Helpful Tips: Office Surgery Inspections

In Florida, all applicants for office surgery registration must undergo a pre-registration inspection by the Department of Health (DOH), regardless of whether the office is nationally accredited.  Once you are registered, you will not undergo any more Department inspections unless a complaint is filed against the office surgery registration or a physician practicing in the office.

Applicants must pass the pre-registration inspection in order to be registered by the Florida Board of Medicine. Many offices fail their pre-registration inspection. Some offices are just not prepared. If that happens, the office is required to submit a Corrective Action Plan that explains how the deficiencies found during the inspection have been corrected.  Often, this leads to a second inspection to confirm the deficiencies have been corrected.  Failure to pass the second inspection may result in being denied an office surgery registration. 

What inspectors typically look for (and what raises red flags)

Inspectors are required to ensure each office surgery facility meets the standards provided in law and rule.  They review surgical logs, medical records, and other documents such as staff credentialing, the medical crash cart, and equipment to ensure the office complies with the applicable laws and rules.

The biggest reasons facilities fail inspections are a non-compliant crash cart or failing to update the Board of Medicine with changes in the facility. The standards for MDs and DOs are included in the following Florida Administrative Code. 

• Law for MDs: s. 458.328, Florida Statutes  (Rule 64B8-9.009, Florida Administrative Code)
• Law for DOs: s. 459.0138, Florida Statutes (Rule 64B15-14.007, Florida Administrative Code)  

Documentation and Protocols OSRs Must Have in Place

1. Office policy and procedures that address Quality Assessments and Improvements
2. Risk Management policy and procedures, documentation of quarterly risk management meetings where adverse incidents are reviewed and discussed. 
3. Copies of their original registration application and all updates sent to the Board of Medicine.
4. Surgical logs
5. Staff credentialing records
6. Current physician hospital privileges or a transfer agreement.

Common Mistakes that Lead to Fines or License Suspension

• Failing an inspection. Failing an inspection means the office surgery facility did not meet the standards outlined in laws and rules. The facility is notified the day of the inspection about the deficiencies. The facility has 30 days to submit a Corrective Action Plan or CAP to the Department of Health.  The CAP must address all deficiencies and how the deficiencies were corrected and should be supported by documentation (when that is possible).  Sometimes a reinspection is required. Failing to submit the CAP and/or failing to address all deficiencies found will result in a complaint against the facility and the Designated Physician and the possibility of the suspension of the facility.
• Refusal to allow an inspection. This will result in an immediate suspension of the office’s registration.

The attorneys at Howell, Buchan & Strong can help you through the inspection process for a successful outcome on the first inspection. To schedule a free consultation with the Firm, contact Howell, Buchan & Strong, Attorneys at Law at 850-877-7776 or email lawyerhelpnow@jsh-pa.com. We assist health care professionals throughout Florida and those outside the state with queries regarding licensing and regulations under Florida law.