QA Investigation Results

Pennsylvania Department of Health
ARMSTRONG PRIMARY CARE CENTER - WEST HILLS
Health Inspection Results
ARMSTRONG PRIMARY CARE CENTER - WEST HILLS
Health Inspection Results For:

This is the only survey for this facility

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:

Based on the findings of an onsite unannounced initial Medicare certification survey completed on 3/2/18, Armstrong Primary Care Center - West Hills was found not to be in compliance with the following requirement(s) of 42 CFR, Part 491.12, Subpart A, Conditions for Certification: Rural Health Clinics - Emergency Preparedness.


Plan of Correction:




491.12(a)(3) STANDARD
EP Program Patient Population

Name - Component - 00
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:]

(3) Address patient/client population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.**

*Note: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC, FQHC, or ESRD facilities.]

Observations:


Based on review of clinic emergency preparedness plan (EPP) and staff (EMP) interview, the clinic failed to ensure the EPP addressed unique vulnerabilities of identified patient population, the types of services the clinic would be able to provide in an emergency, and the identities of staff that would assume specific roles and backup roles in another's absence.

Findings included:

Review of EPP on 3/1/18 at approximately 12 p.m. revealed "The Emergency Plan was updated and approved on Jan 30, 2018...PURPOSE: TO DESCRIBE ACTIONS TO BE TAKEN IN AN EMERGENCY OR EXERCISE TO MAKE SURE THAT THE CLIENTS, STAFF AND VISITORS OF THIS FACILITY ARE KEPT SAFE FROM HARM." EPP detailed response/actions to take in the event of fire, bomb scare, active shooter, loss of water/sewage, power outage, hazardous material spill/exposure, and severe weather including tornado, hurricane, winter storm. EPP did not address the types of services the clinic would be able to provide in an emergency.

EPP continued "THIS FACILITY PROVIDES OUTPATIENT MEDICAL SERVICES TO CLIENTS THAT ARE ADULTS, OLDER ADULTS, OVER 85 YEARS OLD." Plan did not address unique vulnerabilities of this patient population.

EPP continued "DELEGATION OF AUTHORITY THAT WILL BE FOLLOWED IN AN EMERGENCY IS DOCUMENTED ON THE ORGANIZATION CHART...THIS CHART IDENTIFIES WHO IS AUTHORIZED TO ACTIVATE THE PLAN AND MAKE DECISIONS OR ACT ON BEHALF OF THE FACILITY IF LEADERSHIP IS UNAVAILABLE DURING AN EMERGENCY. WHEN AN EMERGENCY HAPPENS, THE PERSON IN CHARGE, AS LISTED IN THE ORGANIZATIONAL CHART WILL BE INFORMED IMMEDIATELY. IN THE EVENT THAT THE INDICATED PERSON BY POSITION IS NOT PRESENT IN THE FACILITY OR AVAILABLE, THE NEXT PERSON IN THE DELEGATION OF AUTHORITY OR THE LEAD PERSON'S DESIGNEE WILL ASSUME THE IN CHARGE POSITION." No chart noted in EPP.

EPP continued "ORDERS OF SUCCESSION A STAGING AREA COORDINATOR IS ASSIGNED TO LIST ALL CLIENTS, VISITORS AND STAFF PRESENT IN THE FACILITY AND IDENTIFIED AT THE STAGING AREA. A PRINTED COPY OF ELECTRONIC SCHEDULE IN THE EVENT THAT POWER IS LOST OR EVACUATION IS REQUIRED. COPY OF SCHEDULE WILL BE KEPT WITH EMERGENCY BINDER AND BROUGHT TO SUITE 230 AREA WITH A RECEPTIONIST. INCIDENT COMMANDER WILL DETERMINE WHETHER TO LOCKDOWN THE FACILITY, SHELTER IN PLACE OR EVACUATE. IN THE EVENT...INCIDENT COMMANDER WILL DETERMINE RELOCATION AREA. INCIDENT COMMANDER IS ONLY PERSON TO ISSUE AN ALL CLEAR INDICATING FACILITY IS READY TO ASSUME NORMAL OPERATIONS." Plan did not identify staff that would assume specific roles and backup roles in another's absence. Surveyor unable to determine who incident command was (and his/her backup). Surveyor unable to determine who staging area coordinator was (and his/her backup). Surveyor unable to determine which receptionist would be responsible for taking emergency binder (with copy of schedules) in the event of an evacuation. (Clinic employed 2 receptionists at time of survey.)

Staff interview with EMP10 and EMP11 on 3/2/18 at approximately 1:12 p.m. confirmed findings.



Plan of Correction:

The facility Emergency Plan (the Plan) has been revised to include language that addresses:
- Unique vulnerabilities of the Patient Population (Section: A. III, page 4) as follows:
"The facility provides outpatient services to an adult patient population from age 18 and above. Unique vulnerabilities of this population include:
- Mobility limitations (wheelchair bound)
- Hearing Impairment
- Vision Impairment
- Mentation limitations"

- Types of services the clinic would be able to provide in an emergency (Section: B. IV, pages 8 and 9)
"Depending on the type of emergency, services may be:
- Continued
- Curtailed
- Restricted
In the event that an emergency results in the facility's inability to provide any services, clients will be notified by phone of this situation and offered alternative medical resources.

(Please reference the Emergency Plans in Section C of this plan for services that will be provided during different types of emergencies)."

- Insertion of Organizational Chart designating lines of authority (Section A. V, page 6)
An organizational chart identifying the command structure for delegation of authority has been added to the plan. This structure includes the Incident Commander as leader for the direction of all assignments and management of the event. There are five emergency operations positions reporting to the Incident Commander including: Communications, Client Liaison, Facility and Environmental Coordinator, Client Resource and Supply Coordinator and Medical Care and Triage Coordinator. These positions are appointed by the Incident Commander as needed at the time of the event. Each of these five positions has the authority to enlist additional staff resources to assist with the position responsibilities.

The Incident Commander position is assumed by the Office Manager. In the event of the Office Manager's absence, the following order of succession will be followed:
o Staff RN
o Senior Medical Assistant
o Receptionist

- Incident Command Responsibility Assignment and Backup Designation (Section A. V, page 6)
Same as provided above under the response to the insertion of the organizational chart.
- Staging Area Coordinator Assignment and Backup Designation (this Assignment was eliminated and duties included in other assignments)
- Staff Member responsible for taking Emergency Operations Plan with staff schedules in the event of an evacuation (this assignment is now included in specific job titles)
Revisions to the Plan were completed on March 12, 2018.
These job duty assignments and job descriptions will be included in Plan "Section C. Procedures". Each Emergency scenario will delineate the specific job duties assigned to each role in the " Incident Command Delegation of Authority flow diagram" (Section: A. V, page 6). The Plan will be kept in the reception area and will be accessible to all staff.
Staff categories assigned to these roles and responsibilities will be educated on duty requirements during the mandatory staff in-service conducted by the Safety Coordinator by March 31, 2018. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring will be accomplished through periodic drills (at least annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues.

Safety Coordinator is responsible for enactment of the plan.



491.12(a)(4) STANDARD
Local, State, Tribal Collaboration Process

Name - Component - 00
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:]

(4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.

* [For ESRD facilities only at 494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the dialysis facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.

Observations:


Based on review of clinic emergency preparedness plan (EPP) and staff (EMP) interview, the clinic failed to ensure the EPP included documentation of clinic efforts to contact, cooperate, and collaborate with emergency preparedness officials (local, tribal, regional, state, federal) in order to facilitate an integrated response during a disaster situation.

Findings included:

Review of EPP on 3/1/18 at approximately 12 p.m. revealed "The Emergency Plan was updated and approved on Jan 30, 2018...THIS EOP [emergency operations plan] CONTAINS A LIST OF ALL COUNTY, STATE AND LOCAL EMERGENCY MANAGEMENT PERSONS THAT SHOULD BE NOTIFIED." The list included local police, PA State Police, local fire department, and local EMS. No evidence of contacts with these entities regarding collaboration and cooperation for integrated response during a disaster. No contacts listed for federal, state, regional, local emergency management offices/personnel.

Staff interview with EMP10 and EMP11 on 3/2/18 at approximately 1:12 p.m. confirmed findings. EMP11 reported he communicated with local emergency management staff during development of the EPP and has regular contact with local emergency management staff. EMP11 confirmed no documented evidence of these communications.



Plan of Correction:

The facility Emergency Operations Plan was revised to include language that addresses collaborative and cooperative planning efforts (Section A. IV, page 5) as follows:
"The organization cooperates and collaborates with the Armstrong County Emergency Management Agency to maintain an integrated response during a disaster situation. The Safety Coordinator is a member of the Healthcare Coalition of Southwestern Pennsylvania that supports collaboration with all healthcare facilities in the region. This local and regional coalition provides for emergency resources needed during disaster situations including but not limited to:
- Staffing resources
- Medication
- Personal Protective Equipment
- Decontamination Supplies and Equipment
- Medical Supplies
In addition to Emergency resources the coalition provides emergency preparedness education and training to members and affiliates. Regional drills and exercises are conducted at least annually with all members participating.
State and Federal emergency preparedness coordination is facilitated by the local/regional emergency management agencies. As members of the coalition, the organization participates as required."

These revisions were completed on March 12, 2018.
- Monitoring is accomplished by reviewing documented facility participation in coalition meetings and local/regional drills and trainings at least annually. Compliance will be monitored by the Director of Risk and Quality Management.
Safety Coordinator is the person responsible for this plan



491.12(b)(1) STANDARD
Policies for Evac. and Primary/Alt. Comm.

Name - Component - 00
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:]

Safe evacuation from the [facility], which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.

*[For RNHCs at 403.748(b)(3) and ASCs at 416.54(b)(2):]
Safe evacuation from the [RNHCI or ASC] which includes the following:
(i) Consideration of care needs of evacuees.
(ii) Staff responsibilities.
(iii) Transportation.
(iv) Identification of evacuation location(s).
(v) Primary and alternate means of communication with external sources of assistance.

* [For CORFs at 485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at 485.727(b)(1), and ESRD Facilities at 494.62(b)(2):]
Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients.

* [For RHCs/FQHCs at 491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients.

Observations:


Based on review of clinic emergency preparedness plan (EPP) and staff (EMP) interview, the clinic failed to ensure the EPP addressed needs of patients for safe evacuation.

Findings included:

Review of EPP on 3/1/18 at approximately 12 p.m. revealed "The Emergency Plan was updated and approved on Jan 30, 2018...PURPOSE: TO DESCRIBE ACTIONS TO BE TAKEN IN AN EMERGENCY OR EXERCISE TO MAKE SURE THAT THE CLIENTS, STAFF AND VISITORS OF THIS FACILITY ARE KEPT SAFE FROM HARM." EPP included "EVACUATION PLAN" which detailed staff response/actions to take (who orders evacuation, meeting/staging area, who verifies everyone accounted for, notification to "PROPER AUTHORITIES.") Plan did not address needs of patients (care and treatment) to ensure safe evacuation.

Staff interview with EMP10 and EMP11 on 3/2/18 at approximately 1:12 p.m. confirmed findings.





