Initial Comments:
Based on the findings of an onsite unannounced initial Medicare certification survey completed August 30, 2023, Lifeline Therapy Grove City Llc was found to have the following standard level deficiency that was determined to be in substantial compliance with the following requirement of 42 CFR, Part 485.68, Subpart B, Conditions of Participation: Comprehensive Outpatient Rehabilitation Facilities - Emergency Preparedness.
Plan of Correction:
485.68(a)(1)-(2) STANDARD
Plan Based on All Hazards Risk Assessment
Name - Component - 00
§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)
[(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:]
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*
(2) Include strategies for addressing emergency events identified by the risk assessment.
* [For Hospices at §418.113(a):] Emergency Plan. The Hospice 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:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.
*[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 the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.
*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID 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:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.
Observations:
Based on review of facility's emergency preparedness plan, facility policy, and staff (EMP) interview the facility failed to develop an emergency preparedness plan that was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
Review of facility policy on August 30, 2023, at 11:10 a.m.
"Section 8: Emergency Preparedness Policy # 8.01 Policy Title: Emergency Preparedness Plan ... POLICY: Lifeline Therapy and Pulmonary Rehabilitation (Lifeline) will maintain an effective Emergency Preparedness Plan (EPP) ... to effectively prepare employees for the management of an internal or external disaster and provide or arrange care for patients and/or casualties. ... Definition The term "comprehensive" in this requirement is to ensure that facilities do not only choose one potential emergency that may occur in their area, but rather consider a multitude of events and be able to demonstrate that they have considered this during their development of the Emergency Preparedness Plan. Key Components of Emergency Preparedness CMS has defined the four components of emergency preparedness to be: 1. Risk Assessment and Emergency Planning (All Hazards)."
"Section 8: Emergency Preparedness Policy # 8.02 Policy Title: Emergency Preparedness: Development ... PROCEDURE: In order to meet the requirements of this policy the following will be addressed as part of the Lifeline's EPP: 1. Lifeline's EPP is based on a documented facility-based risk assessment utilizing an all hazards approach. Lifeline will also coordinate with community officials on a community risk assessment for each [EMPHASIS] of the locations in which we have clinics. ... 'All Hazard Vulnerability Risk Assessments' for each CORF (clinic) in Lifeline's ... Health System: ... Lifeline Grove City."
Review of facility's emergency preparedness plan on August 30, 2023, at 11:10 a.m. did not show that a facility-based and community-based risk assessment, utilizing an all-hazards approach had been completed. Per EMP1, the facility has been operating at its current location since approximately 7/25/2023. EMP1 noted he/she would contact another Lifeline location to obtain the risk assessment. At approximately 11:30 a.m., EMP1 produced a document purported to be the risk assessment for Lifeline Grove City. The document was completed on 6/8/2022, contained nothing to show it was for Grove City (only operational since July 2023), and did not contain a risk assessment concerning the airport (air disaster) located across the road (.27 miles or 1425 feet) from the facility.
Interview with EMP1 on August 30, 2023, at 11:30 a.m. confirmed above findings, and that he/she could not show that the document pertained to or was specific the Grove City location and its community.
Plan of Correction:Lifeline Therapy updated and completed their emergency preparedness plan for Grove City that included air disasters and state that these plans will be reviewed and updated as needed and at a minimum of every 2 years. Lifeline will add a corporate policy that prior to another facility opening all EPP will be reviewed and updated for each location specific and also updated at a minimum of every 2 years. The developed plan will do the following:
1. It is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
a. The risk assessment was broken down into three level segments and scored. The three levels are for probability level, vulnerability level and our preparedness level for the following.
i. Natural
ii. Biological/Environmental
iii. Man-Made
iv. Operational
2. Included strategies for addressing emergency events identified by the risk assessment.
i. Hurricane
ii. Heat
iii. Cold
iv. Thunderstorms
v. Tornado
vi. Flooding
vii. Fire
viii. Epidemic/pandemic
ix. Chemical
x. Nuclear
xi. Air Pollution
xii. Civil Disobedience
xiii. Workplace Violence
xiv. Electrical Failure
xv. Water Failure
xvi. Transportation Failure
xvii. IS Failure
xviii. Aircraft Disasters
Initial Comments:
Based on the findings of an onsite unannounced initial Medicare certification survey completed August 30, 2023, Lifeline Therapy Grove City Llc was found identified to have the following standard level deficiency that was determined to be in substantial compliance with the following requirement of 42 CFR, Part 485, Subpart B, Conditions of Participation: Comprehensive Outpatient Rehabilitation Facilities.
Plan of Correction:
485.56(b)(2) STANDARD
ADMINISTRATOR
Name - Component - 00
The governing body must appoint an administrator who implements and enforces the facility's policies and procedures.
Observations:
Based on review of facility policy, personnel files, and staff (EMP) interview, the administrator failed to implement and enforce facility policy and procedure for two (2) of two (2) personnel files reviewed (PF1, & PF2).
Findings included:
Review of facility policy on August 30, 2023, at 11:30 a.m. showed, "Policy # 7.04 Policy Title: New Employee Orientation ... POLICY: It is the policy of Lifeline Therapy that each employee, within two weeks of first day of work, will complete the New Employee Orientation Program. The New Employee Orientation Outline listed before for reference. Upon completion of the program, each new employee will complete, sign and date the New Employee Orientation Completion Form. This form will then become and be maintained as part of the employee's employment file."
Review of PF1 (physical therapist and site manager) on August 30, 2023, at 11:45 a.m. showed he/she was hired and working on 8/7/2023 and observed working with patients during the 8/30/2023 onsite survey. PF1's "LIFELINE ORIENTATION/ONBOARDING" form was incomplete and not signed by the employee. A few topics were dated 8/8/2023 but most items such as "Emergency Exits," and "Review evacuation and emergency procedure" were not completed.
Review of PF2 (front end office personnel) on August 30, 2023, at 11:50 a.m. showed he/she was hired and working on 7/17/2023. PF2's "LIFELINE ORIENTATION/ONBOARDING" form was not located in PF2 (faxed/emailed from another Lifeline location) and once produced was not signed by the employee.
Interview with EMP1 (owner/administrator) on August 30, 2023, at 11:55 a.m. confirmed above findings.
Plan of Correction:
Lifeline Therapy will assure that each new employee will complete the New Employee Orientation program within the first 90 days of employment. Each employee will complete the orientation section titled: Human Resources/New Hire Paperwork/Employee File and will also be required to complete and sign Emergency procedures and Compliance Training within the first two weeks of the employee's start date. The New Employee Orientation Program will include, but shall not be limited to, those items as contained in the New Employee Orientation Outline listed before for reference.
Upon completion of program, each new employee will complete, sign and date the New Employee Orientation Completion Form. This form will then be captured in an online format that is accessible by members of the leadership team and will become and be maintained as part of the employee's employment file.
The New Hire Paperwork/Employee File completion and compliance will be monitored by the Lifeline Compliance officer in a weekly review during onboarding to assure completion of all sections, during all phases first 90 days of employment, and the orientation process until completed. Compliance Officer will deliver a report to the Leadership Team at each quarterly meeting to assure compliance has been maintained.
|