Initial Comments:
Based on the findings of an on-site unannounced Medicare recertification survey conducted August 27, 2024, through August 28, 2024, Newtown Dialysis Center 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, on-site Medicare re-certification survey conducted August 27, 2024, through August 28, 2024, Newtown Dialysis Center 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 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 review of facility policy, in-center hemodialysis treatment area observations (OBS), and an interview with the facility staff, the facility failed to ensure the staff followed infection control protocols during one (1) of three (3) central venous catheter (CVC) exit site care observations (OBS), (OBS #5); during the discontinuation of dialysis with a CVC for one (1) of two (2) OBS (OBS #7); during initiation of dialysis with an AV fistula or graft for one (1) of two (2) OBS (OBS #9) and during discontinuation of dialysis with an AV fistula or graft for one (1) of two (2) OBS (OBS #11); and during cleaning and disinfection of the dialysis station for one (1) of two (2) OBS (OBS #13).
Findings included:
Review of Policy # 1-05-01 titled "Infection Control For Dialysis Facilities" on August 28, 2024, at approximately 4:15 P.M. stated, "Hand Hygiene: 1. All teammates, Physicians and Non-Physicians (NPP) will perform hand hygiene... b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e., plugging/unplugging acid/bicarb lines from dialysis machine, changing acid types, when exchanging a dialysis machine), f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse..."
Observations in the in-center hemodialysis treatment area on August 28, 2024, from approximately 10:25 A.M. to 11:45 A.M., and from approximately 2:30 P.M. to 3:15 P.M. revealed the following:
OBS #5, Station #7, on August 28, 2024, at 10:35 A.M., PCT (patient care technician) #4 was observed completing CVC exit site care with patient (PT) #3. PCT #4 performed hand hygiene, donned clean gloves, removed the old exit site dressing and continued to perform the exit site care without removing gloves, performing hand hygiene and donning new gloves.
OBS #7, Station #7, on August 28, 2024, at 2:30 P.M., PCT #4 was observed discontinuing dialysis on PT #3 with a CVC. PCT #4 performed hand hygiene/donned clean gloves and reinfused the blood from the circuit. PCT #4 did not change gloves/perform hand hygiene prior to disconnecting the blood lines and connecting the syringes. The patient was moving around in the chair causing the patient's blanket to touch the syringes and the hub connections. PCT #4 rearranged the blanket and did not change gloves/perform hand hygiene.
OBS #9, Station #1, on August 28, 2024, at 10:45 A.M., PCT #6 was observed accessing an AV fistula (arteriovenous fistula) on PT #4 for initiation of dialysis. PCT #6 performed hand hygiene/donned clean gloves and evaluated the cannulation sites. PCT #6 continued on to cleanse the cannulation sites and insert the cannulation needles without removing gloves, performing hand hygiene and donning clean gloves.
OBS #11, Station #13, on August 28, 2024, at 11:05 A.M., PCT #2 was observed discontinuing dialysis on PT #7 with an AV fistula. PCT #2 performed hand hygiene/donned clean gloves, reinfused the blood from the circuit, touched the dialysis machine, disposed of the blood lines, removed the dialysis needle, and touched the dialysis machine without changing gloves and performing hand hygiene.
OBS #13, Station # 8, on August 28, 2024, at 11:00 A.M., PCT # 4 was observed cleaning and disinfecting the dialysis station. PCT #4 removed all of the soiled supplies, emptied the prime waste container, removed gloves and donned clean gloves without performing hand hygiene.
An interview with the Facility Administrator on August 28, 2024, at approximately 6:00 P.M. confirmed the above findings.
Plan of Correction:V 0113
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 09/16/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" with emphasis on but not limited to: 1) All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene ... b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e., plugging/unplugging acid/bicarb lines form dialysis machine, changing acid types, when exchanging a dialysis machine) f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee will conduct infection control audits to verify teammates are compliant with hand hygiene prior to gloving and immediately after removal of gloves: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with monthly infection control audits. Instances of non-adherence will be corrected immediately.
The Facility Administrator or designee will review audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assurance and Performance Improvement meetings known as Facility Health Meetings. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed when needed until sustained compliance is achieved. Supporting documentation will be included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
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