Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on October 24, 2023, Renal Care Group-Limerick, was found to be in compliance with the requirements of 42 CFR, Part 494.62, Subpart B, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services-Emergency Preparedness.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on October 24, 2023 Renal Care Group-Limerick, was identified to have the following standard level deficiency, and was determined to be in substantial compliance with the following requirements of 42 CFR, Part 494, Subparts A, B, C, and D, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services.
Plan of Correction:
494.150(c)(2)(i) STANDARD
MD RESP-ENSURE ALL ADHERE TO P&P
Name - Component - 00
The medical director must-
(2) Ensure that-
(i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;
Observations:
Based upon Personnel File (PF) review, ESRD policy and procedure review, and an interview with the ESRD administrator, it was determined the Medical Director failed to ensure Employee Tuberculosis Testing was conducted according to ESRD policy for three (3) out of three (3) PF's reviewed (PF#1-PF#3).
Review of ESRD policy "Employee Tuberculosis Testing" states "...TB testing using the two-step tuberculin skin test (TST) method is required upon hire."
Review of PF#1 (Date of Hire (DOH) 1/01/2023) on 10/24/2023 at approximately 10:50 AM revealed no documentation of a two-step tuberculin skin test (TST) screening
Review of PF#2 (DOH: 8/23/2021) on 10/24/2023 at approximately 11:00 AM revealed no documentation of a two-step tuberculin skin test (TST) screening.
Review of PF#3 (DOH: 11/11/2021) on 10/24/2023 at approximately 11:10 AM revealed no documentation of a two-step tuberculin skin test (TST) screening.
An interview with the facility administrator on 10/24/2023 at approximately 1:15 PM confirmed the above findings.
Plan of Correction:For ongoing compliance by November 1, 2023, The Director of Operations (DO) will meet with the Facility Administrator (FA) to review:
· Employee Tuberculosis Testing
The meeting will review the importance of all newly hired staff having a two-step tuberculin skin test (TST) administered upon hire.
To ensure compliance, all employees' files will be reviewed for their tuberculosis status by the FA or designee. If their medical record does not have evidence of a two-step TST completed upon hire, a two-step TST will be administered. Documentation of the tuberculin testing with the results will be available in the employees' personnel file. The audit of the employee files will be completed by November 10, 2023.
By November 3, 2023, the Director of Operations (DO) and the FA will meet with the Medical Director to review the Medical Director Responsibilities as defined in the Conditions for Coverage. The meeting will also review the following policy:
· Employee Tuberculosis Testing
The Medical Director will be informed at the meeting with the DO and FA that the FA has received education of the above policy with the focus on the importance of ensuring that all new employees receive a two-step tuberculin skin test upon hire. The training will also review the importance of ensuring that there is documentation of the testing in the employee's personnel file.
The inservice will be completed by November 3, 2023, with documentation on file at the facility.
The FA or designee will perform audits of all newly hired staff within two weeks of the start date. The FA will report the findings of the new hire TB audit at the monthly Quality Assessment and Performance Improvement (QAPI) schedule. A plan of correction (POC) audit tool will be used for the audits.
Issues of non-compliance will be re-education and counseling by the DO.
Sustained compliance will be monitored by the QAPI committee.
Completion date: December 8, 2023
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