Plan of Correction:

The facility Emergency Preparedness Plan was amended to include language that addresses individual patient care and treatment needs to ensure safe evacuation (Section: B, III (a-h), page 7 and 8) as follows:
a. There are a number of hazards that could cause an evacuation. The most common would be a fire in or near the facility, rising flood waters or an evacuation order issued by the police, fire department or other government authority.

b. Evacuation maps are posted in all patient rooms, offices and waiting areas.

c. All exits are identified by illuminated exit signs.

d. In the event that evacuation is deemed necessary, the incident commander will order the evacuation.

e. The Incident Commander directs the Communication Coordinator (position # 1 on the organization chart) to call 911 and the ACMH switchboard. ACMH switchboard will contact other appropriate personnel.

f. The Incident Commander will direct the "Client Liaison" position #2 on the organization chart to coordinate an assessment of the client and visitor population on site at the time of the emergency to determine any specific evacuation needs based on individual patient vulnerabilities. The Client Liaison will take possession of the daily patient schedule, employee roster and log any visitors on site. As needed the Client Liaison position will direct other staff members to assist with evacuation of any individuals who need additional assistance. Based on the plan vulnerability analysis, this may include patients with no or limited mobility, vision or hearing impaired or those with varying degrees of mentation limitation. The Medical Care and Triage coordinator (position # 5 on the organizational chart) will be engaged as needed to triage and provide medical care for any client, visitor or staff who has sustained injury during the emergency situation. Staff will be assigned to provide available equipment necessary for evacuation of those clients or visitors with limited mobility. Wheelchairs will be available for this purpose (clients with their own wheelchair will be evacuated using this equipment; there will also be one additional wheelchair available on site if needed). The Client Liaison will be responsible for assuring that all clients and visitors are directed to the assembly area designated by the office Incident Commander and/or the responding local Emergency Services Chief.

g. Post evacuation, the clients, visitors and staff will report to the assembly area located in suite 230 across the street from the clinic.

h. The Client Liaison position, utilizing the comprehensive patient, visitor and staff list, will verify that all identified individuals are accounted for either at the assembly area or by documenting their location.

Plan revisions were completed by March 13, 2018.
Staff categories assigned to these roles and responsibilities will be educated on duty requirements during the mandatory staff in-service conducted by the Safety Coordinator by March 31, 2018. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring will be accomplished through periodic drills (at least annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues.
Safety Coordinator is responsible for enactment of the plan.



491.12(b)(2) STANDARD
Policies/Procedures for Sheltering in Place

Name - Component - 00
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:]

(4) A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility].

*[For Inpatient Hospices at 418.113(b):] Policies and procedures.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following:
(i) A means to shelter in place for patients, hospice employees who remain in the hospice.

Observations:


Based on review of clinic emergency preparedness plan (EPP) and staff (EMP) interview, the clinic failed to ensure the EPP addressed means to safely shelter patients and staff in the event of a disaster.

Findings included:

Staff interview with EMP4 on 3/1/18 at approximately 9:30 a.m. revealed clinic does not have linens. Clinic uses disposable coverings for examination tables, etc.

Review of EPP on 3/1/18 at approximately 12 p.m. revealed "The Emergency Plan was updated and approved on Jan 30, 2018...PURPOSE: TO DESCRIBE ACTIONS TO BE TAKEN IN AN EMERGENCY OR EXERCISE TO MAKE SURE THAT THE CLIENTS, STAFF AND VISITORS OF THIS FACILITY ARE KEPT SAFE FROM HARM." EPP included "SHELTER IN PLACE" in event of "SEVERE STORMS, TORNADOS, AND VIOLENCE/TERRORISM OR HAZARD MATERIALS CONDITIONS IN THE AREA...WINDOWS AND DOORS WILL BE CLOSED...IN THE EVENT OF A HAZARDOUS CHEMICAL INCIDENT...ALL FANS, AIR CONDITIONERS, VENTILATORS WILL BE TURNED OFF. CLOTHS WILL BE STUFFED AROUND GAPS AT THE BOTTOM OF DOORS." Surveyor unable to discern that cloths would be available if needed as no linens onsite. Plan did not address needs of patients and staff to ensure sheltered in place safely. No mention of subsistence (food/drink), bathroom facilities, care/treatment of patients, or duration that shelter in place could be implemented safely.

Staff interview with EMP10 and EMP11 on 3/2/18 at approximately 1:12 p.m. confirmed findings.




Plan of Correction:

The Emergency Operation Plan was revised to include language that further defines the "Shelter in Place" procedure (Section: B II, (a-f), page 7) as follows:
a. "Shelter in place means that the staff, clients and visitors will remain in the building. Sheltering in place can be used due to severe storms, tornados, and violence/terrorism or hazard materials conditions in the area.
b. As this is a medical health clinic with limited visitor sustenance resources, the duration of Shelter in Place is estimated to be approximately 4 hours. If the emergency situation extends beyond 4 hours the Incident Command staff will take appropriate measure to transfer clients, visitors or staff in need of additional care.
c. There will be water and toilet facilities readily available. If any individual requires food, medicines or other medical resources every effort will be made to transfer the person to the nearest hospital.
d. If sheltering in place is result of a weather emergency that requires avoidance of windows and doors, staff, clients and visitors will move to interior rooms and hallways.
e. If sheltering is used in the event of a hazardous chemical incident, windows and doors will be shut and all fans, air conditioners, ventilators will be turned off.
a. The facility will stay in shelter until authorities give an all clear or the emergency threat has ended as determined by the incident commander."

Plan revisions were completed by March 13, 2018.
Staff categories assigned to these roles and responsibilities will be educated on duty requirements during the mandatory staff in-service conducted by the Safety Coordinator by March 31, 2018. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring will be accomplished through periodic drills (at least annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues.
Safety Coordinator is responsible for enactment of the plan.



491.12(b)(3) STANDARD
Policies/Procedures for Medical Documentation

Name - Component - 00
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:]

(5) A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

*[For RNHCIs at 403.748(b):] Policies and procedures. (5) A system of care documentation that does the following:
(i) Preserves patient information.
(ii) Protects confidentiality of patient information.
(iii) Secures and maintains the availability of records.

*[For OPOs at 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.

Observations:


Based on review of clinic emergency preparedness plan (EPP) and staff (EMP) interview, the clinic failed to ensure the EPP addressed a system of medical documentation that preserved patient information and secured and maintained availability of clinical records.

Findings included:

Review of EPP on 3/1/18 at approximately 12 p.m. revealed "The Emergency Plan was updated and approved on Jan 30, 2018...DOCUMENTATION...DURING AN EMERGENCY, DOCUMENTATION SHOULD CONTINUE FOR ALL CLIENTS IN THE PROCESS OF TREATMENT...ALL OFFICES USE AN EMR [electronic medical record]; A PAPER PROGRESS REPORTING SYSTEM IS IN PLACE FOR RECORDING TREATMENT; ONCE THE FACILITY IS OPERATIONAL, THE PAPER PROGRESS NOTE WILL BE SCANNED INTO THE EMR." No paper progress notes attached. Plan did not address storage and security of notes during disaster. Plan did not identify a format for completion of notes. Surveyor unable to determine how paper record availability would be maintained. Surveyor unable to evaluate "PAPER REPORTING SYSTEM" (as referred to in EPP) due to lack of detail in EPP.

Staff interview with EMP10 and EMP11 on 3/2/18 at approximately 1:12 p.m. confirmed findings.




Plan of Correction:

The emergency operations plan was revised to include language that further defines preserving patient information, protecting confidentiality of patient information and secures and maintains availability of records.
In the event of computer down time a paper progress record has been developed to include the following:
- Patient name and DOB
- Chief Complaints
- HPI
- Current Medications
- Allergies
- Family History
- Social History
- ROS
- Vital Signs
- Examination
- Assessment
- Treatment Plan
- Procedures
- Immunizations
- Next Appointment
- Billing Information

As this is a medical health clinic employing a maximum of three (3) providers a determination was made, based on historical patient load data, to have 60 printed paper progress records available in the event of an emergency. Blank copies of this progress record are stored in a designated file in the receptionist area of the office.
Monitoring to ensure the quantity of (60) progress notes is present is the responsibility of Receptionist A. This will be confirmed by a monthly inspection and recorded on a monthly inspection sheet. The practice manager will ensure this process has been followed and initial the monthly inspection sheet. This monitoring will begin by 4/6/18. This evaluation process will be sustained annually with no end date.
Once this progress record is completed by the provider it will be stored in a locked file cabinet in the manager's office until the computer system would be functional again and the record could be scanned into the system and then shredded. In the event the patient must be transferred out of the clinic with the progress note the progress note will be placed in a sealed confidential envelope and given directly to the emergency transporter.
If access to records is required in an emergency situation the ACMH Medical Records department has access to the clinics electronic health record and records can be obtained through them.
Anytime that the emergency medical documentation plan is implemented a debriefing will occur with the office coordinator and medical director and other staff as needed to review the process and ensure that the process functioned adequately. If there was a failure in the process then revisions will be made to correct the problem. If the emergency medical documentation plan is put in process, then the process review team, including the RHC medical director, the chief medical director, physician, APP and the practice manager will conduct a record review of the paper progress note. This review will include utilization of best practice resources, completeness of documentation addressing the patient visit, compliance with ordering and administration of procedures and all follow up care and treatment. Five paper progress notes will be chosen at random to be reviewed. Audit deficiencies will be identified, recorded and addressed with the process review team committee, and practitioners will receive additional education as needed. The office coordinator will be responsible for ensuring that these debriefings take place and any necessary corrections and staff re-education occurs. Evidence of re-education will be documented.
The procedures for the emergency medical documentation plan will be reviewed at the annual rural health office meeting. The blank progress notes will be reviewed at that time to determine that adequate categories of documentation are being captured on the note and to make any changes that the committee recommends.
Staff categories assigned to these roles and responsibilities will be educated on duty requirements during the mandatory staff in-service conducted by the Safety Coordinator by April 6, 2018. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring will be accomplished through periodic drills (at least annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues. The drills will be conducted by the Safety Coordinator.
The Safety Coordinator is responsible for this plan.



491.12(b)(4) STANDARD
Policies/Procedures-Volunteers and Staffing

Name - Component - 00
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:]

(6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

*[For RNHCIs at 403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency.

*[For Hospice at 418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Observations:


Based on review of clinic emergency preparedness plan (EPP) and staff (EMP) interview, the clinic failed to ensure the EPP addressed use of volunteers, including integration of state and federally designated health care professionals, to address surge needs during an emergency.

Findings included:

Review of EPP on 3/1/18 at approximately 12 p.m. revealed "The Emergency Plan was updated and approved on Jan 30, 2018...COMMUNICATIONS...REQUESTING ASSISTANCE...ANY TIME THERE IS IMMINENT DANGER ASSISTANCE SHOULD BE REQUESTED BY CALLING 911. FOR LESS SEVERE INCIDENTS...HOSPITAL AND ITS APPROPRIATE DEPARTMENTS SHOULD BE NOTIFIED AND DETERMINATION MADE FOR OTHER AGENCIES TO BE CONTACTED BASED ON THE SITUATION." Plan did not address use of volunteers with varying levels of skills and training to facilitate support of volunteers during a disaster.

Staff interview with EMP10 and EMP11 on 3/2/18 at approximately 1:12 p.m. confirmed findings.




Plan of Correction:

The Emergency Operations Plan has been amended to include language addressing the use of additional resources and volunteers (Section: B VII, page 11 & 12) as follows:
a. Human Resources
If additional personnel are needed to support management of the emergency situation, the RHC Operations Manager will be contacted to pull clinical and non-clinical resources from other RHC's and or physician office practices to assist. Emergency 911 will be contacted for additional medical resources. The Healthcare Coalition of Southwest Pennsylvania will be contacted to integrate any supportive services from State and Federal designated health care professional resources if needed.
b. Volunteers
Non-medical volunteers who respond to an emergency situation will be directed and assigned by the Client and Resource Supply Coordinator, position # 4 on the organization chart.
The Incident Commander and Client and Resource Supply Coordinator will be educated on their role in requesting additional resources during the mandatory staff in-service conducted by the Safety Coordinator by March 31, 2018. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring will be accomplished through periodic drills (at least annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues.
Safety Coordinator is responsible for enactment of the plan.



