Initial Comments:
Based on the findings of an onsite unannounced initial Medicare certification survey conducted March 6, 2020, NovaCare Rehabilitation was found to have the following standard level deficiency that was 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-Emergency Preparedness.
Plan of Correction:
485.727(d)(2) STANDARD
EP Testing Requirements
Name - Component - 00
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).
*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:
(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:
(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.
*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.
*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.
*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.
*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.
*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.
*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.
*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.
Observations:
Based on review of agency emergency preparedness plan, and staff (EMP) interview, the agency failed to participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. The agency also failed to conduct an additional exercise that included, but was not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based. (B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario and analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.
Findings included:
A review of facility documentation was conducted on March 6, 2020 at approximatley 12:00 p.m. revealed 5 Emergency Drill Report Forms dated 10/15/19 with the following "Type of Drill" noted individually on each document. "Medical Emergency Drill (time:1:00-1:10), Fire Emergency Drill (time 1:15-1:25), Earthquake (time 1:30-1:45), Tornado (time 1:45-2:00), and Bomb threat (time 2:00-2:15.)" Review also included a "Fire Emergency Drill" dated 1/27/2020 (time 8:00-8:15).
Medical Emergency Drill includes only the following documentation; "(Staff members) attend to the victim and perform CPR if necessary...calls 911...prepares the area and obtains first aid kit...directs emergency personnel...transfers authority, provides health information, contacts referring MD [Medical Doctor], documents incident, and contacts MM [Market Manager.]" Report does not include evidence of a group discussion led by a facilitator using a narrated, clinically-relevant emergency scenario, analysis of the [facility's] response to and revision the [facility's] emergency plan, as needed.
Fire Emergency Drill includes only the following documentation; ""(Staff member) calls "Code Red" and pulls fire alarm;...gather and evacuate patients to safe meeting place...calls 911, brings the sign in sheet, and turns off the lights...calls MM[Market Manager] and patient families if needed." Report does not include evidence of a group discussion led by a facilitator using a narrated, clinically-relevant emergency scenario, analysis of the [facility's] response to and revision the [facility's] emergency plan, as needed.
Earthquake includes only the following documentation; "All employees listen to local radio/weather...move patients to room 2 or 3, close doors, turn off electricity, unplug electrical equipment...retrieves First Aid Kit...takes roll call...retrieves essential records...administer first aid...will transfer authority, document incident, notify landlord and MM [Market Manager.]" Report does not include evidence of a group discussion led by a facilitator using a narrated, clinically-relevant emergency scenario, analysis of the [facility's] response to and revision the [facility's] emergency plan, as needed.
Tornado includes the only following documentation; "All employees listen to local radio/weather...advises patients and staff of plan...move patients to room 2 or 3, shut doors, turn off electricity, unplug electrical equipment...retrieves First Aid Kit...takes roll call...administer first aid...transfers authority, documents incident, notifies landlord and MM [Market Manager.]" Report does not include evidence of a group discussion led by a facilitator using a narrated, clinically-relevant emergency scenario, analysis of the [facility's] response to and revision the [facility's] emergency plan, as needed.
Bomb threat includes only the following documentation; "...discovers bomb threat and alerts others...uses cell phone to call 911...obtains and removes patient records, schedule, and sign in sheet...grabs First Aid Kit...evacuate patients...takes roll call...talks with police...documents the incident, contacts landlord and MM [Market Manager.]" Report does not include evidence of a group discussion led by a facilitator using a narrated, clinically-relevant emergency scenario, analysis of the [facility's] response to and revision the [facility's] emergency plan, as needed.
Fire Emergency Drill (dated 1/27/2020) includes only the following documentation; "...calls "Code Red" and pulls fire alarm;...gather and evacuate patients to safe meeting place...calls 911, brings sign in sheet, and turns off the lights...calls MM [Market Manager] and patient families if needed." Report does not include evidence of a group discussion led by a facilitator using a narrated, clinically-relevant emergency scenario, analysis of the [facility's] response to and revision the [facility's] emergency plan, as needed.
Interview with EMP 1 and EMP2 on March 6, 2020 at approximately 12:45 p.m. confirmed no participation in community based exercise.
An exit interview was conducted on March 6, 2020 at approximately 1:30 p.m. with EMP1 and EMP2 and confirmed findings.
Plan of Correction:The Market Manager (MM) for the Connellsville center contacted the Public Health Preparedness Coordinator within the PA Department of Health, regarding community training for the Emergency Preparedness Plan. Under their advisement, the MM enrolled in the HCSWPA to receive updates and access to future training. The MM also contacted the Mt. Pleasant Police Department and spoke to the Chief of Police to arrange an active shooter training for participation in a community-based exercise. Citing the current COVID-19 crisis, the Chief of Police asked the MM to call him again on 03-25-2020 to schedule the training. The Chief of Police agreed to complete this training no later than 04-30-2020.
The current COVID-19 pandemic represents a full-scale community-based emergency drill. The Emergency Plan for COVID-19 is activated and being tested. Once the COVID-19 crisis is abated (indefinite time period), an after-action review will be completed by the MM or Center Manager (CM). The MM or CM will document all aspects of the drill on the Emergency Drill Report Form, Form 9.01c, and conduct an after-action review with all Connellsville staff members to openly discuss all aspects of the drill pertaining to staff responses, including communication, resources, safety, staff management, and patient management. The MM or CM will file the documentation (Form 9.01c) within Section 9 of the Center Handbook.
Additionally, community-based training will occur no less than every 2 years with appropriate documentation as represented in CMS requirements. Training will be verified by the MM via mock state survey audits within the Connellsville center.
Prior to an additional center-based Emergency Drill, the MM or designee will review the Emergency Plan, Policy 9.01, will all Connellsville staff members. The MM will also educate the CM on proper documentation of an Emergency Drill and how to appropriately conduct and document an after-action review. The CM will schedule and conduct all future Emergency Drills to test the Emergency Plan, Policy 9.01, twice annually, and the MM will confirm with the CM that all future Emergency Drills are scheduled, conducted, and documented appropriately via mock state surveys conducted and documented quarterly.
The MM or CM will facilitate and narrate a facility-based emergency fire drill exercise with all Connellsville staff in accordance with the Emergency Plan, Policy 9.01. The MM or CM will document all aspects of the drill on the Emergency Drill Report Form, Form 9.01c, and conduct an after-action review with all Connellsville staff to openly discuss all aspects of the drill pertaining to staff responses, including but not limited to: communication, resources, safety, staff management, and patient management.
The after-action review of the COVID-19 Emergency Plan will be conducted following the crisis (after an indefinite period of time). All other actions below will be completed by end-of-business on 03-27-2020.
Initial Comments:
Based on the findings of an onsite unannounced initial Medicare certification survey completed on March 6, 2020, NovaCare Rehabilitation, was found to be in compliance with the following requirement(s) 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:
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