Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on 1/18/2019, Western Pennsylvania Sports Medicine & Rehabilitation Clinic Inc. was found to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42 CFR, Part 485.727, Subpart H, Conditions of Participation for Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services - Emergency Preparedness.
Plan of Correction:
485.727(a)(1)-(2) STANDARD
Plan Based on All Hazards Risk Assessment
Name - Component - 00
§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*
(2) Include strategies for addressing emergency events identified by the risk assessment.
* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.
*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.
*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.
Observations:
Based on review of facility documentation, and staff (EMP) interviews, the facility failed to develop, establish, review and maintain a comprehensive emergency preparedness program based on a facility-based and community-based risk assessment, utilizing an all-hazards approach.
Findings included:
A review of facility documentation was conducted on 1/11/2019 at approximately 2:35 PM The "Emergency Preparedness/External Disaster Plan" documentation did not confirm the facility met this standard. Facility failed to complete risk assessment.
During interview with (EMP1) and (EMP2) on 1/9/2019 at approximately 9:56 AM. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types Interpretive Guidance Table of Contents" with both employees.
An exit interview with conducted on 1/11/2019 at approximately 12:10 PM with the administrator and physical therapist confirmed above findings.
Plan of Correction:Administrator will Develop an Emergency preparedness plan using and all hazards approach to meeting the needs of patients and staff. Based on the Risk Assessment, the plan will address at a minimum a strategy to respond to 1) Natural Disasters (Flood, Severe Weather, Snowstorms, Tornadoes), 2) Cybersecurity, 3) Active Shooter or Similar attacks, 4) Influenza or Pandemic, and 5) Fires. The plan will be developed in consultation with Local Safety and other Emergency preparedness officials. The plan will be reviewed and updated annually.
485.727(a)(5) STANDARD
Local, State, Tribal Collaboration Process
Name - Component - 00
§403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4)
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:]
(4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. *
* [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.
Observations:
Based on review of facility documentation, and staff (EMP) interviews, the facility failed to develop, maintain and review an emergency preparedness plan that included a process for cooperation and collaboration with local, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.
Findings included:
A review of facility documentation was conducted on 1/11/2019 at approximatly 2:35 PM The "Emergency Preparedness/External Disaster Plan" documentation did notcontain evidence of the facility establishing cooperation and collaboration with local, regional, State, and Federal emergency preparedness officials. Facility failed to provide documentation to confirm facility had met this standard. Facility failed to provide documentation of participation with healthcare coalition and documentaton of collaboration with local, regional, State and Federal emergnecy prepadness officials.
During interview with (EMP1) and (EMP2) on 1/9/2019 at approximately 9:56 AM. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types Interpretive Guidance Table of Contents" with both employees.
An exit interview was conducted on 1/11/2019 at approximately 12:10 PM with the administrator and physical therapist which confirmed above findings.
Plan of Correction:Administrator will contact local and regional Emergency management agencies to coordinate with regional Emergency preparedness, obtain input on risk assessment, and the determine the extent the facility operations will be affected during an Emergency.
The EPP will be sent/given to local first responders and the county EMS. A transmittal letter will accompany the request and documentation returned by the responders and any recommmendations on the plan will be recorded and maintained.
485.727(b) STANDARD
Development of EP Policies and Procedures
Name - Component - 00
§403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b).
(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years.
*[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.
*Additional Requirements for PACE and ESRD Facilities:
*[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years.
*[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area.
Observations:
Based on review of facility documentation, observation (OBS) and staff (EMP) interviews, the facility failed to develop, review and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section.
Findings included:
During an observational tour (OBV#3) of the branch office on 1/10/2019 at approximately 10:30 AM revealed part of the facility's treatment area was a pool in a separate room. A patient was receiving therapy services in the pool at the time of the tour. A staff member was in the room outside the pool while the patient was receiving services. The pool/aquatic area had a floor that allows entry into the pool on one side with steps and a railing.
The surveyor's requested policies, procedures or training related to the pool/aquatic program from EMP6 on 1/10/2019 at approximately 11:05 AM. EMP6 confirmed no policies existed pertaining to the pool/aquatic program and no documentation of staff training or drills was available for review. There was no documention available to confirm that the facility conducted initial staff training or annual training pertaining to the aquatic/pool therapy program related to any related emergencies or evacuations requirements. During an interview on 1/10/2019 at approximately 1:45 PM (EMP1) confirmed no policies or procedures exit for pool/aquatic therapy services.
