QA Investigation Results

Pennsylvania Department of Health
ALBERT EINSTEIN MEDICAL CENTER ESRD
Health Inspection Results
ALBERT EINSTEIN MEDICAL CENTER ESRD
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 upon the findings of an unannounced onsite Medicare recertification survey conducted January 24-26, 2018, Albert Einstein Medical Center Esrd was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.









Plan of Correction:




Initial Comments:


Based on the findings of an unannounced Medicare recertification survey conducted January 24-26, 2018, Albert Einstein Medical Center Esrd 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 for End-Stage Renal Disease Facilities.







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, review of facility policy, and an interview with the facility Director of Regulatory Agencies, the facility failed to ensure the staff followed infection control protocols, including but not limited to, hand hygiene/don clean gloves, for one (1) of two (2) Access of AV fistula or Graft for Initiation of Dialysis observations (Observations #1); failed to ensure the staff followed infection control protocols, including but not limited to, hand hygiene/don clean gloves, for two (2) of two (2) Central Venous Exit Site Care observations (Observation #2, #3); failed to ensure the staff followed infection control protocols, including but not limited to, hand hygiene/don clean gloves, for one (1) of two (2) Parenteral Medication Preparation and Administration observations (Observation #4).

Findings include:

A review was conducted of facility policy on January 26, 2018 at approximately 11:00 a.m. Policy:7-03-02 'Hand Hygiene' section 1 states "Hands will be washed upon entering the hospital/facility, prior to gloving, after removal of gloves, .........". Procedure: 7-06-01E 'Preparation and Administration of IV Medications including Albumin' 'Preparation of IV Medications' #1 states "Perform hand hygiene. Put on PPE". 'Administration of IV medications using the luer lock line or LockSite on the saline infusion line' #3 states "Perform hand hygiene. Put on PPE".

Observations conducted in patient treatment area on January 24, 2018 at approximately 12:35 p.m. revealed the following:

Observation #1: On January 24, 2018 at approximately 12:35 p.m. during the 'Access of AV fistula or Graft for Initiation of Dialysis' observation #1, Employee #17 was observed at station #2, patient #2. Employee #17 removed gloves after removing site bandage/evaluated access site and did not perform hand hygiene prior to donning new gloves/applying antiseptic to skin over cannulation site.

Observation #2: On January 24, 2018 at approximately 12:00 p.m. during a Central Venous Exit Site Care observation #1, Employee #18 was observed at station #8, patient #7. Employee #18 removed gloves after removing site bandage and did not perform hand hygiene prior to donning new gloves/cleansing area around CVC exit site with antiseptic.

Observation #3: On January 24, 2018 at approximately 1:35 p.m. during a Central Venous Exit Site Care observation #2, Employee #17 was observed at station #7, patient #6. Employee #17 removed gloves after removing site bandage and did not perform hand hygiene prior to donning new gloves/cleansing area around CVC exit site with antiseptic.

Observation #4: On January 26, 2018 at approximately 8:30 a.m. during a Parenteral Medication Preparation and Administration observation #2, Employee #20 was observed at station #8, patient #7. Employee #20 did not perform hand hygiene/don clean gloves after preparing medication and before administering medication.

An interview with the facility Director of Regulatory Agencies on January 26, 2018 at approximately 1:00 p.m. confirmed the above findings.









































Plan of Correction:

All hemodialysis staff will be re-educated on the importance of following infection control protocols for hand hygiene/don clean gloves when providing care including but not limited to, access initiation of dialysis, central venous exit site care and parenteral mediation administration preparation. This education will be completed on or before 2/23/18.

Beginning 2/24/18 for a period of four weeks the Facility Administrator will be responsible for conducting 10 observations per week for compliance with appropriate infection control practices. The results will be shared weekly with the Clinical Director who will be responsible for taking immediate action to correct any identified deficiencies. At the end of the four week time period the Clinical Director will determine the need for continued audits, based on performance. The Clinical Director has ultimate accountability for this corrective action.



494.30(a)(1)(i) STANDARD
IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK

Name - Component - 00
Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory.


