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(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
Q 0000
Bldg. 00
This visit was for investigation of a federal
ambulatory surgery center complaint.
Complaint Number: IN00309965
Substantiated: Deficiencies related to the
allegations are cited.
Date of Survey: 11/13/19
Facility Number: 005401
QA: 11/21/19
Q 0000 Agreed that survey for a complaint
was performed on 11/13/2019
416.46(a)
ORGANIZATION AND STAFFING
Patient care responsibilities must be
delineated for all nursing service personnel.
Nursing services must be provided in
accordance with recognized standards of
practice. There must be a registered nurse
available for emergency treatment whenever
there is a patient in the ASC.
Q 0141
Bldg. 00
Based on document review, observation and
interview, the center failed to ensure that
delineated responsibilities for nursing service
personnel was provided in accordance with
standard of practice and facility policies by: 1.
employing 2 employees (N7 and N12) as nurses
without having documentation of an Indiana
license, 2. failing to ensure staffing requirements
were met for quality patient care, and 3. failing to
ensure implementation of the center's policy for
demonstrated competency for 5 of 9 nursing staff
(N2, N5, N7, N8 and N12).
Findings include:
Q 0141 Eye Surgery Center of New
Albany, LLC, 15C0001020
Plan of Correction - Complaint
Survey 11/13/2019
Q 141
01. B. Governing Board
Minutes dated 10 September 2018
indicates approval of policy
manual and all contained policies
for the renamed surgery center.
During
survey the Clinical Director
12/13/2019 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete
Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determin
other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclo
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to
continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
_____________________________________________________________________________________________________Event ID: X66R11 Facility ID: 005401
TITLE
If continuation sheet Page 1 of 26
(X6) DATE
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
1. Policy review:
A. Review of the center's policy titled
"Competency Assessment System", unable to
determine approval date, indicated the following:
POLICY: It is the responsibility of the
Governing Board, Administration, and Center
leadership to ensure that each Center employee is
competent in knowledge/skills required and
safe/effective use of equipment as appropriate to
his/her responsibilities.
The competency program includes the
following: 1. licensing; 2. orientation documents;
3. credentials and documents (skill records,
competency forms, educational records); 4.
Performance Improvement system; and 5.
professional certification.
PROCEDURE: 1. Hiring process: Initial
competency is assess upon hire via licensing
verification, school records, work history,
reference checks and personal interviews by the
hiring supervisor. 2. Job Descriptions: The
employee is assigned duties/responsibilities,
based on the education preparation, applicable
licensing laws and regulations, assessment of
current competence, and criteria based job
description/evaluations. 3. Orientation will be
provided to all new employees and contract
related employees. 4. Evaluation: Evaluation of
each employee's competence is an ongoing
process. It is assessed as part of the
preemployment, hiring, and orientation process
and annually thereafter. Yearly competency
assessment includes core competencies and work
area competencies which address, but are not
limited to, age specific skills, use of equipment,
acceptable performance of new procedures and
high risk/problem prone tasks and skills which
require validation of performance.
B. Review of the clinical staffing policy
provided a staffing grid that is not
policy but rather
a guideline
for optimal staffing. Historically,
staffing by department has been
as follows:
Pre-OP 2
employees (2 RN, 1 RN/1 LPN, 1
RN / 1 Tech), PACU 2 employees
(1 RN / 1 LPN,
2 RN, 1 RN / I Tech or 2 LPN with
RN Supervision), ORs 5
employees (2 nurse circulators /
2 surg. tech. / 1 prep / instrument
tech / nurse), Laser Suite 1
certified laser operator,
YAG laser 1 trained nurse / tech
to assist surgeon, 1 CRNA floating
between cases, Pre-
OP and Post OP.
03. The staff roster has
been updated to include staff that
are part of the regional travel team
to reflect the job classification for
the duties they can perform, this
includes N12.
04. A. N2 has and had
previous evaluations indication
additional education and training
was assigned in regards to clinical
skills. The majority of staff
education is/was through on-line
training programs.
B. N5 Job Description
and annual competency
assessment has been updated by
the Clinical Director and N5. This
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 2 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
provided, titled "Addendum to General Clinical"
Subject: "Staffing", unable to determine approval
date, indicated the following:
POLICY: Ensure during the Center's
operational hours that staffing requirements are
met for quality patient care and that employees do
not provide services in an adjacent office, clinic,
hospital, or other facility at the same time.
Review of the provided staffing grid indicated
the following:
Pre-Op (Pre-operative area): (2) RN's
(Registered Nurse)/1 LPN (Licensed Practical
Nurse).
YAGS (Yttrium, Aluminum and Garnet
laser): RN or LPN
Circulate: OR (Operating Room) 1 RN,
OR 2 RN
Prep (Preparation): LPN vs CST/ST
(Certified Surgical Technician/Surgical
Technician) vs RN
Instrument Tech (Technician): LPN vs
CST/ST
PARR (Post Anesthesia Recovery
Room): (2) RN's/1 LPN, one tech PRN (as needed)
The grid lacked documentation of any reason
for variances of staffing numbers.
2. Review of the Center's job descriptions for RN;
RN Operating/Procedure Room; and RN Post
Anesthesia Care Unit (PACU), indicated the
following for "Required Licensure and
Certification": Has a current license to practice as
a Registered Nurse in the State. The job
description for LPN/Licensed Vocational Nurse
Pre-Procedure and Recovery Areas indicated the
following for "Required Licensure and
Certification": Has a current license to practice as
a Practical Nurse in the State. The job
descriptions also indicated Knowledge, Skills and
Abilities to include: Demonstrates the knowledge
was completed on 12-03-19
C. N7 is still within her
orientation / probationary period
and has not completed her initial
training and verification
documents. Clinical Director will
work with employees in orientation
and maintain the orientation
checklist / credentialing file at the
ASC. This will be done no later
than December 13, 2019.
