QA Investigation Results

Pennsylvania Department of Health
BMA OF PHILADELPHIA
Health Inspection Results
BMA OF PHILADELPHIA
Health Inspection Results For:


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Initial Comments:


Based on the findings of an unannounced onsite complaint, and Medicare re-certification survey conducted from on March 27, 2018, through March 29, 2018, BMA of Philadelphia was found to be in compliance with the requirements of 42 CFR, Part 494.62, Subpart B, Conditions for Coverage of Suppliers of End-Stage Renal Disease, (ESRD), Services-Emergency Preparedness.










Plan of Correction:




Initial Comments:


Based on the findings of an unannounced onsite complaint investigation survey, and Medicare re-certification survey conducted March 27, 2018 through March 29, 2018, BMA of Philadelphia, was found not to be in compliance with the following requirements of 42 CFR, Part 494, Subparts A, B, C, and D, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services.









Plan of Correction:




494.30(a)(1) STANDARD
IC-WEAR GLOVES/HAND HYGIENE

Name - Component - 00
Wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station.




Observations:


Based on observation, facility policy, and interview with the Director of Operations, it was determined that staff failed to perform hand hygiene and/or don new gloves during the performance of duties during observations of patients and staff at two (2) of thirty four (34) stations. (stations #8 and #11).

Findings include:

Review of facility policy, FMS-CS-IC-II-155-090A, "Hand Hygiene" on March 29, 2018 at 3:00 PM states: "Hands will be decontaminated using alcohol based hand rub or by washing hands with antimicrobial soap and water before and after direct contact with patients...before performing any invasive procedures such as vascular access cannulation...Immediately after removing gloves....After contact with inanimate objects near the patient..."

On March 27, 2018, at approximately 11:35 a.m., while performing Central Venous Catheter, (CVC) site care at station #11, Employee #5 was observed placing contaminated dressings on the area containing the clean supplies located on the tray attached to the dialysis chair. Further Observation revealed that employee #5 did not change contaminated gloves before applying a sterile dressing to the Patient's CVC site. On March 27, 2018 at approximately 11:43 a.m., while preparing to initiate dialysis with a CVC, at station #11, Employee #5 was observed touching the tip of the vacutainer with her gloved hand prior to inserting the vacutainer, tip into the hub of the CVC to draw blood.
On March 28, 2018 at approximately 10:15 a.m., while performing a discontinuation of Dialysis and post dialysis access care for an AV graft, at station 10, Employee #8 was observed not removing gloves and not conducting hand hygiene between touching the needle site, and placing a clean bandage over the needle site.

On March 29, 2018 at Approximately 3:20 p.m., in an interview with Director of Operations, it was confirmed that two employees were not following infection control procedures.

























Plan of Correction:

The Education Coordinator (EC) re-educated all the Direct Patient Care (DPC) staff on:
- FMS-CS-IC-11-155-090A Hand Hygiene Policy
- FMS-CS-IC-I-105-002A Initiation of Treatment Using a Central Venous Catheter and Optiflux® Single Use E-beam Dialyzer Policy
- FMS-CS-IC-I-105-029C Termination of Treatment Using Arteriovenous Fistula or Graft and Optiflux® Single Use Ebeam Dialyzer Procedure

Special emphasis will be placed on ensuring that gloves are removed, and hand hygiene is performed after a CVC dressing is removed and before the new dressing is applied to the CVC site. Also reviewed was the need to remove gloves and perform hand hygiene after touching an access site and before applying a clean bandage on the site. The meeting will also reinforce that gloves need to be removed and hand hygiene performed after contact with inanimate objects, including the tip of a vacutainer. Staff will be re-educated on not placing contaminated supplies/dressings in a clean area.
In-servicing was completed on April 13, 2018. Documentation of the training will be on file at the facility.
The Clinic Manager (CM) or designee will perform daily audits for 2 weeks on the DPC for proper hand washing. At that time, if improved compliance is observed the audits will then be completed 2 times/week for 2 weeks. If compliance is maintained after the 2 weeks, the audits will be completed monthly following the Quality Assurance Improvement (QAI) program. A Plan of Correction (POC) specific auditing tool will be used for the audits.
Staff found to be non-compliant will be re-educated and counseled.
The CM will review the audit results and report the findings to the QAI Committee at the monthly meeting. Sustained compliance will be monitored by the QAI committee.
Completion date: May 25, 2018



494.30(a)(1)(i) STANDARD
IC-SINKS AVAILABLE

Name - Component - 00
A sufficient number of sinks with warm water and soap should be available to facilitate hand washing.



