Initial Comments:
Based on the findings of an unannounced on-site initial Medicare certification survey conducted September 26 and 26, 2019, Select Physical Therapy located at 125 E. Main Street, Elizabethville, Pa 17023, was found to be in compliance with the following 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 initial Medicare certification survey conducted September 26 and 27, 2019, Select Physical Therapy located at 125 E. Main Street, Elizabethville, Pa 17023 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.
Plan of Correction:
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 review of policies, owner's manuals, equipment cleaning and maintenance logs and an interview with the facility administrator the infection control committee failed to maintain the hydrocollator and freezer cleaning and maintenance logs in accordance with policy for one (1) of one (1) hydrocollator unit (H unit) and one (1) of one (1) freezer (F unit). (H unit #1 and F unit #1).
Findings include:
Review of Policy '9.19 HYDROCOLLATOR MACHINE MAINTENANCE AND CLEANING' Procedure conducted on 9/27/19 at approximately 10:00 a.m. states "Hydrocollator machines must be cleaned at least quarterly or more frequently as necessary."
Review of Policy '9.18 THERAPEUTIC EQUIPMENT CLEANING AND MAINTENANCE' Procedure conducted on 9/27/19 at approximately 10:10 a.m. states "...6. Other Electrical Equipment (i.e...freezer)...Follow manufacturer's guidelines for cleaning procedures..."
Review of 'Owner's Manual' for Danby's freezer conducted on 9/27/19 at approximately 10:15 a.m. states, "DEFROSTING INSTRUCTIONS:...The freezer compartment should be defrosted any time the frost reaches 3-5 mm (1/4 in.) thick..."
Review of EQUIPMENT CLEANING & MAINTENANCE LOG on 9/26/19 at approximately 1:00 p.m. revealed the following:
H unit #1: No documentation of quarterly cleaning in 2018 for Quarter (Q) #2, Q#3, and Q#4. No documentation of quarterly cleaning in 2019 for: Q#2.
Observation of F unit #1: Danby Freezer, Model # DPF073C2WD8, revealed approximately 1/2 in. thick frost along the interior walls of the freezer. No documentation of defrosting freezer between 1/2/18-5/30/19.
An interview with the administrator on 09/27/19 at approximately 1:45 p.m. confirmed the above findings.
Plan of Correction:0161-
485.725(a) STANDARD INFECTION CONTROL COMMITTEE
Based on findings of lack of hydrocollator and freezer cleaning logs in accordance with Select Physical Therapy Policy stating the "Hydrocollator machines must be cleaned at least quarterly or more frequently as necessary." And "Other Electrical Equipment ( I.e. freezer) to follow manufacturer's guidelines for cleaning procedures"
1. The management team, consisting of the Center Manger, Market Manager and Regional Director has discussed the deficiency as stated above and have worked together to complete the agreed upon plan of correction during staff meeting and collaboration.
2. The center manager will review policy of hydrocollator and freezer safety with all current new staff and/or students participating in the daily operations of the center. Documentation of this will be in new staff employee file as well as yearly compliance training and monthly staff meetings.
3. The center manager has redesigned the hydrocollator and freezer cleaning log to include safe therapeutic temperature ranges and fastened a year's worth of logs together with year clearly printed on top of each page to assure no confusion of dates. The policy of hydrocollator safety and the logs are hanging on wall above the hydrocollator machine and freezer to be a constant reminder of safety and logging. The team at Select Physical Therapy in Elizabethville has conducted a staff meeting to review the above changes and discuss policy of completing daily records of both freezer and hydrocollator temperatures. Quarterly cleaning schedules have also been placed beside the daily logs and printed policy. Documentation will be completed as part of the annual safety drills conducted by the center manager and documented and maintained in the center handbook.
4. The above corrective actions will be monitored weekly by Center Manager to assure logs are being documented and maintained properly for hydrocollator and freezer by visual review on logs hanging above both equipment pieces.
5. The above corrective actions were initiated immediately upon 9/27/19 and will continue to be monitored monthly and reviewed by both center manager and therapists. The deficiencies are addressed and will be completed by 11/8/19.
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