Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on February 27, 2024, and February 28, 2024, at the parent location of 721 Dresher Road, Suite 2100, Horsham, PA 19044, February 28, 2024, at the alternate site location of 1510 Dekalb Pike, Blue Bell, PA 19422, and March 1, 2024, at the alternate site location of 1628 Butler Pike, Conshohocken, PA 19428, NovaCare Outpatient Rehabilitation was identified to have the following standard level deficiency that was determined to be in substantial compliance with the 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(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 rehabilitation facility policy, alternate site location observations (OBS), and staff interviews, the rehabilitation facility failed to ensure medical emergency drills and pool emergency rescue drills were conducted in accordance with rehabilitation facility policy for two (2) of two (2) alternate site locations with a pool. (OBS #2 and 3).
Findings include:
Review of facility policy titled "Therapeutic Pool Safety" on March 1, 2024, at approximately 1:40 P.M. states, "Pool Emergency Drills: Policy 9.01 requires all centers to conduct emergency drills at least annually. Those centers providing aquatic therapy must include pool related emergency evacuation and rescue in their annual drills...Prepare staff to enter the pool during emergency drills. Include at least 1 staff member to pose as a pool patient and represent the target of the rescue/evacuation... Staff members posing as the first and possibly second responders will also need to prepare to get wet during drills. Drills should include practice with all emergency rescue equipment..."
OBS #2 at the alternate site located at 1510 Dekalb Pike, Blue Bell, PA 19422 on February 28, 2024 from approximately 12:30 P.M. to 1:45 P.M. revealed the following:
Review of the rehabilitation facility "Center Handbook" at approximately 12:45 P.M. contained no documentation of pool emergency rescue drills conducted and no medical emergency drills conducted. In an interview with the center manager on February 28, 2024, at approximately 1:15 P.M., the center manager stated that a pool emergency drill was conducted with basic life support recertification in October. No documentation was available. When asked if a pool emergency drill was conducted the previous year, the center manager stated, "No".
OBS #3 at the alternate site located at 1628 Butler Pike, Conshohocken, PA 19428 on March 1, 2024, from approximately 9:15 A.M. to 10:15 A.M. revealed the following: Review of the rehabilitation facility "Center Handbook" at approximately 9:30 A.M. contained no documentation a pool emergency drill. The center manager stated that "a pool emergency drill was conducted with CPR training October, 2023", and they were "waiting for the documentation." The center manager confirmed that pool drill was conducted with staff in the pool. The center manager confirmed that opposite years the drill consists of a review of the procedure with staff, with no in-pool drill.
An interview with the rehabilitation facility Administrator on March 1, 2024, at approximately 12:20 P.M. confirmed the above findings.
Plan of Correction:All emergency drills will be documented at the time of safety training and put into the handbook. This will be reviewed immediately on Monday March 4th with all employees who have a pool in their center and all staff will provide signature that it is reviewed annually. Pool Safety Training will be added on our yearly review to ensure it is being performed and documented accordingly. Current Pool Safety policy will be updated and reviewed with all clinicians with pool on site by March 4th 2024. Any center with a pool will conduct a full scale functional pool drill by March 8th 2024 and document and file in handbook. We will provide a sign in sheet so that that confirm attendance and review of the policy.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on February 27, 2024, and February 28, 2024, at the parent location of 721 Dresher Road, Suite 2100, Horsham, PA 19044, February 28, 2024, at the alternate site location of 1510 Dekalb Pike, Blue Bell, PA 19422, and March 1, 2024, at the alternate site location of 1628 Butler Pike, Conshohocken, PA 19428, NovaCare Outpatient Rehabilitation was found not be in compliance with the 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.
As a result of the survey, one (1) condition level deficiency was cited.
An immediate Jeopardy situation was identified.
Plan of Correction:
485.709(c) STANDARD
PERSONNEL POLICIES
Name - Component - 00
Personnel practices are supported by appropriate written personnel policies that are kept current. Personnel records include the qualifications of all professional and assistant level personnel, as well as evidence of State licensure if applicable.
Observations:
Based on review of rehabilitation facility policies, personnel file (PF) reviews, staff interviews and email communications with human resources (HR) staff, the rehabilitation facility failed to provide documentation of child abuse clearances for four (4) of fourteen (14) PF reviewed (PF # 1, 2, 7, and 14) and documentation of Tuberculosis screening upon hire for one (1) of fourteen (14) PF reviewed (PF # 14).
