Initial Comments:
Based on the findings of an onsite unannounced Medicare Recertification survey completed October 16, 2024, Lifeline Therapy Penn Hills Llc was found to be in compliance with the following requirements of 42 CFR, Part 485.68, Subpart B, Conditions of Participation: Comprehensive Outpatient Rehabilitation Facilities - Emergency Preparedness.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced Medicare Recertification survey completed October 16, 2024, Lifeline Therapy Penn Hills Llc was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42 CFR, Part 485, Subpart B, Conditions of Participation: Comprehensive Outpatient Rehabilitation Facilities.
Plan of Correction:
485.60(a)(3) STANDARD
CONTENT
Name - Component - 00
The clinical record for each patient must contain identification data and consent or authorization forms.
Observations:
Based on review of clinical records (CR) and staff (EMP) interview, the facility failed to ensure consent for treatment was obtained for two (2) of six (6) CR reviewed (CR 1 & 5).
Findings include:
Review of clinical records on October 16, 2024, at approximately 2:30pm revealed:
CR2, start of services 7/8/24, identified patient to be 17 years of age. Consent for treatment on record was signed by the patient themselves, a minor. No record of consent for treatment on file signed by parent or guardian.
CR5, start of services 8/13/24, failed to include record of consent for treatment.
Interview with EMP1 on October 16, 2024, at approximately 3:30pm confirmed findings.
Plan of Correction:Updated Patient Intake Information (policy 5.11) to include a process for obtaining parental or guardian consent for the treatment of minors. When completing the intake for a minor patient, the PCC will add a Contact/Referral to their account, this information is required. The PCC will obtain and complete the Parent/Guardian information in the EMR. The PCC will check all Flag boxes that apply to the minor [Emergency Contact, Guardian, Authorized Representative and any others that apply per the guardian request]. By doing this, the Parent/Guardian added to the account is required to check the patient in at the KIOSK and sign all forms related to the minor patient's treatment. This will be monitored by the Facility Directors at the clinic level at weekly L10 staff meetings and a report will be run via the EMR by the Revenue Cycle Manager each week to monitor at the facility level. These measures will ensure compliance with this policy and ensure all accurate information is collected, and proper consent is obtained with any patient <18 years old. This change is effective 11/18/24.
485.62(b)(2) STANDARD
SANITARY ENVIRONMENT
Name - Component - 00
The facility must monitor the infection control program to ensure that the staff implement the policies and procedures and that the policies and procedures are consistent with current practices in the field.
Observations:
Based on review of facility infection logs, observation, and staff (EMP) interview, the facility failed to monitor its infection control program to ensure staff implemented infection control policies and procedures.
Findings include:
Observation of facility's treatment gym on October 16, 2024, at 10:00 am revealed documentation on a clipboard, " 2024 Infection Control Monitoring Checklist (Conducted on a weekly basis by staff) ..." The checklists on the clipboard did not have the dates filled in. There were designated boxes for the dates that were left blank. This surveyor unable to determine when monitoring conducted and if in accordance with weekly monitoring.
Interview with EMP1 on October 16, 2024, at approximately 11:00 am confirmed findings.
Plan of Correction:Infection control and monitoring policy (Policy 9.60) was updated to include language regarding monitoring of the program. It now states: Each facility will maintain a sanitary environment and take the necessary steps to prevent and control the cause of patient infections. The below guidelines must be followed to maintain a sanitary environment. It is the responsibility of the Facility Director to monitor the infection control at the facility level and of the Administrator at the leadership level to ensure sanitary conditions of each facility and prevent the spread of infection. Each facility will utilize the Weekly Infection Control Checklist, Daily Temperature Logs for the Hydrocollator/HydraTherm, refrigerators and freezers and monthly compliance logs. The completed logs and checklists will be added to the designated folder on the company drive at the end of each month for review. The Facility Director will monitor the infection control policy daily to ensure that staff is adhering to the below guidelines. The Administrator will monitor each facility monthly. Failure to comply with this policy will result in corrective action. This policy is effective 11/5/2025.
485.62(b)(3) STANDARD
SANITARY ENVIRONMENT
Name - Component - 00
The facility must make available at all times a quantity of laundered linen adequate for proper care and comfort of patients. Linens must be handled, stored, and processed in such a manner that prevents the spread of infection.
Observations:
Based on observation and staff (EMP) interview, the facility failed to ensure linens are handled, stored, and processed in such a manner that prevents the spread of infection.
Findings include:
Observation of facility on October 16, 2024, at 10:00 am revealed unfolded laundry in two unlabeled laundry baskets in the laundry/linen storage room. Interview with EMP1 at 11:00am reported one basket to be clean linen that had not yet been folded and one basket to be soiled linen. No clear way to identify soiled linen from clean linen.