A review of facility documentation was conducted on 1/10/2019 at approximately 2:35 PM The "Emergency Preparedness/External Disaster Plan" manual did not contain evidence of the facility to develop, review and implement emergency preparedness policies and procedures.
During interview with (EMP1) the administrator and (EMP2) the billing manager on 1/9/2019 at approximately 9:56 AM. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types Interpretive Guidance Table of Contents" with both employees.
An exit interview was conducted on 1/11/2019 at approximately 12:10 PM with the administrator and physical therapist which confirmed above findings.
Plan of Correction:Administrator will develop polices and procedures for the hazards identified by risk assessment. The policies will include safe evacuation of patients and staff. A provision to shelter in place if needed and communication with staff and other organizations as appropriate. Policies/procedures will be reviewed and updated annually.
Separate policies and procedures will be developed for aquatic services and include plans for evacuation in a medical emergency or disaster. Policy will include initial training in the procedures for handling Emergencies/evacuation and an annual review and training for staff.
485.727(b)(4) STANDARD
Policies/Procedures-Volunteers and Staffing
Name - Component - 00
§403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5).
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]
(6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
*[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency.
*[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
Observations:
Based on a review of agency documentation, email correspondence, and staff interview, the facility failed to develop emergency preparedness policy and procedure that included the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
Findings Included:
A review of facility documentation was conducted on 1/11/2019 at approximately 2:35 PM. The agency's "Emergency Preparedness/External Disaster Plan" did not contain evidence of policy and procedure that included the other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals. Facility failed to provide documentation to confirm facility had met this standard.
During interview with (EMP1) and (EMP2) on 1/9/2019 at approximately 9:56 AM. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types Interpretive Guidance Table of Contents" with both employees.
An exit interview was conducted on 1/11/2019 at approximately 12:10 PM with the administrator and physical therapist which confirmed above findings.
Plan of Correction:Administrator will develop policies/procedures for the use of volunteers in an emergency and procurement of additional staff to address surge needs in an emergency. External agencies will be consulted concerning the development of the procedure and role for integration of State/Federal designated health care professionals.
485.727(c)(2) STANDARD
Emergency Officials Contact Information
Name - Component - 00
§403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2).
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:
(2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.
*[For LTC Facilities at §483.73(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) The State Licensing and Certification Agency.
(iii) The Office of the State Long-Term Care Ombudsman.
(iv) Other sources of assistance.
*[For ICF/IIDs at §483.475(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.
(iii) The State Licensing and Certification Agency.
(iv) The State Protection and Advocacy Agency.
Observations:
Based on a review of agency documentation, email correspondence, and staff interview, the facility failed to develop a communication plan that included the contact information for Federal, State, regional, local emergency staff.
Findings Included:
A review of facility documentation was conducted on 1/11/2019 at approximately 2:35 PM. The agency's "Emergency Preparedness/External Disaster Plan" did not contain evidence of a communication plan that included the contact information for Federal, State, regional staff.
During interview with (EMP1) and (EMP2) on 1/9/2019 at approximately 9:56 AM. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types Interpretive Guidance Table of Contents" with both employees.
An exit interview was conducted on 1/11/2019 at approximately 12:10 PM with the administrator and physical therapist which confirmed above findings.
Plan of Correction:The Emergency plan will include contact information for appropriate Federal, State and Local Emergency preparedness staff. Information will be reviewed and updated annually.
485.727(c)(3) STANDARD
Primary/Alternate Means for Communication
Name - Component - 00
§403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3).
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:
(3) Primary and alternate means for communicating with the following:
(i) [Facility] staff.
(ii) Federal, State, tribal, regional, and local emergency management agencies.
*[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies.
Observations:
Based on a review of the agency Emergency Preparedness Plan (EPP) and staff (EMP) interview, the agency failed to ensure the EPP communication plan included a primary and alternate means to communicate with agency staff and local/regional/state/federal emergency preparedness agencies, and was readily available and accessible during an emergency.
Findings Included:
A review of facility documentation was conducted on 1/11/2019 at approximately 2:35 PM. The agency's "Emergency Preparedness/External Disaster Plan" failed to include a primary and alternate means of communicating with facility staff, Federal, State, tribal, regional and local emergency management agencies.
