Office Surgery Facility Inspections: What does it mean? Part 4

Requirements for Level II Office Surgery

Level II office surgery facilities in Florida are required to register with the Florida Department of Health (Department), Board of Medicine.  New facilities, regardless of national accreditation, will undergo a pre-registration inspection and all non-accredited facilities will undergo annual inspections by the Department.

Department Inspectors are required to look for your compliance with office surgery laws and rules.  For Level II facilities, the Inspectors are looking for, but not limited to, the following:

• The surgeon(s) must have a Transfer Agreement or hospital staff privileges with a licensed hospital within a certain distance from your facility.
• The surgeon(s) must hold staff privileges, be board certified (in the specialty area of the procedures being performed in the facility), or be board eligible. Physicians without those credentials will have to submit comparable training, experience and background to the Board of Medicine to obtain approval to be registered in the facility.
• At least one (1) assistant must be certified with Basic Life Support Certification from an approved
• The surgeon(s) must be certified with Advanced Cardiac Life Support Certification from an approved
• The facility must have the required equipment and supplies as set forth in Board Rule.
• The surgeon(s) must be assisted by a qualified anesthesia provider.
• If additional assistance is required due to the particular surgery or patient circumstances, a physician, osteopathic physician, registered nurse, licensed practical nurse, or operating technician may be used, and this should be documented in the patient and operating room records and must be Advanced Cardiac Life Support certified by an approved The registered nurse must be able to document prior post-anesthesia care.
• Crash cart medications must be maintained in accordance with Board rule and manufacturer’s guidelines. Certain documentation must be maintained if the facility is unable to obtain medication required on the crash cart.

For many facilities, ensuring the medications on the crash cart are maintained appropriately is the most difficult part of the inspection.  It is important to be prepared for Department Inspectors.  Be sure to have all your records ready for the inspector to review on the day of the inspection.

If you fail an inspection, you must submit a Corrective Action Plan (CAP) to the Department within the required number of days.  The Department will then determine if the office is in compliance or, if not, file a complaint against the facility and the designated physician for failing the inspection.

Don’t let this happen.  Let the experienced health law attorneys at Howell, Buchan & Strong help. We can help you prepare for the inspection. If you have already failed the inspection and you are wondering what to do, we can assist you in preparing the CAP.  If you have already received a complaint against the office surgery facility, we can help defend your registration. Contact us today for a free consultation.