Initial Comments:
Based on the findings of an onsite unannounced initial Medicare certification survey completed on March 16, 2021, Butler Rehabilitation Centers was found to be in compliance with the requirements of 42 CFR, Chapter IV, 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 conducted March 16, 2021, Butler Rehabilitation Center - Kittanning was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42 CFR, Chapter IV, Subpart B, Conditions of Participation: Comprehensive Outpatient Rehabilitation Facilities.
Plan of Correction:
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 observation and interview with staff the clinic failed to ensure the facility physician was present in the facility for a sufficient time to participate in plan of treatment review ... utilization reviews for one (1) of one (1) observation made. OBS #1.
Findings include:
OBS #1 completed 3/16/2021 at approximately 1:00PM revealed no physician present in the clinic for any period of time during business hours.
Interview with respiratory therapist completed 3/16/2021 at approximately 3:00PM confirmed the above findings. "We usually don't have a doctor on-site".
Plan of Correction:In order to correct the aforementioned deficiency, Medical Director will be instructed to increase frequency of being present in the facility. In addition to increasing clinic presence, Medical Director will continue to be post review participant per CORF manual guidelines for Quality and Utilization Review.
The CMS CORF Policy and Operations Manual does not specify time to be present in facility by Medical Director. In order to prevent further deficiencies from reoccurring, Medical Director and Administrator has agreed for Medical Director to be present at facility least on a once a week basis. In addition to Facility visits, Medical Director will continue to perform duties and post review conferences of Plan of Care/Utilization Reviews.
In order to monitor the facilities progress to ensure solutions/remedies are sustained, Administrator will review Medical Director's Monthly Time Report to ensure visits to site facility is maintained (Monthly Basis).
Facility has made responsible to monitor the continued implementation of the plan of correction the Administrator and also the Medical Director, as they are responsible for Medical Director's Monthly Time Report and documentation of Medical Director's hours.
485.62(b) STANDARD
SANITARY ENVIRONMENT
Name - Component - 00
The facility must maintain a sanitary environment and establish a program to identify, investigate, prevent, and control the cause of patient infections.
Observations:
Based on policy/procedures review, observations (OBS), and staff interview the agency failed to maintain a sanitary environment for patients for one (1) of one (1) observations made. OBS #1.
Findings include:
Review of policy Ic-1 (I-579): "Sanitary Environment" completed on 3/16/21 at approximately 9:53 AM contained wording on page 2, paragraph 1,"The facility will maintain a sanitary environment and maintain a program to identify, investigate, prevent and control the cause of infection".
page 3, paragraph 3, "Education To Prevent Spread of Infection. All routine job-related functions are to be classified using terminology to assure proper identification of Category 1 and Category 2 tasks and procedures".
Page 5, Ic-3 Universal Precautions, Procedure: Universal precautions shall be observed to prevent contact with blood or other potentially infectious materials. All body fluids shall be considered potentially infectious. f) the above list is not all-inclusive, so judgement is required on the part of the healthcare worker to assess the need for additional barrier protection".
OBS # 1 completed March 16, 2021 between approximately 10:00AM and 11:00AM revealed the following:
An unmarked, uncovered tongue depressor with a white substance on the tip was laying on the bottom shelf of the second cabinet closest to the wall in the sleep study lab. Approximately four (4) unwrapped gauze sponges sitting on the second shelf along side unwrapped electroencephalogram (EEG) electrodes (small metal discs that are attached to the scalp during a sleep study to measure brain electrical activity). The electrodes were not marked. A Johnson & Johnson First Aid Kit was located on the top shelf of the cabinet with an expiration date of: 1/2008.
Shelving to right of the cabinet contained a bottle of Respisoak disinfectant 2% weekly maintenance concentrate, lot no: 0710-075-2 expiration date: 6/2009.
Outside study room #1, Invacare platinum Oxygen concentrator No: 2966 with a sticker reading, "last cleaned": 6/5/18.
In the cabinet located in evaluation rm #1, a small plastic container labeled, "massage cream" located on the bottom shelf of the cabinet with a plastic knife atop. The knife was not labeled or covered. No gloves were located within the exam room. No disinfectant was located for routine cleaning between patients.
Interview with the respiratory therapist confirmed completed March 16, 2021 at approximately 4:00PM confirmed the above findings.
