Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed January 15, 2026, Novacare Rehabilitation 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 Seven Fields parent and New Castle extension site locations.
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 interview, the facility failed to review and update its risk assessment annually in accordance with facility policy at the New Castle extension site for 2023, 2024, and 2025.
Finding included:
Review of facility policy on January 13, 2026, at 12:45 p.m. showed, "9.01 Emergency Plan ... Revision Date 5/1/2025 ... Procedure ... III Center Specific Risk Assessment ... Each center manager ... must assess the risk of occurrence of given disasters based on the centers immediate location and taking into account community surroundings. Centers will review the risk assessment annually and update as necessary or as the plan changes."
Review of New Castle's "Center Specific Risk Assessment" on January 14, 2026, at 11 a.m. showed that it was last reviewed on 4/19/2022 by the center manager (EMP5).
Interview with EMP7 (revenue cycle manager) on January 17, 2026, at approximately 11 a.m. confirmed findings.
Plan of Correction:E 0006 Plan Based on All Hazards Risk Assessment:
· Facility must develop and maintain an emergency preparedness plan that is reviewed and updated at least every 2 years to meet the standard. Organization policy requires an annual review of emergency preparedness plan. Facility will comply with stricter organizational requirement of annual review. Be based on and include a documented, facility-based and community-based risk assessment utilizing an all-hazards approach. Include strategies for addressing emergency events identified by the risk assessment.
o Anticipated completion date 3/29/2026
o Immediate update and revision of form 9.01a Center Specific Emergency Plan, including page 4 Center Specific Risk Assessment (all hazards approach). Annual review and update of form 9.01. Review form 9.01 annually with all staff and with new staff upon hire. Document review of emergency plan on staff meeting form 4.12.
o Ongoing: complete annually and document on forms 9.01, meeting on form 4.12, completion tracked and documented in Center Calendar Checklist
o Responsible party to monitor and track – Center Manager
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 facility documentation, and interviews with staff (EMP), the facility failed to test its emergency plan annually by conducting a full scale exercise, or a facility-based functional exercise, mock disaster drill, or 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 using an all-hazards approach that considered geographic location and community assets for the years 2021 to 2026. Additionally, the agency failed to maintain documentation of its efforts to participate in a community- based full-scale exercise or show that a full scale exercise was not accessible, and failed to follow its own emergency plan policy.
Findings include:
Review of facility policy on January 13, 2026, at 12:45 p.m. showed, "9.01 Emergency Plan [EP] ... Revision Date 5/1/2025 ... Procedure ... Functional Exercises: 1) Center will conduct at least one functional exercise each quarter to test the EP. ... a) Each functional exercise involves a facilitated/guided exercise to the EP. ... 2) The annual minimum required functional exercises include: a) A fire exercise (including training on the use of fire extinguishers). b) A medical emergency exercise c) An active shooter exercise d) A weather emergency (or a documented actual event) ... d) For all functional exercises performed, there will be a facilitated mock situation of the disaster or emergency in the center along with an after action review and summary of the functional exercise and staff performance. III Center Specific Risk Assessment ... B) Centers perform functional exercises for all disasters rated as '1'."
Review of Seven Fields' emergency plan risk assessment on January 13, 2026, at 12:45 p.m. showed that "Pandemic/Emerging Infectious Disease" was ranked as "High Likelihood of Occurrence."
Review of Seven Fields' emergency drills on January 13, 2026, at 1 p.m. with EMP1 (administrator). The facility conducted no drills in 2021. From 2022 to 2025 the facility conducted seven drills with five (5) being fire drills. The facility conducted a medical emergency drill in 2022 but no fire drill. For the year 2025, the facility conducted a weather emergency in addition to a fire drill. The drills did not include after action reports, fire extinguisher training, or the other exercises (active shooter, weather emergency, medical emergency) as outlined in facility policy to include pandemic.
On 5/4/2022 an "Emergency Drill Report Form" showed a mock medical drill was performed by EMP1 (physical therapist) and EMP3 (clerical employee). Time began was 12:30 p.m. and time ended was 12:50 p.m. According to the form's "Comments or Suggestions" portion, "Scenario was handled well with proper competence demonstrated." There was no after action review completed.
