Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on March 28, 2019, Keystone rehabilitation Systems was found to have the following standard level deficiency that was determined to be in substantial compliance with the following requirement 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:
485.727(a)(3) STANDARD
EP Program Patient Population
Name - Component - 00
§403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3).
[(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:]
(3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.**
*[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 all of the following:
(3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.
*NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.]
Observations:
Based on review of facility policy and procedure, and documention, and interviews with staff (EMP), the facility failed to ensure its emergency preparedness plan included delegation of authority and succession plans to allow for continuity of operations for one (1) of one (1) extension site location (West Newton).
Findings included:
Review of facility's disaster plans at McMurray parent location on March 26, 2019, at 1 p.m. showed, "EMPLOYEE-SPECIFIC DUTIES IN CASE OF EMERGENCY ... [EMP1 (facility administrator)] Ranking therapist in clinic Determines severity of emergency and if evacuation or relocation of everyone is necessary." Per this disaster plan EMP3 (office manager) was listed as next in command, "Ranking employee if [EMP1] is not present]."
During an interview with West Newton extension site (center) manager (EMP5) on March 28, 2019, at 11:16 a.m. surveyor asked him/her what facility personnel he/she would contact to lead disaster efforts should a disaster occur and he/she noted he/she would call his/her market manager (EMP6). When EMP5 was asked why he/she would not call EMP1 he/she noted, "[He/she] is the Medicare adminstrator ... [he/she] is in charge of all Medicare things." At 11:25 a.m. EMP5 left the room and returned with an organizational chart. EMP2 was also present at this time. EMP2 noted, "[EMP5] would go to [his/her] upline ... [EMP6]." EMP2 went on to note, "The alternate should be [EMP6] ... is acting administrator for that main site and the other locations." There was no explanation provided for why EMP5 would call the alternate adminstrator first when the adminstrator would be available. The question was not posed for when the adminstrator was not available. EMP6 was not listed in facility's "EMPLOYEE-SPECIFIC DUTIES IN CASE OF EMERGENCY" procedures as noted above.
Review of facility's organizational chart on March 28, 2019, at 11:43 a.m. showed "Updated 10-19-2017 McMurray - North Main Site Medicare #: 39-6640." According to the organization chart the Center Managers were listed directly below EMP1 (adminstrator) and included the extensions site "West Newton Center Manager #1c." EMP6 was not shown as a direct report for EMP5, but instead was listed to the side (ancillary and not direct), "[EMP6] Market Manager Acting Administrator"
Interview with EMP2 on March 28, 2019, at 11:45 a.m. confirmed findings concerning organizational chart.
Review of EMP1's (administrator) job description on March 28, 2019, at 2 p.m. showed, "Select Medical Section 11: Medicare Rehabilitation Agency Administrative Management Policy # 11.01 Policy Title: Adminstrator ... Revision Date: 05/01/2017 ... Policy The administrator will direct and manage the Medicare Rehabilitation Agency ... Procedure ADMINISTRATOR ... 3) Responsibilities of Administrator: ... b) Is responsible for the operations of the Medicare Rehabilitation Agency in accordance with established written policies and procedures. ... d) Is responsible for the administration of all personnel policies in cooperation with each center manager. e) Is responsible for the ongoing administration of each center in cooperation with each center manager."
Review of EMP5's job description on March 28, 2019, at 2 p.m. showed, "Job Title: Center Manager"
Review of West Newton's "EMERGENCY PLAN" on March 28, 2019, at 12 p.m. showed, "Commutation Plan" for who to contact for internal disasters such as medical emergency and bomb threat. The plan also included contact information for external disasters including tornadoes, hurricanes, earthquakes, explosions, chemical spill, flooding, and national disaster or emergency. Further review of who to call showed that the Center Manager (EMP5) was to notify the Market Manager (EMP6) and / or the Regional Manager (EMP2). The extension site's succession planning did not included notification of the facility's adminstrator (EMP1).