Observations:


Based on reviews of observations, facility policy, and an interview with the facility Director of Regulatory Agencies, the facility failed to ensure the staff followed infection control protocols, included but not limited to, wearing personal protective equipment (PPE) during administration of medications through the extracorporeal circuit for one (1) of two (2) observations (Observation #1) and failed to ensure the staff followed infection control protocols, included but not limited to, wearing personal protective equipment (PPE) during the discontinuation of dialysis with central venous catheter for one (1) of two (2) observations (Observation #2).

Findings:

A review was conducted of facility policy/procedure on January 26, 2018 at approximately 11:00 a.m. Procedure: 7-06-01E 'Preparation and Administration of IV Medications including Albumin' 'Administration of IV medications using the luer lock line or LockSite on the saline infusion line' #3 states "Perform hand hygiene. Put on PPE".

Observations conducted in patient treatment area on January 25, 2018 at approximately 9:22 a.m. revealed the following:

Observation #1: On January 25, 2018 at approximately 9:22 a.m. during a Parenteral Medication Preparation and Administration observation #1, Employee #13 was observed at station #7, patient #14. Employee #13 did not don PPE as indicated by potential exposure. Employee #13 did not wear eye/nose/mouth protection while administration of medications through the extracorporeal circuit. Employee only wore personal prescription eyeglasses.

Observation #2: On January 24, 2018 at approximately 11:25 a.m. during a Discontinuation of Dialysis with Central Venous Catheter observation #1, Employee #17 was observed at station #6, patient #8. Employee #17 did not don PPE as indicated by potential exposure. Employee #17 did not wear a mask for nose/mouth protection during discontinuation of dialysis with central venous catheter.

An interview with the facility Director of Regulatory Agencies on January 26, 2018 at approximately 1:00 p.m. confirmed the above findings.






























Plan of Correction:

All hemodialysis staff will be re-educated on the importance of following infection control protocols for wearing personal protective equipment (PPE) during administration of medications through the extracorporeal circuit, including but not limited to, access initiation of dialysis, central venous exit site care, D/C of CVC dialysis and parenteral medication administration preparation. This education will be completed on or before 2/23/18.

Beginning 2/24/18 for a period of four weeks the Facility Administrator will be responsible for conducting 10 observations per week for compliance with appropriate infection control practices. The results will be shared weekly with the Clinical Director who will be responsible for taking immediate action to correct any identified deficiencies. At the end of the four week time period the Clinical Director will determine the need for continued audits, based on performance. The Clinical Director has ultimate accountability for this corrective action.



494.30(a)(1)(i) STANDARD
IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS

Name - Component - 00
Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled.

When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station.

Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients.


Observations:


Based on observations, review of facility policy, and an interview with the facility Director of Regulatory Agencies, the failed to ensure the staff followed infection control protocols, including but not limited to, ensuring medication preparation occurs in a clean area removed from the patient treatment area, for two (2) of two (2) Parenteral Medication Preparation and Administration observations (Observation #1, Observation#2).

Findings include:

CDC (Center for Disease and Control) MMWR (Morbidity and Mortality Weekly Report ) August 15, 2008 'Infection Control Requirements for Dialysis Facilities and Clarification Regarding Guidance on Parenteral Medication Vials' states " All parenteral medications should be prepared in a clean area separate from potentially contaminated items and surfaces. In hemodialysis settings where environmental surfaces and medical supplies are subjected to frequent blood contamination, medication preparation should occur in a clean area removed from the patient treatment area".

A review was conducted of facility policy/procedure on January 26, 2018 at approximately 11:00 a.m. Policy:7-06-01 'Medication Policy including the use of Volume Replacement and/or Volume Expanders' section #16 states "An aseptic environment and aseptic technique should be used when preparing medications. Careful attention to good handwashing should be done at this time". Procedure:7-06-01E 'Medication and Administration of IV Medications including Albumin' 'Preparation of IV Medications' section #2 states "When preparing medication, disinfect surface area with 1:100 (one to one hundred) bleach solution or hospital approved wipes. Remove gloves and perform hand hygiene".

