Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on August 6, 2020, LAS/geriatric Care Services, Inc. was found to have the following standard level deficiencies that were 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(a) STANDARD
Develop EP Plan, Review and Update Annually
Name - Component - 00
§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).
The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:
(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 all of the following:
* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.
* [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.
* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.
.
Observations:
Based on review of agency's emergency preparedness plan, observation, and interview with staff (EMP), the facility failed to develop an emergency plan to include procedures to be followed should a disaster occur in the facility's therapeutic pool at Zelienople parent location.
Findings included:
Observation of the facility's treatment area on August 5, 2020, at 9:30 a.m. revealed a large pool in restricted and enclosed area. Upon entry to pool room, surveyor observed various pieces of equipment including a battery powered lift (to lower patients into and out of pool if needed), a backboard (used to remove patients from the pool if needed), and a pull cord (to call for help and located on land) on wall and near the entrance to the pool. Interview with EMP1 and EMP2 at time of observation confirmed facility currently provides aquatic therapy to its patients using the pool. EMP1 and EMP2 confirmed facility has no emergency procedures concerning the pool, and that emergency drills for the pool have never been rehearsed.
Review of the facility's red emergency preparedness binder on August 5, 2020, at 11:45 a.m. with EMP1 and EMP2 did not show facility had emergency procedures in place for the facility's pool.
Review of "LUTHERAN SENIORLIFE FACILITIES MANUAL Policy Title: Clinical Procedure Aquatic Therapy Directive # 221: Rehabilitation Services Physical Therapy/Occupational Therapy Effective Date: 6/15/2015 Reviewed/Revised: ... 1/20 [2020]" was conducted on August 5, 2020, at 12 p.m. The policy made no mention of emergency procedures or other safety measures such as equipment to be available, how to call for help or the minimum number of staff required.
Review of "Fitness Center Swimming Pool Statistics," on August 5, 2020, at 3 p.m. showed the facility's pool had the following dimensions:
Length: 40' (40 feet)
Width:20'
Depth:4' to 4.5'
Gallons: 24,825 (approximate)
Phone interviews were conducted with EMP3 (PT) and EMP4 (OT) on August 6, 2020, with EMP1 and EMP2 physically present during the interviews.
During a phone interview with EMP4 (occupational therapist) on August 6, 2020, at 9:44 a.m. he/she confirmed he/she is not aware of any emergency procedures concerning the facility's pool, and has never received training or performed drills for a pool emergency.
During a phone interview with EMP3 (physical therapist who provides aquatic therapy to patients) on August 6, 2020, at 9:47 a.m. he/she confirmed facility has no emergency procedures for the facility's pool. EMP3 confirmed he/she provides aquatic therapy to patients in the pool room (separate restricted room enclosed in glass) alone with the patients with no other staff present. EMP3 noted that sometimes he/she provides treatment to patients on land and sometimes he/she gets in the water with the patients (with no other staff present in pool room). When EMP3 was asked how he/she would call for help if he/she and or the patient needed assistance and he/she noted, "pull them out of the water and pull the pull cord." EMP3 confirmed he/she is not aware of any emergency procedures for the pool.
Review of facility's "DISASTER AND FIRE PLAN" on August 6, 2020, at 2 p.m. showed no policy or procedure concerning facility's therapeutic pool.
Plan of Correction:Plan of Correction:
485.727(a) STANDARD
Develop EP Plan, Review, and Update Annually
In order to address the deficiency that stated there was no policy that made mention of emergency procedures or other safety measures such as equipment to be available, how to call for help or minimum number of staff required, the Policy Title: Clinical Procedure Aquatic Therapy Directive #221 was updated with the following changes and updates:
A.Potential Risk Factors of Aqua Therapy
a. The pool itself: water is dangerous
b.Equipment left on the poolside: may cause injury to staff or patients
c.Pool chairs: Staff or patients falling off them and onto poolside or into the pool
d.Infection control: possibility of contamination due to fecal incontinence or vomit episode or disrupted skin integrity
e.Steps: care should be taken on the steps to avoid accidentally slipping. Swimmers should hold onto rails. Patients can be assisted as necessary.
f.Lift: can malfunction and also has a weight limit
g.Phone reception: reception in pool area is poor and unreliable
h.Chemicals: if appropriate levels are not maintained
B.Pool Facility: Aqua therapy occurs at the Fitness and Wellness Center Pool at Passavant Community, Zelienople
a.The owners of the pool are responsible for maintaining the pool per state and local regulations
b.Fitness and Wellness Center Procedure Title: Rules of Conduct, Directive #: FIT.00 will be adhered. Of note in this document include the following rules:
1. No personal belongings are allowed in pool area, except pool shoes and towel.
2.Showers are required before entering pool
3.Shoes and street clothes must be worn when coming to or leaving from the pool area.
