DEPARTMENT OF HEALTH PO BOX 367 TRENTON, N.J

Transcription

1 DEPARTMENT OF HEALTH PO BOX 367 TRENTON, N.J CHRIS CHRISTIE Governor KIM GUADAGNO Lt. Governor MARY E. O'DOWD, M.P.H. Commissioner September 25, 2013 Deborah Martin, RN, BSN Administrator Select Surgical Center At Kennedy 405 Hurffville Cross Keys Road Sewell, NJ Dear Ms. Martin: Thank you for the courtesy and cooperation extended during the Federal Re-certification survey of your facility completed on September 12, 2013 by surveyors from the New Jersey Department of Health. As a result of observation and evaluation certain Federal deficiencies were evident. The deficiencies identified during this visit have resulted in the determination that your facility is not in compliance with the following Medicare Condition(s) for Coverage (CfC) 42 CFR Governing Body and Management 42 CFR Pharmaceutical Services A complete listing of the specific deficiencies identified by the surveyors is enclosed. These Federal deficiencies were discussed with you and/or your staff during the visit and are listed on the left side of the enclosed CMS-2567 form. Please reply to each deficiency, on an item by item basis, with your Plan of Correction (PoC) and the date you expect the correction to be completed. You may write your PoC on the deficiency report in the space provided, or it can be written on a separate document and submitted along with the signature page (page 1 of the deficiency report). Please number your response to correspond to the number of each deficiency statement.

2 Select Surgical Center At Kennedy September 25, 2013 Page 2 The PoC for each deficiency must contain the following elements: 1. How the specific findings cited for each deficiency will be corrected. 2. The systemic changes put into place for each deficiency. 3. The measures that will be put into place to monitor each corrective action to ensure that the plan of correction is effective and that compliance is maintained. 4. The title of the person responsible for implementing the plan of correction. 5. The date on which each item addressed on the PoC will be corrected. 6. Do not reference and/or include attachments with your PoC. 7. Do not include names of individuals in the PoC. Use of titles is acceptable, such as, Administrator, Director of Nursing, Infection Control Practitioner, etc. Please be advised that the PoC will not be accepted for review by this office and will be returned to you if it contains reference to and/or attachments and/or names of individuals. Sign and date the first page of the CMS-2567 form and return the form with your PoC. Please retain a copy of each page for your records. All responses must be returned within 10 calendar days of receipt of this letter to Edward Harbet, RN, BSN, BA, Supervising Health Care Evaluator, New Jersey Department of Health, Health Facilities Evaluation and Licensing, PO Box 367, Trenton, NJ It is important to return the completed forms promptly. Any delay or lack of response may jeopardize the certification status of your facility. If you have any questions concerning this report, please contact Mr. Harbet, at (609) Sincerely, Enc. Crescenza Zizza, RN Health Care Services Evalator Assessment and Survey

3 PRINTED: 01/15/2014 Statement of Deficiencies Citation Summary Sheet For: SELECT SURGICAL CENTER AT KENNEDY ( 31C / NJ24339 ) Survey Event: 5KGD11, Exit Date 09/12/2013 Citations Cited This Visit Regulation Type Regulation ID Regulation Version Building Number Tag Number Tag Title Scope/ Severity Federal FQ INITIAL COMMENTS Federal FQ GOVERNING BODY AND MANAGEMENT Federal FQ ORGANIZATION AND STAFFING Federal FQ FORM AND CONTENT OF RECORD Federal FQ PHARMACEUTICAL SERVICES Federal FQ ADMINISTRATION OF DRUGS Federal FQ RADIOLOGIC SERVICES Federal FQ SANITARY ENVIRONMENT Federal FQ INFECTION CONTROL PROGRAM Federal FQ PRE-SURGICAL ASSESSMENT Federal FQ DISCHARGE WITH RESPONSIBLE ADULT

