Initial Comments:
Based on the findings of an unannounced, initial Medicare survey completed June 21, 2023, Select Physical Therapy, located at 950 Walnut Bottom Road, Suite 19 &20, Carlisle, PA, 17013 and an extension located at 5202 Simpson Ferry Road, Suite # 100, Mechanicsburg, Pa. 17050, was found to be compliant 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, initial Medicare survey completed June 21, 2023, Select Physical Therapy, located at 950 Walnut Bottom Road, Suite 19 &20, Carlisle, PA, 17013 and an extension located at 5202 Simpson Ferry Road, Suite # 100, Mechanicsburg, Pa. 17050, were identified 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:
485.723(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 facility policy, manufacturer 'Water Chemistry Guide', weekly chemical log and interview with staff (EMP), it was determined the facililty failed to ensure alkalinity and calcium were in the required range at the parent location at Walnut Bottom Road for one (1) of one (1) weekly chemical logs reviewed. (Weekly chemical log #1).
Findings included:
Review of policy titled, 'Therapeutic Pool Cleaning and Maintenance: 9.22' on 6/20/23 at approximately 12:00 p.m, reads, "..Procedure:..ii) Weekly: ...(1) Test for alkalinity, add chemicals as needed (ranges 80-120 PPM or by manufacturers guidelines)...iii) Monthly: (1) Check calcium hardness (200-400 PPM) and add chemicals as needed..."
Review of manufacturer 'Water Chemistry Guide' on 6/20/23 at approximately 12:10 p.m. reads, "If alkalinity reading is high...140...Amount of dry acid or sodium bisulfate to add: 5.5 oz (ounce)...160...Amount of dry acid or sodium bisulfate to add: 8 oz....180...Amount of dry acid or sodium bisulfate to add: 11 oz...200...Amount of dry acid or sodium bisulfate to add: 13 oz...220...Amount of dry acid or sodium bisulfate to add: 14 oz...240...Amount of dry acid or sodium bisulfate to add: 1 lb (pound) 3 oz...260...Amount of dry acid or sodium bisulfate to add: 1 lb 6 oz...280...Amount of dry acid or sodium bisulfate to add: 1 lb 8 oz...300...Amount of dry acid or sodium bisulfate to add: 1 lb 9 oz...320...Amount of dry acid or sodium bisulfate to add: 1 lb 11 oz...Ideal Calcium Range 200-400...20...Amount of Hardness Increaser to add: 1 lb...40...Amount of Hardness Increaser to add: 15 oz...60...Amount of Hardness Increaser to add: 13.5 oz...80...Amount of Hardness Increaser to add: 12.5 oz...100...Amount of Hardness Increaser to add: 11.5 oz...120...Amount of Hardness Increaser to add: 10.5 oz...140...Amount of Hardness Increaser to add: 9 oz...160...Amount of Hardness Increaser to add: 8 oz...180...Amount of Hardness Increaser to add: 7 oz..."
Weekly chemical log #1: Review of document titled, ' Weekly Chemical Logs for the date range of 1/4/2023-6/14/2023 on 6/20/23 at approximately 11:00 a.m. revealed the following:
- On 1/4/2023; Alkalinity was recorded as "225". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 1/11/2023; Alkalinity was recorded as "175". Under the 'Adjustments' section of the log "0.5 oz dry acid" was written. The amount of dry acid that was documented to be add is not in accordance with the facility policy and the manufacturer's water chemistry guide.
- On 1/18/2023; Alkalinity was recorded as "250". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 1/25/2023; Alkalinity was recorded as "225". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 2/1/2023; Alkalinity was recorded as "275". Calcium was recorded as "30". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 2/8/2023; Alkalinity was recorded as "270". Calcium was recorded as "40". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 2/15/2023; Alkalinity was recorded as "300". Calcium was recorded as "40". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 2/22/2023; Alkalinity was recorded as "250". Calcium was recorded as "40". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 3/1/2023; Alkalinity was recorded as "275". Calcium was recorded as "40". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 3/8/2023; Alkalinity was recorded as "250". Calcium was recorded as "40". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 3/15/2023; Alkalinity was recorded as "275". Calcium was recorded as "40". Under the 'Adjustments' section of the log "3-17-23 3 oz" was written. Documentation did not identify what chemicals was added.
