Initial Comments:
Based on the findings of an onsite unannounced Medicare Recertification Survey completed November 22, 2024, BRMC Rural Health Clinic Pediatrics, was found to be in compliance with the 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 November 22, 2024, BRMC Rural Health Clinic Pediatrics, 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:
491.10(a)(3)(i)-(iv) STANDARD
PATIENT HEALTH RECORDS
Name - Component - 00
491.10(a) Records system.
(3) For each patient receiving health care services, the clinic . . .. maintains a record that includes, as applicable:
(i) Identification and social data, evidence of consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient;
(ii) Reports of physical examinations, diagnostic and laboratory test results, and consultative findings;
(iii) All physician's orders, reports of treatments and medications, and other pertinent information necessary to monitor the patient's progress;
(iv) Signatures of the physician or other health care professional.
Observations:
Based on review of Clinica Records (CR) and interview with the clinical director (EMP1) the clinic failed to ensure a treatment consent form was completed by the patient/patient representative prior to services being rendered for seventeen (17) of twenty (20) records reviewed (CR#2-CR#4 and CR#6-CR#19).
Findings include:
Review of clinical records completed on November 22, 2024 between approximately 1:00 PM and 2:45 PM revealed the following:
CR#2, service date: 6/21/2024 did not contain a signed "consent to treat" form to provide treatment for service prior to those treatment services being rendered.
CR#3, service date: 6/28/2024 did not contain a signed "consent to treat" form to provide treatment for service prior to those treatment services being rendered.
CR#4, service date: 8/12/2024 did not contain a signed "consent to treat" form to provide treatment for service prior to those treatment services being rendered.
CR#6, service date: 9/9/2024 did not contain a signed "consent to treat" form to provide treatment for service prior to those treatment services being rendered.
CR#7, service date: 9/10/2024 did not contain a signed "consent to treat" form to provide treatment for service prior to those treatment services being rendered.
CR#8, service date: 9/13/2024 did not contain a signed "consent to treat" form to provide treatment for service prior to those treatment services being rendered.
CR#9, service date: 9/24/2024 did not contain a signed "consent to treat" form to provide treatment for service prior to those treatment services being rendered.
CR#10, service date: 10/9/2024 did not contain a signed "consent to treat" form to provide treatment for service prior to those treatment services being rendered.
CR#11, service date: 5/22/2024 did not contain a signed "consent to treat" form to provide treatment for service prior to those treatment services being rendered.
CR#12, service date: 6/4/2024 did not contain a signed "consent to treat" form to provide treatment for service prior to those treatment services being rendered.
CR#13, service date: 7/18/2024 did not contain a signed "consent to treat" form to provide treatment for service prior to those treatment services being rendered.
CR#14, service date: 8/6/2024 did not contain a signed "consent to treat" form to provide treatment for service prior to those treatment services being rendered.
CR#15, service date: 8/29/24 did not contain a signed "consent to treat" form to provide treatment for service prior to those treatment services being rendered.
CR#16, service date: 9/13/2024 did not contain a signed "consent to treat" form to provide treatment for service prior to those treatment services being rendered.
CR#17, service date: 9/26/24did not contain a signed "consent to treat" form to provide treatment for service prior to those treatment services being rendered.
CR#18, service date: 11/8/2024 did not contain a signed "consent to treat" form to provide treatment for service prior to those treatment services being rendered.
CR#19, service date: 11/14/2024 did not contain a signed "consent to treat" form to provide treatment for service prior to those treatment services being rendered.
Interview with EMP1 completed November 22, 2024 at approximately 3:00PM confirmed the above findings.
Plan of Correction:Plan of Correction:
The current consent form was reviewed and updated to include a consent for treatment section. This form will be updated and distributed as appropriate to meet compliance. Staff will be educated by the site supervisor and/or clinical director when distributed to present the new consent to the patients, properly educate patients on what the consent means, and then obtain a signature. Education will be completed via Read and Sign and will be kept with the facility documentation for future on-site visits for review. All new employees will be educated on the consent as part of the onboarding process. The consent will be imported to the patient chart as completed.
The Site Supervisor and/or Clinical Director will audit 10 random charts per week to ensure compliance. Audits will include reviewing for updated consent. This will continue until compliance is 90% for 4 consecutive weeks. After 90% compliance is reached for 4 consecutive weeks audits will decrease to 10 random audits per months to ensure sustained compliance. The Clinical Director and/or Site Supervisor will attend the BRMC Regulatory Meeting monthly to report out audit findings.
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