On 8/4/2023, an "Emergency Drill / Emergency Preparedness Testing Report Form" showed a fire drill was performed by EMP1 and EMP3 from 8:34 a.m. to 9:10 a.m. "Mock Emergency/Disaster Drill ... Mock evacuation of center due to fire emergency. ... Comments or Suggestions ... Proper management shown with the patient sign in sheet gathered; escort; and gathering with roll call performed. Suggested closing of patient charts and locking protected PHI."
On 1/22/2024, an "Emergency Drill / Emergency Preparedness Testing Report Form" showed a fire drill was performed by EMP1 and EMP3 from 1:10 p.m. to 1:35 p.m. "Mock Emergency/Disaster Drill ... Mock evacuation of center due to fire emergency. ... Comments or Suggestions ... Proper management shown with the patient sign in sheet gathered; escort; and gathering with roll call performed. Suggested closing of patient charts and locking protected PHI."
Note: both 8/4/2023 and 1/22/2024 drills contained the exact same text with only the date and time being different. There was no after action review for both. In other words, the after action portion of the documents contained a narrative of the drill but no information that would constitute a post-drill evaluation.
On 8/20/2024, an "Emergency Preparedness Testing Report" showed "Mock Emergency - Fire [conducted simultaneously]" drills were conducted by EMP1 and EMP4 (physical therapy assistant). The drill lasted 6 minutes (8:30 a.m. to 8:36 a.m.) and contained no after action report, "After Action Review ... PT/PTA evacuate pts [patients]. PTA calls 911 [simulated] Emergency services. Closes doors. Collect sign in sheets. Shut off lights. Staff + pts evacuated to east side of picnic table."
On January 2025 (no day indicated), an "Emergency Preparedness Testing Report" showed a weather related "Mock Emergency/Disaster Drill" conducted by EMP1, EMP2 (clerical), and EMP4 The "After Action Review" contained no after action information, "Staff was made aware of salt + shovel placement for sidewalk management + care. The drill lasted 30 minutes.
On 8/11/2025, an "Emergency Preparedness Testing Report" showed a fire drill was conducted by EMP1, EMP2, and EMP4. The portion of the form to indicate exercise type, "This was a fully simulated exercise or an actual emergency/disaster and is used to evaluate the center(s) response to an emergency or disaster" were blank or unchecked indicating that they did not apply. The drill commenced at noon but had no end time. There was no after action report, "Action Items/goals ... [EMP1] take patients out ... [EMP2] call fire station / 911."
On October 2025 (no day indicated), an "Emergency Preparedness Testing Report" showed a fire drill was conducted by EMP1, EMP2, and EMP4. The portion of the form to indicate exercise type showed, "Table Top Exercise." The drill lasted 20 minutes. The "After Action Review" portion of the form contained no after action information, "Fire (mock) discovered ... 911 called [simulated] by [EMP2]. Clinicians escorted pts to east side of building evacuating all ... Doors closed. All clear."
The most recent "Emergency Preparedness Testing Report" completed by the facility contained two dates: 2/9/2025 and 1/12/2026. The two dates shared the same information and showed that a fire drill lasted 36 minutes. The "After Action Review" portion of the form contained no after action information, "PT/PTA evacuate patients. PSS calls 911 emergency services, closes doors shuts off lights grabs [sic] records. Patients evacuated to east side of picnic table."
The above documentation did not show agency made efforts to conduct a full-scale exercise, or a facility-based functional exercise, mock disaster drill, or tabletop exercise or workshop that was 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 using an all-hazards approach that considered the facility's geographic location and community assets since it was certified in 2020. Interview with EMP1 on January 13, 2026, at 1 p.m. confirmed findings and that he/she had not made attempts to contact local and state agencies and healthcare coalitions, where appropriate, to determine if an opportunity exists and determine if their participation would fulfill this requirement. Furthermore, the facility failed to conduct quarterly drills per policy for 2021 (no drills), 2022, 2023, 2024, and 2025. There were no exercises conducted for Pandemic or Emerging Infectious Disease.
Review of New Castle's emergency plan risk assessment on January 14, 2026, at 11 a.m. showed that "Pandemic/Emerging Infectious Disease" was ranked as "High Likelihood of Occurrence."
Review of New Castle extension site's emergency drills on January 14, 2026, at 11 a.m. with EMP7 (revenue cycle manager), and EMP5 (physical therapist/administrator). The facility conducted no drills in 2021. The facility did conduct drills on 4/19/2022, 5/17/2023, 4/17/2024, and 6/11/2025, but the drills did not include after action reports, fire extinguisher training, or the other exercise outline in facility policy. The drills were all identical with no changes from year-to-year. It appeared that someone had erased and changed dates on the 2022 forms from year to year as shown below.
