Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on 6/21/2022, NovaCare Rehabilitation was found 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.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed 6/21/2022, NovaCare Rehabilitation was found to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42 CFR, Part 485, Subpart H, Conditions of Participation for Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services.
Plan of Correction:
485.709(c) STANDARD
PERSONNEL POLICIES
Name - Component - 00
Personnel practices are supported by appropriate written personnel policies that are kept current. Personnel records include the qualifications of all professional and assistant level personnel, as well as evidence of State licensure if applicable.
Observations:
Based on a review of center for disease control (CDC) recommendation, personnel file (PF) review and staff (EMP) interview the agency failed to complete an annual tuberculosis screening for three (3) of nine (9) PF's reviewed (PF4, PF5 and PF6).
Findings include:
Review of recommendations was conducted 6/21/2022 at approximately 2:00 PM. "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019 Weekly / May 17, 2019 / 68(19);439-443 ...The 2005 CDC guidelines for preventing Mycobacterium tuberculosis transmission in health care settings include recommendations for baseline tuberculosis (TB) screening of all U.S. health care personnel and annual testing for health care personnel working in medium-risk settings or settings with potential for ongoing transmission (1). Using evidence from a systematic review conducted by a National Tuberculosis Controllers Association (NTCA)-CDC work group, and following methods adapted from the Guide to Community Preventive Services (2,3), the 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include 1) TB screening with an individual risk assessment and symptom evaluation at baseline (preplacement); 2) TB testing with an interferon-gamma release assay (IGRA) or a tuberculin skin test (TST) for persons without documented prior TB disease or latent TB infection (LTBI); 3) no routine serial TB testing at any interval after baseline in the absence of a known exposure or ongoing transmission; 4) encouragement of treatment for all health care personnel with untreated LTBI, unless treatment is contraindicated; 5) annual symptom screening for health care personnel with untreated LTBI; and 6) annual TB education of all health care personnel."
A review of PF #4, date of hire (DOH) 2/22/2010, was conducted on 6/16/2022 at approximately 10:30 AM the personal file contained a "Tuberculosis Questionnaire Form" dated 1/27/2021, and the next annual tuberculosis form was dated 6/15/2022.
A review of PF #5, date of hire (DOH) 8/25/2003, was conducted on 6/16/2022 at approximately 10:35 AM the personal file contained a "Tuberculosis Questionnaire Form" dated 1/27/2021, and the next annual tuberculosis form was dated 6/15/2022.
A review of PF #6, date of hire (DOH) 5/15/2000, was conducted on 6/16/2022 at approximately 10:40 AM the personal file contained a "Tuberculosis Questionnaire Form" dated 1/26/2021, and the next annual tuberculosis form was dated 6/15/2022.
An interview conducted on 6/16/2022 at 3:45 PM with the vice president of operations which confirmed the above findings.
Plan of Correction:I 0019 – 485.725(c) PERSONNEL POLICIES
-Personnel practices are supported by appropriate written personnel policies that are kept current. Personnel records include the qualifications of all professional and assistant level personnel, as well as evidence of State Licensure if applicable.
1. The management team, consisting of the Center Manager, Market Manager, Vice President, Regional Director of Clinical Services, and Corporate management have discussed the deficiencies cited and have worked together to complete the agreed upon plan of corrections.
2. The management team has noted that a TB risk reassessment form must be completed annually by all personnel.
3. The management team, specifically the Center Manager, Market Manager, Vice President, or Regional Director of Clinical Services, will verify this is completed on 07/18/22.
4. The above listed deficiencies have been addressed and completed on 07/18/22.
5. The Center Manager will verify that the plan is implemented correctly and timely.
6. The management team will ensure that a TB risk reassessment form has been completed by visual inspection of completed surveys.
7. The management team will ensure that TB risk reassessment forms are completed annually and this will be reviewed at PCC meetings.
485.711(b) STANDARD
PLAN OF CARE
Name - Component - 00
For each patient there is a written plan of care established by the physician or by the physical therapist or speech language pathologist who furnishes the services.
The plan of care for physical therapy or speech pathology services indicates anticipated goals and specifies for those services the type, amount, frequency, and duration.
The plan of care and results of treatment are reviewed by the physician or by the individual who established the plan at least as often as the patient's condition requires, and the indicated action is taken. (For Medicare patients, the plan must be reviewed by a physician, nurse practitioner, clinical nurse specialist, or physician assistant at least every thirty days in accordance with 42 CFR 410.61(e).)
Changes in the plan of care are noted in the clinical record. If the patient has an attending physician, the therapist or speech language pathologist who furnishes the services promptly notifies him or her of any change in the patients condition or in the plan of care.
