| Survey Date | Inspection Type | Track ID | Deficiency | Requirement Description | Correction Date |
| 03/17/2022 | Fire/Life/Safety | MPM2 | K0223 | DOORS WITH SELF-CLOSING DEVICES | 04/11/2022 |
| 03/17/2022 | Fire/Life/Safety | MPM2 | K0353 | SPRINKLER SYSTEM - MAINTENANCE AND TESTING | 04/11/2022 |
| 03/17/2022 | Fire/Life/Safety | MPM2 | K0372 | SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE | 03/28/2022 |
| 03/17/2022 | Fire/Life/Safety | MPM2 | K0521 | HVAC | 04/04/2022 |
| 12/02/2019 | Fire/Life/Safety | 5D6R | K0352 | SPRINKLER SYSTEM - SUPERVISORY SIGNALSSprinkler System - Supervisory Signals
Automatic sprinkler system supervisory attachments are installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired.
9.7.2.1, NFPA 72
| 12/30/2019 |
| 07/27/2017 | Fire/Life/Safety | 9MU7 | None | NoneNone | None |
| 03/24/2015 | Fire/Life/Safety | NCJJ | None | NoneNone | None |
| 03/06/2014 | Standard | XOXR | M0007 | ORGANIZED MEDICAL STAFFCommittees -- The structure of
committee organization shall be
determined by the organized medical
staff provided the following required
committee functions are carried out
with sufficient periodicity to assure
that objectives are achieved by
separate committee, combined
committees, or committee of the whole:
(a) Approval of the policies,
procedures, and the activities of all
departments and services.
(b) Interim decision making for the
organized medical staff between staff
meetings, under such limitations as
shall be set by the medical staff.
(c) Follow-up and appropriate
disposition of all reports dealing
with the various staff functions.
(d) Review of all applications for
appointment and biennially review
reappointment of all categories of
medical staff pursuant to ss. 395.0191
and ss. 395.0193, F.S.
(e) Medical records currently
maintained describing the condition,
treatment, and progress of patient in
sufficient completeness to assure
comprehension of transfer of patient
information at any time.
(f) Clinical evaluation of the
quality of medical care provided to
all categories of patients on the
basis of documented evidence.
(g) Review of ambulatory surgical
center admissions with respect to need
for admission, discharge practices and
evaluation of the services ordered and
provided.
(h) Surveillance of ambulatory
surgical center's infection potentials
and cases and the promotion of a
preventive and corrective program,
designed to minimize these hazards.
(i) Surveillance of pharmacy policies
and procedures, including review of at
least monthly on-site consultant
pharmacist visit shall insure
standards of practice are maintained,
including proper disposal of outdated
prescription and controlled drugs in
accordance with [64B16-28.702, F.A.C.],
Chapter 465, F.S., and
Chapter 893, F.S.
59A-5.007(2), F.A.C.
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| 03/06/2014 | Standard | XOXR | M0041 | SURVEIL, PREVENT & CONTROL OF INFECTIONEach ambulatory surgical center shall
establish an Infection Control Program
involving members of the medical
staff, nursing staff, other
professional and administrative staff
as appropriate. The program shall
provide for:
(a) The surveillance, prevention, and
control of infection among patients
and personnel;
(b) The establishment of a system for
identification, reporting, evaluating
and maintaining records of infections;
(c) Ongoing review and evaluation of
aseptic, isolation and sanitation
techniques employed by the center; and
(d) Development and coordination of
training programs in infection control
for all center personnel.
59A-5.011(1), F.A.C.
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| 03/06/2014 | Standard | XOXR | M0050 | MEDICAL RECORDSThe medical records service shall:
(a) Maintain a system of
identification and filing to ensure
the prompt location of a patient's
medical record. Patient records may
be stored on electronic medium such as
computer, microfilm or optical
imaging;
(b) Maintain a current and complete
medical record for every patient
admitted to the ambulatory surgical
center.
(c) All clinical information
pertaining to the patient's medical
treatment shall be centralized in the
patient's medical record.
(d) Ensure that each medical record
shall contain the original of the
following as appropriate to the
service provided:
1. Identification data:
2. Chief complaint;
3. Present illness;
4. Past personal history;
5. Family medical history;
6. Physical examination report;
7. Provisional and pre-operative
diagnosis;
8. Clinical laboratory reports;
9. Radiology, diagnostic imaging, and
ancillary testing reports;
10. Consultation reports;
11. Medical and surgical treatment
notes and reports;
12. The appropriate informed consent
signed by the patient;
13. Record of medication and dosage
administrated;
14. Tissue reports;
15. Physician orders;
16. Physician and nurse progress
notes;
17. Final diagnosis;
18. Discharge summary; and
19. Autopsy report, if appropriate.
(e) Ensure that:
1. Operative reports signed by the
surgeon shall be recorded in the
health record immediately following
surgery or that an operative progress
note is entered in the patient record
to provide pertinent information; and
2. Postoperative information shall
include vital signs, level of
consciousness, medications, blood or
blood components, complications and
management of those events,
identification of direct providers of
care, discharge information from
post-anesthesia care area.
(f) Index, and maintain on a current basis, all
medical records according to surgical
procedure and physician.
59A-5.012(5), F.A.C.
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