Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on June 12, 2023 through June 13, 2023, Caring Healthcare Network was identified to have the following standard level deficiencies that were determined to be in substantial 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:
491.12(d)(2) STANDARD
EP Testing Requirements
Name - Component - 00
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).
*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:
(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:
(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.
*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.
*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.
*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.
*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.
*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.
*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.
*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.
Observations:
Based on review of clinic emergency preparedness plan and interview with the clinic office manager (EMP# 1), it was determined the clinic failed to participate in a full-scale exercise that is community-based exercise is not accessible, an individual, facility-based; failed to conduct an additional exercise that included, but was not limited to the following: (A) A second-full scale exercise that is community-based or individual, facility-based. (B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinical-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan; and failed to analyze the clinic's response to and maintain documentation of all drills, tabletop exercises, and emergency events for one (1) of one (1) emergency preparedness plan reviewd. (Emergency Preparedness Plan #1)
Findings include:
Review of 'Emergency Preparedness Plan' on 6/13/2023 at approximately 11:00 a.m. section, '(2) Testing' states, "The RHC/FQHC must conduct exercises to test the emergency plan at least annually. The RHC/FQHC must do the following: (1) Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based...(ii) Conduct an additional exercise that may include, but is not limited to following: (A) a second full-scale exercise that is community-based or individual, facility based (B) A tabletop exercise that includes a group discussion led by a facilitator, suing a narrated, clinically-designed to challenge an emergency plan. (iii) Analyze the RHC/FQHC's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the RHC/FQHC's emergency plan, as needed."
Emergency Preparedness Plan #1: Documentation provided of a 'Clinic Safety Mock Drill' completed on 10/19/2017. No documentation of any additional drills, tabletop exercises or full-scale exercises since 2017.
An interview with the Office Manager on 6/13/2023 at approximately 1:00 p.m. confirmed the above findings.
Plan of Correction:Video training on Active Shooter, Fire Safety, OSHA Safety is done yearly 2023 was done via Talentlms and Paylocity. This is to continue annually and monitored by Human Resources for due dates and scheduling of video training. This year 2023 was completed between March through May 2023. The log of completed training is in the Emergency Preparedness Manual.
Annual in-person training will be done going forward. To be scheduled twice per year by Human Resources and Practice Manager which will be tracked using Paylocity HR management software and our compliance software InQui for due dates, to ensure all staff is attending. These will include Drill, Tabletop exercised, full-scale exercises.
Evidence and documentation of signature logs will be placed in the emergency preparedness Manual when completed.
The first in person Evacuation drill was done 6/19/2023 signature log and documentation are on file in the Emergency Preparedness Manual.
Continuous scheduled training for 2023 as follows this is to show due diligence in continuing education training.
The great American shakeout to be participating in the next available training.
Fire Safety-Call out to Hope Fire Co to come do in person full scale fire safety training.
Initial Comments:
Based on the findings of an unannounced Medicare recertification survey conducted June 12, through June 13, 2023, Caring Healthcare Network 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:
491.4 STANDARD
COMPLIANCE WITH FED., STATE & LOCAL LAWS
Name - Component - 00
Standard-level Tag
491.4 Compliance with Federal, State and local laws
The rural health clinic . . . and its staff are in compliance with applicable Federal, State and local laws and regulations.
Observations:
Based on review of policies, personnel files (PF) and interview with the Clinic Manager the clinic failed to ensure that personnel were screened and free from Mycobacterium Tuberculosis (TB) for nine (9) of nine (9) files reviewed. PF #1-9.
Findings include:
The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. HCWs with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. (CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Morbidity and Mortality World Report 2005; RR-17').(http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.)
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
Review of policies completed 6/12/23 between approximately 12:30PM and 3:30PM revealed: policy 235.0: Infection Control Policy: section: 4(a) "The clinic shall ensure all employees have been or shall be appropriately screened for communicable diseases as required by federal, state or local law".
Review of personnel files completed on 6/13/23 at approximately 9:20AM revealed the following:
PF #1, Date of hire (DOH): 6/6/2019 contained no documentation to show the employee had been screened and was free from Mycobacterium Tuberculosis (TB).
PF#2, DOH: 1/5/2022 contained no documentation to show the employee had been screened and was free from Mycobacterium Tuberculosis (TB).
PF#3, DOH: 7/3/2018 contained no documentation to show the employee had been screened and was free from Mycobacterium Tuberculosis (TB).
