Initial Comments:
Based on the findings of an unannounced Medicare recertification and state relicensure survey completed on 11/29/2018, Vantage Physical Therapy & 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 485.727, 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)(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 review of facility documentation, and staff (EMP) interviews, the facility failed to develop, establish, review and maintain a comprehensive emergency preparedness program based on a facility-based and community-based risk assessment, utilizing an all-hazards approach.
Findings included:
A review of facility documentation was conducted on 11/27/2018 at approximately 10:20 AM which revealed: The "OPERATIONS MANUAL SECTION J. DISASTER PREPAREDNESS." This plan did not contain evidence of the facility had reviewed or maintained any documentation pertaining to a risk assessment that was community or facility based. The facility failed to provide documentation to confirm facility had met this standard.
An interview was conducted with EMP2 on 11/27/2018 at approximately 10:20 AM, EMP2 was not aware of all emergency preparedness requirements. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types" with EMP2.
An exit interview with administrator and secretary on 11/27/2018 at approximately 3:00 PM confirmed the above findings.
Plan of Correction:We will develop an emergency preparedness plan which describes all hazards approach to meeting health and safety and security needs of staff and patients and how we would coordinate with other health care facilities. We would include strategies for 1) flood, 2) interruption in communication such as cyber attack, 3) terrorist or shooter attack, 4)fires, 5) dam failure, 6) winter storms, 7)influenza pandemic, and 8)thunderstorm/tornadoes. Medicare compliance coordinator will monitor the implementation of the plan of correction with weekly documented meetings with administrator on progress. These procedures will be reviewed annually with the help of local fire, safety, and other agencies, with changes made as necessary.
485.727(a)(5) STANDARD
Local, State, Tribal Collaboration Process
Name - Component - 00
§403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4)
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:]
(4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. *
* [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.
Observations:
Based on review of facility documentation, and staff (EMP) interviews, the facility failed to develop, maintain and review an emergency preparedness plan that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.
Findings included:
A review of facility documentation was conducted on 11/27/2018 at approximately 10:20 AM which revealed: The "OPERATIONS MANUAL SECTION J. DISASTER PREPAREDNESS." This plan did not contain evidence of the facility establishing cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. Facility failed to provide documentation to confirm facility had met this standard.
An interview was conducted with EMP2 on 11/27/2018 at approximately 10:20 AM, EMP2 was not aware of all emergency preparedness requirements. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types" with EMP2.
An exit interview with administrator and secretary on 11/27/2018 at approximately 3:00 PM confirmed the above findings.
Plan of Correction:We will collaborate with local or state emergency management agencies, such as local fire department, on community based risk assessments some of which would be identify functions that should be continued during an emergency and assess the extent to which emergencies may cause the facility to cease or limit operations.Medicare compliance coordinator will monitor the implementation of the plan of correction with weekly documented meetings with administrator on progress. These procedures will be reviewed annually with the help of local fire, safety, and other agencies, with changes made as necessary.
485.727(a)(6) STANDARD
CORF/Clinic Development and Fire Safety
Name - Component - 00
§485.68(a)(5) Condition for Participation:
[(a) Emergency Plan. The Comprehensive Outpatient Rehabilitation Facility (CORF) 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:]
(a)(5) Be developed and maintained with assistance from fire, safety, and other appropriate experts.
§485.727(a)(6) Condition for Participation:
[(a) Emergency Plan. The Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services ("Organizations") 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:]
(a)(6) Be developed and maintained with assistance from fire, safety, and other appropriate experts.
Observations:
Based on a review of agency documentation, email correspondence, and staff interview, the facility failed to initiate and maintain a comprehensive emergency preparedness program that was developed and maintained with assistance from fire, safety, and other appropriate experts.
Findings Included:
A review of facility documentation was conducted on 11/27/2018 at approximately 10:20 AM which revealed: The " OPERATIONS MANUAL SECTION J. DISASTER PREPAREDNESS. " This plan did not contain evidence of that a comprehensive emergency preparedness program that was developed and maintained with assistance from fire, safety, and other appropriate experts. Facility failed to provide documentation to confirm facility had met this standard.