Interview with EMP1 on October 16, 2024, at approximately 11:00 am confirmed findings.
Plan of Correction:Infection Control policy (policy 9.60) was updated on 11/5/24 to include designation of clean and dirty linens. Under "Linen Laundering" it now states that "clean linens will be folded and stored on designated shelving and in treatment room storage cabinets/carts." Under "Changing of Linens" it now states "Immediately after each patient treatment, all linen that comes into contact with the patient shall be discarded into the linen receptacle labeled as "DIRTY". This includes sheets, pillowcase, towels, blankets, and gowns" and "Any linen that is wet or soiled with blood or body fluids is to be placed in a non-permeable plastic bag and that bag will be labeled as "SOILED"." This update will ensure linens are handled, stored and processed to prevent the spread of infection. This policy will be monitored by the Facility Director at the clinic level and the Administrator at the Leadership level.
485.62(c)(1) STANDARD
MAINTENANCE
Name - Component - 00
The facility must establish a written preventive maintenance program to ensure that all equipment is properly maintained and equipment needing periodic calibration is calibrated consistent with the manufacturer's recommendations.
Observations:
Based on review of facility logs, manufacturer's directions for use (DFU), and staff (EMP) interview, the facility failed to ensure that all equipment is properly maintained.
Findings include:
Review of facility hydrocollator temperature and cleaning logs on October 16, 2024, at approximately 9:30 am revealed no temperature recorded for months of September and October 2024. No temperatures recorded for dates of July 11 or 12, 2024, or August 1, 5, 6, 13, 15, 19, 22, or 26-30, 2024. "HYDROCULATOR TEMP CHECK" document notes temperature range to be 158-167 degrees Fahrenheit. Documented temperatures range between 137-140 degrees Fahrenheit. Facility did not provde a policy re the hyrdroculator temperatures.
Review of Hydrocollator manufacturer DFU on October 16, 2024, at 2:00pm revealed: "...PRECAUTIONARY INSTRUCTIONS...The water temperature in the HydraTherm Heating Unit is adjustable from 120 degrees Fahrenheit to 160 degrees Fahrenheit..."
Interview with EMP1 on October 16, 2024, at approximately 2:00 pm confirmed findings and revealed facility had changed hydrocollators and the ranges from the previous one on the temperature logs had not been updated.
Plan of Correction:Updated policy 9.60 INFECTION CONTROL under "EQUIPMENT" to include cleaning instructions specific for the HydraTherm Hydrocollator per manufacturer's guidelines and with ideal temperature ranges for both the HydraTherm and Chattanooga Hydrocollators. An updated version of the temperature log to be specific for the HydraTherm Hydrocollator with correct ideal temperature ranges of 120-140°F. Created a shared folder on the company drive that all monitoring checklists (Temperature logs, and weekly infection control monitoring checklists) will be uploaded for monitoring by the Facility Director daily and the Administrator monthly. This policy update is effective 11/4/2024.
485.66(a) STANDARD
UTILIZATION REVIEW COMMITTEE
Name - Component - 00
The utilization review committee, consisting of the group of professional personnel specified in §485.56(c), a committee of this group, or a group of similar composition, comprised by professional personnel not associated with the facility, must carry out the utilization review plan.
Observations:
Based on interviews with the alternate administrator (EMP1) and reviews of documentation and policies/procedures, the agency failed to conduct utilization reviews with staff representing the full scope of services provided by the CORF for one (1) of one (1) MMs reviewed. (MM1)
Findings include:
A review of policy Utilization Review on 10/22/24 revealed: " The Utilization Review Committee will perform a quarterly evaluation of the clinic ' s medical records. "
A review of agency document Professional/Clinical Staff Licensure on 10/22/24 revealed CORF staff consisting of physical therapists, social worker, and a PT Medical Director.
A review of agency documentation Utilization Review Committee on 10/22/24 revealed: " The Utilization Review Committee is to consist of the following disciplines ... ...Orthopedic Med ...MD ...Social Worker "
A review of Utilization Review Meeting Minutes dated 7/17/24 failed to contain documentation of physician or social worker attendance.
The finding was reviewed during an exit interview with Alternate administrator on 10/22/24 at approximately 3:30 pm.
Plan of Correction:The Utilization Review (UR) Policy (Policy 10.05) was updated on 11/4/2024 to state that one person from each discipline must attend the quarterly meeting. If a member is unable to attend the scheduled meeting, an alternate professional from the same discipline will attend. If an alternate professional is unable to attend, the meeting must be rescheduled to a different date so that all disciplines are represented. The next quarterly meeting will take place on November 13, 2024. Meeting minutes will be taken and available for review.
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