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Based on observation, interview, and record review, the facility failed to be primarily engaged in providing, by or under the supervision of physicians, to inpatients diagnostic services and therapeutic services for medical treatment and care of the injured, disabled or sick persons.

Findings:

On May 6, 2019, an entrance conference was conducted with the Director of Patient care Services and the facility Administrator.

The requested facility census indicated there was no inpatients.

The survey team was unable to conduct the recertification survey.

Review of the facility's admission data indicated there were no scheduled inpatient admissions until May 10, 2019.

Further documents provided by the facility and reviewed indicated the following information:

Facility is Physician owned
Licensed for 10 surgical beds
No ICU, No ED

A return visit to the facility on May 7, 2019, indicated facility census was two outpatient surgeries scheduled- no inpatients.

Requested information from facility indicated:

The volume of outpatient surgical procedures compared to inpatient surgical procedures (facility provided numbers)- in the time frame 4/1/18-3/31/19) was 1213 out patients, 162 inpatients).

Surgical procedures are mostly done on an outpatient basis (per facility).

· Review of 3 months of the surgery schedule (2/1/19-4/30/19) indicated- 352 surgical procedures were scheduled Monday through Friday with one outpatient procedure schedule on a Saturday.
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· Facility provided information indicated the average daily census was 1.27 patients, the average length of stay was 2.85 days, the weekend average daily census 1.865 days.
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· Based on the total inpatient admissions for a 365-day period was 162 averaging a length of stay of 2.85 days . (per facility based on 365-day period 4/1/18-3/31/19).
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· The total number of weekends for a 365 day period was 52 with 97 inpatient days resulting in a weekend average daily census of 1.865 days. (per facility based on 365-day period 4/1/18-3/31/19).
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· Facility web site indicates facility is "A unique surgical hospital", "an acute care hospital that specializes in surgery, pain management and other procedures."

The facility failed to be primarily engaged by failing to have at least two inpatients at the time of an attempted recertification survey.

The cumulative impact of these statistics and information gathered result in the failure of the facility to be primarily engaged in providing inpatient services.