printed: 04/21/2016 department of health and human ... · meridian south surgery center 8830 south...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

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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

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

INDIANAPOLIS, IN 46217

15C0001192 02/25/2016

MERIDIAN SOUTH SURGERY CENTER

8830 SOUTH MERIDIAN STREET

00

S 0000

Bldg. 00

This visit was for a State licensure

survey.

Facility Number: 013119

Survey Date: 02-22/25-2016

QA: cjl 03/30/16

S 0000

410 IAC 15-2.4-1

GOVERNING BODY; POWERS AND

DUTIES

410 IAC 15-2.4-1 (a)

Sec. 1.(a) The governing body shall

function as the supreme authority of

the center. The governing body shall

assume full legal responsibility for

determining, implementing, and

monitoring policies governing the

center's total operation and for

ensuring that these policies are

followed so as to provide quality

health care in a safe environment.

The governing body is legally

responsible for the conduct of the

center as an institution. The

governing body shall do the following:

S 0100

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Based on interview and document review, it

could not clearly be determined the

governing body reviewed and took actions

specifically for Facility #1 for 4 of 4

S 0100 Responsible: Clinical Director

Corrective Action: The Clinical

Director is responsible to ensure

that minutes of quarterly

Governing Body meetings are

04/06/2016 12:00:00AM

State Form

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: RR2H11 Facility ID: 013119

TITLE

If continuation sheet of 25

(X6) DATE




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governing body meeting minutes.

Findings include:

1. Interview of employee #A4, Clinical

Director, on 02-25-2016 at 2:30 pm,

indicated an organization entitled (Facility

#2) Operations Team was the governing

body of 2 separately licensed ambulatory

surgery centers by the State of Indiana:

Facility #1 and Facility #2.

2. Review of documents entitled (Facility

#2) Operations Team MINUTES Thursday,

April 9, 2015, indicated the following

persons were named in the minutes, but it

was not identified as to which facility or

facilities the person was representing:

MD#8, MD#9, MD#10, employee #A6,

MD#11, MD#12 and MD#13



July 9, 2015, indicated the following persons

were named in the minutes, but it was not

identified as to which facility or facilities the

person was representing:

MD#14, MD#10, MD#15, employee #A6 and

employee#A2



October 8, 2015, indicated the following

maintained on site and made

available upon request. The

clinical director will review the

governing body minute book

quarterly to ensure the records

are maintained on location. All

minutes will reflect a division of

Meridian South Surgery Center

and Eagle Highlands Surgery

Center. Exhibit 1-Most recent

governing body minutes

State Form Event ID: RR2H11 Facility ID: 013119 If continuation sheet of 25




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persons were named in the minutes, but it

was not identified as to which facility or

facilities the person was representing:

employee #A7, MD#13, MD#16, MD#17,

MD#10, employee #A2, MD#18, MD#19 and

MD#20

5. Review of the above-stated meeting

minutes indicated that an acronym of EHSC

was used in each of the minutes. Since that

acronym was not defined anywhere, it could

not be determined if the term was referring

to the separately licensed Facility #2 or

Facility #2 governing body.


Director, on 02-25-2016 at 2:30 pm

confirmed all the above and no other

documentation was provided prior to exit.

410 IAC 15-2.4-1


DUTIES

410 IAC 15-2.4-1 (a)(1)(A)

The governing body shall do the

following:

(1) Ensure that the center:

(A) meets all rules and regulations

for licensure and certification, if applicable

S 0102

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Based on document review and interview,

the facility failed to comply with an

applicable state law for 1 of 1 (P5)

S 0102 Responsible: Clinical

ManagerCorrective Action:

IC16-28-13-4 requires healthcare

facilities to query the state’s nurse

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unlicensed employee file reviewed.

Findings include:

1. IC 16-28-13-4 states a health care facility

shall apply within three (3) business days

from the date a person is employed as a

nurse aide or other unlicensed employee, for

a copy of the person's state nurse aide

registry report from the state department and

a limited criminal history from the Indiana

central repository for criminal history

information under IC 5-2-5 or another source

allowed by law.

2. Review of the file of employee P5,

Tech-Endoscopy, indicated the employee

was not a licensed health care provider by

the State of Indiana.

