Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on July 21, 2020, at the parent location of 78 Second Avenue, Collegeville, PA, 19426, and July 22, 2020, at the satellite location of 451 Baltimore Pike, Springfield, PA 19064, and off-site on July 24, 2020, 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 on July 21, 2020, at the parent location of 78 Second Avenue, Collegeville, PA, 19426, and July 22, 2020, at the satellite location of 451 Baltimore Pike, Springfield, PA 19064, and off-site on July 24, 2020, Novacare Outpatient Rehabilitation, was identified to have the following standard level deficiencies and was 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:
485.709(c) STANDARD
PERSONNEL POLICIES
Name - Component - 00
Personnel practices are supported by appropriate written personnel policies that are kept current. Personnel records include the qualifications of all professional and assistant level personnel, as well as evidence of State licensure if applicable.
Observations:
Based on a review of personnel files, rehabilitation center policy, and email communication with Regional Director of Operations, the rehabilitation center failed to provide documentation of initial and/or annual Tuberculosis screening according to rehabilitation center policy for four (4) of six (6) personnel files (PF) reviewed at the Collegeville, PA location (PF #1, 3, 4, and 6) and five (5) of five (5) PF reviewed at the Springfield, PA location (PF #1 - 5).
Findings include:
Review of rehabilitation center policy #9.10 titled "Infection Control and Asepsis" on July 22, 2020, at approximately 1:00 P.M. stated, "Procedure: 5) All new employees will have a Tuberculosis Skin Test (TST) within 10 days of hire. If a new employee has been working ina minimal- to low-risk setting prior to employment with Select Medical and has written proof of a TST that was done within the previous 12 months, it is not necessary to repeat the TST at the time of employment. However, a Tuberculosis Questionnaire Form (9.10d) must be completed and maintained in the personnel file. 7) A Tuberculosis Risk Assessment should be conducted at least annually... "
Review of personnel files at the Collegeville, PA location on July 21, 2020, from approximately 12:00 P.M. to 2:00 P.M. revealed the following:
PF #1, date of hire July 30, 2015, contained no documentation of an initial TST upon hire, or of a Risk Assessment completed annually.
PF #3, date of hire January 25, 2009, contained no documention of an initial TST upon hire, or of a Risk Assessment completed annually.
PF #4, date of hire August 31, 2016, contained no documention of an initial TST upon hire, or of a Risk Assessment completed annually.
PF #6, date of hire November 29, 1993, contained documentation of a TST completed on April 7, 2016. There was no documentation of a TST completed on hire, or of a Risk Assessment completed annually.
Review of personnel files conducted at the Springfield, PA location on July 22, 2020, from approximately 11:00 A.M. to 1:00 P.M. revealed the following:
PF #1, date of hire February 29, 2016, contained no documention of an initial TST upon hire, or of a Risk Assessment completed annually.
PF #2, date of hire February 20, 2017, contained no documentation of a Risk Assessment completed annually.
PF #3, date of hire March 20, 2015, contained no documentation of a Risk Assessment completed annually.
PF #4, date of hire March 20, 2018, contained no documentation of a Risk Assessment completed annually.
PF #5, date of hire March 1, 2019, contained no documentation of a Risk Assessment completed annually.
An exit interview conducted on July 24, 2020, at 12:30 P.M. with the Regional Director of Operations, the Center Manager for the Collegeville, PA location and the Springfield, PA location, the Market Managers, the Human Resources Coordinator, the Regional Director, and the Regional Director of Clinical Services confirmed the above findings.
Plan of Correction:Center Manager will complete annual risk assessment for all current staff using Form 9.10d and place a copy of the assessment in the employee folder and Center Handbook by 8/31/2020.
Center Manager will utilize employee file checklist yearly to ensure this form is completed annually by January 15.
All new hires will complete a 2 step TB test as part of the onboarding process with documentation to be placed in the employee file.
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 a review of rehabilitation center policy, clinical records (CR) and interview with Regional Director of Operations, the rehabilitation center staff failed to complete discharge summaries for three (3) of twelve (12) CR reviewed at the Springfield, PA location. (CR #10, 11, and 12).
Findings:
Review of rehabilitation policy #5.22 titled "Discharge Summary" on July 22, 2020, at approximately 2:30 P.M. stated, "Policy: A discharge summary shall be written within thirty (30) days of the end of the current plan of care."
A review of clinical records conducted at the Springfield, PA location on July 22, 2020, from 11:00 A.M. to 1:00 P.M. revealed the following:
CR#10, start of care January 7, 2020. Discharge visit completed January 28, 2020. Discharge summary completed March 4, 2020.
CR#11, start of care March 19, 2020. Last visit documented on April 22, 2020. Discharge summary completed June 22, 2020.
CR#12, start of care December 4, 2019. Last visit documented January 10, 2020. Discharge summary completed March 23, 2020.
