Initial Comments:
This report is the result of a full Medicare recertification survey conducted on March 21, 2023, at Express Mobile X-ray. It was determined that the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 486 - Conditions of Participation for a Portable X-ray Provider.
Plan of Correction:
486.104(b) STANDARD
PERSONNEL ORIENTATION
Name - Component - 00
The supplier of portable X-ray services must have an orientation program for personnel, based on a procedural manual which is available to all members of the staff, incorporates relevant portions of professionally recognized documents, and includes specifically required instructions.
Observations:
Based on a review of the facility's documents and interview with staff (EMP), it was determined the facility failed to provide evidence of completion of an orientation program which incorporates relevant portions of professionally recognized documents, and includes specifically required instructions, for one of two radiology technologists hired into this position since the last recertification survey.
Findings include:
A review of facility policy "CODE: H23 SUBJECT: Personnel Orientation", last reviewed/revised 2/2022, revealed: " ... All personnel will be thoroughly trained in the established procedures of Express Mobile Diagnostic Services LLC. They will be familiar with the contents of the Employee Handbook/manual and be responsible for its implementation. ...".
On March 21, 2023, at approximately 11:30AM, EMP2 explained that PF4, who was originally hired to work in dispatch, was converted to a radiology technologist on April 10, 2022, after completing the requirements for this position. However, there was no evidence that PF4 completed the orientation program for a radiology technologist. When asked for evidence that PF4 completed the orientation program for radiology technologists, EMP2 replied "It wasn't done".
Plan of Correction:We have revised our H23A Policy on Personnel orientation to include:
1. An additional training form that will be completed online on our electronic PAYCOM portal to enhance our Technologist competency as part of our onboarding process.
2. We have also revised our H23A acknowledgment form to include, a sign off page as receipt of employee handbook, as well as policy and procedure manual and overall completion of the training form.
This will pull together our electronic onboarding and sign offs under the H23A insert operational policies and procedures for Express Personnel orientation
The onboarding process will be the responsibility of the hiring manager and will be monitored by using an electronic checklist in Paycom that will not allow the onboarding process to be completed without all elements being done. This corrective action started on 4/3/23. All documents have been properly uploaded accordingly.
The technologist that did not have properly documented onboarding, Kaylee Thomas, was provided all documents and acknowledged the training with her signature on 4/3/23.
In conclusion, POC tag #0023 has been implemented fully as of 4/3/23.
486.106(a) STANDARD
REFERRAL BY PHYSICIAN or NONPHYSICIAN PRACT
Name - Component - 00
§486.106(a) Standard - Referral by a Physician or nonphysician practitioners.
Portable X-ray examinations are performed only on the order of a physician licensed to practice in the State or by a non-physician practitioner acting within the scope of State law. Such non-physician practitioners may be treated the same as physicians treating beneficiaries for the purpose of this paragraph. The supplier's records show that:
(1) The portable X-ray test was ordered by a physician or a non-physician practitioner acting within the scope of applicable State law; and
(2) Such physician or non-physician practitioner's written, signed order specifies the reason a portable X-ray test is required, the area of the body to be exposed, the number of radiographs to be obtained, and the views needed; it also includes a statement concerning the condition of the patient which indicates why portable X-ray services are necessary.
Observations:
Based on review of facility policies, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure that X-ray examinations are performed only on the complete order from a physician for ten of ten medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, and MR10).
Findings include:
On March 21, 2023, review of facility policy "Referral by a physician [sic]" last revised 02/2022, revealed " ...written, signed order specifies the reason an x-ray exam is required, the area of the body to be exposed, the number of radiographs to be obtained, and the views needed; It also includes a statement concerning the condition of the patient which indicates why portable x-ray services are necessary ... " .
Review of MR1 on March 21, 2023, date of service 1/20/23 revealed the order failed to include the number of radiographs to be obtained, number of views needed, and indication for why portable x-ray services is necessary.
Review of MR2 on March 21, 2023, date of service 1/19/23 revealed the order failed to include the reason for an x-ray exam, the number of radiographs to be obtained, number of views needed, and indication for why portable x-ray services is necessary.
Review of MR3 on March 21, 2023, date of service 2/1/23 revealed the order failed to include the number of radiographs to be obtained and indication for why portable x-ray services is necessary.
Review of MR4 on March 21, 2023, date of service 2/5/23 revealed the order failed to include the number of radiographs to be obtained, number of views needed, and indication for why portable x-ray services is necessary.
Review of MR5 on March 21, 2023, date of service 2/7/23 revealed the order failed to include the number of radiographs to be obtained, number of views needed, and indication for why portable x-ray services is necessary.
Review of MR6 on March 21, 2023, date of service 2/12/23 revealed the order failed to include the reason for an x-ray exam, the number of radiographs to be obtained, and indication for why portable x-ray services is necessary.