Observations:


Based on observation, interview with Machine Equipment/Maintenance Technician, Director of Operations, recommendations, it was determined that the agency failed to maintain a "sufficient number" easily accessible operational sinks or antiseptic hand rub that are readily available for personnel to perform, "Hand Hygiene".

Findings include:
On March 27, 2018 at approximately 11:50 a.m., it was observed in the patient treatment area, that two handwashing sinks located closest to the employee exit were out of order. It was further observed that the wall receptacle for, "Hand Hygiene" , located at the exit door used by employees, did not contain alcohol-based antiseptic solution. It was empty. The closest accessible sink was approximately 40 feet away from the two out of order sinks, and employee exit door from the patient treatment area.
On March 27, 2018 at approximately 11:50 a.m., an interview with the Machine Equipment/Maintenance Technician, it was confirmed that the sinks were out of order and could not be used by the employees at the working close by in the HD treatment area. He pointed to sinks approximately 30 to 40 feet to the other side of the treatment area, and said, "They can wash their hands down there". To the the wall receptacle for " Hand Hygiene " , the Equipment/Maintenance Technician stated that, "We are not using those".
On March 29, 2018 at Approximately 3:20 p.m., in an interview with Director of Operations, it was confirmed that two handwashing sinks were out of order. The Director of Operations stated that, "We are in the process of having it fixed".


























Plan of Correction:

For compliance on Wednesday, April 11, 2018, the Area Technical Operations Manager (ATOM) began the process to obtain estimates for the repair of the sinks which were out of order. The repairs were completed upon approval of the estimate on Wednesday, April 11, 2018.

To ensure ongoing compliance the CM or designee will complete monthly physical plant audits.

Issues of non-compliance will be addressed by the Director of Operations (DO).

The CM will review the audit results and report the physical plant findings at the monthly QAI meetings for ongoing oversight and compliance.

Completion date: May 25, 2018.



494.30(a)(4)(ii) STANDARD
IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL

Name - Component - 00
[The facility must demonstrate that it follows standard infection control precautions by implementing-
(4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-]
(ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment.



Observations:


Based on observation, facility policy, Center for Disease Control, (CDC), recommendations, and interview with the Director of Operations, it was determined that the agency failed to maintain cleaning and disinfection procedures after each patient for two, (2), of 34 hemodialysis stations. (Dialysis stations #10, and 17).

Findings include:

On March 29, 2018, at approximately 3:00 p.m., a review of the agency policy entitled, "FMS Clincal Services", subtitle, "Cleaning and Disinfection of the Stethoscope", revealed that the stethoscope should be wiped with either 70% isopropyl alcohol wipe or cloth dampened with 1:100 hypochlorite solution after each use.
A review of the agency policy entitled, "FMS Clincal Services", subtitle, "Cleaning and Disinfection of the Blood Pressure Cuff", revealed that, "Blood pressure cuffs will be disinfected with a 1:100 dilution of a hypochlorite solution at the completion of each patient treatment."

On March 27, 2018 at approximately 10:50 a.m., This surveyor observed that during preparation for change over, Employee #7 did not disinfect the blood pressure cuff or the stethoscope after the Patient at station #17, had completed a dialysis treatment.

On March 28, 2018 between 10:30 a.m. and 11:30 a.m., This surveyor observed that during preparation for change over, Employee #5 did not disinfect the blood pressure cuff or the stethoscope after the Patient at station #10, had completed a dialysis treatment.

On March 29, 2018 at Approximately 3:20 p.m., in an interview with Director of Operations, it was confirmed that Employees #7 and 10, did not sanitize multi-use equipment between patients.



















Plan of Correction:

To ensure compliance the EC will educate all DPC staff on:
- FMS-CS-IC-II-155-123A Cleaning and Disinfection of the Stethoscope Policy
- FMS-CS-IC-II-155-122A Cleaning and Disinfection of the Blood Pressure Cuff Policy
Emphasis will be placed on ensuring that stethoscopes and blood pressure cuffs are cleaned and disinfected after every patient use and before being returned to the clean storage area,
The in-service was completed on April 13, 2018 and documentation of the training will be on file at the facility.
The CM or designee will perform daily audits on the DPC staff for 2 weeks. At that time if compliance is observed the audits will then be completed 2/week for 2 weeks. If compliance is maintained after the 2 weeks, the audits will then be completed monthly following the QAI schedule. A POC specific audit tool will be used for the audits.

Staff found to be non-compliant will be re-educated and referred for counseling.

The CM will review the audit results and report the findings to the QAI Committee at the monthly meeting. Sustained compliance will be monitored by the QAI committee.

Completion Date: May 25, 2018.