Plan of Correction:As part of our emergency preparedness plan, the delegation of authority and succession for the continuity of operations at the parent location (McMurray North) and extension sites will include notification of the rehab agencies administrator, as detailed in the organizational chart of the rehab agency. The plan of notification will be as follows: each Center Manager of the extension locations will have a direct report to the rehab agency administrator at McMurray. The center manager at each location of this rehab agency (McMurray, West Newton, Monongahela, Washington, and Belle Vernon) will be responsible to review the emergency succession plan with staff and document on staff meeting minutes form #4.12 and retain along with the organizational chart in Section. 9 of the center handbook.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed March 28, 2019, Keystone Rehabilitation Systems 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. The survey was conducted at the McMurray parent location on March 26, 2019, and the West Newton extension site on March 28, 2019.
Plan of Correction:
485.709(a) STANDARD
GOVERNING BODY
Name - Component - 00
There is a governing body (or designated person(s) so functioning) which assumes full legal responsibility for the overall conduct of the clinic or rehabilitation agency and for compliance with applicable law and regulations. The name of the owner(s) of the clinic or rehabilitation agency is fully disclosed to the State agency. In the case of corporations, the names of the corporate officers are made known.
Observations:
Based on review of facility's file, documentation, and observation, and interviews with staff (EMP), the governing body failed to disclose ownership to the state agency.
Findings included:
Review of facility's file during pre-survey preparation on March 25, 2019, at 8:15 a.m. showed facility's legal name was Keystone Rehabilitation Systems - McMurray, and its doing business as name was the same. Email to the Department's central office at 10 a.m. confirmed findings, and no notification to state agency concerning change in ownership
Observation at facility's parent location on March 26, 2019, at 9:43 a.m. showed posted sign which read, "Nova Care Rehabilitation North." Interview with EMP2 at 11:05 a.m. confirmed findings.
Interview with EMP2 (regional director) on March 26, 2019, at 11:05 a.m. confirmed findings and noted facility became Nova Care sometime in 2016.
Per documentation provided by EMP2, and reviewed on March 26, 2019, at 11:26 a.m., "NEWS RELEASE ... Select Medical Holdings Corporation ... Select Medical Holding Corporation Announces Completion of Acquisition of Physiotherapy Associates Holdings, Inc. [Keystone] MECHANICSBURG, PENNSYLVANIA - March 4, 2016 - Select Medical Holdings Corporation ("Select Medical") (NYSE: SEM) Today announced its wholly-owned subsidiary, Select Medical Corporation, has completed its previously announced acquisition of Physiotherapy Associates Holdings, Inc."
Review of facility policy and procedure on March 26, 2019, at 12 p.m., "SECTION 1 / Policy 1.04 OWNERSHIP DISCLOSURE FACT SHEET ATTENTION! Should you receive any forms requesting verification of your center's ownership information, please contact, Manager of Regulatory Affairs, at Select Medical Corporation. ... You may be asked for verification of ownership in the following instances: 1) Medicare Survey. ... Disclosure of Ownership This Rehabilitation agency, KEYSTONE REHABILITATION SYSTEMS OF MCMURRAY ... is owned by SELECT MEDICAL CORPORATION."
Observation at facility's West Newton extension site on March 28, 2019, at 10:04 a.m. showed a posted sign that read, "NovaCare Rehabilitation."
On March 28, 2019, at 10:15 a.m., a review of email sent to EMP2 from facility's legal department. The email was sent to EMP2 on March 26, 2019, at 4:12 p.m., "3/4/2016 - acquired clinics from Physiotherapy. No change to the provider other than updating the parent company and officer/directors."
Plan of Correction:The administrator of the Rehab Agency, appointed by the Governing Board, will provide documentation to the Department of Health confirming ownership by Select Medical of Keystone Rehabilitation Systems – McMurray d/b/a NovaCare Rehabilitation.
485.711(c) STANDARD
EMERGENCY CARE
Name - Component - 00
The rehabilitation agency must establish procedures to be followed by personnel in an emergency, which cover immediate care of the patient, persons to be notified, and reports to be prepared.
