QA Investigation Results

Pennsylvania Department of Health
EAST END - PITTSBURGH DIALYSIS
Health Inspection Results
EAST END - PITTSBURGH DIALYSIS
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 onsite unannounced Medicare recertification survey completed on May 15, 2018 through May 17, 2018, East End-Pittsburgh Dialysis 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 onsite unannounced Medicare recertification survey conducted on May 15, 2018 through May 17, 2018, East End-Pittsburgh Dialysis 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 policies, direct observations, and interview with staff (EMP), it was determined that the facility failed to ensure staff donned gloves prior to touching dialysis machines/patient supplies for one (1) of six (6) staff observed (EMP 4).

Findings included:


Review of facility policies on 5/16/18 at approximately 1:00 PM revealed:

"INFECTION CONTROL FOR DIALYSIS FACILITIES ... TEAMMATE/PATIENT SAFETY ... 11. Teammates will wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station, and will remove gloves and wash hands or perform hand hygiene between each patient and/or station ... "

"MEASURING CONDUCTIVITY, TEMPERATURE AND/OR pH USING THE PHOENIX CONDUCTIVITY METER ... Procedure ... 1. Put on PPE (personal protective equipment) ... Rationale ... PPE is worn for teammate protection ..."

Observations of patient care by staff on May 16, 2018, from 8:30 AM to 11:00 AM revealed failure to don gloves when touching hemodialysis machines and/or patient equipment:

At 10:58 AM, EMP4 was observed to pickup the phoenix meter with bare hands and carried the device to station 14 and rested the device on top of the dialysis machine. The teammate failed to use disposable gloves.

Interview with EMP4, immediately after the observation confirmed that he had not worn gloves to pick up the device.

Exit interview with EMP1, EMP2, EMP3 on May 16, 2018 at approximately 1:00 PM confirmed that EMP4 should not have picked up the device without gloves.



Plan of Correction:

The Facility Administrator (FA) immediately on 5/16/18 started in-servicing the direct patient care teammates (TMs) on policy 1-05-01 Infection Control in the Dialysis Facility and policy 2-08-01 Measuring Conductivity, Temperature and/or pH using the Phoenix Conductivity Meter. Education included but was not limited to: 1) TMs will wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station, and will remove gloves and wash hands or perform hand hygiene between each patient and/or station; 2) TMs will wear PPE when using the Phoenix meter. The Clinical Coordinator (CC) and FA will complete all in-servicing by 5/28/18. Verification of attendance is evidenced by TM signature on in-service sheet. Beginning 5/21/2018 the FA or designee will perform audits daily for two (2) weeks, then weekly for four (4) weeks and then ongoing monthly. Each TM will be observed a minimum of three (3) times and documented on a separate audit sheet. Instances of non-compliance will be addressed immediately. Audit results will be reviewed with the TMs in homeroom meetings and with the Medical Director monthly during Facility Health Meeting (FHM-QAPI) with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.
Completion date: 6/15/18



494.40(a) STANDARD
CARBON ADSORP-MONITOR, TEST FREQUENCY

Name - Component - 00
6.2.5 Carbon adsorption: monitoring, testing freq
Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours.

Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet.

Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L].
Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly.


Observations:


Based on a review of facility policy and procedure, direct observation of staff (EMP), and staff interview, facility staff failed to conduct total chlorine testing as per facility policy and procedure for one (1) of one (1) staff observed (EMP4)

Findings Included:

A review of facility policy and procedure conducted on 5/16/18 at approximately 1:15 p.m. revealed "... Procedure: 2-05-02H ... TITLE: TOTAL CHLORINE TEST USING RPC ULTRA LOW TOTAL CHLORINE TEST STRIP ... Procedure ... 4. Wait 20 seconds for test strip color to develop. ... After the 20 second wait period, immediately compare the strip to the K100-0118 color chart to determine the Total Chlorine level in the sample. ... ."

