Initial Comments:
Based on the findings of an onsite unannounced recertification survey completed on 3/21/24, Lifeline Therapy was found to be in compliance with the requirements of 42 CFR, Part 485.68, Subpart B, Conditions of Participation: Comprehensive Outpatient Rehabilitation Facilities - Emergency Preparedness.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey initiated 3/14/24 and completed off-site 3/21/24, Lifeline Therapy was found to not be in compliance with the requirements of 42 CFR, Part 485, Subpart B, Conditions of Participation: Comprehensive Outpatient Rehabilitation Facilities.
As a result of the survey, one (1) condition level deficiency was identified at: 485.58 comprehensive rehabilitation program that did not result in immediate jeopardy.
Plan of Correction:
485.56(b)(2) STANDARD
ADMINISTRATOR
Name - Component - 00
The governing body must appoint an administrator who implements and enforces the facility's policies and procedures.
Observations:
Based on employee interviews (EMP) and reviews of personnel files (PF) and policies, the administrator failed to enforce the facility's policy for completing employee orientation for one (1) of eight (8) PFs reviewed. (PF3)
Findings included:
A review of agency policy titled Job Description - Facility Director on 3/14/24 revealed: " Essential Job Duties ...5. Ensures compliance to all Company policies and procedures ... "
A review of agency policy titled New Employee Orientation on 3/14/24 revealed: " Policy: ...each employee will complete the New Employee Orientation Program within the first 90 days of employment. ...New Employee Orientation Program will include ...items as contained in the New Employee Orientation Outline ...6. Charting requirements ... "
A review of personnel files (PFs) was conducted on 3/13/24 and completed on 3/14/24 at approximately 12:30 pm.
PF3: Physical Therapist: Date of Hire (DOH): 9/25/23. PF3 contained an orientation checklist titled Lifeline Orientation/Onboarding. The checklist areas titled Raintree training modules/EMR [electronic medical record] training and Software Orientation did not list training completion dates. The orientation checklist failed to verify the employee ' s competency in Electronic Medical Record Charting as per facility policy within the 90-day period.
The finding was discussed with EMP1, Alternate Administrator, on 3/14/24 at approximately 12:00 pm onsite upon completion of a personnel chart review.
Plan of Correction:
a. The Governing Body met on January 11, 2024 and reviewed written policy and procedures, the 2024 budgets for all Lifeline facilities and departmental reports. Annual goals were set and the governing body approved EMPI1 to act as the representative in absence of President/CEO to implement and enforce the facility's policies and procedures. These minutes were completed at the time of meeting but not available at the time of the site visit. This has been placed in the CORF manual and uploaded online for reference.
b. The New Hire Orientation Checklist for PF3 will be completed and signed off by PF3 and EMP1 by 4/11/2024. This will include all competency checklists.
c. The Governing Body has designated two members of the Utilization Review Committee to oversee the training and orientation of all new hires from start date to 90 days of employment to ensure that all orientation and training items are completed as per policy.
485.56(c)(2) STANDARD
GROUP OF PROFESSIONAL PERSONNEL
Name - Component - 00
The facility must have a group of professional personnel associated with the facility that consists of at least one physician and one professional representing each of the services provided by the facility.
Observations:
Based on interviews with EMP1 (Alternate Administrator) and reviews of facility documentation and policies, the facility ' s group of professional personnel failed to consist of at least one physician and representatives from each of the services provided by the facility.
Findings included:
A review of facility policy titled Description of Services on 3/14/24 noted services of physical therapy, physician services, social services, respiratory services, and as needed registered dietician services.
A review of facility policy titled Governing Body on 3/21/24 revealed: " Current Members of the Governing Board are listed in each Facilities Handbook ...Documentation ...activities will be evident through minutes, policy statements, and delegations of authority ... "
A review of Section 1: Company Policy on 3/21/24 read, " The Governing Body ...The Governing Body of Lifeline Therapy consists of [physical therapist] ...President "
Facility documents titled Meeting Minutes dated 1/11/2024, 12/18/2023 obtained during an onsite review failed to provide evidence of representatives from the areas of respiratory therapy, social services, physician services, or registered dietician services.
A 3/21/24 review of facility documentation titled Lifeline Physical Therapy and Pulmonary Rehabilitation Meeting Minutes dated 2/24/21 did not provide evidence of a representative from the area of social services or physician services and representation from the area of respiratory services was unable to be determined.
Findings were discussed with EMP1 during a telephone exit interview on 3/21/24 at approximately 1:00 pm.
Plan of Correction:A group of professional personnel that includes a representative from each discipline (MD, PT, RT, SW) will meet quarterly to develop and review patient care policy. Meeting minutes will be documented and a list of all attendees will be recorded. These quarterly meetings were added to the annual compliance calendar and will be monitored by the Administrator. The first meeting will be completed by April 15, 2024.
