Initial Comments:
Based on the findings of an unannounced Medicare recertification survey completed onsite on 6/30/2023 and completed offsite 7/7/2023, The Rehabilitation Center of Seward in Collaboration with Indiana Regional Medical Center 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 485.727, 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(d)(1) STANDARD
EP Training Program
Name - Component - 00
§403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:]
(1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.
*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and
procedures.
*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.
*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures.
*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.
*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.
*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.
Observations:
Based on review of clinic Emergency Preparedness (EP) Plan, Personnel Files (PF), and staff (EMP) interview, the clinic failed to implement and provide documentation pertaining to the emergency preparedness initial and annual training of staff and the methods used for demonstrating staff knowledge of an emergency preparedness training program.
Findings included:
Review of clinic EP policy and procedure, conducted on 6/27/2023 at approximately 2:00pm revealed: "... Policy # 9.01...Emergency Plan...VII) Emergency and Disaster Plan, A) Staff training, 1) The center Manager is responsible to ensure training of all staff in the appropriate procedures for emergency or disastrous situations specific to their centers, 2) staff to receive annual training on the use of fire extinguishers., a) Document training of new employees at time of hire, 3)Annual review of the EP with all employees, a) Document training of new employees at the time of hire..."
Review of clinic documentation conducted on 6/27/2023 at approximately 2:00pm. The clinic failed to implement an emergency preparedness written training and testing program for individuals providing services and failed to provide any documentation methods used for demonstrating staff knowledge of emergency preparedness training.
Review of PF conducted 6/27/2023 at approximately 2:30pm failed to include evidence of initial or ongoing annual training and demonstration of competency of the emergency preparedness plan for 5 (five) of 5 (five) PFs reviewed.
PF1, date of hire (DOH) 3/20/2022, PF failed to include evidence of initial or ongoing annual training and demonstration of competency of the emergency preparedness plan for 2023.
PF2, DOH 11/14/2019, PF failed to include evidence of initial or ongoing annual training and demonstration of competency of the emergency preparedness plan for 2020, 2021, 2022, or 2023.
PF3, DOH 3/1/2021, PF failed to include evidence of initial or ongoing annual training and demonstration of competency of the emergency preparedness plan for 2022 or 2023.
PF4, DOH 2/22/2006, PF failed to include evidence of ongoing annual training and demonstration of competency of the emergency preparedness plan for 2017, 2018, 2019, 2020, 2021, 2022, or 2023.
PF5, DOH 1/17/2022, PF failed to include evidence of initial or ongoing annual training and demonstration of competency of the emergency preparedness plan for 2023.
Interview with EMP1 on 6/27/2023 at approximately 2:30pm revealed emergency preparedness training and competency not to be included in assigned annual trainings assigned to employees.
Exit interview conducted on 7/5/2023 at approximately 12:30pm with the Clinical Director and Regional Director of Clinical Services confirmed above findings.
Plan of Correction:Reference tag 0037 E0037 485.727(d)
In compliance with Select Medical outpatient policy 9.01: Emergency Plan and State Operations Manual
Appendix A-Z Emergency Preparedness for All Provider and Certified Supplier Types – Training and
Testing Guidelines: Administrator is responsible to update the center specific Emergency Plan, using
forms 9.01a-g, including facility risk assessment and emergency communication plan. Administrator will
provide live training to center staff including education on the emergency plan and center processes in
response to an emergency. This will include but is not limited to individual responsibilities to assist in
emergency, evacuation plan and shelter in place plan, proper use of PPE, procedures to ensure
continuity of patient care. Staff competency of the emergency plan will be tested verbally during the
training and confirmed by staff member signatures of those participating in the training. In addition,
initial training for staff will be completed by the supervision or administrator during the onboarding
period and documented in the new employee checklist, confirmed by employee signature.
Administrator will be responsible to monitor monthly for required emergency drills and to complete,
provide testing, document on the center calendar checklist and ensure competency of all staff on an
initial and annual basis.
