2022 Mid-Year RHC Common Deficiencies

As we look back at the first six months of onsite surveys for 2022, we continue to see a trend with the same deficiencies being cited.  When completing your self-survey prior to an onsite visit with a TCT advisor, pay close attention in evaluating your clinic’s compliance to avoid citations for these common deficiencies.

Here is a short list of the Standard and Condition Level citations we are seeing repeatedly:

Lack of a Biennial review of your practice. QI 1.0 (Condition Level)

This must be done every two years. There was no waiver for this requirement. Pull your last biennial review and look at the date to make sure It’s not more than two years old.

Lack of proof of physician chart review. ADM 6.0.3

How will you show the surveyor that physician chart review is being completed? The number of patient files to be reviewed and frequency must match your policy unless your state requires a specific number.

Single dose vials opened and accessed with a 28-day date on them.  ADM 11.0.3 (Condition Level)

Single dose vials are once and done!  Don’t date the vial, don’t access multiple times and be sure to discard promptly and properly.
Do your Medical Assistants know the difference between single dose and multi-dose vials? Review and retrain today to be sure.

Onsite lab not able to complete six required tests and get the result. DGS 2.0

You must have the equipment and all necessary supplies (control agents etc.) to perform the tests. Check for outdates on supplies and re-order before they expire!

Signage is not consistent with the name on CMS 855a.  ADM 3.0.5

Your name must match what you submitted on your 855a unless you submit a new 855a with the updated information. Check your signage to ensure you are using the exact name submitted to CMS.

Medication refrigerator has drugs in the door. DRG 1.0.1(f)

Are you aware that the CDC says the temperature in the door is not consistent with the rest of the refrigerator and that you should take up that dead air with water bottles?  Medications including vaccines should never be stored in the door of the refrigerator.

Pandemic used as the EP exercise/event last year, but no written analysis documented.  EP 5.0

Perhaps the most important part of an emergency event, once we are through it, is to analyze and evaluate the clinic’s response. What did we learn, what did we do well, what do we need to work on should it happen again? This analysis is frequently missing.

Infection control protocols not followed causing possible cross contamination. INF 1.0

Are you drawing up meds in the dirty area where you do labs? Designate a clean area to handle medications then review and retrain staff on infection control to eliminate possible cross contamination.

Incomplete patient medical records. ADM 9.0

Have you documented reporting of abnormal labs to patients?
The notes should reflect that the patient has been notified of the lab results and the plan moving forward. What instructions are given to the patient?

Utilizing the checklist to complete a self-survey before your onsite visit will help you identify areas of possible non-compliance and help your clinic avoid deficiencies during the survey process.  Sharpen that pencil and grab a clipboard for this open book test. Prepare to do your best to make it a perfect score!