Initial Comments:
Based on the findings of an unannounced Medicare recertification survey conducted on September 26, 27 and 30, 2019, Riverside 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 Plains main site was conducted on September 26, 27 and 30, 2019 and for the Wilkes-Barre extension site on September 27, 2019.
Plan of Correction:
485.727(c)(1) STANDARD
Names and Contact Information
Name - Component - 00
§403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1).
[(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:]
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [facilities].
(v) Volunteers.
*[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [hospitals and CAHs].
(v) Volunteers.
*[For RNHCIs at §403.748(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Next of kin, guardian, or custodian.
(iv) Other RNHCIs.
(v) Volunteers.
*[For ASCs at §416.45(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.
*[For Hospices at §418.113(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Hospice employees.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Other hospices.
*[For HHAs at §484.102(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.
*[For OPOs at §486.360(c):] The communication plan must include all of the following:
(2) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Volunteers.
(iv) Other OPOs.
(v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).
Observations:
Based on a review of facility policies/procedures and documentation, and based on interview with the operations support coordinator (OSS), the clinic failed to ensure the "Emergency Preparedness Plan for Plains" included a current list of the names and contact information for clinic staff.
Findings include:
On September 30, 2019 at approximately 10:05 AM, review of the agency policy titled "Emergency Preparedness and Response-Rehab Agency and Group Practice" revealed the following:
"3. Communication Plan...3.1 The emergency preparedness communication plan must include all of the following...
3.1.1 A designated chain of command and control including emergency contact list to disseminate information: 3.1.1.1 Employees..."
During interview on September 26, 2019 at approximately 2:40 PM, the OSS confirmed that three of the six clinic extension sites/offices (Berwick, Taylor and Tunkhannock) had closed. The OSS confirmed that a change in administrator had occurred in both 2018 and August 2019.
On September 26, 2019 at approximately 2:22 PM, review of the agency's "Emergency Preparedness Plan for Plains" revealed a previous administrator's name was listed on page 22 and that staff names for the Berwick, Taylor and Tunkhannock offices were included on the "Employee Phone Numbers" form. There was a total of 24 clinic staff names included on the "Employee Phone Numbers" form.
On September 27, 2019 at approximately 8:44 AM, review of the updated "Employee Phone Numbers" form which was provided by the OSS revealed a total of 15 staff names were included on the form.
There was no documentation in the "Emergency Preparedness Plan for Plains" which provided evidence that the "Employee Phone Numbers" form had been updated prior to September 26, 2019.
During interview on September 27, 2019 at approximately 10:30 AM, the OSS confirmed the "Employee Phone Numbers" form, which was included in the "Emergency Preparedness Plan for Plains", was not updated to include the names and contact information of current clinic staff prior to September 26, 2019.
Plan of Correction:A current list of employee names and contact information for clinic staff will be maintained at all times at the Plains clinic in the site specific binder.
Procedure for Implementation: The Plains clinic binder was updated with current employee names and phone numbers on 10/1/19.
Plan for Future to ensure compliance:
OPT Administrator will be responsible for updating the changes to the employee list in Plains clinic binder as they occur, to be checked monthly.
OPT Administrator will use calendar reminders to update clinical staff information and ensure all changes have been captured on a monthly basis at the Plains clinic.
The rehab office coordinator will also use calendar reminders to double check updates to all clinical staff information in binder on a monthly basis at the Plains clinic.
Initial Comments:
Based on the findings of an unannounced Medicare recertification survey conducted on September 26, 27 and 30, 2019, Riverside 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 Plains main site was conducted on September 26, 27 and 30, 2019 and for the Wilkes-Barre extension site on September 27, 2019.
Plan of Correction:
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