QA Investigation Results

Pennsylvania Department of Health
CHILDREN'S HOSPITAL OF PHILADELPHIA (THE)
Health Inspection Results
CHILDREN'S HOSPITAL OF PHILADELPHIA (THE)
Health Inspection Results For:


There are  10 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 Recertification Survey conducted April 11, 2018 through April 13, 2018, Children's Hospital of Philadelphia was found to be in compliance with the following requirement 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 Medicare recertification survey conducted April 11, 2018 through April 13, 2018, The Children's Hospital of Philadelphia was found not to be in compliance with the following requirements of 42 CFR, Part 494, Subpart A, B, C and D Conditions for Coverage of End-Stage Renal Disease (ESRD) Facilities.










Plan of Correction:




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 observation during a tour of the new facility, review of facility policy, and interview with the Nurse Manager, it was determined that the facility failed to maintain a functional treatment environment by storing expired medical supplies in the treatment area.

Findings include:

Review of Facility policy entitled " Managing Outdates" conducted on April 13, 2018, at approximately 12:00 PM. states, " Policy: Materials Distribution will minimize the loss of product through outdate and ensure that dated products are withdrawn from the portion of the supply chain they control prior to outdating. Procedure: . . . 5e. Throughout the quarter, par stock technicians will check each labeled item at least once a week. If the item will expire before the end of the following week, it will be removed from stock."

During a tour of the supply room on April 12, 2018, at approximately 2:00 PM, revealed the following expired supplies: five (5) BD Baltec blood culture bottles with an expiration date of 02/28/2018; six (6) BBL culture swabs ( five (5) with an expiration date of 05/2017 and one (1) with an expiration date of 12/2017); seven (7) BD vacutainers with an expiration dyae of 11/2017; eleven (11) red top blood tubes with an expiration date of 03/31/2018; fourteen (14) blue top blood tubes ( eleven (11) with an expiration date of 03/31/2018 and three (3) with an expiration date of 11/30/2017; and eighty-two (82) green top blood tubes with an expiration date of 01/31/2018.



An interview was conducted with the Nurse Manager on April 12, 2018 at approximately 2:20 PM. The Nurse Manager confirmed the above findings and informed the surveyors that the above cited policy is current.













Plan of Correction:

1. Expired supplies were removed from the unit during the survey on 4/12/18.
2. Supply Chain employees, including the Director of Supply Chain logistics, conducted a thorough audit of the supply room on 4/13/18.
3. A Dialysis unit policy will be created by the Nurse Manager regarding the responsibility of nursing staff to check expiration dates before use of supplies for patient care by 6/1/18.
4. The Hospital policy that identifies Supply Chain staff is responsible for removing expired supplies and ensuring the rotation of stock will be updated by 6/1/18. The Nurse Manager of dialysis will work with the Director of Supply Chain Logistics to ensure completion of the policy.
5. Staff will be educated by the Nurse Manager about checking expiration dates before the use of supplies at the May monthly staff meeting on 5/23/18.
6. Audits to ensure there are no outdated supplies in the supply room will occur for the next 4 months until 100% compliance is achieved. Audits will be completed monthly by the nurse manager.



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 a review of Agency policy, Clinical Records, and interview with the Nurse Manager, it was determined, that the Facility did not follow its policy regarding two staff members conducting an initial dialysis machine check to verify the treatment procedures prior to the start of dialysis for one (1) of six (6) clinical records reviewed (Clinical Record # # 5).

Findings include:

1. A review of the policy entitled "Patient Assessment and Machine Check " was conducted on April 13, 2018, at approximately 12:20 PM. Page two, paragraph two reads: " Two clinicians perform an independent, initial machine check prior to the initiation of the hemodialysis treatment...".

2. A review of Clinical Record #5 was conducted on April 13, 2018, at approximately 11:15 AM. The patient contained in this record has an order dated 1-2-18, for one (1) hour and four (4) minutes of dialysis treatment, three times a week.

For the treatment dated 2-12-18, there was no documentation of any two staff verifying the ordered treatment procedures, prior to the start of dialysis treatment.

3. A interview was conducted with the Nurse Manager on April 13, 2018, at approximately 1:00 PM. The Clinical Director confirmed the findings, and informed the Surveyor that the cited policy is current.






















Plan of Correction:

1. Dialysis unit policies will be revised by the nurse manager to include a check of expiration dates for supplies prior to use for patient care by 6/1/18.
a. Dialysate preparation policy
b. Nurse verification policy
2. Nursing staff will be re-educated about the importance of checking expiration dates as part of their work flow by the Nurse Manager at the May monthly staff meeting on 5/23/18.
***NEW 3. The nurse manager will conduct a random check once per week over the next 3 months starting in June 2018 until there is 100% compliance.