Initial Comments:
Based on an onsite unannounced Medicare recertification survey completed on 12/13/24, Lifeline Therapy of West Mifflin 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 completed on 12/13/24, Lifeline Therapy of West Mifflin 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 B, Conditions of Participation: Comprehensive Outpatient Rehabilitation Facilities.
Plan of Correction:
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 a review of policies, site observation, and interviews (EMP), staff failed to follow clinic policy and document equipment cleaning and disinfection affecting seventy-two (72) of seventy-two (72) clinic patients.
Findings included:
A 12/12/24 review of Infection Control policy revealed: Equipment ...3. Hydrocollator: To be drained and cleaned once a month with a 1-part water/8-parts vinegar mixture ... "
During a 12/12/24 onsite observation at approximately 10:00 am a review of the clinic ' s hydrocollator cleaning/temp check log revealed that staff failed to document scheduled cleaning for the months of January, February, June, July, August, and September of 2024.
The finding was reviewed with EMP1 Alternate Administrator during an exit interview on 12/12/24 at approximately 3:00 pm.
Plan of Correction:Updated policy on Infection Control (Policy 9.60) to include language to monitor Hydrocollator cleaning. The updated policy now states that before the cleaning/temperature log is uploaded to the company drive on the last day of the month, it must be signed off by the Facility Director to show that monitoring has occurred. The updated policy now reads:
Each facility will maintain a sanitary environment and take the necessary steps to prevent and control the cause of patient infections. The guidelines below must be followed to maintain a sanitary environment. It is the responsibility of the Facility Director to monitor the infection control at the facility level per the guidelines below and of the Administrator at the leadership level to ensure sanitary conditions of each facility and prevent the spread of infection monthly. Each facility will utilize the Weekly Infection Control Checklist, Daily Temperature Logs for the Hydrocollator/HydraTherm, refrigerators and freezers and monthly compliance logs.
On the last day of each month, the completed logs and checklists will be added to the designated folder on the company drive only after the Facility Director has reviewed and signed off on the logs showing all items, including cleaning and temperature checks were completed. The Administrator will monitor the clinic folders on the company drive each month. Failure to comply with this policy will result in corrective action. This will be implemented 12/20/24.
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 site observations and interviews with the alternate administrator, clinic staff failed to establish a preventative maintenance program that ensured all emergency equipment was maintained as per manufacturer ' s directions for use for two (2) of two (2) fire extinguishers reviewed. (EQU1&2)
Findings include:
A review of the clinic ' s fire extinguisher directions for use on 12/13/24 revealed: " Maintenance: Inspect monthly or at more frequent intervals when circumstances require. Make sure hose and horn are unobstructed. Gauge pressure must be in operable range. Lockpin & tamper seal must be in place ... "
An observation of the facility on 12/12/24 at approximately 9:45 am revealed:
EQU1: Fire extinguisher located near the clinic ' s entryway had an annual inspection tag attached 4/2024. EQU1 ' s tag failed to contain monthly extinguisher inspection entries for the months of September, October, and November.
EQU2: Fire extinguisher located near the clinic ' s rear door and by the onsite washer/dryer had an annual inspection tag attached 4/2024. EQU2 ' s tag failed to contain monthly extinguisher inspection entries for the months of July, August, September, October, and November.
The finding was reviewed with the clinic ' s alternate administrator on 12/12/24 at approximately 1:30 pm.
Plan of Correction:A policy was created for monthly monitoring of clinic fire extinguishers to ensure they are in working order. The policy states:
The clinic will have an annual fire extinguisher inspection from an outside vendor. In addition to this annual check, the facility will perform monthly checks to ensure the fire extinguishers are in proper working order using the following criteria per the manufacturer's recommendations. Staff will ensure that the:
a. Hose and horn are unobstructed
b. Gauge pressure is in operable range
c. Lock pin and tamper seal are in place
Once the fire extinguisher check is completed, the staff member will initial and date the maintenance tag located on the fire extinguisher. This will be completed for all extinguishers present in the clinic. Failure to verify any of the above requires the equipment to be replaced immediately. This will be monitored each month by the Facility Director for each clinic. This will be implemented 12/20/24.
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 a review of policies, meeting minutes, chart audits, and interviews with the alternate administrator (EMP1) the clinic failed to perform a quarterly medical record audit (QA) for two (2) of three (3) audit periods reviewed. (QAs 1&3)
Findings included:
A 12/12/24 review of Utilization Review policy revealed, " The Utilization Review Committee will perform a quarterly evaluation of the clinic ' s medical records. "
A 12/12/24 review of Quality Assurance Program policy revealed, " It is the policy of Lifeline Therapy to have an established Quality Assurance Program. This program shall include, but not be limited to: 1. Chart audits will be performed quarterly ... "
An interview with EMP1 on 12/12/24 at approximately 1:30 pm revealed that Utilization Review Meeting included chart audits which were not exclusive to the surveyed clinic. Rather, charts from multiple clinics with separate CCNs (Medicare Certification Numbers) were audited during each meeting and chart audits were conducted quarterly based on individual therapists. EMP1 verified that they were unsure if chart audits were performed for each Medicare certified site on a quarterly basis, as per clinic policy.
A 12/12/24 review of Utilization/Peer Review Chart Audit-Physical Therapy (chart audit) records revealed:
QA1: Meeting dated 4/16/24 identified as Quarter 1 review. EMP1 verified that the five chart audits performed for QA1 were not patients of the clinic currently being surveyed for recertification. The clinic failed to follow policy and perform a quarterly medical record audit for Quarter 1.
QA3: Meeting dated 11/13/24 identified as Quarter 3. EMP1 verified that the four chart audits performed for QA3 were not patients of the clinic currently being surveyed for recertification. The clinic failed to follow policy and perform a quarterly medical record audit for Quarter 3.
The finding was reviewed with EMP1, Alternate Administrator, during an exit interview conducted on 12/12/24 at approximately 3:00 pm.
Plan of Correction:Updated the Utilization Review policy (policy 10.05) to include language that specifies that at least 1 chart from each clinic will be reviewed during the quarterly utilization review meeting. This change was implemented 12/20/24.
The policy now states as follows:
The Utilization Review Committee will perform a quarterly evaluation of the clinic's medical records. This will include at least one chart from each clinic. One person from each discipline must attend the quarterly meeting. If a member is unable to attend the scheduled meeting, an alternate professional from the same discipline will attend. If an alternate professional is unable to attend, the meeting must be rescheduled to a different date so that all disciplines are represented. The group of professional personnel will review the comments and suggestions made by the Utilization Review Committee and take appropriate action regarding the patient care policies.
If changes are recommended by the Utilization Review Committee, the change will be implemented accordingly by the professional facility personnel. Minutes will be taken at each Utilization Review Committee meeting and available for review. Recommendations will be made to the officers of Lifeline. Decisions and further actions will be made at that time concerning the utilization plan of Lifeline Therapy facility as a result of changes in policy or procedures as recommended by the professional advisory committee. If necessary, the CEO will contact the healthcare professionals providing care if there is concern or problem with patient outcomes or patient care. The healthcare professionals will have the opportunity to meet with the CEO at any time concerning any situation.
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