Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted January 28, 2026, through January 30, 2026, Liberty Dialysis - Doylestown 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 January 28, 2026, through January 30, 2025, Liberty Dialysis - Doylestown was identified to have the following standard level deficiency that was 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 upon staff observations (OBS) in the treatment area, facility policy and procedure review, and an interview with the facility staff, it was determined the facility failed to ensure hand hygiene and donning of new gloves during during discontinuation of dialysis and post dialysis access care for a central venous catheter for one (1) of two (2) observations (OBS #1), during access of an AV fistula for initiation of dialysis for one (1) of three (3) observations (OBS #1), and during discontinuation of dialysis and post dialysis access care for an AV fistula for one (1) of three (3) observations (OBS #3).
Findings include:
Review of facility policy titled 'Hand Hygiene' on January 30, 2026, at approximately 2:00 P.M. states, Policy: "Hands will be decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water: Before and after direct contact with patients... Before performing any invasive procedure such as vascular access cannulation or administration of parenteral medications, immediately after removing gloves, after contact with body fluids or excretion, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled, after contact with inanimate objects near the patient, when moving from a contaminated body site to a clean body site of the same patient, after contact with the dialysis wall box, concentrate, drain or water lines, and after contact with other objects within the patient station or treatment space."
Observations in the treatment area were conducted on January 28, 2026, from approximately 10:30 A.M. to 1:00 P.M., January 29, 2026, from approximately 9:30 A.M. to 12:00 P.M., and January 30, 2026, from approximately 9:30 A.M. to 11:30 A.M. revealed the following:
OBS #1 during discontinuation of dialysis and post dialysis access care for a central venous catheter (CVC) on 1/29/2026 at 2:25 P.M. at Station #10, PCT (patient care technician) #2 performed hand hygiene, donned gloves, disinfected the CVC hubs and disconnected the blood lines. PCT #2 dropped the package containing the sterile port caps, reached between the patient ' s leg and the side of the dialysis chair to retrieve the package, opened the package and applied the sterile port caps, without changing gloves and performing hand hygiene, or obtaining a new package of port caps.
OBS #1 during access of AV fistula for initiation of dialysis on 1/28/2026 at 11:30 A.M. at Station #4, PCT #1 was observed performing hand hygiene and donning gloves, touching the machine keyboard, then removing the thermometer from the patient ' s mouth. PCT #1 removed gloves, performed hand hygiene and donned new gloves. At 11:42 A.M. PCT #1 touched the dialysis machine, then connected the dialysis tubing to the patient catheters, touched the dialysis machine, tubing connections, blood pressure cuff, and the dialysis machine without changing gloves and performing hand hygiene per facility policy.
OBS #3 during discontinuation of dialysis and post dialysis access care for an AV fistula on 1/29/2026 at 9:20 A.M. at Station #7, PCT #1 was observed performing hand hygiene and donning gloves. PCT #1 touched the dialysis machine, set up supplies for the procedure, touched the dialysis machine, clamped the dialysis tubing, disconnected the dialysis tubing, and touched the dialysis machine, then changed gloves and performed hand hygiene and donned new gloves.
An interview with the facility Clinical Manager on January 30, 2026, at approximately 3:30 P.M. confirmed the above findings.
Plan of Correction:V113 IC-Wear gloves/hand hygiene
By 2/24/26, the Clinical Manager (CM) will hold a staff meeting, elicit input, and reinforce the expectations and responsibilities
of the facility staff on the following Policies and Requirements.
Hand Hygiene
Emphasis will be placed on:
Ensuring DPC staff change gloves and perform hand hygiene after contact with inanimate obejcts.
Ensuring DPC staff change gloves and perform hand hygiene when moving from a contaminated body site to a clean
body site on the same patient.
Ensuring DPC staff change gloves and perform hand hygiene after contact with other objects within the patient station or
treatment space.
Effective 2/25/26, the Clinic Manager or designee will conduct daily audits 5 days/wk x 2 weeks and then weekly x 2 weeks
utilizing a POC specific audit tool. Once compliance is sustained, the Governing Body will then resume regularly scheduled
audits based on the QAI calendar. Monitoring will be done through the POC Specific Audit Tool and/or QAI monthly audits.
The Medical Director will review the results of audits each month at the QAPI Committee meeting monthly.
The Clinical Manager is responsible to review, analyze and trend all data and Monitor/Audit results as related to this Plan of
Correction prior to presenting to the QAPI Committee monthly.
The Director of Operations is responsible to present the status of the Plan of Correction and all other actions taken toward the
resolution of the deficiencies at each Governing Body meeting through to the sustained resolution of all identified issues.
The QAPI Committee is responsible to provide oversight, review findings, and take actions as appropriate. The root cause
analysis process is utilized to develop the Plan of Correction. The Plan of correction is reviewed in QAPI monthly.
The Governing Body is responsible to provide oversight to ensure the Plan of Correction, as written to address the issues
identified by the Statement of Deficiency, is effective and is providing resolution of the issues.
The QAPI and Governing Body minutes, education and monitoring documentation, are available for review at the clinic.
Completion Date: 3/6/26
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