Initial Comments:
This report is the result of a full Medicare recertification survey conducted on March 23, 2023, at Tri State Mobile X-Ray, Inc.. It was determined that the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 486 - Conditions of Participation for a Portable X-ray Provider.
Plan of Correction:
486.100(b) STANDARD
LICENSURE OR REGISTRATION OF PERSONNEL
Name - Component - 00
All personnel engaged in operating portable X-ray equipment are currently licensed or registered in accordance with all applicable State and local laws.
Observations:
Based on review of facility documents, personnel files (PF), and staff interview (EMP), it was determined the facility failed to ensure that one of four x-ray technologists maintained current certification (PF1).
Findings include:
Review of facility document "Safe Operating Procedures for X-ray Protection", last review/revision date not identified, revealed: " ... 1.) Only certified individuals, authorized by the practitioner or registrant may operate the x-ray machines. ...".
Review of PF1 on March 23, 2023, at approximately 9:15 AM revealed that the employee to PF1 is an X-ray technologist who is currently performing mobile radiographic procedures for Tri-State Mobile X-ray. Further review of PF1 revealed the following document: "THE AMERICAN REGISTRY OF RADIOLOGIC TECHNOLOGISTS" with the following information: "Valid Thru 09/2022 ... CQR Compliance Period(s) Radiography 9/1/2019 - 8/31/2022 ... This record is from the ARRT Verify Credentials directory, which is the primary source for verifying a Registered Technologist's certification and registration status. ...".
During an interview with EMP1 on March 23, 2023, at approximately 9:30 AM, EMP1 confirmed the above finding and stated that effective immediately, the employee to PF1 is no longer allowed to perform radiographic procedures until EMP1 receives confirmation from the American Registry of Radiologic Technologists that this employee's radiography certification has been renewed.
Plan of Correction: H0007
1. It was determined on March 23, 2023, that one of our four technologists license had expired. The employee was notified and sent home immediately; he is currently on leave until he presents to Tri-State Mobile X-ray a renewed license. The employee is currently working with ARRT on completing his requirements.
2. Management also failed to notice this date's expiration, so there will be (3) policies put into effect to prevent this from recurrence.
3. Plan of correction (1); Effective 03/25/2023 management downloaded and distributed the Pennsylvania Code Title 25 {221.16, this states that an individual who operates an X-ray system shall have additional instructions, including certification and registration in the applicable specialty by a professional organization, in this case ARRT. No employee will be permitted to work without a valid ARRT certification. Management discussed verbally with each individual employee on 03/24/2023 and 03/27/2023 that we will work with the employee to achieve success, by providing information on continuing education credits and access to resources and that we will provide time off for any testing requirements.
4. Plan of correction (2); Effective on 04/01/2023, Management updated the current system from a printed/paper method to an electronic method. The ARRT website https://www.arrt.org/ is a website that employers and x-ray technologists alike can access to check status of licensure. In addition, if there are any disciplinary actions on an employee's license that information will be available to the employer. Another advantage will be advising any employees of an upcoming expiration date. The systemic change we are making will be the monitoring of the AART website monthly. It has been decided that with monthly monitoring of each employee and their license status there will never be another employee permitted to work with an expired license.
5. Plan of correction (3): This will be done on the 15th of each month and a copy of the current license for that month will be digitally uploaded into a PDF file and stored in each employee's file.
486.104(c) STANDARD
EMPLOYEE RECORDS
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Current employee records must be maintained and include a resume of each employee's training and experience. Records also must contain evidence of adequate health supervision of employees including records of all illnesses and accidents occurring on duty, as well as results of preemployment and periodic physical examinations.
Observations:
Based on review of the facility's personnel files (PF) and staff interview (EMP), it was determined that the facility failed to ensure employees had periodic physical examinations for four of four personnel files reviewed (PF1, PF2, PF3, PF4).
Findings Include:
Review of facility's "Physical Exams and TB testing" document, last review/revision date not identified, revealed: " ... In order to stay compliant with the Department of Health requirements, all x-ray technologists that come in contact with Nursing Home residents are required to have periodical (sic) health screenings. ...".
Review of PF1, PF2, PF3, and PF4 on March 23, 2023, between approximately 9:30 AM and 10:30 AM revealed that all of these employees did not receive any periodic physical examinations or periodic health screenings.
During an interview with EMP1 on March 23, 2023, at approximately 11:00 AM, EMP1 confirmed that the employees to PF1, PF2, PF3, and PF4 come in contact with Nursing Home residents. When asked if these employees received any periodic health examinations or screenings, EMP1 confirmed that no periodic health examinations or screenings are conducted and replied "We are not following our policy".
Plan of Correction:H0036
Plan of Correction (1) There has been an update to our policy dated 03/25/2023 to reflect the current periodic health screening requirements and training of all employees following the CDC guidelines.
Plan of correction (2): We have put into place a systematic change to the storage of the employee records. Effective 04/14/2023, a separate folder has been created and is designated for health care related documents only. This folder is labeled, Employee Medical File. This file contains all documents pertaining to that specific employee's medical health records, including periodic screenings and TB test results.
The manager is responsible for maintaining the employees medical file and the manager will be responsible for making sure that the contents of each file are kept up to date.
Plan of Correction(3) To ensure that the contents of each employees medical file are kept up to date, management has put in to place a policy that ties in to each employees annual performance and raise discussion, a review of all of their current records.
The policy dated 04/14/2023 states that during each employees annual performance review, a review of current health screenings to include TB testing will also be presented, discussed and updated.
The employee will be given the materials and the time needed to complete any of their health screening employment requirements. This will include training videos, documents and guidance from the PA TB program.
Oversight by the supervising physician has been established and the manager and supervising physician will work together via e-mail and phone calls to make sure that the training materials, the preventative measures and the periodic health screenings are up to date, followed through and kept current.
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