Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on January 3, 2019, Lifeline Therapy West Mifflin LLC, was identified 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)(3) STANDARD
EP Program Patient Population
Name - Component - 00
§403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3).
[(a) Emergency Plan. The [facility] 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:]
(3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.**
*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following:
(3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.
*NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.]
Observations:
Based on a review of the facility Emergency Preparedness plan (EPP) and staff (EMP) interview, the facility failed to ensure the EPP addressed unique vulnerability of identified patient population, the types of services the facility would be able to provide in an emergency, and the identities of staff and backup roles in another's absence.
Findings Included:
Review of facility EPP on January 3, 2018 at approximately 1:00 p.m. revealed: "...Emergency Preparedness: Develop and Maintain Emergency Program...CMS Standard...CMS Survey Tag E0007...[facility name] will maintain an effective Emergency Preparedness Plan (EPP) and our procedures will be rehearsed periodically in order to effectively prepare our employees for the management of an internal or external disaster and prove or arrange care for our patients and/or causalities. Procedure: In order to meet the requirements of this policy the following will be addressed as part of the [facility name] EPP: 1. [facility name] EPP is based on a documented facility-based risk assessment utilizing an all hazards approach. [facility name] will also coordinate with community official on a community risk assessment for each of the localities in which we have clinics. 2. ...EPP contains strategies for addressing emergency events identified by our risk assessment and includes strategies for other events identified by other disaster authorities...strategies are based upon recommendation from Federal authorities including, but not limited to, the Federal Emergency Management Association (FEMA) and the Department of Homeland Security (DHS)...3...EPP will address our patient population, including, but not limited to, the type of service that [facility name] may have the ability to provide in an emergency. We will address the continuity of operation, including the delegation of authority and succession plans. Given the small size of staff with primary patient care responsibilities the focus is on patient and staff safety in an emergency..."
Interview completed on January 3, 2019 at approximately 2:30 p.m. with EMP3 confirmed the findings. Surveyor asked EMP3 if the policy addressed the population serviced and population vulnerabilities, patient mobility, the continuity of operations plan. EMP3 stated "a consultant has been hired to assist us with the completion of our EPP"
Plan of Correction:Lifeline's EP policy has an attached Emergency Plan – Clinic Response table that was created 1/22/18 which addresses the unique vulnerability of identified patient population and the types of services the facility would be able to provide in an emergency, as well as continuity of the operations plan. The columns are titled "What do we do with our patients in our clinics when a disaster occurs", "What do we do to allow employees to ensure their family and home's safety and security", "What are our obligations to secure the clinical locations (shut off gas, water, lock doors, etc)", "How do we communicate amongst ourselves as to who is safe and able to help", "What services can we then provide to the community". Additionally, there is an attached list identifying staff and backup roles in another's absence entitled "Roles and Responsibilities" last updated 2/1/18. Note, EMP3 is new; this was her first survey. Though all materials were available electronically, she may not have directed surveyor to appropriate documents. EMP3 statement was inaccurate; we had hired a consultant at the end of 2017 who helped us complete our policy by the end of January 2018.
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 a review of the facility Emergency Preparedness Plan (EPP) and staff (EMP) interview, it was determined the facility failed to maintain documentation of collaboration with fire, safety and other appropriate experts in the development of their EPP.