4.No wet suits allowed throughout the building
5.Appropriate swimwear and pool shoes are required for pool use.
- Urinary incontinent swimmers must wear a swim brief that is approved by the Fitness and Wellness Team. Swim briefs must be purchased by the swimmer.
- No oils, body lotions or minerals allowed.
- Pool lift limit is 300 lbs.
- No electrical equipment or items allowed in pool area or on deck.
- Persons with infections of any kind (i.e. eye, skin, ear, respiratory, etc.), unhealed wounds, rashes, communicable diseases, nausea, or diarrhea may not enter the water.
- No oxygen tanks allowed in pool area.
- Spitting, spouting water, blowing the nose or discharging bodily wastes is prohibited.
- No animals or pets are allowed in pool area.
- Non employees are not permitted in pool office or storage rooms.
- Do not prop open any door leading into pool area.
- The authority of staff on any matter pertaining to swimming or the enforcement of rules is final.
C. Safety
a.Therapist and therapist assistant staff that treat patients with aqua therapy will complete a water safety certification course on how to help maintain a comfortable and safe environment for swimmers, prevent accidents and emergencies, and respond to swimmers with illnesses or injuries, such as one presented by the American Red Cross. This will be renewed every two years or as directed by the presenting agency.
b.In conjunction with fitness team, annual drills will be conducted that simulate patient emergency situations. All therapy staff that provide aqua therapy will be required to attend and to sign record of attendance.
c. Staff competencies will be administered annually along with the drills and also at time of new hire/orientation.
d.Signage in Pool area will include depth of water, Fire Exit, and No Diving Permitted as well as other safety precautions
e. Staff will be educated in the proper use of mechanical lift and annual competency will occur.
- Weight limit of lift is 300 lb.
- Maintenance of lift is managed by Fitness and Wellness Center, per Procedure Pool Life Use, Directive # FIT.19
- Additional battery is kept charged in Fitness and Wellness office.
f. As per Lutheran SeniorLife Rehab Services policy, all staff are CPR certified
g.Glasses may be worn by patients to permit them to see therapy staff
h.While providing aqua therapy, staff must have a whistle on their person to alert others of an emergency
i.While providing aqua therapy, there must be an additional person within the pool room area (pool deck) at all times while the patient is in the water in order to provide additional assistance and call for help if there is an emergency.
j.Entry to the pool from the Fitness and Wellness Center is done by fob-key access. Outside doors are locked for entry into pool area.
k.Pool emergency cord is available to call for help and is tested every six month as per Fitness and Wellness Center Procedure: Safety/Risk Management-Pool, Directive # FIT.20
D.Emergency Action Plan:
a.Medical Emergency
1. Therapy staff will alert the second staff member located in the pool deck area.
2. The second individual in pool deck area pulls the emergency response cord, alerting Passavant nursing staff
3. Staff carry out rescue procedures as per training, carrying out appropriate first aid and evacuating individual from pool
4. Ambulatory patients will be assisted from the pool to poolside. Non-ambulatory patients will be assisted utilizing backboard or mechanical life.
5. Therapy or nursing staff will determine if 911 needs to be called
b.Inclement Weather
1. Fitness and Wellness Center Procedure Pool Closure Process-Inclement Weather, Directive # FIT.26 is adhered
2. Of note in the directive is the following "When lighting is within 10 miles, suspend all pool activity for 30 minutes."
3. Patients and Staff should come to the interior of the Fitness and Wellness Center and not remain in the pool area due to the large number of windows.
c.Fire
1. Exit doors should be free of obstacles at all times
2. Upon hearing the fire alarm, the therapist/assistant and patient will exit the pool. Individuals will congregate in the Fitness Center lobby.