Observations conducted in patient treatment area on January 25, 2018 at approximately 9:22 a.m. and on January 26, 2018 at approximately 8:30 a.m. revealed the following:

Observation #1: On January 25, 2018 at approximately 9:22 a.m. during the 'Parenteral Medication Preparation and Administration' observation #1, Employee #13 was observed at station #7, patient #14. Employee #13 prepared IV (intravenous) medication at the patients station on the patients bedside table.

Observation #2: On January 26, 2018 at approximately 8:30 a.m. during the 'Parenteral Medication Preparation and Administration' observation #2, Employee #20 was observed at station #8, patient #7. Employee #20 prepared IV (intravenous) medication at the patients station on the patients bedside table.

An interview with the facility Director of Regulatory Agencies on January 26, 2018 at approximately 1:00 p.m. confirmed the above findings.











Plan of Correction:

A clean area will be designated for the preparation, handling and storage of medications, separate from potentially contaminated items and surfaces. The identification of this designated area will occur on or before 2/23/18
All hemodialysis staff will be re-educated on the importance of following infection control protocols for preparation of medications in a clean area separate from potentially contaminated items and the importance of disinfecting all surfaces used for medication preparation. This education will be completed on or before 2/23/18.
Beginning 2/24/18 for a period of four weeks the Facility Administrator will be responsible for conducting 10 observations per week for compliance with appropriate medication practices. The results will be shared weekly with the Clinical Director who will be responsible for taking immediate action to correct any identified deficiencies. At the end of the four week time period the Clinical Director will determine the need for continued audits, based on performance. The Clinical Director has ultimate accountability for this corrective action.



494.30(a)(1)(i) STANDARD
IC: HBV: TEST ALL,REV RESULTS/STATUS B4 ADMIT

Name - Component - 00
Routine Testing for Hepatitis B

The HBV serological status (i.e. HBsAg, total anti-HBc and anti-HBs) of all patients should be known before admission to the hemodialysis unit.

Routinely test all patients [as required by the referenced schedule for routine testing for Hepatitis B Virus]. Promptly review results, and ensure that patients are managed appropriately based on their testing results.


Observations:


Based on an interview with the facility Director of Regulatory Agencies and a review of medical records, facility failed to complete Hepatitis B testing before admission and prior to first treatment for one (1) out of three (3) peritoneal dialysis medical records reviewed (MR#4).

Findings:

Facilty Hepatitis B patient screening policy requested. Per the facility Director of Regulatory Agencies, "The PD program does not have a written policy regarding this."

A review of medical records was conducted on January 26, 2018 between approximately 8:00 a.m. - 12:30 p.m. Patients admission date is listed below:

MR #4 9/6/17: Patient's first treatment date at the facility was 10/10/17. Documentation of the patients Hepatitis B laboratory results were reported to the facility from the laboratory on 10/12/17. No other documentation of prior Hepatitis B screening provided.

An interview with the facility Director of Regulatory Agencies on January 26, 2018 at approximately 1:00 p.m. confirmed the above findings.

















Plan of Correction:

All PD RNs will be re-educated on the importance of routine testing of all patients for Hepatitis B Virus prior to first treatment. This education will be completed on or before 2/23/18.
Beginning 2/24/18 for a period of four weeks the Clinical Director will be responsible for conducting an audit of all (100%) newly admitted patient records to review for compliance with Hepatitis B Virus testing prior to first treatment and taking immediate action to correct any identified deficiencies. The results will be shared weekly with the Assoc. Chief Nurse At the end of the four week time period the Assoc. Chief Nurse will determine the need for continued audits, based on performance. The Clinical Director will be responsible for developing PD Departmental policies/procedures on or before 3/15/18 that address the care of the PD patient in accordance with established regulations to include but not limited to: Hep B screening, TB screening, comprehensive assessment and the administration of a standardized mental and physical assessment tool.
The Assoc. Chief Nurse has ultimate accountability for this corrective action.



494.30(a)(2) STANDARD
IC-STAFF EDUCATION-CATHETERS/CATHETER CARE

Name - Component - 00
Recommendations for Placement of Intravascular Catheters in Adults and Children

I. Health care worker education and training
A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections.
B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters.

