Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on 10/18/2018, 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 10/18/2018, Novacare Outpatient 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:
485.723(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 review of agency policy, observation and staff (EMP) interview, the facility failed to ensure that the therapeutic pool was utilized in accordance with agency "Therapeutic Pool Safety" protocols for one (1) of one (1) therapeutic pool observation completed.
Findings:
Review of facility "Therapeutic Pool Safety" policy on 10/18/2018 at approximately 11:00 a.m. revealed "Non-electrical equipment must be inspected at least every 6 months. Electrical equipment must be inspected and calibrated at least annually."
An inspection of the Therapeutic Pool Lift on 10/18/2018 at approximately 11:15 revealed an inspection sticker that indicated an inspection was due 7/2015. Surveyor was unable to determine if any inspection had occurred 7/2015 or thereafter. The Therapeutic Pool Lift did not contain any type of seatbelt or other device to secure patients in the lift while in operation.
Interview with EMP1 on 10/18/2018 at approximately 1:00 p.m. confirmed findings.
Plan of Correction:TAG 0118
The aquatic lift will be inspected by qualified personnel by 11/1/2018. At that time, the administrator or designee will verify that the inspection sticker is in place and document is retained in the center handbook. The Center Manager or designee will schedule and insure annual inspections are completed and recorded on the Center Handbook Calendar Checklist. The Agency Administrator will verify completion with visual inspection of the sticker or review of the Calandar Checklist.
The Administrator or designee will replace the seatbelt on the Aquatic lift seat and insure the safety strap is fully functional and secured on or before 11/1/18. Seat belt inspection will be part of the annual inspection of the lift as described above.
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 and staff (EMP) interview, the facility failed to ensure that the therapeutic pool was maintained according to agency policy for one (1) of one (1) therapeutic pool observation completed.
Findings:
Review of facility Safety & Infection Control Procedures on 10/18/2018 at approximately 11:30 a.m. revealed policy #9.22 "Therapeutic Pool Cleaning and Maintenance... Policy All Select Medical centers that offer aquatic therapy service to patients will ensure that the therapeutic pool is cleaned and maintained on a regular schedule by trained personnel. Procedure 1) General Procedures: ...e) The designated staff member will document routine monitoring and maintenance of water quality and equipment....Monitoring and maintenance of water quality and equipment will include the following, at a minimum. i) Daily: 1) Check pH... 2) Test for sanitizer level (Bromide or Chlorine)... 3) Water clarity... 7) Pool temperature... Monthly: 1) Check calcium hardness... 2) As needed, check Oxidation-Reduction Potential (ORP).
Review of the "Water Quality Log" on 10/18/2018 at approximately 12:00 p.m. included a review of logs dated from 10/04/2017 through 10/18/2018.
Logs revealed no recorded "daily" data regarding pH, Bromide or Chlorine, Water clarity and pool temperature for the following dates:
10/13/2017
10/16/2017
10/17/2017
12/06/2017
12/08/2017
1/09/2018
1/19/2018
2/28//2018
3/07/2018
3/21/2018
3/29/2018
4/09/2018
5/24/2018
5/25/2018
5/29/2018
5/30/2018
5/31/2018
6/01/2018
6/14/2018
7/20/2018
8/10/2018
8/24/2018
Logs revealed no recorded "Monthly" data for calcium hardness or oxidation-Reduction Potential (ORP) from 10/04/2017 through 10/18/2018.
Interview with EMP1 on 10/18/2018 at approximately 1:00 p.m. confirmed findings.
Plan of Correction:TAG 0121
The Center Manager or designated staff member will perform and document routine monitoring and maintenance of water quality and equipment, including the aquatic lift seat and safety straps, as described in the Therapeutic Pool Cleaning and Maintenance Policy 9.22. The Sample Water quality log or equivalent will be used for documenting water quality and The Sample Pool Cleaning & Maintenance Log or equivalent will be used for documenting pool cleaning & maintenance. The Center Manager will monitor documentation of the water quality and pool cleaning and maintenance by monthly visual inspection of the Pool Water Quality Log and Pool Cleaning & Maintenance Log. The Administrator or designee will verify completion by reviewing the log monthly.
|