Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed June 22, 2021, Southern Huntingdon County Medical Center was identified to be in compliance with the following requirements of 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 unannounced, on-site Medicare recertification survey completed June 22, 2021, Southern Huntingdon Medical Center was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42CFR, Part 405, Subpart X and 42CFR Part 491.1-491.11 Subpart A, Conditions for Certification: Rural Health Clinics.
Plan of Correction:
491.8(a)(5) and (6) STANDARD
STAFFING AND STAFF RESPONSIBILITIES
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491.8(a) Staffing.
(5) The staff is sufficient to provide the services essential to the operation of the clinic . . .
(6) A physician, nurse practitioner, physician assistant, certified nurse-midwife, clinical social worker, or clinical psychologist is available to furnish patient care services at all times the clinic . . . operates. . . .
Observations:
Based on review of clinic documentation and interview with the clinic administrator the clinic failed to ensure a nurse-midwife, and clinical social worker or clinical psychologist was employed directly or through contract to meet specific patient needs.
Findings include:
Review of personnel files completed June 21, 2021 at approximately 1:00PM revealed no listing of either a clinical social worker or clinical psychologist or nurse-midwife were employed directly by the clinic.
Review of contracts held by the clinic completed June 21, 2021 at approximately 12:30PM revealed no contracts for either a clinical social worker or clinical psychologist or nurse-midwife.
Interview with the clinic administrator completed June 21, 2021 at approximately 11:30AM confirmed the above findings. "we do not have an agreement in place with a nurse midwife, social worker or clinical psychologist".
Plan of Correction:A local nurse midwife has been contacted. We are awaiting a return call from this individual to determine interest in contracting with us. If this local prospect does not come to fruition, efforts will be continued. Recruitment of this position are being conducted by the Chief Operating Officer with the assistance of the Office Manager. Because of the relationship between Southern Huntingdon County Medical Center and the Fulton County Medical Center, we have a Social Worker on staff at the Fulton County Medical Center. This individual will begin covering Social Worker needs at the Southern Huntington County Medical Center beginning July 5, 2021. Education has been provided to the Social Worker.
491.9(b)(3)(iii) STANDARD
PROVISION OF SERVICES
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491.9(b) Patient care policies.
(3) The policies include:
(iii) Rules for the storage, handling, and administration of drugs and biologicals.
Observations:
Based on review of policies/procedures, observations and interview with the clinic administrator the clinic failed to ensure the disposal of expired drugs and/or medical supplies for one (1) of one (1) observations made. OBS #1.
Findings include:
Review of policy PH32, title: EXPIRED MEDICATIONS completed June 22, 2021 at approximately 12:30PM revealed:
Policy: "Outdated and /or unusable medications shall be removed and stored away from usable stock until proper disposition can be accomplished". Procedure: "3. When expired medications are found... the medications shall be immediately pulled from stock".
OBS# 1 conducted June 21, 2021 between approximately 9:30AM- 11:30AM revealed the following:
Two (2) pink bottles, labeled, "Pork Pak 10% buffered Neutral Formalin plastic containers with an expiration date of: 4/2021.
Eight (8) bottles labeled, " C & S non-nutritive stool transplant solution" with an expiration date of: 5/2021.
Two (2) boxes of fifty (50) each BD Vacutainers, blood collection set with an expiration date of: 4/30/2021.
Seven (7) BD Bactec 30ml Blood culture sample bottles, lot# 0183926, with an expiration date of: 4/30/2021.
Four (4) Lytic culture sample bottles, lot# 0217238, with an expiration date of: 5/31/2021.
Three (3) packages: Vicryl 3-0 sutures with an expiration date of: 2/28/2021.
One (1) bottle: Acitdose Activated Charcoal 25 grams/ Sorbitol 48 grams, lot# 9429372, with an expiration date of: 3/2021.
One (1) vial: Benadryl 50mg/ml injectable solution, lot# 6018682, with an expiration date of: 12/2020.
Interview with the clinic administrator completed June 21, 2021 at approximately 11:30PM confirmed the above findings.
Plan of Correction:At the beginning of each month we will properly discard any expired medication and/or supply from the previous month. We will have the supply stock organized with the most recent expiration date available for use first and so on to allow for a more organized approach.
A plan has been implemented to go through all medications and supplies in the building the first week of every month. This will be conducted by an LPN and will be kept on a log sheet for each month. The LPN's initials will verify that it was completed for each month. This task has been completed by the office manager and LPN as of July 1 2021.
