conveniently
accessible drinking fountain(s).
C. Interview
space(s) for private interviews related to social service, medical information,
etc., shall be provided.
D. General
or individual office(s) for business transactions, records, administrative, and
professional staff shall be provided.
E. Clerical
space or rooms for typing, clerical work, and filing, separated from public
areas for confidentiality, shall be provided.
F. Special
storage for staff personal effects with locking drawers or cabinets (may be
individual desks or cabinets) shall be provided. Such storage shall be near
individual work stations and staff controlled.
G. General
storage facilities for supplies and equipment shall be
provided.
H. Nurses
station(s) shall have a work counter, communication system, space for supplies,
and provisions for charting.
I. Drug
distribution station which may be part of the nurses
station and shall include a work counter, sink, refrigerator, and locked
storage for biologicals and drugs.
J. Clean
storage consisting of a separate room or closet for storing clean and sterile
supplies shall be provided and shall be in addition to that of cabinets and
shelves.
K. Soiled
holding which provides for separate collection, storage, and disposal of soiled
materials.
L. Sterilizing
procedures may be done on or off site, or disposables may be used to satisfy
functional needs.
[9/1/56, 7/1/60,
6/27/90; 7.11.2.54 NMAC - Rn & A, 7 NMAC 11.2.54,
02/28/06]
7.11.2.55 LABORATORY:
Facilities licensed pursuant to these regulations that provide
laboratory services must provide the following:
A. laboratory
work counter(s) with sink, and electric services;
B. lavatory(ies) or counter sink(s)
equipped for hand washing;
C. storage
cabinet(s) or closet(s);
D. specimen
collection facilities with a toilet and lavatory;
E. blood
collection facilities shall have seating space, a work counter, and hand
washing facilities.
[9/1/56, 7/1/60,
6/27/90; 7.11.2.55 NMAC - Rn & A, 7 NMAC 11.2.55,
02/28/06]
7.11.2.56 FLOORS AND WALLS:
A. Floor
material shall be readily cleanable and wear resistant.
B. In
all areas subject to wet cleaning, floor materials shall not be physically
affected by liquid germicidal or cleaning solution.
C. Floors
subject to traffic while wet including showers and bath areas shall have a slip
resistant surface.
D. Wall
finishes shall be washable and, in the proximity of plumbing fixtures, shall be
smooth and moisture resistant.
E. Wall
bases in areas subject to wet cleaning shall be covered with the floor, tightly
sealed within the wall and constructed without voids.
F. Floor
and wall areas penetrated by pipes, ducts, and conduits shall be tightly sealed
to minimize entry of rodents and insects. Joints of structural elements shall
be similarly sealed.
G. Threshold
and expansion joint covers shall be flush with the floor surface to facilitate
use of wheelchairs and carts.
H. Floor
drains are not permitted in operating rooms.
[9/1/56, 6/27/90;
7.11.2.56 NMAC - Rn, 7 NMAC 11.2.56, 02/28/06]
7.11.2.57 EXAMINATION ROOMS:
A. General
Purpose Examination Rooms: For medical, obstetrical, and similar
examinations shall meet the following requirements:
(1) minimum floor
area of eighty (80) square feet, excluding vestibules, toilets, and closets;
(2) room arrangement
shall permit at least two (2) feet eight (8) inches clearance at each side and
at the foot of the examination table;
(3) a lavatory or
sink for hand washing; and
(4)
a counter or shelf space for writing.
B. Special Purpose Examination Rooms: For
special examination such as eye, ear, nose, throat, and dental (if provided),
shall meet the following requirements:
(1) floor area
sufficient to accommodate procedures and equipment used but in no case less
than eighty (80) square feet, excluding vestibules, toilets, and closets;
(2) a lavatory or
sink for hand washing;
(3) a counter or
shelf space for writing.
