Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on August 23, 2021 through August 24, 2021, at the parent location of 860 Lancaster Avenue, Devon, PA 19333, and August 23, 2021, at the satellite location of 785 Starr Street Suite 107, Phoenixville, PA 19333, Novacare Outpatient Rehabilitation, 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 August 23, 2021 through August 24, 2021, at the parent location of 860 Lancaster Avenue, Devon, PA 19333, and August 23, 2021, at the satellite location of 785 Starr Street Suite 107, Phoenixville, PA 19333, Novacare Outpatient Rehabilitation, was identified to have the following standard level deficiencies 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:
485.713(b) STANDARD
FACILITIES AND EQUIPMENT
Name - Component - 00
The organization has the equipment and facilities required to provide the range of services necessary in the treatment of the types of disabilities it accepts for service.
Observations:
Based on observations, rehabilitation center policy review, and an interview with the rehabilitation center administrator it was determined the rehabilitation center failed to ensure patient treatment tables to be maintained (Observation #4)
Findings include:
Review of rehabilitation center policies conducted on August 23, 2021, at approximately 1:00 P.M. revealed the following:
Policy #9.18 titled "Therapeutic Cleaning and Maintenance" states, " All equipment used for the provision of patient care services will be maintained and tested to ensure safe operation and for the prevention of injury to patients and employees. All therapeutic equipment must be cleaned and/or replaced as frequently as needed to maintain a sanitary environment...."
"Procedure: 11) Reusable Supplies (i.e., Thera-Band, rice and beans, putty, etc.) a) Inspect for tears and cracks, and replace when necessary for patient safety and the prevention of infection.
Observations of patient treatment areas of the rehabilitation center were conducted on 8/23/2021 from approximately 11:45 AM- 12:30 PM revealing the following:
Observation #4: Five (5) out of Six (6) patient treatment tables located in the patient treatment area contained tears and worn areas of surface cover (Treatment table #1- Treatment table #5) (Phoenixville Location).
An interview with the rehabilitation center Marketing Manager on 8/23/2021 at approximately 1:30 PM confirmed the above findings.
Plan of Correction:Center Manager(CM) will contact Flagship management & schedule repair of all furniture requiring repair of tears/rips. Upon completion, invoice or work order will be retained in center handbook. CM will perform monthly visual inspection of all furniture and remove any from service that are ripped until repair or replaced. Monthly inspections will be marked as complete on the center handbook calendar checklist (CHCC). Market manager (MM) will review CHCC quarterly to verify task completion.
Flagship Management 6-8 week timeframe given
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 upon observation, rehabilitation center policy and procedure review, and an interview with the rehabilitation center Marketing Manager, it was determed the rehabilitation center failed to ensure disposal of expired medications (Observation #1-Observation #3).
Review of policy 9.24; Storage and Disposal of Medications conducted on 8/23/2021 between approximately 10:30 AM and 11:30 AM read:
"Policy: 1. Medication storage: c) Medications will be monitored with each use for expiration dates...
Observations of patient treatment areas of the rehabilitation center were conducted on 8/23/2021 from approximately 11:45 AM- 12:45 PM revealing the following:
Observation #1: Normal Saline Solution 0.9%, 100 mL bottles, expired 8/03/2020 (1), expired 10/29/2020 (2), expired 4/09/2021 (3), located in cabinet #1 in Patient Treatment Area. (Phoenixville Location).
Observation #2: Hypergel 20% sodium chloride 0.17 ounce tube, expiration date 4/2015, located in cabinet #1 in Patient Treatment Area. (Phoenixville Location).
Observation #3: Hygea Sterile Saline wipes, 2 boxes, expiration date 7/2021, located in cabinet #1 in Patient Treatment Area. (Phoenixville Location).
An interview with the rehabilitation center Marketing Manager on 8/23/2021 at approximately 1:30 PM confirmed the above findings.
