Initial Comments:
Based on the findings of an onsite complaint investigation survey conducted on January 13, 2023, Newtown Dialysis Center was identified to have the following standard level deficiency that was determined to be in substantial 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)(i) STANDARD
IC-IF TO STATION=DISP/DEDICATE OR DISINFECT
Name - Component - 00
Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient.
-- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient.
-- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient's station should be used only for that patient and should not be returned to a common clean area or used on other patients.
Observations:
Based on direct observation, facility policy, and an interview with the facility administrator and clinical services manager, the facility did not clean and disinfect items taken to the dialysis station and returned to a common area for three (3) of three (3) observations (OBS). OBS# 1, 2, and 3.
Findings include:
Review of 'INFECTION CONTROL FOR DIALYSIS FACILITIES' policy/procedure on 1/13/23 at 3:30 PM revealed, " 43. Items taken into the dialysis station will be disposed of, dedicated for use only one single patient, or cleaned and disinfected before taken to a common clean area or used on another patient..."
Observation of the clinical area was conducted on 1/13/23 from 9:30 AM- 12:00 PM.
OBS#1 station #12 PCT#1 after manually checking conductivity with the Myron L meter and pH, returned the Myron L meter to a common clean area without wiping it with disinfectant.
OBS#2 station #10 PCT#1 after manually checking conductivity with the Myron L meter and pH, returned the Myron L meter to a common clean area without wiping it with disinfectant.
OBS#3 dirty sink area PCT#1 rinsed the prime bucket in the 1:10 bleach container utilized for the disinfection of and containing used blue clamps.
An interview with the administrator and clinical services manager on 1/13/23 at 1:45 PM confirmed the above findings.
Plan of Correction:00395 Newtown PA CMS Comp 011323
POC Completion Date: 03/14/23
V 116
The Facility Administrator or designee held mandatory in-services for all clinical teammates on 01/25/23. Surveyor observations were reviewed. Education included but was not limited to a review of Procedure 2-08-01B "Operation of Portable Myron L Conductivity Meter (D-1)" and Policy 1-05-01 "Infection Control for Dialysis Facilities" with the emphasis on but not limited to: 1. D1 Meter: 1) When you are finished with the D1 meter, RINSE thoroughly with dialysis quality water. Clean the exterior of the meter with 1:100 bleach solution and place meter in the clean storage location. 2. Infection control: 1) Equipment including the dialysis delivery system, the interior and exterior of the prime container ... as well as all work surfaces will be wiped clean with a bleach solution of the appropriate strength after completion of procedures, before being used on another patient, after spills of blood, throughout the work day, and after each treatment. 2) Priming containers are to be emptied. The interior and exterior should be wiped down with 1:100 (one to one hundred) bleach solution before using on next patient treatment. Verification of attendance is evidenced by teammate's signature on the in-service sheet.
The Facility Administrator or designee will perform observational infection control audits to verify teammates are compliant with disinfection practices for Myron L meters and priming containers prior to being used for the next patient per policy: daily for two (2) weeks, and then weekly for two (2) weeks. Ongoing compliance will be monitored with the facility's monthly infection control audit. Instances of non-compliance will be addressed immediately. The Facility Administrator will review audit results with teammates during homeroom meetings and with the Medical Director during the monthly Quality Assessment Performance Improvement Meeting known as Facility Health Meeting, with supporting documentation in the meeting minutes. The Facility Administrator is responsible for ongoing compliance with this plan of correction.
|