485.56(e)(1) STANDARD
PATIENT CARE POLICIES
Name - Component - 00
The patient care policies must include a description of the services the facility furnishes through employees and those furnished under arrangements.
Observations:
Based on employee interviews (EMP) and medical record (MR) and facility policy reviews, the facility failed to have a written care policy for the social or psychological services provided under arrangement for two (2) of six (6) MRs reviewed. (MRs 2 and 4)
Findings include:
A review of agency Job Description for Social Worker on 3/14/24 revealed, " Act as a consultant to pulmonary rehabilitation participants needing social services during and after rehabilitation. ...Job Status: Full-time, 40-hours a week ...Essential Job duties: 1. Interviews participants upon admission to the pulmonary rehabilitation program to evaluate the need for referral to community agencies ... "
A review of MRs between 3/13/24 to 3/14/24 revealed:
MR2: Certification Period (CERT): 2/13/24 -3/25/24. Diagnosis (Dx): Weakness, SOB [shortness of breath], Chronic obstructive pulmonary disease [lung disease causing SOB related to decreased or blocked airflow]. MR2 contained Physical Therapy (PT) initial evaluation dated 2/27/24 which read, " PLAN: The patient ' s treatment will include Communicate/Coordinate Care with Respiratory Therapist ... " Facility failed to provide a policy outlining the social or psychological services to be provided under arrangement to MR2, a pulmonary rehab patient.
MR4: CERT: 7/10/23 - 9/3/23. Dx: Shortness of breath; Difficulty in walking, not elsewhere classified. MR4 contained a PT initial evaluation dated 7/10/23 which read, " PLAN: The patient ' s treatment will include ...Communicate/Coordinate Care with Respiratory Therapist ... " Facility failed to provide a policy outlining the social or psychological services to be provided under arrangement to MR4, a pulmonary rehab patient.
A review of policies on 3/14/24 revealed, " Policy title: General Patient Care ...[facility] has written care policies that govern the services it furnishes to all patients. The purpose of these policies is to provide guidelines relating to patients seen by [facility] to ensure a standard of care is met. "
A review of facility policy booklet Section 5: Patient Care Table of Contents on 3/14/24 revealed, " 5.03 Pulmonary Therapy Services ...5.04 Physical Therapy Services ... " Patient care policy section did not contain written care policies governing social or psychological services.
During an interview with EMP1, Alternate Administrator, on 3/13/24 at approximately 11:00 am it was determined that the core service of social/psychological services was provided under contract by a Licensed Social Worker.
The findings were reviewed during an onsite exit interview on 3/14/24 at approximately 2:00 pm. A contract for social services was obtained on 3/21/24 from EMP1, alternate administrator, after an offsite telephone exit interview at approximately 1:00 pm.
Plan of Correction:Lifeline has a written "Description of Services" (Policy 5.02) that describes the services the facility furnishes through employees and those furnished under arrangements. A specific written care policy for Social Services was developed and added to the Policy and Procedures manual (reference 5.03a). In addition, a procedure for referral to social services was written and will be implemented at the Quarterly All Staff meeting on April 11, 2024. This procedure outlines the identifying criteria clinicians will use to determine appropriate referral for social services for pulmonary rehab participants. A consultation note will be recorded in the patients EMR as record of the referral and communication with the Social Worker. The job description for the Social Worker has been updated from full time to prn and is as stated below.
5.02 (Description of Services)
Medical and rehabilitation services are provided by the staff of Lifeline Therapy and additional professional healthcare providers as necessary. All patients receiving pulmonary therapy are cared for by the physical therapist and respiratory therapist in the facility. Registered Dietician and Social worker initial consultation and treatment can be provided on site on an as needed basis.
Physical Therapy Services are provided by employees of Lifeline Therapy
Physician Services are provided under contract arrangement.
Social Services are provided by an independent contractor.
Respiratory Therapy Services are provided by employees of Lifeline Therapy.
The Lifeline Therapy facility is a rehabilitation facility which provides services to local physicians treating patients with musculoskeletal, neuromuscular, and/or cardio-pulmonary impairments. Lifeline Therapy provides comprehensive outpatient pulmonary therapy and physical therapy services to patients.
The diagnostic aspect of the facility is two-fold. Patients who enroll in the pulmonary therapy program are assessed by such diagnostic tests as: spirometry, telemetry EKG, and Treadmill Test prior to entrance into the sessions. Pulmonary therapy sessions provide: physical re-conditioning/ exercise, breathing retraining, disease management skill training, education concerning the meter dose inhalers, oxygen and other medications, pacing, energy conservation, and relaxation/stress management. All services provided are multidisciplinary in scope and the respiratory therapist, physical therapist, dietician, and social worker share in presenting the educational materials to the individual patients.
It is understood that certain diagnostics evaluations are acceptable as pre- rehabilitation entry assessments. Such diagnostic tests will include the Treadmill Test, telemetry EKG, Pulmonary Function tests, and physical therapy testing. It is preferred that all tests be performed by the patient in a period of three months prior to entering the rehabilitation services.