II. Surveillance
A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site.

Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients.

VI. Catheter and catheter-site care
B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections].





Observations:


Based on reviews of observations, facility policy, and an interview with the facility Director of Regulatory Agencies, the facility failed to ensure that clinical staff maintain aseptic technique for the care of vascular accesses, including intravascular catheters for two (2) of three (3) observations. (Observation #1, Observation #2).

Findings:

A review was conducted of facility policy/procedure on January 26, 2018 at approximately 11:00 a.m. Procedure: 7-04-02A 'Central Venous Catheter (CVC) Procedure' 'Upon Completion of Dialysis' section #40 states "Place patient in comfortable supine position. Then place barrier under catheter to prevent contamination". Policy: 7-04-02 'Central Venous Catheter (CVC) Care' section #2 states "Dressings will be performed using a medically aseptic technique.....".

Observation conducted in the patient treatment area on January 24, 2018 at approximately 11:25 a.m. revealed the following:

Observation #1: On January 24, 2018 at approximately 11:25 a.m. while observing 'Central Venous Catheter Exit Site Care' observation #1 for patient #8, station #6; Employee #17; Employee #17 did not place a clean field under CVC ports after performing hand hygiene/donning clean gloves and before reinfusing the extracorporeal circuit.

Observation #2: On January 24, 2018 at approximately 12:00 p.m. while observing 'Central Venous Catheter Exit Site Care' observation #2 for patient #7, station #8; Employee #18; Employee #18 initiated CVC exit site care on patient #7. Patient #7 has two (2) central lines, one being a Permacath. Employee #18 did not complete one CVC exit site dressing before starting the other. Employee #18 cleansed CVC Permacath exit site with antiseptic and before applying sterile dressing Employee#18 began CVC exit site care on the second central line, removing old dressing; Employee #18 than completed CVC exit site care on the Permacath site, applying sterile dressing, without performing hand hygiene/donning new gloves.

An interview with the facility Director of Regulatory Agencies on January 26, 2018 at approximately 1:00 p.m. confirmed the above findings.






















Plan of Correction:

All hemodialysis staff will be re-educated on the importance of following infection control protocols for hand hygiene and use of aseptic technique for the care of vascular accesses, including intravascular catheters. This education will be completed on or before 2/23/18.
Beginning 2/24/18 for a period of four weeks the Facility Administrator will be responsible for conducting 10 observations per week for compliance with appropriate infection control practices related to hand hygiene and use of aseptic technique for the care of vascular accesses . The results will be shared weekly with the Clinical Director who will be responsible for taking immediate action to correct any identified deficiencies. At the end of the four week time period the Clinical Director will determine the need for continued audits, based on performance. The Clinical Director has ultimate accountability for this corrective action.



494.80(a)(3) STANDARD
PA-IMMUNIZATION/MEDICATION HISTORY

Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:

Immunization history, and medication history.




Observations:


Based on review of medical records and an interview with the facility Director of Regulatory Agencies, the facility failed to ensure that patients were were tested at least once for baseline tuberculin skin test results (TST) for three (3) of three (3) peritoneal dialysis patient clinical records (CR) reviewed (CR #3-CR#5).

Findings include:

Facilty Tuberculosis patient screening policy requested. Per the facility Director of Regulatory Agencies, "The PD program does not have a written policy for routine screening for TB. As with any outpatient service TB screening is not routine .......".

A review of clinical records was conducted on January 26, 2018 between approximately 8:00 a.m. - 12:30 p.m. Patients admission date is listed below:

CR#3 Date of admission 8/4/17: No documentation of patient being tested for tuberculosis.

CR#4 Date of admission 9/6/17: No documentation of patient being tested for tuberculosis.

CR#5 Date of admission 3/31/16: No documentation of patient being tested for tuberculosis.

An interview with the facility Director of Regulatory Agencies on January 26, 2018 at approximately 1:00 p.m. confirmed the above findings.


















