Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on November 22, 2022, The Jewish Association on Aging was found to be in compliance with the requirements of 42 CFR, Chapter IV, Subpart B, Conditions of Participation: Comprehensive Outpatient Rehabilitation Facilities - Emergency Preparedness.
Plan of Correction:
Initial Comments:
Based on the findings of an unannounced onsite Medicare recertification survey completed on November 22, 2022, The Jewish Association on Aging 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 facility primary site and the extension unit site at 5738 Forbes Avenue, Pittsburgh, PA 15217.
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 policies, observations, and staff interviews (EMP), it was determined the rehabilitation center at 200 JHF Drive, Pittsburgh (parent location) failed to ensure proper monitoring of the rehabilitation equipment, specifically logs for ice pack temperatures, logs for paraffin temperatures and hydrocollator (hot pack) temperatures. (OBS#1).
Findings include:
Review of facility policy "Equipment Management and Electrical Safety," on November 21, 2022 at approximately 11:15 a.m. revealed, "POLICY: The rehab department will assure safe and effective use of all department equipment including education regarding equipment utilization...1. All equipment is to be set up, installed and utilized in accordance with manufacturer's instructions...Therapy personnel will review any operational manual by the manufacturer that provides data on the operating characteristics of the equipment...a. Therapy personnel will note any recommended preventative maintenance, and when appropriate, place the equipment on the routine maintenance schedule."
Review of facility policy "Maintenance of Modalities" on November 21, 2022, at approximately 11:20 a.m. revealed, "POLICY: All modalities will be properly cleaned and serviced in accordance to manufacturer's recommendations...Paraffin bath...Purpose: Cleaning the Paraffin Bath...this procedure is to be done a minimum of every month unless indicated otherwise...Hot Pack Unit...the unit should be cleaned once a month depending on usage..."
Observation of the patient treatment area of the rehabilitation center conducted on 11/21/22 from approximately 11:12 a.m. to 11:25 a.m. revealed the following:
-Ice pack temperature logs that did not include the temperature range provided by manufacturer and what corrective or remedy was taken if outside of temperature range. Review of the temperature log for 1/3/22 through 11/21/22 indicated the ice pack equipment was cleaned 5/20/22. The log did not include staff initials.
-Paraffin temperature logs that did not include the temperature range provided by manufacturer, what corrective or remedy was taken if outside of temperature range. Review of the temperature log for 1/3/22 through 11/21/22 indicated the paraffin bath equipment was cleaned 9/21/22. The log did not include staff initials.
-Hydrocollator temperature logs that did not include the temperature range provided by manufacturer, what corrective or remedy was taken if outside of temperature range. Review of the temperature log for 1/3/22 through 11/21/22 indicated the hydrocollator equipment was not cleaned 8/2022 or 10/2022. The log did not include staff initials.
An interview with the Director of Rehab and the Assistant Director on 11/22/22 at approximately 2:00 p.m. confirmed the above findings.
Plan of Correction:Submission of this Plan of Correction (POC) is to demonstrate the commitment to constant improvement the Jewish Association on Aging (JAA) seeks to provide for our patients and our community. We strive to do this in our daily operations in order to enhance the quality of health care services we deliver in our outpatient rehab facilities.
All outpatient staff will attend and in-service for review of our policies and procedures regarding proper monitoring and cleaning of the clinical modality equipment, specifically the hydrocollators (hot pack), ice pack freezers and paraffin machine.
Review will include the recommended safe therapeutic temperatures of each piece of modality equipment. These temperature ranges will follow the manufacturer's guidelines and will be clearly posted at each piece of equipment. A calendar log will be located at each modality with clear spaces for a daily temperature to be recorded. An additional space will be provided for the staff who checks temperature to sign with their initials. If temperature falls outside the recommended range, additional space will be provided to document temperature correction or repair provided. Modality equipment will not be used for patient care until new temperature is taken and acceptable ranges are recorded.
Rehab Director and/or Assistant Rehab Director will be responsible for monitoring correct implementation of this policy. Quarterly audits will be conducted at appropriate site staff meeting.
Additionally, a second calendar log will be kept at each piece of modality equipment. This will be used to record monthly cleaning of each hydrocollator, ice pack freezer and paraffin machine per manufacturer's guidelines. Staff member who performs appropriate cleaning will date and initial log, which will be clearly posted.
Rehab Director and/or Assistant Rehab Director will be responsible for monitoring correct implementation of this policy. Quarterly audits will be conducted at appropriate site staff meeting.
The JAA outpatient rehab facilities will continue to use an outside vendor for yearly maintenance checks on each piece of modality equipment. Documentation and dates of routine service checks will be kept on file for review.
Above corrective actions will be completed by January 1, 2023.
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 observations (OBS) and staff interview (EMP) it was determined the rehabilitation center at 200 JHF Drive, Pittsburgh (parent location) failed to ensure disposal of expired supplies for OBS #1.
Findings include:
Observation of the patient treatment area of the rehabilitation center conducted on 11/21/22 from approximately 11:12 a.m. to 11:25 a.m. revealed the following:
Observation #1 - Storage cabinet located on the right side wall of the rehabilitation center treatment area:
1 box of alcohol prep pads with expiration date of 5/3/2020
1 bottle of Biofreeze with expiration date of 1/2022
2 bottles of Biofreeze with the expiration date of 1/2021
1 bottle of Diffense with expiration date of 11/2020
1 package of Siligentle Border Gauze with expiration date of 11/26/18
4 packages of ValuTrode Neurostimulation Electrodes with expiration date 2/27/22
5 packages of ValuTrode Neurostimulation Electrodes with expiration date 3/10/22
1 package of Dura-Stick Stimulating Electrodes with expiration date of 5/2013
1 package of Compatch self-adhesive electrodes with expiration date of 7/2001
An interview with the Director of Rehab on 11/21/22 at approximately 11:25 a.m. confirmed the above findings.
Plan of Correction:Submission of this Plan of Correction (POC) is to demonstrate the commitment to constant improvement the Jewish Association on Aging (JAA) seeks to provide for our patients and our community. We strive to do this in our daily operations in order to enhance the quality of health care services we deliver in our outpatient rehab facilities.
All outpatient staff will attend and in-service for review of our policies and procedures regarding proper check and disposal of expired supplies.
Each office location will be provided a binder to keep a clear and legible list of all office supplies. Inventory of each item will be recorded including date of expiration. A weekly check of supply expiration dates will be conducted by a JAA staff member, who will date and sign supply log with their initials. Any expired item will be properly disposed of according to manufacturer's guidelines. New supplies will be ordered as needed. Each new office supply item received will be added to the inventory list. Monitoring of this policy will be conducted by rehab director and/or assistant rehab director quarterly.
Above corrective action will be completed by January 1, 2023.
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