Initial Comments:
Based on the findings of an unannounced onsite federal recertification survey completed August 18, 2023, Ann's Choice, Inc. was found to be in compliance with the following requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.
Plan of Correction:
Initial Comments:
Based on the findings of an unannounced onsite federal recertification survey completed August 18, 2023, Ann's Choice, Inc.was found to have the following standard level deficiencies and was determined to be in substantial 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.
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 a review of facility policy/procedure, observations, and an interview with the facility Administrator, the facility failed to ensure lights are placed at exits for one (1) of one (1) treatment area observations (Observation #1).
Findings include:
A review of facility policy/procedure was conducted on August 18, 2023 at approximately 1:45 p.m. 'Emergency Generators' 'Purpose/Scope' states "To verify operation under emergency power ....." .... 'Life Safety Branch' states ".... Illumination of means of egress, such as ......, and all necessary ways of approach to exits." "Exit signs and exit directional signs." ..... "
Treatment floor observations conducted on August 16, 2023, between approximately 10:15 a.m. - 12:00 p.m. revealed the following:
Observation #1: The facility has two (2) exit doors leading into an adjacent hallway. An 'EXIT' sign, was attached to the wall directly above each exit door. There were no lights placed at exits used by patients, supported by an emergency power source.
An interview with the facility Administrator on August 17, 2023 at approximately 2:45 p.m. confirmed the above findings.
Plan of Correction:1. Lighted exit signs will be installed at each exit door in the Outpatient Rehab Department and will be supported by an emergency power source.
2.An inspection will be conducted to ensure lighted exit signs are placed at the exits for the department.
3.Administrator or designee will educate the Director and Assistant Director of General Services regarding the emergency lighting at exits for the Outpatient Rehab Department.
4.Once installed the lights will be tested annually in accordance with our emergency Generator Policy.
5.Corrective action will be completed by 9/29/23.
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 a review of facility policy/procedure, observations, and an interview with the facility Administrator, the facility failed to ensure all equipment was in good repair for one (1) of one (1) equipment observations (Observation #1) and failed to ensure expired patient supplies were properly disposed of for one (1) of one (1) patient supply observations (Observation #2).
Findings include:
A review of facility policy/procedure was conducted on August 17, 2023 at approximately 2:15 p.m. 'Infection Prevention and Control Safe and Sanitary Environment' 'Purpose/Scope' states "To maintain a safe and sanitary environment through the cleaning, disinfection and/or sterilization of environmental surfaces, as well as the equipment routinely used by residents and employees."
Facility policy related to expired products was requested August 17, 2023 at approximately 2:15 p.m. No policy provided.
Treatment floor observations conducted on August 16, 2023, between approximately 10:15 a.m. - 12:00 p.m. revealed the following:
Observation #1: Examination table (green) located in Physical Therapy Area #1 was noted to have an approximate 1"x1" tear in the vinyl covering in the center of the table. Interior foam exposed.
Patient treatment pad (red) 'Sammons Preston-Ability One' located in Physical Therapy Area #1, approximately 4'x6', had multiple tears in the vinyl covering around (3) of (4) grab handles. Interior foam exposed.
Patient treatment wedge (blue) located in Physical Therapy Area #2, approximately 1'x2', covered in a cloth like fabric. Fabric was porous and unable to be wiped down with disinfectant after use.
Observation #2: The following expired items were observed in the patient treatment area:
One (1) 'Self Adhesive Tens/NMES/FES Stimulating Electrodes' with an expiration date of 3/19/22, general supply.
One (1) 'Self Adhesive Tens/NMES/FES Stimulating Electrodes' with an expiration date of 6/14/23, general supply.
One (1) 'Self Adhesive Tens/NMES/FES Stimulating Electrodes' with an expiration date of 6/14/23, labeled with patient name (CR#26, date of admit 7/28/23).
One (1) 'Self Adhesive Tens/NMES/FES Stimulating Electrodes' with an expiration date of 6/14/23, labeled with patient name (CR#27, date of admit 7/27/23).
One (1) 'Self Adhesive Tens/NMES/FES Stimulating Electrodes' with an expiration date of 6/14/23, labeled with patient name (CR#28, date of admit 7/28/23).
An interview with the facility Administrator on August 17, 2023 at approximately 2:45 p.m. confirmed the above findings.
Plan of Correction:1.The department will have the treatment table, repaired or replaced, the fall mat replaced, and will dispose of the foam wedge and the expired electrodes.
2.An inspection will be conducted to ensure the treatment table, fall mat, treatment wedges and electrodes have been replaced or repaired and are in compliance with regulations.
3.Administrator or designee will educate the safety officer about the treatment table, fall mat, treatment wedge, and electrodes for compliance with regulations.
4.Administrator or designee will audit the treatment table, fall mat, treatment wedge and electrodes to ensure they have been repaired or replaced and are in compliance with regulations. Results of audit will be reviewed at monthly QAPI X 3 months.
5.Corrective action will be completed by 9/29/23.
485.729(a) STANDARD
CLINICAL RECORD REVIEW
Name - Component - 00
A sample of active and closed clinical records is reviewed quarterly by the appropriate health professionals to ensure that established policies are followed in providing services.
Observations:
Based on a review of facility policy/procedure, review of facility 'Committee Minutes', and an interview with the facility Administrator, the facility failed to ensure a sample of active and closed clinical records were reviewed quarterly for one (1) of one (1) documentation reviews (Documentation Review #1).
Findings include:
A review of facility policy/procedure was conducted on August 17, 2023 at approximately 2:15 p.m. 'Quarterly Compliance Audits' 'Purpose/Scope' states "The purpose of requiring quarterly compliance audits is to review the operations of the programs and services for consistence with federal and state laws and regulations governing payments. Monitoring for compliance also supports Erickson's philosophy of providing quality and value in the services available to community residents and other patients. ....."
A review of 'Committee Minutes' conducted on August 16, 2023, at approximately 1:00 p.m. revealed the following:
Documentation Review #1: 'Committee Minutes' dated 02/21/23, 'Reporting Period: October-December 2022' topic #6 'Performance Improvement' "A total of 15 charts were reviewed between October-December .... "
'Committee Minutes' dated 05/16/23, 'Reporting Period: January-March 2023' topic #6 'Performance Improvement' "A total of 15 charts were reviewed between January-March ...."
Committee Minutes' dated 07/11/23, 'Reporting Period: April-June 2023' topic #6 'Performance Improvement' "A total of 12 charts were reviewed between April-June ...."
An interview was conducted with the Administrator on 08/17/23 at approximately 1:30 p.m. Per the Administrator, "Only inactive (closed) patient charts were reviewed in the above stated time periods". No active charts were reviewed during the last three quarterly clinical record reviews.
An interview with the facility Administrator on August 17, 2023 at approximately 2:45 p.m. confirmed the above findings.
Plan of Correction:1.Agency Administrator or designee will complete 1 chart audit x 4 weeks with a mix of active and closed clinical charts for 3 months.
2.An audit will be completed to check that the charts being reviewed are a mix of active and discharged charts.
3.Agency Administrator or designee will educate the team on the proper chart auditing process including a mix of active and closed charts.
4.The agency administrator or designee will audit the charts to make sure there is a mix of active and closed charts being completed. Results of audit will be reviewed at the monthly QAPI meeting X 3 months.
5.Corrective action will be completed by 9/29/23.
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