491.12(c) STANDARD
Development of Communication Plan

Name - Component - 00
(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.

Observations:


Based on review of clinic emergency preparedness plan (EPP) and staff (EMP) interview, the clinic failed to ensure the EPP included a written communication plan that addressed how the clinic would interact and coordinate patient care with other healthcare providers, state and local public health departments, and emergency management agencies and systems in the event of a disaster.

Findings included:

Review of EPP on 3/1/18 at approximately 12 p.m. revealed "The Emergency Plan was updated and approved on Jan 30, 2018...COMMUNICATIONS...EMPLOYEE NAMES; PHYSICIAN NAMES AND EMERGENCY CONTACTS ARE LOCATION IN TAB 5 [list and telephone numbers for staff and other clinics/private physician practices affiliated with same corporate entity/hospital noted]...IN THE EVENT THAT TELEPHONE AND CELL PHONE SERVICES ARE NOT AVAILABLE SOMEONE WILL BE DISPATCHED TO [hospital] FOR USE OF ALTERNATE COMMUNICATION DEVICES...CALL 911 FOR AN EMERGENCY THAT THREATENS THE SAFETY OF LIFE OR STAFF, CLIENTS OR VISITORS...[hospital] SWITCHBOARD SHOULD BE NOTIFIED AND THEY WILL CONTACT ADMINISTRATOR ON CALL, EXECUTIVE DIRECTOR OR OPERATIONS AND OPERATIONS MANAGER...THIS EOP [emergency operations plan] CONTAINS A LIST OF ALL COUNTY, STATE AND LOCAL EMERGENCY MANAGEMENT PERSONS THAT SHOULD BE NOTIFIED [list and telephone numbers for local police, PA State Police, local fire department, and local EMS noted]...THIS EOP CONTAINS A LISTING OF CONTACT INFORMATION FOR OTHER FACILITIES THAT CAN PROVIDE REQUIRED SERVICES FOR CLIENTS AND A LISTING OF NEARBY HOSPITALS THAT CAN PROVIDE EMERGENCY SERVICES [affiliated hospital and telephone number listed]." Communication plan did not have contact information for state and local public health departments. Communication plan did not have contact information for local, tribal, state, and federal emergency managenent officials. Cross refer tag E0031 for additional information. Surveyor unable to discern how the clinic would interact and coordinate patient care with other healthcare providers, state and local public health departments, and emergency management officials in the event of a disaster.

Staff interview with EMP10 and EMP11 on 3/2/18 at approximately 1:12 p.m. confirmed findings.




Plan of Correction:

The Emergency Operations Plan is amended to include a more comprehensive Communications Plan (Section: B VI, page(s) 9, 10 and 11) as follows:
"COMMUNICATION PLAN

a. External Communications
- In the event of a disaster requiring the assistance of local Emergency Management services, the Communications Coordinator (position#1 on the organization Chart) will contact the local Armstrong County Emergency Management Agency at 724-548-3431.
- In addition, when a disaster or emergency cannot be facilitated by the local Emergency Management Agency, that agency personnel will communicate to the Southwest Pennsylvania Healthcare Coalition via the PA Knowledge Center requesting additional support
- Communication Coordinator will contact the local Pennsylvania State Police at 724-543-2011 as necessary depending on the type of disaster.
- Communications Coordinator will contact the County Department of Public Health at 724-543-2700 and/or the PA State Department of Public Health at 717-787-4366 for any disasters associated with public health concerns.
- The local police, fire, and EMS contact information is provided for each RHC with their respective plan. The Communication Coordinator will contact these resources as necessary.
- The Communications Coordinator will address any requests for information, including local news or paper requests and provide briefings as appropriate and approved by the Incident Commander. As necessary, the Communications Coordinator will contact the ACMH hospital human resource vice president to verify any release of information to public entities.
- When an emergency includes utility disruption, the Communications Coordinator will contact the designated utility to notify them of the emergency and request assistance. The phone numbers for local utilities are included in each RHC plan as appropriate. If the land line phone system is out, the Incident Command staff will utilize cell phones to contact the utility and other emergency service resources.
- When necessary, the Communications Coordinator will contact the federal emergency management agency at 1-800-621-3362.
b. Internal Communications
- During an emergency, internal communications at the RHC will be coordinated by the Communications Coordinator who will assure that all other members of the team are kept informed of critical communication issues and needs.
c. Communication with Other Health Care Providers
- Care will be coordinated with other Health Care providers including but not limited to hospitals and Emergency Medical Services as appropriate and necessary based on the type of emergency. The Communications Liaison will contact these entities directly or indirectly through 911 as appropriate.
- ACMH is the closest hospital to all RHC's and would be contacted by calling 724-543-8500. The hospital switchboard operator will direct the call to the necessary department or service based on need.
- Local EMS is contacted via Armstrong County 911.

d. Communication with Clients and Visitors
- The Communication Coordinator will enlist additional staff to notify scheduled clients of the need to cancel and reschedule appointment or otherwise direct them to appropriate care.
- The Communication Coordinator or designee will contact any scheduled visitors to inform them of the emergency situation."

Plan revisions were completed by March 13, 2018.
Staff categories assigned to these roles and responsibilities will be educated on duty requirements during the mandatory staff in-service conducted by the Safety Coordinator by March 31, 2018. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring will be accomplished through periodic drills (at least annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues.
Safety Coordinator is responsible for enactment of the plan.



491.12(c)(2) STANDARD
Emergency Officials Contact Information

Name - Component - 00
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following:

(2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.

*[For LTC Facilities at 483.73(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, or local emergency preparedness staff.
(ii) The State Licensing and Certification Agency.
(iii) The Office of the State Long-Term Care Ombudsman.
(iv) Other sources of assistance.

*[For ICF/IIDs at 483.475(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.
(iii) The State Licensing and Certification Agency.
(iv) The State Protection and Advocacy Agency.

Observations:


Based on review of clinic emergency preparedness plan (EPP) and staff (EMP) interview, the clinic failed to ensure the EPP communication plan included contact information for local, tribal, regional, state, federal emergency preparedness staff.

Findings included:

Review of EPP on 3/1/18 at approximately 12 p.m. revealed "The Emergency Plan was updated and approved on Jan 30, 2018...THIS EOP [emergency operations plan] CONTAINS A LIST OF ALL COUNTY, STATE AND LOCAL EMERGENCY MANAGEMENT PERSONS THAT SHOULD BE NOTIFIED." The list included local police, PA State Police, local fire department, and local EMS. No contacts listed for federal, state, regional, local emergency management offices/personnel.

Staff interview with EMP10 and EMP11 on 3/2/18 at approximately 1:12 p.m. confirmed findings.




Plan of Correction:

The Emergency Operations Plan is amended to include a more comprehensive Communications Plan (Section: B VI, page(s) 9, 10 and 11) as follows:
"COMMUNICATION PLAN

Intent:

The RHC Communication Plan will provide a mechanism for communicating information about the facility's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee.
.
a. External Communications
- In the event of a disaster, when the RHC requires the assistance of local Emergency Management services for assistance with medical transfers, evacuation or medical supplies, the Communications Coordinator (position#1 on the organization Chart) will contact the local Armstrong County Emergency Management Agency at 724-548-3431.
- In addition, when a disaster or emergency cannot be facilitated by the local Emergency Management Agency, that agency personnel will communicate to the Southwest Pennsylvania Healthcare Coalition via the PA Knowledge Center requesting additional support
- Communication Coordinator will contact the local Pennsylvania State Police at 724-543-2011 as necessary depending on the type of disaster.
- Communications Coordinator will contact the County Department of Public Health at 724-543-2700 and/or the PA State Department of Public Health at 717-787-4366 for any disasters associated with public health concerns.
- The local police, fire, and EMS contact information is provided for each RHC with their respective plan. The Communication Coordinator will contact these resources as necessary.
- The Communications Coordinator will address any requests for information, including request for client condition or location and/or local news or paper requests. For inquiries regarding the status or location of a client, the Communications Coordinator will verify that the caller can identify the patient date of birth that is included on the daily visit report. The caller will be given general status of the patient and any transfer location. As necessary, the Communications Coordinator will contact the ACMH hospital human resource vice president to verify any release of information to public entities.
- When an emergency includes utility disruption, the Communications Coordinator will contact the designated utility to notify them of the emergency and request assistance. The phone numbers for local utilities are included in each RHC plan as appropriate. If the land line phone system is out, the Incident Command staff will utilize cell phones to contact the utility and other emergency service resources.
- When necessary, the Communications Coordinator will contact the federal emergency management agency at 1-800-621-3362.
- During a disaster event that impacts the community surrounding the RHC, the Communications Coordinator will notify local Emergency Management agency at 724-548-3431 to provide the RHC's capacity and ability or inability to accommodate additional clients.
b. Internal Communications
- During an emergency, internal communications at the RHC will be coordinated by the Communications Coordinator who will assure that all other members of the team are kept informed of critical communication issues and needs.
c. Communication with Other Health Care Providers
- Care will be coordinated with other Health Care providers including but not limited to hospitals and Emergency Medical Services as appropriate and necessary based on the type of emergency. The Communications Liaison will contact these entities directly or indirectly through 911 as appropriate.
- ACMH is the closest hospital to all RHC's and would be contacted by calling 724-543-8500. The hospital switchboard operator will direct the call to the necessary department or service based on need.
- Local EMS is contacted via Armstrong County 911.

d. Communication with Clients and Visitors
a. The Communication Coordinator will enlist additional staff to notify scheduled clients of the need to cancel and reschedule appointment or otherwise direct them to appropriate care.
b. The Communication Coordinator or designee will contact any scheduled visitors to inform them of the emergency situation."

Plan revisions were completed by March 13, 2018.
Staff categories assigned to these roles and responsibilities will be educated on duty requirements during the mandatory staff in-service conducted by the Safety Coordinator by March 31, 2018. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring will be accomplished through periodic drills (at least annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues.
Safety Coordinator is responsible for enactment of the plan.



491.12(c)(3) STANDARD
Primary/Alternate Means for Communication

Name - Component - 00
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following:

(3) Primary and alternate means for communicating with the following:
(i) [Facility] staff.
(ii) Federal, State, tribal, regional, and local emergency management agencies.

*[For ICF/IIDs at 483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies.

Observations:


Based on review of clinic emergency preparedness plan (EPP) and staff (EMP) interview, the clinic failed to ensure the EPP communication plan adequately addressed alternate means for communicating with staff and federal, state, regional, local emergency management agencies in the event of a disaster.

Findings included:

Review of EPP on 3/1/18 at approximately 12 p.m. revealed "The Emergency Plan was updated and approved on Jan 30, 2018...IN THE EVENT THAT TELEPHONE AND CELL PHONE SERVICES ARE NOT AVAILABLE SOMEONE WILL BE DISPATCHED TO [hospital] FOR USE OF ALTERNATE COMMUNICATION DEVICES." Communication plan did not identify devices. Surveyor unable to discern if alternate means of communication effective due to lack of detail in EPP communication plan. Surveyor unable to discern if staff familiar/trained in use of devices given lack of detail in EPP communication plan.

Staff interview with EMP10 and EMP11 on 3/2/18 at approximately 1:12 p.m. confirmed findings.