PF#4, DOH: 8/22/2016 contained no documentation to show the employee had been screened and was free from Mycobacterium Tuberculosis (TB).
PF#5, DOH: 5/15/2018 contained no documentation to show the employee had been screened and was free from Mycobacterium Tuberculosis (TB).
PF#6, DOH: 6/18/2018 contained no documentation to show the employee had been screened and was free from Mycobacterium Tuberculosis (TB).
PF#7, DOH: 12/5/2022 contained no documentation to show the employee had been screened and was free from Mycobacterium Tuberculosis (TB).
PF#8, DOH: 3/6/2023 contained no documentation to show the employee had been screened and was free from Mycobacterium Tuberculosis (TB).
PF#9, DOH: 3/1/2023 contained no documentation to show the employee had been screened and was free from Mycobacterium Tuberculosis (TB).
An interview with the Clinic Manager conducted 6/13/23 at approximately 12:00PM confirmed the above findings.
Plan of Correction:All staff requiring TB screening will be fully completed by 7/28/2023.
Our onboarding of all new staff will include the TB screening per CDC guideline and repeat testing per guidelines will be performed as necessary.
HR will initiate documentation upon hire and nursing manager will conduct the testing and monitor for ongoing testing.
Documentation will be held in our Evidence Binder via InQui.
491.4(b) STANDARD
LICENSURE/CERT/REGISTRATION OF PERSONNEL
Name - Component - 00
491.4(b) Licensure, certification or registration of personnel.
Staff of the clinic . . . are licensed, certified or registered in accordance with applicable State and local laws.
Observations:
Based on review of personnel files (PF) job descriptions, policies and interview with the Clinic Manager the clinic failed to ensure staff maintained current cardiopulmonary resuscitation (CPR) certification for two (2) of nine (9) files reviewed. PF #4 and PF #7.
Findings include:
Review of personnel files completed on 6/13/23 at approximately 9:20AM revealed the following:
PF#4, DOH: 8/22/2016 contained an a CPR certification expired 3/2023.
PF#7, DOH: 12/5/2022 contained an a CPR certification expired 3/2023.
Review of job description conducted 6/13/2023 at approximately 12:30 PM revealed: section Qualifications: 2. "CPR certification for health care providers".
Review of policies completed 6/12/23 between approximately 12:30PM and 3:30PM revealed: policy: 410.0; Credentialing and Employment policy, Professional Licenses f. "other professional licenses or professional certifications per the scope of practice of services within the clinic".
An interview with the Clinic Manager conducted 6/13/23 at approximately 12:00PM confirmed the above findings.
Plan of Correction:PF#4 and PF#7 is scheduled for CPR class for renewal on August 9th 2023 with Moshannon Valley EMS.
All staff will be monitored using Inqui software for compliance and due dates, Nursing Dept will be in charge of scheduling recertifications.
Documentation will be held in Evidence Binder.
491.7(a)(2) and (b)(1)-(2) STANDARD
ORGANIZATIONAL STRUCTURE
Name - Component - 00
491.7(a) Basic requirements.
(2) The organization's policies and its lines of authority and responsibilities are clearly set forth in writing.
(b) Disclosure. The clinic . . . discloses the names and addresses of:
(1) Its owners, in accordance with section 1124 of the Social Security Act (42 U.S.C. 132 A-3);
(2) The person principally responsible for directing the operations of the clinic . . .
Observations:
Based on review of clinic organizational chart and interview with the clinic office manager (EMP# 1), it was determined that the clinic failed to ensure that the organizational chart (OC)established clear lines of authority and responsibilities for one (1) of one (1) organizational charts reviewed. (OC#1)
Findings include:
OC#1: Review of organizational chart completed June 12, 2023 at approximately 11:00AM revealed a succession starting with the CEO, to the clinic Manager, then to the clinic providers, then,clinic staff and ending at patients. The organizational chart did not include the Medical Director.
An interview with the Office Manager on 6/13/2023 at approximately 1:00 p.m. confirmed the above findings.
Plan of Correction:Organization chart will be updated with Medical Director listed above all providers and clinical staff. This will be found in our evidence binder. This will be updated monthly with new hires and changes to our staffing. This will be conducted by HR during onboarding and off boarding.
491.8(a)(4) STANDARD
STAFFING AND STAFF RESPONSIBILITIES
Name - Component - 00
491.8(a) Staffing.
