Initial Comments:
Based on the findings of an onsite unannounced initial Medicare certification survey completed on January 8, 2026, Penn Highlands Dubois was determined to be in substantial compliance with the following 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 initial Medicare certification survey completed January 7, 2026, Penn Highlands Dubois - Emporium, was found to have the following standard level deficiency that was 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:
491.8(b)(2), 491.8(c)(1)(i), and 491.9(b)(1), (2), (4) STANDARD
STAFFING AND STAFF RESPONSIBILITIES
Name - Component - 00
491.8(b) Physician responsibilities. The physician performs the following:
(2) In conjunction with the physician assistant and/or nurse practitioner member(s), participates in developing, executing, and periodically reviewing the clinic's . . . written policies and the services provided to Federal program patients.
491.8(c) Physician assistant and nurse practitioner responsibilities.
(1) The physician assistant and the nurse practitioner members of the clinic's . . . staff:
(i) Participate in the development, execution and periodic review of the written policies governing the services the clinic . . . furnishes;
§ 491.9(b) Patient care policies . . .
(1) The clinic's … health care services are furnished in accordance with appropriate written policies which are consistent with applicable State law.
(2) The policies are developed with the advice of a group of professional personnel that includes one or more physicians and one or more physician assistants or nurse practitioners. At least one member is not a member of the clinic . . . staff.
(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (b)(2) of this section and reviewed as necessary by the clinic...
Observations:
Based on a review of facility specific policies/procedures, review of patient medical records (MR) and an interview with the clinical director (EMP1) , the clinic failed to ensure provider documentation adhered with facility written policies/procedures for 14 of 20 MR's reviewed. (MR#1, 3, 4, 6, 8, 9, 10, 11, 13, 14, 15, 17, 18 and 19).
Findings include:
Review of facility policy/procedure "...Title: Chart Completion and Charge Submission... Policy: Charts must be completed within 72 hours from the time of the visit... Procedure: When a patient has an encounter in the physician practice with the physician, physician assistant or nurse practitioner, a chart note is started by the clinical staff memeber rooming the patient. The Provider will complete the provider portion of the chart note, enter the charges on the super bill and sign the note within 72 hours of the visit..."
Review of Medical Records (MR) on 1/7/26 between approximately 1:30 pm and 3:30 pm revealed the following:
MR#1; Date of Service (DOS) 1/2/25; documented date of provider signature is 2/22/25; greater than 72 hours from the time of visit.
MR#3; DOS 2/11/25; documented date of provider signature is 4/27/25; greater than 72 hours from the time of visit.
MR#4; DOS 2/21/25; documented date of provider signature is 3/1/25; greater than 72 hours from the time of visit.
MR#6; DOS 3/17/25; documented date of provider signature is 4/11/25; greater than 72 hours from the time of visit.
MR#8; DOS 4/15/25; documented date of provider signature is 4/27/25; greater than 72 hours from the time of visit.
MR#9; DOS 5/14/25; physician assistant signature obtained 5/14/25; physician co-signature not documented; no documentation that physician assistant's clinic visit was reviewed by supervising physician.
MR#10; DOS 5/30/25; documented date of provider signature is 10/31/25; greater than 72 hours from the time of visit.
MR#11; DOS 6/6/25; documented date of provider signature is 6/15/25; greater than 72 hours from the time of visit.
MR#13; DOS 7/21/25; documented date of provider signature is 7/29/25; greater than 72 hours from the time of visit.
MR#14; DOS 7/21/25; documented date of provider signature is 7/30/25; greater than 72 hours from the time of visit.
MR#15; DOS 8/14/25; documented date of provider signature is 9/7/25; greater than 72 hours from the time of visit.
MR#17; DOS 9/25/25; documented date of provider signature is 10/18/25; greater than 72 hours from the time of visit.
MR#18; DOS 9/22/25; documented date of provider signature is 10/16/25; greater than 72 hours from the time of visit.
MR#19; DOS 10/2/25; documented date of provider signature is 10/15/25; greater than 72 hours from the time of visit.
An interview with EMP1 on 1/7/2025 at approximately 4:30pm. confirmed the above findings, "We are aware and have spoken to the provider regarding the completion of the clinic visits in a timely manner."
Plan of Correction:Plan:
1.The Rural Health Center (RHC) Administrator is responsible for the completion of this plan of correction.
2.The RHC Administrator and Regional Manager will provide mandatory education to all providers and staff on February 5, 2026. Any providers who are absent due to illness and/or scheduled time off, will not have any patient contact, until the mandatory training is completed. Training will include the following:
a. Review of the policy and procedures for chart completion must be signed within 72 hours from the time of visit.
3. Beginning February 9, 2026, the RHC Administrator, or Regional Manager, will audit by running "Open Note Report" weekly and reviewing for deficiencies for three consecutive months with an expected target of 100% compliance.
a. If 100% compliance is not achieved in 3 months, weekly reports will continue until 100% compliance is met for three consecutive months. Once 100% compliance is met, reports will continue weekly to validate that compliance is sustained.
b. The Progressive Discipline process will be utilized and documented for providers who do not comply with Chart Completion and Charge Submission policy.
c. Audit results will be reported at the RHC monthly staff meetings and with the Medical Director.
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