QA Investigation Results

Pennsylvania Department of Health
BMA OF POTTSVILLE
Health Inspection Results
BMA OF POTTSVILLE
Health Inspection Results For:


There are  17 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 May 28, 2019 through May 31, 2019, BMA of Pottsville 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 May 28, 2019 through May 31, 2019, BMA of Pottsville, 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:




494.40(a) STANDARD
CARBON ADSORP-MONITOR, TEST FREQUENCY

Name - Component - 00
6.2.5 Carbon adsorption: monitoring, testing freq
Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours.

Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet.

Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L].
Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly.


Observations:

Based on personnel file review (PF), review of policy, and an interview with the Agency Administrator, it was determined that the agency failed to ensure documentation of employees' color blindness test results for two (2) out of three (3) personnel files reviewed. (PF#2 and PF #3)


Findings include:

Review of Fresenius Kidney Care Clinical Services policy: Color blindness testing policy conducted on June 6, 2019 between 2:00 and 2:30 PM revealed the following: BACKGROUND: "Patient care and biomedical staff are in positions that require the ability to interpret or distinguish color when performing water and/or other quality tests or maintenance on dialysis or other equipment. People who suffer from color blindness, may not be able to distinguish between colors used in water and other testing methodologies..."; POLICY: "New-hire, rehire, or transfer staff working in a direct patient care or biomedical position are required to take the Ishihara Test for Color Blindness to ensure the ability to perform the essential functions of their job..." PERFORMING THE TEST: " 3. Maintain documentation of test results in the employees medical file..."


Review of Personnel files conducted on May 31, 2019 between 2:00 PM and 2:30 PM revealed the following:

PF #2, Date of hire (DOH) 10/1992; contained no documentation of color blindness testing.

PF #3, Date of hire(DOH) 6/2008; contained no documentation of color blindness testing.


An interview conducted with the Agency Administrator on May 31, 2019 at approximately 3:00 PM confirmed the above findings. " I spoke to another location's administrator and was informed that any employee that has been here for many years probably had their files purged and sent to Iron Mountain for storage so the color blindness testing will not be on their files. I already created an action plan for it and we are going to complete new color blindness testing on any long term employees, in fact I already started the new testing."











Plan of Correction:

For immediate compliance, on (05/31/2019), the Clinical Manager reviewed all personnel records of facility employees in positions that require the ability to interpret or distinguish color when performing water and/or other quality tests or maintenance on dialysis or other equipment, to ensure they have completed Ishihara Testing for color blindness per FKC Clinical Services color blindness testing policy, FMS-CS-IC-I-101-018A.
For ongoing compliance, the Clinical Manager will develop an audit tool to track all new hire, rehire, or transfer staff who work in a direct patient care or biomedical position, to ensure they have completed Ishihara Testing for color blindness, and have the ability to perform the essential functions of their job.
Staff who have not completed color blindness testing will receive Ishihara Testing prior to assignment of any functions that require the ability to distinguish color.
Staff who have not successfully passed the Ishihara Test and therefore do not have the ability to distinguish colors, will be excluded from performing any testing and/or functions that require the ability to distinguish colors.
Documentation of each employees color blindness test results will be maintained in their medical record on file at the facility.
The clinical manager will present audit results at QAI meetings monthly for committee review.
Completion date: 6/30/19



494.170(a) STANDARD
MR-PROTECT PT RECORDS FM LOSS/CONFIDENTIAL

Name - Component - 00
The dialysis facility must-
(1)Safeguard patient records against loss, destruction, or unauthorized use; and
(2) Keep confidential all information contained in the patient's record, except when release is authorized pursuant to one of the following:
(i) The transfer of the patient to another facility.
(ii) Certain exceptions provided for in the law.
(iii) Provisions allowed under third party payment contracts.
(iv) Approval by the patient.
(v) Inspection by authorized agents of the Secretary, as required for the administration of the dialysis program.



Observations:


Based on observations on the clinical floor and an interview with Agency Administrator, it was determined that the agency failed to ensure privacy and confidentiality of patient's medical records on one (1) observation out of ten (10) observations.

Findings include:

Clinical floor observation conducted on May 29, 2019 between approximately 2:00 PM-2:30 PM revealed the following:

Nursing station computer, located next to the patient scale and sink for patients to clean their access sites prior to treatment, was noted by surveyor to be left opened with patient's medical record and demographic information on the screen. No clinical staff was noted to be at the nurse's station during this time. Several patients entered and exited the area during the observation.

An interview with the Agency Adminstrator conducted on May 29, 2019 at approximately 3:00 PM confirmed the above findings.
















Plan of Correction:

Beginning on 6/17/19 until 6/30/19, the Clinical Manager (CM) and/or designee, will review and reinforce with all direct patient care staff at daily huddles the following policy:
FMS-CS-IC-I-103-005A "Patient Rights and Responsibilities Policy"
With emphasis on:
- Ensuring patients are provided with privacy and confidentially in all aspects of their treatment
- Ensuring patients are provided with privacy and confidentially in all aspects of their medical records
- Staff ensuring computer screens displaying patient information are closed after use and patient information is never left visible to other patients, visitors or persons unauthorized to view patient information
- Protecting patient information from view of others while authorized personnel are viewing the information

Starting on 6/20/19, the CM and/or designee will conduct daily audits on staff closing the computer screen immediately after use until 100% compliance is observed. When 100% compliance is observed, audits will continue weekly x 4 weeks. If compliance has been sustained audits will continue monthly per QAI clinical audit checks.
Education and audit records will be on file in the facility.
Staff found to be non-compliant will be re-educated and/or counseled. Repeat non-compliance will result in the initiation of the progressive discipline process.
For ongoing compliance the CM will present audit results at monthly QAI meetings for committee review

Completion date: 6/30/19