On 4/19/2022, the facility completed four (4) "Emergency Drill Report Form[s]" outlined below per instance that occurred over 13 minutes:
4/19/2022 from 9:00 a.m. to 9:04 a.m., "Type of drill Fire." The drill was conducted by EMP5 and one other staff member. It contained no information other than staff present, date, and time-- no after action report or drill narrative.
4/19/2022 from 9:05 a.m. to 9:08 a.m., "Type of drill MEDICAL." The drill was conducted by EMP5 and one other staff member. It showed, "Appropriate" with no other information such as an after action report.
4/19/2022 from 9:08 a.m. to 9:10 a.m., "Type of drill Active shooter." The drill was conducted by EMP5 and one other staff member. It showed, "Run Hide Fight" with no other information such as an after action report.
4/19/2022 from 9:10 a.m. to 9:13 a.m., "Type of drill Tornado." The drill was conducted by EMP5 and one other staff member. It showed, "Hallway/Bathroom" with no other information such as an after action report.
On 5/17/2023, the facility completed three (3) "Emergency Drill Report Form[s]" outlined below per instance that occurred over 15 minutes:
5/17/2023 from 1 p.m. to 1:10 p.m. "Type of drill MEDICAL." The drill was conducted by EMP5 and one other staff member. It showed, "Appropriate" with no other information such as an after action report (similar to above 4/19/2022 "MEDICAL" drill).
5/17/2023 at 1:10 p.m. "Type of drill Fire." The drill was conducted by EMP5 and one other staff member. It contained no information other than staff present, date, and time-- no after action report or drill narrative (similar to above 4/19/2022 "Fire" drill).
5/17/2023 from 1:10 p.m. to 1:15 p.m., "Type of drill Tornado." The drill was conducted by EMP5 and one other staff member. It showed, "Hallway/Bathroom" with no other information such as an after action report (similar to above 4/19/2022 "Tornado" drill).
On 4/17/2024, the facility completed three (3) "Emergency Drill Report Form[s]" outlined below per instance that occurred over 20 minutes:
4/17/2024 from 1 p.m. to 1:10 p.m. "Type of drill MEDICAL." The drill was conducted by EMP5 and one other staff member. It showed, "Appropriate" with no other information such as an after action report.
4/17/2024 at 1:10 p.m. "Type of drill Fire." The drill was conducted by EMP5 and one other staff member. It contained no information other than staff present, date, and time-- no after action report or drill narrative.
4/17/2024 from 1:15 p.m. to 1:20 p.m., "Type of drill Tornado." The drill was conducted by EMP5 and one other staff member. It showed, "Hallway/Bathroom" with no other information such as an after action report.
On 6/11/2025, the facility completed three (3) "Emergency Drill Report Form[s]" outlined below per instance that occurred over 20 minutes:
6/11/2025 from 2:10 p.m. to 2:15 p.m. "Type of drill MEDICAL." The drill was conducted by EMP5 and one other staff member. It showed, "Appropriate" with no other information such as an after action report.
6/11/2025 at 2 p.m. "Type of drill Fire." The drill was conducted by EMP5 and one other staff member. It contained no information other than staff present, date, and time-- no after action report or drill narrative.
6/11/2025 from 2:15 p.m. to 2:20 p.m., "Type of drill Tornado." The drill was conducted by EMP5 and one other staff member. It showed, "Hallway/Bathroom" with no other information such as an after action report.
The above documentation did not show agency made efforts to conduct a full-scale exercise, or a facility-based functional exercise, mock disaster drill, or tabletop exercise or workshop that was 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 using an all-hazards approach that considered the facility's geographic location and community assets since it was certified in 2020. Interview with EMP7 on January 13, 2026, at 1 p.m. confirmed findings and that facility had not made attempts to contact local and state agencies and healthcare coalitions, where appropriate, to determine if an opportunity exists and determine if their participation would fulfill this requirement. Furthermore, the facility failed to conduct quarterly drills per policy for 2021, 2023, 2024, and 2025.
Interview with EMP7 (revenue cycle manager) on January 14, 2025, at 12 p.m. confirmed above findings at the New Castle extension site.
