Initial Comments:
Based on the findings of an unannounced Medicare survey conducted June 21-22, 2018, The Rehab Center, located at 136 E. Lake Street, Ephrata, Pa. 17522 and a branch located at 270 Granite Run Drive, Lancaster, Pa. 17601 was found to have the following standard level deficiency that was determined to be in substantial compliance with the following requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.
Plan of Correction:
485.727(d)(1) STANDARD
EP Training Program
Name - Component - 00
§403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:]
(1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.
*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and
procedures.
*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.
*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures.
*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.
*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.
*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.
Observations:
Based on an interview with the facility market manager, facility policy, and a review of employee files (EFs), the facility failed to Provide emergency preparedness training at least annually for four (4) of eleven (11) EFs reviewd (EF#6-EF#9).
Findings:
A review was conducted of facility policy on June 22, 2018 at approximately 10:00 a.m. Policy #CPP 11.01 'Disaster and Emergency Preparedness' 'Procedures' section #5 states "Emergency and disaster preparedness and procedures training shall be conducted annually".
A review of employee files was conducted on June 21, 2018, between approximately 9:00 a.m. - 3:00 p.m. and on June 22, 2018 between approximately 9:00 a.m. - 12:00 p.m. Employee date of hire (DOH) is listed below:
EF#6 6/9/14: No documentation of employee emergency and disaster preparedness and procedures training being conducted annually in 2016 and 2017.
EF#7 9/15/03: No documentation of employee emergency and disaster preparedness and procedures training being conducted annually in 2016 and 2017.
EF#8 5/9/14: No documentation of employee emergency and disaster preparedness and procedures training being conducted annually in 2016 and 2017.
EF#9 2/4/13: No documentation of employee emergency and disaster preparedness and procedures training being conducted annually in 2016 and 2017.
An interview with the facility market manager on June 22, 2018 at approximately 12:25 p.m. confirmed the above findings.
Plan of Correction:POC - Each PRN associate completed disaster training at a coverage center but we historically did not have the PRN therapists sign the training log. Plan of correction includes assigning each PRN employee to a specific center to ensure appropriate and consistent training throughout the year. CM at Ephrata and Granite Run will conduct disaster drill as per policy 9.09 by 7/31 or earlier. This will include all PRN employees. Record of the drill including policy form 9.09 will be retained in the center handbook as well as record of training on the center handbook checklist and available for inspection by the market manager or designee.
Initial Comments:
Based on the findings of an unannounced Medicare survey conducted June 21-22, 2018, The Rehab Center, located at 136 E. Lake Street, Ephrata, Pa. 17522, and a branch located at 270 Granite Run Drive, Lancaster, Pa. 17601, were found to have standard level deficiencies but in substantial compliance with the 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:
485.709(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 an interview with the facility market manager, facility policy, and a review of employee files (EFs), the facility failed to ensure that clinical staff is certified in basic CPR (cardiac pulmonary resuscitation) for two (2) of ten (11) EFs reviewd. (EF#3, EF#11).
Findings:
A review was conducted of facility policy on June 22, 2018 at approximately 10:00 a.m. Policy 9.01 'Emergency Procedures' 'Procedure' section #3 states "Center managers should ensure that all clinical staff is CPR certified. Clinical staff shall be re-certified in accordance with certifying agency standards (such as American Heart Association, the American Red Cross or approved provider .....)".
A review of employee files was conducted on June 21, 2018, between approximately 9:00 a.m. - 3:00 p.m. Employee date of hire (DOH) is listed below:
EF#3 DOH 3/27/13: Documentation of completing the American Heart Association Basic Life Support (CPR and AED) program with an "Issue Date of 5/2/16" and a "Recommended Renewal Date of 5/2018". No documentation of employee being re-certified in 2018.
