(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
--
E 0000
Bldg. --
An Emergency Preparedness Survey was
conducted by the Indiana State Department of
Health in accordance with 42 CFR 416.54
Survey Date(s): 08/09/18 & 08/10/18
Facility Number: 002277
Provider Number: 15C0001086
AIM Number: 200255810A
At this Emergency Preparedness survey, Beltway
Surgery Centers LLC was found not in
compliance with Emergency Preparedness
Requirements for Medicare and Medicaid
Participating Providers and Suppliers, 42 CFR
416.54
Quality Review completed on 08/16/18 - DA
The requirement at 42 CFR, Subpart 416.54 is
NOT MET as evidenced by:
E 0000
E 0026
Bldg. --
Based on record review and interview, the facility
failed to ensure emergency preparedness policies
and procedures include the role of the ASC
facility under a waiver declared by the Secretary,
in accordance with section 1135 of the Act, in the
provision of care and treatment at an alternate
care site identified by emergency management
officials in accordance with 42 CFR 416.54(b)(6).
This deficient practice could affect all occupants.
Findings include:
Based on review of "Emergency Response Plan"
E 0026 Correction of deficit: A new
policy was created to address the
documentation specific to the role
of the ASC facility under a waiver
declared by the Secretary, in
accordance with section 1135 of
the ACT.
Prevention of recurring
deficiency: Staff will be educated
on the new policy with the annual
review. Policy attached.
Responsible: The clinical director
is responsible for correction of
08/29/2018 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 determined that
other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
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 disclosable 14
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: EOYR21 Facility ID: 002277
TITLE
If continuation sheet Page 1 of 39
(X6) DATE
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
--
and "MultiSpecialty Surgery Center Policies and
Procedures Manual" documentation with the
Director of ASC Clinical Operations, the
Manager of OR Clinical Operations, the Manager
of PACU Clinical Operations and the Building
Engineer for Health Care Trust of America
(HTA) during record review from 10:15 a.m. to
4:20 p.m. on 08/09/18, the emergency
preparedness plan for the facility did not
expressly state the role of the facility under a
waiver declared by the Secretary, in accordance
with section 1135 of the Act. Based on interview
at the time of record review, the Director of ASC
Clinical Operations stated they must follow IU
Health & Safety notification procedures in the
event of an emergency which may include the role
of the facility under a waiver declared by the
Secretary but agreed documentation for the role
of the facility under a waiver in accordance with
section 1135 of the Act was not available for
review at the time of the survey.
this deficiency.
E 0031
Bldg. --
Based on record review and interview, the facility
failed to ensure the emergency preparedness
communication plan includes (2) Contact
information for the following: (i) Federal, State,
tribal, regional, or local emergency preparedness
staff (ii) Other sources of assistance in accordance
with 42 CFR 416.54(c)(2). This deficient
practice could affect all occupants.
Findings include:
Based on review of "Emergency Response Plan"
and "MultiSpecialty Surgery Center Policies and
Procedures Manual" documentation with the
Director of ASC Clinical Operations, the
Manager of OR Clinical Operations, the Manager
E 0031 Correction of deficit: The
emergency response plan was
updated to include Contact
information for ISDH via the ISDH
Gateway link at
https://gateway.isdh.in.gov as the
primary contact and secondary
method when the ISDH Gateway
is nonoperational, using the
reporting form. This was
also included in the center's
emergency contact information.
Prevention of recurring
deficiency: Staff will be educated
on the updated plan with the
annual review.
08/27/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 2 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
--
of PACU Clinical Operations and the Building
Engineer for Health Care Trust of America
(HTA) during record review from 10:15 a.m. to
4:20 p.m. on 08/09/18, the emergency
preparedness plan did not include contacting the
Indiana State Department of Health via the ISDH
Gateway link at https://gateway.isdh.in.gov as the
primary method or by the secondary method when
the ISDH Gateway is nonoperational by
completing the Incident Reporting form and
e-mailing it to [email protected]. Based on
interview at the time of record review, the
Director of ASC Clinical Operations agreed the
emergency preparedness program documentation
did not include contacting ISDH via the
aforementioned methods.
Responsible: The clinical director
is responsible for correction of
this deficiency.
K 0000
Bldg. 01
A Life Safety Code Recertification Survey was
conducted by the Indiana State Department of
Health in accordance with 42 CFR 416.44(b).
Survey Date(s): 08/09/18 & 08/10/18
Facility Number: 002277
Provider Number: 15C0001086
AIM Number: 200255810A
At this Life Safety Code survey, Beltway Surgery
Centers Llc was found not in compliance with
Requirements for Participation in
Medicare/Medicaid, 42 CFR Subpart 416.44(b),
Life Safety from Fire and the 2012 edition of the
National Fire Protection Association (NFPA) 101,
Life Safety Code (LSC).
The facility, located on the second and third story
of a three story building with a basement, was
determined to be of Type II (000) construction
K 0000
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 3 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
and was fully sprinklered except for the basement
elevator machine room and the adjoining
basement hallway. The facility was surveyed with
NFPA 101, LSC Chapter 21, Existing
Ambulatory Health Care Occupancies. The
facility has a fire alarm system with smoke
detection at the first floor reception area, in the
corridor outside the elevators, in the corridor
outside the Operating Rooms and at the main fire
panel on the second floor.
Quality Review completed on 08/16/18 - DA
NFPA 101
Multiple Occupancies
Multiple Occupancies - Sections of
Ambulatory Health Care Facilities
Multiple occupancies shall be in accordance
with 6.1.14.
Sections of ambulatory health care facilities
shall be permitted to be classified as other
occupancies, provided they meet both of the
following:
* The occupancy is not intended to serve
ambulatory health care occupants for
treatment or customary access.
* They are separated from the ambulatory
health care occupancy by a 1 hour fire
resistance rating.
Ambulatory health care facilities shall be
separated from other tenants and
occupancies and shall meet all of the
following:
* Walls have not less than 1 hour fire
resistance rating and extend from floor slab
to roof slab.
* Doors are constructed of not less than
1-3/4 inches thick, solid-bonded wood core
or equivalent and is equipped with positive
latches.
* Doors are self-closing and are kept in the
closed position, except when in use.
K 0131
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 4 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
* Windows in the barriers are of fixed fire
window assemblies per 8.3.
Per regulation, ASCs are classified as
Ambulatory Health Care Occupancies,
regardless of the number of patients served.
20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR
416.44
Based on record review, observation and
interview; the facility failed to ensure 1 of 1 fire
barriers that separate other occupancies were
protected to maintain the fire resistance rating of
the fire barrier. NFPA 101, 2012 edition, Section
8.3.5.6.1 states membrane penetrations for cables
cable trays conduits, pipes, tubes, combustion
vents and exhaust vents, wires, and similar items
to accommodate electrical, mechanical, plumbing,
and communications systems that pass through a
membrane of a wall, floor, or floor/ceiling
assembly constructed as a fire barrier shall be
protected by a firestop system or device. Section
8.3.5.6.2 states the firestop system or device shall
be tested in accordance with ASTM E 814,
Standard Test Method for Fire Test of Through
Penetration Fire stops, or ANSI/UL 1479,
Standard for Fire Tests of Through-Penetration
Firestops. In addition, doors are self-closing and
are kept in the closed position, except when in
use. This deficient practice could affect all
patients, staff and visitors.
Findings include:
Based on observations with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and with the Building Engineer for
Health Trust of America (HTA) during a tour of
the facility from 10:00 a.m. to 2:10 p.m. on
08/10/18, the following was noted in the tenant
separation fire barrier wall located on the east
side of the atrium:
K 0131 Correction of deficit: The
center's facility manager has
contracted with an outside
vendor to correct the
deficiencies. A quote was
recieved for the project on
8/30/2018.
Prevention of recurring
deficiency: The facility manager
will inspect all ceiling work to
ensure that any firewall
penetration is corrected properly.
Responsible: The facility
manager is responsible for
correction of this deficiency.