D. N8 completed her
orientation / probationary period
and documentation has been
completed and filed by the Clinical
Director. This was completed on
12-3- 2019.
E. N9 has completed the annual
competency assessment with the
Clinical Director on 12-03-2019
The Clinical Director will establish
a set day(s) for completing annual
competencies for all clinical staff,
to be established by 12-13-2019
F. N10 will have an employee file
completed by 12-13-19 and
maintained along with other
employee files. Requirements for
a driver include a valid driver’s
license (to be updated to
equivalent of Public Passenger
Chauffeur or CDL) in the state in
which they reside, a completed
health physical, drug screen,
criminal background check and
BLS CPR certification within 90
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 3 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
and skills in the nursing process.
3. Review of the employee staff list indicated N7
was an RN hired 9/23/19. The list lacked
documentation/identification of N12.
4. Review of personnel files indicated the
following: *Note: Those with a date of hire (DOH)
indicated as 7/1/18, was an "adjusted" DOH due
to new company ownership. Those employees
were; however, previously in employment with the
center prior to new ownership. Dates on
documents may reflect tasks done prior to new
ownership.
A. N2, RN, DOH 7/1/18 had a job description
titled "Staff Nurse - Pre-Operative Unit,
Post-Operative Unit, Circulator", dated 6/1/01.
The file lacked documentation of initial
competency assessment upon hire and/or
orientation to his/her job. The file indicated that
the employee's employment was terminated on
8/15/19 due to failure to discontinue an IV
(intravenous) catheter from a patient prior to
discharge. The file lacked documentation of
training, initial competency and/or annual
competency evaluation of the discharge process
and/or removal of IV catheters.
B. N5, LPN, DOH 7/1/18, had an LPN job
description dated 8/3/88 with a copy of the LPN
job description as noted above. The file lacked
documentation of annual competency evaluations
since 5/16/16.
C. N7, RN, DOH 9/23/19, lacked
documentation of a job description. The file
lacked documentation of competency by license
(no documentation of licensure was in the file),
lacked job orientation documentation and lacked
documentation of an initial competency
assessment.
D. N8, RN, DOH 9/3/19, lacked documentation
days of hire. The Administrator
and Clinical Director will be
responsible for this task.
G. N11 Requirements for a driver
include a valid driver’s license (to
be updated to equivalent of Public
Passenger Chauffeur or CDL) in
the state in which they reside, a
completed health physical, drug
screen, criminal background
check and BLS CPR
Q 141 continued
04. certification within 90
days of hire. The Administrator
will be responsible for verification.
H. N12 is an employee of another
EyeCare Partners surgery center
and are part of a “travel team” that
helps when needed at other
facilities within the region. N12
had an employee file at the
primary surgery center but not
here at the time of the survey.
That has since been corrected as
of 12-03-19. Clinical Director and
Administrator are responsible for
ensuring employee files for all
employees working in the ASC are
available going forward.
05. During survey
the Clinical Director provided a
staffing grid that is not policy but
rather
a guideline
for optimal staffing. Historically,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 4 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
of a job description. The file lacked job
orientation documentation and lacked
documentation of an initial competency
assessment.
E. N9, Certified Ophthalmic Assistant, DOH
7/1/18, had a job description as a pre/post surgical
technician. The file lacked documentation of an
annual competency evaluation since 5/25/17.
F. N10, Transportation Coordinator (van
driver). Unable to determine required competency
due to lack of personnel file.
G. N11, Transportation Coordinator, DOH
7/1/18, lacked documentation of any annual
competency evaluations.
H. N12 (nursing). Unable to determine
required competencies were met due to lack of
documentation of a state license and lack of a
personnel file.
5. In review of staffing sheets provided for 7/1/19
through 11/11/19, appropriate staffing could not
be determined due to documentation and/or lack
of documentation as follows (not all inclusive):
On 7/9/19, 7/10/19, 7/15/19, 7/16/19, 7/17/19,
7/18/19, 8/5/19, 8/6/19, 8/7/19, 9/3/19, 9/4/19,
9/9/19, 9/16/19, 9/17/19, 9/18/19*, 9/20/19*,
9/24/19, 9/25/19 ; staffing sheets lacked
documentation of an LPN, or 3 nurses, having
been scheduled for Pre-Op.
On 9/16/19, 9/17/19, 9/18/19*, 9/19/19,
9/20/19*, 9/24/19, 9/25/19, 9/26/19, 9/27/19, 10/2/19
and 10/4/19; staffing sheets lacked documentation
of any staff having been scheduled as
"Instrument Tech".
On 7/9/19, 7/10/19, 7/15/19, 7/16/19, 7/17/19,
8/5/19, 8/6/19, 8/7/19, 9/3/19, 9/4/19, 9/5/19, 9/9/19,
9/10/19, 9/11/19, 9/12/19, 9/13/19, 9/16/19, 9/17/19,
9/18/19*, 9/19/19, 9/20/19*, 9/23/19, 9/24/19,
9/25/19, 9/26/19, 9/30/19, 10/1/19, 10/2/19, 10/3/19
and 10/4/19; staffing sheets lacked documentation
staffing by department has been
as follows:
Pre-OP 2
employees (2 RN, 1 RN/1 LPN, 1
RN / 1 Tech), PACU 2 employees
(1 RN / 1 LPN,
2 RN, 1 RN / I Tech or 2 LPN with
RN Supervision), ORs 5
employees (2 nurse circulators /
2 surg. tech. / 1 prep / instrument
tech / nurse), Laser Suite 1
certified laser operator,
YAG laser 1 trained nurse / tech
to assist surgeon, 1 CRNA floating
between cases, Pre-
OP and Post OP.
The Clinical Director will maintain
an official copy of the staff
schedules that reflects any
changes with reason and will
maintain at least for the
accreditation cycle of three years.
The CD will also evaluate the staff
roster to determine if there is a
need for additional
PRN staff. These are to be
completed no later than
12/26/2019 (30 days from receipt
of
deficiencies).
