Initial Comments:
Based on the findings of an unannounced, onsite Medicare recertification survey conducted between June 15, 2022 and June 16, 2022, at the parent site located at 550 North 12th Street, Suite 120 Lemoyne, PA 17043, and one extension site located at 1 Valley Street, Suite 104, Carlisle, PA 17013, Select Physical Therapy 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 unannounced, onsite Medicare recertification survey conducted between June 15, 2022 and June 16, 2022, at the parent site located at 550 North 12th Street, Suite 120 Lemoyne, PA 17043, and one extension site located at 1 Valley Street, Suite 104, Carlisle, PA 17013, Select Physical Therapy was identified to have the following standard level deficiencies that were 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 and Speech/ Language Pathology Services.
Plan of Correction:
485.721(c) STANDARD
RECORDS COMPLETION & REPORT CENTRALIZATION
Name - Component - 00
Current clinical records and those of discharged patients are completed promptly. All clinical information pertaining to a patient is centralized in the patient's clinical record. Each physician signs the entries that he or she makes in the clinical record.
Observations:
Based on review of policies, medical record (MRs) review and interview with the facility regional director, it was determined the facility failed to ensure a discharge summary was written within thirty (30) days for two (2) of twenty-five (25) MRs reviewed. (MR# 20 and MR# 21)
Findings include:
Review of Policy 'DISCHARGE SUMMARY', conducted on June 16, 2022 at approximately 10:30 a.m. states, "Policy: A discharge summary shall be written within thirty (30) calendar days of the end of the current plan of care by a therapist......"
Review of MRs conducted on June 16, 2022 at approximately 9:30 a.m. revelaed the following:
MR #20, Start of Care (SOC), 9/2/2021: Last visit was on 2/17/2022. Discharge summary was written on 4/21/22, 64 days later.
MR #21, SOC, 11/30/2018: Last visit was on 2/7/2019. Discharge summary was written on 6/6/2019, 119 days later.
An interview with facility regional director at approximately 2:00 p.m. on June 15, 2022 confirmed the above policies as current, and the above findings.
Plan of Correction:1. All current cases beyond 30 days from last visit will have discharge notes written by August 1, 2022.
2. CM will check inactive report in our EMR system on a weekly basis to ensure all inactive patients are identified prior to 30 days so that they can be discharged as appropriate.
3. The Market Manager will check inactivity report on a monthly basis to ensure compliance with item number 2.
4. This corrective action will be completed effective August 15, 2022.
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 review of policies, observations, and interview with the facility regional director, it was determined the facility failed to ensure expired medications were disposed of at the parent location at 550 North 12th Street, Suite 120, Lemoyne PA 17043 for one (1) of three (3) observations conducted (Observation #3);
Findings include:
Review of Policy 'STORAGE AND DISPOSAL OF MEDICATIONS AND SUPPLIES', conducted on June 15, 2022 at approximately 12:30 p.m. states, "...Procedure: 1. Non-Electrical Equipment: c) Medications and Multidose Vials (MDV's) will be monitored with each use for expiration dates......"
A tour of the parent location on June 15, 2022 at approximately 10:00 a.m. revealed:
Observation #3: The following medications were expired:
- For Patient #26: One (1) Dexamethasone Sodium Phosp (corticosteroid) 120 Solu 30 mL (milliliters) multiple dose vial- Pharmacy label states, "Discard After: 2/12/21
- For Patient #27: One (1) Dexamethasone 120 mg (milligrams)/30 mL multi-dose vial- Label on vial states, "Exp: 05/2017
- For Patient #28: One (1) Dexamethasone Sod Via 1 mL vial- Label on vial states, "Exp" 03/2022
- For Patient #29: One (1) Dexamethasone 120 mg/30 mL multiple dose vial- Label on vial states, "Expiry: 03/2019
- For Patient #30: One (1) Dexamethasone 120 mg/30 mL vial- Label on vial states, "EXP 08/18
An interview with facility regional director at approximately 2:00 p.m. on June 15, 2022 confirmed the above policies as current, and the above findings.
Plan of Correction:1. All expired medication has been disposed of.
2. Going forward – medication will no longer be stored at the center at all. Patients will bring in any medication needed for their treatment and will take it with them when they leave.
3. Center Manager will check for expired supplies/medications and dispose accordingly on a monthly basis & mark as complete on the center handbook calendar checklist.
4. This corrective action will be completed August 15, 2022.
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 interview with the facility regional director, it was determined the facility failed to ensure the equipment was free from any defects at the parent location at 550 North 12th Street, Suite 120, Lemoyne PA 17043 for one (1) of three (3) observations conducted (Observation #1); failed to ensure the equipment was free from any defects at the branch location at 1 Valley Street, Suite 104, Carlisle PA 17013 for one (1) of three (3) obervations conducted. (Observation #2)
Findings include:
Review of Policy '9.17: EQUIPMENT MAINTENANCE AND RECALLED ITEMS', conducted on June 15, 2022 at approximately 1:30 p.m. states, "Policy: Select Medical Outpatient Division will maintain, inspect, and calibrate all equipment to ensure the safety and quality care of patients...Procedure: 1. Non-Electrical Equipment: a) The center staff or outside agency, on at least a semiannual basis will inspect all non-electrical equipment for safety hazards. If a hazard is found at any time, it will be reported to the center manager for immediate repair. The equipment will be taken out of service until necessary repairs are made..."
A tour of the parent location on June 15, 2022 at approximately 10:00 a.m. revealed:
Observation #1: The following equipment showed signs of defect:
- Three (3) gray rolling stools all peeling at the top cushion
- One (1) pillow peeling
- One (1) pillow with yellow stains
- One (1) large wedge peeling on all four corners
- One (1) Thera Band foam roller peeling
- One (1) Push Pull Slider with torn grips on both handles
- One (1) Blue Alrex Pad with cracks
A tour of the branch location at 1 Valley Street, Suite 104, Carlisle PA 17013 on June 16, 2022 at approximately 10 a.m. revealed:
Observation #2 The following equipment showed signs of defect:
- One (1) Thera Band foam roller peeling
- One (1) Blue Alrex Pad with cracks
No noted signage stating this equipment was"out of order" or should not be used was posted.
An interview with facility regional director at approximately 2:00 p.m. on June 15, 2022 and at approximately 11:30 a.m. on June 16, 2022 confirmed the above policies as current, and the above findings.
Plan of Correction:1. Plan for individual items
a. Lemoyne clinic
i. Three gray stools – will be re-covered with vinyl.
ii. 2 pillows – will be discarded and replaced new.
iii. Wedge will be discarded and replaced with new.
iv. Theraband foam roller cover will be discarded – does not need to be replaced
v. Airex pad will be discarded and replaced with new.
vi. Push/Pull slider hand grips will be removed and discarded. Metal handles will be left bare and will be cleaned after every use.
b. Carlisle
i. Theraband foam roller will be discarded and does not need to be replaced
ii. Airex pad will be discarded and does not need to be replaced.
2. All equipment will be inspected by CM on a monthly basis for defects and will be replaced as needed. If an item cannot be immediately removed, it will be marked "Out of order." The Center Manager will mark as complete on the center handbook calendar checklist.
3. This corrective action will be completed by August 15, 2022.
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