During interview with (EMP1) and (EMP2) on 1/9/2019 at approximately 9:56 AM. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types Interpretive Guidance Table of Contents" with both employees.
An exit interview was conducted on 1/11/2019 at approximately 12:10 PM with the administrator and physical therapist which confirmed above findings.
Plan of Correction:The Emergency plan will include primary and alternate means to communicate with staff and Federal, State, regional, and local emergency management agencies.
The administrator will identify, with Emergency management agencies primary and alternate means to communicate with agency staff and EP agencies. These will be documented in the EPP and will be made available to staff as part of the document.
485.727(c)(4) STANDARD
Methods for Sharing Information
Name - Component - 00
§403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6).
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:
(4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care.
(5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)]
(6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4).
*[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative.
*[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4).
Observations:
Based on a review of agency documentation, email correspondence, and staff interview, the facility failed to develop a communication plan that included a method for sharing information and medical documentation for patients under the facility's care, as necessary, with other health providers to maintain the continuity of care.
Findings Included:
A review of facility documentation was conducted on 1/11/2019 at approximately 2:35 PM. The agency's "Emergency Preparedness/External Disaster Plan" did not contain evidence of a communication plan that included a method for sharing information and medical documentation for patients under the facility's care.
During interview with (EMP1) and (EMP2) on 1/9/2019 at approximately 9:56 AM. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types Interpretive Guidance Table of Contents" with both employees.
An exit interview was conducted on 1/11/2019 at approximately 12:10 PM with the administrator and physical therapist which confirmed above findings.
Plan of Correction:Emergency plan will contain a procedure to share information and medical documentation as necessary with other health care providers to maintain continuity of care.
Administrator will insure a procedure is included in the EPP. It will be included as part of staff training on the EPP.
Administrator will continue to monitor overall compliance with the EPP.
485.727(c)(5) STANDARD
Information on Occupancy/Needs
Name - Component - 00
§403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7).
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:
(7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
*[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
*[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
Observations:
Based on a review of agency documentation, email correspondence, and staff interview, the facility failed to develop a communication plan that provided a means of providing information about the facility's occupancy needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
Findings Included:
A review of facility documentation was conducted on 1/11/2019 at approximately 2:35 PM. The agency's "Emergency Preparedness/External Disaster Plan" did not contain evidence of a communication plan that provided a means of providing information about the facility's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
During interview with (EMP1) and (EMP2) on 1/9/2019 at approximately 9:56 AM. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types Interpretive Guidance Table of Contents" with both employees.
An exit interview was conducted on 1/11/2019 at approximately 12:10 PM with the administrator and physical therapist which confirmed above findings.
Plan of Correction:The communication plan developed in the Emergency Plan will contain a method to communicate the organizations Occupancy/Needs to the authority having jurisdiction, the Incident Command Center, or designee.
Administrator will be responsible to communicate with the responsible authority about occupancy and ability to assist in an Emergency.
Administrator is responsible for monitoring continued implementation of the plan of correction.
485.727(d) STANDARD
EP Training and Testing
Name - Component - 00
§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.
*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.
*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).
*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.
Observations:
Based on a review of emergency operations plan and staff (EMP) interview, the facility failed to develop and maintain an emergency preparedness training and testing program that was based on the emergency plan, risk assessment, policies and procedures and communication plan.
Findings Included:
During an observational tour (OBV#3) of the branch office on 1/10/2019 at approximately 10:30 AM revealed part of the facility's treatment area was a pool in a separate room. a patient was receiving therapy services in the pool at the time of the tour. A staff member was in the room outside the pool while the patient was receiving services. The pool/aquatic area had a floor that allows entry into the pool on one side with steps and a railing.
Upon request for policies, procedures or training related to the pool/aquatic program from EMP6 on 1/10/2019 at approximately 11:05 AM. EMP6 confirmed no policies existed pertaining to the pool/aquatic program and no documentation of staff training or drills was available for review. There was no documention available to confirm that facility conducted initial staff training or annual training pertaining to the aquatic/pool therapy program related to emergencies or evacuations requirements. During an interview on 1/10/2019 at approximately 1:45 PM (EMP1) confirmed no policies or procedures exit for pool/aquatic therapy services.
A review of facility documentation was conducted on 1/10/2019 at approximately 2:35 PM. The agency's failed to show documentation that an emergency preparedness training and testing program was ever established.
