Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on August 22, 2023, Central Potter Health Center, was identified to be in 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 Medicare recertification survey completed August 22, 2023, Central Potter 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, policy and procedure review, and interview with the facility office manager and facility administrator, it was determined that the facility failed to ensure proper disposal of expired medical supplies for four (4) of four (4) observation made. Observations #1-#4.
Findings include:
Review of UPMC Cole Medication and Medical Supply Review Policy on 8/23/23 at 2:10 PM revealed: Purpose: " It is the policy of the Cole Memorial Medical group, a division of UPMC Cole, to safely store medications and medical supplies ensuring expired items are not used or available in storage areas. " Definition: " Medication and Medical Supply Review logs will be signed each month after all items have been reviewed for proper expiration dates. " All expired or soon to expire medication or supplies will be removed immediately. " Implementation: " Medication and Medical Supply review logs will be located and maintained in all areas of the practice where medications and supplies are stored .... " " Any supply found during the inspection that will expire before the end of the respective month or month immediately following inspection will be removed from the patient care area ... " Monitoring: " Office managers are responsible to ensure all medication and medical supplies are not expired ... "
Review of UPMC Cold Medication and Medical Supply Review Procedure policy on 8/23/23 at 2:25 PM revealed: Purpose: " It is the policy of the Cole Memorial Medical Group, doing business as (d/b/a) UPMC Cole, to safely store medications and medical supplies ensuring expired items are not used or available in storage areas ... " Definition: " Medication and Medical Supply review logs will signed each month after all items have been reviewed for proper expiration dates ... " " Any supply found during the inspection that will expire before the end of the respective month or month immediately following inspection will be removed from the patient care area ... "
1. Observation #1: On 08/22/23 at approximately 9:50 AM, review of Laboratory and medical supplies revealed the following:
Four (4) boxes of HemoCue Hb 201 Microcuvettes lab testing kits with expiration date of 07/31/23.
2. Observation #2: On 08/22/23 at approximately 12:00 PM, review of Laboratory and medical supplies revealed the following:
Three (3) unopened bottles of Clorox Healthcare Bleach Germicidal Wipes with expiration date of 07/21/23. Four hundred fifty (450) total wipes.
3. Observation #3: On 08/22/23 at approximately 2:40 PM, review of Emergency box revealed the following:
Two (2) twenty (20) gauge by one (1) inch BD Insyte Autoguard with expiration date of 7/31/2023.
4. Observation #4: On 08/22/23 at approximately 2:45 PM, review of Emergency box revealed the following:
Three (3) Braun Introcan Safety IV catheter Winged twenty-two (22) gauge by one (1) inch with expiration date of 7/1/23.
An interview conducted on 08/22/23 at approximately 3:00 PM with the Rural Health Center Administrator and Rural Health Center Office manager confirmed the above findings.
Plan of Correction:8/22/23 Expired items were immediately removed from the patient care area when identified during the survey.
8/23/2023 Office manager and clinical staff members were re-educated on the UPMC Cole Medication and Medical Supply Review Policy and UPMC Cole Medication and Medical Supply Review Procedure and included the following clarifying points.
1. Each month a designated clinical staff member (RN, LPN or MA) will inspect the storage areas for soon to expire medications and supplies.
2. Any supply found during the inspection that will expire before the end of the respective month or month immediately following inspection will be removed from the patient care area and
disposed of properly.
3. The designated staff member must document the inspection on the log for the area being reviewed.
4. The inspection will occur on or before the last day of the month.
Staff were given the opportunity to ask any questions and received clarifying information that any item that will be expiring prior to the next inspection needs to be removed from the patient care area and be disposed of. The manager and staff verbalized understanding and attested to understanding the policy and procedure based on signature on Educational Log Sheet obtained that will be kept on file for record keeping.
Going forward for the next 3 months the office manager will verify that staff responsible for completing the monthly inspection has done so and documented the inspection on the log sheet for the respective areas and will sign off on the log which will then be submitted to the facility administrator for review and record keeping, this will ensure that the process is sustained.
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