Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on February 10, 2022, Penn Highlands Brookville was identified to be in compliance with the requirements of 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 unannounced Medicare recertification survey conducted February 10, 2022 Penn Highlands Brookville was found to be to have the following standard level deficiency that was determined to be in substantial compliance with the following requirements of 42CFR, Part 405, Subpart X and 42CFR Part 491.1-491.11 Subpart A, Conditions for Certification: Rural Health Clinics.
Plan of Correction:
491.10(a)(3)(i)-(iv) STANDARD
PATIENT HEALTH RECORDS
Name - Component - 00
491.10(a) Records system.
(3) 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 Medical Records (MR) and interview with clinic manager the clinic failed to ensure each record contained the social data of each patient receiving health care services for nine (9) of twenty (20) rewords reviewed. (MR #s,4-5, 7-10,13, 19-20).
Findings include:
Review of Medical records completed on 2-10-22 between approximately 1:00PM and 2:30PM revealed the following:
MR #4, treatment date: 1/11/22, did not contain any documented evidence that social data was obtained by the practitioner.
MR #5, treatment date: 1/12/22, did not contain any documented evidence that social data was obtained by the practitioner.
MR #7, treatment date: 1/14/22, did not contain any documented evidence that social data was obtained by the practitioner.
MR #8,treatment date: 1/18/22, did not contain any documented evidence that social data was obtained by the practitioner.
MR #9 treatment date: 1/21/22 did not contain any documented evidence that social data was obtained by the practitioner.
MR #10 treatment date: 11/21/22 did not contain any documented evidence that social data was obtained by the practitioner.
MR# 13, treatment date: 1/26/22 did not contain any documented evidence that social data was obtained by the practitioner.
MR#19, treatment date: 2/1/22 did not contain any documented evidence that social data was obtained by the practitioner.
MR#20, treatment date: 2/2/22 did not contain any documented evidence that social data was obtained by the practitioner.
An interview completed with the clinic Manager on 2/10/22 at approximately 3:00PM confirmed the above findings.
Plan of Correction:The facility will provide education on social data documentation standards to the identified physician assistant. The clinic manager or other qualified designee will complete the documentation education by 2/28/22. The physician assistant will attest in writing that he received this education.
The clinic manager or other qualified designee will conduct an audit of all facility providers to make sure no other providers have been affected by the same deficient practice. This audit will be completed within 60 days of the survey exit date (April 11, 2022).
Ongoing compliance/monitoring: Social data documentation will be audited by clinic manager or other qualified designee as part of the annual chart audit process for all facility providers. This audit will be used to monitor and assure that the deficient practice will not recur. Results of this chart audit will be reviewed by the facility medical director. Chart audit results will also be reviewed as part of the Professional Advisory Committee facility evaluation.
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