09/23/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 5 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
a. a two inch by two inch hole for the passage of
one data cable was noted in the wall above the
suspended ceiling above the corridor door set
serving as the entrance to the Medical Office
Building on the third floor. The wall consisted of
four layers of 5/8ths inch thick drywall.
b. a two inch by two inch hole for the passage of
two electrical conduits was noted in the wall
above the suspended ceiling above the corridor
door set serving as the entrance to the Medical
Office Building on the second floor. The wall
consisted of four layers of 5/8ths inch thick
drywall.
Based on interview at the time of the
observations, the Building Engineer for HTA
agreed the aforementioned holes did not maintain
the minimum fire resistance rating for the east
tenant separation fire wall.
NFPA 101
Building Construction Type and Height
Building Construction Type and Height
Building construction type and stories meet
Table 20.1.6.1 or Table 21.1.6.1,
respectively.
Construction Type
1 I (442), I (332), II (222), Any
number of stories
II (111), III (211), IV (2HH),
non-sprinklered or sprinklered
V (111)
2 II (000), III (200), V (000) One
story non-sprinklered
Any number of stories
sprinklered
Any level below the level of exit discharge
shall be separated by Type II (111), Type III
(211), or Type V (111) construction unless
K 0161
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 6 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
both of the following are met:
1. Such levels are under the control of the
ambulatory health care occupancy.
2. Hazardous spaces are protected per
section 8.7.
Sprinklered stories must be sprinklered
throughout by an approved, supervised
automatic system in accordance with section
9.7. (See 20.3.5 or 21.3.5, respectively)
Give a brief description, in REMARKS, of the
construction, the number of stories,
including basements, floors on which
patients are located, location of smoke or
fire barriers and dates of approval. Complete
sketch or attach small floor plan of the
building as appropriate.
20.1.6.1, 20.1.6.2, 21.1.6.1, 21.1.6.2
Based on record review, observation and
interview; the facility failed to ensure the building
construction type was a permitted type as listed in
Table 21.1.6.1. Table 21.1.6.1 requires a
building of Type II(000) construction and two or
more stories in height to be fully sprinklered.
This deficient practice could affect all patients
and visitors.
Findings include:
Based on record review with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and the Building Engineer for Health
Care Trust of America (HTA) from 10:15 a.m. to
4:20 p.m. on 08/09/18, facility blueprint
documentation and facility construction type
documentation was not available for review.
Based on observations with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and with the Building Engineer for
HTA during a tour of the facility from 10:00 a.m.
K 0161 Correction of deficit: The
center's facility manager has
issued a purchase order to
complete fire proofing and to
ensure the basement elevator
machine room and adjoining
room are sprinklered. Required
parts were ordered the week of
9/3 for the sprinkler additions.
The sprinkler vendor has stated
that lead time on waterproof
controls and panel is 6-8 weeks.
Prevention of recurring
deficiency: The facility manager
will ensure the facility meets
current code requirements
through rounding and routine
maintenance of the facility.
Responsible: The facility
manager is responsible for
correction of this deficiency.
10/27/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 7 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
to 2:10 p.m. on 08/10/18, unprotected steel was
noted for the load bearing columns and the
support beams for floor decking in the supply
room for the second floor Bistro. The Bistro is
located in the three story atrium and is open to the
atrium. The atrium was not separated from the
surgery center suite with two hour fire resistive
construction. Protected steel was noted in load
bearing walls and columns throughout the surgery
suite with a minimum construction type of Type
II(111). In addition, the basement elevator
machine room and the hallway outside the
machine room in the basement were not
sprinklered. Based on interview at the time of the
observations, the Director of ASC Clinical
Operations stated the second and third floor
atrium serves as the patient waiting area for the
surgery center. Based on interview at the time of
the observations, the Building Engineer for HTA
agreed unprotected steel was noted in the load
bearing columns and the support beams for floor
decking in the supply room for the Bistro and
stated the basement elevator machine room and
hallway outside the machine room were not
sprinklered.
NFPA 101
Doors with Self-Closing Devices
Doors with Self-Closing Devices
Doors required to be self-closing are
permitted to be held open by a release
device complying with 7.2.1.8.2 that
automatically closes all such doors
throughout the smoke compartment, entire
facility, and all stair enclosure doors upon
activation of:
* Required manual fire alarm system, and
* Local smoke detectors designed to detect
smoke passing through the opening or a
required smoke detection system; and
* Automatic sprinkler system, if installed;
K 0223
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 8 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
and
* Loss of power
20.2.2.4, 20.2.2.5, 21.2.2.4, 21.2.2.5
Based on observation and interview, the facility
failed to ensure 3 of over 10 self closing doors
would self close to form a smoke resistant barrier.
This deficient practice could affect seven patients
and staff.
Findings include:
Based on observations with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and with the Building Engineer for
Health Trust of America (HTA) during a tour of
the facility from 10:00 a.m. to 2:10 p.m. on
08/10/18, the corridor door to the vestibule by the
elevator within the surgery suite on the second
and third floor was held open with a magnetic
holding device set to release with the fire alarm
system. Each of the two doors failed to self close
and latch into the door frame when tested to close
multiple times. In addition, the third floor
stairwell door by Operating Room 9 was
equipped with a self closing device but the door
failed to fully close and latch into the door frame
when tested to close multiple times. Based on
interview at the time of the observations, the
Building Engineer for HTA agreed the
aforementioned self closing doors failed to self
close and latch into the door frame.
K 0223 Correction of deficit: The
center's facility
manager has contracted with an
outside vendor to complete the
repairs to the doors outlined in
the statement of
deficiencies. The doors require
specialized parts that have a 2 to
3 week lead time.
Prevention of recurring
deficiency: The facility manager
will ensure the facility meets
current code requirements
through rounding and routine
maintenance of the facility.
Responsible: The facility
manager is responsible for
correction of this deficiency.
09/28/2018 12:00:00AM
NFPA 101
Emergency Lighting
Emergency Lighting
Emergency lighting of at least 1-1/2 hour
duration is provided automatically in
accordance with 7.9.
20.2.9.1, 21.2.9.1, 7.9
K 0291
Bldg. 01
Based on observation and interview, the facility K 0291 Correction of deficit: The 09/07/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 9 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
failed to ensure 3 of over 10 battery powered
emergency lights were maintained in accordance
with LSC 7.9. LSC 7.9.2.6 states battery operated
emergency lights shall use only reliable types of
rechargeable batteries provided with suitable
facilities for maintaining them in properly charged
condition. Batteries used in such lights or units
shall be approved for their intended use and shall
comply with NFPA 70 National Electric Code.
LSC 7.9.2.7 states the emergency lighting system
shall be either continuously in operation or shall
be capable of repeated automatic operation
without manual intervention. This deficient
practice could affect all patients, staff and
visitors.
Findings include:
Based on observations with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and with the Building Engineer for
Health Trust of America (HTA) during a tour of
the facility from 10:00 a.m. to 2:10 p.m. on
08/10/18, each of the two battery operated
emergency lights located in the outdoor enclosure
for the facility's emergency generator location
failed to function when its respective test button
was pushed multiple times. In addition, the
battery operated emergency light located in the
SIMS basement supply room also failed to
function when its respective test button was
pushed multiple times. Based on interview at the
time of the observations, the Building Engineer
for HTA stated rain water can get in the battery
operated lights at the generator causing them to
fail to function and agreed each of the
aforementioned three battery operated emergency
lights failed to function when its respective test
button was pushed multiple times.
center's facility
manager has contracted with an
outside vendor to complete the
repairs to the three emergency
lights.
Prevention of recurring
deficiency: The facility manager
will ensure the facility meets
current code requirements
through rounding and routine
maintenance of the facility.
Responsible: The facility
manager is responsible for
correction of this deficiency.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 10 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
NFPA 101
Protection - Other
Protection - Other
List in the REMARKS section any LSC
Section 20.3 and 21.3 Protection
requirements that are not addressed by the
provided K-tags, but are deficient. This
information, along with the applicable Life
Safety Code or NFPA standard citation,
should be included on Form CMS-2567.