Plan of Correction:

The Emergency Operations Plan was amended to include language that addresses alternate means of communication with staff, federal, state, local, and regional emergency management agencies (Section: B VI, page 10) as follows:
- "When an emergency includes utility disruption, the Communications Coordinator will contact the designated utility to notify them of the emergency and request assistance. The phone numbers for local utilities are included in each RHC plan as appropriate. If the land line phone system is out, the Incident Command staff will utilize cell phones to contact the utility and other emergency service resources. In the event that cell service is not available, internet or email notification will be utilized to facilitate contact. When all means of communication are unavailable, the Incident Commander will identify a staff person to travel to the hospital to utilize emergency radio communication available to that site."

Plan revisions were completed by March 13, 2018.
Staff will be educated on Plan language and procedures during the mandatory staff in-service conducted by the Safety Coordinator by March 31, 2018. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring will be accomplished through periodic drills (at least annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues.
Safety Coordinator is responsible for enactment of the plan.



491.12(c)(4) STANDARD
Methods for Sharing Information

Name - Component - 00
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following:

(4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care.

(5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under 484.102(c), CORFs under 485.68(c), and RHCs/FQHCs under 491.12(c).]

(6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4).

*[For RNHCIs at 403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative.

*[For RHCs/FQHCs at 491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4).

Observations:


Based on review of clinic emergency preparedness plan (EPP) and staff (EMP) interview, the clinic failed to ensure the EPP included a written communication plan that addressed how the clinic would provide information about the general condition and location of patients under the clinic's care in the event of a disaster.

Findings included:

Review of EPP on 3/1/18 at approximately 12 p.m. revealed "The Emergency Plan was updated and approved on Jan 30, 2018...DOCUMENTATION...DURING AN EMERGENCY, DOCUMENTATION SHOULD CONTINUE FOR ALL CLIENTS IN THE PROCESS OF TREATMENT...ALL HIPAA POLICIES REMAIN IN EFFECT DURING AN EMERGENCY...COMMUNICATIONS WITH HEALTHCARE PROVIDERS...ONLY THE VP OF HR [employee of affiliated hospital] OR THEIR DESIGNEE IS AUTHORIZED TO RELEASE INFORMATION ON THE LOCATION OR CONDITION OF CLIENTS. INFORMATION MAY BE RELEASE TO THEIR HEALTHCARE PROVIDERS WITH CONSENT OF THE CLIENT AND CONSISTENT WITH HIPAA REGULATIONS." Communication plan did not address what and how information would be shared (means or method). Surveyor unable to evaluate capability of clinic to share accurate, relevant, information about general condition and location of patients in a timely manner in the event of a disaster due to lack of detail in EPP communication plan.

Staff interview with EMP10 and EMP11 on 3/2/18 at approximately 1:12 p.m. confirmed findings.




Plan of Correction:

The Emergency Operations Plan was amended to include language that addresses use and disclosure for disaster relief purposes, establishes requirements for disclosing patient information to public or private entity authorized by law or by charter to assist in disaster relief efforts for purposes of notifying family members, personal representatives or certain others of the patient's location or general condition. All disclosures will be made in compliance with HIPAA Privacy regulations at 45 CFR 164.510 (b)(4). (Section: B VI, page 10) as follows:
"Whenever possible during a disaster, patient consent will be obtained either verbally or in writing regarding disclosure of information to their representative(s). The Communications Coordinator will address any requests for information including those from public or private entity. For inquiries regarding the status or location of a client, the Communications Coordinator will provide general status and location information to the patient's identified representative. Any other disclosures will be dictated by the facilities charter in response to the disaster situation."

Plan revisions were completed by March 22, 2018.
The development of the Emergency Operations Plan provides the mechanism for assuring that any RHC patient on site during a disaster is provided with the best possible care, welfare, safety and security until emergency responders are available to assist or the disaster is abated. The RHC will be prepared to address a disaster via monitoring, evaluation and education demonstrated by the completion of at least two (02) disaster drills annually. Any time that the Emergency Operations plan is implemented a debriefing will occur with the office coordinator and medical director and other staff as needed to review the process and ensure that the plan functioned. If a failure occurred in the process, revisions will be made to correct the problem. These activities will assure that a problem with addressing a disaster does not occur in the future.
Staff will be educated on Plan roles and duties during the mandatory staff education conducted by the Safety Coordinator followed by a table top exercise by April 6, 2018. The Safety Coordinator will be responsible for ensuring that these debriefings take place and any necessary corrections and staff reeducation occurs. Evidence of reeducation will be documented. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring and sustainment will be accomplished through periodic drills (at least twice annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues. This evaluation process will be sustained annually with no end date.
Safety Coordinator is responsible for enactment of the plan.



491.12(c)(5) STANDARD
Information on Occupancy/Needs

Name - Component - 00
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following:

(7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

*[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

*[For Inpatient Hospice at 418.113:] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

Observations:


Based on review of clinic emergency preparedness plan (EPP) and staff (EMP) interview, the clinic failed to ensure the EPP communication plan addressed a means to provide information about the clinic's occupancy needs and its ability to provide assistance to the authority having jurisdiction.

Findings included:

Review of EPP on 3/1/18 at approximately 12 p.m. revealed "The Emergency Plan was updated and approved on Jan 30, 2018...COMMUNICATIONS...REQUESTING ASSISTANCE...ANY TIME THERE IS IMMINENT DANGER ASSISTANCE SHOULD BE REQUESTED BY CALLING 911. FOR LESS SEVERE INCIDENTS...HOSPITAL AND ITS APPROPRIATE DEPARTMENTS SHOULD BE NOTIFIED AND DETERMINATION MADE FOR OTHER AGENCIES TO BE CONTACTED BASED ON THE SITUATION." Communication plan did not have contact information for local, tribal, state, and federal emergency management officials. Cross refer tag E0031 for additional information. Surveyor unable to evaluate clinic's ability to provide information about occupancy needs and ability to provide assistance to the authority having jurisdiction due to lack of detail in EPP communication plan.

Staff interview with EMP10 and EMP11 on 3/2/18 at approximately 1:12 p.m. confirmed findings.




Plan of Correction:

The Emergency Operations Plan was revised to include language that addressed the RHC's process for providing information regarding the clinic occupancy needs and its ability to provide assistance to the authority having jurisdiction (Section: B VI, pages 9 & 10) as follows:
"Intent:

The RHC Communication Plan will provide a mechanism for communicating information about the facility's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee.
.
a. External Communications
- In the event of a disaster, when the RHC requires the assistance of local Emergency Management services for assistance with medical transfers, evacuation or medical supplies, the Communications Coordinator (position#1 on the organization Chart) will contact the local Armstrong County Emergency Management Agency at 724-548-3431.
- During a disaster event that impacts the community surrounding the RHC, the Communications Coordinator will notify local Emergency Management agency at 724-548-3431 to provide the RHC's capacity and ability or inability to accommodate additional clients."

Plan revisions were completed by March 14, 2018.
Staff will be educated on Plan roles and duties during the mandatory staff in-service conducted by the Safety Coordinator by March 31, 2018. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring will be accomplished through periodic drills (at least annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues.
Safety Coordinator is responsible for enactment of the plan.



491.12(d)(1) STANDARD
EP Training Program

Name - Component - 00
(1) Training program. The [facility, except CAHs, ASCs, PACE organizations, PRTFs, Hospices, and dialysis facilities] must do all of the following:

(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
*[For Hospitals at 482.15(d) and RHCs/FQHCs at 491.12:] (1) Training program. The [Hospital or RHC/FQHC] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.

*[For Hospices at 418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least annually.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.

*[For PRTFs at 441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training at least annually.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.

*[For PACE at 460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.

*[For CORFs at 485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.

*[For CAHs at 485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.

*[For CMHCs at 485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least annually.


Observations:


Based on review of clinic emergency preparedness plan (EPP), safety committee meeting minutes, and personnel files (PF) and staff (EMP) interview, the clinic failed to ensure initial staff EP training and testing (to include demonstration of knowledge) was completed for one (1) physician PF reviewed (EMP2).

Findings included:

Review of EPP on 3/1/18 at approximately 12 p.m. revealed "The Emergency Plan was updated and approved on Jan 30, 2018...TRAINING...CURRENT STAFF WILL BE TRAINED ON THE NEW OR UPDATED EOP [emergency operations plan] AT THE TIME OF ITS PUBLICATION...ALL NEW STAFF WILL BE TRAINED ON THE EOP IN OREINTATION [sic]...PHYSICIANS MUST BE TRAINED ON EOP...DOCUMENTATION OF THE TRAINING ON THE EOP AND ANNUALLY EMERGENCY PREPAREDNESS TRAINING WILL BE MAINTAINED BY THE SAFETY COORDINATOR...TESTING...THE FACILITY WILL PARTICIPATE IN A FULL SCALE EXERCISE THAT IS COMMUNITY BASED ON WHEN A COMMUNITY BASED EXERCISE IS NOT ACCESSIBLE, AN INDIVIDUAL FACILITY BASED FULL SCALE EXERCISE WILL BE DONE ANNUALLY...THE FACILITY MUST CONDUCT A SECOND EXERCISE EVERY YEAR...AFTER FULL SCALE EXERCISES, TABLETOPS OR ACTUAL EVENTS, THE FACILITY SHOULD ANALYZE THE RESPONSE, IDENTIFY AREA OF IMPROVEMENT AND UPDATE EOP, IF REQUIRED OR NECESSARY." List of clinic staff noted in EPP binder to signify all staff trained on plan. No testing (exercises) completed at time of survey.

Review of safety committee meeting minutes (for affiliated hospital) on 3/2/18 at approximately 1:50 p.m. revealed no exercises complete yet. Future tentative date for an exercise planned.

Staff interview with EMP10 and EMP11 on 3/2/18 at approximately 1:12 p.m. confirmed above findings. EMP10 and EMP11 confirmed clinic had not yet completed an EP exercise.

Review of PF on 3/2/18 at approximately 9 a.m. revealed no emergency preparedness testing completed by EMP2.

Staff interview on 3/2/18 at approximately 2 p.m. with EMP10 confirmed EMP2 failed to complete mandatory yearly staff in-service training online, which would require successfully passing quizzes/test to complete the courses.




Plan of Correction:

The Emergency Operations Plan has been revised to include language that addresses initial and annual staff and physician training as well as documentation of all training (Section B VIII, page 12) as follows:
VII. "TRAINING, EVALUATIONAND TESTING
a. Physicians and staff will be provided annual education on the EOP during a mandatory in-service coordinated and conducted by the Safety Coordinator. Pre and post testing will be completed by all staff and physicians in order to assess knowledge of the plan.
b. All new physicians and staff will be trained on the EOP in orientation via an education training module. Staff will complete a read and sign documenting training. Post testing will be completed by the employee to demonstrate knowledge of the plan.
c. At least annually, the Safety Coordinator will conduct one emergency response exercise, testing the plan and staff compliance and knowledge with the plan. Additional exercise may be conducted based on newly identified vulnerabilities. These exercises will be observed, critiqued and corrective actions implemented for any deficiencies or gaps identified. Actions may include but not be limited to re-education of staff as needed.
d. Documentation of the initial EOP training the annual EOP training and staff participation in all exercises will be maintained by the Safety Coordinator and the Office Practice Manager."
Plan revisions were completed by March 14, 2018.
Monitoring will be completed by the Director of Risk and Quality Management verifying that"
- All new RHC hires have received education evidenced by sign-off
- All current staff have completed annual education evidenced by sign-off
- All employees have participate in at least one annual exercise
Monitoring will begin post staff education provided March 31, 2018 and conclude annually Monitoring will be documented on a compliance spreadsheet.
Safety Coordinator is responsible for enactment of the plan.