4 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/15/2014 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 31C B. WING 09/12/2013 NAME OF PROVIDER OR SUPPLIER SELECT SURGICAL CENTER AT KENNEDY STREET ADDRESS, CITY, STATE, ZIP CODE 405 HURFFVILLE CROSS KEYS ROAD SEWELL, NJ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Q 000 INITIAL COMMENTS Q 000 Federal Re-certification Employee Files Reviewed/Interviews: 18 Q 040 Medical Records Reviewed: GOVERNING BODY AND MANAGEMENT The ASC must have a governing body that assumes full legal responsibility for determining, implementing,and monitoring policies governing the ASC's total operation. The governing body has oversight and accountability for the quality assessment and performance improvement program, ensures that facility policies and programs are administered so as to provide quality health care in a safe environment, and develops and maintains a disaster preparedness plan. Q 040 Q 141 This CONDITION is not met as evidenced by: Based on observation, review of medical records, review of policies and procedures, and staff interview, it was determined that the governing body failed to demonstrate that it is effective in carrying out the operation and management of the facility. The necessary oversight and leadership was not provided as evidenced by the lack of compliance with 42 CFR Pharmaceutical Services (a) ORGANIZATION AND STAFFING Patient care responsibilities must be delineated for all nursing service personnel. Nursing services must be provided in accordance with recognized standards of practice. There must be Q 141 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KGD11 Facility ID: NJ24339 If continuation sheet Page 1 of 16

5 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/15/2014 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 31C B. WING 09/12/2013 NAME OF PROVIDER OR SUPPLIER SELECT SURGICAL CENTER AT KENNEDY STREET ADDRESS, CITY, STATE, ZIP CODE 405 HURFFVILLE CROSS KEYS ROAD SEWELL, NJ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Q 141 Continued From page 1 Q 141 a registered nurse available for emergency treatment whenever there is a patient in the ASC. This STANDARD is not met as evidenced by: A. Based on medical record review and observation, it was determined that nursing personnel did not provide nursing care in accordance with the State of New Jersey Nurse Practice Act and standard of care. Findings include: Reference: The Nursing Practice Act for the State of New Jersey states, "The practice of nursing as a registered professional nurse RN is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist." 1. Medical Record #5 revealed in The PACU Phase I (post anesthesia care unit) nurse note, dated 7/19/13, that at 0946 a face mask at 40% oxygen high humidity was initiated and discontinued at 10:20 AM. There was no evidence of a physician order. 2. Medical Record #9 indicated a physician order dated 8/22/13 for "Oxygen therapy nasal cannula at 2 liters/minute." The PACU Phase I nurse note indicated that Oxygen via nasal cannula at 4 liters per minute was administered from 9:40 AM until 1005 AM instead of 2, as ordered. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KGD11 Facility ID: NJ24339 If continuation sheet Page 2 of 16

6 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/15/2014 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 31C B. WING 09/12/2013 NAME OF PROVIDER OR SUPPLIER SELECT SURGICAL CENTER AT KENNEDY STREET ADDRESS, CITY, STATE, ZIP CODE 405 HURFFVILLE CROSS KEYS ROAD SEWELL, NJ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Q 141 Continued From page 2 Q Medical Record #7 indicated a physician order dated 7/24/13 for "Oxygen therapy nasal cannula at 3 liters/minute." The PACU Phase I nurse note indicated that Oxygen via nasal cannula at 2 liters per minute was administered from 11:52 AM until 12:27 PM instead of 3, as ordered. 4. Medical Record #11 revealed in the PACU Phase I (post anesthesia care unit) nurse note, dated 8/20/13, that at 13:44 PM oxygen at 2 liters per minute was administered until 13:59. There was no evidence of a physician order. B. Based on review of 3 of 3 medical records of patients who received pain medication, it was determined that the facility failed to ensure that the Pain Assessment and Management policy was implemented. Findings include: Reference: Facility's "Pain Assessment and Management" policy stated, "Procedure Guidelines: D. Pain assessment shall be documented on the patient record Pain shall be reassessed following each pain control intervention...." Medical Record #2 indicated that the patient underwent a procedure on 7/15/13. The PACU Phase 1 nursing note indicated that the patient received at 1248 Percocet one tablet for pain. There was no evidence of a pain reassessment. The patient was discharged at Medical Record #4 indicated that the patient underwent a procedure on 7/19/13. The PACU Phase 1 nursing note indicated that at 11:00 the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KGD11 Facility ID: NJ24339 If continuation sheet Page 3 of 16

