PRINTED: 01/21/2020 DEPARTMENT OF HEALTH AND HUMAN ... · 2 surg. tech. / 1 prep / instrument tech / nurse), Laser Suite 1 certified laser operator, YAG laser 1 trained nurse / tech

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

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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

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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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

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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

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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



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


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





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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






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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



as follows:

Pre-OP 2



(1 RN / 1 LPN,









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





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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.




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


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





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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






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





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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



reflects any



The CD will also






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





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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







The staffing





surgeon offices.



dates, however 9/20





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.





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10. A. N7’s

license was verified and located

under her maiden name and

verified by comparison to the




current name. N7 is still within

her orientation / probationary

period and has not completed her

initial training and verification







B. N12 does not



care that is














responsible companion. Clinical

Director and Office Manager will

ensure the presence of employee

files with clear delineation of the





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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

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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





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(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.


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

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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





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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



as follows:

Pre-OP 2



(1 RN / 1 LPN,









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


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



reflects any





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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


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


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.


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.



The CD will also






from receipt of

deficiencies).

05. The staffing





surgeon offices.



dates, however 9/20





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



reflects any





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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.



The CD will also






from receipt of

S 152 continued

06. deficiencies).

07. The Clinical Director will

maintain an official copy of the

staff schedules that reflects any



The CD will also






from receipt of

deficiencies).

410 IAC 15-2.4-1


DUTIES

410 IAC 15-2.4-1 (c)(5) (L)




(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

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and records of employees which relate

to post offer and subsequent physical

examinations, immunizations, and

tuberculin tests or chest x-rays, as

applicable.


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.


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.


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




current name.

N7 is still within her orientation /

probationary period and has not

completed her initial training and

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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 /



December 13, 2019.

C. N7 is still within her orientation

/ probationary period and has not








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


DUTIES

410 IAC 15-2.4-1 (c)(5) (M)

S 0176

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(M) Demonstrating and documenting

personnel competency in fulfilling

assigned responsibilities and

verifying in-service in special

procedures.


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

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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.


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







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







was done by December 13, 2019.

C. N8 Competency

has been completed and filed by





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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





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





check and BLS CPR certification





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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


care that is














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





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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


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



a Registered Nurse in the State. The job

description for LPN/Licensed Vocational Nurse

Pre-Procedure and Recovery Areas indicated the



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







name. N7 is still within her

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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.


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.




in PACU.




in PACU.

On 9/20/19, it was documented that N12, as

an RN, assisted in PACU for patient P8.


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,










B. N12 does not



care that is















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






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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.











































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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.












S 910 continued







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.
