Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on 5/17/2019, Phoenix Rehabilitation & Health Services Inc was found to have the following standard level deficiency that was determined to be in substantial compliance with the following requirement 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(d)(2) STANDARD
EP Testing Requirements
Name - Component - 00
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).
*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:
(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:
(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.
*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.
*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.
*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.
*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.
*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.
*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.
*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.
Observations:
Based on review of emergency preparedness plan and staff interview (EMP), it was determined that the facility failed to conduct an additional full-scale or tabletop exercise to test the Emergency Preparedness Plan.
Findings included:
A review of agency policy on 5/16/2019 at approximately 10:42 AM revealed: "DOCUMENT REFERENCE ID: COTR-1225...POLICY TITLE: EMERGENCY PREPAREDNESS: POLICIES AND PROCEDURES...2. PROCEDURES...2.1.2 Conduct Emergency Preparedness Testing: 2.2.2.1 (agency) will participate in a full-scale exercise that is community-based or if a community-based exercise is not accessible, an individual, facility-based. If (agency) experiences an actual natural or man-made emergency that requires activation of the Emergency Plan, we are exempt (per CMS) from engaging in a community based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event. 2.1.2.2 (agency) will conduct an additional exercise that may include but is not limited to the following: 2.1.1.1.1 (a) A second full scale exercise that is community-based or individual, facility-based. 2.1.2.2.2 (B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan..."
During a staff interview conducted on 5/16/2019 at approximately 12:10 PM with (EMP2) confirmed that the agency did not conduct a second emergency preparedness exercise.
The agency did not provide documentation of a second full-scale or tabletop exercise. No other documentation of a community-based, individual, facility-base, or a tabletop exercise that includes documentation a second drill was provided.
An exit interview with the chief compliance officer and director of compliance on 5/16/2019 at approximately 4:11 PM confirmed the above findings.
Plan of Correction:1. What corrective action will be accomplished for those individuals and/or practices identified in the deficiency statement(s)?
1.1. Ensure a second full-scale or tabletop exercise is performed for calendar-year 2019 in all locations, and annually thereafter.
1.1.1. Tracking will be achieved by means of online-based proof-of-completion submitted by each facility director to the Director of Compliance. Additionally, the onsite sign-in sheet showing staff member attendance and/or review of the results of the second full-scale or tabletop exercise will be submitted to the Director of Compliance.
1.1.2. Director of Compliance will monitor completion and follow-up with respective facility directors as needed.
1.1.3. Director of Compliance will review submission information to note potential deficiencies and provide guidance for proper procedural elements as needed.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
2.1. Ensure a second full-scale or tabletop exercise is performed for calendar-year 2019 in all locations, and annually thereafter.
2.1.1. Tracking will be achieved by means of online-based proof-of-completion submitted by each facility director to the Director of Compliance. Additionally, the onsite sign-in sheet showing staff member attendance and/or review the results of the second full-scale or tabletop exercise will be submitted to the Director of Compliance.
2.1.2. Director of Compliance will monitor completion and follow-up with respective facility directors as needed.
2.1.3. Director of Compliance will review submission information to note potential deficiencies and provide guidance for proper procedural elements as needed.
3. What measures (actions/forms/system changes, etc.) will be put in place to ensure that the deficient practice does not recur?
3.1. Formalize performance of both components of the Emergency Preparedness Program with mandatory scheduled in-services covering this information. The month of March will cover the initial full-scale emergency drill, and the month of June will cover the second full-scale and/or tabletop exercise.
3.1.1. Tracking will be achieved by means of online-based proof-of-completion submitted by each facility director to the Director of Compliance. Additionally, the onsite sign-in sheet showing staff member attendance and/or review the results of the second full-scale or tabletop exercise will be submitted to the Director of Compliance.
3.1.2. Director of Compliance will monitor completion and follow-up with respective facility directors as needed.
3.1.3. Director of Compliance will review submission information to note potential deficiencies and provide guidance for proper procedural elements as needed.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance programs will be established/followed?
4.1. The Director of Compliance and PHOENIX Rehabilitation and Health Services (PRHS) safety committee will review submission results to assess deficiencies and provide guidance to the facility directors.
4.2. The findings will be used to review and update the current emergency program, quality and safety policies to ensure compliance and relevance based on review. This will occur following the mandatory annual drill and exercise completion in March and June.
5. Date of when the corrective action will be completed.
5.1. The corrective actions will be completed by 07-12-19.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed 5/17/2019, Phoenix Rehabilitation & Health Services Inc. was found to have the following standard level deficiency that was determined to be in substantial compliance with the following requirement 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. The survey was conducted at the Phoenix Rehabilitation and Health Services Cresson parent location on 5/15/2019 to 5/16/2019, and the Phoenix Rehabilitation and Health Services Johnstown and Portage extension locations on 5/16/2019.
Plan of Correction:
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, aquatic logs 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 included:
A review of agency policy on 5/16/2019 at approximately 12:42 PM revealed: "DOCUMENT REFERENCE ID: COTR-1202...POLICY TITLE: AQUA ARK/AQUATIC REHAB POOL MAINTENANCE...2. PROCEDURE 2.1 Aqua Ark 2.1.1 Daily Maintenance 2.1.1.1 Chemical levels: A designated staff member will utilize a kit to test the following level two times per day: 2.1.1.1.1 PH level (normal level= (7.2-7.6) 2.1.1.1.2 Alkalinity level (normal level=(125-175 PPM) 2.1.1.1.3 Bromine level (normal level=(4-6 PPM) 2.1.1.1.4 Calcium hardness level (normal level=175-250 PPM) 2.1.1.2 The test results and any adjustment made to the Ark will be recorded in the daily log and will be accessible to all technicians...2.1.1.4 Pool Temperature: The Aqua Ark temperature will be checked two times per day by a designated staff member and recorded in the daily log. The Aqua Ark temperature will be maintained between 92 and 94 degrees Fahrenheit...2.4 Compliance 2.4.1 Use and maintenance of the Aqua Ark, rehabilitation pool and whirlpool will comply with the local county health department's rules and regulations..."