The staffing
sheets presented regarding 9/18
and 9/20 were the original sheets
completed based upon the original
surgery schedules provided by the
surgeon offices.
The original schedules indicated
no surgery schedules for those
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 5 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
of 2 RNs (not 3 nurses) or any techs having been
scheduled for PARR.
*Note: On 9/18/19 and 9/20/19, staffing
sheets indicated no surgery was
schedule/occurred on that date. All staff
assignment areas were blank.
6. Review of patient surgery logs indicated that
on 9/18/19, one (1) YAG procedure was performed
and that on 9/20/19, 32 procedures; 30 cataract
extractions/IOLs and 2 YAGs, were performed.
7. On 11/13/19, between approximately 12:00 PM
and 12:15 PM, during facility tour, a staffing
schedule was observed to be hanging on the wall
between pre-op and PARR. The sheet was noted
to have multiple markings and changes, unlike the
previous staffing sheets provided for review.
8. Medical record review indicated both N7 and
N12 had performed nursing duties at the center as
follows, not all inclusive:
On 10/4/19, N7 initialed removal of the IV
(intravenous) catheter for patient P5 and N12 was
documented as an RN having assisted in PACU.
On 10/4/19, N7 initialed removal of the IV for
patient P4.
On 9/20/19, N12 was indicated, by initials,
that he/she removed the IV of patient P6 and it
was documented that he/she, as an RN, assisted
in PACU.
On 9/20/19, N12 was indicated, by initials,
that he/she removed the IV of patient P7 and it
was documented that he/she, as an RN, assisted
in PACU.
On 9/20/19, it was documented that N12, as
an RN, assisted in PACU for patient P8.
9. On 11/13/19, the following was indicated in
interview:
dates, however 9/20
was added as an additional
surgery day and staff were
scheduled but the “working”
schedule was not maintained.
06. 9/18 remained an
unscheduled surgery day and N3
was scheduled to make pre-op
calls and was working when an
emergency YAG procedure was
scheduled to relieve elevated eye
pressure that threatened the
patient’s eyesight. N3 was
qualified to assist with YAG
procedures and assisted the
surgeon.
07. The Clinical
Director will maintain an official
copy of the staff schedules that
reflects any
and will maintain at least for the
accreditation cycle of three years.
The CD will also
evaluate the staff roster to
determine if there is a need for
additional PRN staff.
These are to be completed no
later than 12/26/2019 (30 days
from receipt of
deficiencies).
08. A. N7’s license was
verified and located under her
maiden name and verified by
comparison to the presented copy
of the marriage license. N7 has
been instructed to update her
license to reflect her current
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 6 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
Between approximately 12:00 PM and 12:15
PM, A3, Clinical Director, indicated the staffing
sheet on the wall had the originally planned
schedule/assignments plus changes due to staff
being off (sick/call-in, etc). When asked to
provide documentation of the staffing sheets
showing who actually worked on given days
between 7/1/19 and 11/11/19, A3 indicated he/she
did not keep the originals, those were destroyed
after use and they could not be provided.
On 11/13/19, between approximately 4:15 PM
and 5:00 PM, A3, Clinical Director, verified
competency documentation for N2 was marked
"N/A" although N2 had job descriptions requiring
some of the tasks indicated to be not applicable.
A3 then indicated the areas marked "N/A" were
such due to the employee's inability to
demonstrate competence of the skills. A3 verified
the personnel file of N2 lacked documentation of
skills training and/or a plan of correction with
goals to educate, train and re-assess the
employee.
Between approximately 5:30 PM and 7:00 PM,
A3 verified that N7 was employed at the center as
an RN and that the personnel file for N7 lacked
documentation of N7 having a current Indiana
license. A3 verified that surgeries were performed
on 9/18/19 and 9/20/19 and that he/she did not
have documentation of staff having been
scheduled/assigned to patient care for those
dates. A3 also verified that, from the staffing
sheets, it could not be determined that appropriate
numbers of staff were available to provide patient
care in accordance with their grid.
Between approximately 5:30 PM and 7:00 PM,
A1, Office Manager, verified that the center did
not have a personnel file for N12. A1 indicated
that N12 was a nurse who came from their
Kentucky center to work in the Indiana center
during time(s) when staff was low.
name. N7 is still within her
orientation / probationary period
and has not completed her initial
training and verification
documents. Clinical Director will
work with employees in orientation
and maintain the
Q 141 continued
08. orientation checklist /
credentialing file at the ASC. This
will be done no later than
December 13, 2019.
B. N12 does not
possess an Indiana Nursing
License and was not providing
care that is
limited to a nurse by the IN-Nurse
Practice Act. N12 was working in
the capacity of a patient care
assistant (pre/post technician);
assisting with removal of PPE
from patients, taking vital signs,
providing nourishment, removing
saline lock catheters (a procedure
performed by Hospital nursing
assistants, radiology technicians,
emergency department
technicians and others routinely)
and escorting to awaiting vehicle /
responsible companion.
N12’s name was written in
identifying her as an RN. This
was done after the charting had
been completed as evidenced by
the way it was written diagonally
along narrative lines in the notation
area of the PACU record. All staff
members were informed by the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 7 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
10. Review of the Indiana Professional Licensing
Agency website at https://www.in.gov/pla/,
lacked documentation of an Indiana nursing
license for N7 or N12.
Clinical Director that N12 was not
a nurse in Indiana and what tasks
N12 could perform.
09. The Clinical
Director will maintain an official
copy of the staff schedules that
reflects any
and will maintain at least for the
accreditation cycle of three years.
The CD will also
evaluate the staff roster to
determine if there is a need for
additional PRN staff.
These are to be completed no
later than 12/26/2019 (30 days
from receipt of
deficiencies).
N2’s most recent evaluation notes
that N2 was assigned on-line
courses related to nursing
&nursing assessment by the ASC
Administrator. One of her
performance review goals was to
continue with the courses for
re-education and training. There
was a reassessment at the time of
her annual evaluation.
