QA Investigation Results

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


There are  11 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an unannounced Medicare[CORE] follow-up survey conducted on September 21, 2017, BMA of Cambria was found not to have corrected the deficiencies cited under the requirements of 42 CFR, Part 494, Subparts A, B, C and D, Conditions for Coverage for End-Stage Renal Disease Facilities. The deficiencies were cited as the result of a Medicare [CORE] survey completed on August 4, 2017.







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 observations, reviews of facility policy, and an interview with the Clinical Nurse Manager, the facility failed to ensure the staff followed infection control protocols, included but not limited to, hand hygiene/don clean gloves, for one (1) of one (1) observations. (Observations #1).

Findings include:

A review was conducted of facility policy on Septemeber 21, 2017 at approximately 11:00 a.m. Policy #FMS-CS-IC-I-105-032C 'Changing the Catheter Dressing' step #8 states "Discard dressing and remove gloves. Perform hand hygiene".

Observations conducted in patient treatment area on September 21, 2017 between approximately 9:15 a.m. - 11:45 a.m. revealed the following:

Observation #1: During observation #1 of Central Venous Catheter (CVC) Exit Site Care on 9/21/17 at approximately 11:45 a.m. of patient #2, station #11; employee #1 did not remove gloves/perform hand hygiene/don clean gloves after removing old dressing and before cleansing around CVC site.

An interview with the Clinical Nurse Manager on September 21, 2017 at approximately 12:30 p.m. confirmed the above findings.











Plan of Correction:

V 113 494.30(a)(1) Wear Gloves/Hand Hygiene

The EC will re-educate all DPC staff on:
- FMS-CS-IC-II- 155-090A Hand Hygiene Policy
- FMS-CS-IC-II- 155-090C Hand Hygiene Procedure
- FMS-CS-IC-I-105-032A Changing the Catheter Dressing Policy
- FMS-CS-IC-I-105-032C Changing the Catheter Dressing Procedure

Special emphasis will be placed on ensuring that hand hygiene is performed when completing CVC care, including after removing the old CVC dressing, before cleansing the site, before and after applying the sterile dressing to the CVC site and again before initiating treatment. The meeting will also reinforce that gloves must be removed and hand hygiene performed before entering the medication room, preparing medications, administering medications and after emptying the prime bucket. The meeting also will review that gloves are not to be worn when retrieving items from the clean supply cart.

The inservicing will be completed by 10/6/2017 with documentation of the training 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 2x/week for 2 weeks to ensure that compliance is maintained. At that time the audits will then follow the monthly 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: 11/3/2017



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 reviews of observations, facility policy, manufacturer recommendations, and an interview with the Clinical Nurse Manager, the facility failed to ensure the staff followed infection control protocols which include, but not limited to, following the manufacturers (Mesa Laboratories, Inc.) recommendations for use of the phoenix meter for two (2) of two (2) observations of the Preparation of the Hemodialysis Machine/Extracorporeal Circuit (Observation #1-#2).

Findings include:

A review was conducted of facility policy on September 21,2017 at approximately 11:00 a.m. of FMS-CS-IC-II-140-510CI, IS-I-600-028C2, HT-II-310-007C2 'FMS Clinical Services' 'Checking Conductivity and pH of Final Dialysate with the pHoenix Meter' 'Rinsing and Storage of the pHoenix meter' 'Step 6' Action: "Rinse meter with RO (reverse osmosis) water after each measurement".

A review of manufacturer's (Mesa Laboratories, Inc.) recommendations for use of the phoenix meter was conducted on September 22, 2017 at approximately 9:00 a.m. "Rinse the sample cup/tube thoroughly with treated water when finished".

Observation conducted in the patient treatment area on 9/21/17 between approximately 10:24 a.m. and 11:35 a.m. revealed the following:

Observation #1: On 9/21/17 at approximately 10:24 a.m., Employee (Emp) #4 was observed using the phoenix meter to check for conductivity and pH at station #16 for the dialysis treatment of patient #3. After using the phoenix meter, Emp #4 failed to rinse the meter with product water (RO) before placing it back into its holder. Emp#4 stated "I always do it before use".

Observation #2: On 9/21/17 at approximately 11:35 a.m., Emp#1 was observed using the phoenix meter to check for conductivity and pH at station#11, for the dialysis treatment of patient #2. After using the phoenix meter, Emp #1 failed to rinse the meter with product water (RO) before placing it back into its holder.

An interview with the Clinical Nurse Manager on September 21, 2017 at approximately 12:30 p.m. confirmed the above findings.




















Plan of Correction:

V 122 494.30(a)(4)(ii) IC-DISINFECT/SURFACES/EQUIP/WRITTEN PROTOCOL
To ensure compliance the EC will in-service all DPC staff on:
- FMS-CS-IC-II-140-500C2 Checking Conductivity and pH of Final Dialysate with the pHoenix Meter

Emphasis will be placed on ensuring RO water is used to rinse the phoenix meters prior to the meters being returned to their holder. The in-service will additionally reinforce the importance of performing the testing of the pH and conductivity with the pHoenix meter per policy as well as rinsing the sample cup and the meter before replacing it back in the station
Inservicing will be completed by 10/6/2017
All training documentation 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 2x/week for 2 weeks to ensure that compliance is maintained. At that time the audits will then follow the monthly 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: 11/3/2017



494.60(d)(2) STANDARD
PE-ER PREP-PTS ORIENTED/TRAINED

Name - Component - 00
The facility must provide appropriate orientation and training to patients, including the areas specified in paragraphs (d)(1)(i) of this section.