491.9(c)(3) STANDARD
PROVISION OF SERVICES
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491.9(c) Direct services
(3) Emergency. The clinic . . . provides medical emergency procedures as a first response to common life-threatening injuries and acute illness and has available the drugs and biologicals commonly used in life saving procedures, such as analgesics, anesthetics (local), antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids
Observations:
Based on review of policy/procedure, observations made during clinic tour and an interview with the clinic administrator clinic failed to ensure emergency supplies and emergency medications including but not limited to: anticonvulsant and age appropriate supplies were avaible for use as a first response to common life-threatening injuries and acute illnesses for one (1) of one (1) observation made. OBS#1.
Findings include:
Review of policy 350.0 titled: EMERGENCY CARE AND TREATMENT completed on June 21, 2021 at approximately 1:30 PM revealed the following:
Policy statement, "Southern Huntingdon County Medical Center (the clinic) complies with the RHC requirement to be able to provide medical emergency procedures as a first response to common life-threatening injuries and acute illness".
Policy body: Emergency care and Treatment, "1) Emergency kit: Southern.... shall have on hand an emergency kit that includes drugs and biologicals commonly used in life saving procedures such as... d. Anticonvulsant (medication used to control seizures)... e) Antidotes and emetics, serums and toxiods.... h) Other medical supplies and equipment that has been determined necessary for providing emergency care with the scope and trainng of providers".
OBS# 1 conducted June 21, 2021 between approximately 9:30AM- 11:30AM revealed the following:
Emergency kit did not contain Anticonvulsant's and Antidotes and emetics, serums and toxoid medications for emergency use.
Clinic did not maintain an infant sized resuscitation mask and bag.
Automated Emergency Defibrillator (AED) did not contain pediatric sized pads for emergencies.
Interview with the clinic administrator completed June 21, 2021 at approximately 11:30AM confirmed the above findings.
Plan of Correction:Following the exit interview it was found that an anticonvulsive (diazepam), was in the building. Since the medication is a controlled substance, it was in the lock box in the medication closet.
Going forward, we will maintain an emergency medication list with all the emergency medications and where each medication is located in the building. This will be maintained monthly by one of the LPN's. The list will be updated the first week of every month. Medications will be checked for expiration dates and replaced accordingly. The LPN checking medications will be responsible for signing off when the task is completed. This task was completed 7/1/2021 by office manager and LPN.
As of 7/1/2021, an infant sized resuscitation mask, bag and the pediatric sized pads for the AED have been ordered. Upon receipt of these items, we will maintain a supply on hand. An LPN and office manager will be in charge of ordering supplies.
491.10(a)(3)(i)-(iv) STANDARD
PATIENT HEALTH RECORDS
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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) and interview with the clinic Administrator the clinic failed to ensure a consent form was completed by the patient prior to services being rendered for one (1) of ten (10) records reviewed. CR#8.
Findings include:
Review of patient records completed June 21, 2021 between approximately 3:00PM- 4:00PM revealed the following:
CR#8, service date: 6/10/2021 did not contain a signed consent form for service prior to those services being rendered.
Interview with the clinic administrator completed June 21, 2021 at approximately 11:30PM confirmed the above findings.
Plan of Correction:The medical and clinical staff at Southern Huntingdon County Medical Center will be educated on obtaining patient consents. This education will be provided by the Office Manager and will be completed by July 19, 2021. Each staff member will be required to sign off on the education provided. This education sign off will be maintained in their education files for further reference.
491.11(a)-(c) STANDARD
PROGRAM EVALUATION
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§ 491.11 Program evaluation.
(a) The clinic or center carries out, or arranges for, a biennial evaluation of its total program.
(b) The evaluation includes review of:
(1) The utilization of clinic or center services, including at least the number of patients served and the volume of services;
(2) A representative sample of both active and closed clinical records; and
(3) The clinic's or center's health care policies.
(c) The purpose of the evaluation is to determine whether:
(1) The utilization of services was appropriate;
(2) The established policies were followed; and
(3) Any changes are needed.
Observations:
Based on review of policy/procedure, clinic documentation and an interview with the clinic Administrator the clinic failed to ensure periodic review and evaluation of the entire program including but not limited to; clinical records and policies for one (1) of two (2) years reviewed. 2020.
Findings include:
Review of policy 500.0, "PROGRAM EVALUATION", completed on June 21, 2021 at approximately 2:00PM revealed: Policy statement: "Southern Huntingdon County Medical Center shall conduct an annual evaluation of all aspects of the RHC program according to federal and state regulations".
Review of clinic documentation completed June 21, 2021 between approximately 10:00AM- 1:00PM revealed no documented program evaluation for 2020.
Interview with the clinic administrator completed June 21, 2021 at approximately 11:30PM confirmed the above findings.
Plan of Correction:A program evaluation will be completed by the Office Manager by August 1, 2021. This program evaluation will be reviewed in an annual meeting to be scheduled by the Office Manager. This will be completed by August 15, 2021
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