Social Services Care Policy: (5.03a)
1. Collaboration with Referring Professionals: Work in collaboration with professionals who refer patients, including physicians, dentists, osteopaths, and podiatrists, ensuring an integrated approach to care. Understand and respect the scope of practices of these professionals, maintaining communication to align social work interventions with medical treatments.
2. Patient Assessment and Diagnosis: Complement the medical diagnosis with a thorough social work assessment for each patient. Focus on identifying psychosocial factors that may impact the patient's rehabilitation process, including emotional, social, and environmental aspects.
3. Development of a Social Work Treatment Plan: Formulate a detailed social work treatment plan for each patient, in accordance with the overall treatment objectives established by the rehabilitation team. Integrate social work goals with the physical therapy and medical treatment plans.
4. Patient Evaluation and Medical History: Contribute to the evaluation process by providing insights into the patient's psychosocial history and current status. Review and incorporate information from the Medical History form into the social work assessment.
5. Documentation: Maintain comprehensive documentation, including social work assessment, treatment plan, progress notes, interim reassessments, and discharge summary. Ensure that all documentation is consistent with CORF standards and legal requirements.
6. Provision of Social Work Services: Provide counseling, support, and psychoeducation to patients and their families. Assist with resource coordination, including access to community services and support systems.
7. Collaboration in Physical Therapy Services: Support patients receiving various physical therapy services like modalities and treatment/exercise programs by addressing their psychosocial needs. Help patients apply coping strategies and psychoeducation in managing their rehabilitation process.
8. Ethical Practice: Adhere to ethical guidelines specific to social work within a CORF setting. Maintain patient confidentiality and respect patient autonomy.
9. Professional Development: Engage in continuous learning to stay updated with best practices in social work within outpatient rehabilitation settings. Participate in interdisciplinary training programs to enhance collaboration within the CORF.
10. Quality Improvement: Contribute to quality improvement initiatives, aiming to enhance patient care and outcomes.
Procedure for referral to Social Services:
For Social Services a referral will be made:
1. If a patient's HADS score is > 8.
2. If a patient's CES-D score is ≥ 16.
3. If a patient has any community agency needs.
4. The clinician identifies any needs for the patient to receive emotional counseling, stress reduction and additional support for participants and family members.
Once this referral is made, the clinician will document using a "consultation note type" in raintree. Please include:
1. What service(s) are being requested.
2. Reason for referral.
3. Who was contacted (Social worker, PCP).
4. Any other pertinent information.
Lifeline has policies in place that describe the services the facility furnishes through employees and under other arrangements (contract services).
These policies are:
5.03 (Pulmonary Therapy Services)
"The assessment and diagnostic evaluation performed on patients at the facility is performed by the Physical Therapist and/or Respiratory Therapist. The other discipline services available to patients are: Social Work and Dietary Counseling as well as non-CORF physician services..."
485.58 CONDITION
COMPREHENSIVE REHABILITATION PROGRAM
Name - Component - 00
The facility must provide a coordinated rehabilitation program that includes, at a minimum, physicians' services, physical therapy services and social or psychological services. The services must be furnished by personnel that meet the qualifications set forth in §485.70 and must be consistent with the plan of treatment and the results of comprehensive patient assessments.
Observations:
Reviews of policies/procedures, job descriptions, personnel files (PF) including but not limited to: contracts for employees, and interviews with staff the clinic failed to ensure documentation of a coordinated rehabilitation program including but not limited to: physician and social services: failed to maintain a physician onsite for a sufficient time to: provide medical practice, provide medical treatment and supervision, establish the plan of treatment in cases where a plan had not been established.
Findings include:
policy 5.02, Description of Services, reviewed 3/21/24 at approximately 2:00PM revealed, POLICY: "Medical and rehabilitation services are provided by the staff of Lifeline Therapy and additional professional healthcare providers as necessary... Physician Services are provided under contract arrangement. Social Services are provided by an independent contractor...".
Interview with EMP1 (Alternate Administrator) on 3/21/24 at approximately 1:00 PM confirmed the above findings. "Doctors and social worker are not here daily, but are provided to patients as needed".
Cross reference:
485.58(a)(1) Physician Services Tag: 0533- the facility failed to maintain a physician onsite for a sufficient time to participate in patient case review conferences and utilization reviews for two (2) of two (2) contracts reviewed. (MDs 1 and 2)
485.58(c)(4) Coordination of Service Tag 0545- the facility failed to schedule multidisciplinary patient case review conferences to coordinate services for two (2) of six (6) MRs reviewed. (MRs 2 and 4)
485.58(d)(1) Provision of Services Tag 0546- the facility failed to ensure that patient referrals included significant medical history, current medical findings, diagnoses, contraindications to treatment modalities, and rehabilitation goals for three (3) of six (6) MRs reviewed. (MRs 1, 3, and 5).