491.12(d)(2) STANDARD
EP Testing Requirements

Name - Component - 00
(2) Testing. The [facility, except for LTC facilities, RNHCIs and OPOs] must conduct exercises to test the emergency plan at least annually. The [facility, except for RNHCIs and OPOs] must do all of the following:

*[For LTC Facilities at 483.73(d):] (2) Testing. The LTC facility must conduct exercises to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures. The LTC facility must do all of the following:]

(i) Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event.
(ii) Conduct an additional exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based.
(B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

*[For RNHCIs at 403.748 and OPOs at 486.360] (d)(2) Testing. The [RNHCI and OPO] must conduct exercises to test the emergency plan. The [RNHCI and OPO] must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the [RNHCI's and OPO's] response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

Observations:

Based on review of clinic emergency preparedness plan (EPP) and safety committee meeting minutes and staff (EMP) interview, the clinic failed to ensure conduct exercises to test the EPP.

Findings included:

Review of EPP on 3/1/18 at approximately 12 p.m. revealed "The Emergency Plan was updated and approved on Jan 30, 2018......TESTING...THE FACILITY WILL PARTICIPATE IN A FULL SCALE EXERCISE THAT IS COMMUNITY BASED ON WHEN A COMMUNITY BASED EXERCISE IS NOT ACCESSIBLE, AN INDIVIDUAL FACILITY BASED FULL SCALE EXERCISE WILL BE DONE ANNUALLY...THE FACILITY MUST CONDUCT A SECOND EXERCISE EVERY YEAR...AFTER FULL SCALE EXERCISES, TABLETOPS OR ACTUAL EVENTS, THE FACILITY SHOULD ANALYZE THE RESPONSE, IDENTIFY AREA OF IMPROVEMENT AND UPDATE EOP [emergency operations plan], IF REQUIRED OR NECESSARY." No testing (exercises) completed at time of survey.

Clinic EPP integrated with affiliated hospital. Cross refer tag E0042 for additional information. Clinic formerly operated as outpatient physician practice affiliated with hospital for several years prior to survey 3/1/18 and 3/2/18. Hospital had been in operation for several years prior to survey 3/1/18 and 3/2/18.

Review of safety committee meeting minutes (for affiliated hospital) on 3/2/18 at approximately 1:50 p.m. revealed no exercises complete yet. Future tentative date for an exercise planned.

Staff interview with EMP10 and EMP11 on 3/2/18 at approximately 1:12 p.m. confirmed findings.





Plan of Correction:

The Emergency Operations Plan has been revised to include language that addresses the annual exercise and testing of the EOP as well as documentation of all exercises (Section B VIII, page 12) as follows:
a. "At least twice annually, the Safety Coordinator will conduct emergency response exercises, testing the plan and staff compliance and knowledge with the plan. At least one exercise will be community based when possible. In addition, a facility specific exercise will be conducted annually. Any additional exercise may be conducted based on newly identified vulnerabilities. These exercises will be observed, critiqued and corrective actions implemented for any deficiencies or gaps identified. Actions may include but not be limited to re-education of staff as needed."
b. Documentation of the initial EOP training, the annual EOP training and staff participation in all exercises will be maintained by the Safety Coordinator and the Office Practice Manager."

In order to protect patients in the future as it relates to the individual we have developed an Emergency Operations Plan that provides the mechanism for assuring that any RHC patient on site during a disaster is provided the best possible care, welfare, safety and security until emergency responders are available to assist or the disaster is abated. The RHC will be prepared to mitigate damages to any individual patient, staff or visitor via continuous training and education. We will monitor, evaluate and educate our staff via the completion of at least two (02) disaster drills annually. Any time that the Emergency Operations plan is implemented a debriefing will occur with the Safety Coordinator, office coordinator, medical director and other key staff as needed to review the process and ensure that the plan functioned. If a failure occurred in the process, revisions will be made to correct the problem. This process will enable recovery and will identify actions that would mitigate the effects of future disasters as it relates to the RHC and at the individual patient level. Our goal would be to have the RHC and each patient be able to return to normal function and life as soon as possible.

Staff will be educated on Plan roles and duties during the mandatory staff education conducted by the Safety Coordinator followed by a facility-based exercise by April 6, 2018. The Safety Coordinator will be responsible for ensuring that these debriefings take place and any necessary corrections and staff reeducation occurs. Evidence of reeducation will be documented. Evaluation of staff knowledge regarding specific roles will be assessed by post-education testing completed the same date.
Monitoring and sustainment will be accomplished through periodic drills (at least twice annually) to determine staff knowledge of and ability to perform specific assigned roles and duties. Performance will be evaluated and the need for any additional education will be determined based on any identified issues. This evaluation process will be sustained annually with no end date.
Safety Coordinator is responsible for enactment of the plan.



491.12(e) STANDARD
Integrated EP Program

Name - Component - 00
(e) [or (f)]Integrated healthcare systems. If a [facility] is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the [facility] may choose to participate in the healthcare system's coordinated emergency preparedness program.
If elected, the unified and integrated emergency preparedness program must- [do all of the following:]

(1) Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program.

(2) Be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered.

(3) Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance [with the program].

(4) Include a unified and integrated emergency plan that meets the requirements of paragraphs (a)(2), (3), and (4) of this section. The unified and integrated emergency plan must also be based on and include the following:

(i) A documented community-based risk assessment, utilizing an all-hazards approach.

(ii) A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach.

(5) Include integrated policies and procedures that meet the requirements set forth in paragraph (b) of this section, a coordinated communication plan, and training and testing programs that meet the requirements of paragraphs (c) and (d) of this section, respectively.

Observations:


Based on review of clinic emergency preparedness plan (EPP) and deficiencies cited as a result of the current survey and staff (EMP) interview, the clinic failed to ensure integrated EPP developed with active participation of clinic staff and EPP took into account clinic's unique circumstances, patient population, and services offered.

Findings included:

Review of EPP on 3/1/18 at approximately 12 p.m. revealed "The Emergency Plan was updated and approved on Jan 30, 2018." Plan mentioned hospital affiliated with clinic repeatedly as follows:

"EVACUATION PLAN...NOTIFICATION TO THE PROPER AUTHORITIES IS THE RESPONSIBILITY OF THE INCIDENT COMMANDER. INCIDENT COMMANDER WILL DESIGNATE SOMEONE TO CALL 911 AND THE [hospital] SWITCHBOARD...SWITCHBOARD WILL CONTACT OTHER APPROPRIATE PERSONNEL."

"SUSPENSION OF SERVICES...THE FACILITY HAS IDENTIFIED THAT THE HOSPITAL EMERGENCY ROOM WILL ACCOMMODATE PATIENT EMERGENCIES...THE FACILITY IS PART OF AN INTEGRATED HEALTHCARE SYSTEM, AND IF THE CLIENT AGREES, SERVICES MAY BE TRANSFERRED WITHIN THE SYSTEM."

"COMMUNICATIONS...IN THE EVENT THAT TELEPHONE AND CELL PHONE SERVICES ARE NOT AVAILABLE SOMEONE WILL BE DISPATCHED TO [hospital] FOR USE OF ALTERNATE COMMUNICATION DEVICES....EXTERNAL...THE [hospital] SWITCHBOARD SHOULD BE NOTIFIED AND THEY WILL CONTACT ADMINISTRATOR ON CALL, EXECUTIVE DIRECTOR OF OPERATIONS AND OPERATIONS MANAGER...COMMUNICATIONS WITH HEALTHCARE PROVIDERS...ONLY THE VP OF HR [employee of affiliated hospital] OR THEIR DESIGNEE IS AUTHORIZED TO RELEASE INFORMATION ON THE LOCATION OR CONDITION OF CLIENTS. INFORMATION MAY BE RELEASE TO THEIR HEALTHCARE PROVIDERS WITH CONSENT OF THE CLIENT AND CONSISTENT WITH HIPAA REGULATIONS...REQUESTING ASSISTANCE...ANY TIME THERE IS IMMINENT DANGER ASSISTANCE SHOULD BE REQUESTED BY CALLING 911. FOR LESS SEVERE INCIDENTS...HOSPITAL AND ITS APPROPRIATE DEPARTMENTS SHOULD BE NOTIFIED AND DETERMINATION MADE FOR OTHER AGENCIES TO BE CONTACTED BASED ON THE SITUATION."

"TRAINING...DOCUMENTATION OF THE TRAINING ON THE EOP [emergency operations plan] AND ANNUALLY EMERGENCY PREPAREDNESS TRAINING WILL BE MAINTAINED BY THE SAFETY COORDINATOR [employee of affiliated hospital]."

No copy of the hospital's EPP noted. Plan integrated with hospital; however, surveyor unable to evaluate content and effectiveness of integrated plan as no unified plan available for review. Surveyor unable to determine if integrated plan developed with active participation of clinic staff. Surveyor unable to determine if integrated plan took into account clinic's unique circumstances, patient population, and services offered.

The clinic failed to ensure the EPP addressed unique vulnerabilities of identified patient population and the types of services the clinic would be able to provide in an emergency. Cross refer tag E0007 for additional information.

The clinic failed to ensure the EPP included documentation of clinic efforts to contact, cooperate, and collaborate with emergency preparedness officials (local, tribal, regional, state, federal) in order to facilitate an integrated response during a disaster situation. Cross refer tag E0009 for additional information.

The clinic failed to ensure the EPP addressed needs of patients for safe evacuation. Cross refer tag E0020 for additional information.

The clinic failed to ensure the EPP addressed means to safely shelter patients and staff in the event of a disaster. Cross refer tag E0022 for additional information.

The clinic failed to ensure the EPP addressed a system of medical documentation that preserved patient information and secured and maintained availability of clinical records. Cross refer tag E0023 for additional information.

The clinic failed to ensure the EPP addressed use of volunteers, including integration of state and federally designated health care professionals, to address surge needs during an emergency. Cross refer tag E0024 for additional information.

The clinic failed to ensure the EPP included a written communication plan that addressed how the clinic would interact and coordinate patient care with other healthcare providers, state and local public health departments, and emergency management agencies and systems in the event of a disaster. Cross refer tag E0029 for additional information.

The clinic failed to ensure the EPP communication plan included contact information for local, tribal, regional, state, federal emergency preparedness staff. Cross refer tag E0031 for additional information.

The clinic failed to ensure the EPP communication plan adequately addressed alternate means for communicating with staff and federal, state, regional, local emergency management agencies in the event of a disaster. Cross refer tag E0032 for additional information.

The clinic failed to ensure the EPP included a written communication plan that addressed how the clinic would provide information about the general condition and location of patients under the clinic's care in the event of a disaster. Cross refer tag E0033 for additional information.

The clinic failed to ensure the EPP communication plan addressed a means to provide information about the clinic's occupancy needs and its ability to provide assistance to the authority having jurisdiction. Cross refer tag E0034 for additional information.

The clinic failed to ensure initial staff EP training and testing (to include demonstration of knowledge) was completed for one (1) physician. Cross refer tag E0037 for additional information.

Staff interview with EMP10 and EMP11 on 3/2/18 at approximately 1:12 p.m. confirmed findings.