Plan of Correction:

All PD RNs will be re-educated on the importance of testing all patients for baseline screening for Tuberculosis prior to treatment. This education will be completed on or before 2/23/18.
Beginning 2/24/18 for a period of four weeks, the Clinical Director will be responsible for conducting an audit of all (100%) newly admitted patients to ensure baseline screening for Tuberculosis was completed prior to treatment and taking immediate action to correct any identified deficiencies. The results will be shared weekly with the Assoc. Chief Nurse At the end of the four week time period the Clinical Director will determine the need for continued audits, based on performance. The Clinical Director will be responsible for developing PD Departmental policies/procedures on or before 3/15/18 that address the care of the PD patient in accordance with established regulations to include but not limited to: Hep B screening, TB screening, comprehensive assessment and the administration of a standardized mental and physical assessment tool.
The Assoc. Chief Nurse has ultimate accountability for this corrective action.



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 a review of medical records and an interview with the facility Director of Regulatory Agencies, the facility failed to ensure an initial comprehensive assessment was 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, for two (2) of three (3) peritoneal dialysis patient medical records (MRs) reviewed (MR#3, MR#5).

Findings:

Facilty initial patient comprehensive assessment policy requested. Per the facility Director of Regulatory Agencies, "The PD program does not have a written policy."

A review of medical records was conducted on January 26, 2018 between approximately 8:00 a.m. - 12:30 p.m. Patients admission date is listed below:

MR#3 Date of admission 8/4/17: Patients initial interdisciplinary comprehensive assessment was conducted on 9/20/17.

MR#5 Date of admission 3/31/16: Patients first documented initial interdisciplinary comprehensive assessment was conducted on 7/6/16.

An interview with the facility Director of Regulatory Agencies on January 26, 2018 at approximately 1:00 p.m. confirmed the above findings.















Plan of Correction:

All PD RNs will be re-educated on the importance of performing an initial comprehensive assessment on all new patients within the latter of 30 day calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This education will be completed on or before 2/23/18.
Beginning 2/24/18 for a period of four weeks the Clinical Director will be responsible for conducting an audit of all (100%) newly admitted patient records to ensure an initial comprehensive assessment on all new patients within the latter of 30 day calendar days or 13 hemodialysis sessions was completed and taking immediate action to correct any identified deficiencies. The results will be shared weekly with the Assoc. Chief Nurse. At the end of the four week time period the Assoc. Chief Nurse will determine the need for continued audits, based on performance. The Clinical Director will be responsible for developing PD Departmental policies/procedures on or before 3/15/18 that address the care of the PD patient in accordance with established regulations to include but not limited to: Hep B screening, TB screening, comprehensive assessment and the administration of a standardized mental and physical assessment tool.
The Assoc. Chief Nurse has ultimate accountability for this corrective action.



494.90(a)(5) STANDARD
POC-VASCULAR ACCESS-MONITOR/REFERRALS

Name - Component - 00
The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement.


Observations:


Based on observations, review of facility policy, and an interview with the facility Director of Regulatory Agencies; the facility failed to ensure that the staff performed proper aseptic technique while initiating treatment for a patient with an AV fistula for two (2) of two (2) observations witnessed. (Observation #1, Observation #2).

Findings include:

A review was conducted of facility policy/procedure on January 26, 2018 at approximately 11:00 a.m. Policy:7-04-03 'Arteriovenous Fistula (AVF) and Arteriovenous Graft (AVG) Vascular Access Care' section #4 states "Patients are encouraged to wash access extremity with soap and water upon arrival for dialysis. If patient is unable to was the access site, the patient care teammate will clean access extremity with skin cleansing agent and pat dry".

Observations on January 24, 2018 between 12:35 p.m. and 1:50 p.m. revealed the following:

Observation #1: On January 24, 2018 at approximately 12:35 p.m. Employee #17 at station #2, began to initiate dialysis treatment for patient #2. Employee #17 did not wash skin over access with soap and water or antibacterial scrub, prior to evaluating access site, nor verbally confirmed that the patient had cleansed the access site.