Plan of Correction:Lifeline has contracted services with a Licensed Social Worker for social services on an as needed basis. We have updated the job description for this position to reflect this current position description. We will implement a Multidisciplinary Progress Report that will also be completed by PT, RT and SW and reviewed by the Medical Director when indicated for Pulmonary Rehab participants. We have created a procedure that when a patient is recommended for social services, a consultation note is completed in the EMR with the information to become part of the patient's medical record. All staff will be instructed on these procedures by April 11, 2024, and it will go into effect immediately. The Administrator will audit 10 charts after 30 days of implementation to monitor compliance with these procedures. The Medical Director will participate in case conferences with all other disciplines, review cases, provide consultation and establish plans of treatment in cases where a plan has not been established by the referring physician. The Medical Director will hold monthly meetings with the CEO to assist in establishing patient care policies. The Medical Director will participate in utilization reviews quarterly to review the clinic's medical records to assess quality and efficient utilization of services, compatibility of policies and clinical practices, applicability of the plan of treatment to established goals and evaluate admissions, continued care and discharges. The Medical Director will document time spent on the Medical Director Attestation form each month. Upon review of each patient's Plan of Care, the Medical Director will sign off on the Plan of Care to demonstrate it was reviewed and agreed upon.
485.58(a)(1) STANDARD
PHYSICIAN SERVICES
Name - Component - 00
A facility physician must be present in the facility for a sufficient time to--
- Provide, in accordance with accepted principles of medical practice, medical direction, medical care services and consultation;
- Establish the plan of treatment in cases where a plan has not been established by the referring physician;
- Assist in establishing and implementing the facility's patient care policies; and
- Participate in plan of treatment reviews, patient case review conferences, comprehensive patient assessments and reassessments and utilization reviews.
Observations:
Based on employee interviews (EMP), and reviews of job descriptions, contracts (MD) and policies, the facility failed to maintain a physician onsite for a sufficient time to participate in patient case review conferences and utilization reviews for two (2) of two (2) contracts reviewed. (MDs 1 and 2)
During an interview with EMP1 on 3/13/24 at approximately 11:00 am it was determined that the physician services provided by the facility were contractually provided by two physicians.
A review of Administrative Management document titled Contracted Services on 3/13/24 listed MD1 as Medical Director-Pulmonary Rehab and MD2 as Medical Director-Physical Therapy.
A review of physician contracts on 3/14/24 revealed:
MD1: Contract effective 5/1/2020. MD1 reads, " Schedule A ...Medical Director Services ...Responsibilities ...Confer with owner and executives, Clinic manager, therapists, and/or other designated Lifeline representative(s) concerning programs, support services, planning, outcome management, and quality assurance issues ...Meet as needed ...for the purpose of ensuring that patient medical management is consistent with the overall quality assurance program ... "
MD1 related policy titled Physician Medical Director -Pulmonary Therapy Facility read, " such services must include developing plans of treatment, participation in patient case review conferences, and establishing patient care policies for rehabilitation patients ...The medical director will provide consultation to the non-physician team members to establish the plan of treatment and other medical and facility administration activities ... "
MD2: Contract effective 2018 (month and day not specified). MD2 reads, " Schedule A ...Medical Director Services ...Responsibilities ...2. Confer at least monthly with the owner and executives, Clinic manager, physical therapists, and/or other designated Lifeline representative(s) concerning programs, support services, planning, outcome management, and quality assurance issues ...Meet as needed with Lifeline ' s quality assurance staff for the purpose of ensuring that patient medical management is consistent with the overall quality assurance program ... "
MD2 related policy titled Physician Medical Director -- Physical Therapy Facility read, " ...Such services must include developing plans of treatment, participation in patient case review conferences, and establishing patient care policies for rehabilitation patients. ...The medical director will provide consultation to the non-physician team members to establish the plan of treatment and other medical and facility administration activities ... "
A 3/14/24 review of agency document titled Utilization Review Committee read, " The Utilization Review Committee is to consist of the following disciplines: Physical Therapy ...If Needed...Respiratory Therapy ...Pulmonology ...Orthopedic Med ...Social Worker ... " Document fails to clearly specify participation of physicians in Utilization Review Committee.
A 3/14/24 review of agency document titled Quality Assurance Program read, " It is the policy of [agency] to have an established Quality Assurance Program. This program shall include, but not be limited to: 1. Quarterly chart audits by Facility Director ...2. Chart audits shall be performed 1x per year per therapist ... Quality Assurance Program fails to delineate participation of physicians as per Condition of Participation.
Interviews on 3/13/24 and 3/14/24 with EMP1, the physical therapist listed on Utilization Review Committee, determined that neither MD1 nor MD2 were involved in the utilization review process.
