|(a) The ASC shall have a governing body that sets policy
and assumes full legal responsibility for the total operation of the
(b) The governing body shall be responsible for assuring
that medical staff bylaws are current and on file.
(c) The governing body shall address and is fully responsible,
either directly or by appropriate professional delegation, for the
operation and performance of the ASC. Governing body responsibilities
include, but are not limited to:
(1) determining the mission, goals, and objectives
of the ASC;
(2) assuring that facilities and personnel are adequate
and appropriate to carry out the mission;
(3) establishing an organizational structure and specifying
functional relationships among the various components of the ASC;
(4) adopting bylaws or similar rules and regulations
for the orderly development and management of the ASC;
(5) adopting policies or procedures necessary for the
orderly conduct of the ASC;
(6) assuring that the quality of care is evaluated
and that identified problems are addressed;
(7) reviewing all legal and ethical matters concerning
the ASC and its staff and, when necessary, responding appropriately;
(8) maintaining effective communication throughout
(9) establishing a system of financial management and
accountability that includes an audit appropriate to the ASC;
(10) developing, implementing, and enforcing a policy
on the rights of patients;
(11) approving all major contracts or arrangements
affecting the medical care provided under its auspices, including,
but not limited to, those concerning:
(A) the employment of health care practitioners;
(B) an effective procedure for the immediate transfer
to a hospital of patients requiring emergency care beyond the capabilities
of the ASC. The ASC shall have a written transfer agreement with a
hospital or all physicians performing surgery at the ASC shall have
admitting privileges at a local hospital;
(C) the use of external laboratories;
(D) an effective procedure for obtaining emergency
laboratory, radiology, and pharmaceutical services if laboratory,
X-ray, and pharmacy services are not provided on site; and
(E) the provision of education to students and postgraduate
trainees if the ASC participates in such programs;
(12) formulating long-range plans in accordance with
the mission, goals, and objectives of the ASC;
(13) operating the ASC without limitation because of
race, creed, sex, or national origin;
(14) assuring that all marketing and advertising concerning
the ASC does not imply that it provides care or services which it
is not capable of providing; and
(15) developing a system of risk management appropriate
to the ASC including, but not limited to:
(A) periodic review of all litigation involving the
ASC, its staff, and health care practitioners regarding activities
in the ASC;
(B) periodic review of all incidents reported by staff
(C) review of all deaths, trauma, or adverse reactions
occurring on premises; and
(D) evaluation of patient complaints.
(d) The governing body shall provide for full disclosure
of ownership to the department.
(e) The governing body shall meet at least annually
and keep such minutes or other records as may be necessary for the
orderly conduct of the ASC.
(f) If the governing body elects, appoints, or employs
officers and administrators to carry out its directives, the authority,
responsibility, and functions of all such positions shall be defined.
(g) When a majority of its members are physicians,
the governing body, either directly or by delegation, shall make (in
a manner consistent with state law and based on evidence of the education,
training, and current competence of the physician) initial appointments,
reappointments, and assignment or curtailment of medical privileges.
When a majority of the members of the governing body are not physicians,
the ASC's bylaws or similar rules and regulations shall specify a
procedure for establishing medical review for the purpose of making
(in a manner consistent with state law and based on evidence of the
education, training, and current competence of the physician) initial
appointments, reappointments, and assignment or curtailment of medical
(h) The governing body shall provide (in a manner consistent
with state law and based on evidence of education, training, and current
competence) for the initial appointment, reappointment, and assignment
or curtailment of privileges and practice for nonphysician health
care personnel and practitioners.
(i) The governing body shall encourage personnel to
participate in continuing education that is relevant to their responsibilities
within the ASC.
(j) The governing body shall adopt, implement, and
enforce written policies to ensure compliance with Health and Safety
Code, Chapter 324, Consumer Access to Health Care Information.
(k) The governing body shall adopt, implement and enforce
written policies to ensure compliance with applicable state laws.
(l) An ASC that performs abortions shall adopt, implement
and enforce a policy to ensure compliance with Health and Safety Code,
Chapters 245 and 171, Subchapters A and B (relating to Abortion and
(m) Balance Billing.
(1) An ASC may not violate a law that prohibits the
ASC from billing a patient who is an insured, participant, or enrollee
in a managed care plan an amount greater than an applicable copayment,
coinsurance, and deductible under the insured's, participant's, or
enrollee's managed care plan or that imposes a requirement related
to that prohibition.
(2) An ASC shall comply with Senate Bill 1264, 86th
Legislature, Regular Session, 2019, and with related Texas Department
of Insurance rules at 28 TAC Chapter 21, Subchapter OO, §§21.4901
- 21.4904 (relating to Disclosures by Out-of-Network Providers) to
the extent this subchapter applies to the ASC.