Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted July 29, 2020, Tyrone Hospital Rural Health Clinic 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 conducted July 29, 2020, Tyrone Hospital Rural Health Center was found 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:
491.10(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 a review of clinic medical records (MR) and clinic policy and staff (EMP) interview, the clinic failed to obtain provider signatures for "office visits" per agency policy for two (2) of sixteen (16) MRs reviewed (MR5, MR6) and failed to obtain a signed consent form for two (2) of sixteen (16) MRs reviewed. (MR7, MR 15)
Findings Included:
A review of MR conducted 7/29/2020 between approximately 10:30 a.m. to approximately 11:30 a.m.with EMP1 revealed provider signatures must be obtained "within 30 days" and consents are obtained "annually" per clinic policy. Doucmentation within MR revealed:
MR5, date of clinic visit 6/24/2020, did not contain a provider signature for office visit as of 7/29/2020, five (5) days past due per clinic policy.
MR6, date of visit 5/19/2020 did not contain a provider signature for office visit as of 7/29/2020, forty one (41) days past due per clinic policy.
MR7, date of visit 7/19/2020, did not contain a signed consent form.
MR15, date of visit 7/01/2020, did not contain a signed consent form.
Interview with EMP1 during record review at approximately 11:15 a.m. confirmed the above findings, "It's [office note] not signed... It's [consent] not in there...we need to run a report..."
Plan of Correction:The Rural Health Clinic has an existing policy specifically describing the need and frequency for patient consent and provider sign off of office visits within 30 days. Consent will be obtained upon the initiation of treatment and subsequently on an annual basis. The consent will be maintained within the electronic medical record. The policy will identify staff responsible for obtaining patient consent. Office providers will be required to sign off office visit notes within 30 days. The policy will identify that providers are required to sign off office visit notes within 30 days. All staff will review the policies and documentation will be obtained for policy review.
All Tyrone Rural Health employees will receive education regarding the existing policies and appropriate staff will be educated on the process to obtain consent utilizing the electronic medical record. A log of all employees receiving the education will be obtained and will be available for review upon request.
The clinic administrator or designee will perform surveillance for compliance of the above mentioned on a monthly basis for four months. The number of charts to be review will be a minimum of 25 charts per month for patient consents per provider and 20% of provider office note sign offs. The surveillance of the audits will be documented and maintained in the administrator's office. Random monitoring will occur after the initial schedule listed above and documented to assure compliance.
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