3. If fire is in another area of campus, staff and patients will remain in their current location, behind fire doors.
4. If the fire is in the vicinity, staff and patients will evacuate the building quickly and orderly. Staff will assist patients with mobility difficulties.
5. Fire Procedures developed by Passavant Community will be adhered and include the following:
- Master Fire Plan-Fitness Center, Directive #: DIS. 35
- Master Fire Plan-General Instructions, Directive #: DIS.36
d.Malfunction of Lift
1. As lift is battery operated, it is functional in a power failure
2. A spare lift battery is kept charged in the Fitness and Wellness Center office
3. As therapists are specialists in transferring patients, if a patient needs to be transferred and the lift is not available, the therapist will determine a safe transfer and can incorporate such items as a pneumatic Hoyer lift, additional staff, or use of back board.
e.Power failure
1. Staff and patients should evacuate the pool.
2. Therapy staff will assist patients with evacuation to prevent injury.
3. If needed, staff are to access pool flashlights located at the fitness center front desk.
f. Further emergencies including, but not limited to, communications failure, security incidents, snow, floods, water system, civil disturbances, etc. are addressed as per Passavant Community's Disaster Plan.
The facilities manual (red binder) was also reviewed and the following policy labeled was already and there was a policy that addressed the pool on the facility Master Fire Plan- Fitness Center Directive #: DIS.35.
The updated pool policy paired with education, competencies, and drill will help to protect patients in the future and prevent a problem from occurring. Staff will be educated on changes by September 1, 2020.
A Rehab Quality Initiative (QI) monitor will begin September 1, 2020 called "water safety during aquatic therapy". The goal is two therapy staff will be present at all times while aquatic therapy is being performed, with a benchmark of 100% compliance. The performance status of the QI monitor is unannounced spot checks by outpatient rehab manager at a minimum of one time per quarter. This will be reviewed quarterly at the GCS strategic planning meetings.
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 review of facility's emergency preparedness plan risk assessment, observation, and interview with staff (EMP), the facility failed to ensure its facility-based risk assessment utilized an all-hazards approach, and included strategies for addressing emergency events related to the facility's therapeutic pool at Zelienople parent location.
Findings included:
Review of facility's "Lutheran SeniorLife Annual Risk Assessment " was conducted on August 6, 2020, at 2 p.m. The assessment was dated for 2019 and included risk assessments for the facility such as "Environment of Care ... Fire Safety , Power Outage, Facility Grounds ... Workplace Safety ... Hazards, Location." The risk assessment made no mention of facility's pool." Interview with EMP2 (director) on August 6, 2020, at 10 a.m. confirmed findings, and no risk assessment conducted for potential pool emergency or pool related disaster (patient unresponsive in pool).
Observation of the facility's treatment area on August 5, 2020, at 9:30 a.m. revealed a large pool in restricted and enclosed area. Upon entry to pool room, surveyor observed various pieces of equipment including a battery powered lift (to lower patients into and out of pool if needed), a backboard (used to remove patients from the pool if needed), and a pull cord (to call for help and located on land) on wall and near the entrance to the pool. Interview with EMP1 and EMP2 at time of observation confirmed facility currently provides aquatic therapy to its patients using the pool.
Review of the facility's red emergency preparedness binder on August 5, 2020, at 11:45 a.m. with EMP1 and EMP2 did not show facility had emergency procedures in place for the facility's pool.
