Initial Comments:
Based on the findings of an onsite unannounced Medicare initial certification survey conducted on August 17, 2021 , at the parent location of 205 Hampton Avenue Punxsutawney, Pa. 15767 and August 19, 2021 at the satellite location of 470 Jeffers St, DuBois, Pa 15801, Novacare Rehabilitation, 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 onsite unannounced initial Medicare certification survey conducted on August 17, 2021 at the parent location: 205 Hampton Avenue, Punxsutawney, Pa 15767, and on August 19, 2021 at the a sister location: 470 Jeffers St. DuBois Pa, 15801, Novacare Rehabilitation was identified to have the following standard level deficiencies and found 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:
485.709(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 reviews of policy/procedure, medical records (MR), and an interview with the clinic manager the clinic failed to ensure new consent forms were completed by the patient with each new episode for three (3) of twenty five (25) records reviewed. MR 18, 19 and 21.
Findings include:
Review of policy 5.17, CONSENT TO TREAT, completed on 8/19/21 at approximately 12:30PM revealed; POLICY: "Each clinical professional will obtain every patient's informed consent prior to initiating treatment". Section 3: PROCEDURE: 1) OBTAINING WRITTEN CONSENT TO TREAT; a) "Obtaining separate documentation for consent for the therapy is required prior to every new episode of care".
Review of medical records on 8/19/21 between approximately 9:30-10:40AM revealed:
MR 18, contained signed written consents for care episode beginning 3/11/21 only.
MR 19, contained no written consents.
MR 21, contained signed written consents for care episode beginning 4/12/21 only.
Interview with clinic manager on 8/19/21 at approximately 1:00PM confirmed the above findings.
Plan of Correction:The Center Manager will retrain all staff in Policy 5.17, Consent to Treat. In accordance with Policy 5.17, all staff will be trained to obtain written consent to treat prior to every new episode of care during a Staff Meeting and In-Service Training by 09-30-2021. The Center Manager will document this training per Policy 4.12, Staff Meeting and In-Service Training, on form 4.12, Staff Meeting and In-Service Training Minutes, and file the minutes into Section 4 of the Center Handbook for future reference. The Administrator, or designee, will monitor for the appropriate consent to treat process quarterly within the Quality Assurance system during chart audits. The referenced policies are attached.
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 policy/procedures, preventative maintenance logs, and interview with the clinic manager the clinic failed to ensure calibration of equipment for one (1) of two (2) location observations (OBS) made. OBS #1; failed to ensure proper sanitation of equipment used for hand therapy exercises for one (1) of two (2) observations made OBS #2.
Findings include:
Review of policy 9.17, Equipment Maintenance and Recalled Items completed on 8/19/21 between approximately 10:00AM-11:30AM revealed in section: POLICY: Select Medical Outpatient Division will maintain, inspect, and calibrate all equipment to ensure the safety and quality care of patients.; PROCEDURE, 2) Electrical equipment, a) All electrical equipment is to be inspected and calibrated on an annual basis....".
Policy 9.18, Therapeutic Equipment Cleaning and Maintenance, section: POLICY: "All equipment used for the provision of patient care services will be maintained and tested to ensure safe operation... All therapeutic equipment must be cleaned and/or replaced as frequently as needed to maintain a sanitary environment". Section: PROCEDURE, 11) Reusable Supplies, b) When there is a risk of cross-contamination, patients will be issued his/her own therapeutic supplies.
Observations made during clinic tour completed on 8/19/2021 between approximately 9:30AM- 11:00AM revealed the following:
OBS #1, Fat Caliper TEC serial no. 07880244 located in cabinet in gym with no calibration sticker to show annual maintenance.
Medtronic respond select Neuromuscular electrical stimulation system, serial no. 0500461 with no calibration sticker to show annual maintenance.
OBS #2, at parent location, in exam room #4 conducted 8/17/21 at approximately 9:59 AM revealed twelve (12) containers of Theraband Hand trainer putty of varying strengths (beginner- advanced). at branch location: 8/19/21 at approximately 10:00AM one (1) container of Theraband Hand trainer putty and one (1) container of marbles, various sizes. No markings to denote any container was labeled for individual patient use.
Interview with clinic manager on 8/19/21 at approximately 1:00PM confirmed the above findings.
Plan of Correction:In accordance with Policy 9.17, Equipment Maintenance and Recalled Items, the Center Manager will schedule electrical equipment inspection and calibration on an annual basis with proof of inspection and/or calibration filed in Section 9 of the Center Handbook for all electrical equipment. Any uninspected/unused equipment will be taken out of service from the facility by 09-30-2021.
In accordance with Policy 9.18, Therapeutic Equipment Cleaning and Maintenance, the Center Manager will designate all hand therapy putty for specific patient use, label it with the patient's name, and store it appropriately in a clean and secure area of designation. These tasks will be completed by 09-30-2021.
The Center Manager will retrain all staff in the previously mentioned policies via Staff Meeting and In-Service Training by 09-30-2021. The Center Manager will document this training per Policy 4.12, Staff Meeting and In-Service Training, on form 4.12, Staff Meeting and In-Service Training Minutes, and file the minutes into Section 4 of the Center Handbook for future reference. Additionally, the completion of training and the appropriate supportive documentation of training will be verified annually within the Quality Assurance system during the mock state drill process. The referenced policies are attached.
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