Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on May 5, 2022 through May 6, 2022, Kidney Center Home Therapies, 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 onsite unannounced Medicare recertification survey conducted on May 5, 2022 through May 6, 2022, Kidney Center Home Therapies, 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:
494.50(b)(1) STANDARD
INVENTORY CONTROL
Name - Component - 00
9.2 Inventory control
Reprocessing supplies should be used on a first-in, first-out basis, and outdated supplies should be identified and discarded.
Observations:
Based on reviews of observations, facility policy, and an interview with the facility administrator, the facility failed to ensure proper inventory control for four (4) of four (4) observations (Observation #1-#4).
Findings include:
Review of Independent Dialysis Group Policy and Procedure Express Cart/Emergency Supplies Maintenance on 5/6/22 at approximately 12:30 PM revealed: "Policy statement: The emergency cart/emergency supplies are checked daily and monthly to ensure that supplies are available and equipment functions properly. Procedure: Monthly by the chief technician verifies that supplies are complete and not expired. If expired, these items are disposed of and new ones are ordered in their place."
Review of Independent Dialysis Group Policy and Procedure General Items Monthly Audit on 5/16/22 at approximately 8:30 AM revealed: "Policy statement: It is the responsibility of the chief technician to audit the items listed on a monthly basis to ensure a safe physical environment for staff and patients. Procedure: The chief technician performs a monthly audit of the general items listed below. The chief technician documents the audit on the monthly checks and maintenance log. Other monthly checks and maintenance items: Disaster box. Quarterly checks and maintenance items: Rotation of stock."
Review of Independent Dialysis Group Policy and Procedure Rotation of stock audit form on 5/16/22 at approximately 8:50 AM revealed: "Task: Stock room: expiration dates checked on all existing and incoming stock. Treatment room: expiration dates checked on all stock stored in treatment room.
Review of Independent Dialysis Group Policy and Procedure Rotation of stock on 5/16/33 at approximately 9:00 AM revealed: "Policy statement: In order to provide quality care, the facility must maintain adequate stock to sustain them through daily operations and in emergent events such as inclement weather where routine deliveries cannot be made. It is important to verify that stock is being rotated as it is delivered so that expiration dates if applicable are not being reached and that stock on the shelves is used prior to that which just arrived. The patient care technician is assigned to put stock away. The patient care technician will rotate all newly arrived stock so that stock already present is used first. A monthly audit will be performed to ensure no outdated supplies are in the center.
Observations conducted in the center on 5/5/22 between approximately 2:45 PM-3:00 PM and 5/6/22 between 11:40 AM-12:45 PM revealed the following:
Observation #1: Review of emergency cart on 5/5/22 revealed: Three (3) Amsure fourteen (14) French suction catheter kits with expiration date of 9/30/2020
Observation #2: Review of Disaster box on 5/5/22 revealed: Two (2) Henry Schein nasal cannula with expiration date of 11/10/21 and one (1) bottle of care one glucose tablets with expiration date of 1/2022.
Observation #3: Review of storage room #1 on 5/6/22 revealed: Forty (40) units of stay safe caps with expiration date of 3/31/2022
Observation #4: Review of Peritoneal dialysis training room on 5/6/22 revealed: Four (4) bottles liqua cel concentrated liquid protein lemon sugar free with expiration date of 8/2021.
An interview with the facility administrator on 5/6/22 at approximately 1:00 p.m. confirmed the above findings.
Plan of Correction:1. Corrective Action: we modified our monthly inventory process to include non-inventory items and report expiration dates less than 90 days from expiration. We also modified our crash cart maintenance to include an expiration check.
2. Problem Identification: 4 types of products identified as expired. They include; crash cart stock, PD training kit items and dietary supplements.
3. Process Changes: Modified TX23 (Crash Cart Maintenance) to require monthly product expiration checks using checklist TX23B. Modified EC119 (Rotation of Stock) to add expiration checks during the monthly inventory count using the Inventory Count Report for inventoried items and EC119A for non-inventory items.
4. Monitoring of Changes: An audit tool was created for this deficiency. Biomed will be educated on the policy changes that track expiration dates. The Center Manager will audit TX23B and EC119A each month using EC119B (rotation of stock audit form) to ensure that expired items are rotated out of stock for the next 3 months. Findings will be reviewed monthly at our leadership meetings and will be reported in our quarterly governing body meetings.
5. POC Completion Date: 5.26.2022
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