Findings Included:
Review of facility EPP on January 3, 2018 at approximately 1:00 p.m. revealed: "...Emergency Preparedness: Develop and Maintain Emergency Program...CMS Standard...CMS Survey Tag E0011...[facility name] will maintain an effective Emergency Preparedness Plan (EPP) and our procedures will be rehearsed periodically in order to effectively prepare our employees for the management of an internal or external disaster and prove or arrange care for our patients and/or causalities. Procedure: In order to meet the requirements of this policy the following will be addressed as part of the [facility name] EPP: 1. [facility name] EPP is based on a documented facility-based risk assessment utilizing an all hazards approach. [facility name] will also coordinate with community official on a community risk assessment for each of the localities in which we have clinics. 2. ...EPP contains strategies for addressing emergency events identified by our risk assessment and includes strategies for other events identified by other disaster authorities...strategies are based upon recommendation from Federal authorities including, but not limited to, the Federal Emergency Management Association (FEMA) and the Department of Homeland Security (DHS)...3...EPP will address our patient population, including, but not limited to, the type of service that [facility name] may have the ability to provide in an emergency. We will address the continuity of operation, including the delegation of authority and succession plans. Given the small size of staff with primary patient care responsibilities the focus is on patient and staff safety in an emergency...4...EPP includes the location and use of alarm systems and signals; and methods of containing fire based upon our longstanding Disaster Preparedness Plan. This has been continuously part of [facility name] Disaster Preparedness Plan since our inception and Medicare certification as a CORF...5...EPP will include a process for cooperation and collaboration with local, tribal, regional, state, and Federal emergency preparedness officals in efforts to maintain an integrated response during a disaster or emergency situation...6...plan will be developed and maintained with assistance from fire, safety, and other appropriate experts. Our primary sources of information in developing this plan included FEMA and the DHS. We have referenced hazard mitigation strategies from Washington and Allegheny Counties (PA) which have been published on their website's... "
Interview completed on January 3, 2019 at approximately 2:30 p.m. with EMP3 confirmed the findings. Surveyor asked EMP3 if the policy addressed the actual collaboration with local regional, State, and or Federal EP officals. EMP3 stated "a consultant has been hired to assist us with the completion of our EPP. We have documentation where we sent an email to the leader of the healthcare coalition"
Plan of Correction:Lifeline developed our plan with information from FEMA and the Department of Homeland Security. Hazard mitigation strategies from Washington and Allegheny Counties were referenced as stated in our policy. We also collaborated with local fire officials; a letter from the fire chief is available for viewing (and should have been shown to you, but EMP3 is new). This letter states "Lifeline Therapy has met or exceeded our expectations for emergency preparedness." Additionally, all staff viewed and obtained a FEMA certificate in "You Are the Help Until Help Arrives". A staff member attended the Healthcare Coalition of Southwest Pennsylvania on June 26, 2018. Prior to this meeting, we have a documentation log of email communications with them. Note, EMP3 is new; this was her first survey. Though all materials were available electronically, she may not have directed surveyor to appropriate documents. EMP3 statement was inaccurate; we had hired a consultant at the end of 2017 who helped us complete our policy by the end of January 2018.
485.68(b)(3) STANDARD
Policies/Procedures for Medical Documentation
Name - Component - 00
§403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4).
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]
[(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.
*[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following:
(i) Preserves patient information.
(ii) Protects confidentiality of patient information.
(iii) Secures and maintains the availability of records.
*[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.
Observations:
Based on review of the facility Emergency Preparedness Plan (EPP) and staff (EMP) interview, the facility facility to ensure the EPP addressed a system of medical documentation that preserved patient information and secured and maintained availability of clinical records.
Findings Included:
Review of facility EPP on January 3, 2018 at approximately 1:00 p.m. revealed: "...Emergency Preparedness: Policies and Procedures...CMS Standard...CMS Survey Tag E0023...Policy...will develop and implement emergency preparedness policies and procedures based upon [facility name] Risk assessment, Emergency plan and Communication Plan. Procedure: In Order to ensure compliance in meeting this standard the following procedure will be followed: 1. ...policies and procedures are developed based upon our facility and community based risk assessment and communication plan. 2...EPP incorporates: a. Safe evacuation including staff responsibilities, and needs of the patients; b. A means to shelter in place for patients, staff, and volunteers who remain in the facility during an emergency; i. [facility name] has limited capability to shelter in place for staff and patients. A water dispenser and toilet facilities are available at each facility... "
Interview completed on January 3, 2019 at approximately 2:30 p.m. with EMP3 confirmed the findings. Surveyor asked EMP3 if the policy addressed policy and procedure of medical record documentation developed to preserve patient information, protect confidentiality and secure and maintain availability of patient records and supported the continuity of care during an emergency. EMP3 stated "a consultant has been hired to assist us with the completion of our EPP."