NOTE: The documentation for the 5/17/2023, 4/17/2024, and 6/11/2025 drills were identical to the documentation for the 4/19/2022 drills other than a few changes to the times/dates For example the staff member who was listed with EMP5 was erased and changed due to staff turnover, and EMP5's last name had changed (changed on the 6/11/2025 drills but portions of EMP5's previous last name were still visible but faded since it was not completely removed when copied). It appeared that the 5/17/2023, 4/17/2024, and 6/11/2025 forms were same documents with only the dates, times, and a staff members' names being altered using either an eraser or a type of white out product.
Plan of Correction:E 0039 Emergency Plan Testing Requirements:
Center will participate in a full-scale exercise that is community-based every 2 years or conduct a facility-based functional exercise every 2 years, when community-based exercise is not accessible.
Anticipated Completion Date: 3/29/2026
Market manager will review Pennsylvania Emergency Management Agency (PEMA) online resources to seek community based full scale exercise in the region at least every 2 years. If a community-based full-scale exercise is not accessible, market manager will document this effort to locate a community based full-scale exercise in form 9.01a Emergency Plan during the annual review process. Facility will then complete a facility-based functional exercise. Community-based or facility-based exercise will be documented on form 9.01c Emergency Preparedness Testing Report and filed in Center Handbook. Test of emergency plan will include after action review and summary. Market manager will participate in testing and/or review form 9.01c to ensure all criteria are thoroughly and accurately met.
To comply with the Novacare policy requirements, all locations will conduct a test of the emergency plan quarterly and document on the same form 9.01c. Exercise will include clinically-relevant scenario, based on all hazard approach. Test of emergency plan will include after action review and summary. Actual event will meet Novacare policy requirement of quarterly testing for medical, fire, severe weather and active shooter events.
Ongoing: Document and track Emergency Plan testing in Center Calendar Checklist. To ensure compliance with this standard, Market Manager to review annual emergency plan documentation annually for each location, as filed in Center Handbook.
Responsible party to monitor and track – Market Manager
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed January 15, 2026, Novacare Rehabilitation 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 Seven Fields parent and New Castle extension site locations.
Plan of Correction:
485.707(a) STANDARD
LICENSURE OF ORGANIZATION
Name - Component - 00
In any State in which State or applicable local law provides for the licensing of organizations, a clinic, rehabilitation agency, or public health agency is licensed in accordance with applicable laws.
Observations:
Based on review of facility policy, documentation, email, and staff (EMP) interview, the facility failed to obtain an occupancy permit for one (1) of one (1) extension site (New Castle).
Findings included:
Review of facility policy on January 14, 2026, at 11:50 a.m. showed, "4.03 Licensure of Organization ... Policy ... Select Medical Outpatient Division will meet all local, state and federal laws governing the building, fire and safety codes. In any state in which state or local law provides for licensing of centers, rehab agencies, or public health agencies, these will be licensed. ... Procedure 1) A building inspection report or certificate of occupancy, completed by the local building inspector is on file with the county/city/state as required."
Review of New Castle extension site documentation on January 14, 2026, at 11:30 a.m. revealed facility had no occupancy permit or building inspection report on file.
Interview with EMP7 (revenue cycle manager) on January 14, 2026, at 11:30 a.m. confirmed findings, at this time EMP5 (center manager) said he/she would call the township and see if he/she could locate an occupancy permit/inspection report.
Review of email sent from EMP1 (administrator) to surveyor on January 21, 2026, at 6:54 a.m. showed, "In regard to the Certificate of Occupancy for New Castle. The lease began in 1997 and the current LL [land lord] nor our team has a Certificate of Occupancy. We have contacted the municipality, specifically [...], the zoning officer and [...]. They shared that they also do not have the occupancy certificate so therefore we are submitting the activation forms online and will submit to township. He will then come out and inspect clinic for permiting [sic]. Thank you [...] [EMP1]."
Review of email sent from EMP5 to surveyor on January 21, 2026, at 9:02 a.m. showed, "I filled out the form and dropped it down to township yesterday and she said he will be out as early as next week for inspection."
Plan of Correction:0008 Standard Licensure of Organization:
· Center will comply with state, local and federal requirements to submit for occupancy permit and/or building inspection.
o Anticipated Completion Date: 3/29/2026
o Contact made contact with New Castle City zoning office to request and schedule site inspection to obtain occupancy permit. Currently pending schedule of this site inspection. Anticipated completion date may be adjusted based on municipality response. Once complete, certificate of occupancy to be filed and maintained in Center Handbook.
o Responsible party to monitor and track – Center Manage
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 facility policy, personnel files (PF), and staff (EMP) interview, the facility failed to ensure personnel files contained evidence of orientation for three (3) of three (3) personnel files at the New Castle extension site location (PF2, PF3, & PF4).
