Initial Comments:
Name - Component - --Based on the findings of an onsite unannounced recertification survey completed on 3/5/2025, Novacare Rehabilitation 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 onsite unannounced Medicare recertification survey completed 3/5/2025, Novacare Rehabilitation was found to have the following standard level deficiency that was determined to be in substantial compliance with the following requirement 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 agency policy, observation tour (OBV), documents and staff (EMP) interview the facility failed to ensure that the therapeutic pool was maintained according to agency and manufacture policy for one (1) of one (1) observation.
Findings included:
Review of the agency policy was conducted on 2/24/2026 at approximately 2:00 PM which revealed, "Section 9: Safety &; Infection Control Procedures Policy#9.22 Policy Title: Therapeutic Pool Cleaning and MaintenanceCDC Hydrotherapy and Health Swimming ResourcesGeneral ProceduresDaily: (1) Check pH, add chemicals as needed. pH range generally is 7.2-7.8 (2) Test for sanitizer level (Bromine or Chlorine), add sanitizer as needed. Chlorine generally ranges from 1.0 -2.0 parts per million. The Manufacturer's recommendations should be followedPool temperature range generally range: 85-96 degrees F. Room temperature range 72-86 degrees Fpool temperature should not exceed 104 degrees FWeekly: (1) Test for alkalinity, add chemicals as needed (ranges 80-120 PPM or by manufactures guidelines)Monthly: (1) Check calcium hardness (200-400 PPM) and add chemicals as neededof a document was conducted on 2/24/2026 at approximately 1:36 PM which revealed, "STANDARD AQUA ARK &; PROEX (1800 Gals.) Bromine, BEST RANGE 4-6 ppm, INSTRUCTIONS *Test once per day. If heavy patient load twice per day *Should use 6-7 tablets per week. Maintain no more than 12 full size tablets in the brominator at one time#1 was conducted on 2/24/2026, at approximately 10:10 AM, in the gym treatment area with EMP1.
Review of the "Sample Water Quality Log" on 2/24/2026 at approximately 1:30 PM included a review of logs dates from 1/2/2026 through 2/24/2026.
Logs revealed dates recorded for Bromine levels were not within agency parameters for the period of: 1/2/2026 through 2/24/2026 all readings at 10 ppm.
Logs revealed daily recorded PH levels not within agency parameters for the following dates:
2/2/2026 and 2/3/2026 readings at 6.9
2/4/2026, 2/5/2026, 2/6/2026, 2/9/2026, 2/10/2026, 2/11/2026, 2/12/2026, 2/13/2026 readings were 6.8.
Logs revealed daily recorded Alkalinity not within agency parameters for the following dates:
2/9/2026 180 PPM
2/10/2026 180 PPM
2/11/2026 180 PPM
An exit interview with the center manager on 3/5/2026 at approximately 3:00 PM confirmed the above findings.
Plan of Correction: As of 3-6-26 the clinic Updated pool chemical sheet to list the appropriate ranges and ranges are being followed. Center manager reviewed updated form and process with clinic staff. Training documented in March 26 staff meeting. Dates with PH off needed chemicals added and they were. One week when CM was off staff just filled out paper and the numbers do not match the sticks either. Updated instructions attached to the flow sheets for covering staff. All numbers are within ranges now and chemicals added as needed to maintain numbers.
Center manager responsible to track weekly compliance.
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