Based on the findings of an unannounced, onsite Medicare recertification survey conducted August 30 through September 3, 2021, BMA of Wilkes-Barre 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:
Based on the findings of an unannounced, onsite Medicare recertification survey conducted August 30 through September 3, 2021, BMA of Wilkes-Barre was identified to have the following standard level deficiency that were determined to be in substantial compliance with the following requirement of 42 CFR, Part 494, Subparts A, B, C, and D: Conditions for Coverage for End-Stage Renal Disease Facilities.
Plan of Correction:
IC-ASEPTIC TECHNIQUES FOR IV MEDS
Name - Component - 00
[The facility must-]
(2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and
Based on review of facility policies/procedures and personnel files, observation and based on interview with the clinical manager and the administrator, the facility failed to ensure two (2) of two (2) registered nurses (RN) performed intravenous (IV) medication preparation as per facility policies/procedures. (Employees #1 and #2)
On September 1, 2021 at approximately 12:30 PM, review of the facility policy titled "Medication Preparation and Administration" revealed the following under "Drawing Medications from a Vial":
Step 2...wipe rubber stopper with alcohol prep pad.
On September 1, 2021 at approximately 10:59 AM, review of personnel files revealed the following:
Employee #1: The date of hire of the RN was 06/13/2016.
Employee #2: The date of hire of the RN was 01/07/2013.
Observational tour conducted on August 31, 2021 between the approximate times of 10:01 AM and 12:03 PM revealed the following:
Employee #1: After removing the protective cap from the vial of Hectorol (injectable form of Vitamin D), the RN inserted the needle and withdrew the medication from medication vial.
Employee #2: After removing the protective cap from the vial of Venofer (injectable iron replacement medication), the RN inserted the needle and withdrew the medication from medication vial.
Employees #1 and #2 failed to wipe the rubber stop of the above referenced medication vials prior to inserting the needle into the vial.
During interview conducted on September 3, 2021 at approximately 11:46 AM, the clinical manager and administrator confirmed the above referenced employees failed to prepare IV medications as per facility policies/procedures.
Plan of Correction:
The Clinic Manager (CM) or designee will in-service all direct patient care (DPC) staff on:
- Medication Preparation and Administration Policy
The in-service will focus on ensuring that the rubber stopper of the intravenous (IV) medication vial is wiped with an alcohol prep pad prior to the needle insertion. This must be done every time an (IV) medication is being withdrawn from a vial.
In-servicing will be completed by September 23, 2021, and the training documentation will be on file at the facility.
The CM or designee will perform daily audits, when the unit is treating patients, for four (4) weeks. At that time if compliance is observed, the audits will then be completed two (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 with oversight by the GB.
Completion Date: September 30, 2021