Findings included:
Review of facility policy on January 14, 2026, at 10 a.m. showed:
"4.06 New Employee Orientation ... It is the policy of Select Medical Outpatient Division that each employee participates in a new employee orientation. ... Procedure 1) All new employees will participate in new employee orientation on a tiered 90 day schedule. ... 3) Documentation of employee orientation will be maintained in the individual employee's personnel file."
"4.10 Personnel Files - On Site ... To ensure compliance with applicable regulatory requirements, certain documents will be maintained on file at the center. Procedure 1) Upon hire, an on-site personnel file will be created for the new employee. This is a duplicate and partial personnel file. All pertinent documents listed on the Employee Personnel File Checklist (4.10) will be included in the onsite file. ... 2) The on-site file will be reviewed and updated at least annually. 3) The center manager or designee will be responsible for maintaining the on-site files of all employees employed at the center in a locked filing cabinet."
Review of the "Employee Personnel File Checklist" showed the facility is to maintain the following documents in the personnel file, "New or Contract Employee Orientation Checklist."
Review of New Castle personnel files was conducted on January 14, 2026, at 10:30 a.m.
PF2 was hired on 5/9/2025. PF2 contained no orientation.
PF3 was hired on 6/23/2025. PF3 contained no orientation.
PF4 (center manager) hired on 7/20/2009, had no orientation and his/her personnel file was not available for review at the center.
Interview with EMP7 (revenue cycle manager) on January 17, 2026, at approximately 11 a.m. confirmed findings.
Plan of Correction:I 0019 Personnel Policies:
· Centers will maintain electronic and on-site paper personnel files in accordance with this regulation and internal policies and procedures, to include New Employee Orientation.
o Anticipated Completion Date: 3/29/2026
o Center manager will create, maintain and routinely audit employee files to include form 4.06 New Employee Orientation, form 4.10 Employee Personnel File Checklist. All paper employee files in center will be stored in a locked filing cabinet.
o Ongoing: Document and confirm employee personnel file reviews on Center Calendar Checklist in Center Handbook.
o Responsible party to monitor and track – Center Manage
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 policy, observation, and staff (EMP) interview, the facility failed to ensure equipment was maintained free of any defects which are potential hazard to patients for one (1) of three (3) treatment tables at the Seven Fields location and for two (2) of three (3) chairs located in the treatment area at the New Castle location.
Findings included:
Review of facility policy on January 15, 2026, at 3 p.m. showed, "Center Handbook Calendar Checklist ... This calendar is designed to help each center to make sure they stay up to date with all forms and requirements for the center handbook. ... No tears/rips in plinths/equipment /stools/chairs/tables/ etc."
Observation at the Seven Fields' treatment area on January 13, 2026, revealed a treatment table had a tear in its upholstery and some of its edges were abraded.
Interview with EMP1 (administrator) on January 13, 2026, at 1 p.m. confirmed findings.
Observation of New Castle's treatment area on January 14, 2026, at 10 a.m. revealed 3 chairs. Two of the chairs were occupied by patients. Interview with EMP6 (physical therapy assistant) confirmed the chairs are disinfected after patient use. Further observation after the patients vacated the chairs revealed the chairs had multiple areas where the upholstery was missing or abraded on the seat and armrest portions of the chairs.
Interview with center manager (EMP5) on January 14, 2026, at 11 a.m. confirmed findings.
Plan of Correction:I 0121 Maintenance of Equipment, building and grounds:
· Centers will maintain all equipment and furniture in working order, free of defects.
o Completion Date: 3/29/2026
o Chairs and plinth tables identified on survey have been replaced or repaired. Documentation of repairs or new items replaced will be filed in Center Handbook.
o Ongoing: Center manager or designated staff member will inspect all equipment and furniture on routine basis and document completion of this task in Center Calendar Checklist, filed in Center Handbook.
o Responsible party to monitor and track – Center Manager
485.725(a) STANDARD
INFECTION CONTROL COMMITTEE
Name - Component - 00
The infection control committee establishes policies and procedures for investigating, controlling, and preventing infections in the organization and monitors staff performance to ensure that the policies and procedures are executed.