(4) The staff may also include ancillary personnel who are supervised by the professional staff.
Observations:
Based on review of clinic organizational chart and interview with the Clinic Manager the clinic failed to ensure that professional staff were supervised by other professional staff for one of one chart reviewed. Chart #1.
Findings include:
Review of organizational chart completed June 12, 2023 at approximately 11:00AM revealed:
Chart #1 showed clinic nursing staff were directly supervised by the nursing supervisor/x-ray tech. Further investigation showed this person did not possess a current nursing license to practice nursing in the state of Pa. The employee supervising the clinic nursing staff held a certification and registration in radiography.
An interview with the Office Manager on 6/13/2023 at approximately 1:00 p.m. confirmed the above findings.
Plan of Correction:X-Ray Tech was moved to X-Ray department and our Registered Nurse was promoted to Nurse Manager Position on 6/30/2023.
HR and Compliance officer will monitor job duties and staffing to ensure that all staff are qualified and certified for their duties and not working outside their scope.
491.9(b)(3)(iii) STANDARD
PROVISION OF SERVICES
Name - Component - 00
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 clinic policy and procedure, temperature checking directions, refrigerator temperature logs and interview with the clinic office manager (EMP# 1) , it was determined that the clinic failed to ensure refrigerator temperatures was recorded according to company policy for one (1) of one (1) refrigerator logs reviewed. (Refrigerator Log #1)
Findings include:
Review of policy titled, 'Storage, Handling & Administration of Drugs, Biologicals, and Pharmaceuticals 220.0' on 6/12/2023 at approximately 10:30 a.m. states, "...4. Drugs and Products Requiring Refrigeration...a. All products requiring refrigeration will be kept in refrigerators that are monitored daily for temperature control. Temperatures should be logged at least twice a day using ac temperature monitoring device...."
Review of temperature checking directions on 6/12/2023 at approximately 11:00 a.m. states, "Record the Time, Temperature & Initials two times (2) each business day, upon arrival (morning) and when closing the office at the end of the day (evening). Circle the F or C below to identify whether temperatures are taken in Fahrenheit or Celsius."
Refrigerator Log #1: Review of provider office refrigerator for months of June, April and May 2023; and review of break room refrigerator for months of June, April and May 2023 revealed that clinic employees failed to document the refrigerator temperatures twice daily, failed to write their initials, and failed to circle F or C to identify whether temperatures are taken in Fahrenheit or Celsius.
An interview with the Office Manager on 6/13/2023 at approximately 1:00 p.m. confirmed the above findings.
Plan of Correction:Refrigerator/Freezer temperature log procedure has been revised and policy will be followed. Fahrenheit or Celsius will be specified, initials, and checks done twice daily.
The Nursing Manager will monitor refrigerator/Freezer temp logs are being checked twice daily, and this has been added to our mock survey to be audited internally during our quality safety checks monthly.
491.11(a)-(c) STANDARD
PROGRAM EVALUATION
Name - Component - 00
§ 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 clinic policy and procedure, temperature and interview with the clinic office manager (EMP# 1), it was determined 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 one (1) program evaluations. (Program Evaluation #1)
Findings include:
Review of policy titled, 'Program Evaluation Policy 500.0' on 6/12/2023 at approximately 2:00 p.m. states, "Policy Statement: The clinic shall conduct a biennial (every two years) evaluation of all aspects of the RHC (Rural Health Clinic) program according to federal regulations and to state regulations, if they apply....The review findings shall be presented at an organized meeting once every twenty-four (24 months). Data shall be complied for each of the two 12-month periods...."
Program Evaluation #1: Clinic failed to provide documentation of a conducted and reviewed program evaluation at least biennially between the years of 2019 and 2022.
An interview with the Office Manager on 6/13/2023 at approximately 1:00 p.m. confirmed the above findings.
Plan of Correction:Program evaluation policy #500 using the cost report utilization of productivity standards was completed on 5/18/2023. Evidence was in InQuidocs.
Will continue to conduct these evaluations biennial and will schedule organized meetings with review committee which includes. Clinic Director, Medical Director, two Providers, and an outside professional reviewer this has been scheduled for 7/14/2023 which will be our corrective action date, this will include our full review of our clinic standards, every member will sign that they were in attendance, and we will have a review template will be completed on what we went over, changes to be made and monitored. Our ongoing review will be monitored using InQui for due dates and conducted biennial .
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