- On 3/22/2023; Alkalinity was recorded as "150". Calcium was recorded as "50". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 3/29/2023; Alkalinity was recorded as "180". Calcium was recorded as "100". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 4/5/2023; Calcium was recorded as "40". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 4/10/2023; Alkalinity was recorded as "275". Calcium was recorded as "100". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 4/14/2023; Alkalinity was recorded as "275". Calcium was recorded as "80". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 4/26/2023; Alkalinity was recorded as "180". Calcium was recorded as "100". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 5/3/2023; Alkalinity was recorded as "200". Calcium was recorded as "30". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 5/10/2023; Alkalinity was recorded as "175". Calcium was recorded as "20". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 5/17/2023; Alkalinity was recorded as "175". Calcium was recorded as "40". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 5/24/2023; Alkalinity was recorded as "275". Calcium was recorded as "30". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 5/31/2023; Alkalinity was recorded as "175". Calcium was recorded as "20". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
- On 6/7/2023; Alkalinity was recorded as "275". Under the 'Adjustments' section of the log "3.0 oz dry acid" was written. .The amount of dry acid that was documented to be add is not in accordance with the facility policy and the manufacturer's water chemistry guide.
- On 6/14/2023; Alkalinity was recorded as "255". Calcium was recorded as "20". Under the 'Adjustments' section of the log a "-" line was drawn. No documentation of chemicals being added according the facility policy and the manufacturer's water chemistry guide.
Interview conducted with EMP# 1 on 6/21/2023 confirmed the findings.
Plan of Correction:The pool chemical log ill continue to be maintained on a weekly basis by the CM or other designated staff. Effective immediately, when alkalinity and/or calcium levels are found to be out of normal range, the proper chemicals will be added in amounts as specified by the manufacturer's water chemical guide. Names and amounts of chemicals added will be documented in the log.
485.725(d) STANDARD
LINEN
Name - Component - 00
The organization has available at all times a quantity of linen essential for proper care and comfort of patients. Linens are handled, stored, processed, and transported in such a manner as to prevent the spread of infection.
Observations:
Based on review of facility policy, washing machine temperature log and interview with staff (EMP), it was determined the facililty failed to ensure linen was processed in a manner to prevent the spread of infection at the parent location at Walnut Bottom Road for one (1) of one (1) washing machine temperature logs reviewed. (Washing machine temperature log #1)
Findings included:
Review of policy titled, 'Laundry Handling: 9.15' on 6/20/23 at approximately 11:00 a.m, reads, "..Procedure:..1. If facility has a washer and dryer:...b) All laundry will be laundered using the hot water cycle of the waster. Whenever possible, the water temperature should be 140-160 degrees. c) One-quarter (1/4) cup of bleach will be added to the wash cycle if the water temperature does not reach 140 degrees, or if linens are contaminated..."
Washing machine temperature log #1 on 6/20/23 at approximately 10:45 a.m. revealed the following: Review of document titled, '2023 Washing Machine Temperatures' showed temperatures were recorded on a weekly basis between the date range of: "Jan Week 1 - June Week 1" with the temperatures for each week documented as "100No documentation to show the temperature prior each individual wash cycle. No documentation to show one-quarter (1/4) cup of bleach was added to the wash cycle when the water temperature does not reach 140 degrees.
During interview on 6/20/23 at approximately 11:30 a.m., EMP# 1 stated, "We always put in bleach with each wash cycle, it just isn't documented. We have the bleach sitting next to the detergent."
Plan of Correction:Because the water heater does not reach 140 degrees, effective immediately, the procedure for laundry at this location will be to stop the washing machine temperature log add ¼ cup of bleach to every load.
|