Plan of Correction:In order to correct the aforementioned deficiency, all unwrapped/uncovered disposable supplies were removed and thrown away. In addition, any expired equipment, e.g. aforementioned First Aid Kit, Respisoak and any other expired supplies has been disposed of and replaced. The concentrator has been exchanged for another updated concentrator. All staff has been notified of deficiencies and corrected measures. An extra box of gloves and extra bottle of disinfectant was added to exam room/gym for routine cleaning between patients.
In order to prevent further deficiencies from reoccurring, all staff members will review Infection Control Policy and Procedures at quarterly staff meeting, including deficiencies and plan of correction. On a quarterly basis, the administrator and available staff will perform a site assessment of all supplies and appropriate equipment to evaluate for expiration, inadequate disposal and cleanliness. If any supplies are found to be expired, they will be disposed of appropriately. The findings off the site assessment will be reported during the quarterly staff meetings to ensure that this problem does not reoccur.
In order to monitor the facilities progress to ensure solutions/remedies are sustained, a infection control check list has been created and added for indefinite quarterly site checks, to be performed by Administrator or Assistant Administrator and can be utilized by all staff to review.
Facility has made responsible to monitor the continued implementation of the plan of correction all staff members, but Administrator and Assistant Administrator will be responsible for continued implementation of Plan of Correction.
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 a review of agency policy, observations, and an interview with staff the clinic failed to ensure that everyone entering the health care facility was screened and triaged for COVID-19 for one (1) of one (1) observations (Observation #1).
Findings Include:
Pennsylvania Department of Health 'Health Alert Network' dated August 7, 2020 'Subject' 'Update: Interim Infection Prevention and Control Recommendations for Patients with known or Patients Under Investigation for 2019 Novel Coronavirus (COVID-19) in a Healthcare Setting' section (I) Recommended Routine Infection Prevention and Control (IPC) Practices During the COVID-19 Pandemic' (B) 'Screen and Triage Everyone Entering a Healthcare Facility for signs and symptoms of COVID-19':....symptom screening remains an important strategy to identify those who could have COVID-19 .......". "Screen everyone (patients, healthcare personnel, visitors) entering the facility for symptoms consistent with COVID-19 .....". "Actively take their temperature and document absence of symptoms consistent with COVID-19".
Observation #1: No documentation of COVID-19 screening process noted upon entry to the agency office building. On 3/16/2021 the state surveyors entered the clinic, no one documented the surveyor's temperatures nor completed a symptom screening questionaire.
An interview conducted with clinic respiratory therapist on 3/16/2021 at approximately 3:00 p.m. confirmed the above findings. "We are only open Tuesdays and Fridays, and we typically ask our patients about COVID exposure, but do not document anything".
Plan of Correction:In order to correct the aforementioned deficiency, the "CDC Facilities COVID-19 Screening tool" was distributed to all staff members. Staff was instructed to temperature check every patient or "visitor" that enters the facility. Staff was instructed to chart on each patient that screening tool and temperature check was completed prior to patient treatment. The CDC Facilities COVID-19 Screening has been entered into the Infection Control Policies and Procedures Manual for future reference and records. The staff will be re-instructed regarding the change in policy (screening tool and temperature checks) during the next quarter staff meeting to reaffirm the change in policy and new procedures.
In order to prevent further deficiencies from reoccurring, the Covid-19 screening tool and temperature checks will be reviewed during every quarterly staff meetings and included in the annual "Infection Control" meeting. New hires will be educated and trained on CDC Facilities COVID-19 Screening tool and temperature checks until the CDC and/or the PA DOH updates that facilities no longer need to perform. The "CDC Facilities COVID-19 Screening tool" will be entered into the company documents cloud, allowing any individual employee to access it at anytime from any computer.
The facility will monitor its performance to ensure solutions/remedies are sustained by utilizing the quarterly Quality and Utilization Review Committee to review and assess the policy and service (Covid Screenings and temperature checks) regarding Covid. The Quality and Utilization Review is performed on a quarterly basis indefinitely to ensure and assess quality of services provided and determines whether the facility's practice are appropriate. The committee reviews 10% of patient charts discharged from the facility and can assess if Covid screening is being performed continuously and efficiently.
The Facility has made responsible the members of the Quality and Utilization Review Committee to monitor the continued implementation of the plan of correction.
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