QA Investigation Results

Pennsylvania Department of Health
BMA ABINGTON
Health Inspection Results
BMA ABINGTON
Health Inspection Results For:


There are  12 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification survey conducted on January 11, 2022 through January 14, 2022 , BMA Abington, 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 11, 2022 through January 14, 2022 , BMA Abington, 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 during initiation of graft/fistula for two (2) of two (2) observations (Observations #1 and #2) and while performing Central Venous Catheter (CVC) Exit Site Care for one (1) of two (2) observations (Observation #3)

Findings include:

A review of policy "Changing the Catheter Dressing Procedure" was reviewed on January 12, 2022 at approximately 1:00 PM and states, "Inspect and remove old dressing. Check to see if dressing looks visibly soiled with exudate or blood. Visually inspect the exit site and surrounding area...Discard dressing and remove gloves. Perform hand hygiene..."

A review of policy "Access Assessment and Cannulation" was reviewed on January 12, 2022 at approximately 1:00 PM and states, "Disinfect cannulation site..Repeat steps above for second site. Do not touch cannulation sites after skin disinfection...Discard gloves and perform hand hygiene..."

Observation of the treatment area was conducted on January 12, 2022 from approximately 9:15 AM through 12:30 PM.

Observation #1. On 1/12/22 at approximately 11:10 AM, PCT #2 at station H, was observed cleaning fistula/graft site then immediately inserting cannulation needles without first removing gloves, performing hand hygiene, and donning clean gloves.

Observation #2. On 1/12/22 at approximately 10:55 AM, PCT #3 at station J, was observed cleaning fistula/graft site then immediately inserting cannulation needles without first removing gloves, performing hand hygiene, and donning clean gloves.

Observation #3 On 1/12/22 at approximatley 11:38 AM at station B. PCT #1 removed old catheter dressing and then cleansed exit site around CVC without first performing hand hygiene.



An interview with the facility nurse manager on 1/14/22 at approximately 1:00 PM confirmed the above findings.
















Plan of Correction:

The Clinic Manager (CM) or designee re-educated all the direct patient care (DPC) staff on the following policy:
- Changing the catheter Dressing
- Access Assessment and Cannulation

Special emphasis was placed on ensuring that hand hygiene is performed per policy when completing a catheter dressing change. The inservice will also include the importance of hand hygiene when performing access care in preparation for cannulation.

The in-servicing of staff and patients will be completed by January 28, 2022, with documentation of the training on file at the facility.

The CM or designee will perform daily audits for two (2) weeks. At that time if compliance is observed, the audits will then be completed 2 times/week for 2 weeks to ensure that compliance is maintained. At that time, if compliance is sustained, the audits will then follow the monthly Quality Assessment Improvement (QAI) schedule. A Plan of Correction (POC) 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 audit results and report the findings to the QAI Committee at the monthly meeting. Sustained compliance will be monitored by the QAI committee.

Completion Date: February 18, 2022



494.60(b) STANDARD
PE-EQUIPMENT MAINTENANCE-MANUFACTURER'S DFU

Name - Component - 00
The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer's recommendations.



Observations:


Based on review of observations (OBS), and interview with the facility Nurse Manager, the clinic failed to ensure emergency equipment was properly secured with a lock for (1) of one (1) observation made. OBS #1.

Findings include:

Review of clinic policy titled, "Emergency Medication, Equipment and Supplies" conducted on 1/12/22 at approximately 1:00PM states, "Emergency Cart Cart must be: locked when not in use, checked monthly or after use for contents, expiration dates, cleanliness, and proper functioning of all equipment.."

OBS #1, on 1/12/22 at approximately 10:00AM the emergency crash cart located on the treatment floor was observed to have a non-functional lock.



Interview with the nurse manager conducted on 1/14/22 at approximately 1:00 PM confirmed the above findings. The nurse manager stated a new emergency cart was delivered today (1/14/22).











Plan of Correction:

For immediate compliance, on January 12, 2022, a new crash cart with a functioning lock replaced the crash cart with the broken lock identified during the survey by the CM.

The CM or designee re-educated all the DPC staff on the following policy:
- Emergency Mediations, Equipment, and Supplies


The meeting will emphasize the importance of ensuring that the crash cart with the emergency medications, equipment and supplies is always locked when not in use.

The in-servicing of staff will be completed by January 28, 2022, with documentation of the training on file at the facility.

The CM or designee will perform daily audits for 2 weeks. At that time if compliance is observed, the audits will then be completed 2 times/week for 2 weeks to ensure that compliance is maintained. At that time, if compliance is sustained, the audits will then follow the monthly QAI schedule. A POC 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 audit results and report the findings to the QAI Committee at the monthly meeting. Sustained compliance will be monitored by the QAI committee.

Completion Date: February 18, 2022




494.90(a)(5) STANDARD
POC-VASCULAR ACCESS-MONITOR/REFERRALS

Name - Component - 00
The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement.


Observations:



Based on a review of facility policy, observation (OBS) of patient care and staff (EMP) interview, the facility failed to follow its policy about assessing vascular access site prior to the initiation of dialysis using the Arteriovenous Fistula (AVF) for two (2) of two (2) observations (OBS). Observations #1 and #2.


Findings Included:

A review of agency policy "Access Assessment and Cannulation" was conducted on 1/12/22 at approximately 1:00 PM and states, "Assessment of Vascular Access: Prior to treatment ask patient to wash access area with soap...Wash hands and don PPE...Place underpad under access to prevent soiling surrounding area...ASK: complaints of pain, numbness, tingling, coldness and tenderness, fever...LOOK: skin discoloration, hematomas, extremity or other swelling, new or change in aneurysm or Pseudoaneurysm, poor rotation of cannulation sites, pus, greater than expected redness, greater than expected swelling, any other unusual findings...Clean stethoscope with alcohol, LISTEN: Bruit high pitch/whistle, bruit not present throughout access....FEEL: Pulse not soft/not easily compressible, thrill not strong at anastomosis, thrill not present throughout access...Note and report any unusual findings to the nurse in charge or home therapy staff before proceeding with needle insertion. Remove gloves and perform hand hygiene. Don new gloves."

OBS #1: On 1/12/22 at approximately 11:10 AM at dialysis station H. PCT #2 was observed initiating dialysis treatment without first listening to access site.

OBS # 2: On 1/12/22 at approximately 10:50 AM at dialysis station J. PCT #3 was observed initiating dialysis treatment without first listening or feeling access site.



An interview with facility nurse manager on 1/14/22 at approximately 1:00 p.m. confirmed the above findings.
















Plan of Correction:

For immediate compliance, on January 12, 2022, the CM ordered new stethoscopes which will be placed on each machine.

The CM or designee educated all the DPC staff on the following policy:
- Access Assessment and Cannulation
The meeting reinforced the importance of ensuring that the patient's access is always listened to and felt for a thrill prior to cannulation per policy.

The in-servicing of staff will be completed by January 28, 2022, with documentation of the training on file at the facility.

The CM or designee will perform daily audits for 2 weeks. At that time if 100% compliance is observed, the audits will then be completed 3 times/week for 2 weeks to ensure that compliance is maintained. At that time, if compliance is sustained, the audits will then follow the monthly QAI schedule. A POC 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 audit results and report the findings to the QAI Committee at the monthly meeting. Sustained compliance will be monitored by the QAI committee with oversight by the GB.

Completion Date: February 18, 2022