QA Investigation Results

Pennsylvania Department of Health
ELDERTON HEALTH CENTER
Health Inspection Results
ELDERTON HEALTH CENTER
Health Inspection Results For:


There are  3 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:


Based on the findings of an onsite unannounced recertification survey completed on 2/9/18, Elderton Health Center was found to be in compliance with the requirements of 42 CFR, Part 491.12, Subpart A, Conditions for Certification: Rural Health Clinics - Emergency Preparedness.





Plan of Correction:




Initial Comments:

Based on the findings of an onsite unannounced Medicare recertification survey completed 2/9/18, Elderton Health Center was found not to be in compliance with the following requirement(s) 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 a review of Facility Testing Logs and Staff Interview, between 1/4/18 and 2/8/18, the facility failed to fully document Laboratory Testing Logs. Specifically, the facility failed to fully document 3 of 12 Rapid Strep [testing for strep throat] Test logs and 4 of 14 Urinalysis [testing urine for the presence of disease] Test logs.

Findings Included:

A review of Facility Testing Logs on 2/8/18 at approximately 10:00 AM, revealed the following incomplete documentation regarding Urinalysis Testing:

Testing on 1/12/18 and 2/5/18 failed to show documentation of the identity of the Technician performing the test. Additionally, between 1/4/18 and 2/8/18 two additional documented tests failed to show the date the test was completed and the identity of the Technician who performed the test.

A review of Facility Testing Logs on 2/8/18 at approximately 10:00 AM, revealed the following incomplete documentation regarding Rapid Strep Testing.

A test completed on 1/23/18 failed to document the results of the testing and if the backup culture testing [test sent to the lab used confirm the rapid test result] was conducted.

Two tests completed on 1/11/18 failed to document if the backup culture testing was conducted.

An interview with the Office Manager (EMP1) on 2/8/18 at approximately 10:30 AM, confirmed the above findings.




Plan of Correction:

Testing logs were reviewed to determine areas of deficiencies and documentation that was required. Urinalysis testing logs were revised to document control testing and identify patients tested with each lot number. Results of urine testing are no longer recorded on the log sheets as they are recorded in the patient electronic record.
Strep testing logs were also revised to document control testing and patient names. This revision eliminated documentation of a back up culture being sent as this information can be found on the patient electronic record.
All staff were educated on the new urinalysis and strep testing logs on 3/1/18 and the importance of documenting the date and their signatures. A listing of the staff completing the education is maintained in the RHC binder under staff education.
Rachel Navarrete office coordinator will review and initial the log sheets on a weekly basis for compliance. If any staff member is found to be non -compliant they will be re-educated. After a three month period of weekly monitoring and ensured compliance, the reviews of log sheets will be performed monthly.



491.6(b)(2) STANDARD
MAINTENANCE

Name - Component - 00
Drugs and biologicals are appropriately stored; and



Observations:


Based on a review of clinic policies and procedures and the sample medication logs, observations made during a tour of the clinic, and a staff interview with the office manager, the clinic failed to follow policy and procedure to ensure that twenty seven (27) medication logs for sample medications matched the actual count of the sample medications present during the survey.

Findings Included:

A review of agency policy and procedure on 02/09/2018 at approximately 10:00 a.m. revealed "POLICY: SAMPLE MEDICATION IN THE CLINICS ... Procedure ... 2. Upon delivery of samples to the Primary Care Center, the office staff will complete there drug sample log listing the drug name ... total number of units delivered ... 11. Upon dispensing of a sample medication, the patient's name, drug, date dispensed, expiration , lot number, physician and amount dispensed will be documented in the Sample Log Book. ... 15. If any part of this policy, i.e. , inaccurate logs and violations of Federal and State Regulations, is not being followed, medication sample privileges will be REVOKED. ... ."

A review of the sample medication logs conducted on 2/8/18 at approximately 10:45 a.m. revealed the following discrepancies when compared to the actual count of the sample medications conducted during the survey:

Dexilant [medication used to treat heartburn] 60 mg [milligrams] The sample medication log revealed a count of twelve (12) verses an actual count of eleven (11).

Bystolic [medication used to treat high blood pressure] 5mg. The sample medication log revealed a count of three (3) verses an actual count of four (4).

Brintellix [medication used to treat depression] 5mg. The sample medication log revealed a count of twenty three (23) verses an actual count of twenty four (24).

