Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on September 26, 2023 through September 29, 2023, Fresenius Kidney Care Roxborough, 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 completed September 29, 2023, Fresenius Kidney Care Roxborough was identified to have the following standard level deficiency that was 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 on observation of the clinical area, facility policy and an interview with the clinical manager and facility administrator, the facility did not follow policy with regard to changing gloves and performing had hygiene for one (1) of eleven (11) observations. Observations of the clinical area, facility policy and an interview with the clinical manager and facility administrator, the facility did not follow policy with regard to changing a central venous catheter dressing for one (1) of eleven (11) observations.
Findings include:
A review of facility policy was conducted on 9/27/2023 at 1:30 pm.
Policy Fresenius Kidney Care "Hand Hygiene" states: " Hands Will Be...Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water- Before and after direct contact with patients...Before performing any invasive procedure such as vascular access cannulation or administration of parenteral medications. Immediately after removing gloves...After contact with inanimate objects near the patient. When removing from a contaminated body site to a clean body site of the same patient. After contact with inanimate objects near the patient. After contact with the dialysis wall box, concentrate drain, or water lines. After contact with other objects within the patient station or treatment space ......"
Policy Fresenius Kidney Care "Changing a Central Venous Catheter Dressing" states: "Complete catheter exit site care and dressing replacement before any initiation of treatment. 2% Chlorhexidine Gluconate/ 70% alcohol (Chloraprep) is the preferred exit site germicide unless otherwise prescribed by physician. Aseptic technique must be followed to prevent infections. The exit site will have disinfectant applied and a n
Plan of Correction:To ensure compliance the covering Clinic Manager (CM) or designee will in-service all direct patient care (DPC) staff on:
- Hand Hygiene
- Changing a Central Venous Catheter Dressing
The meeting will focus on ensuring that hand hygiene is always performed per policy. This includes removing gloves, performing hand hygiene prior to removing any supplies, such as tape, from a supply cart. The meeting will also review that the catheter exit site must be allowed to air dry completely after cleaning with the antiseptic. The site must never be wiped dry prior to applying the dressing.
Inservicing will be completed by October 20, 2023. All training documentation is on file at the facility.
The covering 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/week for 2 weeks to ensure that compliance is maintained. At that time, the audits will then follow the monthly Quality Assessment and Performance Improvement (QAPI) schedule. A Plan of Correction (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 covering CM will review the audit results and report the findings to the QAPI Committee at the monthly meeting. Sustained compliance will be monitored by the QAPI committee.
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