Going forward the Clinical Director
and Office Manager will make sure
that all evaluations and
competency forms are fully and
accurately completed. This is
effective immediately.
N7’s license was verified and
located under her maiden name
and verified by comparison to the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 8 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
presented copy of the marriage
license. N7 has been instructed
to update her license to reflect her
current name. N7 is still within
her orientation / probationary
period and has not completed her
initial training and verification
documents. Clinical Director will
work with employees in orientation
and maintain the orientation
checklist / credentialing file at the
ASC. This will be done no later
than December 13, 2019.
The staffing
sheets presented regarding 9/18
and 9/20 were the original sheets
completed based upon the original
surgery schedules provided by the
surgeon offices.
The original schedules indicated
no surgery schedules for those
dates, however 9/20
was added as an additional
surgery day and staff were
scheduled but the “working”
schedule was not maintained.
9/18 remained an unscheduled
surgery day and N3 was
scheduled to make pre-op calls
and was working when an
emergency YAG procedure was
scheduled to relieve elevated
Q 141 continued
09. eye pressure that
threatened the patient’s eyesight.
N3 was qualified to assist with
YAG procedures and assisted the
surgeon.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 9 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
10. A. N7’s
license was verified and located
under her maiden name and
verified by comparison to the
presented copy of the marriage
license. N7 has been instructed
to update her license to reflect her
current name. N7 is still within
her orientation / probationary
period and has not completed her
initial training and verification
documents. Clinical Director will
work with employees in orientation
and maintain the orientation
checklist / credentialing file at the
ASC. This will be done no later
than December 13, 2019.
B. N12 does not
possess an Indiana Nursing
License and was not providing
care that is
limited to a nurse by the IN-Nurse
Practice Act. N12 was working in
the capacity of a patient care
assistant (pre/post technician);
assisting with removal of PPE
from patients, taking vital signs,
providing nourishment, removing
saline lock catheters (a procedure
performed by Hospital nursing
assistants, radiology technicians,
emergency department
technicians and others routinely)
and escorting to awaiting vehicle /
responsible companion. Clinical
Director and Office Manager will
ensure the presence of employee
files with clear delineation of the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 10 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
role and qualifications of the staff
member. This is in effect as of
12-03-2019
S 0000
Bldg. 00
This visit was for investigation of a state licensure
ambulatory surgery center complaint.
Complaint Number: IN00309965
Substantiated: Deficiencies related to the
allegations are cited.
Date of Survey: 11/13/19
Facility Number: 005401
QA: 11/21/19
IDR Committee met on 01/06/2020. Tags S172 &
S176 modified.
S 0000 Agree that a complaint survey was
performed on 11/13/2019
410 IAC 15-2.2-2
SURVEY PROCEDURES
410 IAC 15-2.2-2 (c)(1)
(c) All documents in legally
reproducible form must be maintained
within the center for the period
required by statutes of limitations
and must be made available upon
S 0028
Bldg. 00
State Form Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 11 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
request for inspection, including
copying by representatives of the
department as follows:
(1) Items to include, but not limited
to, the following:
(A) Documents showing ownership,
certified copy of articles of
incorporation (if incorporated).
(B) Constitution and bylaws of
governing body.
(C) Minutes of meetings of the
governing body and committees
thereof.
(D) Minutes of meetings of the
medical staff and committees
thereof.
(E) All documents pertaining to
quality assurance and improvement
of patient care and medical care.
(F) A current roster of members of
the medical staff with designated
privileges.
(G) Personnel records.
(H) Medical records.
(I) Reports pursuant to IC
16-21-2-6.
Based on document review and interview, the
center failed to maintain and make available, 2
personnel records (van driver N10 and nurse N12)
and 1 medical record (P3) requested for inspection
in 1 facility.
Findings include:
1. Review of the facility's employee list lacked
documentation of staff personnel N10 and N12.
2. Review of the patient registry logs for 7/1/19
through 11/11/19 indicated patient P3 had left eye
S 0028 Employee files will have been
copied and a clinical competency
will be completed for the level of
care to be provided, according to
license held in the State of
Indiana. These files will be
completed and treated the same
as regular staff files.
Clinical Director and Administrator
will be responsible to complete by
12/06/2019
Office manager will develop a log
12/06/2019 12:00:00AM
State Form Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 12 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
(OS) cataract removal and intraocular lens
replacement (COS/IOL) on 10/4/19.
3. Review of medical records (MR) lacked
documentation of a MR for patient P3 on
admission date 10/4/19.
4. Review of personnel files lacked
documentation of a personnel file for N10 or N12.
5. On 11/13/19, between approximately 5:30 PM
and 7:00 PM, A1, Office Manager, verified that
he/she could not find/make available; the 10/4/19
MR for patient P3 and that the patient did have
surgery on that date. A1 also verified that the
center did not have a personnel file for N10 nor
N12. A1 indicated that N10 was a new van driver
for the center who had just started and that N12
was a nurse who came from their Kentucky center
to work in the center during time(s) when staff
was low.
to better track which charts have
been returned to the surgeon or
nursing staff for completion or have
been uploaded into the digital
storage files. The process for
medical record management
includes the review and closing of
medical records within 48 hours
when possible with the goal to
have all charts uploaded into
secured digital storage within 30
days. Charts requiring completion
are returned to the appropriate
department for completion and
once returned are added to the
queue with other charts from the
same date of service.
Office Manger / Medical Records
custodian responsible to have this
in place no later than December
31, 2019
410 IAC 15-2.4-1
GOVERNING BODY; POWERS AND
DUTIES
410 IAC 15-2.4-1 (c) (5) (B)
Require that the chief executive
officer develop and implement policies
and programs for the following:
(B) Ensuring that during the center's
operational hours that staffing
requirements are met for quality
patient care and that employees do not
provide services in an adjacent
office, clinic, hospital, or other
facility at the same time.
