Initial Comments:
Based on the findings of an unannounced Medicare recertification survey conducted on June 4, 2018, Novacare Outpatient Rehabilitation, was found not to be in compliance with the following requirement of 42 CFR, Part 485.707, Subpart D, Conditions of Participation: Outpatient Physical Therapy-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 a review of facility policies/procedures, documentation, and interview with the administrator, the facility failed to develop an emergency preparedness plan ("Continuity of Operations Plan (COOP))".
Findings include:
On June 4, 2018 at 2:20 PM, review of facility policy 9.03, titled "Continuity of Operations Plan (COOP)" revealed the following:
"Policy...All centers will have an Emergency Plan for continuity of operations in the event of a severe hazard that impacts normal business processes. The plan will include facility personnel names and contact information, state and local emergency contacts as needed, and a facility organizational chart...
Procedure...
1) The Emergency Plan includes:
a) Facility personnel names and contact information
b) Contact information of local and/or state emergency managers as needed
c) Facility organizational charts
d) Any considerations of building construction/presence of Life Safety Systems (extinguishers/sprinkler systems, earthquake protection systems), etc.
e) Specific information about the characteristics and needs of individuals for whom care is provided...
3) The Center Manager will maintain, review, and update center specific information within the All Hazards COOP as required, and ensure compliance with all procedures..."
On June 4, 2018 at 1:07 PM, review of "Patient Care Committee Meeting Minutes" dated March 30, 2017 and December 12, 2017, which included reports from the "Quality Assurance Management Sub-Committee", failed to reveal that the facility had developed a "Continuity of Operations Plan (COOP)" as required under facility policy 9.03.
During telephone interview on June 4, 2018 at 2:25 PM, the administrator confirmed that the facility failed to develop a "Continuity of Operations Plan (COOP)" as required under facility policy 9.03.
Plan of Correction:Plan of Correction for observation #0006
As part of our existing Clinical Policy #9.30 – Continuity of Operations Plan (COOP),The center manager will document the required local market information on page #3, section 10 of the plan, that will include location of facility personnel names and contact information, local emergency management contact name & phone # - including date contacted, and the location of the facilities organizational chart on or before June 29th 2018. After completing the plan, the center manager will review the plan with all center staff, and conduct a center specific drill on or before 7/3/2018. The drill report will be documented on the Emergency Drill Report – form #9.09, and maintained in section #9 of the center handbook. Completion of the COOP plan and drill will be verified in the Center Handbook Calendar Checklist by the center manager and available for review by local market leadership (market manager or Regional director of Operations). The COOP plan will reviewed and the drill conducted by the center manager annually, in the First Quarter prior to the Patient Care committee meeting, so results can be discussed at the meeting. The annual plan review and drill report will be documented on form #9.09 and maintained in the center handbook. Completion of the annual review and drill will be indicated in the Center Handbook Calendar Checklist and available for review by local market leadership (market manager or Regional Director of Operations).
Initial Comments:
Based on the findings of an unannounced Medicare recertification survey conducted on June 4, 2018, Novacare Rehabilitation was found to be in 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:
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