K 0300
Bldg. 01
Based on observation and interview, the facility
failed to ensure 2 of over 10 doors equipped with
latching devices latched into its respective door
frame. NFPA 101 in 4.6.12.3 states existing life
safety features obvious to the public, if not
required by the Code, shall be maintained. This
deficient practice could affect all patients, staff,
and visitors.
Findings include:
Based on observations with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and with the Building Engineer for
Health Trust of America (HTA) during a tour of
the facility from 10:00 a.m. to 2:10 p.m. on
08/10/18, the following was noted in the required
smoke barrier wall for compartmentation of each
floor:
a. the latching hardware in the west door in the
corridor door set serving as the main entrance to
the operating room corridor on the third floor
failed to function correctly and latch the door into
the door frame. The cover for the latching
hardware at the top of the door was removed and
a binder clip was inserted in the latching
hardware.
b. the strike plate was missing on the door frame
for the west door in the corridor door set serving
as the main entrance to the operating room
K 0300 Correction of deficit: The
center's facility
manager has contracted with an
outside vendor to complete the
repairs to the doors outlined in
the statement of
deficiencies. The doors require
specialized parts that have a 4
to 5 week lead time
Prevention of recurring
deficiency: The facility manager
will ensure the facility meets
current code requirements
through rounding and routine
maintenance of the facility.
Responsible: The facility
manager is responsible for
correction of this deficiency.
10/05/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 11 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
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BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
corridor on the second floor. With the strike
place missing, the latching hardware failed to
function properly to latch the door into the door
frame.
Based on interview at the time of the
observations, the Building Engineer for HTA
agreed the aforementioned latching devices failed
to function properly to latch the door into the
door frame.
NFPA 101
Vertical Openings - Enclosure
Vertical Openings - Enclosure
2012 EXISTING
Vertical openings shall be enclosed or
protected per 8.6, unless one of the
following conditions exist:
1. Unenclosed vertical openings per
8.6.9.1 are permitted.
2. Unenclosed openings which do not
serve as a required means of egress are
permitted.
3. Exit access stairs may be unenclosed if
they meet the following conditions:
Two stories or less
a. Building is protected throughout by a
supervised sprinkler system per 9.7.1.1(1).
b. Total travel distance to outside does
not exceed 100 feet.
Three stories or less
a. Occupant load per story does not
exceed 15 people.
b. Building is sprinkler protected
throughout per 9.7.1.1(1).
c. Building contains an automatic
smoke detection system per 9.6.
d. Activation of the sprinkler system or
smoke detection system notifies all
occupants of the building.
e. Total travel distance to outside does
not exceed 100 feet.
Floors that are below the street level and are
K 0311
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 12 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
used for storage or any use other than a
business occupancy, shall not have any
unprotected openings to the business
occupancy floors.
21.3.1, 39.3.1.1, 39.3.1.2
Based on observation and interview, the facility
failed to maintain protection of 1 of 2 interior
stairwells. LSC 21.3.1 requires protection of
vertical openings in accordance with 39.3.1. LSC
39.3.1 requires vertical opening shall be enclosed
or protected in accordance with Section 8.6. LSC
8.6.1 requires every floor that separates stories in
a building shall be constructed as a smoke barrier.
LSC 8.6.5 states see 7.1.3.2.1 for enclosures of
exits. LSC 7.1.3.2.1 states the separation shall
have a minimum 1-hr fire resistance rating where
the exit connects three stories or less. Openings
in the separation shall be protected by fire door
assemblies equipped with door closers complying
with 7.2.1.8. Existing penetrations shall be
protected in accordance with 8.3.5. This deficient
practice could affect all patients, staff and
visitors.
Findings include:
Based on observations with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and with the Building Engineer for
Health Trust of America (HTA) during a tour of
the facility from 10:00 a.m. to 2:10 p.m. on
08/10/18, the third floor stairwell door by
Operating Room 9 was equipped with a self
closing device but the door failed to fully close
and latch into the door frame when tested to close
multiple times. The door was rated at 90 minute
fire resistance rating with an affixed rating label.
Based on interview at the time of the
observations, the Building Engineer for HTA
agreed the aforementioned stairwell door failed to
K 0311 Correction of deficit: The
center's facility
manager has corrected the door
latching mechanism.
Prevention of recurring
deficiency: The facility manager
will ensure the facility meets
current code requirements
through rounding and routine
maintenance of the facility.
Responsible: The facility
manager is responsible for
correction of this deficiency.
08/24/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 13 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
fully close and latch into the door frame when
tested to close multiple times.
NFPA 101
Fire Alarm System - Testing and
Maintenance
Fire Alarm Systems - Testing and
Maintenance
A fire alarm system is tested and maintained
in accordance with an approved program
complying with the requirements of NFPA
70, National Electric Code, and NFPA 72,
National Fire Alarm and Signaling Code.
Records of system acceptance,
maintenance and testing are readily
available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
K 0345
Bldg. 01
1. Based on record review and interview, it could
not be assured all facility fire alarm system
initiating devices were functional tested annually.
LSC 9.6.1.3 requires a fire alarm system to be
installed, tested, and maintained in accordance
with NFPA 70, National Electrical Code and
NFPA 72, National Fire Alarm and Signaling
Code. NFPA 72, 2010 Edition, Section 14.4.5
states unless otherwise permitted by other sections
of this code, testing shall be performed in
accordance with the schedules in Table 14.4.5, or
more often if required by the authority having
jurisdiction. Table 14.4.5 Testing Frequencies
states initiating devices shall be functional tested
annually. This deficient practice could affect all
patients, staff and visitors.
Findings include:
Based on review of Koorsen Fire & Security
"Inspection and Test Report" documentation
dated 01/27/18 with the Director of ASC Clinical
Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
K 0345 Correction of deficit: The
center's facility manager will
ensure the following corrective
steps:
A. Contracted with an outside
vendor to provide functional
testing for all smoke
detectors and all duct detectors.
Results of that testing will be
maintained by the facility
manager.
b. The main fire panel room
behind the second floor Bistro
supply room will be restricted to
authorized personnel. The entry
door to the room, the electrical
panel containing the breaker and
the breaker will be locked at all
times.
c. Contracted with an outside
vendor to verify and correct, if
needed, that the fire alarm
system breaker is on the
emergency generator.
Prevention of recurring
09/29/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 14 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
Operations and the Building Engineer for Health
Care Trust of America (HTA) during record
review from 10:15 a.m. to 4:20 p.m. on 08/09/18,
the results of functional testing for 14 of 31
smoke detectors were documented as "Visual" or
"Not Tested." Functional testing results for 4 of
28 duct detectors were also listed as "Visual" or
"Not Tested" and functional testing results for 2
of 19 manual pull stations were listed as "Visual."
Based on interview at the time of record review,
the Building Engineer for HTA stated additional
functional testing documentation for all fire alarm
system initiating devices not functional tested on
01/27/18 within the most recent twelve month
period was not available for review at the time of
the survey.
2. Based on observation and interview, the
facility failed to ensure 1 of 1 fire alarm systems
was maintained in accordance with the applicable
requirements of NFPA 72, National Fire Alarm
Code. NFPA 72, 2010 Edition, Section 10.5.5.1
states connections to the light and power service
shall be on a dedicated branch circuit(s). Circuit
disconnecting means shall have a red marking,
shall be accessible only to authorized personnel,
and shall be identified as FIRE ALARM
CIRCUIT. The location of the circuit
disconnecting means shall be permanently
identified at the fire alarm control unit. Section
10.5.5.4 states an overcurrent protective device of
suitable current carrying capacity and capable of
interrupting the maximum short circuit current to
which it may be subject shall be provided in each
ungrounded conductor. The dedicated branch
circuit(s) and connections shall be protected
against physical damage. This deficient practice
could affect all patients, staff and visitors.
Findings include:
deficiency: The facility manager
will ensure the facility meets
current code requirements
through rounding and routine
maintenance of the facility.
