Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on 6/10/19 through 6/12/19, Family Health Care Meyersdale RHC 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 conducted on 6/10/19 through 6/12/19, Family Health Care Meyersdale RHC was identified to have the following standard level deficiencies that were determined to be in substantial 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:
491.4(b) STANDARD
LICENSURE/CERT/REGISTRATION OF PERSONNEL
Name - Component - 00
Staff of the clinic ... are licensed, certified or registered in accordance with applicable State and local laws.
Observations:
Based on review of State Board of Nursing requirements, personnel file review and interview with staff (EMP), the facility failed to ensure, two (2) of two (2) collaborative agreements for CRNPs were reviewed and updated once every two (2) years (EMP3, EMP4).
Findings included:
Per STATE BOARD OF NURSING [49 PA. CODE CH. 21] Certified Registered Nurse Practitioners; General Revisions [39 Pa.B. 6994]
"...21.285. Prescriptive authority collaborative agreements.
(a) The prescriptive authority collaborative agreement between a physician and a CRNP who will prescribe and dispense drugs and other medical therapeutic or corrective measures, as set forth in 21.283(a) (relating to authority and qualifications for prescribing, dispensing and ordering drugs) must satisfy the following requirements. The agreement must:
...(7) Be reviewed and updated by the parties at least once every 2 years or whenever the agreement is changed..."
Review of personnel files on 6/10/19 at approximately 2:30 p.m., revealed the following:
PF 3, date of hire 2/23/17, contained collaborative agreement between EMP5 (MD) and EMP6 (medical director) and EMP3 (CRNP) effective 1/31/17. Evidence for agreement reviewed and/or updated once every two years was not found.
PF 4, date of hire 7/13/09, contained collaborative agreement between EMP6 (medical director) and EMP4 (CRNP) effective 8/31/15. Evidence for agreement reviewed and/or updated once every two years was not found.
During interview on 6/10/19 at approximately 4:00 p.m., EMP19 confirmed findings, "...normally HR [human relations] handles credentialing...didn't realize not done...will fix this..."
Plan of Correction:The collaborative agreements for the CRNP's were reviewed and updated with their collaborating physicians immediately following the survey.
On an annual basis during the CRNP's yearly evaluation, the collaborative agreements will be reviewed, updated, signed and retained on file by the office practice manager. Facilitating this process during the yearly employee evaluations will ensure compliance of this regulation.
491.6(b)(2) STANDARD
MAINTENANCE
Name - Component - 00
Drugs and biologicals are appropriately stored; and
Observations:
Based on observations, and staff (EMP) interview, the facility failed to maintain a preventative maintenance program to ensure expired drugs and supplies were not available for use and were discarded in accordance with manufacturer's directions for use.
Findings included:
During observational tour of facility on 6/10/19 at approximately 11:35 a.m., surveyor observed the following:
Laboratory area: Potassium Hydroxide Reagent Droppers (more than 20) lot#6130857, expired 4/30/18. (used for direct smears to exam for fungal elements.) Four bottles of Hemocult developer solution (used for fecal occult blood testing) expired 3/19.
Exam room 1: Sterile Water 500 ml bottle open, partially used, lot#G132175, expiration 1/21.
Exam room 6: Sterile Water 500 ml bottle open, partially used, lot#G134379, expiration 5/21, and labeled opened 5/21/19.
Exam room 9: Sterile Water 500 ml bottle open, partially used, lot#G132175, expiration 1/21, and labeled opened 4/2/18.
Exam room 12: Hemocult developer solution expired 3/19.
Exam room 13: Sterile Water 500 ml bottle open, partially used, lot#G134379, expiration 5/21, and labeled opened 1/25/19.
During tour on 6/10/19 at approximately 11:35 a.m., EMP19 confirmed the above findings, "...staff are assigned areas...supplies should have been checked and discarded..."
Review on 6/10/19 at approximately 12:35 p.m., per manufacturer directions for use, Sterile Water for Irrigation, "...use the contents of the opened container immediately to minimize the potential for bacterial growth and pyrogen formation. Discard the unused contents of opened containers, as Sterile Water for Irrigation contains no antimicrobial preservative..."
Plan of Correction:A supply inventory checklist was developed. On a weekly basis staff will be assigned to facilitate weekly supply inventory which will include review for expired supplies. The employee will sign and date weekly checklist. The office manager will complete a monthly spot check review for the purpose of ensuring expired supplies are removed from the office during the weekly checks. The compliance of the weekly and monthly checklists will become a standing agenda item during the monthly staff meeting.
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