Initial Comments:
Based on the findings of an onsite unannounced initial Medicare survey completed on 12/12/18, Conemaugh Nason Physician Group 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 initial Medicare survey completed on 12/12/18, Conemaugh Nason Physician Group 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)(2) STANDARD
MAINTENANCE
Name - Component - 00
Drugs and biologicals are appropriately stored; and
Observations:
Based on direct observations, clinic policy and procedure, and staff (EMP) interview, the clinic failed to follow agency policy and procedure and maintain a preventative maintenance program to ensure expired supplies were not available for use.
Findings Included:
A review of clinic policy and procedure conducted on 12/12/18 at approximately 10:00 a.m. revealed "... Drug and Biological Storage Policy ... The monthly inspections will ensure that all expired drugs have been removed form the storage area. Lab supplies and reagents will also be inspected to ensure that all expired material has been removed. ... ."
During a tour of the clinic's patient treatment rooms on 12/11/18 at approximately 11:40 a.m., the following expired supplies was discovered:
1. Approximately one hundred twenty (120) blue top vacutainer tubes [used for blood collection during a blood draw] with an expiration date of 11/30/18.
2. Approximately twenty one (21) "Chlamydia Swabs" with an expiration date of 10/20/18..
An interview with the clinic office manager (EMP1) on 12/11/18 at approximately 12:00 p.m. confirmed the above findings and confirmed that the clinic did not have a preventative maintenance program, as per policy and procedure, that ensured expired supplies were not being used within the clinic.
Plan of Correction:J0023 – Maintenance
Claysburg Rural Health Clinic staff members failed to remove expired lab supplies. The Rural Health Clinic Policy and Procedure Manual, Physical Plant and Environment, Drug and Biological Storage Policy, states: The purpose of this policy is to ensure proper security, storage, and disposal of drugs and biologicals. Clinic nursing staff members will provide monthly inspection for expired material, including medical supplies with expiration dates. The RN or MA will oversee all inspections to ensure that they occur in a timely, consistent manner. The monthly inspection will ensure lab supplies and reagents will also be inspected to ensure that all expired material has been removed. All expired drug samples, lab supplies, reagents, and multi-use vials opened for more than a thirty day period will be discarded on a monthly basis. A log will be kept for documentation of the monthly inspection. The individual who has checked that all lab supplies and reagents are not expired will sign and date this sheet at the time of the monthly outdate check. All out dated lab supplies and reagents will be disposed of (i.e. hazardous waste). All appropriate staff members will be re-educated of our Rural Health Clinic Policy and Procedure Manual, Physical Plant and Environment, Drug and Biological Storage Policy by the Director of Clinical Services for Conemaugh Physician Group by 1/11/2019.
The Office Manager will assign the inspection duty to a staff member and monitor that it is completed on a monthly basis. To ensure that the inspection continues monthly all staff members will review this policy upon hire during their orientation period and then with the annual evaluation review in January of each year.
491.9(c)(3) STANDARD
DIRECT SERVICES - EMERGENCY
Name - Component - 00
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 direct observation during the initial tour of the facility, agency policy and procedure, and staff interview the clinic failed to ensure all emergency medications were available for immediate use.
Findings Included:
A review of clinic policy and procedure conducted on 12/12/18 at approximately 10:00 a.m. revealed "... Medical Emergency Plan ... 2. The procedure shall be to make certain the person whose life is threatened has: ... b. Breathing (start oxygen ...) ... ."
Clinic Policy "... Emergency Procedures ... The kit is checked by the nurse to make sure the appropriate drugs have been replaced if used and drugs that have been expired/outdated are removed and replaced. ... ."
During the initial tour on 12/11/18 at approximately 11:55 a.m., it was discovered that the oxygen tank that was included as part of the emergency medications was empty.
An interview with EMP1 on 12/11/18 at approximately 12:00 p.m. confirmed the above findings and the oxygen tank was empty stating "I will get it replaced today". EMP1 also revealed that the emergency medications are checked monthly and were last checked on 12/3/18, but the checklist does not include checking the amount of oxygen within the tank.
Plan of Correction:J0062 – Direct Emergency Services
Claysburg Rural Health Clinic staff members failed to maintain emergency medical supplies as per Rural Health Clinic Policy and Procedure Manual, Provision of Services, Emergency Procedures and Medical Emergency Plan. Procedure: whenever an emergency medical situation presents RHC staff members shall make certain the person whose life is threatened has: b. breathing (start/oxygen/cardiopulmonary resuscitation). The drugs commonly used in life saving procedures will be kept in the clinic and checked by the nurse to make sure the appropriate drugs have been replaced if used and drugs that have become expired / outdated are removed and replaced. A log will be kept for documentation of the monthly inspection. The individual who has checked that all drugs are not expired will sign and date this sheet at the time of the monthly outdate check. All out dated drugs will be disposed of (i.e. hazardous waste), oxygen will be replaced if empty. The log will be amended to include the check of the amount of oxygen in the tank on the monthly inspection. All appropriate staff members will be re-educated of our Rural Health Clinic Policy and Procedure Manual, Emergency Procedures and Medical Emergency Plan by the Director of Clinical Services for Conemaugh Physician Group by 1/11/2019.
The Office Manager will assign the inspection duty to a staff member and monitor that it is completed on a monthly basis. To ensure that the inspection continues monthly all staff members will review this policy upon hire during their orientation period and then with the annual evaluation review in January of each year.
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