3. Review of the Job Description for

employee P5, dated March 06, 2009 and last

approved June, 2013, indicated "Assists with

basic patient care including ... giving

enemas,

starting IVs ... ".

4. Thus, employee P5 was unlicensed and

did provide patient care activities.

5. Review of the file of employee P5

indicated there was no documentation of the

employee's state nurse aide registry report

from the state department and a limited

criminal history from the Indiana central

repository for criminal history information

under IC 5-2-5 or another source allowed by

aide registry and receive a copy o

fa limited criminal history report

from the Indiana Central

Repository for Criminal History.

The clinical manager will ensure

that the required documentation

will be kept in the employee files

for all nurse aides. On-going

compliance will be ensured by

adding this requirement to the

employee file checklists for any

nurse aide.





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law.

6. In interview, on 02-25-2016 at 2:25 pm,

employee #A1, Clinical Manager, confirmed

there was no documentation of the

employee's state nurse aide registry report

from the state department, and there was no

documentation of a limited criminal history

from the Indiana central repository for

criminal history information under IC 5-2-5

or another source allowed by law. No

further documentation was provided prior to

exit.

410 IAC 15-2.4-1


DUTIES

410 IAC 15-2.4-1 (a)(5)

The governing body shall do the

following:

(5) Review, at least quarterly,

reports of management operations,

including, but not limited to, quality

assessment and improvement program,

patient services provided, results

attained, recommendations made,

actions taken, and follow-up.

S 0110

Bldg. 00

Based on document review and

interview, the facility's governing board

failed to review reports of the quality

assessment performance improvement

(QAPI) program of 1 activity (discharges)

during calendar year 2015, as part of the

S 0110 The Clinical Director is

responsible for reporting to the

governing body Quality Indicators

for Meridian South Surgery

Center, including the patient

discharge. Responsible: Clinical

Director Corrective Action:The

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facility's QAPI program.

Findings include:

1. Review of the governing board

meeting minutes for calendar year 2015

indicated the

governing board failed to review QAPI

activities of the activity of discharges.


Manager, on 02-23-2016 at 2:00 pm,

confirmed all the above and no other

documentation was provided prior to

exit.

Clinical Director will include

discharges in the centers quality

reporting to reflect indicators that

patient discharge criteria is met

and patients are discharged as

planned. This information will be

reported to the governing body for

review. Ongoing compliance

shall be ensured by the clinical

director verifying that discharges

are included in the centers quality

reporting Exhibit 2 – Quality

Assessment Process

Improvement Meeting Agenda

(with Discharge Quality Indicator

included)

410 IAC 15-2.4-1


DUTIES

410 IAC 15-2.4-1(e)(4)

The governing body is

responsible for services delivered in

the center whether or not they are

delivered under contracts. The

governing body shall do the following:

(4) Ensure that the center maintains a

written transfer agreement with one

(1) or more hospitals for immediate

acceptance of patients who develop

complications or require

postoperative confinement, and that

all physicians, dentists, and

podiatrists performing surgery in the

S 0228

Bldg. 00





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center maintain admitting privileges

at one (1) or more hospitals in the

same county or in an Indiana county

adjacent to the county in which the

center is located.


interview, the governing board failed to

assure that 1 of 7 credentialed staff,

MD#7, a podiatrist, who performed

surgery in the facility, maintained

admitting privileges at one (1) or more

hospitals in the same county or in an

Indiana county adjacent to the county in

which the facility is located, or, failed to

have a written agreement, signed by both

parties, with another facility-credentialed

physician who did have admitting

privileges at a hospital in the same or

adjacent county in which the ambulatory

surgery center is located, that the

physician would admit patients to the

hospital, if needed.

Findings include:

1. Review of 7 medical staff credential

files indicated MD#7, a podiatrist, did

not have documentation of admitting

privileges at one (1) or more hospitals in

the same county or in an Indiana county

adjacent to the county in which the

facility is located. Further review

indicated the practitioner did not have a

written agreement, signed by both parties,

with another facility-credentialed

S 0228 Responsible: Clinical Director The

Clinical Director will ensure that

podiatrists and dentists have an

agreement with physicians who

are members of the medical staff

of the hospital(s), in which the

center has a transfer agreement,

to admit podiatry and/or dental

patients to the hospitals if a

transfer is necessary. On-going

compliance shall be ensured by

adding this to our appointment

and re-appointment application

requirements for Dentists and

Podiatrists. Exhibit 5 - Agreement

for Podiatry and Dentists

04/27/2016 12:00:00AM





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physician who did have admitting

privileges at a hospital in the same or

adjacent county in which the ambulatory

surgery center is located, that the

physician would admit patients to the

hospital, if needed.

