Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on March 15, 2023 through March 16, 2023, Sundance Rehabilitation Agency of Pennsylvania was found to be in compliance with the 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:
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted March 15, 2023 through March 16, 2023, Sundance Rehabilitation Agency of Pennsylvania was identified to 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(c) STANDARD
PERSONNEL POLICIES
Name - Component - 00
Personnel practices are supported by appropriate written personnel policies that are kept current. Personnel records include the qualifications of all professional and assistant level personnel, as well as evidence of State licensure if applicable.
Observations:
Based on review of CDC Guidelines, personnel policies, personnel files (PF) and interview with administrator, the agency failed to ensure personnel policies were followed, and personnel files were complete, including but not limited to: screening for TB, and performance evaluations, for six (6) of six (6) files reviewed. (PF #1-6)
Findings include:
The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. HCWs with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. (CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Morbidity and Mortality World Report 2005; RR-17').(http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.)
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
Policies were reviewed on 3/15/23 approximately 3:00 PM to 3:30PM.
Policy Title "PB SH105 Mycobacterium Tuberculosis Screening", Process, 2. "Administration of the TST for employees is conducted in accordance with state regulations...".
Policy Title "PB HR305 Performance Evaluation and Merit Appraisals" process 1.2. "formal evaluations: "performance evaluations are required at the conclusion of an employee's 90-day introductory period and, at a minimum, annually thereafter".
Review of personnel files (PF) completed 3/15/23 approximately 11:30 AM to 1:30 PM revealed:
PF#1 showed a date of hire, 3/11/13, no documentation of a performance evaluation for 2021, no documentation of annual TB education.
PF #2, showed a date of hire, 4/1/13, no documentation of a performance evaluation for 2021, no documentation of annual TB education.
PF #3, showed a date of hire, 2/13/12, no documentation of annual TB education.
PF#4, showed a date of hire, 10/25/22, no documentation of annual TB education.
PF#5, showed a date of hire, 11/22/04, no documentation of annual TB education.
PF#6, showed a date of hire, 11/16/20, no documentation of annual TB education.
Interview with both Administrator and Alternate Administrator on 3/15/23 at approximately 4:15 PM confirmed the above findings.
Plan of Correction:1. By 3/22/23, agency Administrator will add printed Performance reviews for all current employees in their employee files.
2. By 3/22/23, agency Administrator will ensure annual Tuberculosis (TB) education/training for all current and new employees will be documented in human resources online files.
3. Starting 3/22/23 and performing annually, agency administrator or designee will audit all current and new employees for documented annual performance evaluations and TB education. Agency Administrator or Designee will address any non-compliant audit findings and ensure compliance with these requirements.
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 observations of the patient treatment area, review of cleaning logs and interview with the administrator, the facility failed to ensure equipment was not obstructing entrance doorway into the facility; failed to ensure additional space used by staff and patients contained necessary emergency postings including but not limited to: evacuation routes, lighting and fire alarms for two (2) of two (2) observations made. (OBS #1-2).
Findings Include:
Observations conducted on 3/15/23 approximately 9:30 AM to 4:00 PM revealed:
OBS #1: On 3/15/23 at approximately 2:00 PM observed, one (1) Hydrocollator (Tropic Heater Heating Unit, 6-PAC Model) filled with water and heated at approximately 161 degrees Fahrenheit, storing five rows of hot-packs. The Hydrocollator was sitting on top of a portable cart which was placed inside the entrance doorway of the facility, between the entrance doorway and the sink, which could obstruct a stretcher from entering easily.
OBS #2: On 3/15/23 at approximately 10:15 AM an additional room containing a treadmill and two (2) exercise bicycles located behind the general dining area was identified. the room had two doors one leading to a general area and the other to resident dining area connecting to a hallway that led to the facility entrance. Staff identified this as "shared area" for both residents of the assisted living community and facility staff/patients. No noted signage showing evacuation routes were posted, no emergency lighting was hung on the walls nor any fire alarms were noted within the room.
Interview with both Administrator and Alternate Administrator on 3/15/23 at approximately 4:15 PM confirmed the above findings. "We moved the cart to this outlet as we needed to have the Hydrocollator plugged into a grounding outlet and this is the only one in the room".
Plan of Correction:1. On 3/22/23, agency Administrator relocated the hydrocollator machine away from the doorway entrance and near a GFI outlet.
2. On 3/22/23, Administrator provided education to all staff regarding the need for machine relocation.
3. On 3/24/23, Administrator reviewed recommendations for Fitness Room with with ED of Juniper Village. She had exit signs placed above both doors as well as emergency lighting places above both doors as well as an emergency evacuation sign placed in room.
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 reviews of policy, observations, and interview with the administrator the facility failed to ensure all rehabilitation equipment contained a calibration/maintenance sticker for two (2) of seven (7) pieces of equipment observed (EQUIP #1-2).
Findings Include:
Policies were reviewed on 3/15/23 approximately 3:00 PM to 3:30PM.