Responsible: The facility
manager is responsible for
correction of this deficiency.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 15 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
Based on observations with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and with the Building Engineer for
Health Trust of America (HTA) during a tour of
the facility from 10:00 a.m. to 2:10 p.m. on
08/10/18, access to the fire alarm system breaker
located in the electrical panel identified as
"LRPZ" in the main fire panel room behind the
second floor Bistro supply room was not
restricted to authorized personnel. The entry door
to the room, the electrical panel containing the
breaker and the breaker were each not locked. In
addition, it could not be assured the fire alarm
system breaker was also on the emergency
generator should the primary power source be on
emergency generator power. Based on interview
at the time of the observations, the Building
Engineer for HTA stated the electrical panel
containing the breaker was not also on the
emergency generator and agreed access to the fire
alarm system breaker was not restricted to
authorized personnel.
NFPA 101
Fire Alarm System - Out of Service
Fire Alarm - Out of Service
Fire alarms that are out of service for 4
hours in a 24 hour period, the authority
having jurisdiction shall be notified, and the
building shall be evacuated or an approved
fire watch shall be provided for all parties left
unprotected by the shutdown until the fire
alarm system has been returned to service.
9.6.1.6
K 0346
Bldg. 01
Based on record review and interview, the facility
failed to provide a complete written policy for the
protection of patients indicating procedures to be
followed in the event the fire alarm system has to
be placed out of service for four hours or more in
a twenty four hour period in accordance with
K 0346 Correction of deficit: The
emergency response plan was
updated to include Contact
information for ISDH via the ISDH
Gateway link at
https://gateway.isdh.in.gov as the
08/27/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 16 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
LSC, Section 9.6.1.6. This deficient practice
could affect all patients, staff, and visitors.
Findings include:
Based on review of "Emergency Response Plan:
Fire Watch - Incident Action Plan"
documentation with the Director of ASC Clinical
Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and the Building Engineer for Health
Care Trust of America (HTA) during record
review from 10:15 a.m. to 4:20 p.m. on 08/09/18,
the fire watch plan for fire alarm system
impairment was incomplete. The plan failed to
include contacting the Indiana State Department
of Health via the ISDH Gateway link at
https://gateway.isdh.in.gov as the primary method
or by the secondary method when the ISDH
Gateway is nonoperational by completing the
Incident Reporting form and e-mailing it to
[email protected]. Based on interview at the
time of record review, the Director of ASC
Clinical Operations agreed the fire watch
documentation for fire alarm system impairment
did not state to contact the Indiana State
Department of Health via the ISDH Gateway link
or at the e-mail address listed above.
primary contact and secondary
method when the ISDH Gateway
is nonoperational, using the
reporting form. This was
also included in the center's
emergency contact information.
Prevention of recurring
deficiency: Staff will be educated
on the updated plan with the
annual review.
Responsible: The clinical director
is responsible for correction of
this deficiency.
Plan attached.
NFPA 101
Sprinkler System - Installation
Sprinkler System - Installation
Sprinkler systems (if installed) are installed
per NFPA 13.
Where more than two sprinklers are
installed in a single area for protection,
waterflow devices shall be provided to sound
the building fire alarm system or to notify a
constantly attended location such as a PBX,
security office, or emergency room.
20.3.5.1, 20.3.5.2, 21.3.5.1, 21.3.5.2,
K 0351
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 17 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
9.7.1.2, 9.7, NFPA 13
1. Based on observation and interview, the
facility failed to ensure the spray pattern for
sprinkler heads were not obstructed in 3 of over
50 rooms in accordance with NFPA 13, Standard
for the Installation of Sprinkler Systems. NFPA
13, 2010 edition, Section 8.5.5.1 states sprinklers
shall be located so as to minimize obstructions to
discharge as defined in 8.5.5.2 and 8.5.5.3 or
additional sprinklers shall be provided to ensure
adequate coverage of the hazard. Sections 8.5.5.2
and 8.5.5.3 do not permit continuous or
noncontinuous obstructions less than or equal to
18 inches below the sprinkler deflector or in a
horizontal plane more than 18 inches below the
sprinkler deflector that prevent the spray pattern
from fully developing. This deficient practice
could affect over three staff and visitors.
Findings include:
Based on observations with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and with the Building Engineer for
Health Trust of America (HTA) during a tour of
the facility from 10:00 a.m. to 2:10 p.m. on
08/10/18, the following was noted:
a. storage supply items were stored on shelving up
to the ceiling in the DME Room in the basement.
b. storage supply items were stored on shelving
two inches below the ceiling in the IVF storage
room in the basement.
c. items were stored on shelving six inches below
the ceiling by the refrigerator in the Andrology
Lab on the second floor.
Based on interview at the time of the
observations, the Building Engineer for HTA
agreed the spray pattern for ceiling mounted
sprinkler heads in the aforementioned rooms was
obstructed by shelf storage within 18 inches of the
K 0351 Correction of deficit: The
center's facility
manager has corrected the door
latching mechanism.
1. Users of the supply room in
the basement and the second
floor were informed and educated
about maintaining 18 inches of
ceiling clearance in their storage
areas.
2. The facility manager and staff
were also informed about the
need for all sprinklers to have a
cover plate.
Prevention of recurring
deficiency: The facility manager
will ensure the facility meets
current code requirements
through rounding and routine
maintenance of the facility. The
life safety representative will
verify these conditions during
rounding.
Responsible: The facility
manager is responsible for
correction of this deficiency.
08/31/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 18 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
ceiling.
2. Based on observation and interview, the
facility failed to ensure 1 of over 100 sprinkler
heads in the facility were installed in accordance
with NFPA 13. NFPA 13, Standard for the
Installation of Sprinkler Systems, 2010 Edition,
Section 6.2.7.2 states escutcheons used with
recessed, flush-type or concealed sprinklers shall
be part of a listed sprinkler assembly. This
deficient practice could affect one patient, staff
and visitors in the vicinity of second floor
Andrology Lab.
Findings include:
Based on observations with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and with the Building Engineer for
Health Trust of America (HTA) during a tour of
the facility from 10:00 a.m. to 2:10 p.m. on
08/10/18, one of one recessed sprinklers in the
second floor Janitor's Closet by the Andrology
Lab was missing its cover plate. Based on
interview at the time of the observations, the
Building Engineer for HTA agreed the
aforementioned sprinkler location was missing its
cover plate.
NFPA 101
Sprinkler System - Maintenance and Testing
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems
are inspected, tested, and maintained in
accordance with NFPA 25, Standard for the
Inspection, Testing, and Maintaining of
Water-based Fire Protection Systems.
Records of system design, maintenance,
inspection and testing are maintained in a
secure location and readily available.
K 0353
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 19 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
a) Date sprinkler system last checked
_____________________
b) Who provided system test
____________________________
c) Water system supply source
__________________________
Provide in REMARKS information on
coverage for any non-required or partial
automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
1. Based on record review, observation and
interview; the facility failed to provide written
documentation or other evidence the sprinkler
system components had been inspected and tested
for 1 of 4 quarters. LSC 4.6.12.1 requires any
device, equipment or system required for
compliance with this Code be maintained in
accordance with applicable NFPA requirements.
Sprinkler systems shall be properly maintained in
accordance with NFPA 25, Standard for the
Inspection, Testing, and Maintenance of
Water-Based Fire Protection Systems. NFPA 25,
4.3.1 requires records shall be made for all
inspections, tests, and maintenance of the system
components and shall be made available to the
authority having jurisdiction upon request. 4.3.2
requires that records shall indicate the procedure
performed (e.g., inspection, test, or maintenance),
the organization that performed the work, the
results, and the date. NFPA 25, 5.2.5 requires
that waterflow alarm devices shall be inspected
quarterly to verify they are free of physical
damage. NFPA 25, 5.3.3.1 requires the
mechanical waterflow alarm devices including,
but not limited to, water motor gongs, shall be
tested quarterly. 5.3.3.2 requires vane-type and
pressure switch-type waterflow alarm devices
shall be tested semiannually. This deficient
practice could affect all patients, staff, and
visitors in the facility.
