Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on June 22, 2022 through June 23, 2022, Bowman Health Center was found 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 June 22, 2022 through June 23, 2022, Bowman Health Center, 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, review of the specimen temperature recording log documentation and interview with the facility practice manager (EMP1), it was determined that the facility failed to ensure proper and complete documentation and monitoring of laboratory refrigerator and freezer temperatures for 4 (four) of 4 (four) observation dates. (OBS. #1 - #4)
Findings include:
On June 22, 2022, at approximately 10 a.m., tour of clinic laboratory with direct observation and review of Specimen Temperature Recording Log revealed the following:
OBS#1 - June 17th revealed no documentation
OBS#2 - June 20th revealed no documentation
OBS #3 - June 21st revealed no documentation
OBS #4 - June 22nd revealed no documentation.
NO year is documented with month.
Calibration date of refrigerator thermometer is blank.
Calibration date of freezer thermometer is blank.
EMP1 provided SA with copy of the current specimen temperature recording log. An interview with the EMP1 conducted on June 22, 2022, at approximately 10:20 a.m. confirmed the above findings. EMP1 stated "I don't think we have a specific policy for that, but I know they do them. They just didn ' t document the temperatures for those dates or the calibration dates and the year I guess. "
Plan of Correction:6/23/22 EMP1 educated on requirements for checking and logging specimen fridge and freezer temps daily. Also reviewed the need to document the Month, year, office location and the thermometer calibration dates on the specimen log.
Verbalized understanding.
The procedure has been reviewed with other clinical staff in the office as well.
6/27/22 Upon further investigation is was noted that the calibration date was listed on the back of the thermometer and since it is a traceable NIST thermometer we were able to obtain a duplicate certificate of calibration from the manufacturer which is now on file in the office.
The Month, year and calibration date are now filled in on the specimen log appropriately.
Beginning the week of 6/27/22 and for the next 2 months the log will be sent to the director of the RHC at the end of each week to ensure that it is completed appropriately.
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