Building a New Ambulatory Surgery Center in Texas: What Changes When You Start From the Ground

Most surgery centers in Texas go into existing buildings. Building one from the ground up changes the questions. Instead of asking whether a building can be made to work, you are choosing land, a building type, and a structure, and the state's rules for ambulatory surgical centers (ASCs) apply to those choices from the first site visit. This guide covers what is different about a new freestanding ASC. For the full licensing sequence, see our guide to ASC construction and licensing steps in Texas.

Where the rules are

The Texas Health and Human Services Commission (HHSC) licenses ASCs under Chapter 243 of the Texas Health and Safety Code. For years the licensing rules were in Title 25 of the Texas Administrative Code, Chapter 135, and many consultants and older documents still cite them there. Effective January 31, 2025, those rules were transferred to Title 26, Chapter 508, with the section numbers carried over: 25 TAC section 135.52 is now 26 TAC section 508.52, and so on. The physical plant and construction requirements are in Subchapter C.

The section that matters most for a ground-up project is section 508.52, Construction Requirements for a New Ambulatory Surgical Center. It requires new construction to meet NFPA 101, the Life Safety Code, Chapter 20 for new ambulatory health care occupancies, in the edition the rule names. The city's building code applies as well, and where requirements differ, the more stringent one governs. Medicare certification has its own building standards on top of the state's. Your architect should confirm the current text of each before design starts.

Site rules that matter when you buy the land

Several of the state's requirements are about location, which means they are settled the day you close on a site. Under section 508.52:

• A new ASC must be easily accessible to the community and to service vehicles such as delivery trucks, ambulances, and fire apparatus.
• It may not be built within 150 feet of the easement boundaries or setbacks of hazardous underground locations, such as liquid petroleum or natural gas transmission lines and high-pressure lines, and not within the easement of high-voltage electrical lines.
• It may not be built within 300 feet of certain above-ground or underground storage tanks of flammable liquids, such as those at a bulk plant or a liquefied petroleum gas bottling plant.
• It may not be near nuisance-producing sites such as industrial sites, feed lots, sanitary landfills, or manufacturing plants.
• In a designated 100-year flood plain, the finished floor must be one foot above the base flood elevation, and the building must meet local flood rules.

Pipeline easements and flood lines are on the survey and in the title work, so put these rules in front of your surveyor and civil engineer during due diligence. Our guide to buying land for a medical building covers the rest of that work.

Parking, drives, and a covered entrance

The rule sets minimum off-street parking at two spaces for each operating room, one for each staff member, and one visitor space for each operating room. The city will have its own parking requirement, so the site plan needs to meet whichever is greater. Paved drives must run within the lot from the public road to the main entrance.

Entrances must be at grade, accessible, and protected from weather from the point where patients are loaded and unloaded to the building entrance. In practice that means a drop-off canopy. On a ground-up building it is part of the shell and the site plan from the start, sized for the vehicles that pick patients up after surgery. Texas Health Spine Surgery Center Rockwall, a ground-up surgery center we built, has a covered entry canopy with a flat projecting roof at the front doors.

Freestanding or inside another building

The state rule allows an ASC to be a separate part of a hospital, its own building, or a space inside an office or commercial building. When an ASC is part of a larger building, it must be separated from the rest with at least one-hour fire-rated construction (two-hour in some one-story buildings), and in a building of two or more stories the whole building must meet the Life Safety Code's construction requirements. Those conditions are why many existing buildings are hard to convert.

A freestanding building avoids most of that. You choose the construction type, the roof structure, and the floor-to-deck height for surgical ductwork, lights, and booms. You can also build an ASC and a clinic together under one roof. GI Alliance Mansfield Endoscopy Center and Clinic, a ground-up building we built as a design-assist project with the architect, was finished out with a state-licensed endoscopy center and clinic space, on a site that includes an onsite detention pond.

Emergency power and the generator

Section 508.52 requires a Type 1 essential electrical system, installed, maintained, and tested under NFPA 99, NFPA 101, and NFPA 110. Fuel storage for an on-site generator must allow continuous operation under full load for eight hours of testing. When a vapor gas system is used, the rule does not require 24 hours of fuel on site, but it does require a dedicated fuel supply. On a new site, decide early where the generator, its fuel, and the transfer switches go, how service trucks reach them, and how the city's screening rules apply. These choices affect the site plan, the electrical service, and the structure.

Plan review comes before the slab

Under section 508.54, ASC owners may not begin construction of a new building until the state approves final construction documents, prepared by registered architects or licensed engineers. Section 508.55 adds that construction may not start until plan review deficiencies are resolved, the licensing fee is paid, and the state issues a letter approving the start. For a ground-up project, that review covers the whole building, not only the interior, so it sits ahead of site work, foundations, and the shell. Ask HHSC early what, if anything, may proceed before approval, and plan the schedule with state review on the critical path. The city's site plan, plat, and civil reviews can run during the same period; our guide to site approvals covers those.

Learn more about how we build new buildings from the ground up and our surgery center construction work. Structures and Interiors also finishes out and renovates existing space, including surgery centers in existing buildings.

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