Asmanex HFA [medication used to treat asthma] 200mcg [micrograms]. The sample medication log revealed a count of one (1) verses an actual count of two (2).

Dulera [medication used to treat asthma] 100mcg/5mcg. The sample medication log revealed a count of four (4) verses an actual count of three (3).

Eucrisa Ointment 2% [ointment to treat skin irritation]. The sample medication log revealed a count of eighteen (18) verses an actual count of ten (10).

Invokamet [medication used to treat diabetes] 50/500mg. The sample medication log revealed a count of zero (0) verses an actual count of two (2).

Invokamet 150/500mg. The sample medication log revealed a count of two (2) verses an actual count of zero (0).

Invokamet 150/1000mg. The sample medication log revealed a count of one (1) verses an actual count of zero (0).

Invokamet XR [extended release] 50/1000mg. The sample medication log revealed a count of five (5) verses an actual count of zero (0).

Januvia [medication used to treat diabetes] 100mg. The sample medication log revealed a count of two (2) verses an actual count of one (1).

Jentadueto [medication used to treat diabetes] 2.5mg/850mg. The sample medication log revealed a count of four (4) verses an actual count of zero (0).

Movantik [medication used to treat constipation] 25mg. The sample medication log revealed a count of four (4) verses an actual count of zero (0).

Nexium 24 hour [medication used to treat acid reflux]. The sample medication log revealed a count of sixteen (16) verses an actual count of eleven (11).

Onglyza [medication used to treat diabetes] 2.5mg. The sample medication log revealed a count of five (5) verses an actual count of one (1).

Spiriva Resp [medication used to treat asthma] 2.5mcg. The sample medication log revealed a count of six (6) verses an actual count of five (5).

Symbacort [medication used to treat asthma] 80/4.5. The sample medication log revealed a count of one (1) verses an actual count of zero (0).

Symbacort 160/4.5. The sample medication log revealed a count of five (5) verses an actual count of one (1).

Synjardy [medication used to treat diabetes] 5/500mg. The sample medication log revealed a count of three (3) verses an actual count of two (2).

Synjardy XR 5mg/1000mg. The sample medication log revealed a count of two (2) verses an actual count of zero (0).

Trintellix [medication used to treat depression] 5mg. The sample medication log revealed a count of thirty six (36 verses an actual count of sixteen (16).

Viagra [medication used to treat erectile dysfunction] 100mg. The sample medication log revealed a count of eight (8) verses an actual count of nine (9).

Viibryd [medication used to treat depression] 40mg. The sample medication log revealed a count of three (3) verses an actual count of zero (0).

Vytorin [medication used to treat high cholesterol] 10/20mg. The sample medication log revealed a count of one (1) verses an actual count of none (0).

Xarelto [medication used to prevent blood clots] 15mg. The sample medication log revealed a count of five (5) verses an actual count of zero (0).

Xarelto [medication used to prevent blood clots] 20mg. The sample medication log revealed a count of ten (10) verses an actual count of seven (7).

Zetia [medication used treat high cholesterol] 10mg. The sample medication log revealed a count of four (4) verses an actual count of zero (0).

An interview with the clinic office manager (EMP1) on 2/8/18 at approximately 11:40 a.m. confirmed the above findings.




































Plan of Correction:

In accordance with APCC Sample Medication in the Clinics Policy number 5806 item 15 "if any part of this policy, i.e. inaccurate logs and violations of Federal and State Regulations, is not being followed, medication sample privileges will be revoked."

All sample medications were identified and removed from the clinic on 2/13/18 by Linda McCollough Operations Manager and disposed of according to sample medication APCC policy number 5806, item 14 which states that sample meds can be disposed of by removing from packaging and mixing with used coffee grounds and placed in a biohazard container. This process was witnessed and verified by Rachel Navarrete office coordinator
All staff was educated on 2/13/18 that the office was no longer accepting any sample medications and that any samples received by mail will be returned to sender. A confirmation education read and sign was completed on 3/1/18. A copy of the education sheet is filed in the RHC binder.
The office coordinator will survey the office weekly to ensure compliance with this process. A log will be maintained showing completion. This log will be maintained in the RHC binder under the monthly tabs. Upon compliance at the end of three months, surveys will be completed monthly. If at any time the office is found to be non compliant then staff will be re-educated and the office coordinator will resume weekly inspections and remove any sample medications found.
Rachel Navarrete practice coordinator is responsible for implementing and monitoring this POC.