2. Interview of employee #A3, physician

credentialing, on 02-23-2016 at 11:30

am, confirmed all the above and no other


exit.

410 IAC 15-2.4-2

QUALITY ASSESSMENT AND

IMPROVEMENT

410 IAC 15-2.4-2(a)(2)

The program shall be ongoing and

have a written plan of

implementation that evaluates, but is

not limited to, the following:

(2) All functions, including, but not

limited to, the following:

(A) Discharge and transfer.

(B) Infection control.

(C) Medication errors.

(D) Response to patient emergencies.

S 0320

Bldg. 00


interview, the facility failed to include a

monitor and standard for the activity of

discharges in its quality assessment and

S 0320 Responsible: Clinical Director


Director will include discharges in

the centers quality reporting to

reflect indicators that discharge

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performance improvement (QAPI)

program for calendar year 2015.

Findings include:

1. Review of the facility's QAPI program

for calendar year 2015 indicated it did not

include a monitor and standard for the

activity of discharges.


Manager, on 02-23-2016 at 2:00 pm,

confirmed the above and no other


exit.

criteria is met and patients are

discharged as planned. This

information will be reported to the

governing body for

review. Ongoing compliance shall

be ensured by the clinical director

verifying that discharges are

included in the centers quality

reporting. Exhibit 2 – Quality

Assessment Process

Improvement Meeting Agenda

(with Discharge Quality Indicator

included)

410 IAC 15-2.5-1

INFECTION CONTROL PROGRAM

410 IAC 15-2.5-1(f)(2)(E)(iii)

The infection control committee

responsibilities must include, but are

not limited to:

(E) Reviewing and recommending

changes in procedures, policies, and

programs which are pertinent to

infection control. These include, but

are not limited to, the following:

(iii) Cleaning, disinfection, and

sterilization.

S 0432

Bldg. 00

Based on review of documents and

interview, the infection control

committee failed to review cleaning,

disinfection and sterilization issues in 1

S 0432 The infection control committee

responsibilities include the review

and recommendation of changes

in procedures, policies, and

programs pertinent to infection

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instance.

Findings include:

1. Review of the facility's Infection

Control Committee minutes for calendar

year 2015 indicated they did not include

review of cleaning, disinfection and

sterilization issues.

2. In interview on 02-25-2016 at 2:50

pm, employee #A4, Clinical Director,



exit.

control, including cleaning,

disinfection and sterilization. The

infection control committee

minutes do not reflect review of

Cleaning, disinfection, and

sterilization. Responsible:

Clinical Manager Corrective

Action: The Clinical Director will

be responsible for over sight of

the infection control committee for

the inclusion of an annual review

of cleaning, disinfection, and

sterilization. Included in the

minutes will be periodic biological

monitoring to check the

sterilization processes and any

necessary corrective action

taken. Ongoing compliance will


by review of the Infection Control

meeting minutes. Exhibit 3

– Quality Assessment Process

Improvement and Infection

Prevention Meeting Agenda

410 IAC 15-2.5-1


410 IAC 15-2.5-1(f)(2)(E)(iv)



not limited to:






(iv) Aseptic technique, invasive

procedures, and equipment usage.

S 0434

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Based on document review and S 0434 The infection control committee 04/06/2016 12:00:00AM





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committee failed to review invasive

procedures issues in 1 instance.

Findings include:




review of invasive procedures issues.





exit.





control, including aseptic

technique, invasive procedures,

and equipment usage. The

infection control committee


aseptic technique,invasive

procedures, and equipment

usage. Responsible: Clinical

Director Corrective Action: The

Clinical Director will be

responsible for oversight of the

infection control committee for the

inclusion of an annual review of

aseptic technique, invasive

procedures, and equipment

usage policies and procedures

and any necessary corrective

action taken. Ongoing

compliance will be ensured by the

clinical director by review of the

Infection Control meeting

minutes. Exhibit 3 – Quality

Assessment Process



410 IAC 15-2.5-1


410 IAC 15-2.5-1(f)(2)(E)(vi)



not limited to:





S 0438

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(vi) A patient isolation system.



committee failed to review isolation

system issues in 1 instance.