Update: Emergency plan for Seward location to be updated by administrator, with involvement and
approval from Regional Directors of Operations and Clinical Services. This includes, but is not limited
to, Center-specific Communication Plan, All Hazards Risk Assessment, Review of Patient Population
Risks, Maintenance and Security of Medical Records, Emergency Equipment including AED, PPE, fire
safety equipment, first aid, aquatic-specific lifesaving equipment and development of a Center specific Emergency and Disaster Plan. Training on the updated EP will be provided in a live training
format to all staff to include review of EP, center and staff responsibilities to manage emergency types
(fire, medical, disaster, other as identified as high risk on hazard assessment), evacuation procedure.
This training will include an assessment of employee competency of emergency policy and
procedures, including acknowledgement, signature and date of all participating staff. New employees
will receive the same written and verbal training, including competency documentation. Review,
update, documentation and training on emergency plan will be completed annually in likewise
manner.
Update: Supporting documentation submitted: Policy 9.01 Emergency Plan (revised 3/1/23) and
sample Emergency Plan (to be complete by date below, along with training and competency)
Completion date: 9/15/23 to accommodate scheduled in-person training for 9/13/23. Monitoring:
ongoing on at least monthly basis. Responsible party: Facility Administrator, Regional Director of
Operations with support from Regional Director of Clinical Services
485.727(d)(2) STANDARD
EP Testing Requirements
Name - Component - 00
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).
*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:
(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:
(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.
*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.
*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.
*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.
*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.
*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.
*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.
*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.
Observations:
Based on review of clinic Emergency Preparedness (EP) plan and staff (EMP) interview, the clinic failed to conduct exercises to fully test and evaluate their EP plan.
Findings included:
Review of clinic EP policy and procedure, conducted on 6/27/2023 at approximately 2:00pm revealed: "... Policy # 9.01...Emergency Plan...IX) Emergency Drills, Centers shall test the EP by performing drills. Testing allows for suggestions and recommendations for improvement of the EP. Centers shall make suggestions for changes to the EP through the Patient Care Committee or directly to the Regional Director of Clinical Services, A) Drills to test the Emergency Plan 1) Perform dills with staff to test the EP annually or if there are significant changes to the plan...a) Every 2 years the drill must be either, i) A full scale Exercise (FSE)...OR, ii) A Functional Exercise (FE)...b) On alternate years the center shall conduct at least one of the following: i) An FSE, ii) An FE, iii) A Mock disaster Drill, iv) A Tabletop Exercise, or, v) A workshop that includes a group discussion led by facilitator..."
Review of clinic documentation conducted on 6/27/2023 at approximately 2:00pm failed to include evidence that the clinic participated in and evaluated implementation of the emergency plan by conducting a full scale or tabletop exercise for 2017-2023.
Exit interview conducted on 7/5/2023 at approximately 12:30pm with the Clinical Director and Regional Director of Clinical Services confirmed above findings.
Plan of Correction:
CM has joined the SW Healthcare Coalition in order to have access to more information regarding the implementation of the Full scale exercises for the EP. We have reached out to Seward volunteer Fire Department in regards to opportunity to work with them on a community drill. The Seward Fire Chief performed site inspection and recommendations: completed 7/19/23. As stated in response Trainings will be led by the CM with all employees to sign off regarding competency. In accordance with Select Outpatient policy 9.01, the center manager will lead and perform emergency drills as part of the monthly center staff meeting. This will include required and recommended annual drills as reflected in the Center Specific Risk Assessment, as well as the tabletop and full scale community drills on alternating years. There will be a quarterly meeting with the Regional Director of Clinical services which will review the exercises, confirm their completion, assess progress, confirm documentation, and suggest future drills. All drills and and reports will be maintained in the EP and the Center Handbook.
Completion date 8/31/23
Initial Comments:
Based on the findings of an unannounced Medicare recertification survey completed onsite on 6/30/2023 and completed offsite 7/7/2023, The Rahabilitation Center of Seward in Collaboration with Indiana Regional Medical Center 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.