Plan of Correction:

The RHC Emergency Operations Plan is developed in conjunction with the ACMH Hospital Emergency Preparedness Plan taking into account the RHC's unique circumstances, patient population and services offered. The RHC staff plays an active role in development and sustainment of this plan. This facility is capable of actively utilizing the unified integrated emergency operation plan. Integration is achieved by the following activities:
- Participation in joint community drills with local Emergency Management agencies
- Members of the RHC actively participate in the safety program of the hospital and provide input regarding RHC emergency operations plans.
- Hospital staff provide education and assistance to the RHC in regard to Emergency Preparedness and assist with RHC specific exercises.
- The hospital and RHC plans will evidence integration of relevant processes and procedures.
The elements of the Emergency Operations Plan cited in this deficiency were specifically addressed in each plan of correction submitted.
Monitoring is achieved through the coordinated activities outlined in the plans of correction submitted. The coordination between the entities will be sustained through the continuous review and amendment of the coordinated plans, annual exercises, evaluation of staff execution of the plan, and the provision of reeducation as deemed necessary.

The Safety Coordinator is responsible for the continued implementation of this plan of correction.



Initial Comments:

Based on the findings of an onsite unannounced initial Medicare certification survey completed 3/2/18, Armstrong Primary Care Center - West Hills was found not to be in compliance with the following requirements of 42 CFR, Part 405, Subpart X and 42 CFR, Part 491.1 - 491.12, Subpart A, Conditions for Certification: Rural Health Clinics.




Plan of Correction:




491.6(b)(1) STANDARD
MAINTENANCE

Name - Component - 00
All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition;


Observations:


Based on observation, review of eye wash weekly check documentation and clinic policy, and staff (EMP) interview, the clinic failed to maintain patient care equipment/supplies in safe operating condition.

Findings included:

Observation during tour on clinic on 3/1/18 at approximately 9:10 a.m. revealed the following patient care supplies:

Exam room D1
- 4 oz. tube of lubricating jelly expired May 2016
Workstation located in hallway outside Exam room D1
- aerosol foam hand sanitizer expired August 2017
- foam hand sanitizer pump with illegible expiration date 8/12/20XX (year wore off bottle and no date/initials to signify when first opened)
Exam room E1
- foam hand sanitizer pump with no expiration date or date/initials to signify when first opened
Exam room B3
- sterile package of gauze sponges lying beside sink and hand towels to dry hands after washing (wrapper was made of paper and prone to becoming wet)
- foam hand sanitizer pump with no expiration date or date/initials to signify when first opened
Exam room B2
- foam hand sanitizer pump with no expiration date or date/initials to signify when first opened
Workstation located in hallway outside Exam room B2
- aromatic deodorizer expired 10/2015
Exam room B1
- foam hand sanitizer pump expired "8/12/2010"
Eye wash sink in laboratory area
- "EYE WASH STATION WEEKLY CHECK" last completed 2/12/2018

Untimely eye wash station checks confirmed with EMP5 at time of observation.

Review of clinic policy on 3/1/18 at approximately 11:30 am revealed "Infection Control...Storage of supplies. 1. Proper storage and handling of sterile supplies is maintained. 2. Stock will be rotated to reduce the need for re-sterilization and prevent outdates. 3. Dated items will be checked monthly and prior to use."




Plan of Correction:

All outdated items and sterile package of gauze sponges (as indicated in 0022) were removed from exam rooms and work stations and disposed of. Staff will be educated to include room deodorizers, hand sanitizers and lubricating jelly to their monthly outdate checks. Staff will be educated on proper storage of medical supplies with an emphasis on Storage of Supplies items 1 through 3. This education will ensure that outdated items are disposed of and medical supplies will be properly stored. All staff will be educated by 3/16/18 and will complete a read and sign of infection control policy 231. This read and sign signature sheet will be located in the RHC binder. The MA's are responsible to follow the policy, to check and rotate and remove the expired products weekly. This will be confirmed with the monthly inspection for outdated/expired products by the staff RN. Spot checks will be performed by the office manager monthly and recorded by initializing the monthly inspection sheet . Spot checks will also be performed by the operations manager and recorded by initializing the monthly inspection sheet. This monthly inspection sheet is located in the Inspection Binder.
Eye wash check sheet was updated to include the calendar of weekly dates to ensure that no weeks pass without a documented inspection and the eye wash station is functioning properly. Staff will be educated on the revised eye wash sheet by 3/16/18. A staff member has been assigned the responsibility for weekly eye wash inspection and documentation. The office manager will review and initial the sheet weekly for compliance for the first two months. Once compliance is achieved spot checks will be performed by the office manager and recorded on the weekly eye wash sheet. This inspection sheet is located in the inspection binder.



491.9(b)(1) STANDARD
PATIENT CARE POLICIES

Name - Component - 00
The clinic's ... health care services are furnished in accordance with appropriate written policies which are consistent with applicable State law.



Observations:


Based on observation, review of clinic policy and personnel files, and staff (EMP) interview, the clinic failed to ensure staff performed hand hygiene after removal of gloves during the provision of direct patient care for one (1) of three (3) patient visits observed (PV1).

Findings included:

Observation of PV1 on 3/1/18 at approximately 1 p.m. revealed EMP2 assess (repeatedly touch) patient's finger with gloved hand. Patient complained of swelling and tenderness to finger. EMP2 then removed and discarded gloves in trash container. EMP2 did not perform hand hygiene. EMP2 proceeded to type (document) on the laptop in the room.

During staff interview on 3/2/18 at approximately 10:42 a.m., EMP3 reported hand hygiene education/training is to be completed by staff at least yearly. EMP3 confirmed clinic staff were expected to wash hands after removing gloves during the provision of direct patient care.

Review of clinic policy on 3/1/18 at approximately 11:30 am revealed "Infection Control...Standard precautions will be utilized for all patients. Hand hygiene will be performed before and after each patient contact."

Review of PF on 3/2/18 at approximately 9 a.m. revealed no hand hygiene education/training completed by EMP2. Staff interview on 3/2/18 at approximately 2 p.m. with EMP10 confirmed EMP2 failed to complete mandatory yearly staff in-service training which would include hand hygiene and standard precautions.




Plan of Correction:


Staff re-education regarding hand hygiene included in the Infection Control Policy 231 will be reviewed with all staff by the practice manager and will be completed by 3/16/2018. A read and sign will be completed by all staff to indicate they read and understand Infection Control Policy 231. A copy of the signature sheet will be contained in the RHC binder. Additionally all staff completed the Net Dimensions online course on Infection Control. Verification of course completion is contained in the RHC binder. To ensure that the hand hygiene protocol is being followed, the practice manager will perform random observations of hand hygiene weekly beginning the week of 3/19/2018. The practice manager will document inspections on a log sheet for compliance or noncompliance. Noncompliance of this policy will result in discipline per ACMH protocol. If after two months the weekly inspections have found all staff to be in compliance the random checks will decrease to monthly observations.



491.9(b)(3) STANDARD
PATIENT CARE POLICIES

Name - Component - 00
The policies include:

(i) A description of the services the clinic ... furnishes directly and those furnished through agreement or arrangement;

(ii) Guidelines for the medical management of health problems which include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the clinic ...; and

(iii) Rules for the storage, handling, and administration of drugs and biologicals.



Observations:


Based on review of clinic policy and clinical records (CR) and staff (EMP) interview, the clinic failed to ensure policies identified guidelines for medical management of health problems. Medical management of health problems did not meet medical director expectations for five (5) of twenty (20) CR reviewed (CR7, CR14-CR17).

Findings included:

Review of clinic policy on 3/1/18 at approximately 11:30 am revealed no policy pertaining to guidelines for the medical management of health problems.

Review of CR on 3/2/18 at approximately 10:10 a.m., 10:59 a.m., and 12:34 p.m. revealed:

CR7 (86 year old male) visited clinic on 1/31/18. "Reason for Appointment...4 mo. [followup]." Medical history included diabetes with long term insulin use and blood glucose monitoring supplies listed as current medications/treatments for patient. EMP2 (physician) noted "We reviewed recent lab" (hemoglobin A1C of 6.0 on 1/24/18 -- within desired range). No evaluation of blood sugar readings obtained at home by patient/family/representative. According to prior visit 9/28/17, patient checking blood sugars every other day.

CR14 (67 year old female) visited clinic on 2/26/18, "patient complains of, itching lesion left back." No assessment of lesion. No treatment/care plan for lesion. No education to patient about lesion. Next visit to clinic on 3/1/18. No evaluation of lesion. No treatment/care plan for lesion. No education to patient about lesion.

CR15 (61 year old female) visited clinic on 2/14/18. "Reason for Appointment...New [patient]." Medical history included hyperlipidemia and pure hypercholesterolemia. EMP2 noted "She does not take meds for high triglycerides or cholesterol...We reviewed recent labs" (blood urea nitrogen, calculated glomerular filtration rate, and creatinine -- no lipid studies). No treatment/care plan for high lipids. No education to patient about high lipids (i.e. diet, exercise). Medical records from prior primary care physician noted in CR. According to those records, lipid studies last completed in 10/2017 with elevated results. Cholesterol 280 mg/dl (desired range 0-200, high if greater than 240), triglycerides 242 mg/dl (high if 200-499), LDL 164 mg/dl (high if 160-189). Unclear if patient was aware of test results as not addressed with patient during 2/14/18 visit.

CR16 (40 year old female) visited clinic on 2/26/18. "Reason for Appointment...New/establish." Family history of diabetes (father) and heart disease (mother). EMP2 noted "menses are irregular...c/o [complaints of] fatigue and exhausted, has not been sleeping well, more facial hair." EMP2 ordered laboratory tests (testosterone) as treatment plan for hirsutism (hair growth) and TSH (thyroid studies) for fatigue. No evaluation of hair growth severity (i.e. Ferriman-Gallwey scale). No assessment or treatment/care plan for preventive care (i.e. vaccination history, gynecological care, laboratory studies to include CMP and lipids due to immediate family history of diabetes and heart disease). No education to patient.

CR17 (56 year old male) visited clinic on 3/1/18. "Review of Systems...patient complains of has [sic] pulsatile tinnitis right ear...Hospitalization/Major Diagnostic Procedure...ER Diverticulitis 2/2018." EMP2 noted "Recently had diverticulitis, went to ER and given ABX [antibiotic], few weeks ago." No evaluation of right ear or gastrointestinal system.

EMP8 was present during review of aforementioned CR and confirmed findings.

Staff interview with EMP1 (physician and medical director) on 3/2/18 at approximately 12:30 p.m. revealed no written, online, or other guidelines pertaining to medical management of health problems. EMP1 stated the guidelines used by clinic staff were "provider-specific" and confirmed there was no book or other resource available to direct expectations for care/medical management. Surveyor reviewed above findings for CR7, CR15-CR17 with EMP1 and requested he review the CR to determine if care met expectations for medical management of health problems.

On 3/2/18 at approximately 1:11 p.m., EMP1 confirmed findings for CR7 and that care did not meet his expectations for medical management.

On 3/2/18 at approximately 2:35 p.m., EMP1 confirmed findings for CR15, stated "no plan," and confirmed that care did not meet his expectations for medical management.

On 3/2/18 at approximately 2:40 p.m., EMP1 confirmed findings for CR16 and that care did not meet his expectations for medical management.. EMP1 confirmed visit note lacked evaluation of hair growth and treatment/care plan focused on hair growth only.

On 3/2/18 at approximately 3:20 p.m., EMP1 confirmed findings for CR17 and that care did not meet his expectations for medical management.