Findings include:




review of isolation issues.





exit.






control, including patient isolation

system. The infection control

committee minutes do not reflect

review of patient isolation system.

Responsible: Clinical Director


Director will be responsible for

oversight of the infection control

committee for the inclusion of an

annual review of patient isolation

system policies and procedures

and any necessary corrective

action taken. Ongoing




minutes. Exhibit 3 – Quality

Assessment Process



04/06/2016 12:00:00AM

410 IAC 15-2.5-1


410 IAC 15-2.5-1(f)(2)(E)(vii)


responsibilities must include, but not

be limited to:






S 0440

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(vii) A system, which complies with

state and federal law, to monitor the

immune status of health care workers

exposed to communicable diseases.



committee failed to review monitoring

the immune status of health care workers

exposed to communicable diseases in 1

instance.

Findings include:




review monitoring the immune status of

health care workers exposed to

communicable diseases.





exit.






control. The infection control


review of system to monitor

immune status of health care

workers exposed to

communicable disease. Ongoing




minutes. Responsible: Clinical

Director Corrective Action: The

Clinical Director will be


infection control committee for

including an annual review of

system to monitor immune status

of health care workers exposed to

communicable disease policies

and procedures and any



been ensured by the clinical

director by review of the Infection

Control meeting minutes. Exhibit

3 – Quality Assessment Process



04/06/2016 12:00:00AM

410 IAC 15-2.5-1


410 IAC 15-2.5-1(f)(2)(E)(viii)

S 0442

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not limited to:






(viii) An employee health program to

determine the communicable disease

history of new personnel as well as an

ongoing program for current personnel

as required by state and federal

agencies.



committee failed to review an appropriate

employee health program to determine

the communicable disease history of

employees in 1 instance.

Findings include:




reviewing an appropriate employee health

program to determine the communicable

disease history of employees.





exit.






control, including an employee

health program to determine the

communicable disease history of

new personnel and ongoing

program for current personnel.



an employee health program to

determine the communicable

disease history of new personnel

and ongoing program for current

personnel.






annual review of an employee

health program to determine the

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communicable disease history of

new personnel and ongoing

program for current personnel

policies and procedures and any





meeting minutes.

Exhibit 3 – Quality Assessment

Process Improvement and

Infection Prevention Meeting

Agenda

410 IAC 15-2.5-1


410 IAC 15-2.5-1(f)(2)(E)(ix)



not limited to:






(ix) Requirements for personal hygiene

and attire that meet acceptable

standards of practice.

S 0444

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committee failed to review requirements

for personal hygiene and appropriate

attire that meet acceptable standards in 1

instance.


responsibilities include thereview



programspertinent to infection

control, including personal

hygiene and attire that

meetacceptable standards of

practice. Theinfection control

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Findings include:




review of requirements for personal

hygiene and appropriate attire that meet

acceptable standards.





exit.


review requirements forpersonal

hygiene and attire that meet

acceptable standards of practice.



Director will be responsiblefor



annualreview requirements for

personal hygiene and attire that

meet acceptablestandards of

practice policies and procedures

and any necessary

correctiveaction taken. Ongoing


clinical director byreview of the


minutes.

DOC: 4-6-16

Exhibit 3 – Quality Assessment

Process Improvement

andInfection Prevention Meeting

Agenda

410 IAC 15-2.5-1


410 IAC 15-2.5-1(f)(2)(E)(x)



not limited to:






(x) A program of linen management.

S 0446

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responsibilities include the review 04/06/2016 12:00:00AM





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committee failed to review the linen

management program in 1 instance.

Findings include:




review of the linen management program.





exit.




control, linen management

program. The infection control


review requirements for a linen

management program.






annual review requirements for a

linen management program

policies and procedures and any





meeting minutes. Exhibit 3 –

Quality Assessment Process



410 IAC 15-2.5-4

MEDICAL STAFF; ANESTHESIA AND

SURGICAL

410 IAC 15-2.5-4(b)(3)(B)

These bylaws

and rules must be as follows:

(3) Include, at a minimum, the following:

(B) Meeting requirements of the

medical staff to include, at a

minimum, the following:

(i) Frequency, at least quarterly.