K 0353 Correction of deficit: The
center's facility
manager has contracted with a
vendor to perform the following
corrections:
1. Ensure that quarterly
waterflow device testing
documentation is maintained on
site and made available upon
request.
2. Remove cabling affixed to the
sprinkler piping noted in the
statement of deficiencies.
Prevention of recurring
deficiency: The facility manager
will ensure the facility meets
current code requirements
through rounding and routine
maintenance of the facility.
Responsible: The facility
manager is responsible for
correction of this deficiency.
09/21/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 20 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
Findings include:
Based on review of Koorsen Fire & Security
"Inspection and Test Report" documentation
dated 01/27/18, 04/28/18 and 08/04/18 with the
Director of ASC Clinical Operations, the
Manager of OR Clinical Operations, the Manager
of PACU Clinical Operations and the Building
Engineer for Health Care Trust of America
(HTA) during record review from 10:15 a.m. to
4:20 p.m. on 08/09/18, quarterly waterflow alarm
device testing documentation for the fourth
quarter (October, November, December) 2017
was not available for review. Based on
observations with the Director of ASC Clinical
Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and with the Building Engineer for
HTA during a tour of the facility from 10:00 a.m.
to 2:10 p.m. on 08/10/18, hanging tags affixed to
the sprinkler system riser in the basement by
Koorsen documented waterflow alarm inspection
and testing within the most recent twelve month
period on 01/27/18, 04/28/18 and 08/04/18 but
not for the fourth quarter 2017. Based on
interview at the time of record review and of the
observations, the Building Engineer for HTA
stated he was certain Koorsen conducted the
fourth quarter 2017 testing but agreed waterflow
alarm inspection and testing documentation for
the fourth quarter 2017 was not available for
review at the time of the survey.
2. Based on observation and interview, the
facility failed to maintain 1 of 1 sprinkler systems
in accordance with NFPA 25. NFPA 25,
Standard for the Inspection, Testing, and
Maintenance of Water-Based Fire Protection
Systems, 2011 edition, Section 5.2.2.2 states
sprinkler piping shall not be subjected to external
loads by materials either resting on the pipe or
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 21 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
hung from the pipe. This deficient practice could
affect over three staff and visitors in the
basement.
Findings include:
Based on observations with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and with the Building Engineer for
Health Trust of America (HTA) during a tour of
the facility from 10:00 a.m. to 2:10 p.m. on
08/10/18, four data cables were affixed to a thirty
foot length of horizontal sprinkler pipe behind
AHU #2 in the basement. In addition, one white
data cable was wrapped around a sprinkler pipe in
the hallway outside the basement elevator
machine room. Based on interview at the time of
the observations, the Building Engineer for HTA
agreed the aforementioned sprinkler pipe
locations were used to support non-system
components.
NFPA 101
Sprinkler System - Out of Service
Sprinkler System - Out of Service
Where the sprinkler system is impaired, the
extent and duration of the impairment has
been determined, areas or buildings
involved are inspected and risks are
determined, recommendations are
submitted to management or designated
representative, and the fire department and
other authorities having jurisdiction have
been notified. Where the sprinkler system is
out of service for more than 10 hours in a 24
hour period, the building or portion of the
building affected are evacuated or an
approved fire watch is provided until the
sprinkler system has been returned to
service.
K 0354
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 22 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
9.7.5, 15.5.2 (NFPA 25)
Based on record review and interview, the facility
failed to provide a complete written policy
containing procedures to be followed for the
protection of all patients in the event the
automatic sprinkler system has to be placed
out-of-service for 10 hours or more in a 24-hour
period in accordance with LSC, Section 9.7.5.
LSC 9.7.5 requires sprinkler impairment
procedures comply with NFPA 25, 2011 Edition,
the Standard for the Inspection, Testing and
Maintenance of Water-Based Fire Protection
Systems. NFPA 25, 2011 Edition, Section 15.5.2
requires the fire department, insurance carrier, the
alarm company, the property owner or designated
representative and other authorities having
jurisdiction be notified. This deficient practice
could affect all patients, staff and visitors.
Findings include:
Based on review of "Emergency Response Plan:
Fire Watch - Incident Action Plan"
documentation with the Director of ASC Clinical
Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and the Building Engineer for Health
Care Trust of America (HTA) during record
review from 10:15 a.m. to 4:20 p.m. on 08/09/18,
the fire watch plan for automatic sprinkler system
impairment was incomplete. The plan failed to
include contacting the Indiana State Department
of Health via the ISDH Gateway link at
https://gateway.isdh.in.gov as the primary method
or by the secondary method when the ISDH
Gateway is nonoperational by completing the
Incident Reporting form and e-mailing it to
[email protected]. In addition, the fire watch
plan for automatic sprinkler system impairment
failed to include notification of the alarm
monitoring company and the insurance carrier.
K 0354 Correction of deficit: The
emergency response plan was
updated to include Contact
information for ISDH via the ISDH
Gateway link at
https://gateway.isdh.in.gov as the
primary contact and secondary
method when the ISDH Gateway
is nonoperational, using the
reporting form. This was
also included in the center's
emergency contact information.
Prevention of recurring
deficiency: Staff will be educated
on the updated plan with the
annual review.
Responsible: The clinical director
is responsible for correction of
this deficiency.
08/27/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 23 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
Based on interview at the time of record review,
the Director of ASC Clinical Operations agreed
the fire watch documentation for fire alarm
system impairment did not state to contact the
Indiana State Department of Health via the ISDH
Gateway link or at the e-mail address listed above
and also did not include notification of the alarm
monitoring company and the insurance carrier.
NFPA 101
Subdivision of Building Spaces - Smoke
Barrie
Subdivision of Building Spaces - Smoke
Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2
hour fire resistance rating per 8.5. Smoke
barriers shall be permitted to terminate at an
atrium wall. Smoke dampers are not
required in duct penetrations in fully ducted
HVAC systems where an approved sprinkler
system is installed for smoke compartments
adjacent to the smoke barrier.
21.3.7.5, 21.3.7.6, 8.5
K 0372
Bldg. 01
Based on record review, observation and
interview; the facility failed to ensure 2 of 2
smoke barriers which divide the suite into two
separate smoke compartments was constructed in
accordance with LSC Section 8.5 unless
otherwise permitted by Section 21.3.7.6. LSC
Section 8.5.6.2 states penetrations for cables,
conduits, pipes and similar items that pass
through a wall constructed as a smoke barrier
shall be protected by a system or material capable
of resisting the transfer of smoke. Where a smoke
barrier is also constructed as a fire barrier, the
penetrations shall be protected in accordance with
the requirements of Section 8.3.5 to limit the
spread of fire for a time period equal to the fire
resistance of the assembly and Section 8.5.6.
This deficient practice could affect all patients
K 0372 Correction of deficit: The
center's facility manager has
contracted with an outside
vendor to correct the
deficiencies. A quote was
recieved for the project on
8/30/2018.
Prevention of recurring
deficiency: The facility manager
will inspect all ceiling work to
ensure that any firewall
penetration is corrected properly.
Responsible: The facility
manager is responsible for
correction of this deficiency.
09/23/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 24 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
and staff if smoke from a fire were to infiltrate the
protective barrier.
Findings include:
Based on record review with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and the Building Engineer for Health
Care Trust of America (HTA) from 10:15 a.m. to
4:20 p.m. on 08/09/18, facility blueprint
documentation and facility construction type
documentation was not available for review.