Policy Title "PB SH101 Cleaning and maintenance of Rehabilitation Equipment", Process: 1. Contract sites of service and subcontracted entities: 1.1 "company staff defer to the provider's clinical, maintenance, and/or administration department requirements for: 1.1.2.1 "Equipment calibration, per manufacturer guidelines;".
Observations of equipment completed 3/15/23 approximately 10:00 AM to 11:00 AM revealed:
EQUIP #1, Transcutaneous Electrical Nerve Stimulation (TENS) machine, Model 3000; ID# 5160544848 contained a sticker reading last serviced: 6-30-20, Due: 6/2021.
EQUIP #2, Jamar Hydraulic Pinch gauge, Model 74980, S/N 61212207 contained no sticker showing an annual calibration had been completed per manufacturer guidelines.
Interview with both Administrator and Alternate Administrator on 3/15/23 at approximately 4:15 PM confirmed the above findings.
Plan of Correction:1. On 3/22/23, agency Administrator removed the Transcutaneous Electrical Nerve Stimulation (TENS) machine and Jamar Hydraulic Pinch gauge from agency office. These equipment items will not be used on patients.
2. Starting 3/22/23, agency Administrator or designee will perform annual audit on all equipment requiring calibrations to ensure inspection. Next annual inspection is due October '23 for all equipment.
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 of the patient treatment area, review of cleaning logs and interview with the administrator, the facility failed to ensure equipment was not obstructing entrance doorway into the facility for one (1) of one (1) observation made. (OBS #1).
Findings Include:
Observations conducted on 3/15/23 approximately 9:30 AM to 4:00 PM revealed:
OBS #1: On 3/15/23 at approximately 2:00 PM observed, one (1) Hydrocollator (Tropic Heater Heating Unit, 6-PAC Model) filled with water and heated at approximately 161 degrees Fahrenheit, storing five rows of hot-packs. The Hydrocollator was sitting on top of a portable cart which was placed inside the entrance doorway of the facility, between the entrance doorway and the sink, which could obstruct a stretcher from entering easily.
Interview with both Administrator and Alternate Administrator on 3/15/23 at approximately 4:15 PM confirmed the above findings. "We moved the cart to this outlet as we needed to have the Hydrocollator plugged into a grounding outlet and this is the only one in the room".
Plan of Correction:1. On 3/22/23, agency Administrator relocated the hydrocollator machine away from the doorway entrance and near a GFI outlet.
2. On 3/22/23, Administrator provided education to all staff regarding the need for machine relocation.
485.725(c) STANDARD
HOUSEKEEPING
Name - Component - 00
The organization employs sufficient housekeeping personnel and provides all necessary equipment to maintain a safe, clean, and orderly interior. A full-time employee is designated as the one responsible for the housekeeping services and for supervision and training of housekeeping personnel.
An organization that has a contract with an outside resource for housekeeping services may be found to be in compliance with this standard provided the organization or outside resource both meet requirements of the standard.
Observations:
Based on reviews of policy, observations, review of Genesis Rehabilitation Cleaning Log, and interview with the administrator the facility failed to ensure the ultrasound machine was cleaned and stored properly between each patient use for one (1) of one (1) machine observed. (OBS #1).
Findings Include:
Policies were reviewed on 3/15/23 approximately 3:00 PM to 3:30PM.
Policy Title "PB SH101 Cleaning and maintenance of Rehabilitation Equipment", Process: 3. "Cleaning and Disinfection of Equipment: 3.1. " Equipment must be cleaned and disinfected with a proper product and method following each patient use consistent with standard precautions and manufacturer direction/guidelines...".
Review of Genesis Rehabilitation services cleaning logs conducted on 3/15/23 approximately 1:30 PM for months December 2022, January 2023 and February 2023 revealed: Ultra Sound Machine was cleaned "weekly". No documentation of the machine being cleaned after each patient use.
OBS #1, completed 3/15/23 approximately 10:00 AM revealed the Ultrasound Machine stored to the left of the entrance doorway without a covering on the probe. Four (4) open packages of electrodes were stored in the left side pocket of the machine with patient initials marked on each. The pocket contained what appeared to be dust, stains and miscellaneous debris gathered in the bottom.
Interview with both Administrator and Alternate Administrator on 3/15/23 at approximately 4:15 PM confirmed the above findings.
Plan of Correction:1. On 3/23/23, agency Administrator updated cleaning log sheet to require infection control cleaning instructions after each patient use and coverage of the Ultrasound probe with cover provided by manufacture to prevent dust accumulation.
2. On 3/22/23, agency Administrator or designee performed a thorough cleaning procedure on the Ultrasound equipment (inclusive of all side drawers).
3. On 3/22/23, agency Administrator or designee re-organized the method of storing current patient' electrodes package by re-marking each bag with a marker - patient specific as well as placing each electrode bag in an addition bag, ensuring both bags are sealed tightly.
|