[9/1/56, 7/1/60,
6/27/90; 7.11.2.57 NMAC - Rn & A, 7 NMAC 11.2.57,
02/28/06]
7.11.2.58 TREATMENT ROOMS:
A. Rooms
for minor surgical and cast procedures (if these services are provided) shall
have a minimum floor area of one hundred (120) square feet, excluding
vestibule, toilet, and closets.
B. The
minimum room dimension shall be ten (10) feet.
C. A
lavatory or sink for hand washing shall be provided.
D. A
counter or shelf for writing shall be provided.
[9/1/56, 7/1/60,
6/27/90; 7.11.2.58 NMAC - Rn, 7 NMAC 11.2.58,
02/28/06]
7.11.2.59 OBSERVATION ROOMS: Those
facilities licensed pursuant to these regulations which require an observation
room for the isolation of suspect or disturbed patients must meet the following
requirements:
A. The
minimum floor area must be eighty (80) square feet.
B. The
observation room must be convenient to a nurse or control station to permit
close observation of patients.
C. A
toilet room with lavatory must be immediately accessible.
D. An
examination room may be modified to use as an observation room.
[9/1/56, 7/1/60,
6/27/90; 7.11.2.59 NMAC - Rn, 7 NMAC 11.2.59,
02/28/06]
7.11.2.60 SPECIAL REQUIREMENTS FOR
AMBULATORY SURGICAL CENTERS: In addition to all other requirements
contained in these regulations ambulatory surgical centers will provide the
following.
A. A
covered entrance for pickup of patients after surgery.
B. A
medical records room equipped for recording, and retrieval of medical records.
C. At
least one examination or treatment room meeting the requirements outlined in
Sections 57 and 58 of 7.11.2 NMAC shall be provided for examination and testing
of patients prior to surgery.
D. Operating Rooms or Surgical Suites.
(1) Each operating room will have a minimum
clear area of at least two hundred-fifty (250) square feet.
(2) An emergency communication system
connected with the surgical control station shall be provided.
(3) At least one x-ray film illuminator shall
be provided in each operating room.
(4) Closed storage space for splints and
traction equipment shall be provided for orthopedic surgery.
(5) Room(s) for post-anesthesia recovery of
outpatient surgical patients shall be provided meeting the following
requirements:
(a) at least three
(3) feet shall be provided at each side and at the foot of each bed as needed
for work and/or circulation;
(b) if pediatric
surgery is part of the services, separation from the adult section and space
for parents shall be provided.
(6) A designated supervised recovery lounge
shall be provided for patients who do not require post-anesthesia recovery but
need additional time for their vital signs to stabilize before safely leaving
the facility. This lounge shall contain:
(a) control station;
(b) space for family
members;
(c) provisions for
privacy; and
(d) convenient
patient access to toilets large enough to accommodate patient, wheelchair, and
an assistant.
(7) The following shall be provided in the
surgical service areas:
(a) a control station
located to permit visual surveillance of all traffic entering the operating
suite;
(b) a drug
distribution station; provision shall be made for storage and preparation of
medications administered to patients;
(c) scrub facilities
shall be provided near the entrance to each operating room which is arranged to
minimize incidental splatter on nearby personnel or supply carts;
(d) a soiled workroom which shall contain a
clinical sink or equivalent flushing type fixture, a work counter, a sink for
hand washing, and waste receptacle(s);
(e) fluid waste
disposal facilities which shall be convenient to the general operating rooms; a
clinical sink or equivalent equipment in a soiled workroom shall meet this
requirement;
(f) a clean workroom
or a clean supply room:
(i) a clean workroom is required when clean materials are
assembled within the facility prior to use and shall contain: work counter;
sink equipped for hand washing; and, space for clean and sterile supplies;
(ii) a clean supply
room may be used when the facility does not assemble the material and has
procedures for the storage of sterile and clean supplies;
(g) anesthesia
storage facilities which meet the standards as outlined in national fire
protection association life safety code pamphlet 99; anesthesia may be stored
inside or outside as long as the standards are met;
(h) anesthesia
workroom for cleaning, testing, and storing anesthesia equipment which shall
contain: work counter and sink;
(i) equipment storage room(s) for equipment and supplies used in
the surgical area;
(j) staff clothing
change area which shall contain: lockers; showers; toilets; lavatories for hand
washing; and, space for donning scrub attire;
(k) outpatient
surgery change areas for patients to change from street clothing into hospital
gowns and to prepare for surgery which shall have the following: waiting
room(s); lockers; clothing change or gowning areas; space for administering
medications; and, provisions for securing patients' personal effects;
(l) stretcher storage
area which shall be convenient for use and out of the direct line of traffic;
(m) for facilities
having three (3) or more operating rooms, a lounge and toilet facilities will
be provided for the surgical staff;
(n) a nurse's toilet
room shall be provided near the recovery room(s);
(o) a janitor's
closet exclusively for the surgical suite which shall have: a floor receptor or
service sink, and storage space exclusively for house keeping supplies and
equipment for the surgical suite;
(p) space for the
temporary storage of wheelchairs; and
(q) provisions for
convenient access to and use of emergency crash carts at both the surgical and
recovery areas.
