Initial Comments:
Based on the findings of an onsite unannounced initial Medicare certification survey conducted March 23, 2022, 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(a)(1)-(2) STANDARD
Plan Based on All Hazards Risk Assessment
Name - Component - 00
§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*
(2) Include strategies for addressing emergency events identified by the risk assessment.
* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.
*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.
*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.
Observations:
Based on review of facility documentation, and staff (EMP) interviews, the facility failed to develop, establish, review and maintain a comprehensive emergency preparedness program based on a facility-based and community-based risk assessment, utilizing an all-hazards approach.
Findings included:
Review of the agency Emergency Plan on March 23, 2022 at approximately 11:30am revealed: "Emergency Plan...II) Center Specific Risk Assessment, Using an "all hazards" approach, each center, market, or rehab agency must assess for the likely occurrence of given disasters in their immediate location (center and community)..."
A review of the facility documentation provided on March 23, 202 at approximately 12:00PM failed to provide evidence that the facilities emergency preparedness program was a facility-based and community-based risk assessment utilizing an all-hazards approach. Emergency plan policies and procedures contained outlined format inclusive of chart labeled "Center Specific Risk Assessment." Chart not completed, risks not identified.
An exit interview was conducted on March 23, 2022 approximately 2:00PM with the Market Manager and Multisite Manager that confirmed the above findings.
Plan of Correction:E0006
On 04-01-2022, the Market Manager completed the Center Specific Risk Assessment, per the Emergency Plan (Policy 9.01), and reviewed it with the Multi-site Manager and Masontown staff. The Market Manager documented the review meeting on form 4.12, Staff Meeting and In-service Training Minutes, and filed it into Section 4 of the Center Handbook.
Moving forward, the Multi-site Manager will complete the Center Specific Risk Assessment on an annual basis and review it with Masontown staff during a staff meeting. The Multi-site Manager will document all annual reviews of the Center Specific Risk Assessment on form 4.12, Staff Meeting and In-service Training Minutes, and file the form into Section 4 of the Center Handbook. For monitoring purposes, the Multi-site Manager will note the annual update and review of the Center Specific Risk Assessment within the Quality Assurance database during the annual Mock State Survey.
For additional monitoring, on an annual basis, the Market Manager will review the Center Specific Risk Assessment, the Staff Meeting and In-service Training Minutes, and the Mock State Survey within the Quality Assurance database to ensure completion.
485.727(d)(1) STANDARD
EP Training Program
Name - Component - 00
§403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:]
(1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.
*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and
procedures.
*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.
*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures.
*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.
*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.
*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.
Observations:
Based on personnel file (PF) review and staff (EMP) interviews, the facility failed to provide initial training in emergency preparedness policies and procedures for four (4) of four (4) PF's reviewed (PF1-4), failed to provide emergency preparedness training annually (per agency policy) four (4) of four (4) PF's reviewed (PF1-4), failed to mintain documentation of all emergency preparedness training four (4) of four (4) PF's reviewed (PF1-4), and failed to demonstrate staff knowledge of emergency procedures four (4) of four (4) PF's reviewed (PF1-4), .
.
Findings included:
Review of the agency Emergency Plan (EP) on March 23, 2022 at approximately 11:30am revealed: "Emergency Plan...VII) Emergency and Disaster Plan, A) Staff training, 10 The Center Manager is responsible to ensure training of all staff in the appropriate procedures for an emergency or disastrous situations specific to their centers...3) Annual review of EP with all employees, a) Document training of new employees at time of hire..."
A review of the PF on March 23, 202 at approximately 1:00PM revealed:
PF1, date of hire (DOH), 10/6/2020, PF failed to contain evidence of initial and annual emergency preparedness training.
PF2, DOH 8/30/2021, PF failed to contain evidence of initial and annual emergency preparedness training.
PF3, DOH 4/29/2005, PF failed to contain evidence of initial and annual emergency preparedness training.
PF4, DOH 11/15/2021, PF failed to contain evidence of initial and annual emergency preparedness training.
Interview with EMP 1 on March 23, 2022 at approximately 10:10AM revealed employee is unfamiliar with greatest emergency risk for center and specific role in emergency situation. "I do not believe i ever got [EP taining] since I started with the agency."
An exit interview was conducted on March 23, 2022 approximately 2:00PM with the Market Manager and Multisite Manager that confirmed the above findings.
Plan of Correction:E0037
The Market Manager conducted a staff meeting on 04-06-2022 with the Multi-site Manager and Masontown staff to review the Emergency Plan, Policy 9.01, in its entirety and documented the meeting on form 4.12, Staff Meeting and In-service Training Minutes, before filing the minutes into Section 4 of the Center Handbook.
Moving forward, the Multi-site Manager will train all new employees on the Emergency Plan, Policy 9.01, and indicate this training on form 4.06, New Employee Orientation Checklist, before filing the checklist into the employee's personnel file. For monitoring purposes, on a monthly basis, the Market Manager will audit form 4.06 for all new employees to ensure completion of training on the Emergency Plan, Policy 9.01.
The Multi-site manager will schedule/facilitate all Emergency Plan Specific Drills and training, as per the requirements of the Emergency Plan (Policy 9.01), and document the drills/training on the Emergency Drill/Emergency Preparedness Testing Report Form (9.01c) before filing it into Section 9 of the Center Handbook. For monitoring purposes, on a monthly basis, the Market Manager will audit Section 9 of the Center Handbook to ensure completion and documentation of all emergency drills via form 9.01c.
For additional monitoring purposes, the Multi-site Manager will conduct and submit the required Mock State Survey annually into the Quality Assurance database, which the market manager will audit to ensure completion.
Lastly, the Patient Care Committee, which meets biannually, will review the center-specific components of the Emergency Plan to support staff training, ensure compliance with plan components, and promote safety of patients and staff.
Initial Comments:
Based on the findings of an onsite unannounced initial Medicare certification survey conducted March 23, 2022, NovaCare Rehabilitation was found to be in 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:
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