Plan of Correction:
485.709(b) STANDARD
ADMINISTRATOR
Name - Component - 00
The governing body appoints a full time qualified administrator, delegates to the administrator the internal operation of the clinic or rehabilitation agency in accordance with established written policies, defines clearly the administrator's responsibilities for procurement and directions to personnel, and designates a competent individual to act during temporary absence of the administrator.
Observations:
Based on review of governing body meeting minutes and staff (EMP) interviews, the governing body failed to designate a competent individual to act during temporary absence of the administrator.
Findings included:
Review of governing Body meeting minutes on 6/27/2023 at approximately 11:00am, the documentation failed to include the identity and appointment of and alternate administrator to act in the temporary absence of the administrator.
Exit interview was conducted on 7/5/2023 at approximately 12:30pm with the Clinical Director and Regional Director of Clinical Services confirmed above findings.
Plan of Correction:Reference tag 0015 I0015 485.709(b)
In compliance with Select Medical outpatient policy 11.01: Medicare Rehabilitation Agency
Administrative Management and State Operations Manual Standard 485.709(b) Administrator, the
Select Medical outpatient division governing board appointed the Administrator for this rehabilitation
agency. There has been no change in the approved administrator for this provider license. In alignment
with policy 11.01 and to avoid delay in designating an acting administrator when needed, the SM policy
states that a member of the Governing Board may appoint and approve the Acting Administrator,
documented on Administrative Appointment Approval Form 11.01a. Completion of this task includes
appointment, submission, approval and documentation of the Acting Administrator for this
rehabilitation agency by a member of the Governing Board.
Update: submission on 8/23/23 includes Administrative Appointment Approval Form 11.01a listing
current provider administrator, acting administrator and additional alternate administrator, in the
event that the primary administrator and/or acting administrator are not available. This document
has been reviewed and approved by a representative of the Governing Board, dated 8/23/23. This
signed document will be filed in the center handbook. The center Administrator is responsible to
review this at least quarterly and document review in the center handbook Calendar Checklist. In
addition, administrator designations will be reviewed semiannually by the Governing Board and the
Patient Care Committee.
Update: Supporting documentation submitted: Form 11.01a Administrative Appointment Approval
Form, Policy 11.01 Medicare Rehabilitation Agency Administrative Management (revised 3/1/23)
Completion date: 8/23/23. Monitoring: ongoing on at least monthly basis. Responsible party: Facility
Administrator
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 policy and procedure, equipment monitoring logs, observation, and staff (EMP) interview the clinic failed to ensure that the therapeutic pool was maintained according to agency policy for one (1) of one (1) therapeutic pool on site, failed to ensure proper monitoring of the rehabilitation equipment, specifically logs for one (1) of one (1) ice pack, one (1) of one (1) paraffin, and one (1) of one (1) hydrocollator temperatures and cleaning, the clinic failed to ensure equipment was inspected on an annual basis for one (1) of one (1) observation of clinic treatment rooms and gym. The clinic staff failed to record actions taken to correct out-of-range findings for water quality testing (pH and Bromine) and failed to properly store pool maintenance chemicals onsite for one (1) of one (1) observation.
Findings included:
Observation #1 made during initial tour of clinic on 6/27/23 at approximately 8:15am revealed all equipment in the facility gym and treatment rooms including but not limited to treadmills, elliptical, hydrocollator, ultrasound machines, etc. to be labeled with inspection stickers dated 5/2022 with next inspection written to be due 5/2023. No evidence of inspection conducted since 5/2022 to date of survey.
During interview on 6/30/23 at approximately 9:00am EMP1 stated, "...we looked into the inspection and determined that the employee that was to come inspect that day called off with an emergency and was to call to reschedule..." EMP1 subsequently confirmed that the company did not call to reschedule and also that the facility did not follow-up to ensure inspection occurred.
Observation #1 made during initial tour of clinic on 6/27/23 at approximately 8:15am also revealed no chemicals available on-site for maintenance of therapeutic pool.