7 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/15/2014 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 31C B. WING 09/12/2013 NAME OF PROVIDER OR SUPPLIER SELECT SURGICAL CENTER AT KENNEDY STREET ADDRESS, CITY, STATE, ZIP CODE 405 HURFFVILLE CROSS KEYS ROAD SEWELL, NJ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Q 141 Continued From page 3 Q 141 patient received Vicodan 1 tablet for pain. There was no evidence of a pain reassessment. The patient was discharged at Q 162 Medical Record #1 indicated that the patient underwent a procedure on 7/11/13. The PACU Phase 1 nursing note indicated that at 1020 the patient received Tylenol with Codeine 7.5 ml (milliliter) for pain. There was no evidence of a pain reassessment. The patient was discharged at (b) FORM AND CONTENT OF RECORD The ASC must maintain a medical record for each patient. Every record must be accurate, legible, and promptly completed. Medical records must include at least the following: (1) Patient identification. (2) Significant medical history and results of physical examination. (3) Pre-operative diagnostic studies (entered before surgery), if performed. (4) Findings and techniques of the operation, including a pathologist's report on all tissues removed during surgery, except those exempted by the governing body. (5) Any allergies and abnormal drug reactions. (6) Entries related to anesthesia administration. (7) Documentation of properly executed informed patient consent. (8) Discharge diagnosis. This STANDARD is not met as evidenced by: Based on document review, it was determined that the facility failed to ensure that the medical records were accurate. Q 162 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KGD11 Facility ID: NJ24339 If continuation sheet Page 4 of 16

8 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/15/2014 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 31C B. WING 09/12/2013 NAME OF PROVIDER OR SUPPLIER SELECT SURGICAL CENTER AT KENNEDY STREET ADDRESS, CITY, STATE, ZIP CODE 405 HURFFVILLE CROSS KEYS ROAD SEWELL, NJ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Q 162 Continued From page 4 Q 162 Findings include: 1. Medical Record #2, date of procedure 7/15/15 contained an Order Sheet/Post-Op-Note that lacked the date the Post-Op orders were written. The Post-Op Note/Discharge Note was blank with the exception of the physician signature. Q Medical Record #23 and #24 indicated that both patients underwent a procedure on 8/9/13 and 5/15/13, respectively. Both patients were transferred to a hospital following the procedures. There was no evidence in the medical record of a note by the physician regarding the transfers PHARMACEUTICAL SERVICES The ASC must provide drugs and biologicals in a safe and effective manner, in accordance with accepted professional practice, and under the direction of an individual designated responsible for pharmaceutical services. Q 180 This CONDITION is not met as evidenced by: Based on record review and staff interview conducted on 9/3/13, it was determined that the facility failed to ensure that medications were provided in a safe manner in accordance with accepted professional practice. Findings include: 1. The facility failed to ensure that single dose vials were used for just one patient. (Refer to Tag 0181) This was cause for an Immediate Jeopardy to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KGD11 Facility ID: NJ24339 If continuation sheet Page 5 of 16

