Provider Type: Ambulatory Surgical Center
Inspection Data from January 1, 2008 to present
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Survey DateInspection TypeTrack IDDeficiencyRequirement DescriptionCorrection Date
03/06/2014StandardXOXRM0007ORGANIZED 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on-site consultant pharmacist visit shall insure standards of practice are maintained, including proper disposal of outdated prescription and controlled drugs in accordance with [64B16-28.702, F.A.C.], Chapter 465, F.S., and Chapter 893, F.S. 59A-5.007(2), F.A.C.  
03/06/2014StandardXOXRM0041SURVEIL, 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.  
03/06/2014StandardXOXRM0050MEDICAL 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.  
03/06/2014StandardXOXRQ0162FORM AND CONTENT OF RECORDThe ASC 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: (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. (8) Discharge diagnosis. 
03/06/2014StandardXOXRQ0181ADMINISTRATION OF DRUGSDrugs must be prepared and administered according to established policies and acceptable standards of practice.  
03/06/2014StandardXOXRQ0241SANITARY ENVIRONMENTThe ASC must provide a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice.  
03/06/2014StandardXOXRQ0261ADMISSION ASSESSMENTNot more than 30 days before the date of the scheduled surgery, each patient must have a comprehensive medical history and physical assessment completed by a physician (as defined in section 1861(r) of the Act) or other qualified practitioner in accordance with applicable State health and safety laws, standards or practice, and ASC policy.  
03/06/2014StandardXOXRQ0262PRE-SURGICAL ASSESSMENTUpon admission, each patient must have a pre-surgical assessment completed by a physician or other qualified practitioner in accordance with applicable State health and safety laws, standards of practice, and ASC policy that includes, at a minimum, an updated medical record entry documenting an examination for any changes in the patient's condition since completion of the most recently documented medical history and physical assessment, including documentation of any allergies to drugs and biologicals.