Initial Comments:
Based on the findings of an onsite unannounced recertification survey completed on 1/31/2024, Armstrong Primary Care Center - West Hills - Kittanning, was found to be in compliance with the following requirement(s) 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 recertification survey completed on 1/31/2024, Armstrong Primary Care Center - West Hills - Kittanning, was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the 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:
491.8(b)(3) and (c)(1)(ii) STANDARD
STAFFING AND STAFF RESPONSIBILITIES
Name - Component - 00
491.8(b) Physician responsibilities. The physician performs the following:
(3) Periodically reviews the clinic's . . . patient records . . .
491.8(c) Physician assistant and nurse practitioner responsibilities.
(1) The physician assistant and the nurse practitioner members of the clinic's . . . . staff:
(ii) Participate with a physician in a periodic review of the patients' health records.
Observations:
Based on a review of the clinic's policies/procedure, Pennsylvania Society of Physician Assistants SBOM (State Board Of Medicine) Regulations, interview with staff/interim facility manager and review of clinical records (CR) the clinic failed to maintain the clinical record system, failed to ensure providers signatures were documented, failed to ensure supervising physician signature(s) obtained certifying review of medical record and failed to specify a maximum interval between record reviews in its policies and procedures insuring that they are completely and accurately documented, readily accessible, and systematically organized for 4(four) of 12 clinical records reviewed. (CR# 4, #7, #8 and #9)
Findings include:
1-31-24 review of SBOM at approximately 1:15 pm revealed:
"Title 49. Professional and Vocational Standards
Part I. Department of State Subpart A. Professional and Occupational Affairs Chapter 25. State Board of Osteopathic Medicine
Subchapter C. PHYSICIAN ASSISTANT PROVISIONS,... 25.142. Definitions...Supervision - The opportunity or ability of the physician, or in his absence a substitute supervising physician, to provide or exercise control and direction over the services of physician assistants...
...(iii) Personal and regular-at least weekly-review by the supervising physician of the patient records upon which entries are made by the physician assistant..."
A review of the clinic's "Documentation Standards for the Medical Record" Policy no.: 2510 conducted on January 31, 2024 at approximately 11:50 am revealed:
"Policy: To provide standards to promote the capturing of accurate, legible, consitent, timely documentation in the ACMD Medical record...Standards...'V'. Signatures... A. Authors of all entries are to be identified in the medical record; therefore, all entries are to be signed..."
1/31/24 a review of CR #4, at approximately 1:30 pm revealed: Date of Service (DOS): 1/8/24, care provided by Physician Assistant - signature documented by Physician's Assistant and no signature obtained from supervising physician verifying record review.
1/31/24 a review of CR #7, at approximately 2:10 pm revealed: DOS: 1/16/24, care provided by Physician Assistant - signature documented by Physician's Assistant and no signature obtained from supervising physician verifying record review.
1/31/24 a review of CR #8, at approximately 2:25 pm revealed: DOS: 1/18/24, care provided by Physician Assistant - signature documented by Physician's Assistant and no signature obtained from supervising physician verifying record review.
1/31/24 a review of CR #9, at approximately 2:35 pm revealed: DOS: 1/22/24, care provided by Physician Assistant - signature documented by Physician's Assistant and no signature obtained from supervising physician verifying record review.
An interview with the staff/interim manager on January 31, 2024 at approximately 3:00 pm, confirmed the above findings. "Our policy says a timely manner. It does not give a specific time frame for chart review or signature requirements."
Plan of Correction:Our current policy and bylaws state that physician sign off will occur in a "timely" manner. Moving forward, we will update our RHC policy to incorporate the minimum requirements set forth by the State Board of Medicine regarding supervising physician sign off. The updated policy will read, "Patient records must be signed off in a timely manner, not to exceed 7 days." To implement this policy, we will need to block time for the supervising physicians and APPs that will be dedicated to chart review and other administrative tasks. We have instituted blocks in all provider and APP schedules beginning Feb 26, 2024 at this location. This policy change has been sent to office managers and providers to make them aware of the updates. We will also review this at the upcoming practice meeting on March 21, 2024 and each annual RCH meeting. The practice manager will be responsible for assuring charts are signed off, reviewed within 7 days, and provider schedules are blocked for administrative time.
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 clinical records (CR), policy/procedure and interview with staff/interim manager, the clinic failed to ensure a consent form was completed by the patient prior to services being rendered for one (1) of 12 records reviewed. CR#11.
Findings include:
1/31/24 a review of policy no. 4590 "Subject: Consents" at approximately 12:00 pm revealed: "POLICY: 4590 CONSENTS...Before a patient evaluation and treatment is provided, consent must be obtained from the appropriate person..."
Review of patient records completed January 31, 2024 between approximately 1:00 pm- 3:00 pm revealed the following:
CR#11, service date: 1/29/24 did not contain a signed consent form for services prior to those services being rendered.
Interview with the staff/interim manager completed January 31, 2024 at approximately 3:00 pm confirmed the above findings.
Plan of Correction:Due to the one missing consent of the twelve records reviewed, another self audit of 20 charts were performed between the dates of December 1, 2023 and January 31, 2024. 20 of 20 charts had completed patient consent forms. We feel this was an isolated employee error. Electronic workflow was confirmed by our tech support and all appropriate resources are in place to capture the required information. The workflow on how to obtain patient information and consent was confirmed and reviewed with all staff. Quarterly chart review will be implemented to spot check and ensure all information, including consent, is properly obtained. Findings of these quarterly audits, will be added to the annual RHC report for this office and reviewed at the end of 2024. The practice manager will be responsible for these spot audits and documentation of the findings for review.
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