9 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/15/2014 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 31C B. WING 09/12/2013 NAME OF PROVIDER OR SUPPLIER SELECT SURGICAL CENTER AT KENNEDY STREET ADDRESS, CITY, STATE, ZIP CODE 405 HURFFVILLE CROSS KEYS ROAD SEWELL, NJ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Q 180 Continued From page 5 Q 180 identified on 9/3/13. The Immediate Jeopardy was abated on the afternoon of 9/3/13 after receiving an acceptable plan of correction from Staff #1. Q The facility failed to implement policies and procedures for the control and accountability of controlled dangerous substances (CDS). (Refer to Tag 0181) (a) ADMINISTRATION OF DRUGS Drugs must be prepared and administered according to established policies and acceptable standards of practice. Q 181 This STANDARD is not met as evidenced by: A. Based on record review, policy review, and staff interview, it was determined that the facility failed to implement policies and procedures to ensure that drugs in single dose vials are used for only one patient. Findings include: Reference: Facility policy titled "Storage of Medications" (Policy Number: P&T 21) states, "...Single dose vials or ampules are to be used for single patient use only and not to be saved because they do not contain preservatives and must be discarded after being opened." 1. Review of the facility's controlled drug records on 9/3/13, revealed that single dose vials of fentanyl 100mcg (microgram)/2ml (milliliter) were used to administer doses to multiple patients. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KGD11 Facility ID: NJ24339 If continuation sheet Page 6 of 16

10 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/15/2014 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 31C B. WING 09/12/2013 NAME OF PROVIDER OR SUPPLIER SELECT SURGICAL CENTER AT KENNEDY STREET ADDRESS, CITY, STATE, ZIP CODE 405 HURFFVILLE CROSS KEYS ROAD SEWELL, NJ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Q 181 Continued From page 6 Q 181 a. The Narcotic and Controlled Drug Administration Record dated 7/16/13, revealed that 1 fentanyl 100mcg/2ml vial was used to administer doses to 2 patients (Patient #19 and #20). b. The Narcotic and Controlled Drug Administration Record dated 8/28/13, revealed that 4 fentanyl 100mcg/2ml vials were used to administer doses to 6 patients (Patient #13, #14, #15, #16, #17, and #18). c. The manufacturer's label on fentanyl 100mcg/2ml vials read "Single dose vial". d. These findings were confirmed with Staff #1 and #2. B. Based on record review, policy review, and staff interview conducted on 9/3/13, it was determined that the facility failed to implement policies and procedures addressing the intentional wasting of partial doses of controlled dangerous substances (CDS). Findings include: Reference: Facility policy titled "Narcotic Count/Access" (Policy Number: P&T 14) states, "...Intentional wasting of controlled drugs, including the disposition of partial doses, and for documentation, the signature of a second person who witnessed the disposition shall be included on the narcotic count sheet." 1. Review of the Narcotic and Controlled Drug Administration Record dated 8/5/13, revealed that the signature of a second person witnessing the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KGD11 Facility ID: NJ24339 If continuation sheet Page 7 of 16

11 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/15/2014 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 31C B. WING 09/12/2013 NAME OF PROVIDER OR SUPPLIER SELECT SURGICAL CENTER AT KENNEDY STREET ADDRESS, CITY, STATE, ZIP CODE 405 HURFFVILLE CROSS KEYS ROAD SEWELL, NJ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Q 181 Continued From page 7 Q 181 intentional controlled drug wasting of partial doses was not recorded for 3 out of 4 patients who received fentanyl (Patient #25, #26 and #27). 2. Review of the Narcotic and Controlled Drug Administration Record dated 8/30/13, revealed that the signature of a second person witnessing the intentional controlled drug wasting of partial doses was not recorded for 6 out of 6 patients who received fentanyl (Patient #28, #29, #30, 31, #32, and #34). 3. Review of the Narcotic and Controlled Drug Administration Record dated 8/30/13, revealed that the signature of a second person witnessing the intentional controlled drug wasting of partial doses was not recorded for 6 out of 7 patients who received midazolam (Patient # 28, #29, #30, #31, #32, and #33). Q These findings were confirmed with Staff #1 and # (b) RADIOLOGIC SERVICES (1) The ASC must have procedures for obtaining radiological services from a Medicare approved facility to meet the needs of patients. Q 202 This STANDARD is not met as evidenced by: Based on document review, it was determined that the facility failed to ensure that the radiology technicians were not assessed or deemed competent in accordance with facility policy. Findings include: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KGD11 Facility ID: NJ24339 If continuation sheet Page 8 of 16