Based on interview at the time of record review,
the Building Engineer for HTA stated he obtained
the approximate square footage for each floor of
the surgery suite by telephone from his supervisor
at the time of the survey. The second and third
floor each measured, approximately, 14,463
square feet. Based on observations with the
Director of ASC Clinical Operations, the
Manager of OR Clinical Operations, the Manager
of PACU Clinical Operations and with the
Building Engineer for Health Trust of America
(HTA) during a tour of the facility from 10:00
a.m. to 2:10 p.m. on 08/10/18, a one inch in
diameter hole was noted above the suspended
ceiling by the corridor smoke barrier door set by
Bay 1 on the third floor. In addition, the door in
the smoke barrier wall behind the nurse's station
in the operating room area on the second floor
failed to fully self close when tested to close
multiple times. Based on interview at the time of
the observations, the Building Engineer for HTA
stated the location of the hole and the door was in
required smoke barrier walls and agreed the
aforementioned openings in the smoke barrier
wall did not maintain the fire resistance rating of
the smoke barrier wall.
NFPA 101 K 0511
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 25 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
Utilities - Gas and Electric
Utilities - Gas and Electric
Equipment using gas or related gas piping
complies with NFPA 54, National Fuel Gas
Code, electrical wiring and equipment
complies with NFPA 70, National Electric
Code. Existing installations can continue in
service provided no hazard to life.
20.5.1, 21.5.1, 21.5.1.2, 9.1.1, 9.1.2
Bldg. 01
Based on observation and interview, the facility
failed to ensure all electrical wiring in the facility
was maintained in safe operating condition. LSC
21.5.1 requires utilities comply with Section 9.1.
LSC 9.1.2 requires electrical wiring and
equipment to comply with NFPA 70, National
Electrical Code. NFPA 70, 2011 Edition, Article
314 states exposed terminals and receptacles shall
be enclosed so that live wiring terminals are not
exposed to contact. This deficient practice could
affect one staff.
Findings include:
Based on observations with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and with the Building Engineer for
Health Trust of America (HTA) during a tour of
the facility from 10:00 a.m. to 2:10 p.m. on
08/10/18, spliced electrical wiring above the
suspended ceiling above the corridor door set by
Bay 4 on the second floor was confined within a
junction box but the junction box was not
provided with a cover compatible with the box.
Based on interview at the time of the
observations, the Building Engineer for HTA
agreed the aforementioned junction box was not
provided with a cover compatible with the box.
K 0511 Correction of deficit: The
center's facility manager will
provide a compatible cover for the
junction box noted above bay 4
on the second floor.
Prevention of recurring
deficiency: The facility manager
will inspect all ceiling work to
ensure that compliant work is
performed in the center.
Responsible: The facility
manager is responsible for
correction of this deficiency.
09/15/2018 12:00:00AM
NFPA 101
HVAC
K 0521
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 26 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
HVAC
Heating, ventilation, and air conditioning
shall comply with 9.2 and shall be installed in
accordance with the manufacturer's
specifications.
20.5.2.1, 21.5.2.1, 9.2
Bldg. 01
Based on record review, observation and
interview; the facility failed to ensure 100 % of
fire dampers in the facility were inspected and
provided necessary maintenance at least every
four years in accordance with NFPA 90A. LSC
9.2.1 requires heating, ventilating and air
conditioning (HVAC) ductwork and related
equipment shall be in accordance with NFPA
90A, Standard for the Installation of
Air-Conditioning and Ventilating Systems.
NFPA 90A, 2012 Edition, Section 5.4.8.1 states
fire dampers shall be maintained in accordance
with NFPA 80, Standard for Fire Doors and Other
Opening Protectives. NFPA 80, 2010 Edition,
Section 19.4.1 states each damper shall be tested
and inspected 1 year after installation. The test
and inspection frequency shall be every 4 years.
If the damper is equipped with a fusible link, the
link shall be removed for testing to ensure full
closure and lock-in-place if so equipped. The
damper shall not be blocked from closure in any
way. All inspections and testing shall be
documented, indicating the location of the fire
damper, date of inspection, name of inspector and
deficiencies discovered. The documentation shall
have a space to indicate when and how the
deficiencies were corrected. This deficient
practice could affect all patients, staff and
visitors.
Findings include:
Based on record review with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
K 0521 Correction of deficit: The
center's facility manager is
responsible to ensure that fire
dampers are tested, at the
required intervals, and that
documentation is maintained on
site of all testing.
Prevention of recurring
deficiency: The facility manager
will ensure compliance with this
requirement by utilizing his
building systems to track
completed work.
Responsible: The facility
manager is responsible for
correction of this deficiency.
09/21/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 27 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
Operations and the Building Engineer for Health
Care Trust of America (HTA) from 10:15 a.m. to
4:20 p.m. on 08/09/18, documentation of facility
fire damper inspection and maintenance within
the most recent four year period was not available
for review. Based on interview at the time of
record review, the Building Engineer stated the
facility has fire dampers but agreed
documentation of facility fire damper inspection
and maintenance within the most recent four year
period was not available for review. Based on
observations with the Director of ASC Clinical
Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and with the Building Engineer for
HTA during a tour of the facility from 10:00 a.m.
to 2:10 p.m. on 08/10/18, two fire dampers were
noted in HVAC ductwork in the elevator machine
room in the basement and one fire damper was
noted in HVAC ductwork in the hallway outside
the basement elevator machine room. In addition,
fire dampers were also noted in the elevator shaft
in the atrium by the entrance to the Medical
Office Building. No inspection documentation
was affixed to any of the observed fire dampers.
NFPA 101
Fire Drills
Fire Drills
Fire drills include the transmission of a fire
alarm signal and simulation of emergency
fire conditions. Fire drills are held at
expected and unexpected times under
varying conditions, at least quarterly on each
shift The staff is familiar with procedures
and is aware that drills are part of
established routine. Where drills are
conducted between 9:00 PM and 6:00 AM, a
coded announcement may be used instead
of audible alarms.
21.7.1.4 through 21.7.1.7
K 0712
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 28 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
1. Based on record review and interview, the
facility failed to document activation of the fire
alarm system for second shift fire drills conducted
between 6:00 a.m. and 9:00 p.m. for 2 of 4
quarters. LSC 21.7.1.4 states fire drills in health
care occupancies shall include the transmission of
the fire alarm signal and simulation of emergency
fire conditions. When drills are conducted
between 9:00 p.m. (2100 hours) and 6:00 a.m.
(0600 hours), a coded announcement shall be
permitted to be used instead of audible alarms.
This deficient practice could affect all patients,
staff and visitors in the facility.
Findings include:
Based on review of "Code Red Drill Evaluation
Report" and "Fire Drill Participation Sign In"
documentation with the Director of ASC Clinical
Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and the Building Engineer for Health
Care Trust of America (HTA) during record
review from 10:15 a.m. to 4:20 p.m. on 08/09/18,
documentation for second shift fire drills
conducted on 03/23/18 at 8:00 p.m. and on
05/11/18 at 7:55 p.m. each did not verify
activation of the fire alarm system and
transmission of the fire alarm signal. The
aforementioned documentation stated "Yes" in
response to "Was alarm signal received at alarm
monitoring office" but stated "N/A" in response to
"Were fire alarm chimes/bells and strobe lights
functional in the area" and in response to "Did
automatic fire doors close properly." Based on
interview at the time of record review, the
Building Engineer for HTA stated he can silence
the fire alarm system but still activates the fire
alarm system during daytime fire drills but was
not present for each of the two fire drills as they
were conducted after his shift time was over.
K 0712 Correction of deficit: Second
shift staff have been educated to
conduct second fire drills at
random times between 7pm and
7am. They have been educated
on the proper use of the drill
report sheet “Code Red Drill
Evaluation Report”. The sheets
“Evaluation of Building
Equipment” section will reflect
that an audible overhead
announcement was done and an
alarm signal was not sent to the
monitoring office. (See recent
second shift fire drill evaluation
form).
Prevention of recurring
deficiency: The PACU manager
will ensure that drills are
performed in the first and second
shifts each quarter.
Responsible: The
clinical manager of PACU is
responsible for correction of this
deficiency.
08/27/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 29 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
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INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
Based on interview at the time of record review,
the Manager of PACU Clinical Operations stated
the ASC staff are not familiar with silencing the
fire alarm system for fire drills and, as a result,
the fire alarm system was probably not activated
for these two fire drills conducted after 6:00 a.m.
but before 9:00 p.m.
