Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on September 11, 2018, Novacare Outpatient Rehabilitation (Extention site 1415 Lincoln Highway Levittown Pa. 19056) was identified to have the following standard level deficiency that was to be in substantial compliance with the following requirements of 42 CFR, Part 485.707, Subpart D, Conditions of Participation: Outpatient Physical Therapy - Emergency Preparedness.
Plan of Correction:
485.727(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 a review of facility documentation,agency policy and an interview with the Center Manager, the extension site did not conduct any emergency drills for 2016 or 2017.
Findings include:
1. A review of facility policy, 9.09 "Emergency Drills" on September 11, 2018 at 1:00 PM states: "All Select Medical Outpatient Division employees will review and/or complete fire, disaster, bomb, and medical emergency drills as described...on an annual basis....Procedure 1.g Document the results in each emergency disaster drill performed on the Emergency Drill Report Form. h. Maintain copy of drill report in the Center Handbook."
2. A review of the Center Handbook was conducted on September 11, 2018 at 1:15 PM. There was no documentation of any fire and disaster drills conducted at the facility for 2016 or 2017.
3. An interview with the Center Manager on September 11, 2018 at 1:30 PM confirmed that no fire or emergency drills were conducted at the facility for 2016 or 2017.
Plan of Correction:The Center Manager at the Levittown extension location will review policies 9.01 through 9.07 (Emergency Procedures) and 9.09 (Emergency Drills) with the staff on 9/24/18 so all the staff is familiar with the requirement to implement emergency drills at each center. The Center Manager will also hold Emergency Drills annually and upon new hire beginning 9/24/18 to specifically practice emergency procedures as outlined in policies 9.01 through 9.07 including mock simulation in the event of fire, bomb threat, tornado, hurricane, earthquake, power outages, and general disasters. The Center Manager will be responsible to document each Emergency Drill as outlined in policy 9.09 and retain a copy of these drills in the Center Handbook, and mark as complete on the Center Handbook Calendar Checklist. New hire emergency drill training will also be documented on Form #4.06 "New Employee Orientation check list" and a copy maintained in the employee's personal file. The Market Manager will verify that the drills are being completed by monitoring the Center Handbook and staff meeting minutes on a quarterly basis.
Initial Comments:
Based on the findings of an unannounced Medicare Recertification Survey of the parent and one extension site location conducted on September 11, 2018, Novacare Outpatient Rehab East (Parent), 1034 Second Street Pike, Richboro Pa. 18954 and Nova Care extension located at 1415 Lincoln Hwy. Levittown Pa. 19056 were identified to have the following standard deficiency, that was 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.
Plan of Correction:
485.725(e) STANDARD
PEST CONTROL
Name - Component - 00
The organization's premises are maintained free from insects and rodents through operation of a pest control program.
Observations:
Based on a review of facility documentation,agency policy and an interview with the Center Manager, the extension site did not have any contract with either the owner of the building nor did the Facility establish one, with any outside agency, for pest control.
Findings include:
1. A review of facility policy, 9.16 "Pest Control" was conducted on September 11, 2018 at 12:45 PM. Page one, Paragraph two, reads: " The Center Manager will ensure that pest control services will be provided as indicated, if no previous arrangement exists via the center lease agreement". Evidence of pest control activities will be maintained in the Center Handbook. along with a copy of the contract for pest control services".
2. A review of the Facility rental lease was conducted on September 11, 2018, at approximately 12:35 PM. No provision for pest control activities was contained in this document.
3. A review of the Center Handbook was conducted on September 11, 2018 at 12:40 PM. There was no documentation of any contract between the Facility and any pest control company for services.
3. An interview with the Center Manager on September 11, 2018 at 1:30 PM confirmed that there was no provision for pest control, either by the Facility or the owner of the building for pest control, at the time of the survey.
Plan of Correction:The Center Manager/Market Manager/Acting Administrator of the Levittown extension location will review policy 9.16(Pest Control). Effective 9/19/2018, Orkin pest control service was designated to provide pest control as per policy 9.16 at the Levittown center. They will be on-site to provide services on a quarterly basis and contract will be placed in the Center Handbook along with copy of activities. The center Manager will mark as complete in the Center Handbook Calendar Checklist each quarterly service. The Market Manager will verify completion by viewing the Center Handbook and Calendar checklist on a semi-annual basis.
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