Observations:
Based on a review of agency policy, personnel file (PF) review and staff (EMP) interview the agency failed to ensure physician orders were obtained for three (3) of twenty (20) CR's reviewed, (CR6, CR12 and CR18).
Findings included:
Review of agency policy was conducted 6/21/2022 at approximately 2:00 PM which revealed. "Plan of Care, Certification and Recertification Reference Guide...Certification and Recertification Procedures and Requirements *Verbal orders for referral, treatment or certification purposes must be followed up in writing (a physician/NPP signature) within 14 days or in accordance with your state practice act, if stricter. *Medicare Part B requires the physician or non-physician practitioner certify the POC with their legible signature and date (no stamps)...Every effort must be made to obtain the physician's signature on the POC as quickly as possible (within 30 days of the evaluation)..."
A review of CR #6 Start of Care (SOC) 4/6/2022 Date of Discharge 5/24/2022 was conducted on 6/16/2022 at approximately 11:15 AM, the agency was unable to provide documentation of a physician signature for orders for treatment.
A review of CR #12 Start of Care (SOC) 6/1/2022 was conducted on 6/16/2022 at approximately 1:11 PM the agency was unable to provide documentation of a physician signature for orders for treatment.
A review of CR #18 Start of Care (SOC) 5/16/2022 was conducted on 6/16/2022 at approximately 2:08 PM the agency was unable to provide documentation of a physician signature for orders for treatment.
An interview conducted on 6/16/2022 at 3:45 PM with the vice president of operations which confirmed the above findings.
Plan of Correction:I 0050 – 485.711(b) PLAN OF CARE
- For each patient there is a written plan of care established by the physician or by the physical therapist or speech language pathologist who furnishes the services. The plan of care for physical therapy or speech pathology services indicates anticipated goals and specifies for those services the type, amount, frequency, and duration. The plan of care and results of treatment are reviewed by the physician or by the individual who established the plan at least as often as the patient's condition requires, and the indicated action is taken. (For Medicare patients, the plan must be reviewed by a physician, nurse practitioner, clinical nurse specialist, or physician assistant at least every thirty days in accordance with 42 CFR 410.61(e).) Changes in the plan of care are noted in the clinical record. If the patient has an attending physician, the therapist or speech language pathologist who furnishes the services promptly notifies him or her of any change in the patients condition or in the plan of care.
1. The management team, consisting of the Center Manager, Market Manager, Vice President, Regional Director of Clinical Services, and Corporate Management have discussed the deficiencies cited and have worked together to complete the agreed upon plan of corrections.
2. The management team has noted that a physician signature must be obtained to certify the POC. To address this, additional training will be completed to instruct the patient service specialists on the importance of obtaining a physicians signature on the POC as well as offering techniques to obtain the physicians signature.
3. The management team, specifically the Center Manager, Market Manager, Vice President, or Regional Director of Clinical Services, will assure this is completed on 07/18/22.
4. The above listed deficiencies have been addressed and completed on 07/18/22.
5. The Center Manager will verify that the plan is implemented correctly and timely and will monitor this activity on the 'plan of care worklist' report twice week.
6. It is the expectation of the management team that every effort is made to obtain the physician's signature on the POC as quickly as possible.
7. The management team will ensure that the physician's signature is on the POC during internal inspections throughout the calendar year and viewing the 'plan of care worklist' report as part of QA.
485.723(b) STANDARD
MAINTENANCE OF EQUIPMENT/BUILDINGS/GROUNDS
Name - Component - 00
The organization establishes a written preventive maintenance program to ensure that the equipment is operative and is properly calibrated, and the interior and exterior of the building are clean and orderly and maintained free of any defects which are a potential hazard to patients, personnel, and the public.
Observations:
Based on review of agency policy, observation (OBV), agency documents and staff (EMP) interview, the facility failed to ensure aquatic maintenance checks were completed within the parameters agency policy for two (2) of three (3) aquatic system observation completed (OBV1 and OBV2).
Findings:
Review of the agency policy on 6/21/2022 at approximately 3:45 PM revealed, " i) Daily:
(1) Check pH, add chemicals as needed. pH range generally is 7.2-7.8. (2) Test for sanitizer level (Bromine or Chlorine), add sanitizer as needed. Chlorine generally ranges from 1.0 - 2.0 parts per million ...The manufacturer ' s recommendations should be followed. (7) Pool temperature range generally range: 85-96 degrees F. Room temperature range 72-86 degrees F. However, the temperature could vary depending on the types of patients seen. Temperature will be monitored as required by local, state or county Health Departments or appropriate agency. The pool temperature should not exceed 104 degrees F ...ii ...Weekly: (1) Test for alkalinity, add chemicals as needed (ranges 80-120 PPM or by manufacturers guidelines) ... iii) Monthly:(1) Check calcium hardness (200-400 PPM) and add chemicals as needed. (2) As needed, check Oxidation-Reduction Potential (ORP) reading for a minimum of 650..."