E. Toilet
rooms in surgery and recovery areas for patient use shall be equipped with
doors and hardware that permit access from the outside in emergencies. When
such rooms have only one opening or are small, the doors shall open outward.
F. Flammable
anesthetics shall not be used in ambulatory surgical centers.
G. Ambulatory
surgical centers in the same building as another provider such as hospital or
clinic must meet the following:
(1) the ambulatory surgical center is not
required to be in a building separate from other health care activities (e.g.,
hospital, clinic, etc.); it must however, be separated physically by at least
semi-permanent walls and doors;
(2) the ambulatory
surgical center and another entity must not mix functions and operations in a
common space during concurrent or overlapping hours of operation;
(3) sharing of a
common space at non-overlapping times is acceptable if the ambulatory surgical
center is able to fully function without interruption during its scheduled
hours of operation;
(4) use of the
ambulatory surgical center space by another entity, or host entity if the
ambulatory surgical center is on the premises of another health facility,
during the ambulatory surgical center's hours of operation is prohibited.
[9/1/56, 7/1/60,
6/27/90; 7.11.2.60 NMAC - Rn & A, 7 NMAC 11.2.60,
02/28/06]
7.11.2.61 SPECIAL REQUIREMENTS FOR
INFIRMARIES: In addition to all other requirements
contained in these regulations Infirmaries will provide the following:
A. patient rooms which have a minimum of one hundred (100)
square feet for single occupancy or one hundred sixty (160) square feet for
double occupancy;
B. patient
rooms must have a call system to summon help in case of emergency.
[9/1/56, 7/1/60,
6/27/90; 7.11.2.61 NMAC - Rn, 7 NMAC 11.2.61,
02/28/06]
7.11.2.62 GOVERNING BODY: All
facilities licensed pursuant to these regulations must have a governing body
that assumes full legal responsibility for determining, implementing, and
monitoring policies governing the total operation of the facility and for
ensuring that these policies are administered so as to provide quality health
care in a safe environment. When services are provided through a contract with
an outside resource, the facility assures that these services are provided in a
safe and effective manner.
[6/27/90; 7.11.2.62
NMAC - Rn, 7 NMAC 11.2.62, 02/28/06]
7.11.2.63 ADMINISTRATOR, DIRECTOR OR
MANAGER: Each facility must have an administrator/
director/manager hired or appointed by the governing body to whom authority has
been delegated to manage the daily operation of a facility and implement the policies
and procedures adopted by the governing body.
[6/27/90; 7.11.2.63
NMAC - Rn & A, 7 NMAC 11.2.63, 02/28/06]
7.11.2.64 STAFF EVALUATION AND DEVELOPMENT: A
facility licensed pursuant to these regulations must have a written plan for
the orientation, ongoing staff development, supervision and evaluation of all
staff members, including but not limited to the following:
A. facility's
emergency and safety procedures;
B. policies
and procedures of the facility;
C. quality
assurance program; and
D. staff
training.