A 3/14/24 review of agency policy Coordination of Care revealed: " Meetings are called by the clinical coordinator to review individual cases with other members of the multidisciplinary professional team. Most of these meetings are informal in nature and occur on a daily basis ... " Coordination of Care policy fails to delineate participation of physicians in coordinated patient case review.
Interviews with EMP3 (physical therapist) and EMP4 (physical therapist) on 3/14/24 at approximately 1:00 pm determined that staff were unaware of patient case review conferences.
It was determined through the review of existing documentation and policies, and interviews with EMP1 that no documentation was available to verify MD1 or MD2 participation in patient case review conferences or utilization reviews.
The finding that MD1 and MD2 did not participate in patient case review conferences or utilization review activities was verified with EMP1 (Alternate Administrator) during an onsite exit interview on 3/14/24 at approximately 2:00 pm.
Plan of Correction:We have revised the Medical Director attestation with specific language that identifies that the MD was present in the facilities each month to provide medical direction, medical care services and consultation. The Medical Director will participate in case conferences with all other disciplines, review cases, provide consultation and establish plans of treatment in cases where a plan has not been established by the referring physician. The Medical Director will hold monthly meetings with the CEO to assist in establishing patient care policies. The Medical Director will participate in utilization reviews quarterly to review the clinic's medical records to assess quality and efficient utilization of services, compatibility of policies and clinical practices, applicability of the plan of treatment to established goals and evaluate admissions, continued care and discharges. Upon review of each patient's Plan of Care, the Medical Director will sign off on the Plan of Care to demonstrate it was reviewed and agreed upon. This will be implemented starting April 15, 2024. The Administrator will audit 10 charts to ensure there is evidence of the Medical Director signing off on the Plans of Care.
485.58(c)(4) STANDARD
COORDINATION OF SERVICES
Name - Component - 00
Mechanisms to assist in the coordination of services must include scheduling patient case review conferences for purposes of determining appropriateness of treatment, when indicated by the results of the initial comprehensive patient assessment, reassessment(s), the recommendation of the facility physician (or other physician who established the plan of treatment), or upon recommendation of one of the professionals providing services.
Observations:
Based on employee interviews (EMP) and reviews of policies, physician contracts [MD], and medical records (MR) the facility failed to schedule multidisciplinary patient case review conferences to coordinate services for two (2) of six (6) MRs reviewed. (MRs 2 and 4)
Findings included:
A 3/14/24 review of agency policy Coordination of Care revealed: " Meetings are called by the clinical coordinator to review individual cases with other members of the multidisciplinary professional team. Most of these meetings are informal in nature and occur on a daily basis ... "
A review of physician contracts on 3/14/24 revealed:
MD1: Contract effective 5/1/2020. MD1 reads, " Schedule A ...Medical Director Services ...Responsibilities ...Confer with ... Clinic manager, therapists ...[for] support services, planning, outcome management ...Meet as needed ...for the purpose of ensuring that patient medical management is consistent with the overall quality assurance program ... "
MD1 related policy titled Physician Medical Director -Pulmonary Therapy Facility read, " such services must include developing plans of treatment, participation in patient case review conferences, and establishing patient care policies for rehabilitation patients ...The medical director will provide consultation to the non-physician team members to establish the plan of treatment and other medical and facility administration activities ... "
MD2: Contract effective 2018 (month and day not specified). MD1 reads, " Schedule A ...Medical Director Services ...Responsibilities ...2. Confer at least monthly with ... Clinic manager, physical therapists ... concerning programs, support services, planning, outcome management ...Meet as needed with Lifeline ' s quality assurance staff for the purpose of ensuring that patient medical management is consistent with the overall quality assurance program ... "
MD2 related policy titled Physician Medical Director -- Physical Therapy Facility read, " ...Such services must include developing plans of treatment, participation in patient case review conferences, and establishing patient care policies for rehabilitation patients. ...The medical director will provide consultation to the non-physician team members to establish the plan of treatment and other medical and facility administration activities ... "
A review of medical records between 3/13/24 - 3/14/24 revealed:
MR2: Certification Period (CERT): 2/13/24 -3/25/24. Diagnosis (Dx): Weakness, SOB [shortness of breath], Chronic obstructive pulmonary disease [lung disease causing SOB related to decreased or blocked airflow]. MR2 contained Physical Therapy (PT) initial evaluation dated 2/27/24 which read, " PLAN: The patient ' s treatment will include Communicate/Coordinate Care with Respiratory Therapist ... " Agency failed to document Physical Therapy, Respiratory Therapy, and physician communication conference.
MR4: CERT: 7/10/23 - 9/3/23. Dx: Shortness of breath; Difficulty in walking, not elsewhere classified. MR4 contained a PT initial evaluation dated 7/10/23 which read, " PLAN: The patient ' s treatment will include ...Communicate/Coordinate Care with Respiratory Therapist ... " Agency failed to document Physical Therapy, Respiratory Therapy, and physician communication conference.