An interview was conducted with EMP2 on 11/27/2018 at approximately 10:20 AM, EMP2 was not aware of all emergency preparedness requirements. The surveyor reviewed a copy of the " State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types " with EMP2.
An exit interview with administrator and secretary on 11/27/2018 at approximately 3:00 PM confirmed the above findings.
Plan of Correction:We will develop policies and procedures to align with the identified hazards and the safe evacuation of patients, particularly patients with limited mobility. These policies will be developed in collaboration with local fire and safety agencies. Medicare compliance coordinator will monitor the implementation of the plan of correction with weekly documented meetings with administrator on progress. These procedures will be reviewed annually with the help of local fire, safety, and other agencies, with changes made as necessary.
485.727(b)(2) STANDARD
Policies/Procedures for Sheltering in Place
Name - Component - 00
§403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3).
(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]
[(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility].
*[For Inpatient Hospices at §418.113(b):] Policies and procedures.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following:
(i) A means to shelter in place for patients, hospice employees who remain in the hospice.
Observations:
Based on a review of agency documentation, email correspondence, and staff interview, the facility failed to develop polices and procedures that included a means to shelter in place for patients and staff who remain in the facility.
Findings Included:
A review of facility documentation was conducted on 11/27/2018 at approximately 10:20 AM which revealed: The "OPERATIONS MANUAL SECTION J. DISASTER PREPAREDNESS." Facility emergency preparedness plan did not contain policies and procedures to shelter in place.
An interview was conducted with EMP2 on 11/27/2018 at approximately 10:20 AM, EMP2 was not aware of all emergency preparedness requirements. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types" with EMP2.
An exit interview with administrator and secretary on 11/27/2018 at approximately 3:00 PM confirmed the above findings.
Plan of Correction:We will develop a procedure that addresses the means to shelter in place for patients, staff and volunteers who remain in the facility. Medicare compliance coordinator will monitor the implementation of the plan of correction with weekly documented meetings with administrator on progress. These procedures will be reviewed annually with the help of local fire, safety, and other agencies, with changes made as necessary.
485.727(b)(3) STANDARD
Policies/Procedures for Medical Documentation
Name - Component - 00
§403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4).
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]
[(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.
*[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following:
(i) Preserves patient information.
(ii) Protects confidentiality of patient information.
(iii) Secures and maintains the availability of records.
*[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.
Observations:
Based on a review of agency documentation, email correspondence, and staff interview, the facility failed to develop emergency preparedness policy and procedure that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.
Findings Included:
A review of facility documentation was conducted on 11/27/2018 at approximately 10:20 AM which revealed: The "OPERATIONS MANUAL SECTION J. DISASTER PREPAREDNESS. "This plan did not contain evidence of a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. Facility failed to provide documentation to confirm that the facility had met this standard.
An interview was conducted with EMP2 on 11/27/2018 at approximately 10:20 AM, EMP2 was not aware of all emergency preparedness requirements. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types" with EMP2.
An exit interview with administrator and secretary on 11/27/2018 at approximately 3:00 PM confirmed the above findings.
Plan of Correction:We will create a policy and procedure that will ensure patient records are secure and safe and readily available to support continuity of care. This plan will need to be which in compliance with HIPPA regulations. Medicare compliance coordinator will monitor the implementation of the plan of correction with weekly documented meetings with administrator on progress. These procedures will be reviewed annually with the help of local fire, safety, and other agencies, with changes made as necessary.
485.727(b)(4) STANDARD
Policies/Procedures-Volunteers and Staffing
Name - Component - 00
§403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5).
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]
(6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
*[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency.
*[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
Observations:
Based on a review of agency documentation, email correspondence, and staff interview, the facility failed to develop emergency preparedness policy and procedure that included the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
Findings Included:
A review of facility documentation was conducted on 11/27/2018 at approximately 10:20 AM which revealed: The "OPERATIONS MANUAL SECTION J. DISASTER PREPAREDNESS." This plan did not contain evidence of policy and procedure that included the other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals. Facility failed to provide documentation to confirm facility had met this standard.