S 0152
Bldg. 00
Based on document review, observation and
interview, it could not be determined that the S 0152 S 152
02. During survey 12/26/2019 12:00:00AM
State Form Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 13 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
Chief Executive Officer (CEO) ensured, that during
the center's operational hours, staffing
requirement were met for quality patient care in
one facility.
Findings include:
1. Review of the clinical staffing policy provided,
titled "Addendum to General Clinical" Subject:
"Staffing", unable to determine approval date,
indicated the following: POLICY: Ensure during
the Center's operational hours that staffing
requirements are met for quality patient care and
that employees do not provide services in an
adjacent office, clinic, hospital, or other facility at
the same time.
2. Review of the provided staffing grid indicated
the following:
Pre-Op (Pre-operative area): (2) RN's
(Registered Nurse)/1 LPN (Licensed Practical
Nurse).
YAGS (Yttrium, Aluminum and Garnet laser):
RN or LPN
Circulate: OR (Operating Room) 1 RN, OR 2
RN
Prep (Preparation): LPN vs CST/ST (Certified
Surgical Technician/Surgical Technician) vs RN
Instrument Tech (Technician): LPN vs
CST/ST
PARR (Post Anesthesia Recovery Room): (2)
RN's/1 LPN, one tech PRN (as needed)
The grid lacked documentation of any reason for
variances of staffing numbers.
3. In review of staffing sheets provided for 7/1/19
through 11/11/19, appropriate staffing could not
be determined due to documentation and lack of
documentation as follows (not all inclusive):
On 7/9/19, 7/10/19, 7/15/19, 7/16/19, 7/17/19,
the Clinical Director provided a
staffing grid that is not policy but
rather
a guideline
for optimal staffing. Historically,
staffing by department has been
as follows:
Pre-OP 2
employees (2 RN, 1 RN/1 LPN, 1
RN / 1 Tech), PACU 2 employees
(1 RN / 1 LPN,
2 RN, 1 RN / I Tech or 2 LPN with
RN Supervision), ORs 5
employees (2 nurse circulators /
2 surg. tech. / 1 prep / instrument
tech / nurse), Laser Suite 1
certified laser operator,
YAG laser 1 trained nurse / tech
to assist surgeon, 1 CRNA floating
between cases, Pre-
OP and Post OP.
The Clinical Director will maintain
an official copy of the staff
schedules that reflects any
changes with reason and will
maintain at least for the
accreditation cycle of three years.
The CD will also evaluate the staff
roster to determine if there is a
need for additional
PRN staff. These are to be
completed no later than
12/26/2019 (30 days from receipt
of
deficiencies).
03. The Clinical
Director will maintain an official
copy of the staff schedules that
reflects any
State Form Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 14 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
7/18/19, 8/5/19, 8/6/19, 8/7/19, 9/3/19, 9/4/19,
9/9/19, 9/16/19, 9/17/19, 9/18/19*, 9/20/19*,
9/24/19, 9/25/19 ; staffing sheets lacked
documentation of an LPN, or 3 nurses, having
been scheduled for Pre-Op.
On 9/16/19, 9/17/19, 9/18/19*, 9/19/19,
9/20/19*, 9/24/19, 9/25/19, 9/26/19, 9/27/19, 10/2/19
and 10/4/19; staffing sheets lacked documentation
of any staff having been scheduled as
"Instrument Tech".
On 7/9/19, 7/10/19, 7/15/19, 7/16/19, 7/17/19,
8/5/19, 8/6/19, 8/7/19, 9/3/19, 9/4/19, 9/5/19, 9/9/19,
9/10/19, 9/11/19, 9/12/19, 9/13/19, 9/16/19, 9/17/19,
9/18/19*, 9/19/19, 9/20/19*, 9/23/19, 9/24/19,
9/25/19, 9/26/19, 9/30/19, 10/1/19, 10/2/19, 10/3/19
and 10/4/19; staffing sheets lacked documentation
of 2 RNs (not 3 nurses) or any techs having been
scheduled for PARR.
*Note: On 9/18/19 and 9/20/19, staffing
sheets indicated no surgery was
schedule/occurred on that date. All staff
assignment areas were blank.
4. Review of incident reports indicated the facility
had PARR related incidents for patient's IVs
(intravenous) catheters left in place at discharge
on 10/3/19 and on 10/4/19.
5. Review of patient surgery logs indicated that
on 9/18/19, one (1) YAG procedure was performed
and that on 9/20/19, 32 procedures, 30 cataract
extractions/IOLs and 2 YAGs, were performed.
6. On 11/13/19, between approximately 12:00 PM
and 12:15 PM, during facility tour, a staffing
schedule was observed to be hanging on the wall
between pre-op and PARR. The sheet was noted
to have multiple markings and changes, unlike the
previous staffing sheets provided for review.
and will maintain at least for the
accreditation cycle of three years.
The CD will also
evaluate the staff roster to
determine if there is a need for
additional PRN staff.
These are to be completed no
later than 12/26/2019 (30 days
from receipt of
deficiencies).
05. The staffing
sheets presented regarding 9/18
and 9/20 were the original sheets
completed based upon the original
surgery schedules provided by the
surgeon offices.
The original schedules indicated
no surgery schedules for those
dates, however 9/20
was added as an additional
surgery day and staff were
scheduled but the “working”
schedule was not maintained.
9/18 remained an unscheduled
surgery day and N3 was
scheduled to make pre-op calls
and was working when an
emergency YAG procedure
was scheduled to relieve elevated
eye pressure that threatened the
patient’s eyesight.
N3 was qualified to assist with
YAG procedures and assisted the
surgeon.
06. The Clinical
Director will maintain an official
copy of the staff schedules that
reflects any
State Form Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 15 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
7. On 11/13/19, between approximately 12:00 PM
and 12:15 PM, A3, Clinical Director, indicated the
staffing sheet on the wall had the originally
planned schedule/assignments plus changes due
to staff being off (sick/call-in, etc). When asked
to provide documentation of the staffing sheets
showing who actually worked on given days
between 7/1/19 and 11/11/19, A3 indicated he/she
did not keep the originals, those were destroyed
after use and they could not be provided.
