Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed July 10, 2019, Lifeline Therapy 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 485.68, Subpart B, Conditions of Participation: Comprehensive Outpatient Rehabilitation Facilities - Emergency Preparedness.
Plan of Correction:
485.68(a)(5) STANDARD
CORF/Clinic Development and Fire Safety
Name - Component - 00
§485.68(a)(5) Condition for Participation:
[(a) Emergency Plan. The Comprehensive Outpatient Rehabilitation Facility (CORF) 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:]
(a)(5) Be developed and maintained with assistance from fire, safety, and other appropriate experts.
§485.727(a)(6) Condition for Participation:
[(a) Emergency Plan. The Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services ("Organizations") 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:]
(a)(6) Be developed and maintained with assistance from fire, safety, and other appropriate experts.
Observations:
Based on review of facility documentation, policies and procedures, and staff (EMP) interview, the facility failed to ensure it maintained its emergency preparedness plan annually with the assistance from fire, safety, and other appropriate experts for the year 2018-2019.
Findings included:
Observation of emergency evacuation routes posted in the facility on July 10, 2019, at 10:37 a.m. showed an emergency egress route through facility's back door. At this time, observation of the back door shown on posted emergency evacuation route revealed it was obstructed.
Review of facility policy and procedure on July 10, 2019, at 11:47 a.m. "LIFELINE THERAPY Safety Policies and Procedures 1. ... Exit plans are posted in each treatment room, gym, offices, and work room with exit routes clearly marked."
During interview with EMP5 on July 10, 2019, at 1 p.m. he/she confirmed no documentation to show facility had its emergency plan maintained (reviewed) with assistance from fire, safety, and other appropriate experts for the year 2018-2019. EMP5 noted the last time the plan would have been reviewed with the assistance of fire, safety or other appropriate personnel would have been in January 2018 when facility's emergency preparedness plan was finalized.
During interview with EMP2 on July 10, 2019, at 1:45 p.m. he/she confirmed posted evacuation route was not accurate. He/she noted the door referenced on aforementioned evacuation route is not an emergency exit since it does not go anywhere (leads to another hallway within building).
Plan of Correction:On 7/11/2019 emergency evacuation route signs were revised with the addition of fire extinguishers and the removal of the rear emergency egress route. Lifeline Therapy reached out to the local fire chief 7/17/19 via voice mail to coordinate a fire inspection. Fire inspection scheduled for Lifeline Therapy Emergency Preparedness Policy was reviewed and signed off in January, but we failed to date stamp the policy itself. We have now date stamped it with a revised date of 01/2019. Administrative Assistant will be accountable for creating a workflow process of annual date stamping of Emergency Preparedness, alerting facility director to complete and document annual fire drill. Administrative Assistant will add and minitour date stamping to Emergency Preparedness and Annual Fire Drill to our yearly compliance checklist.
485.68(d) STANDARD
EP Training and Testing
Name - Component - 00
§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.
*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.
*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).
*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.
Observations:
Based on review of facility policy and procedure, logs, and staff (EMP) interviews, the facility failed to conduct a recent annual fire drill (2018-2019).
Findings included:
Review of "Fire Drill Log/ Disaster Plan Review" on July 10, 2019, at 10:30 a.m. showed facility conducted a fire drill on 2/26/2018.
During interview with EMP4 on July 10, 2019, at 10:57 a.m. he/she noted last fire drill was "sometime in the fall of last year." When he/she was shown fire drill logs he/she noted, "I guess it was later than that."
Interview with EMP5 on July 10, 2019, at 11:12 a.m. confirmed fire drill was "missed" for February 2019.
Review of facility policy and procedure on July 10, 2019, at 11:47 a.m. "LIFELINE THERAPY Safety Policies and Procedures ... 6. Fire Drills: A fire drill will be conducted at least on an annual basis."
Review of facility policy and procedure on July 10, 2019, at 1 p.m. showed, "STANDARD: DRILLS AND STAFF TRAINING ... The facility must periodically practice the emergency plan. A fire and disaster drill will be conducted or reviewed at least one time per year. Practicing the plan will ensure that the staff is fully prepared to handle emergencies, staff members are familiar with emergency plan, and the plan is workable and responsive to facility needs."
Plan of Correction:Annual fire drill was completed on 7/10/2019. Documentation complete. Staff did participate in a live fire drill in spring of 2019 which facility director failed to document. The Administrative Assistant will be accountable for creating a workflow process of alerting facility director to complete and document annual fire drill. Angela Iorio-Administrative Assistant will add Annual Fire Drill to our yearly compliance checklist and monitor compliance checklist.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed July 10, 2019, Lifeline Therapy was found to be in compliance with the requirements of 42 CFR, Part 485, Subpart B, Conditions of Participation: Comprehensive Outpatient Rehabilitation Facilities.
Plan of Correction:
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