Initial Comments:
Based on the findings of an onsite unannounced recertification survey completed on 12/6/18, BRMC Rural Health Clinic Pediatric Associates was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42 CFR, Part 491.12, Subpart A, Conditions for Certification: Rural Health Clinics - Emergency Preparedness.
Plan of Correction:
491.12(d)(1) STANDARD
EP Training Program
Name - Component - 00
§403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:]
(1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.
*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and
procedures.
*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.
*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures.
*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.
*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.
*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.
Observations:
Based on a review of clinic policy, emergency preparedness documentation and staff interview, the clinic failed to conduct initial training in emergency preparedness policies and procedure to all new or existing staff.
Findings Included:
A review of agency policy and procedure, conducted on 12/5/18 at approximately 1:00 p.m. revealed: ".... TITLE: Emergency Operations Plan ... Education Education and in-service training is done at the time of hire through, new employee orientation program and department orientation, the annual in-service education process, and through disaster drill exercises. Staff competencies will be completed yearly and staff will also be evaluated during disaster drills. ... ."
A review of clinic emergency preparedness documentation on 12/5/18 at approximately 12:10 p.m. revealed no documentation to show that new or existing staff received initial and/or annual training on emergency preparedness policy and procedure.
An interview with EMP3 on 12/5/18 at approximately 12:22 p.m. confirmed the above findings revealing "Correct, it [emergency preparedness training] is scheduled for sometime in the future".
An interview with the Emergency Preparedness Manager (EMP7) on 12/6/18 at approximately 9:35 a.m. revealed that the clinic's initial emergency training education is scheduled for "12/13/18 at 7:30 a.m.".
Plan of Correction:Pediatric Associates will participate in an individual emergency preparedness annual exercise. In addition, Director of plant services and Manager of physician practices will facility will develop a tabletop exercise for the staff at the practice. The office coordinator or a representative from the office will participate in the emergency preparedness team meetings at BRMC. This meeting will include the development and implementation of training for natural or man-made emergency situations. The team, member in conjunction with the practice management team and a facilitator, will provide training to the office staff, documentation of the trainings and discussion will be maintained. The emergency preparedness plan will be adjusted based on any findings during these discussions to ensure that we are effectively managing natural or man-made emergency situations. These trainings will include tabletop trainings.
The first training exercise was conducted on 12/13/18. Minutes of the exercise and after action plans were be done and kept in the Emergency Preparedness binder on site.
The annual exercise will be provided to the Hospital Safety Committee for review.
The 2019 annual training will be provided during the next 8 months
Initial Comments:
Based on the findings of an onsite unannounced recertification survey completed on 12/6/18, BRMC Rural Health Clinic Pediatric Associates was identified to have the following standard level deficiencies that were 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)(2) STANDARD
MAINTENANCE
Name - Component - 00
Drugs and biologicals are appropriately stored; and
Observations:
Based on a review of clinic refrigerator and freezer temperature logs and staff interview the clinic staff failed to notify the practice manager with daily temperature readings that were documented as out of range to ensure all drugs and biologicals were being stored and maintained in accordance with clinic temperature ranges from 10/1/18 to 11/30/18.
Findings Included
A review of clinic freezer logs on 12/5/18 at approximately 11:00 a.m. revealed " ... Record CURRENT, MIN [minimum], and MAX [maximum] TEMPERATURES TWICE A DAY. ... Frozen vaccine SAFETY ZONE IS 5?F [degrees farenheit] (-15?C[degrees celsius]) or lower. 0?F or colder is ideal.
A further review of clinic freezer logs revealed that temperature readings were documented as out of range on the following dates: 10/4/18, 10/7/18, 11/1/18, 11/2/18, 11/5/18, 11/6/18, 11/7/18, 11/12/18, 11/27/18, and 11/30/18.
A review of clinic refrigerator logs no 12/5/18 at approximately 11:00 a.m. revealed "... Record CURRENT, MIN [minimum], and MAX [maximum] TEMPERATURES TWICE A DAY. ... Refrigerated vaccine safety zone is between 36? to 46?F (2? to 8?C) or lower. 40?F is ideal. ... ."
A further review of clinic refrigerator logs revealed that temperature readings were documented as out of range on the following dates: 10/21/18 and 10/9/18
There was no documentation of any notification of the aforementioned temperature readings that were documented as out of range to ensure all drugs and biologicals were being stored and maintained in accordance with clinic temperature ranges.
An interview with EMP3 and EMP4 on 12/6/18 at approximately 11:00 a.m. confirmed the above findings that nobody was notified of the readings documented as out of range with EMP4 stating "it should have been handled". EMP3 revealed that the refrigerators and freezers had a backup system to monitor temperature that would alarm in the pharmacy of the hospital that this clinic is part of if the temperature readings went out of range. When asked if the temperature readings documented as out of range were ever compared to the online backup system to determine accuracy, EMP4 revealed that they were not.
Plan of Correction:All employees were re-educated as to policy of out of range temperatures.
Temperature logs will be faxed for review to the practice manager weekly and reviewed with staff weekly. All out of range temps are reported daily to practice management. Logs will be faxed for a period of three (3) months for compliance. This started on 12/10/18 and will continue through March 10, 2019. If logs are not 100% compliant during these 3 months, continuous monitoring will be ongoing through 2019 weekly until 100% compliance is reached continuously for a period of 3 month increments.
491.11(d) STANDARD
EVALUATION FINDINGS & ACTION TAKEN
Name - Component - 00
The clinic ... staff considers the findings of the evaluation and takes corrective action if necessary.
Observations:
Based on a review of the clinic annual program evaluation and staff interview, the clinic failed to ensure the medical director was directly involved in the program evaluation, evaluation findings and recommendations for change for 2017.
Findings Included:
A review on 12/5/18 at approximately 12:00 p.m. of the agency annual program review for 2017 revealed "... ANNUAL PROGRAM EVALUATION REPORT ... DATE: December 22, 2017 ... Signature Page for the Acceptance of Annual Evaluation ... ."
A further review of the agency annual report revealed that the signature for the medical director (EMP7) was missing from the signature page for acceptance of the annual evaluation.
A further document reviewed on 12/5/18 at approximately 12:00 p.m. titled "Review and Education of [clinic name] Rural Health Policies" dated 12/22/17 was also missing the signature of the medical director (EMP7) as proof of attendance.
An interview with EMP3 on 12/5/18 at approximately 12:35 a.m. confirmed the findings stating "I think [EMP7] was called away".
Plan of Correction:Clinic annual program evaluations are done annually with staff and providers in the office.
As per policy if the medical director is not available for the initial review meeting the director of physician practice or designee will review the evaluation with them and then obtain the medical director signature where indicated.
All evaluations will be reviewed for completeness by the director of physician practice prior to filing final evaluation.
The 2017 annual review was reviewed with the medical director on 12/13/18.
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