Between approximately 5:30 PM and 7:00 PM, A3
indicated that he/she did not have accurate
documentation of staffing. A3 verified that
surgeries were performed on 9/18/19 and 9/20/19;
however he/she did not have documentation of
any staff having been scheduled/assigned to
patient care. A3 also verified that, from the
staffing sheets, it could not be determined that
appropriate numbers of staff were available to
provide patient care.
and will maintain at least for the
accreditation cycle of three years.
The CD will also
evaluate the staff roster to
determine if there is a need for
additional PRN staff.
These are to be completed no
later than 12/26/2019 (30 days
from receipt of
S 152 continued
06. deficiencies).
07. The Clinical Director will
maintain an official copy of the
staff schedules that reflects any
and will maintain at least for the
accreditation cycle of three years.
The CD will also
evaluate the staff roster to
determine if there is a need for
additional PRN staff.
These are to be completed no
later than 12/26/2019 (30 days
from receipt of
deficiencies).
410 IAC 15-2.4-1
GOVERNING BODY; POWERS AND
DUTIES
410 IAC 15-2.4-1 (c)(5) (L)
Require that the chief executive
officer develop and implement policies
and programs for the following:
(L) Maintaining personnel records for
each employee of the center which
include personal data, education and
experience, evidence of participation
in job related educational activities,
S 0172
Bldg. 00
State Form Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 16 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
and records of employees which relate
to post offer and subsequent physical
examinations, immunizations, and
tuberculin tests or chest x-rays, as
applicable.
Based on document review and interview, the
governing body (GB) failed to maintain personnel
records which included personal data, education
and experience, evidence of participation in job
related educational activities for 3 (two) current
employees (N3, N7 and N8).
Findings include:
1. Review of a list of staff employed between
7/1/19 and 11/11/19 indicated the following:
A. Name: N3. Adjusted Hired Date: 7/1/19.
Job Title: Registered Nurse (RN). Status:
Terminated. Termination Date: 10/7/19
B. Name: N7. Adjusted Hired Date: 9/23/19.
Job Title: RN. Status: Active.
C. Name: N8. Adjusted Hired Date: 9/3/19.
Job Title: RN. Status: Active.
2. Review of personnel files indicated the
following:
A. The personnel file for N3 lacked
documentation of N3's participation in job related
educational activities.
B. The personnel file for N7 lacked evidence
of N7 being licensed as an RN, lacked
documentation of education and experience
verification as an RN, and lacked documentation
of participation in job related educational
activities.
C. The personnel file for N8 lacked evidence
of N8's participation in job related educational
activities.
3. On 11/13/19, between approximately 5:30 PM
S 0172 S 172
02. A. EyeCare
Partners, the parent company for
the ASC utilizes a corporate
Human
Resources department which
includes a centralized depository
for Employee Records.
Per the regional HR manager,
employee disciplinary actions
related to termination are
not made available to local
administrators, which is why there
was not documentation related to
N3’s termination available on site.
REQUEST IDR as we dispute the
ISDH has authority to review and
or question disciplinary action
including termination. The IN
PLC, EEOC and Unemployment
Board would be the appropriate
agencies to review disciplinary
actions.
B. N7’s license was verified and
located under her maiden name
and verified by comparison to the
presented copy of the marriage
license. N7 has been instructed
to update her license to reflect her
current name.
N7 is still within her orientation /
probationary period and has not
completed her initial training and
12/13/2019 12:00:00AM
State Form Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 17 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
and 7:00 PM, A3 indicated that the files for N7 and
N8 did not yet have the information in the file due
to the employees having it with them. A3 verified
that the personnel file for N7 lacked
documentation of his/her status as an RN and that
the files for both N7 and N8 lacked documentation
of participation in job related educational
activities.
verification documents. Clinical
Director will work with employees
in orientation and maintain the
orientation checklist /
credentialing file at the ASC. This
will be done no later than
December 13, 2019.
C. N7 is still within her orientation
/ probationary period and has not
completed her initial training and
verification documents. Clinical
Director will work with employees
in orientation and maintain the
orientation checklist /
credentialing file at the ASC. This
will be done no later than
December 13, 2019.
03. EyeCare
Partners, the parent company for
the ASC utilizes a corporate
Human
Resources department which
includes a centralized depository
for Employee Records.
Per the regional HR manager,
employee disciplinary actions
related to termination are
not made available to local
administrators, which is why there
was not documentation related to
N3’s termination available on
site.
410 IAC 15-2.4-1
GOVERNING BODY; POWERS AND
DUTIES
410 IAC 15-2.4-1 (c)(5) (M)
S 0176
Bldg. 00
State Form Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 18 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
Require that the chief executive
officer develop and implement policies
and programs for the following:
(M) Demonstrating and documenting
personnel competency in fulfilling
assigned responsibilities and
verifying in-service in special
procedures.
Based on document review and interview, the
Chief Executive Officer (CEO) failed to ensure
implementation of the center's policy for
demonstrated competency of personnel to fulfill
their assigned responsibilities for 6 of 12
employees N5,N7, N8, N10, N11 and N12.
Findings include:
1. Review of the center's policy titled
"Competency Assessment System", unable to
determine approval date, indicated the following:
POLICY: It is the responsibility of the
Governing Board, Administration, and Center
leadership to ensure that each Center employee is
competent in knowledge/skills required and
safe/effective use of equipment as appropriate to
his/her responsibilities.
The competency program includes the
following: 1. licensing; 2. orientation documents;
3. credentials and documents (skill records,
competency forms, educational records); 4.
Performance Improvement system; and 5.
professional certification.