Observation #2: On January 24, 2018 at approximately 1:50 p.m Employee #18 at station #5, began to initiate dialysis treatment for patient #9. Employee #18 did not wash skin over access with soap and water or antibacterial scrub prior to evaluating access site, nor verbally confirmed that the patient had cleansed the access site.

An interview with the facility Director of Regulatory Agencies on January 26, 2018 at approximately 1:00 p.m. confirmed the above findings.















Plan of Correction:

All hemodialysis staff will be re-educated on the importance of following proper aseptic technique while initiating treatment for a patient with and AV fistula. This education will be completed on or before 2/23/18.
Beginning 2/24/18 for a period of four weeks the Facility Administrator will be responsible for conducting 10 observations per week for compliance with appropriate aseptic technique while initiating treatment for patient(s) with an AV fistula. The results will be shared weekly with the Clinical Director who will be responsible for taking immediate action to correct any identified deficiencies. At the end of the four week time period the Clinical Director will determine the need for continued audits, based on performance. The Clinical Director has ultimate accountability for this corrective action.



494.90(a)(6) STANDARD
POC-P/S COUNSELING/REFERRALS/HRQOL TOOL

Name - Component - 00
The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis.


Observations:


Based on a review of medical records and an interview with the facility Director of Regulatory Agencies, the facility failed to ensure that a standardized mental and physical assessment tool was administered by the time of the first reassessment (i.e., within 4 months of initiating treatment), and/or repeated at least annually for two (2) of three (3) peritoneal dialysis patient medical records (MRs) reviewed (MR#3, MR#5).

Findings:

Facilty standardized patient mental and physical assessment policy requested. Per the facility Director of Regulatory Agencies, "Einstein began using the PHQ-9 in November 2017 and is in the process of developing a policy".

A review of medical records was conducted on January 26, 2018 between approximately 8:00 a.m. - 12:30 p.m. Patients admission date is listed below:

MR#3: Patient admitted to this facility on 8/4/17. No documentation provided of the administration of an intial standardized mental and physical assessment.
No documentation of patient refusing to complete an intial standardized mental and physical assessment.

MR#5: Patient admitted to this facility on 3/31/16. No documentation provided of the administration of an intial standardized mental and physical assessment. No documentation provided of the administration of an annual standardized mental and physical assessment. No documentation of patient refusing to complete an intial/annual standardized mental and physical assessment.

An interview with the facility Director of Regulatory Agencies on Janaury 26, 2018 at approximately 1:00 p.m. confirmed the above findings.













Plan of Correction:

All PD staff and Physicians will be re-educated on the importance of administering a standardized mental and physical assessment tool by the time of the first assessment and/or repeated at least annually. This education will be completed on or before 2/23/18.
Beginning 2/24/18 for a period of four weeks, the Clinical Director will be responsible for conducting an audit of all (100%) patient records to assess compliance with administering the standardized mental and physical assessment tool by the time of the first assessment and/or repeated at least annually and taking immediate action to correct any identified deficiencies. The results will be shared weekly with the Assoc. Chief Nurse. At the end of the four week time period the Assoc. Chief Nurse will determine the need for continued audits, based on performance. The Clinical Director will be responsible for developing PD Departmental policies/procedures on or before 3/15/18 that address the care of the PD patient in accordance with established regulations to include but not limited to: Hep B screening, TB screening, comprehensive assessment and the administration of a standardized mental and physical assessment tool.
The Assoc. Chief Nurse has ultimate accountability for this corrective action.



494.110(a)(2) STANDARD
QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS

Name - Component - 00
The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves.


Observations:


Based on a review of the QAPI (quality assessment and performance improvement) program and an interview with the facility Director of Regulatory Agencies, the facility failed to ensure that health outcomes (physical and mental functioning) are included in facility QAPI monitoring.

Findings include:

Facilty QAPI policy requested. Per the facility Director of Regulatory Agencies, "There is not a policy. QAPI focus areas are developed by a multidisciplinary team who reviews data and other sources of information to include the medical record to identify the areas of focus and improvement".

A 2017 QAPI review was conducted on January 26, 2018 at approximately 12:00 p.m. No documentation of physical and mental functioning outcomes being included in the QAPI program. The facility utilizes the 'Patient Health Questionnaire-9 (PHQ-9).

