QA Investigation Results

Pennsylvania Department of Health
EAST NORRITON DIALYSIS
Health Inspection Results
EAST NORRITON DIALYSIS
Health Inspection Results For:


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Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification survey conducted on August 18, 2020 through August 20, 2020, East Norriton Dialysis 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 August 18, 2020 through August 20, 2020, East Norriton 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)(4)(ii) STANDARD
IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL

Name - Component - 00
[The facility must demonstrate that it follows standard infection control precautions by implementing-
(4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-]
(ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment.



Observations:


Based on observation of the clinical area, a review of facility policy and procedure, and an interview with the clinical manager, the facility did not follow its policy regarding cleaning and disinfection of the dialysis station for one (1) of two (2) observations. Observation #1.

Findings include:

A review of policy FMS-CS-IC-II-110A "Cleaning and Disinfection of the Dialysis Station" was conducted on August 19, 2020 at 10:30 AM states: "Definition Dialysis Station Area including the dialysis machine..and other reusable equipment...BP cuff... All work surfaces shall be cleaned with 1:100 bleach solution after competion of procedures..."


Observation of the clinical area was conducted on 8/18/2020 from approximately 8:40 AM through 1:00 PM.

During observation #1 PCT#2 did not disinfect the blood pressure (BP) cuff with 1:100 bleach solution after dialysis treatment at machine #25.

An interview with the clinical manager on 8/20/2020 at 1:15 PM confirmed the above findings.






Plan of Correction:

To ensure compliance the Clinic Manager (CM) or designee will in-service all direct patient care (DPC) staff on:
- FMS-CS-IC-II-155-110A Cleaning and Disinfection of the Dialysis Station

The meeting will focus on ensuring that the blood pressure (BP) cuffs are disinfected after each use/treatment.

In-servicing will be completed by 9/12/2020.

The CM or designee will perform daily audits for 2 weeks using a Plan of Correction (POC) specific audit tool. With compliance shown, audits will then be completed 2 times a week for 2 weeks to ensure that compliance is maintained. With continued compliance, auditing will then follow the monthly Quality Assessment Improvement (QAI) schedule.

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.



494.30(a)(2) STANDARD
IC-STAFF EDUCATION-CATHETERS/CATHETER CARE

Name - Component - 00
Recommendations for Placement of Intravascular Catheters in Adults and Children

I. Health care worker education and training
A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections.
B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters.

II. Surveillance
A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site.

Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients.

VI. Catheter and catheter-site care
B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections].





Observations:


Based on observation of the clinical area, facililty policy and procedure and an interview with the clinical manager, the facility did not follow procedure for catheter care for two (2) of two (2) observations. Observation #1 and 2.

Findings include:

A review of facility procedure, FMS-CS-105-032C "Changing the Catheter Dressing" was conducted on 8/19/2020 at 10:30 AM states: "Step 1 Place an underpad under catheter limbs to protect work area and clothing...Apply a dressing to the exit site Step 1 Using aseptic technique, apply the catheter dressing over dry exit site, being careful not to touch the patient side of the dressing with goved hands or to any surface..."

Observation of the clinical area was conducted on 8/18/2020 from approximately 8:40 AM through 1:00 PM.

During the catheter dressing change/initiation of treatment, PCT#3 at Machine # 13 Observation #1 placed the catheter limbs with tubing attached through a hole made in the blue underpad. Interview with PCT#3 stated this procedure was done "in case of bleeding from access." PCT#3 was also observed (Observation #2) touching the machine and then connecting the tubing to the catheter limbs without changing gloves, performing hand hygiene and donning new gloves.

An interview with the clinical manager on 8/20/2020 at 1:15 PM confirmed the above findings.








Plan of Correction:

To ensure compliance the CM or designee will in-service all DPC staff on policy:
- FMS-CS-IC-I-105-032A Changing the Catheter Dressing Policy
- FMS-CS-IC-II-155-090A Hand Hygiene Policy

Emphasis will be placed on ensuring that a clean under pad is placed under the catheter limbs prior to beginning the cleaning and disinfection of the catheter cap and hub. The meeting also informed the staff that holes are not to be made in the under pads and the catheter is to be placed on top of the under pad. Also reviewed was the importance of performing hand hygiene per policy, including after touching the machine and completing another task.

In-servicing will be completed by 9/12/2020.

The CM or designee will perform daily audits for 2 weeks using a POC specific audit tool. At that time if compliance is observed the audits will then be completed 2 times a week for 2 weeks to ensure that compliance is maintained. At that time the audits will then follow the monthly QAI schedule.

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.



494.80(a)(2) STANDARD
PA-ASSESS B/P, FLUID MANAGEMENT NEEDS

Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:

Blood pressure, and fluid management needs.




Observations:


Based on review of medical records (MR), faciity policy and an interview with the clinical manager, the facility did not follow its policy regarding blood pressure management for one (1) of ten (10) MRs. MR#8.