PROCEDURE: 1. Hiring process: Initial
competency is assess upon hire via licensing
verification, school records, work history,
reference checks and personal interviews by the
hiring supervisor. ..... 4. Evaluation: Evaluation
of each employee's competence is an ongoing
process. It is assessed as part of the
S 0176 S 176
M. The CEO did not discuss
competency training with the
Surveyor as stated in the citation.
RN ASC Administrator / CEO
recalls meeting with the Surveyor
when she arrived and explained
the reason for the survey and
when she came to the
administrator’s office to provide the
exit conference, otherwise had
very limited interaction with the
surveyor. Survey participation
included Clinical Director and
Office Manager.
01. Governing Board
Minutes dated 10 September 2018
indicates approval of policy
manual and all contained policies
for the renamed surgery center.
02. A. N5 has completed an
updated LPN job Description and
Competency Assessment.
The Clinical Director
will establish an annual
“competency” day or days in
January of each calendar year.
The Clinical Director and Office
Manager are responsible for
12/13/2019 12:00:00AM
State Form Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 19 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
preemployment, hiring, and orientation process
and annually thereafter. Yearly competency
assessment includes core competencies and work
area competencies which address, but are not
limited to, age specific skills, use of equipment,
acceptable performance of new procedures and
high risk/problem prone tasks and skills which
require validation of performance.
2. Review of personnel files indicated the
following:
A. N5, LPN, DOH 7/1/18, had an LPN job
description dated 8/3/88 with a copy of the LPN
job description as noted above. (new hire date
given due to change in ownership of facility) The
file lacked documentation of annual competency
evaluations since 5/16/16.
B. N7, RN, DOH 9/23/19, lacked
documentation of competency by license (no
documentation of licensure was in the file) and
lacked documentation of an initial competency
assessment.
C. N8, RN, DOH 9/3/19, lacked documentation
of an initial competency assessment.
D. N10, Transportation Coordinator (van
driver). Unable to determine required competency
due to lack of personnel file.
E. N11, Transportation Coordinator, DOH
7/1/18, lacked documentation of any annual
competency evaluations.
F. N12 (nursing). Unable to determine
required competencies were met due to lack of a
personnel file.
reviewing employee files for
completion. In the event the
records are lacking documentation
the respective manager will be
responsible for working with the
employee to complete their files.
The plan for this was completed
by 12-03-2019
S 176 Continued
02. B. N7’s license was
verified and located under her
maiden name and verified by
comparison to the presented copy
of the marriage license. N7 has
been instructed to update her
license to reflect her current
name. In the future, the employee
will be required to provide
documentation to support the
name change in the event the
name on their nursing license
does not match their driver’s
license or application for
employment. The Clinical Director
and / or Office Manager will be
responsible for verifying names
and documentation.
N7 is still within her orientation /
probationary period and has not
completed her initial training and
verification documents. Clinical
Director will work with employees
in orientation and maintain the
orientation checklist /
credentialing file at the ASC. This
was done by December 13, 2019.
C. N8 Competency
has been completed and filed by
State Form Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 20 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
3. On 11/13/19, between approximately 5:30 PM
and 7:00 PM, A1, Office Manager, verified that
N10 and N12 had provided services in the center,
did not have a personnel file available, and that
the center did not have documentation of their
orientation and/or competency to perform the jobs
for which they were assigned. During that same
time period, A3, Clinical Director, verified the file
findings as noted above.
Clinical Director. The Clinical
Director will establish an annual
“competency” day or days in
January of each calendar year.
The Clinical Director and Office
Manager are responsible for
reviewing employee files for
completion. In the event the
records are lacking documentation
the respective manager will be
responsible for working with the
employee to complete their files.
The plan for this was completed
by 12-03-2019
D. N10 will have an
employee file completed by
12-13-19 and maintained along
with other employee files.
Requirements for a driver include a
valid driver’s license (to be
updated to equivalent of Public
Passenger Chauffeur or CDL) in
the state in which they reside, a
completed health physical, drug
screen, criminal background
check and BLS CPR certification
within 90 days of hire. The
Administrator, Office Manager and
Transportation Manager will be
responsible for this task.
E. N11 Requirements for a driver
include a valid driver’s license (to
be updated to equivalent of Public
Passenger Chauffeur or CDL) in
the state in which they reside, a
completed health physical, drug
screen, criminal background
check and BLS CPR certification
State Form Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 21 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
within 90 days of hire. The
Administrator will be responsible
for verification.
F. N12
employee file has been completed
as of 12-03-2019 by the Clinical
Director.
N12 does
not possess an Indiana Nursing
License and was not providing
care that is
limited to a nurse by the IN-Nurse
Practice Act. N12 was working in
the capacity of a patient care
assistant (pre/post technician);
assisting with removal of PPE
from patients, taking vital signs,
providing nourishment, removing
saline lock catheters (a procedure
performed by Hospital nursing
assistants, radiology technicians,
emergency department
technicians and others routinely)
and escorting to awaiting vehicle /
responsible companion. [Request
IDR]
03. N10 and N12
are employees of another EyeCare
Partners surgery center and are
part of
a “travel team” that helps when
needed at other facilities within the
region. Both had employee files
at their primary surgery center but
not here at the time of the survey.
That has since been corrected as
of 12-03-19. Clinical Director and
Administrator are responsible for
State Form Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 22 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
ensuring employee files for all
employees working in the ASC are
available going forward..
Request IDR regarding N12 not
possessing a valid IN RN
License. N12 was working in the
capacity of a past-op technician
and did not perform any duties
identified by IC 25-23-1-1.1 as RN
duties.
410 IAC 15-2.5-5
PATIENT CARE SERVICES
410 IAC 15-2.5-5(a)(4)
(a) Patient care services must
require the following:
(4) That all registered nurses and
licensed practical nurses must be
currently licensed in Indiana.
S 0910
Bldg. 00
Based on document review and interview, the
center failed to ensure that 2 of 9 (N7 and N12)
registered nurses (RN) and/or licensed practical
nurses (LPN) were currently licensed in Indiana.