EF#11 DOH 1/16/07: Documentation of completing the American Heart Association "Healthcare Provider" program with a "Course Date of 4/4/16" and a "Recommended Renewal Date of 4/2018". No documentation of employee being re-certified in 2018.
An interview with the facility market manager on June 22, 2018 at approximately 12:25 p.m. confirmed the above findings.
Plan of Correction:The CM at Ephrata has ensured that all clinical staff will complete CPR recertification by 7/31/18 as per clinical policy 9.01. Verification of this certification is present in the employee file and marked as completed on the center handbook checklist. This is available for inspection by the Market Manager or designee. Ongoing certification will be ensured by the CM for all clinical staff.
485.709(d) STANDARD
PATIENT CARE POLICIES
Name - Component - 00
Patient care practices and procedures are supported by written policies established by a group of professional personnel including one or more physicians associated with the clinic or rehabilitation agency, one or more qualified physical therapists (if physical therapy services are provided) and one or more qualified speech pathologists (if speech pathology services are provided). The policies govern the outpatient physical therapy and/or speech pathology services and related services that are provided. The policies are evaluated at least annually by the group of professional personnel, and revised as necessary based upon this evaluation.
Observations:
Based on an interview with the facility market manager, facility policy, and a review of the therapeutic pool cleaning and maintenance logs, the facility failed to ensure documentation of routine monitoring and maintenance of the water quality and equipment for one (1) of one (1) observations (Observation #1).
Findings:
A review was conducted of facility policy on June 21, 2018 at approximately 10:00 a.m. Policy 9.22 'Therapeutic Pool Cleaning and Maintenance' 'policy' states " All Select Medical centers that offer aquatic therapy service to patients will ensure that the therapeutic pool is clean and maintained on a regular schedule by trained personnel". 'Procedure' section 1e states "The designated staff member will document routine monitoring and maintenance of water quality and equipment. The Sample Water Quality log (9.22a) may be used for documenting water quality; The Sample Pool Cleaning and Maintenance Log (9.22b) may be used for documenting pool cleaning and maintenance".
The therapeutic pool cleaning and maintenance log reviews were conducted on June 21, 2018, between approximately 9:00 a.m. - 12:00 p.m. at the Ephrata location. The following was revealed:
Observation #1: The 'Sample Water Quality Logs' were reviewed with the "Date" section only listing the month/day. "2017" is marked at the top of the log. the dates listed are from "12/27" to 1/20". The 'Sample Pool Cleaning and Maintenance Logs' were reviewed with the "Date" section only listing the month/day. No year marked on the Logs, with the exception of 3/22/17-6/20/17. "2017" was marked at the top of the logs dated "7/12"-"12/29".
An interview with the facility market manager on June 22, 2018 at approximately 12:25 p.m. confirmed the above findings.
Plan of Correction:Consistent with policy 9.22, Center Manager (CM) will ensure accurate reporting including month, date, and year related to maintenance log. The CM will review the log monthly and mark as complete on the compliance checklist. This is available for inspection by the Market Manager or designee.
485.723(a) STANDARD
SAFETY OF PATIENTS
Name - Component - 00
The organization satisfies the following requirements:
(1) It complies with all applicable State and local building, fire, and safety codes.
(2) Permanently attached automatic fire-extinguishing systems of adequate capacity are installed in all areas of the premises considered to have special fire hazards. Fire extinguishers are conveniently located on each floor of the premises. Fire regulations are prominently posted.
(3) Doorways, passageways, and stairwells negotiated by patients are of adequate width to allow for easy movement of all patients (including those on stretchers or in wheelchairs), free from obstruction at all times, and, in the case of stairwells, equipped with firmly attached handrails on at least one side.
(4) Lights are placed at exits and in corridors used by patients and are supported by an emergency power source.
(5) A fire alarm system with local alarm capability and, where applicable, an emergency power source is functional.
(6) At least two persons are on duty on the premises of the organization whenever a patient is being treated.
