Initial Comments:
Based on the findings of an unannounced Medicare survey conducted August 13-15, 2018, Novacare Outpatient Rehabilitation, located at 1800 Village Circle, Lancaster, Pa. 17603 and an extension location at 4243 Oregon Pike, Ephrata, Pa. 17601 was found 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 CONDITION
Establishment of the Emergency Program (EP)
Name - Component - 00
§403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12
The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements:
* (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.)
*[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:
*[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:
Observations:
Based on an interview with the facility market manager and a review of facility policy, the facility failed to provide documentation of a comprehensive approach to meeting the health and safety needs of a patient population encompassing the elements for emergency preparedness planning, based on the "all-hazards" definition and specific to the location of the facility.
Findings:
A review was conducted of facility policy on August 13, 2018 at approximately 1:00 p.m. Form 9.30 'All Hazards Continuity of Operations (COOP) Plan' states "Each center will implement an All Hazards COOP and Emergency Plan in accordance with the procedures outlined below". Documentation of a facility specific emergency preparedness plan was requested. None could be provided. A corporate wide policy/procedure was provided.
An interview with the facility market manager on August 15, 2018 at approximately 12:15 p.m. confirmed the above findings.
Plan of Correction:An approved Plan of Correction is not on file.
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 three (3) of eight (8) EFs reviewd (EF#1, EF#4, EF#7).
Findings:
A review was conducted of facility policy on August 13, 2018 at approximately 1:00 p.m. Policy 9.02 'Fire Safety and Evacuation Plan' 'Procedure' section #1 states "The center manager is responsible for ensuring and documenting that fire emergency drills involving the entire staff are held annually at a minimum, when new employees are hired and if the plan changes".
A review of employee files was conducted on August 13, 2018 between approximately 12:00 p.m. - 3:00 p.m. Employee date of hire (DOH) is listed below:
EF#1 01/19/81: No documentation of employee emergency and disaster preparedness and procedures training being conducted annually in 2016 and 2017.
EF#4 03/18/15: No documentation of employee emergency and disaster preparedness and procedures training being conducted annually in 2016 and 2017.
EF#7 07/21/04: No documentation of employee emergency and disaster preparedness and procedures training being conducted annually in 2016.
An interview with the facility market manager on August 15, 2018 at approximately 12:15 p.m. confirmed the above findings.
Plan of Correction:An approved Plan of Correction is not on file.
Initial Comments:
Based on the findings of an onsite unannounced follow-up survey completed August 31, 2018, Novacare Outpatient Rehabilitation had corrected the condition level deficiency cited under 42 CFR, Chapter IV, Subpart H, Conditions of Participation for Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services. The Immediate Jeopardy identified was abated at approximately 2:30PM. As a result of the survey, the clinic located at: 1800 Village Circle was determined to be in substantial compliance. The deficiencies and the Immediate Jeopardy were initially cited as a result of a recertification survey completed August 15, 2018.
Plan of Correction:
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, the facility failed to ensure there is a center-specific plan for pool evacuation and rescue in case of emergency, per policy; facility failed to include in the patient discharge summary information regarding the patient status at the time treatment was initiated.
Findings:
A review was conducted of facility policy on August 13, 2018 at approximately 1:00 p.m. 'Therapeutic Pool Safety' 'Staff preparation for an aquatic emergency' states "Center Manager will ensure there is a center specific plan for pool evacuation and rescue in case of an emergency". Policy 5.22 'Discharge Summary' 'Procedure' section 1 states "The discharge summary shall be documented and must include the following: ..........". Section 2 states "The discharge summary may include the following: ......".
No documentation provided of a center specific plan for pool evacuation and rescue in case of an emergency.
Interpretive Guidelines for 485.721(b) 'Content' section 'A-General' state "The discharge summary should contain ........, information regarding the patient status at the time treatment was initiated, ..........". The facility Discharge Summary Form does not include information regarding the patient status at the time treatment was initiated.
An interview with the facility market manager on August 15, 2018 at approximately 12:15 p.m. confirmed the above findings.
Plan of Correction:An approved Plan of Correction is not on file.