An exit interview conducted on July 24, 2020, at 12:30 P.M. with the Regional Director of Operations, the Center Manager for the Collegeville, PA location and the Springfield, PA location, the Market Managers, the Human Resources Coordinator, the Regional Director, and the Regional Director of Clinical Services confirmed the above findings.
Plan of Correction:Discharge summaries will be completed by 9/13/2020 for CR #10, 11, 12.
Going forward, Center Manager will run Patient Inactivity Report in Therapy Source monthly and check all discharges for completion and document on the Center Handbook Calendar.
Market Manager will check with Center Manager monthly for completion of inactivity report and discharge summaries and document on the Center Handbook Calendar.
485.721(a) STANDARD
PROTECTION OF CLINICAL RECORD INFORMATION
Name - Component - 00
The organization recognizes the confidentiality of clinical record information and provides safeguards against loss, destruction, or unauthorized use. Written procedures govern the use and removal of records and the conditions for release of information. The patient's written consent is required for release of information not authorized by law.
Observations:
Based on review of agency policy, observation tours, and interview with the center manager, the agency failed to ensure billing records containing patient information were stored and maintained in accordance with its policy and procedure for one (1) of two (2) observation tours. (#1)
Findings included:
A review of rehabilitation center policy #6.01 titled "Document Retention" on July 21, 2020, at approximately 2:00 PM revealed, "General Information: 3) Records containing confidential and proprietary information will be securely maintained, controlled and protected to prevent unauthorized access..."
During observation tour #1 of the Collegeville, PA location on July 21, 2020, at approximately 10:30 A.M., the center manager was asked to unlock a file cabinet located behind the receptionist's desk which contained billing information for patients. It was noted at this time that three (3) of the file cabinet drawers were not seated properly on the track inside the cabinet, which caused the drawers to not lock properly. The center manager stated that she was not aware of why the drawers would not lock properly.
An exit interview conducted on July 24, 2020, at 12:30 P.M. with the Regional Director of Operations, the Center Manager for the Collegeville, PA location and the Springfield, PA location, the Market Managers, the Human Resources Coordinator, the Regional Director, and the Regional Director of Clinical Services confirmed the above findings.
Plan of Correction:Immediate action completed on 7/28/2020, Center Manager and Patient Service Specialist moved all documentation containing PHI into the locking file cabinet drawers.
Center Manager will obtain a new file cabinet with locking mechanism by 9/13/2020
Center Manager will check locks monthly and document on Center Handbook Calendar
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 observation tours at the Collegeville, PA and Springfield, PA locations, rehabilitation center policy review, review of cleaning and temperature logs, and interview with rehabilitation center staff at both locations, it was determined the rehabilitation center failed to ensure patient equipment was maintained and the interior of the building was free from defects which are a potential hazard to patients, personnel and the public for two (2) of two (2) observation tours completed. (#1 and 2).
Findings include:
Review of rehabilitation center policies conducted on July 21, 2020, at approximately 2:00 P.M. revealed the following:
Policy #9.18 titled "Therapeutic Cleaning and Maintenance" states, " 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 be cleaned and/or replaced as frequently as needed to maintain a sanitary environment...."
"Procedure: 11) Reusable Supplies (i.e., Thera-Band, rice and beans, putty, etc.) a) Inspect for tears and cracks, and replace when necessary for patient safety and the prevention of infection.
Policy #9.19 titled "Hydrocollator Machine Maintenance and Cleaning" states, "Procedure: 2) Cleaning Procedures: Hydrocollator machines must be cleaned at least quarterly or more frequently as necessary..."
Review of the rehabilitation center policy manual revealed no policies pertaining to temperature logs or recommended temperatures of hydrocollators or freezers, nor the frequency of the temperature checks.
Observation tour #1 conducted at the Collegeville, PA location on July 21, 2020, from approximately 9:30 A.M. to 11:00 A.M. revealed the following:
1. A tear in the left front area of the seat of the Cybex Lateral Pull-Down machine (fourth machine from the reception area against the window)
2. A tear in the left arm cushion of the blue Cybex machine (seventh machine from the reception area adjacent to the wall).
3. A tear in the black cushion on the left side of the large double exercise table against the rear wall.
4. Multiple large cracks in the blue cushion pad in the holder on the left side of the center desk facing the rear of the room.
5. Hydrocollator lid crusted with white residue along the outside perimeter of the lid. White residue crusted on the inner perimeter of the lid and a brown spot approximately the size of a quarter on the center of the
inner side of the lid.
6. Large area of torn flooring in the left corner under the physical therapy (PT) table in the Utiligard section. Large area of torn flooring in the left corner of the floor under the PT table in the examination room on the right near the hydrocollator. Large area of torn flooring in the left corner under the large exercise table in the rear of the room. Small area of torn flooring in the left corner under the PT table in thera-band section. Multiple ripples noted in the flooring near the desk in the center of the room.
