Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on 9/24/2021, Procare PT Lp 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 completed 9/24/2021, Procare Pt Lp 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 Altoona, PA parent location on 9/22/2021 and the Hollidaysburg branch or extension location on 9/23/2021.
Plan of Correction:
485.709(a) STANDARD
GOVERNING BODY
Name - Component - 00
There is a governing body (or designated person(s) so functioning) which assumes full legal responsibility for the overall conduct of the clinic or rehabilitation agency and for compliance with applicable law and regulations. The name of the owner(s) of the clinic or rehabilitation agency is fully disclosed to the State agency. In the case of corporations, the names of the corporate officers are made known.
Observations:
Based on review of Department documentation, facility documents, governing body meeting minutes and staff (EMP) interview the facility failed to notify the Department of a physical address location of one (1) branch opening and two (2) branch closures of three (3) extension sites.
Findings included:
Review of the agency policy on 9/23/2021 at approximately 4:00 PM revealed, P/P TITLE: Agency Governing Body ...Policy: The governing body assumes responsibility for overall conduct and compliance of the Agency. Procedure: The Governing Body assumes full legal authority and responsibility for the operations of Agency sites (Parent and Extensions), Agency policies and procedures, program stability and compliance with applicable Federal, State and local laws and regulations ... "
During an outpatient physical therapy onsite extension location inspection at the agency Tyrone branch site on 9/22/2021 at approximately 9:35 AM the surveyor was at the site listed on the Departments documentation and the business was not listed as the agency. The surveyor confirmed with Division staff at 9:48 AM that no notification of closure was received from any sources.
During interview with EMP1 on 9/22/2021 at approximately 12:03 PM EMP1 was informed that the surveyor planned to conduct an outpatient physical therapy onsite extension location inspection at the agency Tyrone branch site, EMP1 confirmed the location was closed. EMP1 was shown the Departments document "ASPEN: Full Facility Profile (FFP)" with "Branches" listed.
EMP1 confirms that the Tyrone and Johnstown Branch sites listed on the full facility profile are closed, and the Hollidaysburg location was not listed on the Department's documentation.
Johnstown branch opened: 9/14/2010 closed 9/13/2018
Tyrone branch opened: 10/02/2017 closed: 3/26/2020
Hollidaysburg opened: September 2018
The surveyor asked EMP1 to provide any documentation submitted to CMS or the Department for closure or opening of the three sites on 9/22/2021. No documentation was received by close of business on 9/24/2021.
An interview was conducted with the administrator on 9/23/2021 at approximately 4:05 PM which confirmed the above findings.
Plan of Correction:According to Facility Policies & Procedures M1.008 Governing Body, 'The governing body assumes responsibility for overall conduct and compliance of the Agency including the parent and extension sites including compliance with the reporting of parent and extension site changes of location and closures.
The Administrator confirmed that the closure of the Tyrone and Johnstown clinics had not be properly reported to the State Department of Health as required due to transition from deemed credentialing with AAAASF and credentialing by the State. The information was sent to AAAASF but, did not get to the State during that transition. When the Hollidaysburg clinic opened it was enrolled as a Therapist in Private Practice Site and not as part of the Certified Rehab Agency.
The Administrator ensured that an 855A was submitted immediately after this Site Survey to add Hollidaysburg to the Rehab Agency and delete the Tyrone and Johnstown Clinics from the agency. An application for the opening of the Hollidaysburg clinic was submitted to CMS in a timely manner.
In addition, the Administrator ensured that a letter was to the Director of the Bureau of Facility, Licensure & Certification PA Department of Health notifying her of the deletions of the Tyrone and Johnstown locations and the addition of the Hollidaysburg location. The Department was also told that an 855A had been submitted and that it is in process.
Going forward the Medicare & Regulatory Specialist shall monitor all changes that occur if the credentialing is changed from deemed accreditation to accreditation by the State department of health to ensure that all parties are informed of the changes and not relying on communication between AAAASF and CMS or the State.
485.721(b) STANDARD
CONTENT
Name - Component - 00
The clinical record contains sufficient information to identify the patient clearly, to justify the diagnosis(es) and treatment, and to document the results accurately. All clinical records must contain the following general categories of data:
(1) Documented evidence of the assessment of the needs of the patient, of an appropriate plan of care, and of the care and services furnished.
(2) Identification data and consent forms.
(3) Medical history.
(4) Report of physical examinations, if any.
(5) Observations and progress notes.
(6) Reports of treatments and clinical findings.
(7) Discharge summary including final diagnosis(es) and prognosis.
Observations:
Based on a review of the facility policy, medical records (MR) and staff (EMP) interviews the facility failed to ensure a discharge summary was completed per agency policy and procedure for one (1) of twenty (20) MR's reviewed (MR6).
Findings Included:
A review of agency policy was conducted on 9/23/2021 at approximately 3:00 PM that revealed, "P/P TITLE ...Policy: The facility will follow all outlined procedures to ensure that all medical records are maintained in accordance with accepted professional standards and practices and applicable legal requirements. Procedure: There are multiple purposes for maintaining a patient medical record on each patient in accordance with good record keeping practices: To document the details of medical care rendered to the patient, the reasons for treatment, findings and recommendations. To act as a vehicle of and for communication among clinicians and providers serving the patient. To provide a means for assessing the quality of care by the clinician and facility and/or other health care providers working with the patient ...Content The content of the patient medical record should be sufficient to present a total, adequate picture of the care being given to the patient. The patient medical record should contain all information accumulated about the patient, the illness and/or injury and the treatment and sufficient information to identify the patient clearly, justify the diagnosis and treatment, and document the results of care accurately. The following is a list of basic items which should be in a completed patient medical record ...8. Discharge summary, including the following A. Date and reason for discharge. B. A brief summary of the current status of the patient at time of discharge. C. Where applicable, any provision for referral of the patient to another source for continuing care..."
A review of MRs was conducted on 9/23/2021 between approximately 1:30 PM and 3:00 PM.
Review of MR#6 was conducted on 9/23/2021 at approximately 1:53 PM. The date of the patient's therapy orders were 4/23/2021 the patients initial evaluation was 4/28/2021 with information listed under the "PLAN" section documented as follows: "The patient will be seen 2 times per week for 12 weeks..." No actual discharge date was identified, and no discharge summary was completed.
An interview conducted with (EMP1) the administrator on 9/23/2021 at approximately 4:00 PM EMP1 confirmed discharge documents were not completed for the patient.
Plan of Correction:The Administrator shall ensure that a discharge summary report is completed as outlined in the Facility P&P M5.005 'Discharge' for the patient in question. This discharge summary shall outline the condition of discharge for this patient. A copy of the Discharge Summary Report shall be sent to the patients referring physician and a copy shall be maintained in the patient's chart.
Going forward the Administrator shall ensure that that all discharged patients shall have a Discharge Summary Note completed within 20 business days of their last visit to the clinic or 5 days of a planned discharge from treatment. The discharge summary shall include the condition(s) that lead the therapist to recommend discharge.
To ensure that a similar incident does not occur again, the Administrator shall review the Facility P&P M5.006 and set up a process in the facility to run an Active Patient List for the facility each week and determine which patients need to be contacted for follow up and future scheduling and which need discharge summary reports to be completed.
Therapist shall complete the required discharge summary within 20 business days for an unplanned discharge and 5 business days for a planned discharge. By running the report on a weekly basis the Administrator shall be able to ensure that patients discharge reports are being completed in a timely manner.
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