| Survey Date | Inspection Type | Track ID | Deficiency | Requirement Description | Correction Date |
| 10/01/2015 | Complaint | YC0T | B0036 | CLINICAL RECORDS SHALL CONTAIN383.32 Clinical records.-
(1) Clinical records shall contain information prescribed by rule, including, but not limited to:
(a) Identifying information.
(b) Risk assessments.
(c) Information relating to prenatal visits.
(d) Information relating to the course of labor and intrapartum care.
(e) Information relating to consultation, referral, and transport to a hospital.
(f) Newborn assessment, APGAR score, treatments as required, and followup.
(g) Postpartum followup.
(2) Clinical records shall be immediately available at the birth center:
(a) At the time of admission.
(b) When transfer of care is necessary.
(c) For audit by licensure personnel.
(3) Clinical records shall be kept confidential in accordance with s. 456.057 and exempt from the provisions of s. 119.07(1). A client ' s clinical records shall be open to inspection only under the following conditions:
(a) A consent to release information has been signed by the client; or
(b) The review is made by the agency for a licensure survey or complaint investigation.
(4)(a) Clinical records shall be audited periodically, but no less frequently than every 3 months, to evaluate the process and outcome of care.
59A-11.005(4)(a-o),
The birth center shall have a defined client record system, policies and procedures which provide for identification, security, confidentiality, control, retrieval, and preservation of client care data and information. A current and complete clinical record for each patient accepted for care in the birth center shall include at a minimum, the following data:
(a) Identifying information including client ' s name, address and telephone number;
(b) Initial history and physical examination including laboratory findings and dates;
(c) Obstetrical risk assessments and pre-term labor risk assessments including the dates of the assessments;
(d) The dates and topics of the educational sessions attended;
(e) The date and time of the onset of labor;
(f) The course of labor including all pertinent examinations and findings;
(g) The exact date and time of birth, the presenting part, the sex of the newborn, the numerical order of birth in the event of more than one newborn, to include filing of the birth certificate, and the Apgar score at one minute and five minutes;
(h) Time of expulsion and condition of placenta;
(i) All treatments rendered to the mother and newborn including prescribing prescriptions, the time, type, and dose of eye prophylaxis;
(j) Copy of the Metobolic screening report;
(k) Condition of the mother and newborn including any complications and action taken;
(l) All medical consultations relevant to the client specifically;
(m) Referrals for medical care and transfers to hospitals including that information germane to the circumstances;
(n) Examinations of the newborn and postpartum mother; and
(o) Instructions given to the client regarding postpartum care, family planning, care of the newborn, arrangements for metabolic testing, immunizations, and follow-up pediatric care.
1. All entries shall be dated and signed by the attending clinical staff members.
2. The clinical record is confidential and shall not be released without the written consent of the client except under the following conditions:
a. When the client is transferred to another source of care; and
b. For audit by the agency during licensure inspection or complaint investigation.
3. The clinical records shall be kept on file for a minimum of seven years from the date of last entry.
4. The clinical record shall be immediately available at the time of the client ' s admission to the birth center in labor and to the practitioner or hospital when the client is transferred.
| 11/17/2015 |
| 10/01/2015 | Complaint | YC0T | B0043 | TRANSFER REPORTA written report of the transfer shall be documented and available for quality assurance review and agency inspection. The report shall include:
1. The client ' s name;
2. The date of the event;
3. The reason for transfer;
4. The provider and mode of transportation to the hospital;
5. The exact time of the initial call, any subsequent calls;
6. Arrival of the emergency personnel;
7. Departure of the client;
8. Arrival at the hospital;
9. Name of the hospital;
10. Initiation of emergency medical services;
11. The condition of the client at the time of transfer; and
12. Any information regarding the medical care of the client and outcome.
| 11/17/2015 |
| 06/08/2015 | Standard | M2DI | None | NoneNone | None |
| 12/23/2014 | Complaint | YU1P | B0069 | INTRAPARTUM CAREThe clinical staff monitors the progress of labor and condition of the mother and fetus at intervals
sufficiently frequent to identify abnormalities of complications at the earliest possible time.
| 01/23/2015 |
| 07/29/2014 | Fire/Life/Safety | D1FL | K0116 | STAFF TRAININGExtinguisher Training. Designated employees of business occupancies shall be periodically instructed in the use of portable fire extinguishers in accordance with NFPA 101 (Life safety Code) (2009) Section 38.7.3 & 39.7.3
| 07/31/2014 |
| 07/29/2014 | Fire/Life/Safety | D1FL | K0125 | DISASTER PLANEach birth center shall develop a written disaster plan which shall be rehearsed by personnel at least twice a year and shall cover internal casualty producing incidents. The plan shall include provisions for complete evacuation of the facility during an actual disaster. 59A-11.027
| 07/31/2014 |
| 07/28/2014 | Complaint | 7VXR | B0069 | INTRAPARTUM CAREThe clinical staff monitors the progress of labor and condition of the mother and fetus at intervals
sufficiently frequent to identify abnormalities of complications at the earliest possible time.
| 08/28/2014 |
| 07/28/2014 | Standard | WZVP | B0127 | EQUIPMENT AND SUPPLIESEquipment includes at a minimum:
(a) examining table and stool;
(b) examination light;
(c) sphygmomanometer and stethoscope;
(d) clinical thermometer;
(e) fetoscope or doppler unit;
(f) adult beam scale;
(g) infant scale;
(h) sweep second hand clock;
(i) mechanical suction or bulb suction;
(j) oxygen with flow meter and mask or equivalent;
(k) resuscitation equipment to include resuscitation bags and oral airways; laryngoscopes and endotracheal tubesappropriate for the newborn;
(l) emergency medications and intravenous fluids with supplies and equipment appropriate for
administration;
(m) sterile suturing equipment and supplies;
(n) bassinet; and
(o) a firm surface suitable for resuscitation.
| 08/28/2014 |
| 09/04/2013 | Fire/Life/Safety | 49TQ | None | NoneNone | None |
| 08/09/2012 | Fire/Life/Safety | KC72 | K0106 | EGRESS LIGHTINGEgress normal illumination and emergency lighting shall be in accordance with NFPA 101(Life safety Code)(2006) Section 7.8-.9 and 39.2.9.
| 09/11/2012 |
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