12 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/15/2014 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 31C B. WING 09/12/2013 NAME OF PROVIDER OR SUPPLIER SELECT SURGICAL CENTER AT KENNEDY STREET ADDRESS, CITY, STATE, ZIP CODE 405 HURFFVILLE CROSS KEYS ROAD SEWELL, NJ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Q 202 Continued From page 8 Q 202 Reference: Facility's "Orientation of Newly Hired Staff" policy stated, "... New Employee Orientation:... Orientation to the employee's department unit, work setting and/or program-specific policies and procedures will be conducted by the department manager/director/supervisor.... Procedure for Orientation of New Employees:... The employee will be assessed for his/her ability to carry out assigned responsibilities safely, competently and in a timely manner upon completion of orientation by his /her department manager/director/supervisor. Successful completion of orientation will be documented on the New Hire Processing Checklist by the employee's department manager/director/supervisor and kept in the employee's personnel file." 1. The employee file of Staff #18 indicated that he/she is employed as a radiology technician per diem as of 11/2012. The Clinical Orientation check off sheet completed at hire and at 90 day evaluation, lacked evidence of any competency related to the job description. Q The employee file of Staff #17, a contracted staff, employed as a radiology technician revealed no successful completion of orientation or further evaluations (a) SANITARY ENVIRONMENT The ASC must provide a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice. Q 241 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KGD11 Facility ID: NJ24339 If continuation sheet Page 9 of 16

13 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/15/2014 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 31C B. WING 09/12/2013 NAME OF PROVIDER OR SUPPLIER SELECT SURGICAL CENTER AT KENNEDY STREET ADDRESS, CITY, STATE, ZIP CODE 405 HURFFVILLE CROSS KEYS ROAD SEWELL, NJ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Q 241 Continued From page 9 Q 241 This STANDARD is not met as evidenced by: Based on observation, it was determined the facility failed to provide a sanitary environment for the provision of surgical services. Findings include: 1. On 9/9/13 at 10:05 AM, in the presence of Staff #1, the wall was gouged at the OR (operating room) entry sink. 2. On 9/9/13 at 10:10 AM, in the presence of Staff #1, the doors to OR #1 were chipped. 3. On 9/9/13 at 10:15 AM, in the presence of Staff #1, in OR #1 the lower vents were dusty. 4. On 9/9/13 at 10:50 AM, in the presence of Staff #1, in the storage room, 3 OR table pads were stored with their edges on the floor. Q On 9/9/13 at 11:05 AM, in the presence of Staff #1, the side wall of the pediatric recovery room was gouged (b) INFECTION CONTROL PROGRAM The ASC must maintain an ongoing program designed to prevent, control, and investigate infections and communicable diseases. In addition, the infection control and prevent program must include documentation that the ASC has considered, selected, and implemented nationally recognized infection control guidelines. Q 242 This STANDARD is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KGD11 Facility ID: NJ24339 If continuation sheet Page 10 of 16

14 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/15/2014 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 31C B. WING 09/12/2013 NAME OF PROVIDER OR SUPPLIER SELECT SURGICAL CENTER AT KENNEDY STREET ADDRESS, CITY, STATE, ZIP CODE 405 HURFFVILLE CROSS KEYS ROAD SEWELL, NJ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Q 242 Continued From page 10 Q 242 Based on document review, it was determined that the facility failed to ensure that the Employee Health policy was implemented. Findings include: Reference: Facility's "Employee Health" policy stated, "Procedure Guidelines:... A physical exam will be completed upon hiring and every four years thereafter... Each employee who cannot document the results of a previous, rubella, rubeola... screening test shall be given a blood screening test... An employee who can document seropositivity from a previous MMR [measles, mumps, rubella]screening test or who can document inoculation with MMR vaccine shall not be required to have a MMR screening test.... An optional item is: each employee born in 1957 or latter shall be given a varicella screening test upon employment. An employee who can document receipt of a varicella vaccine, physician-diagnosed chickenpox, or serologic evidence of immunity shall not be required to have a screening test.... Upon employment, the facility shall administer a two-step Mantoux tuberculin skin test... Exceptions: Employees who provide documentation of negative results of a single Mantoux skin test performed within the 12 months preceding he start of employment shall receive only one Mantoux skin test upon hire. Employees with prior documentation of negative results of two Mantoux skin test performed within 12 months of preceding start of employment and without signs and symptoms of active tuberculosis, shall not required to be tested upon FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KGD11 Facility ID: NJ24339 If continuation sheet Page 11 of 16

