Initial Comments:
Based on the findings of an onsite unannounced survey completed on October 24, 2019, New St. Barnabas Medical Center Outpatient Physical Therapy was found not to be in compliance with the requirements of 42 CFR, Part 485.727, Subpart H, Conditions of Participation for Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services - Emergency Preparedness. The survey was conducted at the facility primary site and the extension site located at 5827 Meridian Road, Gibsonia, PA 15044.
Plan of Correction:
485.727(a)(5) STANDARD
Local, State, Tribal Collaboration Process
Name - Component - 00
§403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4)
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:]
(4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. *
* [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.
Observations:
Based on a review of the facility Emergency Preparedness Plan (EPP) and staff (EMP) interview, the facility failed to ensure the EPP included documentation of the facility efforts to contact, cooperate, and collaborate with emergency preparedness officials (local, tribal, regional, state, federal) in order to facilitate an integrated response during a disaster situation.
Findings Included:
Review conducted 10/24/19 at approximately 12:28 PM of facility Emergency Preparedness Plan (EPP). Facility EPP did not contain documented evidence to confirm local, regional, State or Federal emergency officials were contacted and made aware of the facility's requirements during an emergency or disaster.
An exit conference was conducted 10/24/19 at approximately 2:40 PM. EMP1 confirmed the above findings.
Plan of Correction:The facility will document attempts to contact, cooperate, and collaborate with emergency preparedness officials in order to facilitate an integrated response during a disaster situation. Form "Emergency Preparedness Exercise / After Action Reporting" has been revised with a designated section to document evidence that local, regional, State, or Federal emergency officials were contacted and made aware of the facility's requirements during an emergency or disaster. The Outpatient Therapy Administrator or designee will QA to ensure the revised forms contain communication documentation regarding the facility's attempts to contact emergency officials and make them aware of the facility's requirements during an emergency or disaster as indicated, summary of findings will be reviewed during the Quarterly QA meeting.
485.727(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 a review of the facility Emergency Preparedness Plan (EPP) and staff (EMP) interview, the facility failed to develop emergency preparedness policy and procedure that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records (paper records).
Findings Included:
Review conducted 10/24/19 at approximately 12:28 PM of facility Emergency Preparedness Plan (EPP). Facility EPP did not contain documented evidence of a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records (paper records).
An exit conference was conducted 10/24/19 at approximately 2:40 PM. EMP1 confirmed the above findings.
Plan of Correction:The facility has revised Emergency Preparedness Policy "Securing Records". Records will be stored, and transported in a locked fire box to ensure patient medical documentation is kept confidential, and protected in the event of a disaster or emergency. A locked box will be available on site and will be used to transport records to secondary treatment locations as indicated. All Therapists will be educated regarding the need to lock medical records in the fire box to ensure confidentiality and that patient information is protected in the event of an emergency or disaster. The Outpatient Therapy Administrator or designee will QA to ensure all records are stored and transported in the locked fire box as indicated, summary of findings will be reviewed during the Quarterly QA meeting.
485.727(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 Plan (EPP) and staff (EMP) interview, it was determined the facility failed to develop and maintain a procedure for the use of volunteers in an emergency or emergency staffing strategies.
Findings Included:
Review conducted 10/24/19 at approximately 12:28 PM of facility Emergency Preparedness Plan (EPP). Facility EPP did not contain documented evidence of a procedure for the use of volunteers in an emergency or emergency staffing strategies.
An exit conference was conducted 10/24/19 at approximately 2:40 PM. EMP1 confirmed the above findings.
Plan of Correction:The facility policy "Emergency Staffing Strategies" has been revised. It is the policy of the facility to ensure we have adequate staffing during emergencies. The policy has been revised to include a process for vetting volunteers. Through the emergency management protocols of our local area we may integrate State and/or federally designated health care professionals to address surge needs during an emergency. The Outpatient Therapy Administrator will educate the Assistant Administrator and therapists regarding the steps to follow before utilizing volunteers in the event of an emergency or disaster. The Outpatient Therapy Administrator or designee will QA to ensure the volunteer forms and policy are in the Emergency Preparedness Binder as indicated. A summary of findings will be reviewed during the Quarterly QA Meeting.
485.727(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 staff, entities providing services under arrangement, patient physicians, and volunteers readily available and accessible during an emergency.
Findings Included:
Review conducted 10/24/19 at approximately 12:28 PM of facility Emergency Preparedness Plan (EPP). Facility EPP did not contain documented evidence of a communication plan that included names and contact information for staff, entities providing services under arrangement, patient physicians, and volunteers readily available and accessible during an emergency.
An exit conference was conducted 10/24/19 at approximately 2:40 PM. EMP1 confirmed the above findings.