EMP2, at time of observation, reported, "we were cited last time for chemical storage, so the director keeps them offsite..." EMP2 confirmed no chemicals available on-site to appropriately respond to out-of-range water readings. Reports, "...we get them when needed..."
Review of clinic policy and procedure, conducted on 6/29/2023 at approximately 4:15pm revealed: "... Policy # 9.22 ...Therapeutic Pool Cleaning and Maintenance ...Procedure, 1) General Procedures: ...i) Daily: 1) Check pH, add chemicals as needed ..., 2) Test sanitizer level (Bromine or Chlorine), add sanitizer as needed ...5) If chemicals need to be added, the name and amount of chemical is documented on the log ...iii) Monthly: ...3) Monitor supply of chemicals and orders as needed. All chemicals will be stored in original containers and kept in ventilated area that prevents unauthorized access ...iv) Annually ...: 1) Drain entire pool and clean walls, floor, and fixtures, as directed by manufacturer or pool company guidelines., 2) Check for structural damage and have repaired as needed. Have heater pump inspected and record on Pool Maintenance Log..., 3) refill pool and balance chemicals ... "
Review of Pool Cleaning & Maintenance Logs for dated 1/1/2022-6/27/2023 on 6/30/2023 at approximately 10:00am revealed "1/4" documented in the "Drain & Clean" column on dates of 3/6/2022, 4/18/2022, 6/9/2022, 7/15/2022, 10/5/2023, 1/16/2023, and 4/7/2023. EMP1 revealed, at this time, that the documentation meant that the pool was "...drained to 1/4 full... " and acknowledged that this does not follow agency pool cleaning policy.
EMP2 confirmed on 6/30/2023 at approximately 10:30am confirmed pool not to have ever be completely drained to the best of this employee's knowledge.
Review of Therapeutic Pool manufacturer ' s directions for use and maintenance on 6/29/23 at approximately 11:00am revealed the following: "...BEST RANGE, Bromine 4-6ppm, pH 7.4-7.6.
Review of Sample Water Quality Logs documented from 1/3/2022-6/27/2023 on 6/29/2023 at approximately 11:30am revealed:
pH documented to be:
7.0 on 3/24/22, 11/21/22, 11/22/22, an illegible date documented prior to and including 11/30/22, and the following 3 illegibly dated entries, on the 2 illegibly dated entries prior to 12/19/22,7.9 on 5/11/22 and 5/12/22, 2/13/23, 3/24/23, 6/8/23-6/13/23, and 6/19/23-6/21/23
7.1 on 5/18/22, 1/2/23
7.9 on 4/28/23
Bromine documented to be:
0ppm on 4/1/22, 4/4/22, 4/19/22, 4/26/22, 4/27/22, 5/19/22, 5/20/22, 11/3/22, 11/4/22, 11/7/22, 11/19/22, the 2 illegibly dated entries prior to 12/19/22, 3/22/23, the last entry in 4/2023 which is illegibly dated, the third entry of 5/3023 which is illegibly dated, the eleventh entry of 5/3023 which is illegibly dated, 6/15/2023-6/8/2023
8ppm on 4/21/22
10ppm on 3/25/22, 1/16/23
The log failed to include the name and amount of chemical added due to out of range readings, per clinic policy.