15 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/15/2014 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 31C B. WING 09/12/2013 NAME OF PROVIDER OR SUPPLIER SELECT SURGICAL CENTER AT KENNEDY STREET ADDRESS, CITY, STATE, ZIP CODE 405 HURFFVILLE CROSS KEYS ROAD SEWELL, NJ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Q 242 Continued From page 11 Q 242 hire; however, a Mantoux skin test shall be required within 12 months months of the last tuberculin skin test...." 1. Review of the following health files revealed: a. The health file of Staff #5 contained a physical exam without a date of when it was performed. There was no evidence of a rubella screening test or inoculation with the MMR vaccine. b. The health file of Staff #4, born after 1957, lacked evidence of a rubella screening test or inoculation with the MMR vaccine. c. The health file of Staff #9, lacked evidence of a physical exam. There was no evidence of a rubella screening test or inoculation with MMR vaccine. e. The health file of Staff #10 lacked evidence of a rubella screening test or inoculation with the MMR vaccine. f. The health file of Staff #11, lacked evidence of a rubella screening test or inoculation with the MMR vaccine. g. The health file of Staff #12, born after 1957, lacked evidence of a rubella and rubeola screening test or inoculation with the MMR vaccine. h. The health file of Staff #13, date of hire 1/2012, lacked evidence of a second Mantoux tuberculin skin test. i. The health file of Staff #14, date of hire 11/2011, lacked evidence of a second Mantoux FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KGD11 Facility ID: NJ24339 If continuation sheet Page 12 of 16

16 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/15/2014 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 31C B. WING 09/12/2013 NAME OF PROVIDER OR SUPPLIER SELECT SURGICAL CENTER AT KENNEDY STREET ADDRESS, CITY, STATE, ZIP CODE 405 HURFFVILLE CROSS KEYS ROAD SEWELL, NJ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Q 242 Continued From page 12 Q 242 tuberculin skin test. k. The health file of Staff #15, lacked evidence of Mantoux tuberculin skin test for The last test was performed on 5/18/12. l. The health file of Staff #16, date of hire 8/2011, lacked evidence of Mantoux tuberculin skin test for m. The health file of Staff #17, a contracted staff, lacked evidence of a physical exam, and rubella screening test. Based on observation, staff interview, and a review of policy and procedures, it was determined that the ASC failed to adhere to professionally acceptable standards of practice for hand washing. Findings include: Reference #1: Guideline for Hand Hygiene in Health Care Settings: Recommendation of the Healthcare Infection Control Practices Advisory Committee and the ICA/SHEA/APIC/IDSA Hand Hygiene Task Force, published in the Morbidity and Mortality Weekly Report at MMWR 2002; 51 (No. RR-16). Recommendations: 1. Indications for Handwashing and Hand antisepsis... C. Decontaminate hands before having direct contact with patients. E. Decontaminate hands before inserting...peripheral vascular catheters, or other invasive devices... FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KGD11 Facility ID: NJ24339 If continuation sheet Page 13 of 16