(7) No occupancies or activities undesirable or injurious to the health and safety of patients are located in the building.
Observations:
Based on an interview with the facility market manager, and patient restroom observations, the facility failed to ensure that patient restrooms, located on the treatment floor, were equipped with an emergency call bell or similar mechanism for patients to call for assistance when needed for two (2) of two (2) patient restrooms observed (Observation #1-2).
Findings:
Treatment floor observations were conducted on June 22, 2018, between approximately 9:00 a.m. - 12:00 p.m. The following was revealed:
Observation #1-#2: Two restrooms (utilized by patients and staff ), adjacent to the patient treatment room, did not have any method of summoning assistance when needed by unattended patients.
An interview with the facility market manager on June 22, 2018 at approximately 12:25 p.m. confirmed the above findings.
Plan of Correction:CM at Granite Run location has checked and will install wireless call bells by 7/12/18 in the bathrooms that do not currently have pre wired calling cords. The CM will check function of the Call bell semiannually and documented on the compliance checklist. This is available for inspection by the Market Manager or designee.
DATE CHANGED TO REFLECT REJECTION COMMENT.
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 an interview with the facility market manager, facility policy, and treatment room observations, the facility failed to ensure treatment room equipment was calibrated on an annual basis for four (4) of ten (10) treatment room equipment observations (Observation #1-#3 and #9-10).
Findings:
A review was conducted of facility policy on June 22, 2018 at approximately 10:00 a.m. Policy 9.17 'Equipment Maintenance and Recalled items' 'Policy' states "Select Medical Outpatient Division will maintain, inspect, and calibrate all equipment to ensure the safety and quality care of patients". 'Procedure' section 2a states " All electrical equipment is to be inspected and calibrated on an annual basis".
Treatment floor observations were conducted on June 21, 2018, between approximately 9:00 a.m. - 12:00 p.m. at the Ephrata location. The following was revealed:
Observation #1: Unit: Game Ready (GR) Pro, Model: 2.1, Serial No: B3W Calibration sticker on machine listed "Calibration due 3/18".
Observation #3: Unit: Thermasonic gel warmer (ultrasound gel warming machine), General inspection sticker on machine listed "last check 3/16, Due 3/17".
Observation #9: Unit: CPS Model: Forte 200 Combo Serial No: 1144. contained an inspection sticker dated 3/2017. Electrical Safety Inspection documentation of calibration check on 3/27/18 revealed, "failed safety check" stating, "Customer did not want it repaired".
Treatment floor observations were conducted on June 22, 2018, between approximately 9:00 a.m. - 12:00 p.m. at the Lancaster location. The following was revealed:
Observation #10: Unit: Alter G anti gravity treadmill, Serial No: 1300-0734. Calibration sticker on machine listed "Calibration due 3/18".
An interview with the facility market manager on June 22, 2018 at approximately 12:25 p.m. confirmed the above findings.
Plan of Correction:The center managers (CM) at the Rehab Center in Ephrata and Granite Run had above mentioned equipment inspected and appropriately tagged since 6/22/18. A copy of the equipment inspection will be maintained in the center handbook. Inspection will be completed annually as part of clinical policy 9.18 and documented on the compliance checklist. This is available for inspection by the Market Manager or designee.
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 interview with market manager, observation and review of facility policy the facility failed to ensure all equipment was in good repair for three (3) of ten (10) observations. (#2, #5 and #6); failed to ensure expired cleaning supplies were properly disposed of for one (1) of ten (10) observations. (#8).
Findings include:
Review of facility policy conducted on June 21, 2018 at approximately 10:00 a.m. revealed: Policy # CPP 9.12: Environmental Health & Safety, Revised :7/2011, Policy: It is the Company policy that all containers known to have hazardous materials shall be labeled to identify the hazardous chemical(s),... Procedure: 1., "The Facility Director shall be responsible for providing facilty employees with the direction and information regarding appropriate container labeling of specific chemical products at the facility. 2. Appropriate labeling the containers shall support the proper use and prevent the accidental misuse of the material by employees".
