Initial Comments:
Based on the findings of an unannounced, onsite Medicare complaint investigation survey conducted on December 28, 2021, Cawley Physical Therapy and Rehabilitation 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.
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 clinic policies/procedures and observational tour, and based on interview with the billing manager (employee #1), the office manager (employee #2) and the administrator, the facility failed to ensure the therapy pool changing room was maintained/cleaned as per facility policy/procedure.
Findings include:
On December 28, 2021 at approximately 12:07 PM, review of the facility policy titled "Pool Operations and Maintenance" revealed the following:
Keeping Logs and Schedules: Another step toward proper pool maintenance is keeping logs and schedules for various elements of pool operations...A cleaning schedule should also be kept for the (pool) deck and locker rooms. The deck and locker rooms should be cleaned thoroughly at least once per day. Thus, the frequency of cleaning...should be kept in this log...
Department Cleanliness...The pool deck, bathrooms, showers will be cleaned with disinfecting agent at the end of each day. This will be done to help prevent the growth of bacteria, reduce the risk of infection...
Observational tour conducted on December 28, 2021 at approximately 11:34 AM revealed the therapy pool room included an inground pool, pool deck, chemical storage/mechanical room and a patient changing room. Observation of the patient changing room revealed the following:
-The wall behind and to the left of the bench were noted to have a light-brown colored residue on the first three (3) rows of cinder blocks located above the bench.
-The wall under the bench was noted to have a dark grayish/brown colored residue.
-The center portion of the floor was noted to have a dark grayish/brown colored residue in the grout between the floor tiles.
During interview conducted on December 28, 2021 at approximately 12:12 PM, the billing manager (employee #1) reported that cleaning of the therapy pool room is performed by clinic staff on Tuesdays and Thursdays when pool therapy sessions are not conducted.
On December 28, 2021 at approximately 12:56 PM, review of therapy pool room cleaning log documentation between 09/01/2021 and 12/27/2021 revealed cleaning tasks included, but were not limited to, scrubbing of walls and sweeping/mopping of floors. There was no documentation on the therapy room cleaning log which provided evidence that wall-scrubbing was completed after 10/20/2021 and there was no documentation which provided evidence that the changing room floors were swept/mopped with a disinfecting agent on a daily basis.
During telephone interview conducted on December 28, 2021 at approximately 12:24 PM, the office manager (employee #2) and the administrator confirmed the therapy pool changing room was not maintained/cleaned as per clinic policy/procedure.
Plan of Correction:The facility will monitor the pool room maintenance through the usage of a written log which will be posted and maintained in the pool room area. The individual(s) responsible for the maintenance and assurance of completion of the written log will be our Physical Therapy Technician or in the event of her absence the treating therapist assigned to the pool for that given day will handle the task. The written log will be signed by each individual who is responsible for the written log daily. Monitoring will be maintained by the treating therapist who is assigned to the pool each specific treatment day. Monitoring process will include daily checks of the pool changing room area for cleanliness after each use. Disinfecting the pool changing room area on each treating day. Wiping down and rinsing of the pool changing room walls, seating surfaces, and floor daily. This will be done to prevent the growth of bacteria and reduce the risk of infection. Additionally there will be the Installation of an electric floor drain to enable proper drainage cleaning and sanitizing of the changing room.The walls, floor and bench involving the changing room will be resurfaced and deep cleaned in order to minimize and mitigate the risk for bacteria growth uncleanliness or infection.
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