Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on 8/28/18, Medical Associates of Boswell 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 on 8/28/18, Medical Associates of Boswell was identified to have had 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)(1) STANDARD
MAINTENANCE
Name - Component - 00
All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition;
Observations:
Based on a review of clinic policy and procedure, Facility Testing Logs and Staff Interview, the clinic failed to perform quality control controls on laboratory testing equipment as per clinic policy and procedure to ensure the accuracy of patient results from 12/8/17 to 8/9/18.
Findings Included:
A review of clinic policy and procedure, conducted on 8/28/18 at approximately 11:15 a.m. revealed "QUALITY CONTROLS ... Quality Controls help monitor equipment used for testing, and accuracy of patient results on a daily basis. Quality controls are mandatory. ... DIPSTICK URINALYSIS TESTING A positive and negative control will be run each week of patient testing and with each new lot number. ... GLUCOMETER READINGS Two levels of external liquid control should be run each day of patient testing. ... HEMOGLOBIN TESTING RESULTS A control cuvette will be performed each day of patient testing. One abnormal control will be performed each week of patient testing alternating high and low controls. ... ."
A review of clinic testing logs on 8/27/18 at approximately 11:00 a.m. revealed the following:
Hemoglobin Testing: Hemoglobin testing from 12/18/17 to 7/20/18 revealed patient sample testing was completed without performing a control sample on 1/3/18, 1/18/18, 1/20/18, 2/28/18, 4/4/18, 4/12/18, 4/18/18, 5/4/18, 5/31/18, 6/15/18, 6/18/18, and 7/20/18.
Glucometer Testing: Glucometer testing from 3/9/18 to 7/21/18 revealed sample testing was completed without performing a control sample on 3/9/18, 4/14/18, 4/27/18, 5/3/18, 5/8/18, 5/25/18, 6/19/18, and 7/21/18.
Dipstick Urinalysis Testing: Dipstick urinalysis testing controls were not completed weekly from 7/27/18 to 8/9/18. (13 days). Documentation shows that a total of six (6) patient tests were performed during that time period.
An interview on 8/28/18 at approximately 12:35 p.m. with the clinic office manager (EMP1) and director of nursing (EMP3) confirmed the above findings with EMP3 stating "controls should have been completed".
Plan of Correction:All nursing staff retrained/reoriented on importance of doing controls, logging results, understanding the results and importance of control results.
Reinforce that any abnormalities need to be documented and reported to the Nursing Supervisor or the Medical Director.
A nurse will be assigned daily to ensure that controls are completed, signing off on a chart daily that is kept in the laboratory. Any deficiencies will be reported to the Nursing Supervisor who will in turn investigate and follow up with anyone who has not followed procedure. The Nursing Supervisor will also sign off on the control sheets monthly to ensure correct procedure has been followed.
Provide any updates/changes regularly to the control process.
491.6(b)(2) STANDARD
MAINTENANCE
Name - Component - 00
Drugs and biologicals are appropriately stored; and
Observations:
Based on direct observations, and staff (EMP) interview, the facility failed to maintain a preventative maintenance program to ensure expired supplies were not available for use.
Findings Included:
During a tour of the clinic's patient treatment rooms on 8/27/18 at approximately 11:00 a.m., the following expired supplies was discovered:
-Culture Swabs: six (6) swabs with an expiration date of July 2018
-Hologic [brand name company] unisex swab collection kits: seven (7) with an expiration date of January 2018 and two (2) with an expiration date of January 2017
-3ml [milliliter] VCM/Swab Set [culture swab for specific parts of the body]:
Lesion/Other: two (2) with an expiration date of July 2017
Urethral [tube that connects to the urinary bladder]: three (3) with an expiration date of May 2018
Cervical: three (3) with an expiration date of May 2018
-Vaginal Swab Specimen Collection Kit: four (4) with an expiration date of January 2018 and two (2) with an expiration date of July 2018.
-Gentamicin 0.3% eye drop [medication to treat eye infections] medication bottle with an expiration date of December 2017
-Steri-Strips [non-invasive wound closure product]: three (3) packages with an expiration date of February 2017.
An interview with the clinic office manager (EMP1) on 8/27/18 at approximately 1:20 p.m. confirmed the above findings and confirmed that the clinic did not have a preventative maintenance program that ensured expired supplies were not being used within the clinic.
Plan of Correction:All expired medications/supplies were removed from the office. New supplies have been ordered.
