QA Investigation Results

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


There are  11 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification survey conducted on January 8, 2019 through January 11, 2019, BMA of Abington was identified 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 unannounced Medicare recertification survey conducted January 8, 2019 through January 11, 2019, BMA of 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 STANDARD
IC-SANITARY ENVIRONMENT

Name - Component - 00
The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas.


Observations:


Based on observation, and a review of Facility policy, with an interview conducted with Area Technical Operations Manager, it was determined, that the facility failed to ensure the removal of expired supplies. Findings include:
1. A review of policy entitled "Storage of supplies" was conducted on January 8, 2019 at appoximately 2:15 PM. Page 1, Paragragraph 3, reads " Stock will be rotated on a regular basis according to expiration dates".
2. On January 8, 2019 at appoximately 10:30 AM during the observational tour it was observed that the supply area contained 3-32 oz. Bottles of "Myron L" TDS/Conductivity Fluid:

Two (2) bottles had the expiration date of 11-9-18.

One (1) bottle had the expiration date of 11-6-19.

3. An interview was conducted with the Area Technical Operations Manager, on January 8, 2019, at appoximately 10:45 AM. The Area Technical Operations Manager, confirmed the above findings, and informed the surveyor that the above cited policy is current.



















Plan of Correction:

The Education Coordinator (EC) will re-educate all the direct patient care (DPC) staff and the Biomedical technician (BMT) on:
- FMS-CS-IC-1-120-005A Storage of Supplies
Emphasis will be placed on ensuring that all supplies, including Myron L Meter solutions, are stored properly and rotated on a regular basis based on expiration dates. The meeting will review that there needs to be a Material Safety Data Sheet (MSDS) for all chemicals used in the facility.
The inservicing will be completed by February 15, 2019 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/week for 2 weeks to ensure that compliance is maintained. At that time the audits will then follow the monthly Quality Assessment Improvement (QAI) schedule. A POC specific 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.



494.150(c)(2)(i) STANDARD
MD RESP-ENSURE ALL ADHERE TO P&P

Name - Component - 00
The medical director must-
(2) Ensure that-
(i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;



Observations:


Based on review of Facility Water Softener Logs, Facility policy, and an interview with the Area Technical Operations Manager Manager, it was determined, that the facility failed to ensure that the Water Softener Log was completed in its entirety for the month of November 2018.

Findings include:

1. A review of the Facility policy entitled "Water Softener" was conducted on January 10, 2019, at approximately 1:30 PM. Page three (3), Paragraph three (3) reads : " Water softener performance measurements will be documented on the Water Softener log sheet".

2. A review of the Water Softener log for the month of November was conducted on January 10, 2019, at approximately 12:00 PM.

For the date of November 4, 2018, the log was not completed in its entirety.

For the date of November 20, 2018, the log was not completed in its entirety.

3. An interview was conducted with the Area Technical Operations Manager Manager, on January 10, 2019, at approximately 12:30 PM. The Area Technical Operations Manager confirmed the above findings, and informed the Surveyor that the above cited policy is current.










Plan of Correction:

V715
On, January 28, 2019 the Director of Operations (DO) and the CM met with the Medical Director to discuss Medical Director Responsibilities as defined in the Conditions for Coverage. The meeting also reviewed the Medical Staff Bylaws and FMS-CS-IC-II-140-126A Water Softener Policy. Emphasis will be placed on the Medical Director responsibilities to ensure that the DPC staff document the water softener performance measurements on the water softener log per policy.
Documentation of the meeting will be on file at the facility.

At the meeting, the Medical Director determined that all DPC staff will be in-serviced by the EC on:
- FMS-CS-IC-II-140-126A Water Softener Policy
The meeting will emphasize the importance of ensuring that there is proper documentation of the results of the water softener performance measurements on the water log daily per policy.

The inservicing will be completed by February 15, 2019 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/week for 2 weeks to ensure that compliance is maintained. At that time the audits will then follow the monthly Quality Assessment Improvement (QAI) schedule. A POC specific 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.