Plan of Correction:
Lifeline's EP Policy has an attached Medical Records Policy, as well as a HIPPA flow chart outlining disclosure with individual authorization, disclosure of a limited data set, disclosures related to treatment and public health, disclosure to a public health authority. Note, EMP3 is new; this was her first survey. Though all materials were available electronically, she may not have directed surveyor to appropriate documents. EMP3 statement was inaccurate; we had hired a consultant at the end of 2017 who helped us complete our policy by the end of January 2018.
485.68(b)(4) STANDARD
Policies/Procedures-Volunteers and Staffing
Name - Component - 00
§403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5).
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]
(6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
*[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency.
*[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
Observations:
Based on a review of the facility Emergency Preparedness (EP) Plan and staff (EMP) interview, it was determined the facility failed to ensure the plan included policies and procedures for the use of volunteers and other staffing strategies.
Findings Included:
Review of facility EPP on January 3, 2018 at approximately 1:00 p.m. revealed: "...Emergency Preparedness: Policies and Procedures...CMS Standard...CMS Survey Tag E0024...Policy...will develop and implement emergency preparedness policies and procedures based upon [facility name] Risk assessment, Emergency plan and Communication Plan. Procedure: In Order to ensure compliance in meeting this standard the following procedure will be followed: 1. ...policies and procedures are developed based upon our facility and community based risk assessment and communication plan. 2...EPP incorporates: a. Safe evacuation including staff responsibilities, and needs of the patients; b. A means to shelter in place for patients, staff, and volunteers who remain in the facility during an emergency; i. [facility name] has limited capability to shelter in place for staff and patients. A water dispenser and toilet facilities are available at each facility ii. ...does not have the capability of storing or maintaining food. c. Preservation of patient information, protects confidentiality of patient information, and secures and maintains availably of records. d. The use of volunteers, as indicated in an emergency as well as other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professional to address surge needs during an emergency... "
Interview completed on January 3, 2019 at approximately 2:30 p.m. with EMP3 confirmed the findings. Surveyor asked EMP3 if the policy addressed policy and procedure for the use of volunteers in an emergency including emergency staffing strategies. EMP3 stated "a consultant has been hired to assist us with the completion of our EPP."
Plan of Correction:Lifeline's EP Policy does include procedures for the use of volunteers and other staffing strategies. The Lifeline Communication Plan (page 15 in the manual) states that we do not routinely use volunteers as part of our services delivered to patients. We have a list of names and contact information for Greater Pittsburgh Area CORFS and PRN staff to contact in the event of an emergency. Note, EMP3 is new; this was her first survey. Though all materials were available electronically, she may not have directed surveyor to appropriate documents. EMP3 statement was inaccurate; we had hired a consultant at the end of 2017 who helped us complete our policy by the end of January 2018.
485.68(c)(1) STANDARD
Names and Contact Information
Name - Component - 00
§403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1).
[(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:]
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [facilities].
(v) Volunteers.
*[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [hospitals and CAHs].
(v) Volunteers.
*[For RNHCIs at §403.748(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Next of kin, guardian, or custodian.
(iv) Other RNHCIs.
(v) Volunteers.
*[For ASCs at §416.45(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.
*[For Hospices at §418.113(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Hospice employees.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Other hospices.
*[For HHAs at §484.102(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.
*[For OPOs at §486.360(c):] The communication plan must include all of the following:
(2) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Volunteers.
(iv) Other OPOs.
(v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).
Observations:
Based on a review of the facility Emergency Preparedness Plan (EPP) and staff (EMP) interview, the facility failed to ensure the EPP communication plan included names and contact information for other CORF's, patient physicians, and contract entities readily available and accessible during an emergency.