An interview was conducted with EMP2 on 11/27/2018 at approximately 10:20 AM, EMP2 was not aware of all emergency preparedness requirements. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types" with EMP2.
An exit interview with administrator and secretary on 11/27/2018 at approximately 3:00 PM confirmed the above findings.
Plan of Correction:We will create a policy and procedure for volunteers or emergency staffing which would include emergency plan for contacting off duty staff and utilizing staff from other facilities. Medicare compliance coordinator will monitor the implementation of the plan of correction with weekly documented meetings with administrator on progress. These procedures will be reviewed annually with the help of local fire, safety, and other agencies, with changes made as necessary.
485.727(c)(1) STANDARD
Names and Contact Information
Name - Component - 00
§403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1).
[(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:]
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [facilities].
(v) Volunteers.
*[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [hospitals and CAHs].
(v) Volunteers.
*[For RNHCIs at §403.748(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Next of kin, guardian, or custodian.
(iv) Other RNHCIs.
(v) Volunteers.
*[For ASCs at §416.45(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.
*[For Hospices at §418.113(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Hospice employees.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Other hospices.
*[For HHAs at §484.102(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.
*[For OPOs at §486.360(c):] The communication plan must include all of the following:
(2) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Volunteers.
(iv) Other OPOs.
(v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).
Observations:
Based on a review of agency documentation, email correspondence, and staff interview, the facility failed to develop a communication plan that included the name and contact information for all staff, entities providing services under arrangement, patient's physicians and other facilities of the same type.
Findings Included:
A review of facility documentation was conducted on 11/27/2018 at approximately 10:20 AM which revealed: The "OPERATIONS MANUAL SECTION J. DISASTER PREPAREDNESS." This plan did not contain evidence of a communication plan that included the name and contact information for all staff, entities providing services under arrangement, patient's physicians and other facilities of the same type. Facility failed to provide documentation to confirm facility had met this standard.
An interview was conducted with EMP2 on 11/27/2018 at approximately 10:20 AM, EMP2 was not aware of all emergency preparedness requirements. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types" with EMP2.
An exit interview with administrator and secretary on 11/27/2018 at approximately 3:00 PM confirmed the above findings.
Plan of Correction:We will develop a communication plan that includes name and contact information for staff, entities providing services under arrangement, patients, physicians, and volunteers which will be updated annually.Medicare compliance coordinator will monitor the implementation of the plan of correction with weekly documented meetings with administrator on progress.
485.727(c)(2) STANDARD
Emergency Officials Contact Information
Name - Component - 00
§403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2).
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:
(2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.
*[For LTC Facilities at §483.73(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) The State Licensing and Certification Agency.
(iii) The Office of the State Long-Term Care Ombudsman.
(iv) Other sources of assistance.
*[For ICF/IIDs at §483.475(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.
(iii) The State Licensing and Certification Agency.
(iv) The State Protection and Advocacy Agency.
Observations:
Based on a review of agency documentation, email correspondence, and staff interview, the facility failed to develop a communication plan that included the contact information for Federal, State, regional, local emergency staff and other sources of assistance.
Findings Included:
A review of facility documentation was conducted on 11/27/2018 at approximately 10:20 AM which revealed: The "OPERATIONS MANUAL SECTION J. DISASTER PREPAREDNESS." This plan did not contain evidence of a communication plan that included the contact information for Federal, State, regional, local emergency staff and other sources of assistance. Facility failed to provide documentation to confirm facility had met this standard.
An interview was conducted with EMP2 on 11/27/2018 at approximately 10:20 AM, EMP2 was not aware of all emergency preparedness requirements. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types" with EMP2.
An exit interview with administrator and secretary on 11/27/2018 at approximately 3:00 PM confirmed the above findings.
Plan of Correction:We will create a policy and procedure for contacting emergency local, state and federal agencies in case of a disaster. This will be reviewed annually. Medicare compliance coordinator will monitor the implementation of the plan of correction with weekly documented meetings with administrator on progress.
