Initial Comments:
An onsite follow-up survey conducted on June 13, 2021, at the parent location of 1570 Egypt Road Suite 120, Phoenixville, PA 19460, and at the satellite location of 701 Pothouse Road, Phoenixville, PA 19460, found that Aquasport Physical Therapy, had corrected the following deficiency cited under 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 that was completed on April 27, 2022.
Plan of Correction:
Initial Comments:
An onsite follow-up survey conducted on June 13, 2022, at the parent location of 1570 Egypt Road Suite 120, Phoenixville, PA 19460, and at the satellite location of 701 Pothouse Road, Phoenixville, PA 19460, found that Aquasport Physical Therapy, had corrected the following conditional level deficiencies and was determined to be in substantial compliance 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. As a result of the survey, the conditional level citations have been lifted as verified onsite by full implementation of the plan of correction. The deficiencies were cited as a result of a Medicare recertification survey that was completed on April 27, 2022.
Plan of Correction:
485.721(b) STANDARD
CONTENT
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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 clinical record (CR) review and an interview with the Administrative Assistant, it was determined the Rehabilitation Center failed to ensure a discharge summary for five (5) out of five (5) clinical records reviewed (CR#1-CR#5).
Findings include:
CR#1-CR#5 were reviewed on 6/13/2022 from approximately 10:30 AM- 11:00 AM revealing the following:
CR#1 (Start of care: 1/7/22) Last physical therapy session was dated 1/19/2022. No documentation of a discharge summary in the record.
CR#2 (Start of care: 5/11/22) Last physical therapy session was dated 5/13/2022. No documentation of a discharge summary in the record.
CR#3 (Start of care: 5/23/22) Last physical therapy session was dated 6/01/2022. No documentation of a discharge summary in the record.
CR#4 (Start of care: 3/11/22) Last physical therapy session was dated 4/01/2022. No documentation of a discharge summary in the record.
CR#5 (Start of care: 12/15/2021) Last physical therapy session was dated 1/19/2022. No documentation of a discharge summary in the record.
An interview with the Administrative Assistant on 6/13/2022 at approximately 11:00 AM confirmed the above findings.
Plan of Correction:Documentation is the cornerstone of patient care. Proper documentation is critical in the complete care system.
Individual who have not returned to PT, or self-DC need to have closure in this documentation.
Individuals who see care through are provided a final evaluation and complete this closure.
Many past patients have not returned for various reasons. There needs to be a Final note documenting this scenario.
All current staff has been made aware of this policy. It will be noted in the Policy and procedure policy for all future personnel as well
Beginning 7-08-2022 each chart that is completed will have
1. A formal evaluation confirming DC or
2.***** A Type written DC that indicated the person did not return or respond to our outreach******.
This procedure will be checked for during the monthly chart review assuring future patient care integrity.
Executive Director and the assistant executive director will oversee this chart review and record in our monthly Medicare chart review form.
Deficits will be noted and corrective actions taken
485.725(b) STANDARD
ASEPTIC & ISOLATTION TECHNIQUES
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All personnel follow written procedures for effective aseptic techniques. The procedures are reviewed annually and revised if necessary to improve them.
Observations:
Based upon observation, and interview with Physical Therapist #1, it was determined the Rehabilitation Center failed to ensure disposal of opened syringes and needles (Observation #1).
Findings include:
Observations conducted at the Primary Site exam room on 6/13/2022 from approximately 11:30 AM- 12:00 PM revealed the following:
Observation #1: Three (3) opened syringes and two (2) opened syringes with capped needles in a locked toolbox.
An interview with Physical Therapist #1 on 6/13/2022 at 12:00 PM confirmed the above findings.
Plan of Correction:Proper medication and syringe handling/and use of Sharps containers ensure patient and staff safety. Needles that are not disposed of properly have potential to harm past and current patients, staff and visitors at our facility.
Proper use and disposal would prevent such occurrences in the future. And be the best practice for the safety of our staff as well as patients and visitors now and in the future.
0n 5-28-22 sharps containers were placed in each of our facilities. These are scheduled to be delivered on 5/28/22 these will be utilized to contain our used syringes.
This action will assure future patient safety. They can be confident that the needles and syringes are utilized and disposed of in the safest manor.
****Staff education has been conducted on
7-6-22 to ensure no unsealed needle/syringe is stored in any area of our office. This will include the lock box for syringe and medication storage.******
We have been monitoring the medical lock box on a quarterly basis since the time of our last inspection. We dispose of used needles/Expired medication and medication from those who have been DC'd or not returned for treatment and self-DC'd.
Failure to do this by AquaSport employees is a gross negligence. This responsibility falls upon the responsibility of the Executive Director or in their absence the assistant executive director.
We only utilize medication provided by the patient through a prescription from their physician. We do not provide any controlled medications. Each patient has their own vial of medication that is withdrawn via needle and used on disposable iontophoresis patches. No medication is injected in our facilities. The medication is put upon the Negative side while provided water packets are dispersed upon the positive side of the patch. These are then applied over the desired area as an in dwelling battery supplies the ion field to deliver the medication. (14) The needles should be emptied completely and needles disposed of in the sharps container in the adjacent joining office at Kimberton.
Patient safety is foremost in our practice. Proper monitoring of these products will ensure safety for all patients and staff.
485.725(c) STANDARD
HOUSEKEEPING
Name - Component - 00
The organization employs sufficient housekeeping personnel and provides all necessary equipment to maintain a safe, clean, and orderly interior. A full-time employee is designated as the one responsible for the housekeeping services and for supervision and training of housekeeping personnel.
An organization that has a contract with an outside resource for housekeeping services may be found to be in compliance with this standard provided the organization or outside resource both meet requirements of the standard.
Observations:
Based upon policy and procedure review, observation, and interview with the administrative assistant, it was determined the Rehabilitation Center failed to ensure documenation of weekly cleanings for the extension site for 6/10/2023-6/13/2022 and failed to ensure documentation of daily hydrocollator temperature checks for the extension site for 6/10/2022-6/13/2022 (Observation #2).
Review of policy and procedure manual revealed a facility weekly cleaning checklist for each month. There was no documenation of the checklist utilized for the extension location.
Observation #2, 6/13/2022 at approximately 10:25 AM, revealed a working in use hydrocollator at the extension site. No temperature logs were available for review upon request.
An interview with the administrative assistant on 6/13/2022 at approximately 11:00 AM confirmed the above findings.
Plan of Correction:Weekly cleanings
Quarterly report logs for infection control have been kept for 20 years
Clean and safe offices are mandatory for Patient safety and well-being.
We will have a cleaning log weekly to indicate continued cleaning our facilities.
***** These logs have been updated since June 2022 at each of our facilities. Logs have been placed in obvious locations and are available for documentation viewing at all time.*****
Failure to perform this act would put patients in jeopardy as confirmation of this practice is lacking in the written form.
#4 Heat modality maintenance is imperative for patient safety and minimize risk of infection. The constant need for cleaning/water fill and rust stain continues to be a weekly endeavor. #6 The hard water present in our area makes these tasks more challenging. we need to consistently clean the lid and tongs using lime away to prevent scaling and rust stains/Deposits. A new hydrocollator has been purchased and will be inspected and put into service after 5-26-21 We will increase and record the cleaning and maintenance efforts.
***** A weekly cleaning and temperature log will be kept in addition to the water temperature log*****.
No patients have had complications from use of our heat modalities.
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