During the direct observation of a total chlorine test on 5/15/18 at approximately 1:30 p.m., EMP4 removed the test strip from the testing solution and immediately compared the test strip to the K100-0118 color chart. When this surveyor asked how long he/she should wait before comparing the test strip with the color chart, EMP4 stated "I always do it right away." When asked if there was a wait period, EMP4 stated he/she was not sure and then referred to the policy located near the testing location and stated "20 seconds." When this surveyor asked EMP4 if he/she waited 20 seconds prior to comparing the test strip to the color chart during this observation, EMP4 stated "no, I didn't."

An interview with EMP2 and EMP3 on 5/16/18 at approximately 1:20 p.m. confirmed the observed procedure did not meet facility policy and procedure with EMP3 stating "he/she immediately came to me [after the observation] and we initiated training for all of our staff."



Plan of Correction:

The Clinical Service Specialist (CSS) and Group Facility Administrator (GFA) immediately on 5/16/2018 started in-servicing the direct patient care TMs on policy 2-05-02H Total Chlorine Test Using RPC Ultralow Total Chlorine Test Strips. Education included but was not limited to: 1) Rinse the sample collection cup thoroughly with the water to be tested. Fill the sample cup to the line marked 100 ml with the sample; 2) Remove one test strip from the foil package and dip it in the water sample for 60 seconds. While dipping the strip, move it back and forth at a constant gentle rate of approximately two, 1-2 inch wide strokes per second; 3) Remove the strip and shake once, briskly, to remove excess water; 4) Wait 20 seconds for the test strip color to develop. While waiting, fold the white plastic handle of the test strip under the test pad area so that it provides a consistent viewing background. As an alternative to folding the strip the reagent pad can be placed directly on the white surface of the color chart when comparing colors; 6) immediately compare the strip color to the K100-0118 color chart to determine the Total Chlorine level in the sample. The CC and FA will complete all in-servicing by 5/21/16. Verification of attendance is evidenced by TM signature on in-service sheet. The FA or designee will perform observational audits daily for two (2) weeks, then weekly for four (4) weeks. Each TM will be observed a minimum of three (3) times and documented on a separate audit sheet. Instances of non-compliance will be addressed immediately. Audit results will be reviewed with the TMs in homeroom meetings and with the Medical Director monthly during Facility Health Meeting (FHM-QAPI) with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.
Completion date: 6/15/18



494.90(a)(1) STANDARD
POC-ACHIEVE ADEQUATE CLEARANCE

Name - Component - 00
Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis.


Observations:

Based on a review of facility policies, governing body (GB) meeting minutes, medical records (MR) and staff (EMP) interviews, it was determined that the facility failed to ensure treatments were delivered in accordance with the dialysis prescriptions ordered by the physician as specified in the patient plan of care for four (4) of ten (10) CR reviewed who received in-center dialysis treatments (MR6, 8, 9, and 11).

Findings included:

Review of facility policies on 5/16/18 at approximately 1:00 PM revealed:

"Policy: 1-01-09 ... SHORTENED/EARLY TERMINATION OF TREATMENT OR EXTENDED TREATMENT ... POLICY: A. COMPLETION OF THE EARLY TERMINATION OF TREATMENT AGAINST MEDICAL ADVICE FORM ... 1. The RN (Registered Nurse) will verify that a patient signs the Early Termination of Treatment Against Medical Advice form any time that the patient requests to terminate their treatment earlier than the prescribed run time ... "

"Policy: 1-03-08 ... PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT ... 3. Patient ... prescription and machine settings are verified by teammate prior to initiation of treatment ... The prescription components are confirmed by a licensed nurse after onset of treatment within (1) hour of treatment initiation ... Prescription components include ... b. treatment time ... 10. If the dialysis prescription is not being met ... the reason will be documented and the licensed nurse will be informed ... 11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately ... 12. The licensed nurse notifies the physician ... as needed of changes in patient status ... 13. All findings, interventions and patient response will be documented in the patient's medical record ..."