Review of the "Therapeutic Pool Checks" on 5/16/2016 at approximately 8:40 PM included a review of logs dated from 2/6/2019 through 5/15/2019.
Logs revealed daily recorded pool temperature not within agency parameters for the following dates:
2/6/2019 through 2/8/2019 95 degrees Farenheit
2/12/2019 through 2/13/2019 95 degrees Farenheit
2/19/2019 91 degrees Farenheit
2/21/2019 90 degrees Farenheit
2/25/2019 91 and 95 degrees Farenheit
2/27/2019 no readings
4/15/2019 through 4/17/2019 95 degrees Farenheit
4/23/2019 95 degrees Farenheit
5/14/2019 95 degrees Farenheit
Logs revealed daily recorded Bromine levels not within agency parameters for the following dates:
2/6/2019 through 2/8/2019 10 PPM
2/11/2019 9 and 8 PPM
2/12/2019 8 and 8 PPM
2/19/2019 and 2/21/2019 2 PPM
2/25/2019 through 2/282019 under 4 PPM
3/18/2019 through 3/20/2019 under 4PPM
3/27/2019 through 3/29/2019 10 PPM
4/1/2019 through 4/5/2019 10 PPM
4/8/2019 through 4/10/2019 10 PPM
4/11/2019 through 4/12/2019 7 PPM
4/18/2019 through 4/19/2019 3 PPM
4/23/2019 through 4/25/2019 under 4 PPM
4/29/2019 through 5/3/2019 10 PPM
5/6//2019 10 PPM
5/7/2019 9 PPM
5/8/2019 10 and 7 PPM
5/13/2019 through 5/15/2019 under 4 PPM
Logs revealed daily recorded PH levels not within agency parameters for the following dates:
2/28/2019 7.2
3/4/2019 through 3/6/2019 7.2
3/8/2019 7.2
3/19/2019 through 3/22/2019 7.8
3/25/2019 through 3/29/2019 above 7.6
4/1/2019 through 4/3/2019 above 7.6
Logs revealed daily recorded Alkalinity not within agency parameters for the following dates:
2/13/2019 120 PPM
2/19/2019 120 PPM
2/21/2019 120 PPM
3/6/2019 through 3/7/2019 under 125 PPM
3/11/2019 through 3/12/2019 120 PPM
3/18/2019 through 3/22/2019 under 125 PPM
3/26/2019 120 PPM
4/5/52019 120 PPM
4/8/2019 through 4/12/2019 under 125 PPM
4/15/2019 through 4/16/2019 under 125 PPM
4/23/2019 through 4/26/2019 120 PPM
4/29/2019 through 5/3/2019 120 PPM
5/6/2019 through 5/7/2019 110 PPM
5/10/2019 120 PPM
5/13/2019 120 PPM
Logs revealed a missing reading to be completed twice a day in the required five categories listed on the "Therapeutic Pool" logs for the following dates:
2/8/2019
2/15/2019
2/19/2019
2/21/2019
2/25/2019
2/28/2019
3/6/2019
3/8/2019
3/14/2019
3/15/2019
3/22/2019
3/29/2019
4/5/2019
4/12/2019
4/19/2019
4/26/2019
4/29/2019
5/3/2019
5/7/2019
5/10/2019
5/13/2019
An exit interview with the chief compliance officer and director of compliance on 5/16/2019 at approximately 4:11 PM confirmed the above findings.
Plan of Correction:1. What corrective action will be accomplished for those individuals and/or practices identified in the deficiency statement(s)?
1.1. Policy revision to include exceptions to the twice-daily temperature and chemical monitoring for occasions of scheduled half-day, closures, and/or no patient use. The documentation of these occasions will be included on therapeutic pool checks.
1.2. Distribution of revised policy, mandatory review of policy and proof of in-service will be required by all sites with therapeutic pools.
1.3. Director of Compliance will monitor completion and follow-up with respective facility directors as needed.
1.4. Director of Compliance will review submission information to note potential deficiencies and provide guidance for proper procedural elements as needed.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
2.1. All sites with therapeutic pools will be required to submit the last 60 days of therapeutic pool check logs to identify the potential deficient practice.
2.1.1. Director of Compliance will review submission information to note potential deficiencies and provide guidance and oversight for proper procedural elements as needed.
3. What measures (actions/forms/system changes, etc.) will be put in place to ensure that the deficient practice does not recur?
3.1. Policy revision to include exceptions to the twice-daily temperature and chemical monitoring for occasions of scheduled half-day, closures, and/or no patient use. The documentation of these occasions will be included on therapeutic pool checks.
3.1.1. Tracking will be monitored through the annual onsite mock survey process for all rehab agency offices performed by the Compliance Specialist.
3.1.2. Director of Compliance will review findings to note potential deficiencies and provide guidance and oversight for proper procedural elements as needed.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance programs will be established/followed?
4.1. Policy revision to include exceptions to the twice-daily temperature and chemical monitoring for occasions of scheduled half-day, closures, and/or no patient use. The documentation of these occasions will be included on therapeutic pool checks.
4.1.1. Tracking will be monitored through the annual onsite mock survey process for all rehab agency offices performed by the Compliance Specialist.
4.1.2. Director of Compliance will review findings to note potential deficiencies and provide guidance and oversight for proper procedural elements as needed.
5. Date of when the corrective action will be completed.
5.1. The corrective actions will be completed by 07-12-19.
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