Findings Included:
Review of facility EPP on January 3, 2018 at approximately 1:00 p.m. revealed: "...Emergency Preparedness: Communication Plan...CMS Standard...CMS Survey Tag E0030...Policy on Communication Plan...must develop and maintain an emergency preparedness communication plan that complies with Federal State, and local laws and must be reviewed and updated at least annually. Procedure In order to ensure compliance in meeting this standard the following procedure will be followed: ...will develop the following as part of the Communication Plan: Names and contact information for the following: Staff, Entities providing services under arrangement (List of PRN Staff), Patients physicians (contained in the Therapy Source EMR), other organizations, volunteers, contact information for the following, federal, state, tribal, regional and local emergency preparedness staff, other sources of assistance, ... "
Interview completed on January 3, 2019 at approximately 2:30 p.m. with EMP3 confirmed the findings. Surveyor stated EPP does not contain a list of patient physicians. EMP3 stated "a consultant has been hired to assist us with the completion of our EPP."
Plan of Correction:Lifeline's EP Policy does include names and contact information or other CORFs on an attachment entitled "additional communication plan contacts". Our patient physician's information is available in the EMR as noted in our policy. This attachment also has names and phone numbers for our contract (PRN) staff. Note, EMP3 is new; this was her first survey. Though all materials were available electronically, she may not have directed surveyor to appropriate documents. EMP3 statement was inaccurate; we had hired a consultant at the end of 2017 who helped us complete our policy by the end of January 2018.
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 the facility Emergency Preparedness Plan (EPP) and staff (EMP) interview, the facility failed to develop and maintain an emergency preparedness training and testing program based on the facility's emergency plan and to review and update the training/testing program annually.
Findings Included:
Review of facility EPP on January 3, 2018 at approximately 1:00 p.m. revealed: "...Emergency Preparedness: Training and Testing...CMS Standard...CMS Survey Tag E0036...Policy on Training and Testing...must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, policies and procedures, and the communication plan. The training and test program will be reviewed and updated at least annually. Training program...will complete all of the following as part of ...EPP Training Program: All employees will receive initial training in emergency preparedness policies and procedures to encompass all new and existing staff...consistent with their expected roles. Provide emergency preparedness training to all [facility name] employees at least annually. Maintain documentation of [facility name] employee training. Assign staff to online training in the Medbridge learning management portal as part of our training program. records of attendance will be maintained. Periodically rehearse drills so that staff can demonstrate staff knowledge of emergency procedures..."
Review of fire and safety inspections completed on January 3, 2019 at approximately 11:00 a.m. revealed fire drills completed on 3/21/2018 and 6/12/2018.
Review of facility EPP clinic response completed on January 3, 2019 at approximately 12:00 p.m. revealed facility risks for hurricane, heat, cold, thunderstorms, tornado, flood, fire, epidemic/pandemic, chemical, nuclear, air pollution, civil disobedience, workplace violence, electrical failure, water failure, transportation failure, and internet failure.
Interview completed on January 3, 2019 at approximately 2:30 p.m. with EMP3 confirmed the findings. Surveyor asked what does EPP training consist of. EMP3 stated "a review of the EPP policies and procedures."
Plan of Correction:Lifeline has evidence of EP training and testing documented 4/26/18. A physical copy of the sign-in was available to surveyor in the EP folder at the clinic. Per our policy, we will do our annual review and update to the training/testing program in 2019. Note, EMP3 is new; this was her first survey. Though all materials were available, she may not have directed surveyor to appropriate documents. Surveyor asked EMPS "what does EPP training consist of?" EMP3 stated "a review of the EPP policies and procedures". The full response is on page 12 of our manual. Medbridge Learning Management Portal, initial and annual training in emergency preparedness policies and procedures, drill rehearsal, participation in a full-scale community-based exercise, a tabletop exercise (2 if community-based is not available), participation in healthcare coalition meetings.
485.68(d)(1) STANDARD
EP Training Program
Name - Component - 00
§403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:]
(1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.