Findings include:
Review of rehabilitation facility policy #9.10 titled " Infection Control and Asepsis " on February 29, 2024, at approximately 10:00 A.M. stated, " Procedure: 5) All new employees will be tested for Tuberculosis (TB) within 10 days of hire ... "
An email communication with the HR Manager on February 29, 2024, at approximately 12:40 P.M., stated, " Child abuse clearances expire after five years. "
Review of PF on February 27, 2024, from approximately 1:30 P.M. to 2:30 P.M., February 28, 2024, from approximately 8:00 A.M. to 9:00 A.M. and February 29, 2024, from approximately 10:00 A.M. to 10:30 A.M. revealed the following:
PF #1, date of hire October 8, 1999, contained a child abuse clearance dated October 9, 2015. There was no documentation of a child abuse clearance completed after that date.
PF #2, date of hire June 21, 2004, contained a child abuse clearance dated October 14, 2015. There was no documentation of a child abuse clearance completed after that date.
PF #7, date of hire April 28, 2003, contained no documentation of a child abuse clearance.
PF #14, date of hire June 22, 2015, contained no documentation of a child abuse and no documentation of TB testing completed upon hire.
An interview with the rehabilitation facility Administrator on March 1, 2024, at approximately 12:20 P.M. confirmed the above findings.
Plan of Correction:All employees identified as having missing child abuse clearances, FBI background checks & documentation of Tuberculosis screening have been completed & placed in their Human Resource personnel file. Going forward, HR Onboarding requires all new hires to complete initial child abuse clearance & FBI background check prior to their start date, and requires completion of TB testing within (10) days of their start date. For existing employees, Human Resources will run a monthly report to audit any existing employees that require updated child abuse clearance or background check updates within the next 60 days. Once identified, Human Resources will send a notification email with links for completion at minimum 2 weeks prior to the clearance expiring. Market Managers will perform a yearly random audit of (5) employees checking on their Human Resource personnel file to ensure compliance of initial & updated child abuse clearance and FBI background check requirements along with Tuberculosis screening results which will be documented on the Center Handbook Compliance Checklist.
485.711(c) STANDARD
EMERGENCY CARE
Name - Component - 00
The rehabilitation agency must establish procedures to be followed by personnel in an emergency, which cover immediate care of the patient, persons to be notified, and reports to be prepared.
Observations:
Based on review of rehabilitation facility policy, alternate site location observations (OBS), and staff interviews, the rehabilitation facility failed to ensure medical emergency drills and pool emergency rescue drills were conducted in accordance with rehabilitation facility policy for two (2) of two (2) alternate site locations with a pool. (OBS #2 and 3).
Findings include:
Review of facility policy titled "Therapeutic Pool Safety" on March 1, 2024, at approximately 1:40 P.M. states, "Pool Emergency Drills: Policy 9.01 requires all centers to conduct emergency drills at least annually. Those centers providing aquatic therapy must include pool related emergency evacuation and rescue in their annual drills...Prepare staff to enter the pool during emergency drills. Include at least 1 staff member to pose as a pool patient and represent the target of the rescue/evacuation... Staff members posing as the first and possibly second responders will also need to prepare to get wet during drills. Drills should include practice with all emergency rescue equipment..."
OBS #2 at the alternate site located at 1510 Dekalb Pike, Blue Bell, PA 19422 on February 28, 2024 from approximately 12:30 P.M. to 1:45 P.M. revealed the following:
Review of the rehabilitation facility "Center Handbook" at approximately 12:45 P.M. contained no documentation of pool emergency rescue drills conducted and no medical emergency drills conducted. In an interview with the center manager on February 28, 2024, at approximately 1:15 P.M., the center manager stated that a pool emergency drill was conducted with basic life support recertification in October. No documentation was available. When asked if a pool emergency drill was conducted the previous year, the center manager stated, "No".
OBS #3 at the alternate site located at 1628 Butler Pike, Conshohocken, PA 19428 on March 1, 2024, from approximately 9:15 A.M. to 10:15 A.M. revealed the following: Review of the rehabilitation facility "Center Handbook" at approximately 9:30 A.M. contained no documentation a pool emergency drill. The center manager stated that "a pool emergency drill was conducted with CPR training October, 2023", and they were "waiting for the documentation." The center manager confirmed that pool drill was conducted with staff in the pool. The center manager confirmed that opposite years the drill consists of a review of the procedure with staff, with no in-pool drill.
An interview with the rehabilitation facility Administrator on March 1, 2024, at approximately 12:20 P.M. confirmed the above findings.
