Initial Comments:
Based on the findings of an unannounced onsite Medicare recertification survey completed July 19, 2024, Liberty Dialysis-Banksville LLC 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 onsite Medicare recertification survey completed on July 19, 2024, Liberty Dialysis Banksville LLC 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)(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 review of facility policy, observations, and staff interview (EMP), the facility failed to ensure that the staff followed infection control protocols, included but not limited to use of Personal Protective Equipment (PPE) for two (2) of two (2) observations. (Observation # 1 & #2).
Findings include:
Review of agency policy on 7/19/24 at approximately 11:00 a.m. revealed Clinical Services Policy: "Personal Protective Equipment (PPE)...All personal protective equipment shall be removed prior to leaving the treatment area."
Observation #1 on 7/19/24 at 10:37 a.m., EMP #8 was observed exiting the treatment room floor to outside lobby without removing personal protective equipment (PPE) and returned to the treatment floor without changing PPE.
Observation #2 on 7/19/24 at 10:45 a.m., EMP #8 was observed exiting the treatment room floor to outside lobby without removing personal protective equipment (PPE) and returned to the treatment floor without changing PPE.
Interview on 7/19/24 at approximately 12:30 p.m. with the Director of Operations (EMP1) and Clinical Nurse managers (EMP2 and EMP3) confirmed that PPE should be removed prior to leaving the clinical floor.
Plan of Correction:Recertification July 2024
V 115
To ensure compliance the clinic manager (CM) or designee will in-service all the staff on policy:
- Personal Protective Equipment
The in-service will focus on all the staff ensuring that they remove their Personal Protective Equipment (PPE) prior to leaving the treatment floor. This includes removing PPE prior to entering the lobby.
Inservicing will be completed by August 5, 2024. All training documentation will be on file at the facility.
The CM or designee will perform daily audits for two (2) weeks. At that time if one hundred percent (100%) compliance is observed the audits will then be completed 2 times/week for 2 weeks to ensure that compliance is maintained. At that time, the audits will then follow the monthly Quality Assessment and Performance Improvement (QAPI) schedule. A plan of correction (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 audits and report the findings to the QAPI Committee at the monthly meeting. The QAPI committee will be responsible for further guidance and ongoing oversight.
494.90(a)(1) STANDARD
POC-MANAGE VOLUME STATUS
Name - Component - 00
The plan of care must address, but not be limited to, the following:
(1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient's volume status;
Observations:
Based on review of facility policy, review of medical records (MR) that included patients who received in-center hemodialysis(ICHD), home peritoneal dialysis (PD) and home hemo-dialysis (HHD) and staff (EMP) interview the facility failed to assess and/or monitor patient status for three (3) of eight (8) MR reviewed. (MR2-ICHD, MR3-ICHD, MR6-ICHD).
Findings include:
Review of facility policy on 7/18/24 at approximately 9:45 a.m. revealed: Patient Assessment and Monitoring... During Treatment-"Obtain blood pressure and pulse rate every 30 minutes or more as needed but do not exceed 45 minutes or per state regulations. Document machine parameters and safety checks every 30 minutes or more often as needed but not to exceed 45 minutes or per state regulations."
Review of MRs on 7/17/24 at approximately 9:30 a.m. to 12:30 p.m. for ICHD and on 7/18/24 at approximatley 8:30 a.m. to 9:30 a.m. for PD and HHD revealed the following:
MR2, admission date of 5/8/22. Review of treatment records dated 7/2/24 through 7/13/24. Treatment sheet dated 7/9/24 revealed patient was assessed at 11:01 a.m. and patient was not assessed again until 12:06 p.m. (65 minutes between assessments).
MR3, admission date of 6/6/22. Review of treatment records dated 7/2/24 through 7/13/24. Treatment sheet dated 7/5/24 revealed patient was assessed at 12:05 p.m. and patient was not assessed again until 1:04 p.m. (59 minutes between assessments).
MR6, admission date of 4/29/24. Review of treatment records dated 7/3/24 through 7/15/24. Treatment sheet dated 7/8/24 revealed patient was assessed at 1:33 p.m. and patient was not assessed again until 2:31 p.m. (58 minutes between assessments).
Interview on 7/19/24 at approximately 12:30 p.m. with the Director of Operations (EMP1) and Clinical Nurse managers (EMP2 and EMP3) confirmed the above findings.
Plan of Correction:To ensure compliance the CM or designee will in-service all the direct patient care (DPC) staff on policy:
- Patient Assessment and Monitoring
Emphasis will be placed on ensuring that patients must be monitored for their vital signs (VS) every thirty (30) minutes, not to exceed forty-five (45) minutes, during treatment. The meeting will review the need to document VS timely.
Inservicing will be completed by August 5, 2024. All training documentation will be on file at the facility.
The CM or designee will perform daily audits for 2 weeks. At that time if one 100% compliance is observed the audits will then be completed 2 times/week for 2 weeks to ensure that compliance is maintained. At that time, the audits will then follow the monthly QAPI 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 audits and report the findings to the QAPI Committee at the monthly meeting. The QAPI committee will be responsible for further guidance and ongoing oversight.
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