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Based on interview, record review and document review, the facility failed to ensure a medical assistant (MA) who was functioning as a radiologic technologist (RT) during pain management procedures was licensed pursuant to Nevada Revised Statutes (NRS) 653 - Radiation Therapy and Radiologic Imaging; and failed to provide documented evidence the MA completed the required training for RT, skills competency, and job description for 1 of 10 sampled employees (Employee 9).

Findings include:

Patient 4's date of service was 03/03/2022, for fluoroscopically directed radiofrequency ablation of the sacroiliac joint nerves. The patient's Pain Management Procedure Record dated 03/03/2022, documented the pain management personnel during the procedure included Employee 9 as the RT.

Patient 5's date of service was 03/15/2022, for spinal cord stimulator trial. The patient's Intraoperative Record dated 03/15/2022, documented the surgical personnel included Employee 9 as the RT.

The Staffing Schedule dated 03/15/2022, documented Employee 8 and Employee 9 were assigned in fluoroscopy in procedure room 1 and 2, respectively.

Review of Employee 9's personnel files revealed the following:
- There was no documented evidence the employee obtained a limited license in fluoroscopy pursuant to NRS 653.
- There was no documented evidence of training completed in radiology and skills competency.
- The job description contained in the employee's personnel file was for an MA and signed by the employee and the Administrator on 05/10/2021. There was no documented evidence of a signed job description for the employee's function as an RT during pain management procedures.
- The Facility Orientation Checklist / Acknowledgement form signed by the employee lacked documented evidence of the date when the employee signed the form and a preceptor checked off and signed the form.

On 03/15/2022 at 11:43 AM, Employee 9 revealed being hired at the facility in May 2021 as an MA. The employee indicated to have started working in the procedure room around July 2021 and had performed the function of an RT such as moving the C-arm (a medical imaging device) during a procedure under the direct supervision of a physician. The employee confirmed a limited license in fluoroscopy was not obtained and had not received training in radiology at the facility prior to being assigned in the procedure room as an RT. The employee previously worked in another facility as a fluoroscopy technician.

On 03/15/2022 at 2:33 PM, the Administrator confirmed the findings in the personnel record review of Employee 9 as enumerated above. The Administrator acknowledged Employee 9 should have obtained a limited license in fluoroscopy pursuant to NRS 653, completed a training in radiology and skills competency prior to the employee's designation as an RT during pain management procedures. The Administrator indicated the job description should have included the employee's functions in the procedure room as an RT.

The Administrator revealed Employee 8 was a certified RT. The Administrator confirmed both Employee 8 and Employee 9 were assigned in each procedure room on 03/15/2022 to function as an RT.

NRS 653.640 Fluoroscopy: Requirements; penalty. [Effective January 1, 2020.]
1. A person shall not perform fluoroscopy except as authorized in this section and NRS 653.620.
2. A holder of a license may perform fluoroscopy:
(a) If he or she is certified by the American Registry of Radiologic Technologists, or its successor organization, to practice in the area of radiation therapy;
(b) Only within the scope of his or her practice; and
(c) Only to the extent authorized by the regulations adopted pursuant to NRS 653.460.
3. A person who performs fluoroscopy in violation of this section is guilty of a misdemeanor.
(Added to NRS by 2019, 2730, effective January 1, 2020)

NRS653.620 Taking X-ray photographs: Requirements; registration. [Effective January 1, 2020.]
1. A person who does not hold a license or limited license may take X-ray photographs under the supervision of a physician or physician assistant as part of his or her employment or service as an independent contractor in a rural health clinic or federally qualified health center described in subsection 2 if the person:
(a) Registers with the Division in the form prescribed by the Division;
(b) Submits to the Division proof that he or she has completed training in radiation safety and proper positioning for X-ray photographs provided by the holder of a license; and
(c) Completes the continuing education prescribed by regulation of the Department.