Observations:
Based on review of facility policy, personnel files, Centers for Disease Control and Prevention Guidelines (CDC), Pennsylvania Department of Health Guidelines, and staff (EMP) interview, the infection control committee failed to implement its policy for investigating, controlling, and preventing infections for three (3) of three (3) personnel files hired after the year 2019 (PF1-PF3).
Findings included:
Review of facility policy on January 14, 2026, at 11 a.m. showed, "Policy # 9.10 ... Infection Control and Asepsis ... Revision Date: 03/01/2023 ... Policy To prevent the spread of infectious disease, staff members will follow all policies and procedures ... References ... CDC Update on TB Screening [EMPHASIS] ... Procedure ... 5) All new employees will be tested for Tuberculosis (TB) within 10 days of hire. ... A baseline Individual TB Risk Assessment form for Health Care Personnel form ... must be completed and maintained in the personnel file. ... State-specific regulations will be followed if they are more stringent."
According to the CDC, and as mentioned in above policy, "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019 ... Updated Recommendations ... Here, TB screening is defined as a process that includes a TB risk assessment, symptom evaluation, TB testing for M. tuberculosis infection (by either IGRA or TST) for health care personnel without documented evidence of prior LTBI or TB disease, and additional workup for TB disease for health care personnel with positive test results or symptoms compatible with TB disease. ... Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay [blood test]) or TST [tuberculin skin test], shall include a symptom screen questionnaire and an individual TB risk assessment." Retrieved from https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6819-H.pdf
According to the Pennsylvania Department of Health, "On May 17, 2019 the Centers for Disease Control and Prevention (CDC) issued updated recommendations for TB testing of health care personnel. Key points include: The updated recommendations call for health care personnel to be screened for TB upon hire with an individual risk assessment, a symptom evaluation, and a TB test (either the interferon gamma-release assay, or IGRA, blood test or the tuberculin skin test). Thereafter, annual TB testing is not recommended unless there is a known exposure to a case of infectious TB disease or there is ongoing transmission in the health care setting where the individual works." Retrieved from https://www.pa.gov/agencies/health/diseases-conditions/infectious-disease/tuberculosis/tb-testing-health-care-workers
Review of Seven Fields personnel files was conducted on January 13, 2026, at 12:15 p.m.
PF1 was hired on 5/6/2021. PF1 contained a negative TST from 9/23/2020 with no second step completed. PF1 did not contain an individual risk assessment or a symptom evaluation completed upon hire.
Interview with EMP1 on January 13, 2026, at 1 p.m. confirmed findings.
Review of New Castle personnel files was conducted on January 14, 2026, at 10:30 a.m.
PF2 was hired on 5/9/2025. PF2 contained no TB testing/screening.
PF3 was hired on 6/23/2025. PF3 contained no TB testing/screening.
Interview with EMP7 (revenue cycle manager) on January 17, 2026, at approximately 11 a.m. confirmed findings.
Plan of Correction:I 0161 Infection Control Committee:
· Centers will implement and maintain process for TB screening and testing for all new hire employees.
o Anticipated completion Date: 3/29/2026
o New hires will complete TB test prior to date of hire. as executed by Human Resources onboarding representative. HR representative will provide results of TB test to center manager, who will review TB test results and file in employee personnel file. In addition, new hires will complete a TB individual risk assessment form and a baseline TB symptom screening questionnaire, both. Results of TB test to be reviewed by CM and filed in employee personnel file. In addition, new hires will complete a TB individual risk assessment symptom questionnaire, to be completed within 10 days of hire and filed in employee personnel file. CM to use New Employee Orientation Checklist form 4.06 to confirm completion. New Employee Orientation Checklist form 4.06 submitted to Governing Board for proposed revision to include further details on initial TB screening requirements. Policy 9.10 Infection Control and Asepsis under review by Outpatient Division Governing Board as part of annual Outpatient Division Clinical Operations Policies and Procedures review protocol to determine if revision is needed. Patient Care Committee Safety and Infection Control subcommittee to report on and review this survey recommendation at next meeting Q2 2026. PCC meeting minutes will be distributed to all centers, reviewed at staff meeting and filed in Center Handbook as per Policy 7.04 Patient Care Committee.
o Ongoing: Center manager to complete Center Calendar Checklist to audit for any new employees each quarter. Market Manager to audit employee files quarterly to ensure all new employees have completed this requirement.
o Responsible party to monitor and track – Center Manager
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