Plan of Correction:The facility Communication Plan has been revised. Names and contact information of staff, entities providing services under arrangement, physicians, and volunteers has been revised and is in the Emergency Preparedness Binder. The Outpatient Therapy Administrator will educate the Assistant Administrator and therapists regarding the need to update the list as indicated. The Outpatient Therapy Administrator or designee will QA to ensure the list of names is updated and is located in the Emergency Binder as indicated. A summary of findings will be reviewed during the Quarterly QA Meeting.
485.727(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 a review of the facility Emergency Preparedness Plan (EPP) and staff (EMP) interview, the facility failed to ensure exercises were conducted annually in 2018 and failed to analyze the facility response and maintain documentation for a facility tabletop exercise conducted February 6, 2019.
Findings included:
Review conducted 10/24/19 at approximately 12:28 PM of facility Emergency Preparedness Plan (EPP). Facility EPP did not contain documented evidence of any facility exercises (participaton in a full scale exercise, facility based exercise, emergency event, or tabletop exercise) conducted in 2018. There was documentation of a tabletop exercise conducted on 2/6/2019 titled "Gas Leak outside facility" which documented inclusion of the Outpatient Physical Therapy (OPT) facility in the exercise but did not have any OPT facility staff members documented on the exercise "sign in log" sheet dated 2/6/19. There was no documented evidence of an analysis (After Action Report) completed for the tabletop exercise conducted on 2/6/2019 titled "Gas Leak outside facility".
An exit conference was conducted 10/24/19 at approximately 2:40 PM. EMP1 confirmed the above findings.
Plan of Correction:The facility will conduct facility exercises as indicated. The facility will analyze the response to and will maintain documentation of all exercises and emergency event. The facility will revise the plan as needed. Form "Emergency Preparedness / After Action Reporting" has been implemented. The revised form includes specific documentation areas to ensure staff participating sign-in, evidence of an analysis for an exercise, emergency event, or table top exercise. The Outpatient Therapy Administrator or designee will QA to ensure exercises are completed and documentation is in place as indicated. A summary of findings will be reviewed during the Quarterly QA Meeting.
Addendum: The Exercises will take place on November 21, 2019.
Initial Comments:
Based on the findings of an onsite unannounced survey completed on October 24, 2019, New St. Barnabas Medical Center Outpatient Physical Therapy was found not to be in compliance with the requirements of 42 CFR, Part 485, Subpart H, Conditions of Participation for Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services. The survey was conducted at the facility primary site and the extension unit site at 5827 Meridian Road, Gibsonia, PA 15044.
Plan of Correction:
485.717(b) STANDARD
ARRANGEMENTS FOR SERVICES
Name - Component - 00
If services are provided under contract, the contract must specify the term of the contract, the manner of termination or renewal and provide that the agency retains responsibility for the control and supervision of the services.
Observations:
Based on an observation tour of aquatic therapy site utilized by facility, and staff (EMP) interview, the facility failed to ensure services were provided under contract specifying the term of the contract, the manner of termination or renewal and that the Outpatient Physical Therapy facility retained responsibility for the control and supervision of the services provided.
Findings included:
Entrance conference was conducted on 10/23/19 with EMP1 and EMP2. EMP1 confirmed the facility aqua therapy was provided by facility staff at site that is not listed as facility extension site.
An observation tour of aqua therapy site was conducted on 10/24/19 at approximately 10:30 AM. EMP1, site manager and site pool manager were present during tour. Site manager and site pool manager confirmed swimming pool was a "private pool" available for rental. Surveyor asked EMP1 if facility had a contract service agreement with site to provide services. EMP1 stated "...need to find out if there is a contract..." EMP1 confirmed facility "rented" site for patient therapy sessions.
An exit conference was conducted 10/24/19 at approximately 2:40 PM. EMP1 confirmed he/she contacted corporate "legal department" asking "...if there was a contract..." with aquatic therapy site. EMP1 stated "...legal department thinks they have a contract..." Surveyor requested contract be emailed Monday, 10/28/19, start of business day (AM). EMP1 confirmed he/she had surveyor business card with email and that "...if legal had contract...will email (surveyor) by Monday morning..." As of 2:35 PM on 10/28/19, surveyor had not received email related to facility aqua therapy site contract/service agreement.
Plan of Correction:The facility will ensure if any services are provided under contract, that the contract specify the terms of the contract, the manner of termination or renewal and provide that the agency retains responsibility for the control and supervision of the services. The Crystal Conservatories is listed as an extension site on CMS form 381. The Administrator will maintain a copy of the contract with Crystal Conservatories at the Primary site location. The Outpatient Administrator or designee will QA to ensure a contract for Crystal Conservatories is in place and that a copy is maintained at the Primary site. A summary of findings will be reviewed during the Quarterly QA meeting.
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