(ii) Attendance.

S 0736

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interview, the medical staff bylaws did

not specify the number of members to be

present for a quorum for medical staff

meetings in 1 instance. The resultant

effect was there was not a quorum

present for 4 of 4 medical staff meetings

in calendar year 2015 and consequently,

any actions taken were invalid.

Findings include:

1. Review of the medical staff bylaws,

approved by both the governing board

and medical staff on 06-12-2013,

indicated there was no description of

what constituted a quorum for medical

staff meetings:

2. Review of Robert's Rules of Order

Newly Revised, 11th Edition, by General

Henry M. Robert, published 09-27-2011,

a guide for conducting meetings and

making decision for a group, indicated

"A Quorum of an assembly is such a

number that must be present in order that

business can be legally transacted. The

quorum refers to the number present, not

the number voting."

3. Further review of Robert's Rules of

Order indicated "The quorum of any ...

deliberative assembly with an enrolled

membership (unless the by-laws provide

for a smaller quorum), is a majority of all

rules must include meeting

requirements of the medical staff

to include attendance. The

medical staff bylaws for Meridian

South Surgery Center did not

specify the number of members

to be present for a quorum for

medical staff meetings. The

effect was there was not a

quorum present for 4 of 4 medical

staff meetings. Responsible:

Clinical Director Corrective

Action: The medical staff bylaws

will be amended to include the

definition of a quorum to specify

two (2) medical staff members.

The amended bylaws will be

reviewed and approved by the

Medical Staff and Governing

Body. Exhibit 4 – Page 8 from

the Medical Staff Bylaws showing

amendment.





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the members."

4. Review of a List of Active Medical

Staff Members for the facility, indicated

there were 17 Active members.

Therefore, based on Robert's Rules of

Order, there must be at least 9 Active

Medical Staff Members for a majority to

be present at a medical staff meeting.

5. Review of documents entitled

Meridian South Surgery Center Medical

Staff Meeting Minutes, indicated the

following:

February 4th, 2015 - 4 medical staff

members present

May 6th, 2015 - 2 medical staff members

present

August 5th, 2015 - 2 medical staff

members present

November 4th, 2015 - 3 medical staff

members present

Based on the above meetings, a quorum

of 9 members present did not occur.

5. Further review of Robert's Rules of

Order indicated "The only business that

can be transacted in the absence of a

quorum is to take measures to obtain a

quorum, to fix the time to which to

ad-journ, and to adjourn, or to take a

recess."





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6. Review of the above-stated meeting

minutes indicated the business conducted

in each meeting was Review and

Approval of prior meeting minutes,

Quality, Credentialing Report, and

Other Business.

7. Based on the above meetings,

activities were conducted not permitted

by Robert's Rules of Order and therefore,

the actions were invalid.


Director, on 02-25-2016 at 3:45 pm,

confirmed the above-stated meeting

minutes and meeting actions, and no

further documentation was provided prior

to exit.

410 IAC 15-2.5-4

MEDICAL STAFF; ANESTHESIA AND

SURGICAL

410 IAC 15-2.5-4(c)(1)(F)(iv)

The medical staff shall write and

implement policies and procedures and

the governing body shall approve

policies and procedures which include

but are not limited to, the following:

(F) The delineation of preanesthesia,

S 0836

Bldg. 00





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intra-operative, and postanesthesia

responsibilities as follows:

(iv) The requirement that all

postoperative patients shall be

discharged from the postanesthetic

care unit by the practitioner

described in clause (C) as responsible

for the patient's care in accordance

with center policy.


interview, the facility failed to implement

its policy that all post-operative patients

be discharged by the attending physician

in 5 (Pt#1, Pt#3, Pt#4, Pt#6 and Pt#8) of

10 patient medical records reviewed.

Findings include:

1. Review of Policy Number MS2.20,

entitled RULES AND REGULATIONS -

MEDICAL STAFF, Amended Approval

Date: June 2013, indicated "Patients shall

be discharged only on a written order of

the Anesthesiologist. Gastroenterology

cases which do not involve the evaluation

of an anesthesiologist either before or

after surgery unless requested by the

attending surgeon, dentist or podiatrist,

shall be discharged by the attending

physician.

