Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted October 4 through October 5, 2023, Susquehanna Health Medical Plaza At Mansfield 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, Medicare recertification survey completed October 4 through October 5, 2023, Susquehanna Health Medical Plaza At Mansfield was identified 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.
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/procedures, monthly logs and interview with staff (EMP # 1) the clinic failed to ensure the the pool was tested twice daily for free active chlorine, pH, and water temperature and/or twice monthly for total alkalinity and water hardness for five (5) of eight (8) months reviewed. Mo#1, #2, #5, #6, & #9.
Findings include:
Review of policy/procedure: Water Quality completed on 10/4/2023 at approximately 3:00PM revealed:
Policy: "The Aquatic Therapy Pool is equipped with an automatic control device that continuously reads pH and Oxygen Reduction Potential (ORP), and in response dispenses corrective amounts of chlorine for sanitization, and CO2 gas for pH control. Manual water testing shall be performed to assure water quality, according to the schedule included in this policy".
Procedure: "Manual testing shall be performed according to the following schedule: Twice daily at the opening and closing on active pool days: free active chlorine, pH, and water temperature. Twice each month: total alkalinity and water hardness".
Review of Pool Water Quality Testing logs completed on 10/4/2023 between approximately 3:10PM and 3:30PM showed the following:
Mo#1, Jan 2023, contained documentation showing the total alkalinity of the pool water on 1/15 at 10:02 at 130 ppm. No documented reading to show the water hardness. No further documentation showing a second reading for the month.
Mo#2, Feb 2023, showed a documented reading for the total alkalinity of the pool water on 2/2 at 9:20 AM at 120 ppm and the water hardness at 190 ppm. No further documentation documentation showing a second reading for the month.
Mo#5, May 2023, showed a reading of 120 in the total alkalinity section of the log, and a water hardness reading of 200 ppm. No documented date or time. The second line showed a reading of 130 in the total alkalinity section of the log, and a water hardness reading of 190 ppm. No documented date or time.
Mo#6, June 2023, on 6/15 the following readings were documented at opening:
chlorine: 2.6, pH: 7.5, temp: 92. No documented readings at closing.
Mo#9, Sept 2023, on 9/14 the following readings were documented at opening:
chlorine: 2.4, pH: 7.5, temp: 92. No documented readings at closing.
An interview with the clinic Administrator (EMP #1) completed October 5, 2023 at approximately 2:30 PM confirmed the above findings.
Plan of Correction:Tag # 0121
The organization has implemented the following corrective actions to ensure compliance with appropriate testing of the pool water per policy:
- The Manager and Supervisor of Therapy Services provided education to all staff who are responsible for testing and recording the pool water data. The education consisted of a review of the appropriate policy. The employees signed the education confirming understanding of the policy including the frequency that the testing needs to be performed and recorded. The education was completed immediately following the survey on October 5th, 2023.
- Responsible Person: Clinic Supervisor
- Audits: The clinic Supervisor will review the log sheet on a weekly basis to ensure compliance with testing of the pool water per the policy. If non-compliance is noted, the employee will be coached by the Supervisor in real time.
- Compliance: Audits will continue until 100% compliance with testing and recording of pool water data is achieved for three (3) consecutive months.
Plan of Correction Completion Date October 23, 2023
485.725(a) STANDARD
INFECTION CONTROL COMMITTEE
Name - Component - 00
The infection control committee establishes policies and procedures for investigating, controlling, and preventing infections in the organization and monitors staff performance to ensure that the policies and procedures are executed.
Observations:
Based on observations (OBS) and interview with clinic Administrator the clinic failed to ensure expired supplies were discarded once they reached their expiration date for four (4) of four (4) observations made (OBS #1-4).
Findings include:
Observations made on October 4, 2023 at approximately 2:30 PM revealed:
OBS #1, one (1) 100ml 3.4 oz. bottle of 0.9 % Normal Saline solution approximately 1/4 full expired: 4/1/2021.
OBS #2, one (1) bottle containing Dexamethasone 120mg/30ml, 4mg/ml expired August 2023.
OBS #3, one (1) bottle containing Dexamethasone 120mg/30ml, 4mg/ml expired July 2023.
OBS #4, ten (10) Medichoice standard tongue depressors lot # 1611DG09A expired 10/31/2019.
An interview with the clinic Administrator (EMP #1) completed October 5, 2023 at approximately 2:30 PM confirmed the above findings. "It is the patient's responsibility to take their medications home with them once they are discharged from therapy. We do not have a formal policy for expired supplies but it is our procedure for staff to check the supplies routinely and remove expired items".
Plan of Correction:Tag # 0161
Plan of Correction:
The organization has implemented the following corrective actions to ensure supplies are discarded once they reach their expiration date:
- The Manager and Supervisor of Therapy Services provided education to all staff who are responsible for ordering supplies about the expectation that all supplies are looked at on a monthly basis. Anything that is expired should be discarded and replacements ordered if appropriate. Also, a log was created for employees to document their monthly supply checks. The employees signed the education confirming understanding of the expectation of discarding expired supplies and logging their monthly checks. The education was completed immediately following the survey on October 5th, 2023.
- Responsible Person: Clinic Supervisor
- Audits: The clinic Supervisor will review the log sheet on a monthly basis to ensure compliance with checking for expired supplies. If non-compliance is noted, the employee will be coached by the Supervisor in real time.
- Compliance: Audits will continue until 100% compliance with doing a monthly check for expired supplies is achieved for three (3) consecutive months.
Completion Date: October 23, 2023
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