During interview with (EMP1) and (EMP2) on 1/9/2019 at approximately 9:56 AM. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types Interpretive Guidance Table of Contents" with both employees.
An exit interview was conducted on 1/11/2019 at approximately 12:10 PM with the administrator and physical therapist which confirmed above findings.
Plan of Correction:Facility will develop a training and testing program for the Emergency preparedness Plan. The training be based on the emergency plan, risk assessment, policies and procedures and the communication plan. The training plan will include the requirements for emergencies/evacuations for the aquatic/pool therapy program.
Administrator will be responsible for implementing a training and testing program consistent with the EPP. Training will include initial company-wide training on the plan, new hire orientation to the plan, and drills/training annually. Training will include testing and evaluation of of employee understanding of the plan. Employee attendance and participation will be documented.
Clinic directors will be responsible for conducting annual review and drill on the EPP. Additional training exercises on particular risks identified will also be included and documented.
Clinic director will insure that staff working in the aquatic area will receive particular training in the procedures associated with the aquatic program.
485.727(d)(1) STANDARD
EP Training Program
Name - Component - 00
§403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:]
(1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.
*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and
procedures.
*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.
*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures.
*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.
*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.
*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.
Observations:
Based on review of agency emergency preparedness plan, and staff (EMP) interview, the agency failed to implement and provide documentation pertaining to the emergency preparedness initial training of staff and the methods used for demonstrating staff knowledge of an emergency preparedness training program.
Findings included:
A review of facility documentation was conducted on 1/11/2019 at approximately 2:35 PM. The agency's that the agency failed to implement an emergency preparedness written training and testing program for individuals providing services and failed to provide any documentation methods used for demonstrating staff knowledge of emergency preparedness training.
During interview with (EMP1) and (EMP2) on 1/9/2019 at approximately 9:56 AM. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types Interpretive Guidance Table of Contents" with both employees.
An exit interview was conducted on 1/11/2019 at approximately 12:10 PM with the administrator and physical therapist which confirmed above findings.
Plan of Correction:All new and existing staff will receive initial training on the EP Plan, policies and procedures. Emergency preparedness training will be provided and documented annually. Staff will demonstrate knowledge of emergency procedures.
Administrator will maintain a record of employee training program attendance and a log of continued annual training. Administrator will schedule initial training which will include Q&A opportunities and staff demonstration. If available, all training will incorporate quizzes/testing in order to determine staff understanding of program requirements.
485.727(d)(2) STANDARD
EP Testing Requirements
Name - Component - 00
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).
*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:
(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:
(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.
*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.
*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.
*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.
*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.
*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.
*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.
*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.
Observations:
Based on review of agency emergency preparedness plan, and staff (EMP) interview, the agency failed to participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. The agency also failed to conduct an additional exercise that included, but was not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based. (B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario.
Findings included:
A review of facility documentation was conducted on 1/11/2019 at approximatly 2:35 PM. The agency failed to provide documentation to confirm the agency participate in a full-scale exercise that is community-based or an individual facility-based exercise. The agency also failed to provide documentation that a second additional exercise was conducted.
During interview with (EMP1) and (EMP2) on 1/9/2019 at approximately 9:56 AM. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types Interpretive Guidance Table of Contents" with both employees.
An exit interview was conducted on 1/11/2019 at approximately 12:10 PM with the administrator and physical therapist which confirmed above findings.
Plan of Correction:The facility will conduct exercises to test the emergency plan at least annually with a community-based exercise or a facility-based exercise in the form of a drill. A second tabletop exercise or facility-based drill will also be conducted. Participation by staff will be documented.
Administrator will identify any opportunities for community-based program participation. Administrator will develop a program for initial staff training on the requirements of the EPP and annual drills/training as required. A record will be maintained of employee participation. Clinic directors will be responsible for conducting annual drills as required and maintaining documentation of attendance.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed 1/14/2019, Western Pennsylvania Sports Medicine & Rehabilitation Clinic Inc. was found 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 H, Conditions of Participation for Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services. The survey was conducted at the Johnstown parent location on 1/9/2019 and completed on 1/11/2019 and the Ebensburg and Somerset branch or extension location on 1/10/2019.