Plan of Correction:

In conjunction with the clinic medical director, physicians and APP a policy was developed to define the process for medical management and assessment of the patient and to ensure that all elements of patient medical management, assessment and care are complete. This policy is Patient Medical Management and Assessment- policy number 120 and is located in the RHC clinic policy and procedure manual. The policy language addresses the guidelines for medical management of health problems to include the reference source for medical guidelines, access to those guidelines and their relevance to management of patient order sets and templates as follows:
"POLICY: Medical Management and Patient Assessment
PURPOSE: To provide RHC practitioners with best practice guidelines and determine the process for medical management and assessment of the patients' health status based on these guidelines in addition to physician judgment and expertise for the development of the patient plan of care.
Definition:
Medical Management is the comprehensive plan for patient assessment and management providing clinicians with practical state of the art information on the diagnoses and treatment of medical conditions.
Patient Assessment- a comprehensive review of patient history, presenting condition, medications, physical examination, and determination of the need for additional health care services
PROCEDURE:
1. Medical Management is facilitated by the following processes:
a. Development of order sets that guide medical management of health problems in accordance with best practice guidelines. When order sets are developed or reviewed, the practitioners utilize "UpToDate" an on line, evidenced based clinical decision support that critically evaluates available medical literature, includes treatment recommendation, drug information and educational resources. UpToDate in integrated with the EMR so that practitioners can access the best practice recommendations as a guide for medical management.
b. When order sets are not utilized for medical management (example: treatment of the common cold), the EMR support team and the clinicians utilize "UpToDate" to
Develop templates to capture current conditions and treatment plans for patient care and assessment.
c. Performance of a comprehensive patient assessment
d. Development of a treatment plan
e. Determining a need for consultation and or referral
f. Identification of the need for follow-up care
g. Scheduling of the next follow-up appointment

2. Patient Assessment
The scope of assessment is determined by the patients ':
- Chief complaint
- History of present illness and family/social history
- Review of systems
- Vitals
- Physical Examination and assessment
- Current medications
- Condition and diagnosis
- Response to any previous care
- Consent to treatment
The provider will complete an assessment of the patient to include: review pertinent physical and medical history, presenting patient issues and concerns, current medications, physical exam as indicated, determination of the appropriate plan of care, the need for prescriptions for medications, orders for any follow up care or treatment and/or consult/referrals for specialty services, need for patient education and follow up visit.
3. Documentation of Medical Management and Assessment
All practitioners will be responsible for addressing the chief complaint with the patient and ensuring that that complaint is documented, updated and addressed at the visit. The process for management of the chief complaint is as follows:
a. Patients calling for appointments for a specific issue and for patient scheduling follow up or annual visits will have a chief reason/complaint logged into the note section of the Electronic Health Record (EHR) appointment screen. This chief complaint will flow electronically to the provider progress note.
b. The medical assistant will verify the reason for the patient visit and edit the chief complaint as needed. If no chief complaint is listed, the medical assistant will log the reason for the patient's visit into the electronic record.
c. The provider will review the documentation provided by the MA or nurse in the EHR.
d. The provider medical management plan will be documented in the electronic record progress note including the patient assessment, treatment plan, medications, recommendations for consultation/referral, follow-up visits and testing.
e. The provider will direct office support staff on any follow up visits or testing to be scheduled.
f. Any testing scheduled will be documented in the patients EHR."

Practitioner will be educated on policy content and responsibilities during the next RHC staff meeting scheduled on March 29, 2018. Evidence of education will be documented via read and sign of the policy.
Monitoring of the process for medical management will be accomplished by establishment of a process review team including the RHC Medical Director, Chief Medical Officer (CMO), physician, APP and the practice manager. The process review team will conduct audits of the process beginning in April (date to be coordinated with practitioners' schedules). The process review team will develop an audit tool and audit criteria that will include evaluation of the medical management process including: utilization of best practice resources, completeness of documentation addressing the patient visit, compliance with ordering and administration procedures and all follow up care and treatment. Five (05) charts will be chosen at random from the prior week's schedule. Audit deficiencies will be identified, recorded and addressed with the process review team committee, and practitioners will receive additional education as needed. When audits consistently confirm charts are properly completed without deficiency, audits will then be conducted on a monthly basis reviewing a minimum of ten (10) charts for an additional three (03) months.



491.9(c)(1) STANDARD
DIRECT SERVICES - GENERAL

Name - Component - 00
General. The clinic ... staff furnishes those diagnostic and therapeutic services and supplies that are commonly furnished in a physician's office or at the entry point into the health care delivery system. These include medical history, physical examination, assessment of health status, and treatment for a variety of medical conditions. .


Observations:


Based on review of clinic policy and clinical records (CR) and staff (EMP) interview, the clinical records lacked evidence that staff furnished diagnostic and therapeutic services, performed physical examinations, conducted assessments of health status, and developed and implemented treatment plans for a variety of medical conditions for nine (9) of twenty (20) CR reviewed (CR2, CR3, CR7, CR12-CR17).

Findings included:

Review of clinic policy on 3/1/18 at approximately 11:30 am revealed "Scope of Services...provide primary health care services to ambulatory adults, newborns and children."

Review of CR on 3/2/18 at approximately 10:10 a.m., 10:59 a.m., and 12:34 p.m. revealed:

CR2 (69 year old female) visited clinic on 1/2/18. "Reason for Appointment...Get Established [new patient]." EMP1 (physician and clinic medical director) noted "Colon cancer screening...Will check hemoccult testing. Never had c-scope [colonoscopy]." Patient to return to clinic in "6 Months." No evidence hemoccult testing completed. No followup with patient about hemoccult testing.

CR3 (83 year old male) visited clinic on 1/26/18. EMP1 ordered laboratory testing to including complete blood count with differential (CBC with diff) and comprehensive metabolic profile (CMP). Tests completed 2/6/18. Reviewed by EMP3 2/8/18. No evidence to show patient/family/representative informed of results.

CR7 (86 year old male) visited clinic on 1/31/18. "Reason for Appointment...4 mo. [followup]." Medical history included diabetes with long term insulin use and blood glucose monitoring supplies listed as current mediations/treatments for patient. EMP2 (physician) noted "We reviewed recent lab" (hemoglobin A1C of 6.0 on 1/24/18 -- within desired range). No evaluation of blood sugar readings obtained at home by patient/family/representative. According to prior visit 9/28/17, patient checking blood sugars every other day.

CR12 (101 year old female) visited clinic on 2/21/18 (first visit to clinic after hospital discharge). Patient was admitted to hospital and discharged 2/8/18. EMP1 noted "Left knee skin tear: steri strips pulled apart. Dressed with xeroform, as I instructed not to place [documentation unclear]...Seems to be granulating in well. Will need to heal by secondary intention. C/w [continue with] telfa and gauze wraps. Would like to see it dry up a bit." No education regarding wound care to patient/family/representative.

CR13 (85 year old male) visited clinic on 2/26/18. "Reason for Appointment...ER [emergency room] f/u/fell/staples in head/concussion." EMP1 noted "Fall in (into) shower or empty bathtub...Sounds that he slipped. I doubt syncope." No education regarding fall prevention interventions and/or assistive devices to assist with safe bathing to patient/family/representative.

CR14 (67 year old female) visited clinic on 2/26/18, "patient complains of, itching lesion left back." No assessment of lesion. No treatment/care plan for lesion. No education to patient about lesion. Next visit to clinic on 3/1/18. No evaluation of lesion. No treatment/care plan for lesion. No education to patient about lesion.

CR15 (61 year old female) visited clinic on 2/14/18. "Reason for Appointment...New [patient]." Medical history included hyperlipidemia and pure hypercholesterolemia. EMP2 noted "She does not take meds for high triglycerides or cholesterol...We reviewed recent labs" (blood urea nitrogen, calculated glomerular filtration rate, and creatinine -- no lipid studies). No treatment/care plan for high lipids. No education to patient about high lipids (i.e. diet, exercise). Medical records from prior primary care physician noted in CR. According to those records, lipid studies last completed in 10/2017 with elevated results. Cholesterol 280 mg/dl (desired range 0-200, high if greater than 240), triglycerides 242 mg/dl (high if 200-499), LDL 164 mg/dl (high if 160-189). Unclear if patient was aware of test results as not addressed with patient during 2/14/18 visit.

CR16 (40 year old female) visited clinic on 2/26/18. "Reason for Appointment...New/establish." Family history of diabetes (father) and heart disease (mother). EMP2 noted "menses are irregular...c/o [complaints of] fatigue and exhausted, has not been sleeping well, more facial hair." EMP2 ordered laboratory tests (testosterone) as treatment for hirsutism (hair growth) and TSH (thyroid studies) for fatigue. No evaluation of hair growth severity (i.e. Ferriman-Gallwey scale). No assessment or treatment/care plan for preventive care (i.e. vaccination history, gynecological care, laboratory studies to include CMP and lipids due to immediate family history of diabetes and heart disease). No education to patient.

CR17 (56 year old male) visited clinic on 3/1/18. "Review of Systems...patient complains of has [sic] pulsatile tinnitis right ear...Hospitalization/Major Diagnostic Procedure...ER Diverticulitis 2/2018." EMP2 noted "Recently had diverticulitis, went to ER and given ABX [antibiotic], few weeks ago." No evaluation of right ear or gastrointestinal system.

EMP8 was present during review of aforementioned CR and confirmed findings.

In addition, surveyor reviewed above findings for CR2, CR7, CR15-CR17 with EMP1 on 3/2/18 at approximately 12:55 p.m. and requested he review the CR to determine if care met expectations for patient care.

On 3/2/18 at approximately 1:02 p.m., EMP1 confirmed findings for CR2 and that care did not meet his expectations. EMP1 confirmed no evidence hemoccult cards given to patient/family/representative and no followup with patient to determine if testing completed.

On 3/2/18 at approximately 1:11 p.m., EMP1 confirmed findings for CR7 and that care did not meet his expectations.

On 3/2/18 at approximately 2:35 p.m., EMP1 confirmed findings for CR15, stated "no plan," and confirmed that care did not meet his expectations.

On 3/2/18 at approximately 2:40 p.m., EMP1 confirmed findings for CR16 and that care did not meet his expectations. EMP1 confirmed visit note lack evaluation of hair growth and treatment/care plan focused on hair growth only.

On 3/2/18 at approximately 3:20 p.m., EMP1 confirmed findings for CR17 and that care did not meet his expectations.




Plan of Correction:

In order to demonstrate evidence that the clinical records document the provision of diagnostic and therapeutic services, performance of physical examinations, conduction of the assessment of patient health status and development and implementation of treatment plans for a variety of medical conditions has been achieved; we have developed a chart audit of compliance with medical management processes.
The development of policy 120 "Medical Management and Patient Assessment" and its content demonstrates that the RHC staff have been provided with comprehensive guidelines and procedures to drive education efforts and the construct for monitoring and continued sustainment.
Practitioners will be educated on policy content and responsibilities during the next RHC staff meeting scheduled on March 29, 2018. Evidence of education will be documented via read and sign of the policy.
Monitoring of the process for medical management will be accomplished by establishment of a process review team including the RHC Medical Director, Chief Medical Officer (CMO), physician, APP and the practice manager. The process review team will conduct audits of the process beginning in April (date to be coordinated with practitioners' schedules). The process review team will develop an audit tool and audit criteria that will include evaluation of the medical management process including: utilization of best practice resources, completeness of documentation addressing the patient visit, compliance with ordering and administration procedures and all follow up care and treatment. Five (05) charts will be chosen at random from the prior week's schedule. Audit deficiencies will be identified, recorded and addressed with the process review team committee, and practitioners will receive additional education as needed. When audits consistently confirm charts are properly completed without deficiency, audits will then be conducted on a monthly basis reviewing a minimum of ten (10) charts for an additional three (3) months.



491.9(c)(3) STANDARD
DIRECT SERVICES - EMERGENCY

Name - Component - 00
The clinic ... provides medical emergency procedures as a first response to common life-threatening injuries and acute illness, and has available the drugs and biologicals commonly used in life saving procedures, such as analgesics, anesthetics (local), antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids.