[6/27/90; 7.11.2.64
NMAC - Rn & A, 7 NMAC 11.2.64, 02/28/06]
7.11.2.65 DIRECT SERVICE STAFF: Each
staff member who provides direct medical services to patients, such as
physicians, dentists, certified
registered nurse anesthetists, nurses, physicians assistants,
etc., who are required to be licensed, registered or certified by the state of
New Mexico must have a current license, registration, or certificate from the
state of New Mexico.
[9/1/56, 6/27/90;
7.11.2.65 NMAC - Rn & A, 7 NMAC 11.2.65,
02/28/06]
7.11.2.66 MINIMUM STAFFING REQUIREMENTS:
A. Ambulatory Surgical Centers:
(1) Personnel trained in the use of emergency
equipment and in cardiopulmonary resuscitation must be available whenever there
is a patient in the facility.
(2) Surgical staff of qualified physicians who
have been granted clinical privileges by the governing body of the facility
must perform all surgical procedures. A physician must be on duty whenever
there is a patient in the facility.
(3) A certified
registered nurse anesthetist or registered nurse must be
available for emergency treatment whenever there is a patient in the facility.
B. Diagnostic and Treatment Centers:
(1) A physician must be on duty or on
immediate call whenever primary medical services are being provided to
patients.
(2) A certified
registered nurse anesthetist, registered nurse, licensed practical
nurse, nurse practitioner or physician assistant must be on duty whenever
patients are in the facility.
(3) Personnel trained in the use of emergency
equipment and cardiopulmonary resuscitation must be on duty whenever a patient
is in the facility.
C. Limited Diagnostic and Treatment Centers:
(1) A physician must be on call whenever
medical services are being given to patients.
(2) A registered nurse, licensed practical
nurse, nurse practitioner or physician assistant must be on duty whenever
patients are in the facility receiving medical services.
(3) Personnel trained in the use of emergency
equipment and cardiopulmonary resuscitation must be on duty whenever a patient
is in the facility.
D. Rural Health Clinic:
(1) The physician responsible for the medical
direction of the facility must be available through direct telecommunication
for consultation, assistance with medical emergencies, or patient referral.
(2) A physician, nurse practitioner,
physician's assistant, registered nurse, or licensed practical nurse must be
available to furnish patient care services at all times during the facility's
regular hours of operation.
E. Infirmaries:
(1) A physician is on duty or on immediate
call whenever primary medical services are being provided to patients.
(2) A registered nurse, licensed practical
nurse, nurse practitioner, or physician assistant must be on duty whenever
patients are in the facility. This includes nighttime hours when patients are
being kept overnight for observation or treatment.
(3) Personnel trained in the use of emergency
equipment and cardiopulmonary resuscitation must be on duty whenever a patient
is in the facility.
F. New or Innovative Clinic:
(1) Will meet the staffing requirements of
Subsection B of 7.11.2.66 NMAC of these regulations.
(2) Additional staffing or modification of
staffing may be determined by the licensing authority during the initial phase
of the licensing process as outlined in Paragraph 3 of Subsection A of 7.11.2.10
NMAC.
[9/1/56, 7/1/60,
6/27/90; 7.11.2.66 NMAC - Rn & A, 7 NMAC 11.2.66,
02/28/06]
7.11.2.67 EMERGENCY MEDICAL SERVICES:
A. Each
facility licensed pursuant to these regulations must maintain a crash cart or
emergency medical tray to provide emergency life saving procedures which may be
needed in the facility.
B. Crash
carts or emergency trays will be supplied with the drugs and biologicals commonly used in life saving procedures such as
analgesics, anesthetics (local), antibiotics, anticonvulsants, antidotes and
emetics, serums and toxoids. Supplies and equipment
for the crash carts or emergency trays will be determined by the medical
director of the facility.
C. Each
crash cart or emergency tray will have an (a) equipment
and supply list to be used as an inventory guide. Crash carts or emergency
trays must be replenished as supplies or equipment are (is) used.