2. Review of 10 patient medical records

indicated :

Pt#1: document entitled

S 0836 Medical records reveiwed

indicated documentation that

post-operative instructions were

given to the patient with no

signature by the ordering

physician. Responsible: Clinical

DirectorCorrective Action: The

Clinical Manager is responsible

for oversight for compliance to

the facility policy #CLR 6.00

Content of Medical Records. All

entries in the midcal record must

be confirmed by written

signatures of computer signature,

identifying the credentials of the

author. The Clinical Manager is

responsible for oversight for

complicance to the facility policy #

AAP 10.05 Pre-printed Physician

Specific Orders. All pre-printed

discharge instruction orders are

reviewed and signed by the

individual physician for each

patient. All pre-printed physician

specific orders will be reviewed

and renewed annually by the

physician. 1. Ongoing the Clinical

Manager will obtain signature and

date reviewed on all pre-printed

discharge instructions. 2.

Ongoing monitoring for

compliance, the Clincial Manager

04/06/2016 12:00:00AM





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POST-OPERATIVE INSTRUCTIONS

FOR MYRINGOTOMIES, dated June

12, 2015, was signed by the patient as

having received them. However, there

was no signature by the physician as

having approved of them as an order to

be given to the patient. Further review of

the patient's medical record indicated

there was no written or verbal order

elsewhere in the medical record for these

post-operative instructions.

Pt#3: document entitled POST

INJECTION FOLLOW-UP

INSTRUCTIONS, dated

11-30-15, was signed by the patient as







elsewhere in the medical record for this

post injection follow-up.

Pt#4: document entitled ENDOSCOPY

DISCHARGE INSTRUCTIONS, dated








will audit random charts to

monitor compliance and report

deficiencies to the Clinical

Director. Exhibit 6 Policy CLR

6.00 Content of Medical Records

Page 3Exhibit 7 Policy AAP 10.05

Pre-printed Physician Specific

OrdersExhibit 8 Example of

pre-printed discharge instruction

sheet reviewed, signed and dated

by the ordering physician





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endoscopy discharge instructions.























3. In interview at 9:40 am on 02-25-2016,

employee #A1, Clinical Manager, was asked

if the medical staff had previously approved

the above-stated instructions to be used by

the facility as discharge orders. The

employee indicated they had not been

approved.





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4. In interview at 9:40 am on

02-25-2016, employee #A1 confirmed all

the above and no further documentation

was provided prior to exit.

410 IAC 15-2.5-7

PHYSICAL PLANT, EQUIPMENT

MAINTENANCE,

410 IAC 15-2.5-7(b)(3)(C)

(b) The condition of the physical

plant and the overall center

environment must be developed and

maintained in such a manner that the

safety and well-being of patients are

assured as follows:

(3) Provision must be made for the

periodic inspection, preventive

maintenance, and repair of the

physical plant and equipment by

qualified personnel as follows:

(C) Operational and maintenance

control records must be established

and analyzed at least triennially.

These records must be readily

available on the premises.

S 1154

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Based on interview, the facility failed to

document operational and maintenance

control records having been analyzed at

least triennially for 2 (smoke detector and

S 1154 The Clinical Director is


physical plant and equipment

maintenance. The building

engineer was unable to provide

04/22/2016 12:00:00AM





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fire alarm systems) of 6 systems of

equipment.

Findings include:

1. On 02-22-2016 at 10:45 am, employee

#A1, Clinical Manager, was requested to

provide documentation of the operational

and maintenance control records for the

heating, ventilation, air conditioning,

emergency generator, smoke detector and

fire alarm systems having been analyzed

at least triennially.

2. Interview of employee #A5, Engineer,

on 02-23-2016 at 2:15 pm, confirmed

there was no above-requested

documentation for the smoke detector

and fire alarm systems and no other


exit.

documentation of the triennial

analysis of the smoke detector

and the fire alarm systems.



Director with review engineering

log records to ensure ongoing

compliance with adding triennial

maintenance requirements to the

facilities Physical Plant and

equipment maintenance

checklists.


printed: 04/21/2016 department of health and human ... · meridian south surgery center 8830 south...

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