Initial Comments:
Based on the findings of an unannounced Medicare initial certification survey conducted February 27, 2020, Select Physical Therapy, located at 1251 East Main Street, Annville, Pa. 17003 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 unannounced Medicare initial certification survey conducted February 27, 2020, Select Physical Therapy, located at 1251 East Main Street, Annville, Pa. 17003 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.
Plan of Correction:
485.709(d) STANDARD
PATIENT CARE POLICIES
Name - Component - 00
Patient care practices and procedures are supported by written policies established by a group of professional personnel including one or more physicians associated with the clinic or rehabilitation agency, one or more qualified physical therapists (if physical therapy services are provided) and one or more qualified speech pathologists (if speech pathology services are provided). The policies govern the outpatient physical therapy and/or speech pathology services and related services that are provided. The policies are evaluated at least annually by the group of professional personnel, and revised as necessary based upon this evaluation.
Observations:
Based on review of facility policy, clinical records (CR), and an interview with the facility Market Manager, facility failed to ensure a discharge summary was completed within thirty (30) days of the end of the plan of care, per policy, for two (2) of eight (8) inactive CRs reviewed (CR#22, CR#24).
Findings:
A review was conducted of facility policy on February 27, 2020 at approximately 1:00 p.m. Policy 5.22 'Discharge Summary' 'Policy' states: A discharge summary shall be written within thirty (30) days of the end of the current plan of care by a therapist".
A review of CRs was conducted on February 27, 2020 between approximately 12:30 p.m. - 4:30 p.m. Patient start of care (SOC) is listed below:
CR#22 SOC 10/23/19: Patients first and only treatment visit on 10/23/19. Patient discharge summary completed on 12/04/19. (48 days)
CR#24 SOC 07/03/19: Patients last treatment visit was on 07/11/19. Patient discharge summary completed on 09/11/19. (60 days)
An interview with the facility market manager on February 27, 2020 at approximately 3:45 p.m. confirmed the above findings.
Plan of Correction:1. According to Discharge Summary Policy 5.22, discharges are to be completed within 30 days of the last date of service. The market manager will inform the treating therapist that discharge summaries for CR#22 and CR#24 were not completed in a timely manner.
2. As a means of preventing late discharge summaries (greater than 30 days following last date of service) or incomplete discharge summaries the patient care manager will run a patient inactivity list every 30 days at a minimum. This process will be implemented immediately. This list will include all patients not seen within this time period and be provided to individual therapist for completion of the discharge summary within 30 days of the last date of service.
3. A staff meeting will be held no later than 4/17/2020 to review Discharge Summary Policy 5.22. to be conducted by the market manager. The minutes of this meeting will be documented on Form 4.12 and maintained in section 4 of the center handbook
4. Through the use of our quarterly quality assurance programs s indicated in Policy 7.01 there will be random chart audits to ensure compliance with Policy 5.22. These audits will be performed by another physical therapist who does not treat patients at this facility. The auditor will document finding with the quality assurance database and final record of the audit will be placed in Section 7 of the center handbook.
5. All task to be completed by 4/17/2020
485.713(a) STANDARD
ADEQUATE PROGRAM
Name - Component - 00
The organization is considered to have an adequate outpatient physical therapy program if it can provide services using therapeutic exercise and the modalities of heat, cold, water, and electricity; conduct patient evaluations; and administer tests and measurements of strength, balance, endurance, range of motion, and activities of daily living.
A qualified physical therapist is present or readily available to offer supervision when a physical therapist assistant furnishes services.
If a qualified physical therapist is not on the premises during all hours of operation, patients are scheduled so as to ensure that the therapist is present when special skills are needed, for example, for evaluation and reevaluation.
When a physical therapist assistant furnishes services off the organization's premises, those services are supervised by a qualified physical therapist who makes an onsite supervisory visit at least once every 30 days.
Observations:
Based on observations and an interview with the facility Market Manager, the facility failed to ensure the organization provided the modality of "water" to ensure, as part of the services for an adequate outpatient physical therapy program, all modalities were available for the treatment of patients for one (1) of one (1) observations conducted (Observation#1).
Findings include:
A review was conducted of facility policy on February 27, 2020 at approximately 1:00 p.m. Policy #11.04 'Medical Necessity Guidelines for Medicare' states "Medicare requires that services provided are medically necessary and supported with appropriate documentation. ........." 'Procedure' section #1 states "Medically necessary treatment must meet standards and guidelines established by the Centers for Medicare and Medicaid Services (CMS) ........".
Treatment floor observations were conducted on February 27, 2020 between approximately 9:30 a.m.-10:30 a.m. The following was revealed:
Observation #1: Observation conducted on February 27, 2020, at approximately 10:00 a.m. revealed the organization was not providing the modality of "water". An interview with the administrator was conducted at approximately 11:30 a.m. and he confirmed that "equipment is not onsite to offer this modality". He stated "typically the facility should have a tub for an emergent bath".
An interview with the facility market manager on February 27, 2020 at approximately 3:45 p.m. confirmed the above findings.
Plan of Correction:1. The market managerwill obtain 2 tubs to provide contrast bath of hot and cold water modality to satisfy Procedure Section #1 stating "Medically necessary treatment must meet standards and guidelines established by the Centers for Medicare and Medicaid Services (CMS) ........". This will also be in accordance with Policy #11.04 'Medical Necessity Guidelines for Medicare' states "Medicare requires that services provided are medically necessary and supported with appropriate documentation
2. An audit of the facility will be performed by the market manager on or before 4/17/20 to ensure all required modalities are being provided as indicated in Procedure Section #1.
3. In accordance with policy 7.01 Clinical Quarterly Assurance Program there will be a mock state survey performed in quarter 1 of each year. This audit will include ensuring compliance with Procedure Section #1 and Policy #11.04.
4. The appropriate equipment will be obtained by 3/6/2020 to allow for implementation of the water modality within the facility. Results of the mock state survey audit will be reviewed with staff through a staff meeting on or before 4/17/20.
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