Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on September 14, 2021, at the parent location of 20 - 30 West Baltimore Pike, Lansdowne, PA 19050, and September 15, 2021, at the satellite location of 1426 Frankford Avenue, Philadelphia, PA 19125, 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 September 14, 2021, at the parent location of 20 - 30 West Baltimore Pike, Lansdowne, PA 19050, and September 15, 2021, at the satellite location of 1426 Frankford Avenue, Philadelphia, PA 19125, NovaCare Outpatient Rehabilitation, was identified to have the following standard level deficiency 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:
485.723(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 observations, rehabilitation center policy and procedure review, and interviews with the rehabilitation center's Alternate Administrator and Marketing Manager, it was determined the rehabilitation center in Lansdowne (parent location) and Fishtown (satellite location) failed to ensure disposal of expired supplies for Observation #1 and Observation #2.
Findings included:
Review of policy 9.24, titled " Storage and Disposal of Medications and Supplies " conducted on 9/15/2021 at approximately 2:30PM, states, " (3) Supplies: (a) Supplies will be monitored for expiration date(s) when applicable. If a supply is found to have expired it will be disposed of appropriately or according to manufacturer recommendations. "
Observation of patient treatment areas of the rehabilitation centers was conducted on 9/14/2021 from approximately 9:45AM - 11:30AM, and 9/15/2021 from approximately 9:25AM - 10:15AM, revealed:
Observation #1 - 9/14/2021 (Lansdowne Location) - Storage shelf located adjacent to far right wall across from the Vision Fitness bikes.
Nine (9) packs of ValuTrode Neurostimulation Electrodes (Lot: AM000066110) - Expired: 8/1/2021
One (1) pack of ValuTrode Neurostimulation Electrodes (Lot: AM000066524) - Expired: 8/9/2021
One (1) box of Anchor Fix Multi-Purpose Cover Tape (Lot: B1402) - Expired: 6/2019
Observation #2 - 9/15/2021 (Fishtown Location) - In a box on the countertop across from the Hydrocollator and Freezer.
Two (2) packs of ValuTrode Neurostimulation Electrodes (Lot: AM000048624) - Expired: 7/26/2020
Two (2) packs of ValuTrode Neurostimulation Electrodes (Lot: AM000062340) - Expired: 5/9/2021
Four (4) packs of ValuTrode Neurostimulation Electrodes (Lot: AM000063094) - Expired: 5/23/2021
Observation #2 - 9/15/2021 (Fishtown Location) - In cabinet above the countertop across from the Hydrocollator and Freezer.
Ziplock bag containing approximately (10 - 15) packs of ValuTrode Neurostimulation Electrodes (Lot: AM000066998) - Expired: 8/20/2021
An interview with the rehabilitation center Alternate Administrator on 9/14/2021 at approximately 3:20PM, Marketing Manager on 9/15/2021 at approximately 12:15PM confirmed the above findings.
Plan of Correction:CM/ACM/Assigned Staff will inspect all supplies and medications in the centers for marked expiration dates and dispose of expired supplies/medications accordingly. The CM will retrain all staff to verify supplies/medications are not expired prior to using with a patient during next Staff Meeting and In-Service Training on 10/12/21. The CM will document this training per Policy 4.12, Staff Meeting and In-Service Training, on form 4.12, Staff Meeting and In-Service Training Minutes, and file the minutes into Section 4 of the Center Handbook for future reference. Additionally, the CM or designee will perform monthly inspections and log inspections on the center handbook calendar checklist (CHCC). The Administrator, or designee, will review CHCC quarterly to verify task completion.
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