The facility's policy titled Imaging Services dated November 2016, documented radiology services consisted only of fluoroscopy to meet the needs of the patients. Healthcare professionals, to include preferred certified radiologist technologists and approved physicians, who provided imaging services should have appropriate training and credentials. Documentation of the radiologic technologist's training and national licensure were kept and maintained in employee's personnel file.

The facility's policy titled Quality of Care Provided dated July 2019, documented one certified radiologist technologist was assigned for each procedure which required radiology services.

The facility's policy titled Personnel Policies dated July 2019, documented the facility employed personnel with qualifications which would be commensurate with job responsibilities and authority, including required or appropriate licensure. Periodic and at a minimum yearly appraisal of each person's job performance, including observations of current competencies were performed by the respective supervisor.

Complaint #NV00064712

Based on observation, interview, record review and document review, the facility failed to ensure a periodic skills competency and a job description were completed for an employee who functioned as a gastrointestinal (GI) decontamination technician (GI Tech) for 1 of 10 sampled employees (Employee 2) per facility policy.

Findings include:

The facility's policy titled Personnel Policies dated July 2019, documented the facility employed personnel with qualifications which would be commensurate with job responsibilities and authority, including required or appropriate licensure. Periodic and at a minimum yearly appraisal of each person's job performance, including observations of current competencies were performed by the respective supervisor.

On 03/15/2022 at 10:45 AM, Employee 2 was observed working inside Decontamination Room 2. The employee explained the regular functions of a GI Decontamination Technician such as pre-cleaning and high-level disinfection of endoscopes, operating the automated endoscope reprocessor, labeling, and storage of reprocessed endoscopes. The employee revealed having been hired to assist in transporting patients from the operating room to the recovery room, cleaning, and disinfecting patient care areas. The employee was then transferred to the GI reprocessing unit as a GI Decontamination Technician for less than a year.

On 03/15/2022 at 2:18 PM, a review of the personnel record of Employee 2 was conducted with the Administrator. The employee's personnel record lacked documented evidence a skills competency check and a job description for GI Decontamination Technician were completed. The Administrator confirmed the findings and acknowledged a skills competency, and a job description should have been completed when Employee 2 was first assigned in the GI reprocessing unit. The Administrator indicated the job description contained in the employee's personnel record was for a Transporter which was the employee's position title upon hire. The Administrator provided a copy of the job description of a GI Decontamination Technician and explained the same job description should have been completed for Employee 2.

The Administrator explained a skills competency should have been completed by the employee's supervisor initially then annually and as needed. The Administrator explained the facility utilized a skills competency form for each position title to be completed and signed by the employee and the supervisor. The results of the skills competency could have been used to assess the employee's strengths, weaknesses, and areas of learning needs. The completed skills competency form should have been filed in the employee's personnel record.

On 03/15/2022 at 3:19 PM, the Lead Tech and the GI Supervisor provided a copy of the GI Tech Supervisory Evaluation form dated 03/10/2022 for Employee 2 and signed by the GI Supervisor. A copy of the GI Tech Self-Evaluation form dated 03/10/2022 completed by Employee 2 was also provided. The Lead Tech explained the forms were found in human resources office for filing in the employee's personnel record. The GI Supervisor indicated the GI Tech Supervisory Evaluation form was used for the evaluation and skills competency of Employee 2.

The following sections of the GI Tech Supervisory Evaluation form dated 03/10/2022 for Employee 2 were left blank:

- Evaluation Period: 3-month, Annual, Follow-up
- Employee review of performance evaluation such as employee comments, signature, and date.

The GI Supervisor confirmed the findings and explained the form should have been completed to indicate whether the evaluation period was within three months, annual, or follow-up. The GI Supervisor indicated Employee 2 should have signed the form with the date of signature. The GI Supervisor revealed the form was completed as a baseline or initial evaluation and skills competency for Employee 2 which should have been done last year when the employee had started to work as a GI Decontamination Technician.


Complaint #NV00064712