D. Crash
carts or emergency trays will be checked on a weekly basis for completeness and
a log maintained with date and by whom the check was made.
E. All
direct service medical staff must know the location of and be trained in the
use of the crash carts or emergency trays.
F. Operating
rooms of ambulatory surgical centers must include at least the following:
(1) emergency call
system;
(2) oxygen;
(3) mechanical ventilatory assistance equipment including airways, manual
breathing bag, and ventilator;
(4) cardiac
defibrillator;
(5)
cardiac monitoring equipment;
(6) thoracotomy
set;
(7) tracheostomy
set;
(8) laryngoscopes and
endotracheal tubes;
(9) suction equipment;
(10) emergency drugs
and supplies specified by the medical staff.
[9/1/56, 7/1/60,
6/27/90; 7.11.2.67 NMAC - Rn & A, 7 NMAC 11.2.67,
02/28/06]
7.11.2.68 HOURS OF OPERATION: Each
facility licensed pursuant to these regulations must post its hours of
operation where they can be clearly seen by patients.
[6/27/90; 7.11.2.68
NMAC - Rn, 7 NMAC 11.2.68, 02/28/06]
7.11.2.69 NURSING SERVICES:
Patient care responsibilities must be delineated for all nursing
personnel. Nursing services must be provided in accordance with standards of
nursing practice as outlined in the current rules and regulations of the New
Mexico board of nursing.
[9/1/56, 6/27/90;
7.11.2.69 NMAC - Rn, 7 NMAC 11.2.69, 02/28/06]
7.11.2.70 ANESTHESIA SERVICES FOR
AMBULATORY SURGICAL CENTERS:
A. A
physician must examine the patient immediately before surgery to evaluate the
risk of anesthesia and of the procedure to be performed.
B. Before
discharge from the facility each patient must be evaluated by a physician or a certified registered nurse anesthetist for proper anesthesia
recovery.
C. All
patients will be discharged in the company of a responsible adult, except those
exempted by the attending physician.
D. Anesthetics
must be administered by only:
(1) a qualified
anesthesiologist;
(2) a physician
qualified to administer anesthesia, a supervised trainee in an approved
educational program or an anesthesia assistant. In those cases where a trainee or an anesthesia assistant
administers the anesthesia, the anesthetist must be under the supervision of
the operating physician; anesthesia assistants must have successfully completed
four (4) year education program for physician assistants that include two (2)
years of specialized academic and clinical training in anesthesia;
(3) a
certified registered nurse anesthetist; certified registered nurse anesthetists
shall function in an interdependent role as a member of a health care team in
which the medical care of the patient is directed by a licensed physician,
osteopathic physician, dentist or podiatrist licensed in New Mexico pursuant to
Chapter 61, Article 5A, 6, 8 or 10 NMSA 1978; the
certified registered nurse anesthetist shall collaborate with the licensed
physician, osteopathic physician, dentist or podiatrist concerning the
anesthesia care of the patient; as used in this subsection,
"collaboration" means the process in which each health care provider
contributes his respective expertise; collaboration includes systematic formal
planning and evaluation between the health care professionals involved in the
collaborative practice arrangement.
[6/27/90; 7.11.2.70
NMAC - Rn & A, 7 NMAC 11.2.70, 02/28/06]
7.11.2.71 PHARMACEUTICAL SERVICES:
A. Drugs
and biologicals must be stored, prepared and
administered in accordance to acceptable standards of practice and in
compliance with the New Mexico state board of pharmacy.
B. Outdated
drugs and biologicals must be disposed of in
accordance with methods outlined by the New Mexico state board of pharmacy.
C. One
individual shall be designated responsibility for pharmaceutical services to
include accountability and safeguarding.
D. Keys
to the drug room or pharmacy must be made available only to personnel
authorized by the individual having responsibility for pharmaceutical services.
