TITLE 8               SOCIAL SERVICES

CHAPTER 370  OVERSIGHT OF LICENSED HEALTHCARE FACILITIES AND COMMUNITY BASED WAIVER PROGRAMS

PART 18              REQUIREMENTS FOR FACILITIES PROVIDING OUTPATIENT MEDICAL SERVICES AND INFIRMARIES

 

8.370.18.1             ISSUING AGENCY:  New Mexico Health Care Authority.

[8.370.18.1 NMAC - N, 7/1/2024]

 

8.370.18.2             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.

[8.370.18.2 NMAC - N, 7/1/2024]

 

8.370.18.3             STATUTORY AUTHORITY:  The regulations set forth herein are promulgated pursuant to the general authority granted under Subsection E of Section 9-8-6 NMSA 1978; and the authority granted under Subsection D of Section 24-1-2, Subsection I of Section 24-1-3, and Section 24-1-5 of the Public Health Act, NMSA 1978, as amended.  Section 9-8-1 et seq.  NMSA 1978 establishes the health care authority (authority) as a single, unified department to administer laws and exercise functions relating to health care purchasing and regulation.

[8.370.18.3 NMAC - N, 7/1/2024]

 

8.370.18.4             DURATION:  Permanent.

[8.370.18.4 NMAC - N, 7/1/2024]

 

8.370.18.5             EFFECTIVE DATE:  July 1, 2024, unless a later date is specified at the end of a section.

[8.370.18.5 NMAC - N, 7/1/2024]

 

8.370.18.6             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.

[8.370.18.6 NMAC - N, 7/1/2024]

 

8.370.18.7             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.            "Facility" means a building or buildings in which outpatient medical services are provided to the public and which is licensed pursuant to this rule.

                F.            "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.

                G.            "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 year.

                H.            “Licensed practical nurse" means a person licensed as a trained practical nurse under the Nursing Practice Act, Section 61-3-19 NMSA 1978.

                I.             “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.

                J.             "Licensing authority" means the New Mexico health care authority.

                K.            "NMSA" means the New Mexico Statutes Annotated, 1978 compilation, and all the revisions and compilations thereof.

                L.            "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.

                M.           "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.

                N.            "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.

                O.            "Policy" means a statement of principle that guides and determines present and future decisions and actions.

                P.            "Premises" means all parts of buildings, grounds, and equipment of a facility.

                Q.            "Procedure" means the action(s) that must be taken in order to implement a policy.

                R.            "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.

                S.             "Resident" as defined in Section 3 (I) of the Resident Abuse and Neglect Act means any person who receives treatment from a health facility.

                T.            "U/L approved" means approved for safety by the national underwriters laboratory.

                U.            "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.

                V.            "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.

[8.370.18.7 NMAC - N, 7/1/2024]

 

8.370.18.8             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.

[8.370.18.8 NMAC - N, 7/1/2024]

 

8.370.18.9             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 health care authority 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 8.370.18.9 NMAC of these regulations, it may be licensed at the sole discretion of the licensing authority, if all requirements outlined in 8.370.18.10 NMAC below have been met.

[8.370.18.9 NMAC - N, 7/1/2024]

 

8.370.18.10          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.

[8.370.18.10 NMAC - N, 7/1/2024]

 

8.370.18.11          LICENSES:

                A.            Annual license:  An annual license is issued for a one 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 120 days, during which the facility must correct all specified deficiencies.

                                (2)           In accordance with Subsection D of Section 24-1-5 NMSA 1978, no more than two 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 10 working days of the change.

[8.370.18.11 NMAC - N, 7/1/2024]

 

8.370.18.12          LICENSE RENEWAL:

                A.            Licensee must submit a renewal application on forms provided by the licensing authority, along with the required fee at least 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.  Subsection A of Section 24-1-5 NMSA 1978, as amended, provides that no health facility shall be operated without a license.

[8.370.18.12 NMAC - N, 7/1/2024]

 

8.370.18.13          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.

[8.370.18.13 NMAC - N, 7/1/2024]

 

8.370.18.14          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 8.370.18.14 NMAC above must submit an application for initial licensure in accordance with 8.370.18.10 NMAC of these regulations at least 30 days prior to the anticipated change.

[8.370.18.14 NMAC - N, 7/1/2024]

 

8.370.18.15          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 or license; or

                C.            on the day a facility changes location.

[8.370.18.15 NMAC - N, 7/1/2024]

 

8.370.18.16          SUSPENSION OF LICENSE WITHOUT PRIOR HEARING.  In accordance with Subsection H of Section 24-1-5 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 working days of the suspension, unless waived by the licensee.