Plan of Correction:A live pool emergency drill was performed by the Center Manager at both the Blue Bell and Conshohocken centers on 3/11/24 and documented on an Emergency Drill Report Form (9.01c) and placed in section 9 of the Center Handbook. Going forward, an annual live in-person training of emergency evacuation from the pool will be performed annually by the center manager and will be added to the annual Center Handbook Compliance Checklist, which will be monitored by the Market Manager annually. As per Clinical Policy 9.01, a medical emergency drill will be performed annually and documented on Form 9.01c by the Center Manager and retained in section 9 of the Center Handbook. Monitoring for completion will be performed by the market manager annually by verifying completion of the Center Handbook Calendar Checklist.
485.723 CONDITION
PHYSICAL ENVIRONMENT
Name - Component - 00
The building housing the organization is constructed, equipped, and maintained to protect the health and safety of patients, personnel, and the public and provides a functional, sanitary, and comfortable environment.
Observations:
Based on review of rehabilitation facility policy, observations (OBS), and staff interviews, the rehabilitation facility failed to ensure patient safety through supervision of patients while receiving aquatic therapy at the extension site located at 1510 Dekalb Pike, Blue Bell, PA 19422; failed to ensure patient safety through establishment and implementation of personnel training/periodic review of emergency/disaster training for their aquatic therapy program located at 1510 Dekalb Pike, Blue Bell, PA 19422, and 1628 Butler Pike, Conshohocken, PA 19428.
Cross reference:
484.723(a) Tag I-0118 The rehabilitation facility failed to provide direct supervision of a patient receiving aquatic therapy at the extension site at 1510 Dekalb Pike, Blue Bell, PA 19422.
The rehabilitation facility failed to have ensure training was documented for medical emergencies and pool emergencies for its aquatic therapy programs located at 1510 Dekalb Pike, Blue Bell, PA 19422, and 1628 Butler Pike, Conshohocken, PA 19428.
As a result of the systemic deficient practice that led to significant patient safety risk, an immediate jeopardy situation was identified on March 1, 2024, at 2:52 P.M.
An immediate jeopardy (IJ) removal plan was submitted by the rehabilitation facility on March 1, 2024, at 3:58 P.M. and rejected at 4:08 P.M., as it did not contain all necessary elements needed to remove the immediate threat.
A second IJ removal plan was submitted by the rehabilitation facility on March 1, 2024, at 4:15 P.M. and accepted on March 1, 2024, at 4:17 P.M.
On-site verification completed March 11, 2024, from approximately 8:50 A.M. to 12:00 P.M. verified that the sites located at: 1510 Dekalb Pike, Blue Bell, PA 19422 and 1628 Butler Pike, Conshohocken, PA 19428, completed implementation of the removal plan approved on March 1, 2024 removing the immediate jeopardy (IJ) through observations, reviews of staff emergency training records and clinical records. An interview with clinic Manager confirmed the findings.
Plan of Correction:Pool patients will be supervised by a clinician and in direct line of site at all times during any aquatic session as of March 4th, 2024- All employees will be notified immediately and will review safety of pool patients and acknowledge this nolater then March 4th.. Therapist will document in the chart that the clinician was in direct line of site at all times. Quarterly observational audits will be performed by Center Manager, Market Manager or Regional Director. We will update the pool guidance document by March 22nd and have all clinician's sign that they reviewed it and will abide by the pool safety policies by March 29th 2024.
485.723(a) STANDARD
SAFETY OF PATIENTS
Name - Component - 00
The organization satisfies the following requirements:
(1) It complies with all applicable State and local building, fire, and safety codes.
(2) Permanently attached automatic fire-extinguishing systems of adequate capacity are installed in all areas of the premises considered to have special fire hazards. Fire extinguishers are conveniently located on each floor of the premises. Fire regulations are prominently posted.
(3) Doorways, passageways, and stairwells negotiated by patients are of adequate width to allow for easy movement of all patients (including those on stretchers or in wheelchairs), free from obstruction at all times, and, in the case of stairwells, equipped with firmly attached handrails on at least one side.
(4) Lights are placed at exits and in corridors used by patients and are supported by an emergency power source.
(5) A fire alarm system with local alarm capability and, where applicable, an emergency power source is functional.
(6) At least two persons are on duty on the premises of the organization whenever a patient is being treated.
(7) No occupancies or activities undesirable or injurious to the health and safety of patients are located in the building.
Observations:
Based on review of rehabilitation facility policy, alternate site location observations (OBS), and staff interviews, the rehabilitation facility failed to ensure the safety of patients while in the pool area for one (1) of two (2) observations of rehabilitation facility extension sites with a pool. (OBS #2).
