There are  6 surveys for this facility. Please select a date to view the survey results.

1. As noted per the survey on March 18,2024: Nazareth Endoscopy Center was deficient in 555.22(c) (1-5) Licensure Surgical-Services- Preoperative Care.
2. The Nazareth Endoscopy Center follows Nursing Policy and Procedure, Policy 101.1 which states the following.
A. The pre-operative procedure instructions are to be approved by the Medical Staff at EPGI/office setting.
B. The approved pre-operative procedure instructions are given to the patient when the patient visits the office and schedules a procedure at the Center, e.g. colonoscopy procedure instructions.
C. A copy of the pre-operative procedure instructions is sent to the Center along with additional patient information (history and physical, etc.).
D. A copy of the pre-operative procedure instructions is placed on the Center's chart by the person/s assigned to chart preparation.
E. The pre-operative procedure instructions are to be a permanent part of the patient's medical record. It is not to be discarded.
F. If there is not a copy on the patient's chart the receptionist or an assigned staff member is to notify the office/EPGI and obtain a copy of the patient's pre-operative procedure instructions and add it to the Center's chart.
G. The copy of the pre-operative procedure instructions can be used as a reference for the nursing staff if the patients should call with questions concerning their pre-operative procedure instructions or when the nurses make the pre-assessment/pre-procedure phone call to the patient.
H. The pre-operative procedure written instructions are required to include the following information:
- Applicable restrictions in regard to food and drink prior to surgery/procedure.
- Special preparations to be made by the patient.
- An understanding that the patient may require admission to the hospital in the event of medical need.
- Upon discharge of a patient who has received MAC sedation, a responsible person shall be available to escort the patient home.
3. Nazareth Endoscopy is responsible for ensuring that the patient received the pre-procedure instructions and documentation of such is on the patient records. The Administrator had a clinical staff meeting with the nursing following the DOH report on 4/9/24. It was reinforced that during the pre-assessment phone call the patient would be asked if received instructions and a review would be completed. The nurse would ensure that a copy was sent from the office to the center, if not the nurse will reach out to the office and obtain a copy to be placed in the patient medical record.
4. The Patient Safety Officer for Nazareth Endoscopy Center has been assigned to randomly monitor 20 charts per month starting 4/22/2024 to ensure this is being completed per 555.22. The PSO will report this to the DON, Administrator and QA committee quarterly.

1. As noted per the survey on March 18,2024: Nazareth Endoscopy Center was deficient with identifying problems through a monitoring and evaluation process and then taking corrective actions to improve the quality of patient care (573B).
2. As stated in our quality management plan on a monthly basis data is monitored and compiled, then reported quarterly to the Quality Management Committee, for the following indicators: patient satisfaction, types of procedures performed, infection control, serious complications and deaths, adverse situations in the pre-post procedure area, hospital admissions and ER visits, patient event reporting, medical record chart review, patient post-procedure phone call, and ASA-3 patients.
3. It has been acknowledged that Nazareth Endoscopy Center needs to perform a quality assessment plan on a quarterly basis. As our QA study for 2024, we have chosen to do timeouts in the procedure room, before the induction of anesthesia, by all staff in the procedure room.
4. This data will be collected intermittently and randomly, by direct observation, by the DON and reported to the center administrator.
5. The data will be observed, recorded and compiled during the 2nd quarter of 2024, then revisited until the goal of 95% is achieved.
6. The data will be reviewed monthly with the QA committee and reported quarterly to the governing board.