485.721(b) STANDARD
CONTENT
Name - Component - 00
The clinical record contains sufficient information to identify the patient clearly, to justify the diagnosis(es) and treatment, and to document the results accurately. All clinical records must contain the following general categories of data:
(1) Documented evidence of the assessment of the needs of the patient, of an appropriate plan of care, and of the care and services furnished.
(2) Identification data and consent forms.
(3) Medical history.
(4) Report of physical examinations, if any.
(5) Observations and progress notes.
(6) Reports of treatments and clinical findings.
(7) Discharge summary including final diagnosis(es) and prognosis.
Observations:
Based on an interview with the facility market manager, review of facility policy and clinical records (CR), facility failed to ensure a discharge summary was completed within thirty (30) days of the end of the plan of care for two (2) of two (2) CRs reviewed (CR#1, CR#9); the facility failed to ensure a discharge summary was completed on two (2) of twenty five (25) CRs reviewed (CR#16, CR#19).
Findings:
A review was conducted of facility policy on August 13, 2018 at approximately 1:00 p.m. Policy 5.22 'Discharge Summary' 'Policy' states: A discharge summary shall be written within thirty (30) days of the end of the current plan of care by a therapist".
A review of CRs was conducted on August 14, 2018 between approximately 9:00 a.m. - 2:00 p.m. Patient start of care (SOC) is listed below:
CR#1 SOC 12/15/17: Patient discharged from facility on 04/11/18. Patient discharge summary completed on 08/13/18.
CR#9 SOC 05/29/18: Patient discharged from facility on 07/11/18. Patient discharge summary completed on 08/13/18.
CR#16 SOC 05/29/18: Patient discharged from facility. No actual discharge date could be provided. No discharge summary completed. Per the facility market manager, this patient is no longer on the active patient list.
CR#19 SOC 02/21/18: Patient discharged from facility 04/4/18. No discharge summary completed.
An interview with the facility market manager on August 15, 2018 at approximately 12:15 p.m. confirmed the above findings.
Plan of Correction:An approved Plan of Correction is not on file.
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/shower-locker room observations, the facility failed to ensure these areas 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) and two (2) of two (2) shower-locker rooms observed (Observation #3-#4).
Findings:
Observations were conducted of patient use restrooms in the main lobby area and patient use shower-locker rooms on August 13, 2018, between approximately 9:30 a.m. - 10:30 p.m. The following was revealed:
Observation #1-#2: Two restrooms (utilized by patients and staff) in the main facility lobby area located at: 1800 Village Circle Lancaster, Pa 17603 did not have any method of summoning assistance if needed by unattended patients.
Observation #3-#4: The male shower-locker room and the female shower-locker room(utilized by patients) located at: 1800 Village Circle Lancaster, Pa 17603 did not have any method of summoning assistance if needed by unattended patients nor emergency exit lighting.
An interview with the facility market manager on August 15, 2018 at approximately 12:15 p.m. confirmed the above findings.
Plan of Correction:An approved Plan of Correction is not on file.
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, review of facility policy, and treatment room observations, the facility failed to ensure treatment room equipment was calibrated on an annual basis for four (4) of four (4) treatment room equipment observations (Observation #1-Observation#4).
Findings:
A review was conducted of facility policy on August 13, 2018 at approximately 1:00 p.m. revealing the following: Policy # 9.18, "Therapeutic Equipment Cleaning and Maintenance" Policy: "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 cleaned and/or replaced as frequently as needed to maintain a sanitary environment".
Treatment floor observations were conducted on August 13, 2018, between approximately 9:30 a.m. - 10:30 p.m. located at: 1800 Village Circle Lancaster, Pa 17603. The following was revealed:
Observation #1: Unit: Paraffin Heat Therapy machine (serial #009189) in occupational therapy area: "Last Test 4/25/17".
Observation #2: Unit: Hydrocollator machine (control #006902) in facility boiler room: "Last Test 4/25/17".
Observation #3: Unit: Freezer (control #003864) in facility boiler room: "Last Test 4/25/17".
Observation #4: Unit: Weight Scale (serial #MMR12287) in physical therapy treatment area: "Last Service 08/18/10, next Due 08/-/2011".
An interview with the facility market manager on August 15, 2018 at approximately 12:15 p.m. confirmed the above findings.
Plan of Correction:An approved Plan of Correction is not on file.
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