Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on April 22, 2021 through April 23, 2021, St. Luke's Miners Health Center-Hometown, was determined to be in compliance with the following 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 onsite unannounced Medicare recertification survey completed April 22, 2021 through April 23, 2021, St. Luke's Miners Health Center-Hometown was identified 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:
491.6(b) and (b)(1) STANDARD
PHYSICAL PLANT AND ENVIRONMENT
Name - Component - 00
491.6(b) Maintenance:
The clinic . . . has a preventive maintenance program to ensure that:
(1) All essential mechanical, electrical and patient-care equipment is maintained in safe operating condition;
Observations:
Based upon observation, policy and procedure review, and interview with the facility practice supervisor and facility administrator, it was determined that the facility failed to ensure proper disposal of expired laboratory supplies for one (1) of one (1) observation made. Observation #1
Findings include:
An interview with the facility administrator conducted on 04/23/21 at approximately 2:00 PM revealed: administrator stated "There hasn't been any changes made or any new policies created just additional checks on supplies since our survey at Nesquehoning."
Observation #1: On 04/22/21 at approximately 1:15 PM, review of Laboratory and supplies revealed the following:
Five (5) of five (5) culture swabs with expiration date 03/31/2021
One hundred fifty three (153) of one hundred fifty three (153) Mckesson insulin syringes with needles with expiration date 03/20/2020
Forty six (46) of forty six (46) purple top vacuttes six (6) milliliters (ml) with expiration date 04/16/2021
Three (3) of three (3) Quantiferon TB Gold Plus testing kits, four (4) tube test kit with expiration date 05/31/2020
Five (5) of five (5) 2.0 millimeter (mm) biopsy punch with expiration date 02/25/2021
Five(5) of five (5) 3.0 millimeter (mm) biopsy punch with expiration date 02/25/2021
Four(4) of four (4) 4.0 millimeter (mm) biopsy punch with expiration date 03/11/2021
Five(5)of five (5) 5.0 millimeter (mm) biopsy punch with expiration date 03/18/2021
Three(3) of three (3) 6.0 millimeter (mm) biopsy punch with expiration date 03/11/2021
An interview conducted on 04/23/21 at approximately 2:15 PM with the Rural Health Center Administrator and Rural Health Center Practice Supervisor confirmed the above findings.
Plan of Correction:Plan of Correction
Expired Products - Plan of Correction
- Re-educate staff on 4/30/21 on the proper way and the importance to accurately document and check needed for outdated supplies.
- We will continue to practice the tracking system with stickers to prevent expired meds.
- Implement an in-house mock survey.
Ensure plan of correction stays in place:
- We will be conducting an in-house mock survey by pulling Medical Assistants from different clinics to conduct surveys at other locations.
- Random checks – once every two months by staff members conducting a mock survey and report findings to practice manager Suzanne Smith who will provide evidence of these checks to the Director of RHC
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