Review of the "Sample Water Quality Log" on 6/21/2022 at approximately 2:00 PM revealed,
Logs for OVB1 revealed daily recorded pool temperature not within agency parameters for the following dates:
2/17/2022 110 degrees Fahrenheit
2/20/2022 110 degrees Fahrenheit
2/21/2022 110 degrees Fahrenheit
2/22/2022 105 degrees Fahrenheit
2/25/2022 70 degrees Fahrenheit
2/28/2022 70 degrees Fahrenheit
Logs for OBV1 revealed daily recorded Alkalinity not within agency parameters for the following dates:
2/10/2022 60 PPM 2/11/2022 60 PPM 2/14/2022 60 PPM 2/15/2022 50 PPM 2/16/2022 50 PPM 2/17/2022 50 PPM 2/20/2022 40 PPM 2/21/2022 40 PPM 2/22/2022 40 PPM 2/23/2022 40 PPM 2/24/2022 40 PPM 2/25/2022 40 PPM
2/28/2022 40 PPM
3/4/2022 70 PPM 3/7/2022 70 PPM 3/8/2022 70 PPM 3/9//2022 60 PPM 3/10/2022 60 PPM 3/11/2022 60 PPM 3/17/2022 60 PPM 3/18/2022 60 PPM 3/21/2022 50 PPM 3/22/2022 50 PPM 3/23/2022 40 PPM 3/24/2022 40 PPM 3/25/2022 40 PPM
5/3/2022 70 PPM 5/4/2022 70 PPM 5/5/2022 60 PPM 5/6/2022 60 PPM 5/9/2022 60 PPM 5/10/2022 60 PPM 5/11/2022 60 PPM 5/12/2022 50 PPM 5/13/2022 50 PPM 5/16/2022 50 PPM 5/17/2022 50 PPM 5/18/20022 50 PPM 5/19/2022 40 PPM 5/23/2022 40 PPM 5/24/2022 40 PPM 5/25/2022 40 PPM 5/27/2022 No reading 5/27/2022 No reading
Logs review from OBV2 revealed daily recorded PH levels not within agency parameters for the following dates:
3/14/2022 6.8, 3/16/2022 6.8, 3/17/2022 6.8, 3/18/2022 6.8, 3/21/2022 6.8, 3/22/2022 6.8, 3/23/2022 6.8, 4/14/2022 6.8, 5/2/2022 6.8, 5/3/2022 6.8, 5/4/2022 6.8, 5/5/2022 6.8, 5/6/2022 6.8, 5/9/2022 6.8, 5/18/2022 6.8, 5/19/2022 6.8, 5/20/2022 6.8, 5/27/2022 6.8 and 6/9/2022 6.8
Plan of Correction:I 0121 – 485.723(b) MAINTENANCE OF EQUIPMENT/BUILDING/GROUNDS
- The organization establishes a written preventive maintenance program to ensure that the equipment is operative and is properly calibrated, and the interior and exterior of the building are clean and orderly and maintained free of any defects which are a potential hazard to patients, personnel, and the public.
1. The management team, consisting of the Center Manager, Market Manager, Vice President, Regional Director of Clinical Services, and Corporate Management have discussed the deficiencies cited and have worked together to complete the agreed upon plan of corrections.
2. The management team has noted that aquatic maintenance checks will be completed within the parameters of the policy and will be documented on the 'Water Quality Log' as outlined in the policy.
3. The management team, specifically the Center Manager, Market Manager, Vice President, or Regional Director of Clinical Services, will assure this is completed on 07/18/22.
4. The above listed deficiencies have been addressed and completed on 07/18/22.
5. The Center Manager will verify that the plan is implemented correctly and timely by reviewing the water quality logs monthly.
6. The management team will ensure that that aquatic maintenance checks will be completed within the parameters of the policy and will be documented on the 'Water Quality Log' as outlined in the policy and will periodically check the logs for compliance.
7. The management team will ensure that that aquatic maintenance checks will be completed within the parameters of the policy and will be documented on the 'Water Quality Log' as outlined in the policy and will be verified during internal inspections throughout the calendar year as part of QA.
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