Findings include:

A review of procedure FMS-CS-IC-I-110-131C "Patient Assessment and Monitoring" on 8/20/2020 at 10:30 AM states: " Pre Treatment Assessment, Post treatment assessment, Monitoring During Treatment Step 1 Blood Pressure...Report to the nurse: Systolic blood pressures greater than 180 mm/Hg Diastolic blood pressure greater than 100mm/Hg..."

A review of MRs was conducted on 8/19/2020 from approximately 10:00 AM-3:00PM and 8/20/2020 9:00 AM-10:30 AM.

MR#8 admission date 9/5/15 a review of treatment sheets revealed the following:
8/8/2020 post treatment BP 211/108 no intervention noted
8/11/2020 pre treatment BP 215/133
12:40 PM BP 210/125 "Treatment initiated without problem.."
1300 PM BP 208/117 "Denies complaints..."
1322 PM BP 206/117 "Denies complaints..."
1342 PM BP 221/130 "Denies complaints.."
15:11 PM BP 222/116 "Treatment discontinued."
Post treatment BP 214/115
Patient was given clonidine (antihypertensive) 0.2 mg at 14:43 PM "d/t (due to) bp remain high per pam np (nurse practitioner) continue evening bp." Per nursing evaluation "d/c (discharge) wheelchair, no c/os. Stable treatment...flowsheet reviewed."
Blood pressures were high pre treatment and throughout treatment with half hourly documentation stating "denies complaints" with no documentation of reporting these blood pressures to the nurse and a nursing post assessment stating "stable treatment with a review of the treatment sheet."
8/13/2020 post treatment BP 187/100 was given clonidine 0.2 mg PO. Post treatment note states patient taken to ER by husband due to high blood pressures.

An interview with the clinical manager on 8/20/2020 at 1:15 PM confirmed the above findings and stated the patient remains hospitalized.






Plan of Correction:

To ensure compliance the CM or designee will in-service all DPC staff on policy:
- FMS-CS-IC-I-110-131C Patient Assessment and Monitoring

Emphasis will be placed on ensuring that any BP not within the acceptable limits must be reported to the Registered Nurse (RN) with the DPC documentation of the RN notification. The meeting also reinforced the need for the RN to complete an assessment with documentation of findings and any interventions taken. There must also be a follow up to the intervention.

In-servicing will be completed by 9/12/2020.

The CM or designee will perform daily audits for 2 weeks using a POC specific audit tool. At that time if compliance is observed the audits will then be completed 2 times a week for 2 weeks to ensure that compliance is maintained. At that time the audits will then follow the monthly QAI schedule.

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.



494.80(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 medical records (MR), facility policy, the Absence and Hospitalization Report and an interview with the clinical manager, the facility did not follow its policy regarding conducting a revision to the plan of care for one (1) of ten (10) MRs. MR#9.


Findings include:

A review of policy FMS-CS-IC-I-110-125A "Comprehensive Interdisciplinary Assessment and Plan of Care" was conducted on 8/20/2020 at 10:30 AM states: "Unstable patients must be reassessed by the IDT (interdisciplinary team) monthly...The following are unstable criteria: Extended or Frequent hospitalizations: Hospitalization of more than 15 days with discharge occurring withi the last 30 days, or More than 3 admissions in the last 30 days...Change in mentation or psychosocial needs severe enough to interfere with the patient's ability to follow aspects of the treatment plan..."

A review of the facility Absence and Hospitalization Report states hospitalizations for hypoglycemia on the following dates:
1/26/20-2/11/20, 2/17/-2/18/20, 2/24-2/25/20, 3/9-2/10/20, 3/20-25/20, 4/8-14/20,
4/20-28/20, 4/28-5/1/20, 5/18-21/20, 6/26-28/20, 7/10-16/20, 7/31-8/4/20, 8/12/20-present.
MR #1 admission date10/23/19 diagnosis bipolar schizophrenia, hypertension and diabetes.
A review of the medical record revealed that the patient resides in a group home and has daily auditory hallucinations. The last plan of care is dated 1/14/2020. The patient was not deemed unstable.

An interview with the clinical manager on 8/20/2020 at 1:15 PM confirmed the above findings and stated the patient remains hospitalized.










Plan of Correction:

To ensure compliance the CM or designee will in-service all Interdisciplinary staff on policy:
- FMS-CS-IC-I-110-125A Comprehensive Interdisciplinary Assessment and Plan of Care Policy

The meeting will review the unstable criteria with emphasis on ensuring that all unstable patients have a monthly assessment completed by all Interdisciplinary members within the proper timeline until deemed stable per policy.

The in-servicing will be been completed on 9/12/2020.

For continued compliance, the CM or designee will audit assessments monthly for all unstable patients. The audits will be completed monthly for the next 4 months. At that time if compliance, the audits will be completed following the QAI Medical Records audit.

IDT members 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.