QA Investigation Results

Pennsylvania Department of Health
CAWLEY PHYSICAL THERAPY AND REHABILITATION
Health Inspection Results
CAWLEY PHYSICAL THERAPY AND REHABILITATION
Health Inspection Results For:


There are  6 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:

Based on the findings of an unannounced, onsite Medicare recertification survey conducted on April 7 and April 8, 2021, Cawley Physical Therapy and Rehabilitation was identified to have the following standard level deficiency that was determined to be in substantial compliance with the requirements of 42 CFR, Part 485.707, Subpart D, Conditions of Participation: Outpatient Physical Therapy-Emergency Preparedness. The Medicare recertification survey for the Pittston main site was conducted on April 7, 2021 and for the Scranton extension site on April 8, 2021.







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), 485.625(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 agency policies/procedures, documentation, and interview with the office manager, the facility failed to complete a facility and community based all-hazard risk analysis (hazard vulnerability analysis) in 2017, 2018, 2019 nor 2020.

Findings include:

On April 7, 2021 at approximately 2:50 PM, review of agency policy titled "Internal Disaster Plan" revealed the following:
Policy...An internal disaster is any occurrence which causes significant disruption of a facility's normal operation.

Between April 7, 2021 at approximately 11:12 AM and April 8, 2021 at approximately 11:31 AM, review of the agency disaster plan.

During telephone interview on June 4, 2018 at 2:25 PM, the administrator confirmed that the facility failed to develop a "Continuity of Operations Plan (COOP)" as required under facility policy 9.03.














Plan of Correction:

Hazard Vulnerability Assessment Was completed 4/19/2021.
Responsibility of: The Office Manager for monitoring plans of contacts & corrections.



Cawley Physical Therapy & Rehab will incorporate this strategy into our quarterly and annual leadership team meetings to minimize or eliminate the risk of deficiency and to stay in compliance in the future. These meetings are held once every quarter with dates announced at each meeting. We will review HVA at annual meeting. The office will conduct drills annually.


Initial Comments:

Based on the findings of an unannounced, onsite Medicare recertification survey conducted on April 7 and April 8, 2021, Cawley Physical Therapy and Rehabilitation was found to be in compliance with the 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. The Medicare recertification survey for the Pittston main site was conducted on April 7, 2021 and for the Scranton extension site on April 8, 2021.







Plan of Correction: