This report is the result of a full Medicare recertification survey conducted on August 19, 2019, at Apex Medical Services, with additional documentation review concluding September 16, 2019. 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:
LICENSURE OR REGISTRATION OF EQUIPMENT
Name - Component - 00
All portable X-ray equipment used in providing portable X-ray services is licensed or registered in accordance with all applicable State and local laws.
Based on review of facility documents and staff interview (EMP), it was determined that the facility failed to ensure that all X-ray equipment used in providing portable X-ray services was registered in accordance with all applicable State and local laws.
Apex Medical Services was not in compliance with Pennsylvania State Code, Title 25 Environmental Protection, Chapter 216.
Pennsylvania State Code, Title 25 Environmental Protection, Chapter 216. Registration of Radiation-Producing Machines and Radiation-Producing Machine Service Providers 216.2. Registration of radiation-producing machines. ... (d) A registrant shall have the currently valid certificate of registration available for inspection by the Department.
This is not evidenced by:
Based on review of facility documents, it was determined that the facility failed to ensure that all X-ray equipment used in providing portable X-ray services have the currently valid certificate of registration available for inspection by the Department for one of one machine.
1) Review of the certification of the portable X-ray machine on August 19, 2019, at 2:00 PM revealed the Certificate of Registration for Radiation-Producing Machine 576698 expired on May 31, 2019.
2. During a telephone interview on August 21, 2019, at approximately 2:00 PM EMP1 indicated that the current registration would be provided. As of September 16, 2019, the Department had not received a current registration for the X-ray machine.
Plan of Correction:
I have been in contact with the local representative handling our account in The Department of Environmental Protection (Pittsburgh office) to ensure that Apex Medical Services is current in its registration and compliance. As of this transmission we are and have been.
Apex had not received its most recent copy of such verification via snail mail but the local contact (that handles our account) from The Department of Environmental Protection has submitted the verification to the Commonwealth of PA and we are simply awaiting this physical document.
Should a copy of this document be needed, we will gladly provide it the moment it is received.
Apex Medical Services, Inc. has made changes to the manner in which these reviews are handled internally, as a company, to avoid any future verification issues and verify constant and on-going compliance.
Apex will periodically monitor on a quarterly basis all compliance records to ensure it is in constant & on-going compliance.
Date of second verification was the week of March 9th, 2020
* The above information was verified the week of March 9th for the second time with the appropriate local contact with The Department of Environmental Protection in Pittsburgh.
The machine IS registered and the verification process has been noted above.