Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on January 4, 2024, at the parent location of 444 North York Road, Suite A1, Hatboro, PA 19040, and at the satellite location of 1244 Fort Washington Avenue, Suite M1, Fort Washington, PA 19034, NovaCare Outpatient 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 conducted on January 3, 2024, and January 5, 2023, at the parent location of 444 North York Road, Suite A1, Hatboro, PA 19040, and at the satellite location of 1244 Fort Washington Avenue, Suite M1, Fort Washington, PA 19034, NovaCare Outpatient Rehabilitation 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, 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:
485.723(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 observations, rehabilitation center policy review, and an interview with the rehabilitation center administrator it was determined the rehabilitation center failed to ensure equipment was maintained in accordance with the center's policies. (Observation #2)
Findings include:
Review of rehabilitation center policies conducted on January 5, 2024, at approximately 1:00 P.M. revealed the following:
Policy #9.18 titled "Equipment and Center Cleaning and Maintenance" states, "All equipment and/or supplies that are used as part of the patient care in treatment areas/waiting room will be maintained and tested to ensure safe operation and for the prevention of injury to patients and employees. All equipment/reusable supplies must be cleaned and/or replaced as frequently as needed to maintain a sanitary environment. All therapeutic equipment and reusable supplies in patient care areas and/or waiting room must be cleaned, inspected and/or replaced as frequently as needed to maintain a safe and sanitary environment."
Observation of patient treatment area at the rehabilitation center satellite site at 1244 Fort Washington Road, Suite M1, Fort Washington, PA, 19034 conducted on January 3, 2024, from approximately 4:30 P.M. to 5:15 P.M. revealed the following:
Observation #2: Hydrocollator located in the rear left area of the rehabilitation center was noted to have rust colored staining on the outer surface around the top rear area of the lid. The entire inner perimeter of the hydrocollator lid surface contained rust colored staining with what appeared to be flaking of the metal surface in several areas of the perimeter.
An interview with the rehabilitation center location manager on January 3, 2024, at approximately 5:10 P.M. confirmed the above findings. A follow-up telephone call was placed to the rehabilitation center Administrator on January 4, 2024, at approximately 4:00 P.M. to update and confirm the above findings.
Plan of Correction:The hydocollator at the Fort Washington Location will be replaced. A new hydocollator has been ordered and delivery is anticipated within 60 days. In the interim, the center manager or designee will clean the hydocollator as per clinical policy 9.19 procedure #2.
The Agency Administrator will communicate with center managers at all extension locations to visually inspect their hydocollator units for rust or any other defects and to follow and complete clinical policy 9.19 procedure #2- cleaning procedures – on or before January 31.
Center managers will continue to review and complete all actions detailed in the Center Readiness Plan sent from clinical services on 1/3/2024. Completed activities will be marked on the center handbook calendar checklist and be available for review by the agency Administrator, to insure on going compliance with policies #9.18 and #9.19.
485.723(c) STANDARD
OTHER ENVIRONMENTAL CONSIDERATIONS
Name - Component - 00
The organization provides a functional, sanitary, and comfortable environment for patients, personnel, and the public.
(1) Provision is made for adequate and comfortable lighting levels in all areas; limitation of sounds at comfort levels; a comfortable room temperature; and adequate ventilation through windows, mechanical means, or a combination of both.
(2) Toilet rooms, toilet stalls, and lavatories must be accessible and constructed so as to allow use by nonambulatory and semiambulatory individuals.
(3) Whatever the size of the building, there must be an adequate amount of space for the services provided and disabilities treated, including reception area, staff space, examining room, treatment areas, and storage.
Observations:
Based on observations, rehabilitation center policy review, and an interview with the rehabilitation center administrator, it was determined the rehabilitation center failed to ensure equipment was maintained in accordance with the center's policy for one (1) of two (2) observations. (Observation #2)
Review of policy "#9.24 Storage and Disposal of Medications and Supplies" conducted on January 5, 2024, at approximately 1:00 P.M. stated, "Procedure: 1. Medication storage: (c) Medications and multi-dose vials (MDV) will be monitored with each use for expiration dates... 3. Supplies (a) Supplies will be monitored for expiration date(s) when applicable. If a supply is found to have expired it will be disposed of appropriately or according to manufacturer recommendations."
Observation of the patient treatment area of the rehabilitation center located at 1244 Fort Washington Avenue, Suite M1, Fort Washington, PA 19034 conducted on January 3, 2024, from approximately 4:20 P.M. to 5:15 P.M. revealed the following:
Observation #2: Sink area located in the mid right side of the rehabilitation center, upper cabinets contained the following outdated medications and supplies:
Isopropyl Alcohol 70% expired September, 2018
Biofreeze Gel - four (4) tubes expired in January, 2019 and April, 2021
Biofreeze Spray expired September, 2019
Two (2) additional tubes of Biofreeze Gel located in a display at the front desk area expired February, 2023.
An interview with the rehabilitation center location manager on January 3, 2024, at approximately 5:10 P.M. confirmed the above findings. A follow-up telephone call was placed to the rehabilitation center Administrator on January 4, 2024, at approximately 4:00 P.M. to update and confirm the above findings.
Plan of Correction:The expired supplies observed at the Fort Washington center have been immediately discarded by the center manager. The center manager or designee will inspect the entire center for any additional expired supplies and remove on or before January 31, 2024.
The Agency Administrator will communicate with center managers at all extension locations to review clinical policy #9.24 and procedures 1 through 3 and to complete visual inspection of their centers for any expired supplies and to immediately discard on or before January 31.
Center managers will continue to review and complete all actions detailed in the Center Readiness Plan sent from clinical services on 1/3/2024. Completed activities will be marked on the center handbook calendar checklist and be available for review by the agency Administrator, to insure on going compliance with policy #9.24
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