Findings include:
1. Review of the Center's job descriptions for RN;
RN Operating/Procedure Room; and RN Post
Anesthesia Care Unit (PACU), indicated the
following for "Required Licensure and
Certification": Has a current license to practice as
a Registered Nurse in the State. The job
description for LPN/Licensed Vocational Nurse
Pre-Procedure and Recovery Areas indicated the
following for "Required Licensure and
Certification": Has a current license to practice as
a Practical Nurse in the State.
S 0910 S 910
02. All staff
members including those that are
part of the “travel team” have been
added to
an updated staff roster. This task
was completed by the
Administrator on 12-03-19.
S 910 continued
03. A. N7’s license was
verified and located under her
maiden name and verified by
comparison to the presented copy
of the marriage license. N7 has
been instructed to update her
license to reflect her current
name. N7 is still within her
12/13/2019 12:00:00AM
State Form Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 23 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
2. Review of the employee staff list dated 11/11/9,
indicated N7 was an RN hired 9/23/19. The list
lacked documentation/identification of N12.
3. Review of personnel files indicated the
following:
A. Employee N7 was hired on 9/23/19. The
file lacked documentation of a job description;
however, a "Conversation Note" in the file
indicated N7 was an RN. The file lacked
documentation of a currently license for N7.
B. Personnel file review lacked
documentation of a file and/or Indiana license for
N12.
4. Medical record review indicated both N7 and
N12 had performed nursing duties at the center as
follows, not all inclusive:
On 10/4/19, N7 initialed removal of the IV
(intravenous) catheter for patient P5 and N12 was
documented as an RN having assisted in PACU.
On 10/4/19, N7 initialed removal of the IV for
patient P4.
On 9/20/19, N12 was indicated, by initials,
that he/she removed the IV of patient P6 and it
was documented that he/she, as an RN, assisted
in PACU.
On 9/20/19, N12 was indicated, by initials,
that he/she removed the IV of patient P7 and it
was documented that he/she, as an RN, assisted
in PACU.
On 9/20/19, it was documented that N12, as
an RN, assisted in PACU for patient P8.
5. On 11/13/19, between approximately 5:30 PM
and 7:00 PM, A3, Clinical Director, verified that N7
was employed at the center as an RN and that the
personnel file for N7 lacked documentation of N7
having a current Indiana license. Nothing more
was provided prior to exit. During that time, A1,
orientation / probationary period
and has not completed her initial
training and verification
documents. Clinical Director will
work with employees in orientation
and maintain the orientation
checklist / credentialing file at the
ASC. This will be done no later
than December 13, 2019.
B. N12 does not
possess an Indiana Nursing
License and was not providing
care that is
limited to a nurse by the IN-Nurse
Practice Act. N12 was working in
the capacity of a patient care
assistant (pre/post technician);
assisting with removal of PPE
from patients, taking vital signs,
providing nourishment, removing
saline lock catheters (a procedure
performed by Hospital nursing
assistants, radiology technicians,
emergency department
technicians and others routinely)
and escorting to awaiting vehicle /
responsible companion.
04. N7’s license was verified
and located under her maiden
name and verified by comparison
to the presented copy of the
marriage license. N7 has been
instructed to update her license to
reflect her current name.
N12 does not possess
an Indiana Nursing License and
was not providing care that is
limited to a nurse by the IN-Nurse
State Form Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 24 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
Office Manager, verified that the center did not
have a personnel file for N12. A1 indicated that
N12 was a nurse who came from their Kentucky
center to work in the center during time(s) when
staff was low.
6. Review of the Indiana Professional Licensing
Agency website at https://www.in.gov/pla/,
lacked documentation of an Indiana nursing
license for N7 or N12.
Practice Act. N12 was working in
the capacity of a patient care
assistant (pre/post technician);
assisting with removal of PPE
from patients, taking vital signs,
providing nourishment, removing
saline lock catheters (a procedure
performed by Hospital nursing
assistants, radiology technicians,
emergency department
technicians and others routinely)
and escorting to awaiting vehicle /
responsible companion.
05. N7’s license was verified
and located under her maiden
name and verified by comparison
to the presented copy of the
marriage license. N7 has been
instructed to update her license to
reflect her current name.
N12 does not possess
an Indiana Nursing License and
was not providing care that is
limited to a nurse by the IN-Nurse
Practice Act. N12 was working in
the capacity of a patient care
assistant (pre/post technician);
assisting with removal of PPE
from patients, taking vital signs,
providing nourishment, removing
saline lock catheters (a procedure
performed by Hospital nursing
assistants, radiology technicians,
emergency department
technicians and others routinely)
and escorting to awaiting vehicle /
responsible companion.
06. N7’s license was verified
State Form Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 25 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/21/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
NEW ALBANY, IN 47150
15C0001020 11/13/2019
EYE SURGERY CENTER OF NEW ALBANY, LLC
520 W FIRST ST
00
and located under her maiden
name and verified by comparison
to the presented copy of the
marriage license. N7 has been
instructed to update her license to
reflect her current name.
Comparison of N7’ criminal
background check and provided
copy of nursing license and
marriage license proved identity to
match to an active RN license in
Indiana.
N12 does not possess
an Indiana Nursing License and
was not providing care that is
limited to a nurse by the IN-Nurse
Practice Act. N12 was working in
the capacity of a patient care
assistant (pre/post technician);
assisting with removal of PPE
from patients, taking vital signs,
providing nourishment, removing
saline lock catheters (a procedure
S 910 continued
performed by Hospital nursing
assistants, radiology technicians,
emergency department
technicians and others routinely)
and escorting to awaiting vehicle /
responsible companion.
Request IDR based upon IC
25-23-1-1.1 IN Nurse Practice Act
definitions of Registered Nurse
and duties performed by. N12
was not performing duties that fall
under the defined duties of a
Registered Nurse.
State Form Event ID: X66R11 Facility ID: 005401 If continuation sheet Page 26 of 26
Recommended