7. "Freezer Temperature Logs" from January 1, 2020, to July 1, 2020, revealed the freezer temperature documented as 1 degree Fahrenheit for eight of twenty-three days in January, 2020, five of twenty days in February, 2020, ten of twenty-one days in March, 2020, eight of twenty-two days in April, 2020, eight of twenty-one days in May, 2020, and eight of eighteen days in June, 2020. The "Freezer Temperature Log" states, "Temperature should be maintained between -2 and 0 degrees Fahrenheit." The logs did not contain the initials of the employee completing the log for any of the days documented.
Observation tour #2 conducted at the Springfield, PA location on July 22, 2020, from approximately 9:30 A.M. to 10:30 A.M. revealed the following:
1. Schwinn arm bike had missing safety tread on the foot rests and on the base of the unit.
2. No "Freezer Temperature Logs" were present or available.
An exit interview conducted on July 24, 2020, at 12:30 P.M. with the Regional Director of Operations, the Center Manager for the Collegeville, PA location and the Springfield, PA location, the Market Managers, the Human Resources Coordinator, the Regional Director, and the Regional Director of Clinical Services confirmed the above findings.
Plan of Correction:Center manager has identified a staff member that will perform weekly inspection of regularly used equipment including therabands, balance pads, and machines. Center Manager will perform monthly inspection on equipment and address issues as they arise and will document inspection on Center Handbook Monthly Calendar.
To Address #1,2,3 Center Manager has contacted Flagship Management to replace torn pads on equipment including the seat of the Cybex Lateral Pull Down machine, the left arm cushion on the blue Cybex Machine. Flagship management has also been contacted to perform the recovering of the large black cushion on the large double exercise table in the rear of the clinic.
To address #4 The blue airex cushion pad was removed from the clinic floor on 7/28/2020 and staff will continue to use a newer pad.
To address #5, Center Manager and Identified staff will assist in a deep thorough clean of the Hydrocollator to remove calcium build up on the inside and outside of the lid by 8/31/2020. Center Manager Identified staff member who will continue to clean the machine quarterly and document cleaning on the temp log; unless it is determined to be needed more frequently. Center Manager will inspect the machine monthly to ensure cleanliness and safe use. Center Manager will also follow up, by checking the logs to ensure unit is being cleaned at a minimum of quarterly and document on Center Handbook Calendar Checklist.
To address #6 the large areas of torn floor- Center Manager will identify these areas with tape by 8/31/2020 as an immediate solution to bring attention to the areas and minimize pt risk for tripping; however, the whole floor will be replaced to achieve a permanent solution. Center manager and regional director will obtain quotes to replace the floor on or before 9/13/2020 with completion of the work by 11/2/2020. Center Manager identified staff member and CM will inspect the floor monthly to ensure there are no additional uneven areas to keep staff and patients safe and document on the Center Handbook Calendar Checklist.
To Address #7- Center Manager reviewed with all staff on 7/28/2020 the procedure for checking the Freezer and Hydrodollator temps to include daily temp checks and staff initials. Forms have been placed directly above the machines with temp ranges available. Center Manager will check form weekly to ensure all staff are following clinic procedure. Center Manager will also review logs weekly to ensure that temperatures are falling within appropriate ranges based on form and manufacturer guidelines. Center Manager will document on Center Handbook Calendar Checklist.
To address #1 in Springfield- Center Manager will contact vendor to replace the missing safety tread on the Schwinn armbike by 9/13/2020
To address# 1, Identified staff member will perform weekly inspection of regularly used equipment including therabands, balance pads, and machines. Center manager will perform monthly inspection on equipment and address issues as they arise and will document inspection on Center Handbook monthly Calendar.
To address #2, Temperature logs will be completed daily by identified staff member and kept in the center handbook. Center Manager will check form weekly to ensure logs are being appropriately kept. Center manager will document in Center Handbook Calendar Checklist.
485.723(c) STANDARD
OTHER ENVIRONMENTAL CONSIDERATIONS
Name - Component - 00
The organization provides a functional, sanitary, and comfortable environment for patients, personnel, and the public.
(1) Provision is made for adequate and comfortable lighting levels in all areas; limitation of sounds at comfort levels; a comfortable room temperature; and adequate ventilation through windows, mechanical means, or a combination of both.
(2) Toilet rooms, toilet stalls, and lavatories must be accessible and constructed so as to allow use by nonambulatory and semiambulatory individuals.
(3) Whatever the size of the building, there must be an adequate amount of space for the services provided and disabilities treated, including reception area, staff space, examining room, treatment areas, and storage.
