Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on June 26, 2018, Novacare Outpatient Rehabilitation was identified to have the following standard level deficiency that was to be in substantial compliance with the following requirements of 42 CFR, Part 485.707, Subpart D, Conditions of Participation: Outpatient Physical Therapy - Emergency Preparedness.
Plan of Correction:
485.727(a)(1)-(2) STANDARD
Plan Based on All Hazards Risk Assessment
Name - Component - 00
§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*
(2) Include strategies for addressing emergency events identified by the risk assessment.
* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.
*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.
*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.
Observations:
Based on a review of facility documentation,agency policy and an interview with the acting Center Manager and Administrator, the extension site did not conduct any emergency drills for 2017.
Findings include:
A review of facility policy, 9.09 "Emergency Drills" on June 6, 2018 at 12:00 PM states: "All Select Medical Outpatient Division employees will review and/or complete fire, disaster, bomb, and medical emergency drills as described...on an annual basis....Procedure 1.g Document the results in each emergency disaster drill performed on the Emergency Drill Report Form. h. Maintain copy of drill report in the Center Handbook."
A review of the Center Handbook was conducted on June 26, 2018 at 1:00 PM. There was no documentation of any fire and disaster drills conducted at the facility for 2017.
An interview with the acting Center Manager on June 26, 2018 at 1:30 PM confirmed that no fire or emergency drills were conducted at the facility for 2017.
An interview with the Administrator on June 26, 2018 at 1:55 PM confirmed the above findings.
Plan of Correction:On June 28th an emergency drill was conducted by the Center Manager with all staff members and 2 patients present according to our clinical policy 9.09
Patient 1 and Patient 2 (as identified on the center sign in sheet) were directed by therapist A to the emergency exit and escorted out of the building safely.
This was drill was recorded on form #9.09, indicating all staff that were present, and placed in section #9 of the Center Handbook.
The emergency evacuation drill was also documented as complete on the Center Handbook Calendar checklist and will be kept on file and verified by Market Manager annually.
Fire safety plan and emergency evacuation drill will be completed annually by the center manager for all employees and upon hire as per clinical policy 9.09 and documentation of the plan & drill will be completed on form 9.09 and maintained in section 9 of the center handbook. Completion of the emergency evacuation drill will also be indicated on the center handbook calendar checklist and available for verification by the market manager on an annual basis
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on June 26, 2018, Novacare Outpatient Rehabilitation was found to be in compliance 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:
|