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Mar. 13, 2008
Copyright © Las Vegas Review-Journal

Agency late on medical reviews

22 of 50 clinics not checked on time

By SEAN WHALEY and ANNETTE WELLS
REVIEW-JOURNAL

Hepatitis C Investigation

CARSON CITY -- The state agency responsible for inspecting 50 surgery centers in Nevada did not perform those reviews as often as required, including at two Southern Nevada facilities where problems with reusing syringes and other unsafe practices have recently been uncovered.

Of the 50 ambulatory surgery centers now being inspected by the state Bureau of Licensure and Certification for unsafe practices, 22 have not had a recertification survey within the six-year time frame required. Some of them have not been inspected for 12 years.

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Information posted on the state Health Division's Web site shows that the Endoscopy Center of Southern Nevada, which has been linked to an outbreak of hepatitis C in six patients, last saw a routine inspection in December 2001, just over six years ago.

The Gastrointestinal Diagnostic Clinic on South Maryland Parkway, where inspectors last month discovered the reuse of syringes but no infectious outbreak, had last been inspected in September 1996.

Federal requirements set by the U.S. Department of Medicare and Medicaid Services recommend that inspections occur every six years.

The state lists a three-year inspection rule for ambulatory surgical centers, but the federal requirements trump the state's rules if there's a conflict, said Steve George, spokesman for the Department of Health and Human Services.

Regardless, there are no penalties for not meeting the guidelines.

Jack Cheevers, a spokesman for the federal agency, would not comment on the apparent inspection lapses.

George acknowledged inspections have not been conducted as often as recommended.

"Yes, there are some big holes on there," he said of the inspection dates posted on the Web site.

The Web page listing the centers and inspection dates was removed late Wednesday from the site. It is expected to be back online today.

Part of the reason for the lapses is a shortage of staff due to vacancies, and the fact that other types of facilities overseen by the bureau are required to be inspected more often, George said.

Intermediate care facilities for the mentally retarded and skilled nursing centers, for example, must be inspected every year by the same pool of surveyors who also look at the surgery centers, he said.

There are federal penalties for not completing those surveys in a timely fashion.

When the Endoscopy Center's Shadow Lane clinic was given a full Medicare inspection in 2001, deficiencies focused on construction and safety aspects of the building.

Exit doors were not quite wide enough, ceiling tiles and flooring did not comply with regulations, and some rooms were not equipped with emergency lighting.

The facility failed to ensure it was conducting fire drills, according to the survey.

In 2004, the licensure bureau conducted an inspection at the center based on a complaint from someone regarding the manner in which sedated patients were being released to drivers.

The inspection report does not reveal who made the complaint.

On Jan. 30, 2004, state investigators reviewed the medical records of six patients and interviewed staff. Investigators determined the facility did not ensure that patients were discharged in the company of a "responsible adult."

A plan of correction was issued by the clinic, and accepted by the state.

Dr. Lawrence Sands, chief health officer for the Southern Nevada Health District, said inspections only offer one level of assurance.

Ambulatory surgery centers in Nevada probably need to be accredited at the same level as hospitals, he said.

To operate in Nevada, hospitals must be accredited by The Joint Commission, an independent nonprofit organization and the nation's largest and oldest standard-setting health care accrediting body.

Ambulatory surgery centers, under Medicare, also must be accredited but not at the same level.

Sands said approved accrediting agencies offer another layer of oversight and allow more frequent inspections.

"Inspections are just one piece of the puzzle,'' Sands said. "What's the correct frequency of inspections? Certainly we've talked about this with our legislators."

Assemblywoman Sheila Leslie, D-Reno, who held a hearing on the health alert last week as chairwoman of the Legislative Committee on Health Care, said the news "just keeps getting worse. I've run out of adjectives to describe this situation.

"We need to vastly improve our ability to inspect these facilities more frequently and more comprehensively," she said.

The Health Committee will be focusing its attention on improved state oversight, including better and more frequent inspections, an aggressive recruitment and retention plan for health inspectors and creating a culture of safety in regards to medical care, Leslie said.

"We know inspections can save lives, and we need to do whatever it takes to ensure the public's health is not jeopardized," she said.

The information showing the lapses was posted just days after concerns were raised by Leslie about a decision by Gov. Jim Gibbons to oppose hiring 10 new surveyors for the licensure bureau during the 2007 legislative session.

