ASC construction and licensing steps in Texas

Building an ambulatory surgery center (ASC) in Texas means satisfying several authorities at once: the city, the Texas Health and Human Services Commission (HHSC), the state accessibility program, and in most cases Medicare. Each has its own rules and its own inspection. This guide lays out the steps in order so an owner can see where construction and licensing meet.

Who reviews a Texas surgery center

An ordinary medical office answers mainly to the city. An ASC answers to more parties, and the building is not finished until each one has signed off.

• Texas HHSC. Licenses ambulatory surgical centers under Chapter 243 of the Texas Health and Safety Code. The licensing rules are in Title 26 of the Texas Administrative Code, Chapter 508, and include physical plant and construction requirements.
• The city. Issues the building permit, inspects the work, and issues the certificate of occupancy. The fire marshal reviews fire alarm, sprinkler, and life safety items.
• TDLR. The Texas Department of Licensing and Regulation administers the Texas Accessibility Standards (TAS). The project is registered, reviewed, and inspected by a registered accessibility specialist (RAS).
• Medicare. Certification is a federal process under the ASC Conditions for Coverage (42 CFR Part 416). It brings its own building standards, including the Life Safety Code (NFPA 101) and the Health Care Facilities Code (NFPA 99) in the editions Medicare has adopted.

Texas does not have a certificate of need program, so there is no state approval of need to obtain before you build.

Step 1: Test the site before you commit

Most ASC problems are decided by the building. Before a lease or purchase is final, have the architect, engineer, and contractor look at these items:

• Height above the ceiling for surgery-grade ductwork
• Roof structure that can carry larger air handling equipment
• Electrical service size, and a location for a generator and its fuel
• A location for medical gas supply that delivery trucks can reach
• Construction type, fire separation from neighbors, and exits suited to the occupancy
• A covered patient drop-off and discharge route

Step 2: Settle the case mix and the team

The procedures and level of anesthesia you plan determine whether rooms are operating rooms or procedure rooms, and that sets room sizes, clearances, air requirements, and finishes. Decide it before the floor plan is drawn. The team usually includes the administrator, an architect and engineers with ASC experience, the equipment planner or vendors, a general contractor, and sometimes a licensing consultant.

Step 3: Design to the rules, then submit to HHSC

The drawings have to meet the state's physical plant rules and the standards they reference, along with the city's codes. HHSC reviews ASC construction through its Architectural Review Unit. The owner's team submits an application package online and either requests a full plan review, which HHSC says takes about 120 business days, or has the architect and engineers self-certify the design. Construction cannot start until the unit gives written approval.

Starting work before state comments are resolved is a risk the owner should take only with open eyes. A comment that moves a wall or adds a room costs far more after framing than before.

Step 4: City permit and TDLR registration

City plan review runs on its own track and its own calendar. Each North Texas city adopts its own code editions and amendments, so the same drawings can get different comments in Dallas, Fort Worth, or a suburb. The TDLR accessibility registration and RAS plan review happen in the same period. Projects with an estimated construction cost of $50,000 or more must be registered, which covers any surgery center. The plans go to the registered accessibility specialist within 20 business days after they are issued.

Step 5: Build, with inspections along the way

The parts of an ASC that carry the most risk are hidden when the job is done: ductwork and pressure relationships, medical gas piping, the essential electrical system, rated walls and smoke barriers, and the steel above the ceiling that carries surgical lights and booms. Each is inspected before it is covered. The state may also inspect during construction, not only at the end. The approval letter to start construction lists the inspections HHSC requires for the project.

Equipment vendor drawings are construction documents on this kind of project. If lights, booms, and sterilizers are chosen late, the supports, ductwork, and ceiling layout are either guessed at or built twice.

Step 6: Test, document, and close out

Before any final inspection, the building has to be proven on paper. The records reviewers usually ask for include:

• Medical gas verification report from an independent verifier, as NFPA 99 requires
• Air test and balance report showing air changes and room pressures
• Generator and transfer switch test results
• Fire alarm and sprinkler test and acceptance records
• Firestopping and rated wall documentation
• City final inspections and the certificate of occupancy
• RAS accessibility inspection

A missing report can hold up an opening as surely as a failed inspection.

Step 7: State final inspection and license

The owner submits the license application and fee, HHSC holds a pre-survey conference, and the building must pass the final architectural inspection before the license is issued. No patient can be treated until then. The state's licensing survey comes after the center has treated its first patient. The license application covers much more than the building, including ownership, staffing, and policies, so the owner's team should be preparing it during construction.

Step 8: Medicare certification

A new center reaches Medicare certification one of two ways: a survey on behalf of Medicare, or accreditation by a national organization whose ASC program Medicare recognizes, which is called deemed status. Medicare ranks a state survey of a new surgery center as a lower priority, so the wait can be long. Most new centers choose accreditation for that reason. Either way the surveyor will look at the building's life safety features, so the records from Step 6 are used again.

What the contractor does and does not do

The owner's team leads licensing and certification. The contractor builds to the approved drawings, schedules the work so inspections fall in the right order, and delivers the test reports and records each reviewer asks for. That is S&I's role on surgery center projects. The license and Medicare certification stay with the owner and the architect.

Cost and schedule

How long construction of a surgery center in Dallas–Fort Worth takes depends on the mechanical, emergency power, and medical gas work and its testing. State review, licensing, and Medicare certification add time before and after. We do not publish a cost per square foot, because costs move with materials, labor, and the specific building. S&I prepares a first budget for your project at no charge, and a detailed estimate is priced later from the drawings. The number of operating rooms, the mechanical system, emergency power, and the condition of the existing building move the cost and the schedule most. Our guide to surgery center construction cost in Texas covers each of them.

For more on the building systems, see our surgery center and ASC construction page. If you are starting from raw land, building a new ASC in Texas covers what changes. Two completed examples are Axis Brain and Back Institute ASC in Southlake, a surgery center, and GI Alliance Waco Endoscopy Center and Clinic, which pairs an endoscopy center with a clinic.

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