Plan of Correction:
485.721(a) STANDARD
PROTECTION OF CLINICAL RECORD INFORMATION
Name - Component - 00
The organization recognizes the confidentiality of clinical record information and provides safeguards against loss, destruction, or unauthorized use. Written procedures govern the use and removal of records and the conditions for release of information. The patient's written consent is required for release of information not authorized by law.
Observations:
Based on review of agency policy, observation (OBV) tours, and staff (EMP) interview, the agency failed to ensure medical records (MR) were stored and maintained in accordance with its policy and procedure for one (1) of three (3) agency (OBV) tours.
Findings included:
A review of agency policy on 1/9/2019 at approximately 1:45 PM revealed, "Policy #205... Patient Care Policy Clinical Records (agency) maintains accurate, timely and pertinent clinical records in accordance with accepted professional standards and practices. The organization protects against unauthorized release or use of the record. I. RETENTION AND PRESERVATION OF RECORDS: Superceded by HIPAA Policies-Section 500..."
During an observation tour (OBV#3) of an extension site location on 1/10/2019 at approximately 10:30 AM with (EMP8) revealed, an open office located in a hallway adjacent to the patient waiting room which contained files of discharged patient clinical records. Patient discharged files were stacked along the left side of the office from the entrance. (EMP8) confirmed these were clinical records of discharged patients which were to be pick up by an agency and destroyed next week. The surveyor asked (EMP8) if the office could be locked, (EMP8) stated no.
An exit interview was conducted on 1/11/2019 at approximately 12:10 PM with the administrator and physical therapist which confirmed above findings.
Plan of Correction:Locks will be installed in on any area used for temporary record storage.
Clinic directors are responsible for insuring that any record storage areas can be secured.
On a daily basis, front desk personnel are responsible for insuring records and record storage areas are secured and locked at the end of the workday.
485.723(b) STANDARD
MAINTENANCE OF EQUIPMENT/BUILDINGS/GROUNDS
Name - Component - 00
The organization establishes a written preventive maintenance program to ensure that the equipment is operative and is properly calibrated, and the interior and exterior of the building are clean and orderly and maintained free of any defects which are a potential hazard to patients, personnel, and the public.
Observations:
Based on review of agency job descriptions, observation (OBV) tours, and staff (EMP) interview, the agency failed to ensure medications and expired supplies were not accessible to patients, personnel, and the public for two (2) of three (3) OBV tours (OBV1 and OBV2).
Findings Included:
A review of agency policy on 1/9/2019 at approximately 1:45 PM which revealed, "JOB DESCRIPTION...SUPERVISING PHYSICAL THERAPIST, JOB SUMMARY: The supervising physical therapist is directly responsible to the administrator and has responsibility for overall direction, utilization, supervision, instruction and evaluation of professional staff, athletic trainer/aides, volunteers and students utilized in the facility. Responsible for the development, implementation and monitoring of all patient care programs, plans for providing care, quality improvement programs, policies and procedures and equipment to provide patient care...ESSENTIAL FUNCTIONS...C. Maintaining inventory of materials and supplies for the facility..."
A review of agency policy on 1/9/2019 at approximately 1:45 PM which revealed, "JOB DESCRIPTION ATHLETIC TRAINER/PHYSICAL THERAPY AIDE, JOB SUMMARY Provide athletic training services to contracted sports teams, provide treatment modalities within the scope of the athletic training license to injured athletes in the clinic setting. Function as a physical therapy aide for nonathletes in the clinic. Report to: Physical therapist, medical director...Physical Therapy Aide...2. Maintain the clinic inventory, clean and maintain equipment daily..."
During an observation (OBV#2) tour of a branch location on 1/10/2019 at approximately 9:10 AM with (EMP6) and (EMP7) revealed, two medications (patient specific) located in a secured desk at the front of the facility.
The following expired medications are as followed:
Dexamethasone Sodium Phosphate injectable Lot 6113616 Exp 02/18
Dexamethasone Sodium Phosphate injectable Lot 6115103 Exp 08/18
An exit interview was conducted on 1/11/2019 at approximately 12:10 PM with the administrator and physical therapist which confirmed above findings.
Plan of Correction:A policy and procedure have been established to conduct at least monthly an evaluation of supply inventory to check for outdated or any other condition (i.e. open or damaged packages) that should be discarded. Each Clinic Director (or their designee) will be responsible for reviewing the inventory and a record documenting the review and findings is being maintained.
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