*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and
procedures.
*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.
*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures.
*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.
*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.
*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.
Observations:
Based on review of the facility Emergency Preparedness Plan (EPP) and staff (EMP) interview, the facility failed to develop and maintain an emergency preparedness training program based on the facility's emergency plan and ensure new personnel were oriented and assigned specific responsibilities within 2 weeks of their first workday for two (2) of three (3) PF reviewed. (PF2, PF5)
Findings Included:
Review of facility EPP on January 3, 2018 at approximately 1:00 p.m. revealed: "...Emergency Preparedness: Training and Testing...CMS Standard...CMS Survey Tag E0037...Policy on Training and Testing...must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, policies and procedures, and the communication plan. The training and test program will be reviewed and updated at least annually. Training program...will complete all of the following as part of ...EPP Training Program: All employees will receive initial training in emergency preparedness policies and procedures to encompass all new and existing staff...consistent with their expected roles. Provide emergency preparedness training to all [facility name] employees at least annually. Maintain documentation of [facility name] employee training. Assign staff to online training in the Medbridge learning management portal as part of our training program. records of attendance will be maintained. Periodically rehearse drills so that staff can demonstrate staff knowledge of emergency procedures..."
Review of facility policy completed on January 3, 2019 at approximately 1:30 p.m. revealed: "New Employee Orientation...It is the policy of [facility name] that each employee, within two weeks of first day of work will complete the New Employee Orientation Program...
Review of PF completed on January 3, 2019 at approximately 1:10 p.m. revealed:
PF2, date of hire 6/10/2014, completed fire drill training 7/21/2014, policy and procedure, HIPPA, disaster plan, competency evaluations and emergency preparedness training on 7/21/2014. [greater than 2 weeks after date of hire]
PF5, date of hire 5/1/2016, completed fire drill training 8/4/2016, policy and procedure, HIPPA, disaster plan, competency evaluations and emergency preparedness training on 8/4/2016. [greater than 2 weeks after date of hire]
Interview completed on January 3, 2019 at approximately 2:30 p.m. with EMP3 confirmed the findings. Surveyor asked what does EPP training consist of. EMP3 stated "a review of the EPP policies and procedures."
Plan of Correction:Lifeline currently has a protocol to ensure new personnel are oriented and assigned specific responsibilities within 2 weeks of their first workday. Unfortunately, at the time of hire for the two deficient personnel files viewed, Lifeline was in the process of expanding staff roles and responsibilities and defining our organizational chart. Our operations person had resigned and her responsibilities had not all yet been reassigned leaving a gap in the timeliness of orientation for these new employees.
485.68(d)(2) STANDARD
EP Testing Requirements
Name - Component - 00
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).
*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:
(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:
(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.
*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.
*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.
*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.
*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.
*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.
*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.
*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.
Observations:
Based on review of the facility Emergency Preparedness Plan (EPP) and staff (EMP) interview the facility failed to ensure the facility conducted a full scale and a table top exercises to test the emergency plan.
Findings Included:
Based on review of EPP completed on January 3, 2019 at approximately 2:00 p.m. EPP contained evidence of a tabletop exercise related to a flood was completed on 4/26/2018.
Interview completed on January 3, 2019 at approximately 2:30 p.m. with EMP3 confirmed the findings. Surveyor asked Is this the only exercise this facility has completed? EMP3 stated "Yes that I am aware of."
Plan of Correction:Lifeline was not able to attend a full scale community based exercise, as none were available. We have an extensive communication log of attempts made to find an event. We did send a staff member to the Southwestern PA Healthcare Coalition Meeting June 26, 2018 and were of the understanding that this would substitute as the community based exercise. As noted, we did conduct our own flood tabletop on 4/26/18 and registered this event with FEMA. Materials to conduct a winter storm tabletop have been gathered after speaking with surveyor, and we will conduct another in-house tabletop.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on January 3, 2019, Lifeline Therapy West Mifflin, LLC, 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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