Observations:


Based on observation, review of clinic policy, and staff (EMP) interview, the clinic failed to ensure availability of emergency drugs/biologicals commonly used in life saving procedures.

Findings included:

Observation during tour on clinic on 3/1/18 at approximately 9:10 a.m. revealed the following emergency drugs/biologicals: epinephrine (for allergic reaction), nitroglycerin (for chest pain), benadryl (for allergic reaction), rocephin (an antibiotic), aspirin (an antiinflammatory and/or analgesic), zofran (for nausea), and oxygen.

Staff interview with EMP5 at time of observation confirmed finding. Surveyor requested EMP5 write a list of emergency drugs/biologicals available onsite. EMP5 provided list same date at approximately 11:45 a.m. List consistent with observation above.

Review of clinic policy on 3/1/18 at approximately 11:30 am revealed "Clinical care...The clinic will keep the following items on site for emergency situations:...Zofran...Epinephrine...Nitroglycerin...Benadryl...Oxygen." (Did not match list prepared by EMP5 or emergency drugs/biologicals observed during tour.)





Plan of Correction:

The RHC provides medical emergency procedures as a first response to common life-threatening injuries and acute illnesses, and has drugs and biologicals commonly used in life saving procedures relevant to the population of our immediate geographic region and the most commonly identified medical conditions treated by first responders. These decisions are made by the practice physicians in conjunction with local EMS professionals who periodically review the list to determine the need for any amendments. Drugs and biological may be added or excluded from this list based on the geographical region and identified need of the population.
Clinic policy 5015- Medical Emergencies has been revised and updated to include emergency medications and the quantity of each maintained in the clinic. Included in the policy and available in the clinic for emergencies are:
- 4 tabs of Aspirin
- 1 vial of Lidocaine1%
- 1 vial of Rocephin
- 1 tablet of Zofran
- 1 bottle of Nitroglycerine
- 1 vial of Benadryl
- 1 ampule of Epinephrine
- 1 vial of Ativan - located in medication refrigerator
- 1 dose (.5ml) of Tetanus/diphtheria- located in medication refrigerator

Education will be provided to all staff will complete a read and sign of the medical emergencies policy by 3/16/18.
It is the responsibility of the office nurse to ensure that the medication is present in the clinic in the quantities required and continue to perform monthly medication inspections. The operations manager will perform random checks utilizing the emergency medication checklist to verify that medications are present in the quantities specified according to policy.



491.10(a)(3) STANDARD
RECORDS SYSTEM

Name - Component - 00
For each patient receiving health care services, the clinic ... maintains a record that includes, as applicable:

(i) Identification and social data, evidence of consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient;

(ii) Reports of physical examinations, diagnostic and laboratory test results, and consultative findings;

(iii) All physician's orders, reports of treatments and medications and other pertinent information necessary to monitor the patient's progress;

(iv) Signatures of the physician or other health care professional.


Observations:


Based on review of clinic policy and clinical records (CR) and staff (EMP) interview, the clinical records lacked assessment of status/needs, summary of treatment, orders, disposition, instructions to patient/family/representative, and/or other pertinent information for nine (9) of twenty (20) CR reviewed (CR2, CR3, CR7, CR12-CR17).

Findings included:

Review of clinic policy on 3/1/18 at approximately 11:30 am revealed:
"Medication Administration in the Clinics...All medications are given at the direction and under the supervision of a provider."
"Documentation Standards for the Medical Record...Policy: To provide standards to promote the capturing of accurate, legible, consistent, timely documentation in the...Medical record. To provide a concise reference for standards of documentation and promote the concurrent production of a legal document...General Guidelines...Document patient responses to treatment and interventions."

Review of CR on 3/2/18 at approximately 10:10 a.m., 10:59 a.m., and 12:34 p.m. revealed:

CR2 (69 year old female) visited clinic on 1/2/18. "Reason for Appointment...Get Established [new patient]." EMP1 (physician and clinic medical director) noted "Colon cancer screening...Will check hemoccult testing. Never had c-scope [colonoscopy]." Patient to return to clinic in "6 Months." No evidence hemoccult testing completed. No followup with patient about hemoccult testing. EMP8 administered pneumococcal vaccine during visit; however, there was no order to administer it.

CR3 (83 year old male) visited clinic on 1/26/18. EMP1 ordered laboratory testing to including complete blood count with differential (CBC with diff) and comprehensive metabolic profile (CMP). Tests completed 2/6/18. Reviewed by EMP3 2/8/18. No evidence to show patient/family/representative informed of results.

CR7 (86 year old male) visited clinic on 1/31/18. "Reason for Appointment...4 mo. [followup]." Medical history included diabetes with long term insulin use and blood glucose monitoring supplies listed as current mediations/treatments for patient. EMP2 (physician) noted "We reviewed recent lab" (hemoglobin A1C of 6.0 on 1/24/18 -- within desired range). No evaluation of blood sugar readings obtained at home by patient/family/representative. According to prior visit 9/28/17, patient checking blood sugars every other day.

CR12 (101 year old female) visited clinic on 2/21/18 (first visit to clinic after hospital discharge). Patient was admitted to hospital and discharged 2/8/18. EMP1 noted "Left knee skin tear: steri strips pulled apart. Dressed with xeroform, as I instructed not to place [documentation unclear]...Seems to be granulating in well. Will need to heal by secondary intention. C/w [continue with] telfa and gauze wraps. Would like to see if dry up a bit." No education regarding wound care to patient/family/representative.

CR13 (85 year old male) visited clinic on 2/26/18. "Reason for Appointment...ER [emergency room] f/u/fell/staples in head/concussion." EMP1 noted "Fall in (into) shower or empty bathtub...Sounds that he slipped. I doubt syncope." No education regarding fall prevention interventions and/or assistive devices to assist with bathing to patient/family/representative.

CR14 (67 year old female) visited clinic on 2/26/18, "patient complains of, itching lesion left back." No assessment of lesion. No treatment/care plan for lesion. No education to patient about lesion. Next visit to clinic on 3/1/18. No evaluation of lesion. No treatment/care plan for lesion. No education to patient about lesion.

CR15 (61 year old female) visited clinic on 2/14/18. "Reason for Appointment...New [patient]." Medical history included hyperlipidemia and pure hypercholesterolemia. EMP2 noted "She does not take meds for high triglycerides or cholesterol...We reviewed recent labs" (blood urea nitrogen, calculated glomerular filtration rate, and creatinine -- no lipid studies). No treatment/care plan for high lipids. No education to patient about high lipids (i.e. diet, exercise). Medical records from prior primary care physician noted in CR. According to those records, lipid studies last completed in 10/2017 with elevated results. Cholesterol 280 mg/dl (desired range 0-200, high if greater than 240), triglycerides 242 mg/dl (high if 200-499), LDL 164 mg/dl (high if 160-189). Unclear if patient was aware of test results as not addressed with patient during 2/14/18 visit.

CR16 (40 year old female) visited clinic on 2/26/18. "Reason for Appointment...New/establish." Family history of diabetes (father) and heart disease (mother). EMP2 noted "menses are irregular...c/o [complaints of] fatigue and exhausted, has not been sleeping well, more facial hair." EMP2 ordered laboratory tests (testosterone) as treatment for hirsutism (hair growth) and TSH (thyroid studies) for fatigue. No evaluation of hair growth severity (i.e. Ferriman-Gallwey scale). No assessment or treatment/care plan for preventive care (i.e. vaccination history, gynecological care, laboratory studies to include CMP and lipids due to immediate family history of diabetes and heart disease). No education to patient.

CR17 (56 year old male) visited clinic on 3/1/18. "Review of Systems...patient complains of has [sic] pulsatile tinnitis right ear...Hospitalization/Major Diagnostic Procedure...ER Diverticulitis 2/2018." EMP2 noted "Recently had diverticulitis, went to ER and given ABX [antibiotic], few weeks ago." No evaluation of right ear or gastrointestinal system.

EMP8 was present during review of aforementioned CR and confirmed findings.

In addition, surveyor reviewed findings for CR2, CR7, CR15-CR17 with EMP1 on 3/2/18 at approximately 12:55 p.m. and requested he review the CR to determine if care met expectations for patient care.

On 3/2/18 at approximately 1:02 p.m., EMP1 confirmed findings for CR2 and that care did not meet his expectations. EMP1 confirmed no evidence hemoccult cards given to patient/family/representative and no followup with patient to determine if testing completed.

On 3/2/18 at approximately 1:11 p.m., EMP1 confirmed findings for CR7 and that care did not meet his expectations.

On 3/2/18 at approximately 2:35 p.m., EMP1 confirmed findings for CR15, stated "no plan," and confirmed that care did not meet his expectations.

On 3/2/18 at approximately 2:40 p.m., EMP1 confirmed findings for CR16 and that care did not meet his expectations. EMP1 confirmed visit note lack evaluation of hair growth and treatment/care plan focused on hair growth only.

On 3/2/18 at approximately 3:20 p.m., EMP1 confirmed findings for CR17 and that care did not meet his expectations.




Plan of Correction:

In conjunction with the clinic medical director, physicians and APP a policy was developed for patient assessment to ensure patient health care records are complete. This policy ensures all providers orders, reports of treatment and medications and other pertinent information necessary to monitor the patient's progress has been identified and documented. This policy is Patient Assessment- policy number 120 and is located in the clinic policy and procedure manual.
The clinic will utilize the Clinical Record Audit form for periodic audits of patient records. Audits will be conducted by the Medical Director of the RHC, Chief Medical Director, physician and APP and the practice manager (quality improvement team). These audits will be conducted bi-weekly beginning 3/26/18 to review 5 charts per provider chosen at random from the prior weeks schedule. When audits confirm charts are properly completed, audits will be conducted on a monthly basis by the quality improvement team. . When progression is made to monthly audits 10 charts per provider will be chosen at random for review from the prior months schedule. All completed chart audit forms will be housed in the RHC binder.

Deficiencies will be recorded and addressed during the QI meeting. Re-education of deficiencies identified will ensure that providers are aware of importance of completeness of patient medical record in accordance with policy number 120.
The chart reviews will be located in the RHC binder.




491.10(b)(1) STANDARD
PROTECTION OF RECORD INFORMATION

Name - Component - 00
The clinic ... maintains the confidentiality of record information and provides safeguards against loss, destruction, or unauthorized use.


Observations:


Based on observation and staff (EMP) interview, the clinic failed to ensure confidentiality of patient health information.

Findings included:

Observation during tour on clinic on 3/1/18 at approximately 9:10 a.m. revealed "tickler" files with patient health information stored on top of the counter and in a plastic file box (with no lock) under the counter in the reception area. EMP7 reported the "tickler" files were maintained to monitor patient followup. EMP4 was present at the time of the observation and confirmed the finding. When asked who cleaned the clinic, EMP4 reported the clinic contracts with a third party vendor. EMP4 confirmed contract cleaning personnel had access to the reception area including the patient health information in the "tickler" files.





Plan of Correction:

On 3/2/2018 the tickler files were removed from the portable plastic file box. The files were placed in a permanent locking file cabinet within the reception area by the practice manager. The keys to the cabinet are secured by the receptionist and practice manager. The receptionist is responsible for ensuring the cabinet is locked at all times when not in use. This will ensure that these patient files are kept confidential and secure.
To ensure ongoing compliance a closing check list will be instituted by the practice manager and completed daily by an assigned staff member to ensure confidential information is secured at close of business. Practice manager will monitor this sheet daily. Staff will be educated by 3/16/18 on the end of day process. Education sheet with staff signatures confirming education will be located in RHC binder.