[8.370.18.16 NMAC - N, 7/1/2024]

 

8.370.18.17          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.

[8.370.18.17 NMAC - N, 7/1/2024]

 

8.370.18.18          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 8.370.18.16 and 8.370.18.17 NMAC above will be held in accordance with adjudicatory hearings, New Mexico health care authority, 8.370.2 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.

[8.370.18.18 NMAC - N, 7/1/2024]

 

8.370.18.19          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.

[8.370.18.19 NMAC - N, 7/1/2024]

 

8.370.18.20          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 8.370.18.19 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.

[8.370.18.20 NMAC - N, 7/1/2024]

 

8.370.18.21          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 their representative will be required to submit a plan of correction to the licensing authority within 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.

[8.370.18.21 NMAC - N, 7/1/2024]

 

8.370.18.22          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”.

[8.370.18.22 NMAC - N, 7/1/2024]

 

8.370.18.23          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.

[8.370.18.23 NMAC - N, 7/1/2024]

 

8.370.18.24          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 8.370.18.24 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 8.370.18.24 NMAC] above;

                                (2)           any other information deemed necessary by the licensing authority after review and approval of the new or innovative service.

[8.370.18.24 NMAC - N, 7/1/2024]

 

8.370.18.25          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 health care authority, 8.370.18 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.

[8.370.18.25 NMAC - N, 7/1/2024]

 

8.370.18.26          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.

[8.370.18.26 NMAC - N, 7/1/2024]

 

8.370.18.27          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 health care authority 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 months.

[8.370.18.27 NMAC - N, 7/1/2024]

 

8.370.18.28          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 8.370.18.28 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 8.370.18.28 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 8.370.18.28 NMAC of these regulations, may have others required by the licensing authority after review of program and approval of the new or innovative service.

[8.370.18.28 NMAC - N, 7/1/2024]

 

8.370.18.29          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.

[8.370.18.29 NMAC - N, 7/1/2024]

 

8.370.18.30          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.

[8.370.18.30 NMAC - N, 7/1/2024]

 

8.370.18.31          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.

[8.370.18.31 NMAC - N, 7/1/2024]

 

8.370.18.32          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 farenheit.

[8.370.18.32 NMAC - N, 7/1/2024]

 

8.370.18.33          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.

[8.370.18.33 NMAC - N, 7/1/2024]

 

8.370.18.34          FIRE SAFETY COMPLIANCE:  All current applicable requirements of state and local codes for fire prevention and safety must be met by the facility.

[8.370.18.34 NMAC - N, 7/1/2024]

 

8.370.18.35          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.

[8.370.18.35 NMAC - N, 7/1/2024]

 

8.370.18.36          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 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.

[8.370.18.36 NMAC - N, 7/1/2024]

 

8.370.18.37          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.

[8.370.18.37 NMAC - N, 7/1/2024]

 

8.370.18.38          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).

[8.370.18.38 NMAC - N, 7/1/2024]

 

8.370.18.39          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.

[8.370.18.39 NMAC - N, 7/1/2024]

 

8.370.18.40          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.

[8.370.18.40 NMAC - N, 7/1/2024]

 

8.370.18.41          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.

[8.370.18.41 NMAC - N, 7/1/2024]

 

8.370.18.42          JANITORS CLOSET(S):

                A.            Each facility shall have at least one 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.

[8.370.18.42 NMAC - N, 7/1/2024]

 

8.370.18.43          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.

[8.370.18.43 NMAC - N, 7/1/2024]

 

8.370.18.44          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.

[8.370.18.44 NMAC - N, 7/1/2024]

 

8.370.18.45          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.

[8.370.18.45 NMAC - N, 7/1/2024]

 

8.370.18.46          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.

[8.370.18.46 NMAC - N, 7/1/2024]

 

8.370.18.47          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 75 degrees farenheit 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 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 percent.  Operating rooms shall have ninety percent filter efficiencies.

[8.370.18.47 NMAC - N, 7/1/2024]

 

8.370.18.48          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 120 degrees farenheit.

                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).

[8.370.18.48 NMAC - N, 7/1/2024]

 

8.370.18.49          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 8.370.18.49 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.

[8.370.18.49 NMAC - N, 7/1/2024]

 

8.370.18.50          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 four and a half inches, except that handles on clinical sinks shall not be less than six 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.

[8.370.18.50 NMAC - N, 7/1/2024]

 

8.370.18.51          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 inches high whose principle strokes are at least three-fourths 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.

[8.370.18.51 NMAC - N, 7/1/2024]

 

8.370.18.52          CORRIDORS:

                A.            Ambulatory surgical centers:

                                (1)           Minimum corridor width shall be six feet.