Interviews with EMP3 (physical therapist) and EMP4 (physical therapist) on 3/14/24 at approximately 1:00 pm determined that staff were unaware of patient case review conferences.
The finding was reviewed with EMP1 (Alternate Administrator) during an onsite exit conference on 3/14/24 at approximately 2:00 pm.
Plan of Correction:Case review conferences for purposes of determining appropriateness of treatment have been scheduled for 2024 and will include representatives from PT, RT, SW, and an MD. We have scheduled the next case review conference for April 25, 2024. Meeting minutes will be taken with the names and disciplines of all who attend.
485.58(d)(1) STANDARD
PROVISION OF SERVICES
Name - Component - 00
All patients must be referred to the facility by a physician who provides the following information to the facility before treatment is initiated:
-The patient's significant medical history.
-Current medical findings.
-Diagnosis(es) and contraindications to any treatment modality.
-Rehabilitation goals, if determined.
Observations:
Based on a review of medical records (MR) and interviews with the Alternate Administrator (EMP1) the facility failed to ensure that patient referrals included significant medical history, current medical findings, diagnoses, contraindications to treatment modalities, and rehabilitation goals for three (3) of six (6) MRs reviewed. (MRs 1, 3, and 5)
Findings included:
A review of MRs 1-6 between 3/13/24 to 3/14/24 revealed:
MR1: Certification Period (CERT): 2/13/24 - 3/25/24. Diagnoses (Dx): Presence of right artificial hip joint; pain in right hip; difficulty in walking, not elsewhere classified; and weakness.
MR1 contained a referral dated 2/7/24 listing a diagnosis of " S/P total right hip arthroplasty " and referral information which listed, " Status post right THA [total hip replacement] for femoral neck fracture via anterior approach ...Duration (weeks): 4 ...Modalities: Modalities of choice ...AROM [active range of motion] ...AAROM [assisted active range of motion] ...PROM [passive range of motion] Strengthening ...Gait Training ...Balance ...Stretching ...Status: WBAT [weight bearing as tolerated] ...Follow Protocol? Evaluate & Treat ... " Referral failed to contain past medical history, current medical findings, or contraindications to treatment modalities.
MR1 contained a Physical Therapy Initial Evaluation dated 2/13/24 which listed patient reported medical conditions including: " GERD, Chronic Back Pain, MRSA (methicillin resistant staphylococcus aureus) [site unspecified] and Glaucoma. " The referral dated 2/7/24 failed to contain the past medical history provided by the patient during the initial evaluation.
MR3: CERT: 1/25/24 - 2/25/24. Dx: Urge incontinence; Difficulty in walking, not elsewhere classified; and weakness.
MR3 did not have a referral.
MR3 contained a Physical Therapy Initial Evaluation dated 1/15/24 which listed patient reported medical conditions including: " joint pain, osteoarthritis, congestive heart failure, frequent UTI [urinary tract infections], Urinary incontinence [loss of bladder control], Heart Disease, Diabetes Type 2 [insulin resistance type], Bowel incontinence [loss of ability to control stool], hypertension [high blood pressure], and shortness of breath. " MR3 did not have a referral. EMP1 was unable to locate the referral upon request during an interview on 3/14/24.
MR5: CERT: 3/11/24 - 4/21/24. Dx: Presence of right artificial knee joint; pain in right knee; difficulty in walking, not elsewhere classified; and weakness.
MR5 contained a referral dated 2/16/24 listing a diagnosis of ' Status post right knee replacement " and referral information which listed, " Quad [thigh muscle group] strength and ROM [range of motion]. The referral failed to contain past medical history, current medical findings, or contraindications to treatment modalities.
MR5 contained a Physical Therapy Initial Evaluation dated 3/11/24 which listed patient reported medical conditions including: " Sleep disorder and joint pain " and " previous [knee] replacement...where a revision was needed ... " The referral dated 2/16/24 failed to contain the past medical or surgical history provided by the patient during the initial evaluation.
During an interview with EMP1, alternate administrator, on 3/13/24 at approximately 2:00 pm it was determined that initial referral information did not reflect the patient reported past medical and surgical history for MR1. During an interview with EMP1 on 3/14/24 it was determined that initial referral information did not reflect the patient reported past medical history for MR5 and that MR3 did not have a referral.
The findings were reviewed with EMP1 during an onsite exit conference on 3/14/24 at approximately 2:00 pm.
Plan of Correction:Upon receiving a referral for rehabilitation services, the office administrator who receives the referral will review the information received in consultation with the licensed provider (PT, RT, MD, SW) to ensure relevant information is obtained. If relevant medical history, medical findings, and contraindications to any treatments are not sent with the referral, the office administrator will then access the patient's chart in EPIC and retrieve the relevant information and review with the licensed provider. The office administrator will then add it to the patient's chart. We will monitor this during our utilization review/chart audits and the clinicians will be instructed to notify the office administrator if this information is absent from the medical record upon evaluation of the patient. This process will be reviewed with all staff and will be implemented the week of 4/15/24. The Administrator will monitor by auditing 10 charts to ensure that PMH from the referring physician is present in the EMR.
