Initial Comments:
Based on the findings of an onsite unannounced revisit completed on August 16, 2018, Momentum Therapeutics was identified to have the following standard level deficiency that was 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. The deficiency was cited as a result of a Medicare recertification survey completed July 3, 2018. The condition level deficiency was corrected.
Plan of Correction:
485.727(c)(3) STANDARD
Primary/Alternate Means for Communication
Name - Component - 00
§403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3).
[(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:
(3) Primary and alternate means for communicating with the following:
(i) [Facility] staff.
(ii) Federal, State, tribal, regional, and local emergency management agencies.
*[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies.
Observations:
Based on review of facility's plan of correction, emergency preparedness plan, and staff (EMP) interview, the facility failed to ensure the communication plan included an alternate means of communicating with facility staff for three (3) of 13 staff (EMP7, EMP8, & EMP9).
Findings included:
Review of facility's plan of correction on August 15, 2018, showed, "Communication with staff members will be done by text message as the primary, followed in order by cell phone calls and land line calls." Correction date was 7/31/2018.
Review of "Momentum Therapeutics Emergency Preparedness Plan" on August 16, 2018, at 9:17 a.m. showed facility's order of succession to include EMP2 (owner) as primary followed by EMP8 (physical therapy assistant [PTA]). EMP8's contact information listed a phone number with no other means of communication.
"EPP 1.1 Authority:" listed contact information for facility's incident command. The person listed as "Back-up 1 (if primary is not in facility) [EMP8]" contained a phone number, but the "Secondary way to contact" portion of the incident command form was blank.
"Employees of Momentum Therapeutics: ... EPP 5.0" showed contact information for 13 employees.
EMP7's (physical therapist) information listed a cell phone number with no other means of communication.
EMP8's (PTA) information listed a cell phone number with no other means of communication.
EMP9's (physical therapy aide) information listed a cell phone number with no other means of communication.
Interview with EMP4 (office manager) on August 16, 2018, at 11:00 a.m. confirmed above findings.
Plan of Correction:Additional means of communication have been listed for all employees, including landline, cell number, and email addresses. This was completed on the day of inspection. The Office Manager will be responsible for updating the communication sheet whenever an employee leaves our employment or is hired. The staff has been advised that they need to advise the Office Manager whenever they have a change in their phone numbers or email addresses. The Office Manager will also be responsible for reviewing (and modifying if necessary) the list on a yearly basis.
Initial Comments:
Based on the findings of an onsite unannounced revisit completed August 16, 2018, Momentum Therapeutics had corrected the deficiencies cited under 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. The deficiencies were cited as a result of a Medicare recertification survey completed July 3, 2018.
Plan of Correction:
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