Initial Comments:
Based on the findings of an unannounced onsite Medicare recertification survey conducted 11/8/23 through 11/9/23, Coudersport Home Training 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 unannounced, onsite Medicare recertification survey conducted 11/8/23 through 11/9/23, Coudersport Home Training, was identified to have the following standard level deficiencies that were determined to be in sustantial compliance with the following requirements of 42 CFR, Subparts A, B, C, and D: Conditions for Coverage for End-Stage Renal Disease (ESRD) Suppliers.
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 reviews of personnel files (PF), policy and procedure, and an interview with the clinic administrator, it was determined the Medical Director failed to ensure Employee Tuberculosis Testing was conducted according to policy for three (3) out of three (3) PF's reviewed (PF#1-PF#3).
Findings:
Review of clinic policy on 11/9/23 at 9:15 AM states "Tuberculosis Monitoring and Follow Up If exemption criteria for TST is not met, the following testing options are available: i. Baseline TST using a two step Purified Protein Derivative (PPD) Mantoux test (a second TST is repeated one to three weeks after the first, if the initial test is negative. Test results will be recorded on the teammate Health Monitoring Record."
Review of personnel files on 11/9/23 at 8:30 AM revealed the following:
PF#1 (Date of Hire (DOH) 7/2/23) revealed no documentation of a two-step tuberculin skin test (TST) screening.
PF#2 (DOH: 10/4/21) revealed no documentation of a two-step tuberculin skin test (TST) screening.
PF#3 (DOH 5/22/23) revealed no documentation of a two-step tuberculin skin test (TST) screening
An interview with the facility administrator on 11/9/23 at approximately 10:30AM confirmed the above findings.
Plan of Correction:V 715
A Governing Body meeting was held on 11/17/23 with the Medical Director, Facility Administrator, Director of Nursing and Regional Operations Director to review the results of the survey ending on 11/09/23. The Governing Body reviewed Policy COMP-DD-017 "Medical Director Qualifications and Responsibilities" with the Medical Director, who acknowledges that he/she is responsible to ensure 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 non-physician providers. Plan of correction has been developed and initiated to correct identified deficiencies and to sustain compliance.
The Facility Administrator or designee held mandatory in-services for all clinical teammates and Medical Director starting on 11/17/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 4-06-05 "Tuberculosis (TB) Monitoring and Follow Up" with the emphasis on but not limited to: 1) NOTE: Teammates will adhere to requirements related to initial and annual testing if required by their institution or local/state health departments. 2) Baseline new hire requirements for all new teammates including volunteers, per diem teammates, non-agency personnel and teammates will complete the following: 1. TN-Risk Assessment and Symptom Evaluation Questionnaire. 2. Successful completion of Tuberculosis Education for New Teammates course. 3. Testing options ... c. If exemption criteria for TST is not met, the following testing options are available: i. Baseline Tuberculin Skin Testing (TST) using a two-step Purified Protein Derivative (PPD) Mantoux test (a second TST repeated one to three weeks after the first, if the initial test is negative). Test results will be recorded on the Teammate Health Monitoring Record. Verification of attendance at in-service will be evidenced by teammate's and Medical Director's signatures on the in-service sheet.
The Facility Administrator or designee immediately completed a one hundred percent (100%) audit of teammate medical records to verify documentation of TB monitoring is complete. Any missing TST testing information, including testing for teammates identified by the surveyor, will be completed with the first step by 11/29/23 and second step by 12/11/23. The Facility Administrator will audit one hundred percent (100%) of new teammate's medical records monthly for two (2) months to verify screening is completed and documentation recorded per policy. Ongoing compliance will be monitored with quarterly teammate file audits. Instances of non-compliance will be addressed immediately.
The Medical Director will review progress of teammate education, results of all audits, and adherence to this plan of correction during monthly Quality Assessment Performance Improvement meetings known as the Facility Health Meeting. The Facility Administrator will report progress, as well as any barriers to maintaining compliance, with supporting documentation included in the meeting minutes. Action plans will be evaluated for effectiveness, new plans developed as applicable to achieve compliance with teammate adherence to policy and procedure. The Facility Administrator on behalf of the Governing Body is responsible for compliance with this plan of correction.
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