485.62(b)(1) STANDARD
SANITARY ENVIRONMENT
Name - Component - 00
The facility must establish written policies and procedures designed to control and prevent infection in the facility and to investigate and identify possible causes of infection.
Observations:
Based on observations (OBS) and interviews with employees (EMP) the facility did not establish written policies and procedures related to the disinfection of equipment for two (2) of two (2) observation periods. (OBS 1&2)
Findings included:
A review of agency policy titled Infection Control on 3/14/24 revealed: " Equipment 1. Ultrasound: transducers shall be disinfected after each use. ...2. Electrical Stimulation: ...Electrodes shall be disinfected after each use ...4. Traction apparatus: shall be disinfected after each use. ...6. Gym equipment: all equipment will be wiped with a disinfectant after each patient use ... Agency policy failed to identify or specify type of disinfectant to be applied to equipment.
During a facility observation on 3/13/24 at approximately 10:00 am (OBS1) it was noted that the facility used spray bottles with an unknown cleaner to disinfect equipment between patients. It was determined during an interview on 3/13/24 at approximately 3:00 pm with EMP2, front desk attendant, that the spray bottles contained a diluted EPA registered cleaner. EMP2 stated the spray bottle ' s labelling had " worn off. " EMP2 was unaware of a written policy or procedure for diluting the cleaner but EMP2 stated they mixed " two capfuls " of concentrate " into a spray bottle of water. "
A review of the disinfectant cleaner ' s preparation for use instructions on 3/13/24 at approximately 3:00 pm read, " Disinfection - Medical (1:64): 2 oz per gallon of water, Virucide (1/128): 1 oz per gallon of water ...Allow surface to remain wet for 10 minutes. Wipe or allow to air dry ... "
During a facility observation on 3/14/24 at approximately 12:00 pm (OBS2) EMP1 confirmed that spray bottles were not labelled with a preparation date and that a current written policy or procedure for mixing the disinfecting cleaner or directions for use did not exist. Additional interviews with EMP3, Physical Therapist, and EMP4, Physical Therapist, between 1:00 pm to 1:30 pm on 3/14/24 verified that staff mixed disinfecting solution with the undetermined ratio of " two-capfuls " to each spray bottle.
This finding was reviewed with EMP1, alternate administrator, during an exit interview on 3/14/24 at approximately 2:00 pm.
Plan of Correction:Lifeline updated the Infection Control Policy to include specific instructions on how to launder linens, how to clean the hydrocollator, and how to mix disinfectants following the manufacture's instruction for medical grade disinfecting. This updated policy was reviewed with all staff on 4/8/24 and instructions on how to mix specific disinfectants (Member's Mark) were distributed to all clinics on 4/8/2024 and the instructions were hung in visible areas for all staff to reference. The policy was also revised to include instructions on mixing in 1-gallon containers to ensure consistency in dilution and to document the date the solution was mixed. The clinical team must report any suspected or confirmed infections to the administrator for further investigation and review. If it is deemed necessary, additional disinfecting measures (i.e. professional disinfecting services) will be called in to disinfect the clinic.
485.62(c)(1) STANDARD
MAINTENANCE
Name - Component - 00
The facility must establish a written preventive maintenance program to ensure that all equipment is properly maintained and equipment needing periodic calibration is calibrated consistent with the manufacturer's recommendations.
Observations:
Based on observations (OBS), reviews of facility documents, and employee interviews (EMP), the facility failed to establish a written preventative maintenance program that ensured all equipment was properly maintained for seven (7) of seven (7) machines reviewed (EQU 1-7)
Findings include:
An observation (OBS1) of facility treatment areas and equipment conducted on 3/13/24 between approximately 9:30 am to 10:30 am revealed:
EQU1: Seated bike located in the patient care area had an equipment maintenance sticker labeled 4/2022 as date due for maintenance.
Seated bikes EQU2 and EQU3 in the patient care area had no preventative maintenance stickers.
EQU4: Leg press machine in the patient care area had no preventative maintenance sticker.
During a walk through and interview with EMP1 (Alternate Administrator) on 3/13/24 at approximately 11:00 am, it was determined that the facility had an outside company perform equipment maintenance and a new company began servicing equipment in 2023. The absence of equipment maintenance stickers and a late maintenance sticker was reviewed with EMP1.
During OBS2 on 3/14/24 at approximately 11:50 am, the contract for equipment maintenance and the instruction manuals for the fitness equipment were requested from EMP1. A receipt for maintenance services dated 12/14/23 was made available. No written contract was made available for the current preventative maintenance company or preceding company. During OBS2 the following information was noted:
EQU1 (recumbent cross trainer) Nustep T5XR Serial Number:T5119809 Manufacture date August 2019 was labeled with a maintenance sticker reading Date due 4-2022 Health Equipment Services. The facility did not have a written preventative maintenance program for EQU1 and it was not listed on the contracted equipment maintenance receipt.