Observations:
Based on review of facility inservice, policy and procedure, and observation, and interviews with staff (EMP), the facility failed to ensure the AED (automated external defibrillator) was available for use when included in established procedures to be followed by personnel in an emergency. The facility failed to have a facility specific policy and procedure to govern the use of its AED for one (1) of one (1) facility that had an AED (McMurray parent location).
Findings included:
Observation of facility's gym space on March 26, 2019, at 12:18 p.m. revealed an AED in a cabinet "EMERGENCY DEFIBRILLATOR." Upon further inspection the battery status indicator on the AED showed a red X. The unit also emitted an intermittent audible beep.
Review of facility policy and procedure on March 26, 2019, at 12:20 p.m. showed, "Policy # 9.01 Policy Title: Emergency Procedures ... (7) Centers [facilities] that have Automated External Defibrillators (AED's) will develop market specific policies for the device with the assistance of their Regional Director of Clinical Services [EMPHASIS]. The policy should address: a) Location of the AED b) Identification of persons responsible for Medical Oversight c) Training of staff on AED use d) Maintenance of the AED equipment."
Interview with EMP1 on March 26, 2019, at 12:27 p.m. confirmed AED is available for use, "We have drilled with it." EMP1 also confirmed the AED's batteries needed replaced and that the unit was inoperable.
Interview with EMP4 on March 26, 2019, at 1:07 p.m. confirmed AED is available for use. EMP4 described facility's emergency procedures to surveyor and noted he/she would retrieve the AED for patient with suspected cardiac arrest.
Review of facility inservice on March 26, 2019, at 1 p.m. showed it was completed May 2018, attended by facility staff, and contained emergency procedures for an AED, "Inservice: CPR / First Aid - review of AED and procedures ... Department Staff Mtg: Review of safety & environmental checklists"
Note: Surveyor requested policy and procedure from EMP2 (regional director) for facility's AED and was provided the above policy 9.01. No facility specific policy and procedure was provided in accordance with policy 9.01.
Plan of Correction:The Keystone Rehabilitation Systems of McMurray has established a facility specific policy for governing the use of the AED device. The local policy is part of the existing clinical Policy #9.01 Emergency Procedure. This local market policy includes the following:
a.) The location of the AED—on the wall between patient treatment area and gym encased in glass housing with red alarm.
b.) Clinical oversight--The Center manager is responsible for oversight of the AED device.
c.) Training: Center Manager or designee will conduct the annual training of the staff on the use and maintenance of the AED device. The annual drill will be documented on the Emergency Drill Report form #9.09 and retained in Section. 9 of the Center Handbook.
d.) Maintenance: the Center Manager or designee will conduct monthly inspections of the AED, as per the manufacturer's recommendations and sign off on the inspection log placed next the AED unit, and retain a copy of the log in the Center handbook in Section 9.
A new AED battery was ordered on 3/27/19 and installed on 3/29/19. The battery indicator light is now a green checkmark indicating that the unit is fully functioning.
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 observation, and interviews with staff (EMP), the facility failed to ensure the interior building space was maintained free of defects which are a potential hazard to patients, personnel, and the public for one (1) of two (2) locations (McMurray parent).
Findings included:
While walking across facility's gym area on March 26, 2019, at 1:58 p.m. surveyor stumbled on a depression in the floor. Further observation revealed a hole in the floor measuring 3 inches across. The hole was covered by carpeting making it difficult to see when walking. The carpet that covered the hole was pushed into it creating a depression and visible borders that allowed for a measurement.
An interview with EMP2 (regional director) and EMP4 (physical therapist assistant) on March 26, 2019, at 2 p.m. confirmed findings. At this time an employee in the facility noted, "We will have to get a contractor to get it fixed."
Plan of Correction:The Regional Director and Rehab agency administrator have arranged for repair of the small hole in the floor at the McMurray North location. The facilities management team has inspected and evaluated the hole in the floor on 4/2/19 and the issue was corrected. An invoice for proof of completion was sent directly to the Health Facility Quality Examiner.
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