Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on July 25, 2018, at the parent location of 125 Holly Road, Hamburg, PA, 19526 and July 26, 2018, at the satellite location of 1800 Tulpehocken Road, Wyomissing, PA, 19610, Genesis Rehabilitation Services, 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 July 25, 2018, at the parent location of 125 Holly Road, Hamburg, PA, 19526 through July 26, 2018, at the satellite location of 1800 Tulpehocken Road, Wyomissing, PA, 19610, Genesis Rehabilitation Services, was identified to have the following standard level deficiency and was 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, policy and procedure review, review of agency cleaning logs, review of "Chattanooga Hydrocollator User Manual" and interview with the administrator, it was determined the rehabilitation agency failed to ensure bi-weekly cleaning of one (1) of one (1) hydrocollator (Chattanooga Hydrocollator#1) from January 2018 through June 2018, failed to ensure patient equipment to be free from dust and cobwebs (exercise bike#1, balance board #1, and elliptical machine #1) (Observation #1), and failed to ensure intact safety threads on patient equipment (parallel bars #1 and patient scale #1) (Observation#2).
Findings include:
Review of policy "Cleaning and Maintenance of Rehabilitation Equipment" states " It is the responsibility of the provider to regularly clean and maintain equipment used by rehabilitation services in proper working order."
Review of "Chattanooga Hydrocollator User Manual: Maintenance" states "....The tank should also be drained, cleaned and inspected at minimum intervals of every 2 weeks."
On July 26, 2018, at approximately 11:30 AM, Review of "Temperature and Cleaning Log" for Chattanooga Hydrocollator #1 for January 2018-June 2018 revealed documentation of one (1) cleaning performed on 5/29/2018, not every 2 weeks.
Observation #1: On July 25, 2018, at approximately 10:30 AM, a tour of the patient treatment area revealed a layer of dust and cobwebs on Elliptical Machine #1, Balance Board #1, and layer of dust on Exercise Bike #1.
Observation #2: On July 25, 2018, at approximately 10:45 AM, a tour of the patient treatment area revealed the safety threads on Parallel Bars #1 and Patient Scale #1 to be peeling from the surface of the equipment, causing a potential trip hazard for patients.
An interview with the agency Administrator on 7/26/2018 at approximately 1:00 PM confirmed the above findings.
Plan of Correction:Plan of Correction- August 2018
Pennsylvania Department of Health Survey:
Laurel Nursing and Rehab Outpatient Primary Site July 25, 2018
Country Meadows of Wyomissing, Extension Site July 26, 2018
Deficiency for Hydrocollator Cleaning Logs:
1. What corrective action will be accomplished?
a. The hot pack machines will be cleaned every 2 weeks as outlined in the Chattanoga Hydrocollator Manuals.
b. New cleaning logs will be used for monitor of the increased cleaning times
2. How will you identify other individuals having potential to be affected by the same deficient practice?
a. All rehab agency staff will be educated on the new procedures for cleaning and use of the cleaning logs
b. Individual education with Rehab Office Coordinator regarding cleaning process and new cleaning logs. This is the person responsible for cleaning of equipment.
3. What measures (actions/forms/system changes/etc) will be put into place to ensure that the deficient practice does not recur?
a. New cleaning log forms will be put into place with highlighted areas for biweekly cleaning schedules with space for staff initial when procedure completed
b. Staff in-servicing to all rehab staff to be completed immediately and annually with signatures for compliance
4. How will the corrective actions be monitored to ensure that the deficient practice will not recur (ie quality assurance programs)
a. Rehab ROC (rehab office coordinator) will complete biweekly maintenance of the Hydrocollator, in absence of ROC the DOR (director of rehab) will ensure proper cleaning
b. Extension site will fax logs to OPT administrator monthly to ensure procedure properly followed. If cleaning procedure is not followed, OPT Administrator will direct rehab agency staff to immediately perform the cleaning and re-education will be provided.
c. Microsoft Outlook calendar reminders will be used for cleaning dates
d. New forms to be put into place for better accuracy of tracking and reminders (see attached form- Physical Agent Modality Temperature/Cleaning Log)
5. Date of when the corrective action will be COMPLETED.
a. Corrective action will be completed by September 1, 2018
Deficiency for Gym Cleanliness:
1. What corrective action will be accomplished?
a. Strips on the gym parallel bars have been fixed to remove loose areas and secure the strips. Correction was achieved on July 25, 2018 (see attached photo) via Director of Maintenance for the building. Loose ends of non-skid strip was removed from the floor of the parallel bars.
b. Dust and cobwebs were cleaned from OPT gym on 7/25/18 via Director of Housekeeping Services for the building.
c. New updated cleaning logs (see attached form "Housekeeping Cleaning Log") were created to include scheduled cleaning of various area in the gym. Spreadsheet was created for housekeeping staff to initial for weekly dusting, weekly floor cleaning, daily bathroom cleaning and trash removal, and weekly equipment inspection of safety/equipment
2. How will you identify other individuals having potential to be affected by the same deficient practice?
a. Revised Housekeeping Log will be shared with Housekeeping Director and Staff and Rehab Agency Staff. Education will be provided by OPT Administrator to the Director of Housekeeping on updated log and schedule for gym cleaning.
3. What measures (actions/forms/system changes/etc) will be put into place to ensure that the deficient practice does not recur?
a. OPT Administrator and/or OPT Assistant Administrator will perform environmental rounds in OPT Gym weekly to ensure gym is cleaned thoroughly and according to schedule.
b. OPT Administrator and/or OPT Assistant Administrator will record observations by writing initials on the Cleaning log
c. If found to be out of compliance, cleaning will be requested by OPT Administrator and/or OPT Assistant Administrator immediately and Director of Housekeeping notified. Expectation is for Housekeeping Director to provide staff in-servicing and re-education.
4. How will the corrective actions be monitored to ensure that the deficient practice will not recur (ie quality assurance programs)
a. Weekly environmental rounds by OPT Administrator and/or OPT Assistant Administrator to ensure proper cleaning.
b. Microsoft Outlook calendar reminders will be used for reminders to ensure tracking and reminder of environmental rounds
c. New forms to be put into place for better accuracy of tracking and reminders (see attached form- Housekeeping Cleaning Log)
5. Date of when the corrective action will be COMPLETED.
a. Corrective action will be completed by September 1, 2018
New Cleaning logs for hydrocollator and housekeeping logs were created to use per POC.
|