Gibbons rejected the hirings because of his pledge not to raise taxes or fees.

Ultimately, he and the Legislature agreed to fund six new positions. Funding for the positions comes from federal funds and fees charged to the facilities, not the general fund.

Gibbons on Monday rejected the criticism, saying the number of positions approved in 2007 was not an issue in the ability of the bureau to do its inspections. Rather, it is the ability of the agency to fill vacancies, he said.

Of 50 approved positions, the agency has 14 vacancies due to the difficulties in recruiting and retaining surveyors.

Gibbons also said more frequent inspections would not help.

"You do not have enough money, you do not have enough people, to look at every day, every procedure, conducted on every patient," he said. "We could inspect it annually, and then, pretty soon, have we done overkill?

"I think the important thing is to assure the public we have the right policies, the right procedures, in place," Gibbons said.

As of Wednesday, 25 of the 50 centers have been inspected in response to the discovery of hepatitis C cases, 16 in Northern Nevada and nine in Southern Nevada. Infection control issues have been found in seven of the facilities.

Inspectors from the Centers for Disease Control and Prevention on Wednesday began assisting the state with the survey.

Mike Willden, director of the Department of Health and Human Services, has said the inspections of the 50 centers are focusing on basic health care safety issues, the types of things that health care officials know should not be occurring.

He called the basic practices to prevent the spread of infection as "health care 101 stuff" that inspectors haven't necessarily looked for in the past.

"When they do a survey there is an assumption that you may be not reusing a syringe, an assumption of sterilization," Willden said. "They certainly are going to be looking more closely from here forward."

Contact reporter Sean Whaley at swhaley@reviewjournal.com or (775) 687-3900. Contact reporter Annette Wells at awells@reviewjournal.com or (702) 383-0283.