Review of clinic policy and procedure on 6/30/23 at approximately 11:30am revealed: " ...Policy # 9.19...Procedure, 1) General Procedures, a) Hydrocollator heater is thermostatically controlled, and water temperature is maintained according to manufacturers guidelines ...2) Cleaning Procedures: Hydrocollator machines should be cleaned following manufacturer guidelines. Ata minimum they must be cleaned quarterly ... "
Hydrocollator manufacturer directions for use reviewed on 6/30/23 at approximately 11:30am revealed: " ...Features Hydrocollator Mobile Heating Units...M-2...Temperature Range 160-165 degrees Fahrenheit ... "
Review of Hydrocollator Equipment Cleaning & Maintenance Log dated 1/3/2022-6/30/2023 revealed no documentation of cleaning performed. Log also revealed temperatures documented below manufacturer suggested temperature range with no evidence of corrective action
Review of clinic policy and procedure on 6/30/23 at approximately 12:00pm revealed: " ...Policy # 9.20...Paraffin bath Cleaning and Maintenance ...Policy, The paraffin bath is cleaned and the paraffin wax replaces every three months or sooner depending upon manufacturer recommendations and patient use ...Procedure...2) Document cleaning and monitoring of temperature on the Equipment Cleaning & Maintenance Log (9.17) ... "
Paraffin bath manufacturer directions for use reviewed on 6/30/23 at approximately 12:00pm revealed: " ...Technical Information...Operating temperature: 126-134 degrees Fahrenheit ... "
Review of Paraffin Bath Equipment Cleaning & Maintenance Log dated 1/3/2023-6/20/2023 revealed no documentation of cleaning performed. Log also revealed temperatures documented below manufacturer suggested temperature range with no evidence of corrective action.
Review of clinic policy and procedure on 6/30/23 at approximately 12:30pm revealed: " ...Policy # 9.18 ...Procedure ...3) Cold Pack Unit: a The Cold Pack Unit will be defrosted according to manufacturer guidelines or at a minimum every three months ...e0 Document cleaning and maintenance on the Equipment Cleaning & Maintenance Log ...4) ...b) Follow manufacturer ' s guidelines for maintaining and inspecting unit ... "
Ice Pack Unit manufacturer directions for use reviewed on 6/30/23 at approximately 12:30pm revealed: " ...Operating performance of temperature control ...NORMAL -13-1.5 degrees Celsius (8-10 degrees Fahrenheit) ... "
Review of Ice Pack Unit Equipment Cleaning & Maintenance Log dated 1/3/2022-6/30/2023 revealed no documentation of defrosting or cleaning performed. Log also revealed temperatures documented above manufacturer suggested temperature range with no evidence of corrective action.
Exit interview conducted on 7/5/2023 at approximately 12:30pm with the Clinical Director and Regional Director of Clinical Services confirmed above findings.
Repeat deficeincy, previously cited: 7/20/2017
Plan of Correction:All appropriate equipment has been calibrated by our national vendor Flagship Management as of 6/29/23. This site will continue to follow the annual calibration and inspection schedule, utilizing our current agreement with this provider. Fire proof safe purchased and now in use on-site for all pool chemicals to be stored on-site in and locked from patient access in an appropriate manner. Pool drained, cleaned and inspected on 7/28/23. Moving forward, pool levels will be maintained at manufacturer's suggested levels. Additionally, there will training led by CM for all staff on pool maintenance and this will be signed off on by all employees. Training will included appropriate chemical levels, appropriate chemical storage, how to adjust the levels, daily/weekly/quarterly documentation requirements, and yearly cleaning protocols. This again, will be included as part of the new employee training protocol. This is part of the SM new employee training checklist. Pool training will be completed by 8/30/23. All items will be monitored by the CM who will review the logs on Monday of each week and initial forms. In the absence of the CM, this will be performed by the staff PT or PTA.
Equipment logs will be maintained in manufacturer suggested temperature ranges. In addition to documenting monthly cleanings on the monthly checklists, but equipment cleaning, inspection and temperature checks will be documented on the separate temperature logs so they can be better tracked. The new monitoring policy will include training for all employees led by CM and employees will sign off on appropriate understanding of the new policy. This also will be included in new employee training and tracked on the SM new employee training checklist. Equipment log training completed by 8/30/23.
Trainings will be led by the CM with all employees sign off regarding competency.
Ongoing review of all process improvement updates will be the responsibility of the center administrator, utilizing the Select Medical Outpatient Division Center Readiness Plan and Calendar Checklist to confirm task completion for each calendar year
Logs will be audited monthly by Facility administration.
|