Observations:
Based on observation tours, review of rehabilitation center policy, and interview with the center manager, the rehabilitation center failed to ensure cleaning supplies were properly labeled of for one (1) of two (2) observations. (#1).
Based on observation tours, review of rehabilitation center policy, and interview with the center manager, the rehabilitation center failed to ensure Material Safety Data Sheets (MSDS) for all hazardous materials stored in the rehabilitation center for two (2) of two (2) observation tours. (#1 and 2).
Based on observation tours, review of rehabilitation center policy, and interview with the center manager, the rehabilitation center failed to properly secure a receptacle containing hazardous waste for one (1) of two (2) observation tours. (#2).
Findings include:
Review of rehabilitation center policy 9.14 titled "Housekeeping" on July 21, 2020, at approximately 2:00 P.M. stated, "Procedure: 8) Storage of Cleaning Supplies: a) Cleaning supplies are maintained in their original containers. Do not use an unlabeled container..."
Observation tour #1 conducted on July 21, 2020, from approximately 9:30 A.M. to 11:00 A.M. at the Collegeville, PA location revealed the following:
1. An unmarked bottle of cleaning solution was observed at the sink on the left side of the room.
An interview was conducted with the center manager on July 21, 2020, at approximately 1:00 P.M. The center manager stated that the bottle contained Cavicide surface disinfectant.
Review of rehabilitation center policy #9.12 titled "Hazardous Materials and Communication Exposure Control Plan" on July 21, 2020, at approximately 1:30 P.M. stated, "Procedure: 6) For centers that store and use a large number of materials that require SDS (Safety Data Sheets), such as prosthetics and orthotics centers, a listing of all materials should be maintained in the SDS binder, using the Hazardous Chemical Product Inventory Form (9.12b)."
Observation tour #1 conducted on July 21, 2020, from approximately 9:30 A.M. to 11:00 A.M. at the Collegeville, PA location and review of the MSDS Manual revealed the following products that were not listed in the MSDS Manual: BacOff (manufacturer EnvioChem), Dawn dish detergent, Windex, Mr. Clean Magic Eraser, All laundry detergent, Gain fabric softener, Purex laundry detergent, and Tide laundry detergent.
Observation tour #2 conducted on July 22, 2020, from approximately 9:30 A.M. to 10:30 A.M. at the Springfield, PA location and review of the list of hazardous products for the location on July 24, 2020, at approximately 9:00 A.M. revealed no MSDS sheets for the following products: CLR Stainless Steel Cleaner, Magic Eraser, Swiffer Wet Jet, Office Depot Cleaning Duster, Beauty 360 nail polish remover, Watco tung oil, Soft Soap, Comet cleanser, and various paint products.
Review of rehabilitation center policy #9.12 titled "Hazardous Materials and Communication Exposure Control Plan" on July 22, 2020, at approximately 1:00 P.M. stated, "VI) Handling of Biohazardous Waste: B) Hazardous waste, or any PPE that may contain hazardous materials, are placed in containers which are closable, constructed to contain all contents and prevent leakage, appropriately color-coded or labeled with a biohazard label, and closed prior to removal to prevent spillage or protrusion of contents during handling..."
Observation tour #2 conducted on July 22, 2020, from approximately 9:30 A.M. to 10:30 A.M. at the Springfield location revealed the following:
1. Hazardous materials box, lined with a red biohazardous materials bag was located in the third room on the right side of the rehabilitation center. The box was covered with a plastic trash bag. There was no lid observed on the box.
An interview with the center manager on July 24, 2020, at approximately 1:00 P.M. revealed that the container is supplied by the biohazard waste company. The box comes with a lid, which may have been left on the bottom of the box.
An exit interview conducted on July 24, 2020, at 12:30 P.M. with the Regional Director of Operations, the Center Manager for the Collegeville, PA location and the Springfield, PA location, the Market Managers, the Human Resources Coordinator, the Regional Director, and the Regional Director of Clinical Services confirmed the above findings.
Plan of Correction:To address #1 in Collegeville,
Center Manager properly labeled all cleaning supplies on 7/28/2020 to include a clear image of the product name and chemical name. Center Manager will check bottles monthly to ensure labels are legible and appropriate for solution being used.
To address # 2 in Collegeville and #1 in Springfield, Center Manager will review all products in the clinic and compose an updated list of chemicals. Center Manager will obtain all missing MSDS's including newer cleaning supplies, as well as the dish soap, laundry detergent, fabric softener, Windex, Magic Eraser, Swiffer wet jet, CLR Stainless Steel Cleaner as needed by each facility b7 9/13/2020.
Center Manager will review binder of MSDS annually and ensure up to date and document on the Center Handbook Calendar Checklist
To address #2 in Springfield, Center Manager will obtain a lid for the Hazardous Materials box by 9/13/2020 and will inspect monthly to ensure it remains intact and document on the Center Calendar Checklist.
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