17 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/15/2014 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 31C B. WING 09/12/2013 NAME OF PROVIDER OR SUPPLIER SELECT SURGICAL CENTER AT KENNEDY STREET ADDRESS, CITY, STATE, ZIP CODE 405 HURFFVILLE CROSS KEYS ROAD SEWELL, NJ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Q 242 Continued From page 13 Q 242 F. Decontaminate hands after contact with a patient's intact skin... G. Decontaminate hands after contact with... a patient's nonintact skin... I. Decontaminate hands after contact with inanimate objects...in the immediate vicinity of the patient. J. Decontaminate hands after removing gloves. Reference #2: The facility's policy entitled, "Hand Hygiene Protocol," states in the "Indication for Hand Washing and Hand Decontamination" section that, "...X. Decontaminate hands after removing gloves." 1. During observation of a procedure in Operating Romm #3 on 9/4/13, Staff #6 made multiple glove changes without any hand hygiene in between the changes. Q This was confirmed by Staff # (a)(2) PRE-SURGICAL ASSESSMENT Upon admission, each patient must have a pre-surgical assessment completed by a physician or other qualified practitioner in accordance with applicable State health and safety laws, standards of practice, and ASC policy that includes, at a minimum, an updated medical record entry documenting an examination for any changes in the patient's condition since completion of the most recently documented medical history and physical assessment, including documentation of any allergies to drugs and biologicals. Q 262 This STANDARD is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KGD11 Facility ID: NJ24339 If continuation sheet Page 14 of 16

18 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/15/2014 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 31C B. WING 09/12/2013 NAME OF PROVIDER OR SUPPLIER SELECT SURGICAL CENTER AT KENNEDY STREET ADDRESS, CITY, STATE, ZIP CODE 405 HURFFVILLE CROSS KEYS ROAD SEWELL, NJ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Q 262 Continued From page 14 Q 262 Based on review of 2 medical records of patients undergoing a procedure performed by Staff #11, it was determined that the facility failed to ensure that a pre-evaluation assessment was performed prior to the procedure. Findings include: 1. Medical Record #1 indicated that the patient underwent a procedure on 7/11/13. There was no evidence of a pre-evaluation assessment performed by the physician prior to the procedure. Q Medical Record #5 indicated that the patient underwent a procedure on 7/19/13. There was no evidence of a pre-evaluation assessment performed by the physician prior to the procedure (c)(3) DISCHARGE WITH RESPONSIBLE ADULT [The ASC must -] Ensure all patients are discharged in the company of a responsible adult except those patients exempted by the attending physician. Q 267 This STANDARD is not met as evidenced by: Based on review of 1 of 1 medical record of patient who was discharged to self, it was determined that the facility failed to ensure that upon discharge the physician exempted the patient from being accompanied by an adult. Findings include: Reference: Facility's "Discharge of Patients" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KGD11 Facility ID: NJ24339 If continuation sheet Page 15 of 16

19 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/15/2014 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 31C B. WING 09/12/2013 NAME OF PROVIDER OR SUPPLIER SELECT SURGICAL CENTER AT KENNEDY STREET ADDRESS, CITY, STATE, ZIP CODE 405 HURFFVILLE CROSS KEYS ROAD SEWELL, NJ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Q 267 Continued From page 15 Q 267 policy stated, "Procedure Guidelines:... The patient who has received unsupplemented local anesthesia may drive home with the written approval of his or her physician unless the surgical area would interfere with proper operation of a motor vehicle...." 1. Patient #22 underwent a local procedure on 8/23/13. The patient was discharged to self. There was no evidence of a physician discharge order exempting the patient from being accompanied by an adult. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KGD11 Facility ID: NJ24339 If continuation sheet Page 16 of 16

20 CHRIS CHRISTIE Governor KIM GUADAGNO Lt. Governor DEPARTMENT OF HEALTH PO BOX 367 TRENTON, N.J MARY E. O'DOWD, M.P.H. Commissioner December 4, 2013 Deborah Martin, RN, BSN Administrator Select Surgical Center At Kennedy 405 Hurffville Cross Keys Road Sewell, NJ Dear Ms. Martin: Thank you for the courtesy and cooperation extended during the Federal revisit survey of your facility on November 21, 2013 by a surveyor from the New Jersey Department of Health. Enclosed is the CMS-2567B form which indicates that the Federal deficiencies, identified during the survey of September 12, 2013 were corrected. Should you have questions, please do not hesitate to contact Edward Harbet, RN, BSN, BA, Supervising Health Care Evaluator, at (609) Sincerely, Encl. Crescenza Zizza, RN Health Care Services Evaluator Assessment and Survey