485.727(c)(4) STANDARD
Methods for Sharing Information
Name - Component - 00
§403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6).
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:
(4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care.
(5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)]
(6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4).
*[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative.
*[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4).
Observations:
Based on a review of agency documentation, email correspondence, and staff interview, the facility failed to develop a communication plan that included a method for sharing information and medical documentation for patients under the facility's care, as necessary, with other health providers to maintain the continuity of care.
Findings Included:
A review of facility documentation was conducted on 11/27/2018 at approximately 10:20 AM which revealed: The "OPERATIONS MANUAL SECTION J. DISASTER PREPAREDNESS." This plan did not contain evidence of a communication plan that included a method for sharing information and medical documentation for patients under the facility's care. Facility failed to provide documentation to confirm facility had met this standard.
An interview was conducted with EMP2 on 11/27/2018 at approximately 10:20 AM, EMP2 was not aware of all emergency preparedness requirements. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types" with EMP2.
An exit interview with administrator and secretary on 11/27/2018 at approximately 3:00 PM confirmed the above findings.
Plan of Correction:We will develop a method of sharing information and medical documentation for patients under our facilities care with other healthcare providers to maintain continuity of care of those patients. We will follow HIPPA privacy rules in emergency situations. This will be reviewed and updated annually. Medicare compliance coordinator will monitor the implementation of the plan of correction with weekly documented meetings with administrator on progress.
485.727(c)(5) STANDARD
Information on Occupancy/Needs
Name - Component - 00
§403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7).
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:
(7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
*[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
*[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
Observations:
Based on a review of agency documentation, email correspondence, and staff interview, the facility failed to develop a communication plan that provided a means of providing information about the facility's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
Findings Included:
A review of facility documentation was conducted on 11/27/2018 at approximately 10:20 AM which revealed: The "OPERATIONS MANUAL SECTION J. DISASTER PREPAREDNESS." This plan did not contain evidence of a communication plan that provided a means of providing information about the facility's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. Facility failed to provide documentation to confirm facility had met this standard.
An interview was conducted with EMP2 on 11/27/2018 at approximately 10:20 AM, EMP2 was not aware of all emergency preparedness requirements. The surveyor reviewed a copy of the "State Operations Manual Appendix Z Emergency Preparedness for all Provider and Certified Supplier Types" with EMP2.
An exit interview with administrator and secretary on 11/27/2018 at approximately 3:00 PM confirmed the above findings.
Plan of Correction:We will develop and maintain a communication plan that provides information about our facilities needs and its ability to provide assistance to the Cambria County Disaster Coordinator, or other authorities having jurisdiction in our area during a disaster. Medicare compliance coordinator will monitor the implementation of the plan of correction with weekly documented meetings with administrator on progress. These procedures will be reviewed and updated annually.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey completed on 11/29/2018, Vantage Physical Therapy & 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:
485.721(a) STANDARD
PROTECTION OF CLINICAL RECORD INFORMATION
Name - Component - 00
The organization recognizes the confidentiality of clinical record information and provides safeguards against loss, destruction, or unauthorized use. Written procedures govern the use and removal of records and the conditions for release of information. The patient's written consent is required for release of information not authorized by law.
Observations:
Based on review of agency policy, observation (OBV) tours, and staff (EMP) interview, the agency failed to ensure medical records (MR) were stored and maintained in accordance with its policy and procedure for one (1) of two (2) agency (OBV) tours.
Findings included:
A review of agency policy on 11/26/2018 at approximately 11:00 AM which revealed, Policy "OPERATIONS MANUAL...SUBJECT: STANDARDS OF PRACTICE-CLINICAL RECORDS (agency) recognizes the fact that all clinical records are confidential and subsequently will be safeguarded against loss, destruction or unauthorized use...4. Storage of Files, When readily accessible file are completely filled and past records must be placed in storage; these clinical records shall be filed according to years and names of patients. Storage of these files is at the main facility and must be a secured location..."
