Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on November 7, 2022 through November 10, 2022, US Renal Care of St. Mary's was identified to have the following standard level deficiency that was determined 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:
494.62(b)(9) STANDARD
Dialysis Emergency Equipment
Name - Component - 00
§494.62(b)(9) Condition for Coverage:
[(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:]
(9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available.
Observations:
Based on observation, and interview with staff/employee (EMP3), the facility failed to ensure emergency equipment was immediately available at all times for two (2) of two (2) observation (OBS #1 and OBS #2).
Findings included:
OBS #1, of facility's crash cart during treatment observations and interview immediately with EMP3 on November 7, 2022, at approximately 2:10 p.m. revealed the oxygen tank for the emergency "crash" cart was "empty" - PSI level gauge indicator was on zero (0) (empty), and not immediately available for use. EMP3 turned the oxygen control valve was to the "on" position to verify oxygen tank was empty.
OBS #2, of facility's emergency crash cart during treatment observations and interview immediately with EMP3 on November 7, 2022, at approximately 2:10 p.m. revealed Dextrose 50% injection (25g/50ml) lot # 22259EV, medication for emergency use for hypoglycemia, had expired on 1OCT2022.
Interview with EMP1 on November 7, 2022 at approximately 2:15 p.m. confirmed findings. "We are trying to get new order to replenish the supply of the medication and we are waiting for our shipment from the supplier."
Plan of Correction:Staff educated to C-FORMS-0390 AED/Emergency Cart Daily Checklist, C-FORMS-0400 Emergency Cart Contents and C-OS-0170 Oxygen Storage Instruction. Staff checking the crash cart will ensure all items are present and not expired. Staff instructed to replace items 1 month prior to the expiration date to ensure that all items remain current. Oxygen tank meter will be checked every time the cart is checked. FA or designee will audit checklist and contents weekly x4 weeks and monthly for 2 months to ensure supplies are maintained correctly in the Emergency Cart. Findings will be reviewed and assessed for any necessary changes with the Governing Body and reported in monthly QAPI. Identified non-compliance will result in additional staff in-servicing and increased frequency of auditing.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on November 7, 2022 through November 10, 2022, US Renal Care of St. Mary's 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 on review of facility policy, patient treatment area observations and interview with the clinical specialist (EMP# 1), it was determined the facility failed to ensure the staff followed infection control protocols, including but not limited to, ensuring patients performed hand hygiene according to facility procedure, for nine (9) of nine (9) patient treatment area observations (Observation (OBS) #1, # 2, #3, #4, #5, #6, #7, #8, and #9).
Findings include:
A review of facility policy, ' Coronavirus (COVID-19) Guidelines Policy # C-IC-0500 ' on November 7, 2022, at approximately 10:15 a.m. reads, " ...Ensure patient performs hand hygiene upon arrival/departure to and from facility. If patient is unable to perform independently, staff will assist patient. "
Observations (OBS) conducted in the patient treatment area on November 7, 2022, between approximately 11:00 a.m. and 2:45p.m. revealed the following:
OBS #1 On November 7, 2022, at approximately 11:30 a.m., pt#1 at station #13, EMP #7 escorted pt. #1 into treatment area, obtained patient ' s weight at the scale and guided pt. #1 directly to station #13. Patient did not perform hand hygiene upon entering treatment area. EMP #7 failed to ensure patient performed/assisted to perform hand hygiene.
OBS #2 On November 7, 2022, at approximately 2:00p.m., pt#2 at station #6, EMP #8 escorted pt. #1 into treatment area, obtained patient ' s weight at the scale and guided pt. #2 directly to station #6. Patient did not perform hand hygiene upon entering treatment area. EMP #8 failed to ensure patient performed/assisted to perform hand hygiene.
OBS #3 On November 7, 2022, at approximately 1:00 p.m., pt#3 at station #12, EMP #7 escorted pt. #3 into treatment area, obtained patient ' s weight at the scale and guided pt. #3 directly to station #12. Patient did not perform hand hygiene upon entering treatment area. EMP #7 failed to ensure patient performed/assisted to perform hand hygiene.
OBS #4 On November 7, 2022, at approximately 1:15 p.m., pt#5 at station #6, EMP #8 escorted pt. #8 to the exit of the treatment area, obtained patient ' s weight at the scale and guided pt. #5 out of the exit door directly into the waiting area. Patient did not perform hand hygiene upon exiting the treatment area. EMP #7 failed to ensure patient performed/assisted to perform hand hygiene.
OBS #5 On November 7, 2022, at approximately 1:30 p.m., pt. #6 at station #7, EMP #8 escorted pt. #6 to the exit of the treatment area, obtained patient ' s weight at the scale and guided pt. #6 out of the exit door directly into the waiting area. Patient did not perform hand hygiene upon exiting the treatment area. EMP #8 failed to ensure patient performed/assisted to perform hand hygiene.
OBS #6 On November 7, 2022, at approximately 12:30 p.m., pt. #7 at station #9, EMP #5 escorted pt. #7 into treatment area, obtained patient ' s weight at the scale and guided pt. #7 directly to station #9. Patient did not perform hand hygiene upon entering treatment area. EMP #5 failed to ensure patient performed/assisted to perform hand hygiene.
OBS #7 On November 7, 2022, at approximately 1:40 p.m., pt#8 at station #15, EMP #7 escorted pt. #3 into treatment area, obtained patient ' s weight at the scale and guided pt. #8 directly to station #15. Patient did not perform hand hygiene upon entering treatment area. EMP #7 failed to ensure patient performed/assisted to perform hand hygiene.
OBS #8 On November 7, 2022, at approximately 1:20 p.m., pt. #9 at station #2, EMP #4 escorted pt. #9 into treatment area, obtained patient ' s weight at the scale and guided pt. #9 out of the exit door and directly into the waiting area. Patient did not perform hand hygiene upon exiting the treatment area. EMP #4 failed to ensure patient performed/assisted to perform hand hygiene.
OBS #9 On November 7, 2022, at approximately 1:50 p.m., pt#10 at station #10, EMP #5 escorted pt. #10 into treatment area, obtained patient ' s weight at the scale and guided pt. #10 out of the exit door and directly into the waiting area. Patient did not perform hand hygiene upon exiting the treatment area. EMP #5 failed to ensure patient performed/assisted to perform hand hygiene.
Interview conducted on November 7, 2022 with EMP #1, EMP #4 and EMP #8 at approximately 3:45 p.m. confirmed the above findings.
Plan of Correction:Staff educated to C-IC-0500 Coronavirus Guidelines. All staff will follow policy have patients perform hand hygiene upon entry to the treatment floor and prior to being discharged. If the patient is unable, facility staff will assist. FA and or designee will audit this practice weekly for 4 weeks then monthly for 2 months. Findings will be reviewed and assessed for any necessary changes with the Governing Body and reported in monthly QAPI. Identified non-compliance will result in additional staff in-servicing and increased frequency of auditing.
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