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Health Standards Section PRINTED: 02/17/2017 FORM APPROVED STATEMENT OF DEFICIENCIES AND PUM OF CORRECTION (i) PROMDERSUFPLIERCUA roewncanonnumser — | A auicowG, 800004601 (3a) MULTIPLE CONSTRUCTION [oay DATE SURVEY compuereD 2101/2017 NAIIE OF PROVIDER OR SUPPLIER BOSSIER CITY MEDICAL SUITE DOSSIER STREET ADDRESS. GITY, STATE, 2 CODE 1505 DOCTORS ORIVE CITY, LA 71811 ‘SUNwany STATEWENT OF DEFIGIENOIES (ACH DEFICIENCY MUST BE PRECEDED ay FULL REGULATORY OR LSC IDENTIFYING INFORIATION) pan Prerik TAG 9, PREFUC TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (OROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ry tare $009 nial Comments $000 Re-licensing Survey " Abbreviations aoM coc csr | 0ON Administrator Geniers for Disease Control Gentral Sterie Room Director of Nursing Governing Boxy Infection Control Induced termination of pregnaney/ (eporty | LOW Louisiana Department of Health Hiss Heslth Standards Section LEERS Louisiana Electronic Event Registration System LPN Licensed Practical Nurse Med Dit Medical Dicector Pr Performance Improvement aa Qualty Assurance al ‘Quality Assurance Performance Improvement RN Registered Nurse ST Surgical Technologist $063) 4407 E Survey Activities E. Statement of Deficiencies. Folowing any survey, the depertment surveyors shall complete | the staiomont of deficiencies documenting relevant findings including the deficiency, the applicable governing rule, and the evidence supporting winy the rule was not met including but not limited t, observations, interviews, and recard review ofinformation ebtained during the survay. The outpatient abortion facility shall receive @ copy of the statement of deficiencies. | (oer Display. The folowing statements of | RE CFivp, MAR 17 2097 MEALTH STauogegs S043, i The Clinic Director monitored by the Medical Director will ensure that the most recent statement of deficiencies from the last survey (licensing, follow up, and/or complaints) resulting in a statement of deficiencies will be displayed in a conspicuous place on the licensed premises The Clinic Director will moni ‘monthly basis 10 ensure compliance. March 15, 2017 SFT Heath Standards Section LABORATORY pap moma UER REPRESENTATIVES SIGNATURE eda simrerorm ame Vite. Pres 3-)b-17 PRINTED: 02/17/2017 FORM APPROVED Health Standards Section ‘STATEMENT OF DEFIGIENGIES | Ok) PROVIDERISUPPLIERIGLIA | (K2) MULTIPLE CONSTRUGTION ka) DATE SURVEY KD PLAN OF CORRECTION IDENTIFICATION NUMBER Sema ‘couPLeteD 500004601 wn 02/01/2017, NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 41505 DOCTORS DRIVE BOSSIER CITY MEDICAL SUITE SES ery Le Mitt 0 “SUMMARY STATEMENT OF DEFICIENCIES PROVIDERS PLAN OF CORREGTION a PRerk (GACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE couptere TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG ‘CROSS REFERENCED TO THE APPROPRIATE Dae DEFICIENCY) $043 Continued From page 1 $043, deficiencies issued by the department to the ouipatient abortion facility must be posted in a conspicuous place on the licensed premises ‘a, the most recent annual icensing survey statement of deficiencies; and ®. any follow-up andor complaint survey statement of deficiencies issued after the ‘most recent annual licensing survey. 2. Public Disclosure, Any statement of deficiencies issued by the department to an outpatient abortion facilily shall be available for disclosure to the public within 30 calendar days after the outpatient abortion facility submits an acceptable pian of correction to the deficiencies orwithin 90 days of receipt of the statement of deficiencies, whichever occurs first. ‘This Rule is not met as evidenced by: Based on observation and interview, the facility failed to display the statement of deficiencies from the most recent surveys (licensing, follow up, and/or complaint) in a conspicuous place on. the licensed premises as evidenced by no displayed survey results from the last survey. Findings: Observations of the facility on 01/31/17 at 10:10 am., escorted by S1ADM revealed no evidence to indicate the facilly had posted a copy of the statement of deficiencies from the most recent surveys (licensing, follow up, and/or compiaint) in ‘8 conspicuous location on the licensed premises. In an interview on 01/31/17 at 10:10 a.m., S1ADM confirmed that the facility had no posted copy of the statement of deficiencies from the most recent surveys (licensing, follow up, and/or complaint) in @ conspicuous location on the FFIFsalih Standards Section ‘STATE FORM on Pout oortnuaton seat 20f 16 Health Standards Section PRINTED: 02/17/2017 FORM APPROVED ‘STATEMENT OF DEFICIENCIES ND PLAN OF CORRECTION TE) PROMIOERISUPPLIERIOLIA IDENTIFICATION nUMBER. B09004601 (HH) MULTIPLE CONSTRUCTION BULOING [oa DATE SURVEY COMPLETED a 02/01/2047 NAMIE OF PROVIDER OR SUPPLIER. BOSSIER CITY MEDICAL SUITE ‘STREET ADDRESS, CITY, STATE, ZIP CODE 41505 DOCTORS DRIVE BOSSIER CITY, LA 71111 12. ensuring services that are provided through @ contract with an outside source are provided in @ safe and effective manner; 43, ensuring that the outpatient abortion facility develops, implements, monitors, enforces, and reviews at a minimum, quarterly, a quality ‘assurance and performance improvement (QAP!) program; 14. developing, implementing, monitoring, enforcing, and reviewing annually written policies and procedures relating to communication with the administrator, medical director, and medical staff to address problems, including, but not limited to, patient care, cost containment, and improved practices: 46. ensuring that disaster plans for both internal and external occurrences are developed, implemented, monitored, enforced, and annually reviewed and that annual emergency preparedness drilis are held in accordance with the disaster plan, The outpatient abortion facility shall maintain documentation on the licensed premises indicating the date, type of dril participants, and materials; This Rule is not met as evidenced by: Based on record review and interview, the fecilty's Governing Body failed to ensure that all contracted services that were provided were evaluated through the QAPI program to ensure they were provided in a safe and effective way. Finding m0 SUUIARY STATEMENT OF DEFICIENCIES ry 'PROVIGER'S PLAN OF CORRECTION 5), Shere (GACH DEFICIENCY MUST BE PRECEDED BY FULL paerix (EACH CORRECTIVE ACTION SHOULO BE couplers he REGULATORY OR LSC IDENTIFYING INFORIIATION) TAG (GROSS REFERENCED TO THE APPROPRIATE bare DEFICIENCY) $043. Continued From page 2 $043 licensed premises. S118 4421-6 - 12 - 18 Governing Body sus (sus ‘The Governing Body will amend the Quality “Assurance and Performance Improvernent Program (QAPI) policy to include quarterly review of contracted services to ensure they are provided in a safe and effective manner. April 1, 2017 DAR eaih Sandards Section STATE FORM poet eontnuatin shest 316