Review of "Fitness Center Swimming Pool Statistics," on August 5, 2020, at 3 p.m. showed the facility's pool had the following dimensions:
Length: 40' (40 feet)
Width:20'
Depth:4' to 4.5'
Gallons: 24,825 (approximate)
Plan of Correction:485.7279(a)(1)-(2) STANDARD Plan Based on All Hazards Risk Assessment
In order to address the deficiency that the facility failed to ensure its facility-based risk assessment utilized and all-hazards approach, and included strategies for addressing emergency situations related to the facility's therapeutic pool at the Zelienople parent location, the risk assessment tool for LAS Geriatric Care services, Inc. was updated as follows:
Category: Environment of Care
Hazards: 1. Water itself 2. Equipment, chairs left poolside 3. Infection 4. Steps 5. Lift malfunction 6. Poor phone reception 7. Chemicals
Risk Level: 2 Likelihood of Impact (probability that risk can occur): Possible
Consequence Level: High
Risk Rating: Extreme
Interventions: 1. Staff water certification course 2. Annual competency with drills 3. Management of equipment and chairs for safety and organization 4. Management daily of water quality 5. Railings at steps 6. Lift monitored for operation, is battery operated, extra battery available, staff can transfer patient 7. Second staff member within the pool deck area all times while aqua therapy is being performed. 7. Chemicals of pool monitored daily
Future Actions (to control risk): Red Cross water safety staff certification; emergency preparedness drills and competencies, QI monitor for compliance
Responsible Party: Rehab Manager
The updated risk assessment was formulated on August 18, 2020, and will be reviewed annually with the rehab managers at the GCS Strategic planning meeting. On August 17, 2020, the outpatient therapy staff were educated on starting immediately the use of two staff available at all times in the pool deck area while aqua therapy is being performed with patients.
485.727(d) STANDARD
EP Training and Testing
Name - Component - 00
§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.
*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.
*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).
*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.
Observations:
Based on review of agency's emergency preparedness plan, personnel files, and observation, and interviews with staff (EMP), the facility failed to develop an emergency preparedness training and testing program for its therapeutic pool at the Zelienople parent location.
Findings included:
Observation of the facility's treatment area on August 5, 2020, at 9:30 a.m. revealed a large pool in restricted and enclosed area. Upon entry to pool room, surveyor observed various pieces of equipment including a battery powered lift (to lower patients into and out of pool if needed), a backboard (used to remove patients from the pool if needed), and a pull cord (to call for help and located on land) on wall and near the entrance to the pool. Interview with EMP1 and EMP2 at time of observation confirmed facility currently provides aquatic therapy to its patients using the pool. EMP1 and EMP2 confirmed facility has no emergency procedures concerning the pool, and that emergency drills for the pool have never been rehearsed.
Review of personnel files for EMP3 (PT), and EMP4 (OT) on August 5, 2020, at 2:30 p.m. did not show staff received emergency preparedness training / drill for the facility's therapeutic pool. These finding were confirmed during above interview with EMP1 and EMP2 on August 5, 2020, at 9:30 a.m.
Review of "LUTHERAN SENIORLIFE FACILITIES MANUAL Policy Title: Clinical Procedure Aquatic Therapy Directive # 221: Rehabilitation Services Physical Therapy/Occupational Therapy Effective Date: 6/15/2015 Reviewed/Revised: ... 1/20 [2020]" was conducted on August 5, 2020, at 12 p.m. The policy made no mention of emergency procedures or other safety measures such as equipment to be available, how to call for help or the minimum number of staff required.
Review of "Fitness Center Swimming Pool Statistics," on August 5, 2020, at 3 p.m. showed the facility's pool had the following dimensions:
Length: 40' (40 feet)
Width:20'
Depth:4' to 4.5'
Gallons: 24,825 (approximate)
Phone interviews were conducted with EMP3 (PT) and EMP4 (OT) on August 6, 2020, with EMP1 and EMP2 physically present during the interviews.
During a phone interview with EMP4 (occupational therapist) on August 6, 2020, at 9:44 a.m. he/she confirmed he/she is not aware of any emergency procedures concerning the facility's pool, and has never received training or performed drills for a pool emergency.
During a phone interview with EMP3 (physical therapist who provides aquatic therapy to patients) on August 6, 2020, at 9:47 a.m. he/she confirmed he/she is not aware of any emergency procedures for the pool and has never rehearsed a pool emergency of any kind. EMP3 was asked about his/her water safety training/certification, and he/she noted he/she had some training back in the 1990's, and was once lifeguard certified, but does not currently possess any water safety credentials
Cross reference Tag 0004 for more information on the facility's emergency preparedness plan.
Plan of Correction:485.727(d) STANDARD EP Training and Testing
In order to address the deficiency that the facility failed to develop an emergency preparedness training and testing program for its location at the Zelienople parent location, an education program was developed as well as outlined in the Policy Title: Clinical Procedure Aquatic Therapy Directive #221.