Review of MR7 on March 21, 2023, date of service 2/14/23 revealed the order failed to include the reason for an x-ray exam, the number of radiographs to be obtained, number of views needed, and indication for why portable x-ray services is necessary.
Review of MR8 on March 21, 2023, date of service 2/16/23 revealed the order failed to include the number of radiographs to be obtained, number of views needed, and indication for why portable x-ray services is necessary.
Review of MR9 on March 21, 2023, date of service 2/19/23 revealed the order failed to include the reason for an x-ray exam, the number of radiographs to be obtained, number of views needed, and indication for why portable x-ray services is necessary.
Review of MR10 on March 21, 2023, date of service 2/20/23 revealed the order failed to include the number of radiographs to be obtained, number of views needed, and indication for why portable x-ray services is necessary.
On March 21, 2023, at 11:45am, EMP4 confirmed the above findings.
Plan of Correction:We send a requisition to all Medicare providers to include the following:
1. How many views of this exam are required?
2. The reason the exam is medically necessary.
3. The area of the body to be imaged
4. What type of views are needed for the radiologic exam.
5. The number of images obtained
Lastly this includes verbiage that states "This test is medically necessary for the diagnostic and treatment of this patient and exam is to be performed portably"
This is an attestation signed by the ordering clinician before our arrival. Our technologists pick up the designated paperwork for the patient and then it is uploaded in our encrypted pacs system for secure access and storage.
This process is monitored by the Call Center Operations Manager on a weekly basis to ensure that all necessary documentation has been received for each patient receiving diagnostic imaging.
This information was not available on the charts that were reviewed 3/21/23 as Express uses two systems and the additional documentation had been recovered but was no in the system at the time the records were viewed. We have a separate Quality Assurance System that ensures any missing/required documentation is recovered within a week and reported every Friday. This process was fully implemented on 4/5/23 and both the Call Center Operations Manager and the Director of Operations are responsible for maintaining compliance moving forward.
486.106(b) STANDARD
RECORDS OF EXAMINATIONS PERFORMED
Name - Component - 00
The supplier makes for each patient a record of the date of the portable X-ray examination, the name of the patient, a description of the procedures ordered and performed, the referring physician or nonphysician practitioner, the operator(s) of the portable X-ray equipment who performed the examination, the physician to whom the radiograph was sent, and the date it was sent.
Observations:
Based on review of facility policies, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure a complete record for ten of ten medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, and MR10).
Findings include:
On March 21, 2023, review of facility policy "Records of Examination Performed", last revised 02/2022, revealed " ...The supplier creates for each patient a record of the date of the x-ray exam ...and the operator(s) of the portable x-ray equipment who performed the exam ... " .
Review of MR1 on March 21, 2023, date of service 1/20/23 revealed the record did not include the name of the operator.
Review of MR2 on March 21, 2023, date of service 1/19/23 revealed the record did not include the name of the operator.
Review of MR3 on March 21, 2023, date of service 2/1/23 revealed the record did not include the name of the operator.
Review of MR4 on March 21, 2023, date of service 2/5/23 revealed the record did not include the name of the operator.
Review of MR5 on March 21, 2023, date of service 2/7/23 revealed the record did not include the name of the operator.
Review of MR6 on March 21, 2023, date of service 2/12/23 revealed the record did not include the name of the operator.
Review of MR7 on March 21, 2023, date of service 2/14/23 revealed the record did not include the name of the operator.
Review of MR8 on March 21, 2023, date of service 2/16/23 revealed the record did not include the name of the operator.
Review of MR9 on March 21, 2023, date of service 2/19/23 revealed the record did not include the name of the operator.
Review of MR10 on March 21, 2023, date of service 2/20/23 revealed the record did not include the name of the operator.
On March 21, 2023, at 11:45am, EMP4 confirmed the above findings.
Plan of Correction:The Express Mobile Director of Operations worked directly with the IT Director at Flex/Premier (Radiologist Reading Provider) to rewrite their program to include the technologist name as it was missing on the date of the inspection on 3/21/23 when reviewed.
Effective 3/23/2023 every report states the following:
1. Date of record
2. The type of exam (i.e. chest x-ray, hip x-ray, etc.)
3. The reason for the exam based on the ordering physician's documentation
4. All identifying patient information
5. The technologist/operator who performed the exam. This is located directly under the radiologist who read the exam.
The Director of Operations has continued to monitor all outgoing radiologist reports to ensure that the proper changes were made to include the above mentioned required information. This is on every report before it is sent over to the ordering clinician and/or facility. This is to ensure a complete record for all exams completed. As this change was made in the programming of every report that is generated, this will remain in place permanently moving forward.
|