                                (2)           In operating room and surgical suites where patients are transported on stretchers or beds, corridors will have a width of eight feet.

                B.            All other facilities:  minimum corridor width shall be five feet except work corridors less than six feet in length may be four 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 8.370.18.52 NMAC above if not in conflict with building or fire codes and approved by the licensing authority prior to occupying the facility.

[8.370.18.52 NMAC - N, 7/1/2024]

 

8.370.18.53          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".

[8.370.18.53 NMAC - N, 7/1/2024]

 

8.370.18.54          COMMON ELEMENTS FOR OUTPATIENTS FACILITIES:  The following shall apply to each outpatient facility, with additions 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.

[8.370.18.54 NMAC - N, 7/1/2024]

 

8.370.18.55          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.

[8.370.18.55 NMAC - N, 7/1/2024]

 

8.370.18.56          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.

[8.370.18.56 NMAC - N, 7/1/2024]

 

8.370.18.57          EXAMINATION ROOMS:

                A.            General purpose examination rooms:  For medical, obstetrical, and similar examinations shall meet the following requirements:

                                (1)           minimum floor area of 80 square feet, excluding vestibules, toilets, and closets;

                                (2)           room arrangement shall permit at least two feet, eight 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 80 square feet, excluding vestibules, toilets, and closets;

                                (2)           a lavatory or sink for hand washing;

                                (3)           a counter or shelf space for writing.

[8.370.18.57 NMAC - N, 7/1/2024]

 

8.370.18.58          TREATMENT ROOMS:

                A.            Rooms for minor surgical and cast procedures (if these services are provided) shall have a minimum floor area of 120 square feet, excluding vestibule, toilet, and closets.

                B.            The minimum room dimension shall be 10 feet.

                C.            A lavatory or sink for hand washing shall be provided.

                D.            A counter or shelf for writing shall be provided.

[8.370.18.58 NMAC - N, 7/1/2024]

 

8.370.18.59          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 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.

[8.370.18.59 NMAC - N, 7/1/2024]

 

8.370.18.60          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 8.370.18 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 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 feet shall be provided at each side and at the foot of each bed as needed for work 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 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.

[8.370.18.60 NMAC - N, 7/1/2024]

 

8.370.18.61          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 100 square feet for single occupancy or 160 square feet for double occupancy;

                B.            patient rooms must have a call system to summon help in case of emergency.

[8.370.18.61 NMAC - N, 7/1/2024]

 

8.370.18.62          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.

[8.370.18.62 NMAC - N, 7/1/2024]

 

8.370.18.63          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.

[8.370.18.63 NMAC - N, 7/1/2024]

 

8.370.18.64          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.

[8.370.18.64 NMAC - N, 7/1/2024]

 

8.370.18.65          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.

[8.370.18.65 NMAC - N, 7/1/2024]

 

8.370.18.66          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 8.370.18.66 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 8.370.18.10 NMAC.

[8.370.18.66 NMAC - N, 7/1/2024]

 

8.370.18.67          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 equipment and supply list to be used as an inventory guide.  Crash carts or emergency trays must be replenished as supplies or equipment are 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.

[8.370.18.67 NMAC - N, 7/1/2024]

 

8.370.18.68          HOURS OF OPERATION:  Each facility licensed pursuant to these regulations must post its hours of operation where they can be clearly seen by patients.

[8.370.18.68 NMAC - N, 7/1/2024]

 

8.370.18.69          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.

[8.370.18.69 NMAC - N, 7/1/2024]

 

8.370.18.70          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 year education program for physician assistants that include two 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 their respective expertise; collaboration includes systematic formal planning and evaluation between the health care professionals involved in the collaborative practice arrangement.

[8.370.18.70 NMAC - N, 7/1/2024]

 

8.370.18.71          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.

[8.370.18.71 NMAC - N, 7/1/2024]

 

8.370.18.72          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.

[8.370.18.72 NMAC - N, 7/1/2024]

 

8.370.18.73          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.

[8.370.18.73 NMAC - N, 7/1/2024]

 

8.370.18.74          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 nutritionally adequate meals each day and snacks as appropriate or ordered by the physician.

[8.370.18.74 NMAC - N, 7/1/2024]

 

8.370.18.75          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 health care authority, 8.370.3 NMAC.

                B.            Health facility sanctions and civil monetary penalties, 8.370.4 NMAC.

                C.            Adjudicatory hearings, New Mexico health care authority, 8.370.2 NMAC.

[8.370.18.75 NMAC - N, 7/1/2024]

 

 

HISTORY OF 8.370.18 NMAC:  RESERVED