Findings include:
During an observation (OBS #2) conducted at the extension site located at 1015 Dekalb Pike, Blue Bell, PA 19422 on February 28, 2024, at approximately 12:40 P.M., Patient#1 was observed performing exercises in the pool, unattended by therapy center staff. The pool area was visible from the therapy treatment area, but Patient #1 was not visible in the pool from the therapy treatment area due to a wall approximately four (4) feet high obstructing the view.
An interview with the center manager on February 28, 2024, at approximately 1:15 P.M. revealed that staff do not remain in the pool area when patients are undergoing aquatic therapy.
An interview with the rehabilitation facility Administrator on March 1, 2024, at approximately 12:20 P.M. confirmed the above findings.
Plan of Correction:Pool patients will be supervised by a clinician and in direct line of site at all times during any aquatic session as of March 4th, 2024. All responsible employees at the Blue Bell center reviewed, signed, and dated the Therapeutic Pool Safety Policy on 3/13/24 which was placed in Section 9 of the center handbook. All new employees will undergo a review of the Therapeutic Pool Safety Policy during their onboarding process & will acknowledge with a dated signature which will be retained in Section 9 of the center handbook. Review of the therapeutic pool safety policy will be performed annually in conjunction with an annual pool evacuation emergency drill and will be added to the Center Handbook Calendar Checklist, which will be reviewed annually by the market manager. The responsible clinician will document in the chart that the patient was in direct line of site at all times. Quarterly observational audits will be performed by Center Manager and documented in the Center Handbook Calendar Checklist.
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 observations (OBS), review of rehabilitation facility policy, and staff interviews, the rehabilitation facility failed to ensure equipment including but not limited to: the hydrocollator was maintained in accordance with the center's policies for one (1) of three (3) observations. (OBS #2) The rehabilitation facility failed to ensure that the pool drain and surrounding area were clean for one (1) of two (2) locations with a pool. (OBS #2).
Findings include:
Review of rehabilitation center policies conducted on February 28, 2024, at approximately 1:45 P.M. revealed the following:
Policy #9.18 titled "Equipment and Center Cleaning and Maintenance" states, "All equipment and/or supplies that are used as part of the patient care in treatment areas/waiting room will be maintained and tested to ensure safe operation and for the prevention of injury to patients and employees. All equipment/reusable supplies must be cleaned and/or replaced as frequently as needed to maintain a sanitary environment. All therapeutic equipment and reusable supplies in patient care areas and/or waiting room must be cleaned, inspected and/or replaced as frequently as needed to maintain a safe and sanitary environment."
Observation of patient treatment area at the rehabilitation facility satellite site at 1510 Dekalb Pike, Blue Bell, PA 19422 conducted on February 28, 2024, from approximately 12:30 P.M. to 1:45 P.M. revealed the following:
OBS #2: Hydrocollator located in the rear left area of the rehabilitation center was noted to have heavy rust colored staining on the inner lid surface with what appeared to be flaking of the metal surface in several areas of the perimeter. The metal racks that hold the hot packs contained a rust colored material. There was rust colored staining on two (2) of the hot packs in the hydrocollator.
Observation of the pool area located in the right rear area of the rehabilitation revealed a floor drain adjacent to the side of the pool facing the treatment area. The drain cover was covered with a heavy amount of rust colored material. The area surrounding the drain contained a heavy coating of dark colored material. The floor area between the drain and the pool wall contained rust colored stains.
In an interview with the alternate site center manager on February 28, 2024, at approximately 1:30 P.M., the center manager stated that the hydrocollator was "being replaced". When asked when the new hydrocollator was due to arrive, the center manage stated, "A couple of months ago".
An interview with the rehabilitation facility Administrator on March 1, 2024, at approximately
12:20 P.M. confirmed the above findings.
Plan of Correction:The hydrocollator at the Blue Bell location was replaced with a new unit on 3/8/24. The drain sited on the side of the pool adjacent to the wall that separates the pool area and treatment area was thoroughly deep cleaned to remove rust and debris on 3/18/24. The other 2 floor drains in the shower and locker room areas were thoroughly deep cleaned to remove rust & debris on 3/18/24. Going forward, semiannual inspections of the hydrocollator and floor drains will be performed & documented by the center manager on Form 9.17 (Equipment Cleaning and Maintenance Log) which will be placed in Section 9 of the Center Handbook and documented in the Center Handbook Calendar Checklist. The Market Manager will audit the Center Handbook Calendar Checklist semiannually to confirm compliance.
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