All staff is reminded to check expiration dates on medications/supplies before they are given/used for patients.
Training was held for nursing staff on 09-24-2018. Implementation of daily check off list for each exam room along with our laboratory/sample room which will be signed off by the nurse assigned to that exam room for the day. Our paper nurse for the day is responsible for the laboratory and sample room. Nurse will check for expired item, restock and initial on each date along with signature/date/title. Any deficiencies/problems will be immediately reported to the Nursing Supervisor. Nursing Supervisor will take corrective action as needed. These check lists were started on 09-24-2018.
Expired medications/supplies will be logged out and disposed of either by our Medical Waste removal company or regular refuse hauler.
491.10(a)(2) STANDARD
RECORDS SYSTEM
Name - Component - 00
A designated member of the professional staff is responsible for maintaining the records and for insuring that they are completely and accurately documented, readily accessible, and systematically organized.
Observations:
Based on a review of clinic job descriptions, review of clinical Records and staff interview, the clinic failed to document and maintain an accurate and complete patient visit record for two (2) of twenty (20) CRs reviewed (CR2, CR10).
Findings Included:
A review of clinic job descriptions conducted on 8/28/18 at approximately 11:45 a.m. revealed "NON-PHYSICIAN PROVIDED (PHYSICIAN ASSISTANT/CERTIFIED REGISTERED NURSE PRACTIONER... Perform complete and detailed and accurate histories, review patient records to develop comprehensive medical status reports ... Do complete physical examinations and record pertinent data in acceptable medical forms. ... ."
A review of clinical records (CRs) conducted on 8/28/18 approximately between 10:00 a.m. and 11:15 a.m. revealed:
CR2: A review of a visit with the physician assistant (EMP4) from 8/8/18 scheduled for 10:30 a.m. revealed an incomplete patient visit note that lacked documentation of a physical examination and pertinent visit data.
CR10: A review of a visit with the physician assistant (EMP4) from 8/22/18 scheduled for 11:00 a.m. revealed no patient visit note was documented.
An interview with the clinic office manager (EMP1) on 8/28/18 at approximately 11:00 a.m. confined the above findings and stated the expectation was that visit notes should have been documented "within a week".
Plan of Correction:Policy in place to have office visit notes completed within 7 days.
Insurance Biller will give providers weekly list of any unfinished/unsigned notes generated from the computer schedules starting with date of service 09-24-2018.
Insurance Biller will generate monthly report of any unfinished/unsigned notes to the Administrative Assistant to review and investigate. If there are still any unfinished/unsigned notes she will provide this list to the Office Manager. Office Manager will address each provider separately of any delinquent charts for resolution.
Office Manager attests that CR2 and CR10 were completed by PA on 09/24/2018
491.10(a)(3) STANDARD
RECORDS SYSTEM
Name - Component - 00
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 policy and procedure, a review of clinical records (CRs) and staff interview, the clinic failed to show evidence of a signed consent form for ten (10) of twenty (20) CRs reviewed for years 2017 and 2018. (CR3-5, CR7-13)
Findings Included:
A review of clinic policy and procedure conducted on 8/28/18 at approximately 10:00 a.m. revealed "'PATIENT REGISTRATION ... A new demographics sheet/consent for treatment will be updated yearly, as patients come for office visits. ... ."
A review of clinical records (CRs) conducted on 8/28/18 approximately between 10:00 a.m. and 11:15 a.m. revealed CR3, CR4, CR5, CR7, CR9, CR10, and CR12 did not have and updated signed consent for treatment for 2017 and 2018. Additionally, CR8 and CR11 and CR13 did not have a signed consent for treatment for 2018.
An interview with the clinic office manager (EMP1) on 8/28/18 at approximately 11:15 a.m. confirmed the above findings and confirmed that each CR had completed patient visit notes for the years the consent to treat forms were missing stating "they should have been completed and scanned into the system".
Plan of Correction:Retraining/refreshing receptionists on importance of collecting yearly signed consents to treat at staff meeting 09-25-2018.
Receptionists will now be required to sign off daily that all patients for their shift have updated (within the past 1 year) and/or verified that all patient registrations/consents to treat at up to date. This will be implemented on 09/25/2018.
Administrative Assistant will also spot check weekly to ensure the accuracy of this plan of action. Administrative Assistant will report to Office Manager any delinquencies. Office Manager will address each receptionist separately with any concerns.
Quarterly Receptionist/Clerical Staff meetings will be held starting October 24, 2018 to retrain and review policies in place.
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