E. Adverse
reactions to medications must be reported to the physician responsible for the
patient and must be documented in the patient's record.
F. Blood
and blood products must be administered by only physicians, certified registered nurse anesthetists,
registered nurses, nurse practitioners, or physician's assistants.
[9/1/56, 6/27/90;
7.11.2.71 NMAC - Rn & A, 7 NMAC 11.2.71,
02/28/06]
7.11.2.72 LABORATORY SERVICES:
A. All
lab test results performed either at the facility or by contract or arrangement
with another entity must be entered into the patients
record.
B. All
laboratory procedures will be conducted in accordance with acceptable standards
of practice.
C. Special
requirements for rural health clinics: Rural health clinics must provide basic
laboratory services essential to the immediate diagnosis and treatment of the
patient including:
(1) chemical
examinations of urine by stick or tablet methods or both (including urine ketones).
(2) microscopic
examination of urine sediment;
(3) hemoglobin or hematocrit;
(4) blood sugar;
(5) gram stain;
(6) examination of
stool specimens for occult blood;
(7) pregnancy tests;
(8) primary culturing
for transmittal to a certified laboratory;
(9) test for
pinworms.
[9/1/56, 6/27/90;
7.11.2.72 NMAC - Rn, 7 NMAC 11.2.72, 02/28/06]
7.11.2.73 RADIOLOGICAL SERVICES:
A. All
authenticated radiological reports shall be filed in the patient's medical
record.
B. Interpretations
of x-rays shall be written or dictated and signed by qualified physician or
other individual authorized by the medical director.
[9/1/56, 6/27/90;
7.11.2.73 NMAC - Rn, 7 NMAC 11.2.73, 02/28/06]
7.11.2.74 PATIENT CARE FOR INFIRMARIES:
A. Each
patient will have a hospital type bed complete with:
(1) mattress and
water proof mattress cover with pad;
(2) pillow with
pillow case;
(3) two sheets and
blankets adequate for comfort.
B. Each
bed will be provided with a bedside table.
C. Locker
or closet will be provided for storage of patient's personal clothing.
D. Unless
otherwise ordered by the patient's physician, each patient shall be provided
with three (3) nutritionally adequate meals each day and snacks as appropriate
or ordered by the physician.
[9/1/56, 7/1/60,
6/27/90; 7.11.2.74 NMAC - Rn, 7 NMAC 11.2.74,
02/28/06]
7.11.2.75 RELATED REGULATIONS AND CODES:
Facilities or agencies subject to these regulations are also subject to
other regulations, codes and standards as the same may from time to time be
amended as follows:
A. Health
Facility Licensure Fees and Procedures, New Mexico department of health, 7.1.7
NMAC.
B. Health
Facility Sanctions and Civil Monetary Penalties, 7.1.8 NMAC.
C. Adjudicatory
Hearings, New Mexico department of health, 7.1.2 NMAC.
[6/27/90, 10/31/96;
7.11.2.75 NMAC - Rn, 7 NMAC 11.2.75, 02/28/06]
HISTORY OF 7.11.2
NMAC:
Pre-NMAC History: The
material in this part was derived from that previously filed with the state
records center:
HED 90-4 (PHD), Regulations Governing Health Facilities Providing
Outpatient Medical Services and Infirmaries, filed 6/27/90.
History of Repealed Material:
[RESERVED]
Other History:
HED 90-4 (PHD), Regulations Governing Health
Facilities Providing Outpatient Medical Services and Infirmaries (filed
6/27/90) was renumbered, reformatted and replaced by 7 NMAC 11.2, Requirements
Governing Health Facilities Providing Outpatient Medical Services and
Infirmaries, effective 10/31/1996.
7 NMAC 11.2,
Requirements Governing Health Facilities Providing Outpatient Medical Services
and Infirmaries (filed 10/18/96) was renumbered, reformatted, amended and
replaced by 7.11.2 NMAC, Requirements Governing Health Facilities Providing
Outpatient Medical Services and Infirmaries, effective 02/28/06.