Treatment floor observations were conducted on June 21, 2018, between approximately 9:00 a.m. - 12:00 p.m. at the Ephrata location. The following was revealed:
Observation #2, Exam table located in treatment room #2, was noted to have significant rips and tears in the exam table.
Observation #5, two (2) of three (3) trampolines located on the treatment floor were noted to have significant rips and tears along the outer edging.
Observation #6, Unit: Nautilus Elbow press machine. Serial No. 125521 was noted to have worn hand grips on both left and right sides.
Therapeutic pool area observations were conducted on June 21, 2018 between approximately 9:00 a. m. -12: 00 p.m. at the Ephrata location . The following was revealed:
Observation # 8, four (4) bottles of Cavicide surface disinfectant with an expiration date of 5/2018. One (1) bottle of Cavicide surface disinfectant with an illegible expiration date.
An interview with the facility market manager on June 22, 2018 at approximately 12:25 p.m. confirmed the above findings.
Plan of Correction:The center manager (CM) at the Rehab Center in Ephrata will have repairs made to trampolines, mat tables, and machine 125521 on or before July 31, 2018. All Cavicide surface disinfectants will be labeled with clear expiration dates. All equipment will be inspected semi-annually for wear and recorded on the Center Calendar Checklist by the center manager and available for inspection by the Market Manager or designee.
485.725(a) STANDARD
INFECTION CONTROL COMMITTEE
Name - Component - 00
The infection control committee establishes policies and procedures for investigating, controlling, and preventing infections in the organization and monitors staff performance to ensure that the policies and procedures are executed.
Observations:
Based on review of facility policy, patient care committee meeting minutes and an interview with the facility market manager the facility failed to ensure an independent infection control committee was established at both the parent location at 136 E Lake St. Ephrata, Pa and a branch location at 270 Granite Run Drive, Lancaster Pa 17601.; failed to ensure the infection control committee monitored staff performance to ensure that the established policies/procedures are executed for one (1) of one (1) set of meeting minutes reviewed. (meeting minutes #1).
Findings include:
Review of Policy:7.04, Patient Care Committee, last revised; 5/1/18, on June, 22, 2018 at approximately 10:00 a.m. revealed:
Procedure: 2), "Each Patient care committee shall include two subcommittees: the Patient Safety and Infection Control and Quality Assurance, made up of representatives from or recommended by the Patient Care committee".
Review of the Patient Care Meeting minutes#1 for March 23, 2017 conducted on June 21, 2018 at approximately 1:30 p.m. revealed:
Items discussed: "A) Incident Reporting, B) Past Medical History Form, C) Policy Review & Update. No documentation of staff performance monitoring to ensure policies/procedures are executed.
An interview with the facility market manager on June 22, 2018 at approximately 12:25 p.m. confirmed the above findings.
Plan of Correction:The center managers (CM) at the Rehab Center in Ephrata and Granite Run will conduct a staff meeting on or before July 31, 2018 to review the minutes from the Rehab Agencies most recent "Patient Safety – Infection Control" subcommittee meeting, as well as all updated policies & Procedures of the outpatient division, including section 9 – "Safety & Infection Control". The staff meeting minutes will be documented on form 4.12 and include names of all attendees and topics discussed and will be retained in the Center Handbook. Additionally, each employee will attest to reviewing the updated policies in Select University on the Select Medical portal, and evidenced in the individuals transcript to be verified as completed by the Market Manager (MM) or designee. The CM at each location will conduct monthly staff meetings and include review of selected section 9 policies as items for discussion. Staff meeting minutes will be documented on form 4.12 and maintained in the center handbook. Evidence of completed monthly staff meetings will be marked as complete on the Center Calendar Checklist by the center manager and verified quarterly by the Market Manager or designee.
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