2. Based on record review and interview, the
facility failed to conduct quarterly fire drills at
unexpected times under varying conditions on the
first shift for 3 of 4 quarters. This deficient
practice could affect all patients, staff and visitors
in the facility.
Findings include:
Based on review of "Code Red Drill Evaluation
Report" and "Fire Drill Participation Sign In"
documentation with the Director of ASC Clinical
Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and the Building Engineer for Health
Care Trust of America (HTA) during record
review from 10:15 a.m. to 4:20 p.m. on 08/09/18,
documentation for second shift fire drills
conducted on 12/10/17, 03/23/18 and 05/11/18
were conducted at, respectively, 7:00 p.m., 8:00
p.m. and 7:55 p.m. Based on interview at the
time of record review, the Manager of PACU
Clinical Operations stated the facility operates
two shifts per day, the second shift operates from
7:00 p.m. to 7:00 a.m., the facility likes to
perform fire drills during and after shift changes
and agreed the aforementioned second shift fire
drills were not conducted at varied times.
NFPA 101
Electrical Systems - Essential Electric Syste
Electrical Systems - Essential Electric
System Alarm Annunciator
K 0916
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 30 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
A remote annunciator that is storage battery
powered is provided to operate outside of
the generating room in a location readily
observed by operating personnel. The
annunciator is hard-wired to indicate alarm
conditions of the emergency power source.
A centralized computer system (e.g.,
building information system) is not to be
substituted for the alarm annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)
Based on observation and interview, the facility
failed to ensure 1 of 1 emergency generator
annunciator panels was in proper operating
condition. This deficient practice could affect all
the patients, staff and visitors.
Findings include:
Based on observations with the Manager of OR
Clinical Operations and the Manager of PACU
Clinical Operations during the initial walk
through of the facility from 9:50 a.m. to 10:15
a.m. on 08/09/10, the emergency generator's
remote annunciator panel located at the third floor
nurse's station had the "Not in Auto" (yellow)
light illuminated. The Manager of PACU Clinical
Operations stated the light is always illuminated
but facility maintenance staff has been able to
conduct emergency generator testing. The
emergency generator was not running at the time
of the survey. Based on observations with the
Director of ASC Clinical Operations, the
Manager of OR Clinical Operations, the Manager
of PACU Clinical Operations and with the
Building Engineer for Health Trust of America
(HTA) during a tour of the facility from 10:00
a.m. to 2:10 p.m. on 08/10/18, the "Not in Auto"
(yellow) light for the emergency generator's
remote annunciator panel located was still
illuminated. Based on interview at the time of the
observations, the Building Engineer for HTA
K 0916 Correction of deficit: The
center's facility manager is
responsible to ensure that
facilities emergency generator
and support systems are
functioning correctly. The facility
manager is contracting with an
outside vendor for repair or
replacement the third floor panel.
Prevention of recurring
deficiency: The facility manager
will ensure compliance with this
requirement by utilizing his
building systems to track
completed work.
Responsible: The facility
manager is responsible for
correction of this deficiency.
09/29/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 31 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
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INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
stated the light is normally illuminated but the
emergency generator would start in the event of
normal power loss for the building.
NFPA 101
Electrical Systems - Essential Electric Syste
Electrical Systems - Essential Electric
System Maintenance and Testing
The generator or other alternate power
source and associated equipment is capable
of supplying service within 10 seconds. If the
10-second criterion is not met during the
monthly test, a process shall be provided to
annually confirm this capability for the life
safety and critical branches. Maintenance
and testing of the generator and transfer
switches are performed in accordance with
NFPA 110.
Generator sets are inspected weekly,
exercised under load 30 minutes 12 times a
year in 20-40 day intervals, and exercised
once every 36 months for four continuous
hours. Scheduled test under load conditions
include a complete simulated cold start and
automatic or manual transfer of all EES
loads, and are conducted by competent
personnel. Maintenance and testing of
stored energy power sources (Type 3 EES)
are in accordance with NFPA 111. Main and
feeder circuit breakers are inspected
annually, and a program for periodically
exercising the components is established
according to manufacturer requirements.
Written records of maintenance and testing
are maintained and readily available. EES
electrical panels and circuits are marked and
readily identifiable. Minimizing the possibility
of damage of the emergency power source
is a design consideration for new
installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110,
NFPA 111, 700.10 (NFPA 70)
K 0918
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 32 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
1. Based on record review and interview, the
facility failed to ensure the transfer time to the
alternate power source was capable of supplying
service within 10 seconds for monthly load tests
for 4 of the most recent 12 months. NFPA 99,
Health Care Facilities Code, 2012 Edition,
Section 6.4.4.1.1.1 states the generator set or
other alternate power source and associated
equipment, including all appurtenance parts shall
be so maintained as to be capable of supplying
service within the shortest time frame practicable
and within the 10 second interval specified in
6.4.1.1.10 and 6.4.3.1. This deficient practice
could affect all patients, staff and visitors.
Findings include:
Based on record review from 10:15 a.m. to 4:20
p.m. on 08/09/18 with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and the Building Engineer for Health
Care Trust of America (HTA), monthly load
testing documentation for 03/05/18, 05/07/18,
06/04/18, and 07/02/18 listed the transfer time as,
respectively, 15 seconds, 15 seconds, 18 seconds
and 39 seconds. Based on interview at the time of
record review, the Building Engineer for HTA
stated building power would be automatically
transferred to the generator in less than 10
seconds in the event of normal power loss but he
performs a manual start for monthly emergency
generator load testing and waits for normal power
to be stabilized before the transfer of power to the
generator and agreed transfer time documentation
for the aforementioned monthly load tests was
greater than 10 seconds.
2. Based on observation and interview, the
facility failed to ensure 1 of 1 emergency
generators was equipped with a remote manual
K 0918 Correction of deficit: The
center's facility manager is
responsible to ensure that
facilities emergency generator
and support systems are tested
and functioning correctly. The
facility manager is obtaining
quotes to install a remote manual
stop. The facility manager is also
coordinating with the center's
contracted service provider for
emergency generator support to
ensure appropriate transfer times.
Prevention of recurring
deficiency: The facility manager
will ensure compliance with this
requirement by utilizing his
building systems to track
completed work and testing.
Responsible: The facility
manager is responsible for
correction of this deficiency
09/29/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 33 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
stop in accordance with NFPA 99. NFPA 99,
Health Care Facilities Code, 2012 Edition,
Section 15.5.1.3 states emergency generators and
standby power system, where required for
compliance with this code, shall be installed,
tested, and maintained in accordance with NFPA
110, Standard for Emergency and Standby Power
Systems. NFPA 110, 2010 edition, 5.6.5.6 states
all installations shall have a remote manual stop
station of a type to prevent inadvertent or
unintentional operation located outside the room
housing the prime mover, where so installed, or
elsewhere on the premises where the prime mover
is located outside the building. The remote
manual stop station shall be labeled. This
deficient practice could affect all patients, staff
and visitors.
Findings include:
Based on observations with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and with the Building Engineer for
Health Trust of America (HTA) during a tour of
the facility from 10:00 a.m. to 2:10 p.m. on
08/10/18, the 125 kW emergency generator
located outside the facility was not equipped with
a remote manual stop. The date of manufacturer
of the generator could not be determined. Based
on interview at the time of the observations, the
Building Engineer for HTA stated the unit was
probably installed in or around 1994, there is a
remote manual stop inside the weatherproof shell
for the generator but there was no remote manual
stop station for the emergency generator.
