Initial Comments:
Based on the findings of an unannounced, Medicare recertification survey conducted on July 24, 2024, Valley View Haven, Inc., was found to be compliant 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:
Initial Comments:
Based on the findings of an unannounced, recertification Medicare survey completed July 24, 2024, Valley View Haven, located at 4702 East Main Street, Belleville, PA 17004, were identified to have the following standard level deficiency that was 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.
Plan of Correction:
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 facility policies, observations, and an interview with the facility Administrator, facility failed to ensure all equipment was in good repair for eight (8) of eight (8) observations. (Observation #1-#8)
Findings include:
A review was conducted of facility policy on July 24, 2024 at approximately 11:00 a.m.
Policy # 801 'Maintenance of Physical Equipment and materials/Housekeeping/Pest-Control' Policy states "....4. Any defective equipment will be reported to the Rehabilitation Program Manager immediately. The defective equipment will be taken out of service until it is restored to proper working order. 5. All clinical equipment should be of a type, quality, and quantity needed to fulfill the needs of the clinical service and maintained to perform at optimum level...."
Treatment floor observations conducted on July 24, 2024, between approximately 10:30 a.m. - 11:45 a.m. revealed the following:
Observation #1: Two (2) gait belts hanging on the wall both were noted to have frayed fabric along the edges.
Observation #2: One (1) wheel chair pad was noted to have approximately 2 and 1/2 inch tear along the side of the pad exposing the internal pad.
Observation #3: Two (2) balance pads were were noted to have multiple rips in the vinyl surface.
Observation #4: Two (2) wheelchair trunk supports were noted to have multiple rips on the outer surfaces peeling.
Observation #5: One (1) arm rest support was noted to have multiple rips in the outer layer of the covering.
Observation #6: Two (2) knee rollers were noted to have multiple rips in the outer layer of the covering.
Observation #7: Two (2) wheelchair calf supports were noted to have multiple rips in the outer layer of the covering.
Observation #8: Two (2) foot body supports were noted to have multiple rips in the outer layer of the covering.
An interview with the facility Administrator on July 24, 2024 at approximately 2:00 p.m. confirmed the above findings.
Plan of Correction:1) All 14 individual pieces of equipment identified as being defective have been discarded.
2) Current inventory in the therapy gym will be audited in its entirety to ensure no other equipment is defective. Any pieces found to not be in proper working order will be discarded.
3) Therapy Staff will be trained in identifying defective equipment and the process of taking pieces out of service if found to be of such type, quality and quantity that would not fulfill the safe needs of patients.
4) Administrator will complete an observation audit of therapy equipment weekly x4weeks followed by monthly x3months to monitor that the deficient practice does not recur. Results will be reported to QAPI.
5) Date of Compliance: August 30, 2024
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