1. The first component of the training program will consist of all therapists performing aqua therapy to complete a water safety certification (called Safety Training for Swim Coaches) course provided by the Red Cross by September 1, 2020.
2. A competency was developed called "Drills and Emergency Preparedness for Pool and Aqua Therapy". The drills and the competency are scheduled to be performed on September 25, 2020. The competency addresses all pool policies, use of the pool safety equipment (backboard, lift, life guard hook), summoning help during and emergency, evacuation of mobile and non-mobile patients from the pool, location of AED, and procedures during a power outage or weather related emergency.
3. The Policy Title: Clinical Procedure Aquatic Therapy Directive #221 was updated to reflect the certification training, drills,annual competencies, and the need for two staff members in the pool deck area at all times while aqua therapy is being performed. This will be provided to treating therapists, and reviewed with managers for questions and therapists will sign of understanding of the policy updates.
4. Human resource personnel files will be maintained on all trainings and the outpatient manager will review annually.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed August , 2020, LAS/geriatric Care Services, Inc. was found to have the following standard level deficiencies that were 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. The survey was conducted at the Zelienople parent on August 5, 2020, and the Butler Extension site on August 6, 2020.
Plan of Correction:
485.723(a) STANDARD
SAFETY OF PATIENTS
Name - Component - 00
The organization satisfies the following requirements:
(1) It complies with all applicable State and local building, fire, and safety codes.
(2) Permanently attached automatic fire-extinguishing systems of adequate capacity are installed in all areas of the premises considered to have special fire hazards. Fire extinguishers are conveniently located on each floor of the premises. Fire regulations are prominently posted.
(3) Doorways, passageways, and stairwells negotiated by patients are of adequate width to allow for easy movement of all patients (including those on stretchers or in wheelchairs), free from obstruction at all times, and, in the case of stairwells, equipped with firmly attached handrails on at least one side.
(4) Lights are placed at exits and in corridors used by patients and are supported by an emergency power source.
(5) A fire alarm system with local alarm capability and, where applicable, an emergency power source is functional.
(6) At least two persons are on duty on the premises of the organization whenever a patient is being treated.
(7) No occupancies or activities undesirable or injurious to the health and safety of patients are located in the building.
Observations:
Based on observation, and interview with staff (EMP), the facility failed to ensure two (2) staff members were present when patients were receiving aquatic therapy services at the Zelienople parent location.
Findings included:
Observation of facility treatment area on August 5, 2020, at 9:30 a.m. revealed a large pool in restricted and enclosed area. Interview with EMP1 and EMP2 at time of observation confirmed facility currently provides aquatic therapy to its patients using the pool. Upon entry to pool room, surveyor observed various pieces of equipment including a pull cord (to call for help and only accessible when on land) on the wall and near the entrance to the pool. The pull cord would require another person to activate should the therapist be in the pool with the patient at the time an emergency occurred.
Review of "Fitness Center Swimming Pool Statistics," on August 5, 2020, at 3 p.m. showed the following pool dimensions:
Length: 40' (40 feet)
Width:20'
Depth:4' to 4.5'
Gallons: 24,825 (approximate)
During a phone interview with EMP3 (treating physical therapist who provides facility's aquatics therapy to patients) on August 6, 2020, at 9:47 a.m. he/she confirmed the he/she provides aquatic therapy to patients in the pool room (separate restricted room enclosed in with glass and solid wall) alone with the patients with no other staff present. EMP3 noted that sometimes he/she provides treatment to patients while on land and sometimes he/she gets into the water with the patients (with no other staff present). When EMP3 was asked how he/she would call for help if he/she and or the patient needed assistance and he/she noted, "pull them out of the water and then pull the pull cord." This arrangement would require the therapist to stabilize the patient in the water and pull the pull cord (located on land) at the same time which is not physically possible.
EMP1 and EMP2 were physically present during the phone interview with EMP3.
Plan of Correction:485.723 (a) STANDARD Safety of Patients
In order to address the deficiency that the facility failed to ensure that two staff members were present when patients were receiving aqua therapy services at the parent Zelienople location, the following was completed:
1. The Policy Title: Clinical Procedure Aquatic Therapy Directive #221 was updated to reflect that two staff members are in the pool deck area at all times while aquatic therapy is being performed.