During an observation tour of the extension site location on 11/27/2018, at 8:06 AM with EMP6 revealed, a set of stairs leading to the 2nd floor, the second floor consisted of a large open room which contained cardboard boxes of discharged patient clinical records. The cardboard boxes were stacked, and some were stored directly on the room's floor and spread out due to water damage. There were three points of access to the stairwell that led to the file storage area. No door was present at the bottom of the stairway which led to the file storage room leaving the area unsecured to anyone who had access to the stairwell.
Interview with administrator and secretary on 11/27/2018 at approximately 3:00 PM confirmed the above findings.
Plan of Correction:Contractor has been hired to build a walled room at the top of the stairs with a one door access that can be locked. Shelves will be assembled with files stored by year. Landlord was notified and he guaranteed all leakage in roof has been corrected. Administrator will be responsible for weekly check-ins with landlord and contractor to monitor project status. Storage areas will be added to the medicare compliance coordinator's annual checklist. Administrator will review this check list annually.
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 review of agency policy, observation (OBV) tours, and staff (EMP) interview, the agency failed to ensure medications and expired supplies were not accessible to patients, personnel, and the public for three (3) of ten (10) treatment rooms observed (#1, #2 and #7).
Findings Included:
A review of agency policy on 11/26/2018 at approximately 11:00 AM which revealed, Policy "OPERATIONS MANUAL...QUALITY ASSURANCE PLAN...C. Environment Related 3. A department analysis for safety will be done on a quarterly basis and the finding will be documented on the department safety checklist. The purpose of this is to assure that each department is in a safe condition for occupation by patients and staff. "
During an observation tour of the main location on 11/26/2018, at 1:32 PM with EMP7 revealed, three containers in treatment rooms 1, 2 and 7, with laboratory equipment and medications located in unsecured wall cabinets. The following expired lab equipment and medications are as followed:
Treatment Room #1
BD 8.5 ml Vacutainer Ref 367988 Lot 6106988-2017-04-30 (count 3)
3.5 ml vacutainer Ref 367981 5092735-2016-03
10.0 ml BD-Vacutainer 4087813 Exp 2016-03
Treatment Room 2
Lidocaine 1% Lot #69-206-DK Exp 9/1/18 50ml Multiple-dose
Depo-Medrol 40mg/ml 10ml multidose vial Lot R58818 Exp 07/2019
Note: the cap of the container was open and diaphragm was visible. No initial or date was visible to confirm when the vial was opened.
Methylprednisonlone 80 mg/ml 10ml Multidose vial Lot 31324762B Exp 9/19
Gabaurs Ethyl Chloride Fine Point Spray Lot 954 Exp 02/19
An exit interview with administrator and secretary on 11/27/2018 at approximately 3:00 PM confirmed the above findings.
Methylprednisonlone Acetate Inj Suspension 80 mg/ml 5ml Multiple dose vial Lot31324181B
Treatment Room 7
2% Lidocaine HCL 1000mg/ml Lot 74-357-DK Exp 1 Feb 2019
1% Lidocaine HCL 500mg /50ml 50 ml multiple dose Exp 1 Sep 2018
Note: the cap of the container was open and diaphragm was visible. No initial or date was visible to confirm when the vial was opened.
Depo-Medrol 80mg/ml 5ml multidose vial Lot T07607 Exp 01/2020
Note: the cap of the container was open and diaphragm was visible. No initial or date was visible to confirm when the vial was opened.
EMP1 confirmed the medications and supplies belonged to a physician who is renting space from the agency within the facility. An exit interview with administrator and secretary on 11/27/2018 at approximately 3:00 PM confirmed the above findings.
Plan of Correction:On days that offices are utilized by physicians, a checklist will be designed to insure that all areas in the clinic have been secured for the safety of patients and staff. These check lists will be reviewed quarterly for compliance. The facility director will sign off on this checklist before Vantage Physical Therapy patient's are permitted in treatment areas. Procedure has been implemented as of 1/3/2019.
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