Review of Governing Body meeting minutes on 5/16/18 at approximately 1:00 PM revealed, " ... November 10th, 2017 ... Discussion Points/Action Plan ... The GB has approved patients to sign off treatment no more than 10 minutes sooner than their prescribed end of treatment without needing to sign an AMA form. Should patients leave earlier than 10 minutes prior, an AMA form is required ..."

Review of MR6 on May 15, 2018, at approximately 12:03 PM revealed the prescribed treatment duration time ordered by the physician and specified on the plan of care was 220 minutes. Review of nine (9) treatment flow sheets from 4/24/18 to 5/12/18. According to the documentation on treatment flow sheets the treatment time was not achieved on the following dates:
On 4/28/18, completed 205 minutes.
On 5/5/18, completed 198 minutes.

There was no documentation that staff notified the physician of the changes in the dialysis prescription and had obtained a signed AMA document.

Review of MR8 on May 15, 2018, at approximately 1:23 PM revealed the prescribed treatment duration time ordered by the physician and specified on the plan of care was 210 minutes. Review of ten (10) treatment flow sheets from 4/23/18 to 5/11/18. According to the documentation on treatment flow sheets the treatment time was not achieved on the following dates:
On 4/23/17, completed 186 minutes.
On 4/27/17, completed 195 minutes.

There was no documentation that staff notified the physician of the changes in the dialysis prescription and had obtained a signed AMA document.

Review of MR9 on May 15, 2018, at approximately 2:20 PM revealed the prescribed treatment duration time ordered by the physician and specified on the plan of care was 195 minutes. Review of nine (9) treatment flow sheets from 4/23/18 to 5/11/18. According to the documentation on treatment flow sheets the treatment time was not achieved on the following dates:
On 4/30/18, completed 180 minutes.
On 5/7/18, completed 181 minutes.

There was no documentation that staff notified the physician of the changes in the dialysis prescription and had obtained a signed AMA document.

Review of MR11 on May 15, 2018 at approximately 12:35 PM revealed the prescribed treatment duration time ordered by the physician and specified on the plan of care was 240 minutes. Review of ten (10) treatment flow sheets from 4/26/18 to 5/5/18. According to the documentation on treatment flow sheets the treatment time and DFR was not achieved on the following dates:
On 4/26/18, completed 199 minutes.
On 5/5/18, completed 180 minutes.

There was no documentation that staff notified the physician of the changes in the dialysis prescription and had obtained a signed AMA document.

Exit interview with EMP1, EMP2, EMP3 on May 16, 2018 at approximately 1:00 PM confirmed the above findings.

Repeat deficency 11/28/17, 11/6/17




Plan of Correction:

The FA immediately on 5/16/18 started in-servicing the direct patient care TMs on policy 1-01-09 Shortened/Early termination of Treatment or Extended Treatment with emphasis on: 1) the RN will verify that a patient signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time; 2) if a patient's treatment is shortened/early terminated, the RN will document the event in the patient's medical record; 3) the facility's FA will verify that all shortened treatments are recorded and trended, and the FA shall verify that such records are reviewed and discussed at the Facility Health Meetings (FHM-QAPI), as appropriate. The CC and FA completed in-servicing of all East End DaVita direct patient care TMs on 5/18/2018. In addition, the CC will hold a mandatory in-service to review policy 1-03-08 Pre-Intra-Post Data Collection, Monitoring, and Nursing Assessment by 6/2/18. Education will include but not be limited to: 1) the patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment; 2) the prescription components including the treatment time are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment; 3) abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately; 4) the licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary; 5) the licensed nurse notifies the physician as needed of changes in patient status; 6) all findings, interventions and patient response will be documented in the patient's medical record. Verification of attendance will be evidenced by TM signature on in-service sheet. Starting 5/21/18 the FA or designee will audit one hundred percent (100%) of the treatments shortened greater than 10 min to verify the AMA was completed and documented in the medical records daily for two (2) weeks then weekly for four (4) weeks. Audit results will be reviewed with the TMs during homeroom meetings and with the Medical Director monthly during FHM-QAPI with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.

Completion date: 6/15/18