Plan of Correction:CM will inspect all supplies and medication in the center for marked expiration dates and dispose of expired supplies/medications and dispose accordingly. Clinicians will be trained to verify supplies / medications are not expired prior to using with a patient. To prevent having expired supplies/ medications in future, The CM or designee will perform monthly inspections and log inspections on the center handbook calendar checklist (CHCC). Market manager (MM) will review CHCC quarterly to verify task completion.
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 policies, equipment cleaning and maintenance logs and an interview with the rehabilitation center Marketing Manager, it was determined the rehabilitation center failed to ensure documentation of routine quarterly cleanings for two (2) out of (2) two hydrocollator machines (H unit #1 and H unit #2), failed to ensure quarterly cleaning for one (1) paraffin wax bath machine (P unit #1), and failed to ensure quarterly cleanings for two (2) out of two (2) cold pack units (C unit #1 and C unit #2) for 2020 and 2021, and failed to ensure biohazard waste receptacle to be covered with a lid (Observation #5).
Findings include:
Review of Policy 9.18 THERAPEUTIC EQUIPMENT CLEANING AND MAINTENANCE conducted on 8/23/2021 at approximately 1:00 PM states "3. Cold Pack Unit: Once every three months, or as needed, the Cold Pack Unit will be defrosted...c. once defrosted and drained, the inside and outside of the cold pack unit will be cleaned...."
Review of Policy 9.20 PARAFFIN BATH CLEANING AND MAINTENANCE, conducted on August 23, 2021 at approximately 1:15 PM revealed; Policy: "The paraffin bath is cleaned and the paraffin wax replaced every three months or sooner depending upon manufacturer recommendations and patient use". Procedure: 1) "Refer to manufacturer recommendations for specific instructions for the procedure for replacing the wax".
Review of Policy 9.19 HYDROCOLLATOR MACHINE MAINTENANCE AND CLEANING Procedure conducted on August 23, 2021 at approximately 1:10 PM at approximately 2:00 p.m. states "Hydrocollator machines must be cleaned at least quarterly or more frequently as necessary."
Review of Policy #9.12 HAZARDOUS MATERIALS AND COMMUNICATION EXPOSURE PLAN on August 23, 2021, at approximately 1:05 P.M. stated, "VI) Handling of Biohazardous Waste: B) Hazardous waste, or any PPE that may contain hazardous materials, are placed in containers which are closable, constructed to contain all contents and prevent leakage, appropriately color-coded or labeled with a biohazard label, and closed prior to removal to prevent spillage or protrusion of contents during handling..."
Review of EQUIPMENT CLEANING & MAINTENANCE LOGS for 2020 and 2021 on August 23, 2021 at approximately 12:30 PM revealed:
1. H Unit #1- no documented cleanings (Phoenixville).
2. H Unit #2 - documented cleanings on 12/29/2020 and 4/20/2021 (Devon).
3. P Unit #1-- no documented cleanings (Phoenixville).
4. C Unit #1- no documented cleanings or defrosting (Phoenixville).
5. C Unit #2- Defrosting documented on 1/08/2020, 3/02/2020, 8/18/2020. No documented cleanings (Devon).
Observations of patient treatment areas of the rehabilitation center were conducted on 8/23/2021 from approximately 11:45 AM- 12:30 PM revealing the following:
Observation #5: Observation of Exam Room #1 revealed a cardboard box lined with a biohazard bag, with no cover/lid (Phoenixville location).
An interview with the rehabilitation center Marketing Manager on 8/23/2021 at approximately 1:30 PM confirmed the above findings.
Plan of Correction:As per Clinical Policy 9.18, 9.19 & 9.20 – for cleaning & maintenance of hydocollator, cold pack unit & paraffin. This will occur quarterly by PT staff and documented using Form 9.17 as per policy. It will be retained in center Handbook & task completion will be recorded in center handbook calendar checklist (CHCC). CM will review quarterly to verify task completion.
Trash container purchased on 8/30 with lid/foot pedal to open/close to safely and isolate biohazard waste.
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