EQU2 Seated arm bike labeled " SciFit, " had no visible serial number or manufacturer date on the equipment, and EQU2 did not have a preventative maintenance sticker. The maintenance manual contained directions for use (DFU) which required chain lubrication and checking the battery using a voltmeter every six months, inspection of nuts and bolts bimonthly as needed for tightening, and damp cloth cleaning of base roller guide track monthly. The facility did not have a written preventative maintenance program for EQU2 listing the preceding maintenance requirements and it was not listed on the contracted equipment maintenance receipt.
EQU3 Seated bike labeled " Vision Fitness " had no visible serial number or manufacturer date on the equipment and did not have a preventative maintenance sticker. A maintenance manual was requested from EMP1 and EMP2 (front desk assistant) but was not available. The equipment was listed on the contracted equipment maintenance receipt but inspection was not checked off as complete, the facility did not have a written preventative maintenance program for EQU3.
EQU4 Leg press labeled " True fitness technology palladium series " Model #SPL0300 Serial #22-SPL030025G, did not have a preventative maintenance sticker, was not listed on the contracted equipment maintenance receipt, had no written preventative maintenance program, and no instructions for use manual was made available by EMP1 or EMP2.
EQU5 seated bike labeled " Marcy " manufactured by IMPEX had no listed serial number. EQU5 had no preventative maintenance sticker was not listed on the contracted equipment maintenance receipt, had no written preventative maintenance program, and no instructions for use manual was made available by EMP1 or EMP2.
During an observation conducted on 3/13/24 at approximately 10:30 am it was noted that the facility laundered towels onsite using a washer (EQU6) and dryer (EQU7) located in a non patient care area. During an onsite interview with EMP1 (alternate administrator) on 3/14/24 at approximately 2:00 pm it was determined that the facility did not have a written policy/procedure for safely maintaining and sanitizing EQU6 and EQU7.
The findings were reviewed with EMP1 (alternate administrator) during an exit interview at approximately 2:00 pm on 3/14/24.
Plan of Correction:Contracted equipment servicing company came to the facility on 3/22/2024 to inspect any equipment that did not have an inspection sticker. All equipment has now been inspected, passed and stickered. We have implemented an annual compliance calendar that includes annual equipment inspection for preventative maintenance and calibration of all equipment in all clinics. This will be performed annually and will be completed by the contracted equipment servicing company as per our contract. This will be monitored annually by the Administrator.
485.66(a) STANDARD
UTILIZATION REVIEW COMMITTEE
Name - Component - 00
The utilization review committee, consisting of the group of professional personnel specified in §485.56(c), a committee of this group, or a group of similar composition, comprised by professional personnel not associated with the facility, must carry out the utilization review plan.
Observations:
Based on interviews with the alternate administrator (EMP1) and reviews of documentation and policies/procedures, the facility failed to conduct utilization reviews with staff representing the full scope of services provided by the CORF.
Findings included:
A review of facility policy titled Description of Services on 3/14/24 noted services of physical therapy, physician services, social services, respiratory services, and as needed registered dietician services.
A 3/14/24 interview with EMP1, alternate administrator, determined that the facility ' s Utilization Review Plan consisted of a " peer to peer " chart review which would be reviewed by a " team leader. "
3/21/24 a request for policies related to Utilization Review was made to EMP1 and a copy of a document titled Quality Assurance Program was provided. The policy noted, " Chart audits will be performed quarterly ...each therapist will undergo two chart audits annually ... "
A 3/21/24 review of documentation listing chart audits failed to provide evidence of chart reviews related to social or psychological services and the list of auditors did not outline each auditor ' s discipline.
A 3/21/24 review of documentation titled Utilization Review Committee read, " The Utilization Review Committee is to consist of the following disciplines: ...Physical Therapy ...If Needed: ...Respiratory Therapy: ...Pulmonology ...Orthopedic Med ...Social Worker
A 3/21/24 review of documentation titled Utilization Review Meeting Minutes dated 2/22/2024 did not include staff representing the full scope of services provided by a CORF. The meeting did not include representation from physician services or social services, core services to be provided by the facility.
The finding was reviewed with EMP1 on 3/21/24 at approximately 1:00 pm during a telephone exit interview.
Plan of Correction:The Utilization Review Committee was revised to include the following disciplines: PT, RT, and MD and SW. The Utilization Review Policy (Policy 10.05) was revised to state that the "Utilization Review Committee will perform quarterly evaluations of the clinic's medical records." A Utilization Review Committee Meeting schedule was developed and implemented, and the committee will meet each quarter. The first meeting will take place on April 15, 2024. Meeting minutes will be taken and available for review.
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