Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on January 19, 2022 through January 21, 2022, Grant One Dialysis 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(d)(1) STANDARD
ESRD EP Training Program
Name - Component - 00
§494.62(d)(1): Condition for Coverage:
(d)(1) Training program. The dialysis facility must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
Staff training must:
(iii) Demonstrate staff knowledge of emergency procedures, including informing patients of-
(A) What to do;
(B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated;
(C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and
(D) How to disconnect themselves from the dialysis machine if an emergency occurs.
(iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and
(v) Properly train its nursing staff in the use of emergency equipment and emergency drugs.
(vi) Maintain documentation of the training.
(vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures.
Observations:
Based on a review of medical records (MR), facility policy and an interview with the facility administrator, the facility did not provide emergency training to patients according to policy for two (2) of seven (7) MRs. MR# 1 and # 4.
Findings include:
A review of facility policy "Facility Emergency Management Plan" on 1/21/22 at approximately 12:30 PM states: "Training and Education. Emergency Management Plan...Patients: Quaterly....Fire Safety preparedness. Upon Admission to the facility..."
A review of MRs was conducted on 1/20/22 from 9:00AM- 2:30 PM and revealed the following:
MR#1. admission date 11/12/21 did not have a fire drill documented since admission to the facility.
MR#4. admission date 6/17/19 did not have a fire drill documented for the fourth quarter of 2021.
An interview with the facility administrator on 1/21/22, at 1:00PM confirmed the above findings.
Plan of Correction:The Facility Administrator will hold a mandatory in-service(s) for all clinical teammates by 2/07/2021. Using surveyor's observations education will include a review of policy 4-07-01 Facility Emergency Management Plan emphasizing patient training and education on the Emergency Management Plan will be completed upon admission and quarterly going forward. Patient training will be documented on the DaVita Dialysis Emergency Procedure form generated in the Registration System (Reggie). The Facility Administrator or designee will conduct an audit of new patient files weekly for four (4) weeks the monthly for two (2) months then on ten percent (10%) monthly during internal medical records audits. In addition, the Facility Administrator or designee will audit the Quarterly training at the end of Jan, Apr, Jul, and October to verify documentation of training has been completed quarterly. The Facility Administrator will review the audit results with the team in homeroom meetings and with the Medical Director during monthly Quality Assurance and Performance Improvement Meetings known as Facility Health Meetings with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on January 19, 2022 through January 21, 2022, Grant One Dialysis, 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) 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 observation, policy and procedure review, and an interview with the facility nurse manager, it was determined the facility failed to ensure hand hygiene and donning of new gloves while performing Central Venous Catheter (CVC) Exit Site Care for one (1) of three (3) observations (Observation #3)
Findings include:
A review of policy "Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure" was reviewed on 1/20/22 at approximatley 12:00PM stated, "Procedure. Perform hand hygiene per procedure. Put on PPE and provide a mask to the patient...Place patient in comfortable supine position...place second moisture proof barrier under catheter limbs...Remove old dressing and discard. Observe site for signs and symptoms of infections...Verify that both arterial and venous catheter limbs are clamped. Remove gloves and discard. Perform hand hygiene per procedure and re-glove..."
Observation of the treatment area was conducted on January 19, 2022 from approximately 9:45 AM through 12:45 PM.
Observation #3 On 1/19/22 at approximatley 11:32 AM at station #4. Patient Care Technician #2 removed old catheter dressing and then cleansed exit site around CVC without first performing hand hygiene.
An interview with the facility administrator on 1/21/22 at approximately 1:00 PM confirmed the above findings.
Plan of Correction:The Facility Administrator will hold a mandatory in-service(s) for all clinical teammates by 2/7/2022. Education will include a review of surveyor observations and a review of policy 1-04-02B Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure emphasizing that glove will be removed followed by hand hygiene when removing the old catheter dressing during CVC care. Clean glove will be donned prior to continuing with the procedure to perform CVC exit site care. Verification of attendance will be verified by teammate signature on in-service sheet. The Facility Administrator or designee will conduct CVC exit site care audits daily for two (2) weeks then weekly for two (2) weeks then monthly during internal infection control audits to verify compliance. The Facility Administrator will ensure during this period that all teammates are observed. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review the results of the audits with teammates during homeroom meetings and with the Medical Director during monthly Facility Health Meetings with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
494.80(d)(2) STANDARD
PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO
Name - Component - 00
In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted-
At least monthly for unstable patients including, but not limited to, patients with the following:
(i) Extended or frequent hospitalizations;
(ii) Marked deterioration in health status;
(iii) Significant change in psychosocial needs; or
(iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis.
Observations:
Based on a review of facility policy, medical record (MR) review and interview with the Facility Administrator, it was determined that the facility failed to follow its policy pertaining to completing a monthly comprehensive reassessment of an unstable patient for one (1) of one (1) active unstable patients reviewed (Medical Record # 3)
Finding include:
A review of the Facility Policy, "Interdisciplinary Team (IDT) Patient Assessment and Plan of Care" was reviewed on 1/21/22 at approximatley 9:30 AM and stated, "Monthly (unstable patients): (Assessment:) Monthly until patient is determined by the interdisciplinary team to be stable. Complete patient plan of care meeting within 15 days of the completion of the re-assessment and POC (plan of care)..."
A review of MR # 3 was conducted on January 19, 2022, at approximately 11:00 AM. The patient's starting date at the facility was 2/24/21.
In the careplan dated 9/7/21, the patient is listed as "Unstable". The patient continued to be listed as "unstable" for the months of October 2021 through January 2022 (present). There was no comprehensive assessment/plan of care contained in MR #3, for the month of October 2021 and non completed since 11/8/21 (approximately 2 months ago).
An interview was conducted with the facility administrator on January 21, 2022 at approximately 1:00 PM who confirmed the above identified findings, and informed the surveyor that the above cited policy is current.
Plan of Correction:The Facility Administrator will hold a mandatory in-service for all members of the Interdisciplinary team to re-educate on Policy 1-14-01 Interdisciplinary Teams (IDT) Patient Assessment and Plan of Care by 2/7/2022. Education will emphasize that an assessment and plan of care will be completed at least monthly for all unstable patient until the patient is deemed stable by the IDT. The patient plan of care meeting will be completed within 15 days of the completion of the re-assessment. Verification of attendance is evidenced by teammate signature on in-service sheet.
The Facility Administrator or designee will audit 100% of unstable POC's monthly and review the results with the IDT during Core Team Meetings and with the Medical Director at Facility Health Meetings monthly for the next six (6) months with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
|