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Please enter your name Name: Please enter your email Email: Please enter a comment COMMENTS : (word count limit is 300) You have reached the maximum number of words allowed Current Word Count: No name wrote on March 13, 2008 08:08 PM: I work in the medical field and have done so for the past 13 years. I in no way agree with the practices that have been going on and I am ashamed to say that I know/worked with these named doctors. The nurses at these facilities are just as guilty in my mind. Our licenses are given so we can help and protect, NOT harm. They knew proper technique and for whatever reason, management, etc. you NEVER disregard the value of a human life. EVER!!!! I know what to look for as a patient but to those patients who are trusting their lives with doctors and end up with this result is pathetic. There is no reason why people in the medical field can not be recruited on a per diem basis to do "random" inspections, as the "scheduled" inspections will always find medical personnel at their best, but "random" inspections eliminates time for the offices/outpatient surgical centers to actually comply with regulations. It is a very sad day when the all mighty dollar trumps human lives, and I feel for all those patients now faced with an unnecessary reality of these illnesses, which are all serious and all potentially life-threatening. I hope justice is served and these doctors pay the price, but unfortunately, money or them losing their licenses will never let them deal with what all these possible patients will feel everyday of their lives. Stay strong and my thoughts and prayers are will you. Any Scapegoat Will Do wrote on March 13, 2008 06:17 PM: The lazy government bureaucrats can't manage to do 2-day inspections at 50 surgery centers in the State every three years?? State bureaucrats have spent the last couple of weeks whipping up hysteria while carelessly failing to acknowledge that multiple dose vials of medication are used in virtually every hospital and surgery center in the country. When done with proper aseptic technique, the use of syringes or multidose vials poses NO risk to patients WHEN THE SYRINGES ARE NOT USED ON MORE THAN ONE PATIENT. Some people might say that, "For the self-serving government bureaucrats, any scapegoat will do. They've spent the last ten years sitting in their cubicles and ordering pizza. Unfortunately, their laziness and disregard for the public health is becoming public knowledge; they have to find a scapegoat, AND PRONTO." Someone might say, "Suddenly, government inspectors without significant relevant clinical experience have become experts in the administration of anesthesia. Conveniently, they simply ignore the multiple OTHER probable causes of hepatitis at Shadow Lane." "Conveniently, the only available version of the facts is the one they publicize in their self-serving reports. They seem more interested in absolving their own sins than in protecting the public health. They've got their scapegoat, by Gawd, and they're gonna make it stick!" Any Scapegoat Will Do wrote on March 13, 2008 06:06 PM: The health department has spent the last couple of weeks whipping up hysteria while carelessly failing to acknowledge that multiple dose vials of medication are used in virtually every hospital and surgery center in the country. When done with proper aseptic technique, the use of syringes or multidose vials poses NO risk to patients. Some people might say that, "For the department of health, any scapegoat will do. They've spent the last ten years sitting in their cubicles and ordering pizza. Five inspectors can't manage to do a 2-3 day inspection at the 50 surgery centers in the State IN SIX YEARS??? Unfortunately for the government bureaucrats, their laziness and disregard for the public health is becoming public knowledge; they have to find a scapegoat, AND PRONTO." Someone might say, "Suddenly, government inspectors have become experts in the administration of anesthesia. Conveniently, they simply ignore the 30 or so OTHER possible causes of hepatitis at Shadow Lane. They simply ignore that there is no scientific proof that ANY patient in Nevada has been infected due to poor sterile technique on the part of any nurse anesthetist or anesthesiologist." "Conveniently, the only available version of the facts is the one they publicize in their self-serving reports. They seem more interested in absolving their own sins than in protecting the public health. They've got their scapegoat, by Gawd, and they're gonna make it stick!" Char wrote on March 13, 2008 05:39 PM: What are the insurance companies for these medical facilities saying? If they are paying for malpractice insurance, wouldn't you think the insurance company would want to make sure everything is being done properly before they have to settle multi-million dollar lawsuits. I hope they all suffer from the maximum penalty available. Bruce wrote on March 13, 2008 02:15 PM: The only way you can be relatively assured is to hire a personal inspector and have him or her present during your procedure. This person can witness the injection procedures, inspect the propofol `single use' vial, ensure the syringe is remove from it's sealed package, etc... It is a sad state of affairs that it has come down to this. Randy wrote on March 13, 2008 12:23 PM: Truth is, even had the inspectors been doing their job, unless someone confesses, or unless the inspector catches them in the act, the inspector cannot know the standard of care was breached. Julie Gerberding, Director of the CDC, stated as much, and noted that tip lines and other procedures would likely be more effective than increased inspections. I DO NOT hold Gibbons in high esteem, but the bad guys here are Dr. Desai and those who abetted him. br wrote on March 13, 2008 08:18 AM: "I think the important thing is to assure the public we have the right policies, the right procedures, in place," Gibbons says. Hey Gov, that's paperwork. If the state employees don't implement the plans for which they are hired, fire them without severance pay or pensions. First to go are any political hacks you have appointed. Hire the whistle-blowers to run the show. Get on top of all these messes or they will be on top of you, Gov. MAKE A POLICE REPORT! wrote on March 13, 2008 07:58 AM: THIS IS A CRIME! YOU MUST MAKE A POLICE REPORT! YOU'LL NEED IT LATER FOR THE CRIMINAL PRECEDINGS. (NOTICE THE FBI AND METRO ARE ACTING?) DO NO WAIT! IF YOU DO YOU COULD GET SCREWED LATER. THIS IS AT LEAST "NEGLIGENCE OF A PATIENT" IF NOT "ATTEMPTED MURDER" WHICH ARE CLEARLY DEFINED IN THE NEVADA REVISED STATUTES AS CRIMES. IF YOU DO NOT MAKE A POLICE REPORT THAN IT NEVER HAPPENED! LUIS TUPAC, DIPAK DESAI AND THE OTHER ASSASSINS ARE HOPING YOU DON'T MAKE A REPORT. DON'T SELL YOURSELF SHORT, AND DON'T HELP THESE ANIMALS. MAKE A POLICE REPORT, DEMAND IT. Daniel wrote on March 13, 2008 06:49 AM: There is 240 work days in a year (5 day week) and they can not inspect these facilities. One day you go here the next day you go here. These state,city,county employees have to much time on their hands and too much money. But the union says i can only work 3 hours a day for a 8 hour day pay. This state needs to be revamped. phooey wrote on March 13, 2008 06:37 AM: Of the 50 ambulatory surgery centers now being inspected by the state Bureau of Licensure and Certification for unsafe practices, 22 have not had a recertification survey within the six-year time frame required. Some of them have not been inspected for 12 years. So who is getting paid and not doing there jobs? This is not an oversight this is blantant negligence.