2. Outpatient therapy staff were notified on August 17, 2020 of this change in procedure effective immediately.
3. A competency was developed called "Drills and Emergency Preparedness for Pool and Aqua Therapy" that addresses the need for two staff members at all times.
4. A Rehab Quality Initiative (QI) monitor will begin September 1, 2020 called "water safety during aquatic therapy". The goal is two therapy staff will be present in the pool deck area at all times while aquatic therapy is being performed, with a benchmark of 100% compliance. The performance status of the QI monitor is unannounced spot checks by outpatient rehab manager at a minimum of one time per quarter. This will be reviewed quarterly at the GCS strategic planning meetings.
485.725(a) STANDARD
INFECTION CONTROL COMMITTEE
Name - Component - 00
The infection control committee establishes policies and procedures for investigating, controlling, and preventing infections in the organization and monitors staff performance to ensure that the policies and procedures are executed.
Observations:
Based on review of policy, observation, and interview with staff (EMP), the facility's infection control committee failed to provide a sanitary environment, failed to develop policy concerning food items on the treatment floor, and failed to monitor staff to ensure food items were not also stored with patient care equipment and personal protective equipment (PPE) in a treatment floor cupboard at the Butler extension site location.
Findings included:
Review of facility policy on August 6, 2020, at 2:40 p.m. showed, "Policy Title: Rehabilitation Services / Environment of Care Directive #: Rehab .11 ... Policy Statement: The rehabilitation departments of Lutheran Senior Life facilities and the Outpatient Rehabilitation Agency are maintained to protect the health and safety of the residents/patients/clients personnel, and the public and provides a functional, sanitary, and comfortable environment adequate fort the delivery of care. ... In kitchen areas; all surfaces are cleaned regularly, dishes are washed promptly after use, counter tops and table surfaces are cleaned promptly with anti-bacterial soap, refrigerator is cleaned quarterly and out of date products are discarded. All food products are labeled by staff name and date." The policy made no mention of staff storing food items on the treatment floor.
Observation of treatment area cupboard located at Butler extension site on August 6, 2020, at 9:32 a.m. revealed the following food items, PPE, and patient care items all stored together in the same cupboard:
One (1) opened box of surgical masks (PPE)
Two (2) sets of goggles for eye protection (PPE)
Several cloth face coverings situated next to a coffee cup and an opened container of peanuts
An opened bag of potato chips
Three (3) salt shakers (containing salt)
One (1) pepper shaker (containing pepper)
A container of Triscuits (snack food)
A bag of opened popcorn
A jar of body lotion
A TENS unit (modality of electricity [patient care item)])
A hand exerciser
EMP1 and EMP2, who were both present at time of observation confirmed findings.
An interview with EMP2 on August 6, 2020, at 10 a.m. confirmed facility has no policy which prevents/prohibits the storage of food items together with PPE and patient care equipment.
Repeat deficiency from survey completed 6/3/2014.
Plan of Correction:485.725 (a) STANDARD Infection Control Committee
In order to address the deficiency that the facility's infection control committee failed to provide a sanitary environment, failed to develop a policy concerning food items on the treatment floor, and failed to monitor staff to ensure food items were also not stored with patient care equipment and personal protective equipment (PPE) in a treatment floor cupboard at the Butler extension site location, the following was completed:
1. The Policy Title: Rehabilitation Services / Infection Control rehab Directive #10 was updated to include "11. No staff food or drink items are allowed in therapy treatment areas or in cabinets with therapy supplies. Food used for treatment (such as meal preparation training) can be stored in designated therapy space. No food may be kept in freezers designated for ice packs."
2. The food was immediately removed.
3. All therapy staff will be educated and that will be finalized by September 1, 2020. The education will consist of hand out of the updated policy, review with managers for questions, and sign off on attendance.
4. A Quality Initiative (QI) monitor was established called "Infection control in outpatient rehab space". The goal of the monitor is: Therapy staff will refrain from storing food in therapy treatment areas and in cupboards with therapy equipment with a benchmark of 100% compliance. The performance status will include spots checks quarterly to ensure compliance. This will be reviewed quarterly at the GCS strategic planning meetings.
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