Initial Comments:
Based on the findings of an onsite unannounced initial Medicare certification survey conducted on August 31, 2023, Select Physical Therapy 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 unannounced, initial Medicare survey completed August 31, 2023, Select Physical Therapy, was 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 reviews of policy, equipment maintenance logs, manufacturer ' s recommendations, and interview with Regional Director of Operations (EMP #1) the facility failed to ensure the freezer maintenance log contained temperature specifications and showed the freezer had been defrosted at least once every three (3) months for one (1) of two (2) logs reviewed. (Log #1).
Findings include:
Review of policy #9.18: Equipment and Center Supply Cleaning and Maintenance, completed August 31, 2023, at approximately 11:30 AM revealed section: Procedure: 3). Cold Pack Unit, a). "The cold Pack Unit ill be defrosted according to manufacturer guidelines or at a minimum every three months. More frequent defrosting may be necessary depending on use". e), " Document cleaning and maintenance on the Equipment Cleaning & Maintenance Log (9.17), or similar log, and maintain in the Center Handbook" .
Review of Equipment Cleaning and Maintenance logs completed August 31, 2023, between approximately 11:00 AM and 12:00 PM revealed:
Log #1, labeled "freezer" dated 1/7/2022-8/31/2023 contained entries for all days the facility was open for business. Each entry contained the following information: date, temperature of the unit, initials of the employee completing the entry. No specifications for the acceptable temperature limits (hi/low) were listed.
On 5/17/2023, the entry contained description, "defrosted & cleaned". No other entries contained a description showing defrosting of the freezer.
An interview with the Regional Director of Operations completed on August 31, 2023 at approximately 1:45 PM confirmed the above findings.
Plan of Correction:Freezer will be defrosted and cleaned at least every 3 months and this will be noted in the cleaning and maintenance log.
Cold pack unit will be maintained from 10 to 14 degrees Fahrenheit in line with cold pack manufacturer recommendations for storage of the cold packs at 12 degrees. Acceptable range will be noted on top of the temperature log. Temperature will continue to be checked by the Center Manager or delegated personnel each day the office is open and proper adjustments will be made to keep it between 10 and 14 degrees. Temperature and any necessary adjustments will be noted in the temperature log.
The Regional Director of Operations or Market Manager will audit the temperature log as well as the cleaning and maintenance log on a monthly basis and place their signature on the log. This will continue for one year.
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