21 Department of Health and Human Services Centers for Medicare & Medicaid Services Form Approved OMB NO Post-Certification Revisit Report Public reporting for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing the burden, to CMS, Office of Financial Management, P.O. Box 26684, Baltimore, MD 21207; and to the Office of Management and Budget, Paperwork Reduction Project ( ), Washington, D.C (Y1) Provider / Supplier / CLIA / Identification Number 31C (Y2) Multiple Construction A. Building B. Wing (Y3) Date of Revisit 11/21/2013 Name of Facility SELECT SURGICAL CENTER AT KENNEDY Street Address, City, State, Zip Code 405 HURFFVILLE CROSS KEYS ROAD SEWELL, NJ This report is completed by a qualified State surveyor for the Medicare, Medicaid and/ or Clinical Laboratory Improvement Amendments program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on the survey report form). (Y4) Item (Y5) Date (Y4) Item (Y5) Date (Y4) Item (Y5) Date Correction Correction Correction ID Prefix Q0040 Completed 11/21/2013 ID Prefix Q0141 Completed 11/21/2013 ID Prefix Q0162 Completed 11/21/2013 Reg. # LSC Reg. # (a) 0141 LSC Reg. # (b) 0162 LSC Correction Correction Correction ID Prefix Q0180 Completed 11/21/2013 ID Prefix Q0181 Completed 11/21/2013 ID Prefix Q0202 Completed 11/21/2013 Reg. # LSC Reg. # (a) 0181 LSC Reg. # (b) 0202 LSC Correction Correction Correction ID Prefix Q0241 Completed 11/21/2013 ID Prefix Q0242 Completed 11/21/2013 ID Prefix Q0262 Completed 11/21/2013 Reg. # (a) 0241 LSC Reg. # (b) 0242 LSC Reg. # (a)(2) 0262 LSC Correction Correction Correction ID Prefix Q0267 Completed 11/21/2013 ID Prefix Completed ID Prefix Completed Reg. # (c)(3) 0267 LSC Reg. # LSC ZZZZ Reg. # LSC ZZZZ Correction Correction Correction ID Prefix Completed ID Prefix Completed ID Prefix Completed Reg. # LSC ZZZZ Reg. # LSC ZZZZ Reg. # LSC ZZZZ Reviewed By Reviewed By Date: Signature of Surveyor: Date: State Agency Reviewed By Reviewed By Date: Signature of Surveyor: Date: CMS RO Followup to Survey Completed on: 9/12/2013 Check for any Uncorrected Deficiencies. Was a Summary of Uncorrected Deficiencies (CMS-2567) Sent to the Facility? Form CMS B (9-92) Page 1 of 1 Event ID: 5KGD12 YES NO

22 PRINTED: 01/15/2014 Statement of Deficiencies Citation Summary Sheet For: SELECT SURGICAL CENTER AT KENNEDY ( 31C / NJ24339 ) Survey Event: 5KGD21, Exit Date 09/09/2013 Citations Cited This Visit Regulation Type Regulation ID Regulation Version Building Number Tag Number Tag Title Scope/ Severity Federal K A INITIAL COMMENTS

23 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/15/2014 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING A1 (X3) DATE SURVEY COMPLETED 31C B. WING 09/09/2013 NAME OF PROVIDER OR SUPPLIER SELECT SURGICAL CENTER AT KENNEDY STREET ADDRESS, CITY, STATE, ZIP CODE 405 HURFFVILLE CROSS KEYS ROAD SEWELL, NJ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE K 000 INITIAL COMMENTS K 000 The facility was in substantial compliance with the Life Safety Code for this survey only. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5KGD21 Facility ID: NJ24339 If continuation sheet Page 1 of 1

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47