NFPA 101
Electrical Equipment - Power Cords and
Extens
Electrical Equipment - Power Cords and
K 0920
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 34 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
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BELTWAY SURGERY CENTERS LLC
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01
Extension Cords
Power strips in a patient care vicinity are
only used for components of movable
patient-care-related electrical equipment
(PCREE) assembles that have been
assembled by qualified personnel and meet
the conditions of 10.2.3.6. Power strips in
the patient care vicinity may not be used for
non-PCREE (e.g., personal electronics),
except in long-term care resident rooms that
do not use PCREE. Power strips for PCREE
meet UL 1363A or UL 60601-1. Power strips
for non-PCREE in the patient care rooms
(outside of vicinity) meet UL 1363. In
non-patient care rooms, power strips meet
other UL standards. All power strips are
used with general precautions. Extension
cords are not used as a substitute for fixed
wiring of a structure. Extension cords used
temporarily are removed immediately upon
completion of the purpose for which it was
installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99),
400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA
12-5
Based on observation and interview, the facility
failed to ensure 2 of 2 extension cords including
power strips were not used as a substitute for
fixed wiring. LSC 21.5.1 requires utilities to
comply with Section 9.1. LSC 9.1.2 requires
electrical wiring and equipment to comply with
NFPA 70, National Electrical Code, 2011
Edition. NFPA 70, Article 400.8 requires that,
unless specifically permitted, flexible cords and
cables shall not be used as a substitute for fixed
wiring of a structure. LSC Section 4.5.7 states
any building service equipment or safeguard
provided for life safety shall be designed,
installed and approved in accordance with all
applicable NFPA standards. NFPA 99, Standard
for Health Care Facilities, 2012 edition, defines
patient care areas as any portion of a health care
K 0920 Correction of deficit: The
facilities contracted clinical
engineering support team is
ensuring that all power strips
meet current code requirements.
Any power strip that cannot be
verified will be repalced.
Prevention of recurring
deficiency: Clinical engineering
has been educated on this
requirement and will work with the
OR manager to ensure
compliance.
Responsible: The OR
manager is responsible for
correction of this deficiency.
09/15/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 35 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
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INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
facility wherein patients are intended to be
examined or treated. Patient care vicinity is
defined as a space, within a location intended for
the examination and treatment of patients,
extending 6 ft (1.8 m) beyond the normal location
of the bed, chair, table, treadmill, or other device
that supports the patient during examination and
treatment. A patient care vicinity extends
vertically to 7 ft 6 in. (2.3 m) above the floor.
NFPA 99, Section 10.4.2.3 states household or
office appliances not commonly equipped with
grounding conductors in their power cords shall
be permitted provided they are not located within
the patient care vicinity. This deficient practice
could affect 2 patients and staff.
Findings include:
Based on observations with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and with the Building Engineer for
Health Trust of America (HTA) during a tour of
the facility from 10:00 a.m. to 2:10 p.m. on
08/10/18, a power strip was affixed to a Stryker
elecrocauterizer medical device within the patient
care vicinity in Operating Room 3 and in
Operating Room 7. The UL listing of each power
strip was stated as "HC 16." Based on interview
at the time of the observations, the Manager of
OR Clinical Operations agreed power strips were
being used as a substitute for fixed wiring and in
the patient care vicinity.
NFPA 101
Gas Equipment - Cylinder and Container
Storag
Gas Equipment - Cylinder and Container
Storage
*Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed,
K 0923
Bldg. 01
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 36 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
and ventilated in accordance with 5.1.3.3.2
and 5.1.3.3.3.
*Greater than 300 but less than 3,000 cubic
feet
Storage locations are outdoors in an
enclosure or within an enclosed interior
space of non- or limited- combustible
construction, with door (or gates outdoors)
that can be secured. Oxidizing gases are not
stored with flammables, and are separated
from combustibles by 20 feet (5 feet if
sprinklered) or enclosed in a cabinet of
noncombustible construction having a
minimum 1/2 hour fire protection rating.
*Less than or equal to 300 cubic feet
In a single smoke compartment, individual
cylinders available for immediate use in
patient care areas with an aggregate volume
of less than or equal to 300 cubic feet are
not required to be stored in an enclosure.
Cylinders must be handled with precautions
as specified in 11.6.2.
A precautionary sign readable from 5 feet is
on each door or gate of a cylinder storage
room, where the sign includes the wording
as a minimum "CAUTION: OXIDIZING
GAS(ES) STORED WITHIN NO
SMOKING."
Storage is planned so cylinders are used in
order of which they are received from the
supplier. Empty cylinders are segregated
from full cylinders. When facility employs
cylinders with integral pressure gauge, a
threshold pressure considered empty is
established. Empty cylinders are marked to
avoid confusion. Cylinders stored in the
open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA
99)
1. Based on observation and interview, the
facility failed to ensure 1 of 1 indoor
nonflammable gas storage areas was enclosed
K 0923 Correction of deficit: The
center's facility manager is
responsible to ensure that facility
10/27/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 37 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
with a separation of 1 hour fire resistive
construction. NFPA 99, Standard for Health Care
Facilities, 2012 Edition, Section 11.3.1 states
storage for nonflammable gases equal to or
greater than 3000 cubic feet shall comply with
5.1.3.3.2 and 5.1.3.3.3. Section 5.1.3.3.2(2)
states they shall be secured with lockable doors or
gates or otherwise secured. Section 5.1.3.3.2(4)
states locations for central supply systems and the
storage of positive-pressure gases, if indoors,
shall be constructed and use interior finishes of
noncombustible or limited-combustible materials
such that all walls, floors, ceilings, and doors are
of a minimum 1-hour fire resistance rating. This
deficient practice could affect one patient, staff
and visitors.
Findings include:
Based on observations with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and with the Building Engineer for
Health Trust of America (HTA) during a tour of
the facility from 10:00 a.m. to 2:10 p.m. on
08/10/18, one liquid nitrogen storage container
listed as 160 liter capacity and four nitrogen
cylinders each with a capacity of 221.6 cubic feet
were noted in the second floor storage room by
the Andrology Lab. The corridor door set to the
storage room was not locked. The corridor door
set had no fire resistance rating label affixed and
each door in the door set was not equipped with a
self closing device to latch each door into the
door frame. In addition, a six inch in diameter
hole was noted in the wall of the room which
abuts the Andrology Lab. The hole had an open
ended PVC inserted in the hole and appeared to
be a passageway to supply nitrogen to the Lab.
Based on interview at the time of the
observations, the Manager of OR Clinical
maintains code compliance. The
facility manager is obtaining
quotes to ensure the second floor
storage room maintains a 1 hour
rating. He is also coordinating
with the center's contracted
service provider to provide
outside venting for this room.
Prevention of recurring
deficiency: The facility manager
will ensure compliance with this
requirement by utilizing his
building systems to track
completed work and testing.
Responsible: The facility
manager is responsible for
correction of this deficiency.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 38 of 39
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
11/19/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
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 CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
INDIANAPOLIS, IN 46280
15C0001086 08/10/2018
BELTWAY SURGERY CENTERS LLC
151 PENNSYLVANIA PKWY
01
Operations agreed the door set was not locked
and the room was not constructed with a
minimum 1-hour fire resistance rating.
2. Based on observation and interview, the
facility failed to ensure 1 of 1 indoor
nonflammable gas storage areas was vented to the
outside. NFPA 99, Standard for Health Care
Facilities, Section 9.3.7.5 states indoor storage or
manifold areas and storage or manifold buildings
for medical gases shall be provided with natural
ventilation or mechanical ventilation in
accordance with 9.3.7.5.1 through 9.3.7.8. This
deficient practice could affect one patient, staff
and visitors.
Findings include:
Based on observations with the Director of ASC
Clinical Operations, the Manager of OR Clinical
Operations, the Manager of PACU Clinical
Operations and with the Building Engineer for
Health Trust of America (HTA) during a tour of
the facility from 10:00 a.m. to 2:10 p.m. on
08/10/18, one liquid nitrogen storage container
listed as 160 liter capacity and four nitrogen
cylinders each with a capacity of 221.6 cubic feet
were noted in the second floor storage room by
the Andrology Lab. The medical gas systems
storage room was not vented to the outside.
Based on interview at the time of the
observations, the Manager of OR Clinical
Operations agreed the medical gas systems
storage room was not vented to the outside.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet Page 39 of 39