Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on September 11, 2024, at the parent location of 785 Cherry Tree Court, Hanover Pa, 17331, Select Physical Therapy, was found to be in 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:
Initial Comments:
Based on the findings of an unannounced, Medicare recertification survey completed September 11, 2024 at the parent location of 785 Cherry Tree Court Hanover, Pa 17331, Select Physical Therapy, was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42 CFR, Part 485, Subpart 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 policies/procedures, observations (OBS), clinic logs, and interviews with staff (EMP#1 & EMP #2) the clinic failed to ensure the paraffin bath was cleaned every three (3) months per policy for one (1) of three (3) logs reviewed log #1; failed to ensure expired supplies were discarded per policy for three (3) of nine (9) OBS made. OBS #1, #3, #5.
Findings include:
Review of policies/procedures completed 9/11/24 between approximately 1:00PM and 2:00PM revealed:
Policy 9.20 Paraffin Bath Cleaning and Maintenance, policy, "the paraffin bath is cleaned and the paraffin wax replaced every three months or sooner depending upon manufacturer recommendations and patent use". section: Procedure: 2),"document cleaning and monitoring of temperature on the Equipment Cleaning & Maintenance Log (9.17) , or similar log..".
Policy 9.24 Storage and Disposal of Medications and Supplies, Policy, "Select Medical Outpatient Division will maintain a mechanism for the appropriate storage and disposal of medications...Procedure: section 3). Supplies, "Supplies will monitored for expiration date(s) when applicable. If a supply is found to have expired it will be disposed of appropriately or according to manufacturer recommendations".
Observations made on 9/11/24 between approximately 11:00 AM and 1:30 PM revealed:
OBS#1, eleven (11) 8oz. bottles of Purell hand sanitizer in various locations within the clinic. two (2) bottle expired: 5/2023, one (1) bottle expired 1/2024, two (2) expired 4/2024, six remaining bottles expired 5/2024.
OBS #3, three (3) 12oz. bottles of Cavilon Moisturizing Hand lotion located in treatment rooms #1, #3 & 4 expired 7/2023.
OBS #5, two (2) 1200 ml containers of Purell hand sanitizer foam located in a storage closet one container expired: 3/2023 and the other container expired 6/2023.
Review of the clinic log Paraffin Temperature Log completed 9/11/2024 at approximately 12:00PM showed:
log #1, year 2024 contained entries for temperature checks for months January, February, March, April, June, July, August and September. No documention to show cleaning of the paraffin wax bath.
Interview with the Clinic Manager EMP #1 and Regional Director of operations EMP #2 completed 9/11/24 between approximately 4:00PM confirmed the policies as current and the above findings.
Plan of Correction:485.723(b) Maintenance of Equipment/Buildings/Grounds:
TAG 0121
1. The management team, consisting of the Center Manager, Market Manager, and Regional Director have discussed the deficiencies cited and have worked together to complete the agreed upon plan of corrections.
2. The Center Manager (CM) has verified the Paraffin Bath has been cleaned on 9/16/2024 according to Policy 9.20. The documentation of cleanings and temperature is documented on the Equipment Cleaning & Maintenance Log (9.17). The paraffin temperature will be checked monthly and before patient use, to not exceed 130 degrees F, and documented on Log 9.17 Quarterly Monitoring will be performed by the Center Manager as part of the Quality Assurance program with documentation in the center handbook. The Regional Director or Market Manager will monitor by reviewing the Center Handbook Calendar Checklist with the Center Manager to assure the clinic is following Policy #9.20
3. The CM has immediately and appropriately disposed of all expired medications and supplies in the center as described in Clinical Policy 9.24. The management team has agreed that CM or designee will monitor expiration dates of supplies monthly and will dispose of appropriately as per clinical policy 9.24. This will be documented/marked complete monthly on the Center Handbook Calendar Checklist as part of the Quality Assurance Program. The Regional Director or Market Manager will monitor by reviewing the Center Handbook Calendar Checklist with the Center Manager to assure the clinic is following Policy #9.24
4. -All clinical staff at Cherry Tree will participate in a quality assurance meeting within the next 30 days to review Policy #9.20 and Policy #9.24. Documentation of meeting will be including in the staff meeting minutes maintained in the Center Handbook
5. The Center Manager will verify the plan is implemented annually and marked current and complete in the Center Handbook Calendar Checklist.
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