Initial Comments:
Based on the findings of an onsite unannounced Medicare initial certification survey completed September 18, 2020, Fox Chase Adult Day Care Inc., was found to 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 initial Medicare certification survey completed September 18, 2020, Fox Chase Adult Day Care, Inc., was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the 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 review of policy/procedure, and an interview with the clinic administrator the clinic failed to ensure the physician contract included coordination of laboratory services through the referring physician for one (1) of one (1) contract reviewed. PF #7.
Findings include:
Review of policy/procedure completed on September 18, 2020 at approximately 11:00AM revealed no policy documenting coordination of laboratory services through neither the clinic physician nor the referring physician.
Review of PF#7, on September 17, 2020 at approximately 9:45AM revealed, a contract to provide services within the clinic. The contract did not contain any reference to laboratory services.
An interview with the clinic administrator completed on September 18, 2020 at approximately 12:00PM confirmed the above findings.
Plan of Correction:Response:
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual.
In consultation with our contracted physician, Fox Chase has arranged for the usage of a lab to handle specimens of any type as ordered by the CORF Physician. The lab to be used by our CORF physician is: Quest Diagnostics located at 700 Cottman Ave. - Philadelphia, PA 19111.
2. Indicate how the facility will act to protect patients in similar situations.
Patient protection via a contracted relationship with a lab is created by our having the ability to promptly be alerted to specific diagnostic criteria which could alter the CORF Treatment Plan for the affected patient.
3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur.
While in these embryonic stages of the CORF operation, this situation has not presented patient harm. Ongoing, the updated Physician Contract ensures that a lack of prompt lab results does not negatively impact how a patient is cared for. If necessary, the physician can arrange for a local hospital lab to provide the identical service. Our contracted physician can also make usage of any lab other physicians working with this patient may utilize.
4. Indicate how it plans to monitor its performance to make sure that solutions are sustained.
The contract with any CORF physicians is reviewed monthly and include questioning as to whether any arrangements, including for lab services have been impacted or are subject to any interruption; and
5. Provide dates when corrective action will be completed.
This correction is effective October 2, 2020 with a modified Physician Care Agreement.
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 review of clinic policies/procedures and an interview with the clinic administrator it was determined the clinic failed to ensure a written contract was established for the preventative maintenance of all equipment.
Findings include:
A review of clinic policies and procedures completed on September 17, 2020 between approximately 9:30AM and 10:30AM revealed no policy outlining the clinic's procedure for establishing and maintaining a preventative maintenance program consistent with manufacturer recommendations for all equipment including but not limited to: calibration.
An interview with the clinic administrator on September 18, 2020 at approximately 12:00PM confirmed the above findings.
Plan of Correction:Response:
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual;
The CORF has addressed this deficiency with an Equipment Maintenance Policy enacted June 1, 2019.
CORF Policy 485.62 ( c )
Written Preventative Maintenance Program – (Updated June 1, 2019)
- Facility interior and exterior
- Facility equipment
The facility and its equipment are overseen by the Facility Manager. Additionally, there is a maintenance contract in place with a private company for quarterly equipment inspections. Internally, the Facilities Manager follows specific procedures to ensure the following:
A. Physical Plant:
1. Entryways and exits are debris free and safe. Nothing is to be allowed to block evacuation routes at any time.
2. Fire system tested monthly, and proper functionality assured. In the event of any observed malfunction, arrange for immediate service.
3. Equipment used for rehabilitation is in good repair with no loose or missing parts.
B. Equipment Procedures:
1. Test all bolts, alan screws in gait bars, treadmills and any other equipment with moving parts or that bear the weight of patients every day. This process is not complete until any needed repairs or adjustments are made for the sole purpose of promoting patient safety.
2. Ensure sanitary (bleach laced) wipes are available for cleaning all equipment in-between usages by patients.
3. Ensure therapy personnel are reminded in weekly communications of the need to ensure all equipment is cleaned in-between patient uses.
Item Inspected Date Safety Electrical Other Adjustments or Repairs made
1 Gait bars
2 Treadmill
3 Tension Bars
4 Exit Door
5 Entrance Door
6 Other
7 Other
Comments/Actions Warranted: ________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Item Inspected Date Safety Electrical Other Adjustments or Repairs made
1 Gait Bars
2 Treadmill
3 Tension Bars
4 Exit Door
5 Entrance Door
6 Other
7 Other
Comments/Actions Warranted: ________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Page 4
Equipment Maintenance Policy continued...
It has since been complemented by an agreement with an outside maintenance provider for biweekly equipment inspections and any observed and required follow-up. This includes calibration of equipment, lubrication, adjustment, and repair.
2. Indicate how the facility will act to protect patients in similar situations.
The maintenance contract protects patients from potential injury from failing equipment. The potential injury could occur from equipment with loose parts (which can develop over time from prolonged usage) rusted equipment or equipment with moving parts that cease to function mid-usage.
3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur.
The maintenance agreement is subject to quarterly review and its availability protects patients from equipment that could potentially cause physical harm. It should be noted that no CORF patient can use equipment without CORF staff being present.
4. Indicate how it plans to monitor its performance to make sure that solutions are sustained; and
To ensure the work of the maintenance contract is properly supervised, we have assigned two, (2) internal staff to audit equipment function weekly. This is done on Friday in preparation for the next week. In this way, we can call upon our maintenance contractor in-between their regularly scheduled visits when equipment issues are observed internally.
5. Provide dates when corrective action will be completed.
This item corrected as of October 2, 2020, including the assignment of personnel for internal equipment inspections.
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