Observations:


Based on an interview with the Clinical Nurse Manager, a review of facility policy, a review of the facility Plan of Correction (stated completion date of September 15, 2017) for the onsite recertification survey exit date of August 4, 2017; facility failed to provide documentation of conducting stated inservices of fire drills.

Findings:

A review was conducted of facility policy on September 21, 2017 at approximately 11:00 a.m. Policy #FMS-CS-IC-II-130-013A 'Fire Drill' states "Quarterly, all FMS facilities shall perform a fire drill for each shift of patients.......". "Patients should be able to verbalize how they would disconnect themselves from the machine and evacuate the facility....".

A review of the facility Plan of Correction was conducted on September 21, 2017 between approximately 9:00 a.m. - 12:00 p.m. revealed the following:

The Plan of Correction, with a stated completion date of September 15, 2017, stated "The EC will re-educate the DPC staff on: FMS-CS-IC-11-130-013A Fire Drill. Emphasis will be placed on ensuring that Fire Drills Are completed and documented quarterly for both patients and staff. Patients not present the days of the drill will have a verbal review of the fire drill completed upon return to the facility". "The inservicing will be completed by 8/25/17 with documentation of the training on file at the facility". No documentation provided of the inservice being conducted as stated.

An interview with the Clinical Nurse Manager on September 21, 2017 at approximately 12:30 p.m. confirmed the above findings.


















Plan of Correction:

V412 494.60(D)(2) STANDARD PE-ER PREP-PTS ORIENTED/TRAINED
The EC will re-educate all the DPC staff on:
- FMS-CS-IC-11-130-013A Fire Drill
Emphasis will be placed on ensuring that Fire Drills are completed and documented quarterly for both patients and staff. Patients not present the days of the drill will have a verbal review of the fire drill completed upon return to the facility.

The inservicing will be completed by 10/6/2017 with documentation of the training on file at the facility.

To ensure ongoing compliance with the quarterly fire drill schedule the CM/designee will develop a calendar for the year with the weeks that the fire drill are to be held clearly identified. This calendar will be posted at the nurse's station. The CM will also have the weeks of the fire drills for the remainder of the year marked off in her email and QAI calendar.

The QAI committee will be informed quarterly of the weeks that the drills are scheduled. The results of the fire drills when conducted will be reviewed by the CM at the monthly QAI meeting

The CM or designee will perform quarterly audits of the fire drills. 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/designee 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: 11/3/2017



494.80(b)(1) STANDARD
PA-FREQUENCY-INITIAL-30 DAYS/13 TX

Name - Component - 00
An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session.



Observations:


Based on an interview with the Clinical Nurse Manager, a review of facility policy, a review of the facility Plan of Correction (stated completion date of September 15, 2017) for the onsite recertification survey exit date of August 4, 2017; facility failed to provide documentation of conducting stated inservices of Assessments and Plan of Care being completed by IDT (Interdisciplinary Assessment) members within 30 days or 13 treatments of admission.

Findings:

On September 21, 2017 at approximately 11:00 a.m. a review of Policy #FMS-CS-IC-I-110-125A 'Comprehensive Interdisciplinary Assessment (CIA) and Plan of Care (POC)' states "An initial comprehensive interdisciplinary assessment must be conducted on all new patients and a plan of care developed and implemented within the latter of 30 calendar days or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session". 'CIA and POC for Transfers and Transients' section states "Experienced dialysis patients transferring from one dialysis facility to another that have provided the receiving facility with a copy of their initial comprehensive assessment and plan of care will need to have a new comprehensive assessment and plan of care completed by the receiving facility within 3 months of the patients admission to the new facility and then annually thereafter if stable". "If a comprehensive assessment and plan of care have not been received for the transferring or transient patient, the receiving facility must complete the CIA and POC within 30 days".

A review of the facility Plan of Correction was conducted on September 21, 2017 between approximately 9:00 a.m. - 12:00 p.m. revealed the following:

The Plan of Correction, with a stated completion date of September 15, 2017, stated "The EC will re-educate all the Registered Nurse (RN) staff and the Interdisciplinary Team (IDT) members on: FMS-CS-IC-I-110-125A Comprehensive Interdisciplinary Assessment and Plan of Care. Emphasis will be placed on the importance of ensuring that all newly admitted patients will have an Assessment and a Plan of Care completed by all IDT members within 30 days or 13 treatments of admission". "The inservicing will be completed by 8/25/17 with documentation of the training on file at the facility". No documentation provided of the inservice being conducted as stated.

An interview with the Clinical Nurse Manager on September 21, 2017 at approximately 12:30 p.m. confirmed the above findings.















Plan of Correction:

V 516 494.80(B)(1) STANDARD PA-FREQUENCY-INITIAL-30 DAYS/13 TX
The EC will re-educate all the Registered Nurse (RN) staff and the Interdisciplinary Team (IDT) members on:
- FMS-CS-IC-1-110-125A Comprehensive Interdisciplinary Assessment and Plan of Care
Emphasis will be placed on the importance of ensuring that all newly admitted patients have an Assessment and a Plan of Care completed by all IDT members within 30 days or 13 treatments of admission.
The inservicing will be completed by 10/6/2017 with documentation of the training on file at the facility.

The CM or designee will perform monthly audits on all newly admitted patients for the next 6 months. At that time if compliance is observed the audits will then follow the monthly QAI schedule. A POC specific audit tool will be used for the audits.
IDT members 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: 11/3/2017