An interview with the facility Director of Regulatory Agencies on January 26, 2018 at approximately 1:00 p.m. confirmed the above findings.











Plan of Correction:

The Comprehensive Assessment Plan of Care tool has been revised to include the PHQ9 (physical & mental functioning outcomes) data and is currently in use. Beginning 3/1/18 the QAPI program will utilize the newly revised tool to ensure that health outcomes (physical and mental functioning) are included in the QAPI monitoring. These tools will be maintained as part of the QAPI programs documented evidence that physical and mental functioning is included in the QAPI monitoring. The Clinical Director is ultimately responsible for this corrective action.



494.110(a)(2)(viii) STANDARD
QAPI-INDICATOR-PT SATIS & GRIEVANCES

Name - Component - 00
The program must include, but not be limited to, the following:
(viii) Patient satisfaction and grievances.



Observations:


Based on a review of QAPI (quality assessment and performance improvement) program and an interview with the facility Director of Regulatory Agencies, the facility failed to ensure that patient satisfaction and grievances are included in facility QAPI monitoring.

Findings include:

Facilty QAPI policy requested. Per the facility Director of Regulatory Agencies, "There is not a policy. QAPI focus areas are developed by a multidisciplinary team who reviews data and other sources of information to include the medical record to identify the areas of focus and improvement".

A 2017 QAPI review was conducted on January 26, 2018 at approximately 12:00 p.m. No documentation of patient satisfaction and grievances being included in the QAPI program. This facility utilizes the 'Patient Health Questionnaire-9 (PHQ-9).

An interview with the facility Director of Regulatory Agencies on January 26, 2018 at approximately 1:00 p.m. confirmed the above findings.










Plan of Correction:

The Clinical Director in collaboration with the Director of Patient Experience will develop a patient satisfaction survey tool for use in surveying PD Patients on an annual basis. The tool will be developed on or before 2/28/18. The survey will be distributed to all current PD patients beginning 3/1/18. Results will be calculated and reported to QAPI beginning 4/1/18. The Clinical Director will be responsible for obtaining PD program specific patient grievance data from AEMC's Patient Advocacy Department (which is readily available) and reporting this data at the regularly scheduled QAPI meetings beginning 3/1/18. The Clinical Director has ultimate accountability for this corrective action.



494.150(c)(2)(i) STANDARD
MD RESP-ENSURE ALL ADHERE TO P&P

Name - Component - 00
The medical director must-
(2) Ensure that-
(i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;



Observations:


Based on review of medical records and an interview with the facility Director of Regulatory Agencies, the facility failed to ensure newly admitted hemodialysis patients had a minimal evaluation completed by a registered nurse (RN), prior to initiating treatment for immediate needs which contained the minimal elements of nursing standards of care for new dialysis patients for one (1) of two (2) hemodialysis medical records (MRs) reviewed (MR#2).

Findings include:

Facility policy requested. No applicable policy provided.

A review of medical records was conducted on January 26, 2018 between approximately 8:00 a.m. - 12:30 p.m. Patients admission date is listed below:

MR#2 Date of admission 1/23/18: Patients initial treatment flow sheet was dated 1/23/18. No documentation of a registered nurse completing an initial minimal evaluation prior to initiating first dialysis treatment.

An interview with the facility Director of Regulatory Agencies on January 26, 2018 at approximately 1:00 p.m. confirmed the above findings.















Plan of Correction:

All Hemodialysis staff will be re-educated on the importance of all newly admitted patients having an evaluation completed by a registered nurse prior to initiating treatment. This education will be completed on or before 2/23/18.
Beginning 2/24/18 for a period of four weeks the Facility Administrator will be responsible for conducting 10 observations per week for compliance with an evaluation being completed by a registered nurse prior to imitating treatment. The results will be shared weekly with the Clinical Director who will be responsible for taking immediate action to correct any identified deficiencies. At the end of the four week time period the Clinical Director will determine the need for continued audits, based on performance. The Clinical Director has ultimate accountability for this corrective action.