QA Investigation Results

Pennsylvania Department of Health
DELCO DIALYSIS UNIT
Health Inspection Results
DELCO DIALYSIS UNIT
Health Inspection Results For:


There are  17 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 December 8, 2020 through December 10, 2020 Delco Dialysis Unit was identified to have the following standard level deficiency that was determined 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:




494.62(d)(1) STANDARD
ESRD EP Training Program

Name - Component - 00
494.62(d)(1): Condition for Coverage:
(d)(1) Training program. The dialysis facility must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
Staff training must:
(iii) Demonstrate staff knowledge of emergency procedures, including informing patients of-
(A) What to do;
(B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated;
(C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and
(D) How to disconnect themselves from the dialysis machine if an emergency occurs.
(iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and
(v) Properly train its nursing staff in the use of emergency equipment and emergency drugs.
(vi) Maintain documentation of the training.
(vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures.

Observations:


Based on a review of medical records (MR), facility policy and an interview with the clinical manager and team administrator, the facility did not provide emergency training to patients according to policy for three (3) of nine (9) MRs. MR# 2, 3, and 8.

Findings include:

A review of facility policy "Fire Drill" on December 10, 2020 at 1:45 PM states: "Fire Drills Quarterly all FKC facilities shall perform a fire drill for each shift of patients and staff..."

A review of MRs was conducted on December 9, 2020 from 8:45AM- 2:30 PM and December 10 from 9AM-10:30AM.

MR#2 admission date 9/3/19 did not have a fire drill documented for the fourth quarter of 2019.

MR#3 admission date 8/20/16 did not have a fire drill documented for the third and fourth quarter of 2019.

MR#8 admission date 2/12/2020 did not have a fire drill documented for the third quarter of 2020.

An interview with the clinical manager and team administrator on December 10, at 2:15PM confirmed the above findings.






Plan of Correction:

By 12/18/2020, the Director of Operations (DO) will meet with the CM to review the following policies and elicit input and reinforce the expectations and responsibilities of the CM on the following Policies and Procedures.

- Fire Drill
- Fire Drill Procedure
- Patient Participation in Fire Drills

Emphasis was placed on:
- The requirement that Fire Drills for patients and staff must be completed quarterly and Disaster drills must be completed twice a year.

By 12/31/2020 the CM/designee will conduct a Fire and Disaster Drill with all patients and staff with documentation that all patients and staff participated in the drill. Individual patient participation form will be placed in the Hard chart or scanned into Doc Mgr.
Effective 12/18/2020 the Director of Operations (DO) or Manager of Quality will review Fire Drill documentation quarterly x 3, to ensure Fire Drill and Disaster drills are completed with all active patients and staff. until compliance is sustained at 100%, utilizing a POC specific tool. Once compliance is sustained, the Governing Body will resume regularly scheduled audits based on QAI calendar. Monitoring will be done through the QAI Audit tools and POC specific audit tools.

The Medical Director will review the results of audits each month at the QAI Committee meeting monthly.
The Clinical Manager is responsible to review, analyze and trend all data and Monitor/Audit results as
related to this Plan of Correction prior to presenting to the QAI Committee monthly.

The Director of Operations is responsible to present the status of the Plan of Correction and all other actions taken toward the resolution of the deficiencies at each Governing Body meeting through to the sustained resolution of all identified issues.

The QAI Committee is responsible to provide oversight, review findings, and take actions as appropriate.

The Governing Body is responsible to provide oversight to ensure the Plan of Correction, as written to address the issues identified by the Statement of Deficiency, is effective
and is providing resolution of the issues.

Documentation of education, monitoring, QAI, and Governing Body is available for review.

The Clinic Manager is responsible for overall compliance. Completion Date: 1/4/21



Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification survey conducted December 8, 2020 through December 10, 2020 Delco Dialysis Unit 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)(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 (Obs) of the clinical area, facility policy and an interview with the clinical manager and team administrator, the facility did not follow its policy for handwashing while performing clinical tasks for three (3) of ten (10) Obs. Obs#5, 6, and 7.

Findings include:

A review of facility policy "Hand Hygiene" on December 10, 2020 at 1:45 PM states: "Hands will be decontaminated using alcohol based hand rub or by washing hands with antimicrobial soap and water when...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 moving from a contaminated body site to a clean body site of the same patient.."

Observation of the clinical area was conducted on December 8, 2020 from 8:40AM-12:30PM and December 9, 2020 from 10:00AM-10:30AM.

Obs#5 PCT#3 at machine#10 touched the machine for data entry with a gloved hand proceeding to reinfuse the extracorporeal circuit without removing old gloves, performing hand hygiene, donning new gloves.

Obs#6 at machine#10 PCT# 3 did not wash skin over access with soap and water or antimicrobial scrub, (patient was also not observed to wash access at sink) prior to applying antiseptic to skin over cannulation sites and performing cannulation.

Obs#7 at machine#9 PCT#2 touched the machine with a gloved hand proceeding to insert cannulation needles without removing old gloves, performing hand hygiene, donning new gloves.

An interview with the clinical manager and team administrator on December 10, at 2:15PM confirmed the above findings.










Plan of Correction:

By 12/18/2020, the Clinical Manager (CM) will hold huddles and a staff meeting, elicit input, and reinforce the expectations and responsibilities of the facility staff on the following Policies and Procedures.

By 12/18/2020 the Direct Patient Care (DPC) staff will reeducate all patients with internal accesses that they must wash their access site with soap and water on arrival to the treatment floor, Documentation of education will be documented in the Medical Record. Patients unable to wash their access site will be identified so staff are aware they need to wash the access site for the patient.

- FMS-CS-IC-II-155-090C - Hand Hygiene Procedure
- FMS-CS-IC-II-155-090A - Hand Hygiene
- Access Assessment and Cannulation

Emphasis was placed on:
- Requirement to change gloves and perform hand hygiene between data entry and initiating, terminating, or manipulations of the dialysis access during treatment.
- Requirement that the patient or staff must wash the internal access site with soap and water prior to disinfection for cannulation.
- If patient is unable to wash their access site, the Direct Patient Care (DPC) will assist the patient in washing their access site.


Effective 12/18/2020 the Clinical Manager (CM) or designee will conduct daily audits x 2 weeks and then twice weekly until compliance is sustained at 100%, utilizing a POC specific
tool. Once compliance is sustained, the Governing Body will resume regularly scheduled audits based on QAI calendar. Monitoring will be done through the QAI Audit tools and POC specific audit tools.


The Medical Director will review the results of audits each month at the QAI Committee meeting monthly.

The Clinical Manager is responsible to review, analyze and trend all data and Monitor/Audit results as
related to this Plan of Correction prior to presenting to the QAI Committee monthly.

The Director of Operations is responsible to present the status of the Plan of Correction and all other actions taken toward the resolution of the deficiencies at each Governing Body meeting through to the sustained resolution of all identified issues.
The QAI Committee is responsible to provide oversight, review findings, and take actions as appropriate.
The Governing Body is responsible to provide oversight to ensure the Plan of Correction, as written to address the issues identified by the Statement of Deficiency, is effective
and is providing resolution of the issues.

Documentation of education, monitoring, QAI, and Governing Body is available for review.

The Clinic Manager is responsible for overall compliance. Completion Date: 1/4/21



494.60 STANDARD
PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT

Name - Component - 00
The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment.


Observations:


Based on observation of the clinical area, facility policy and an interview with the clinical manager and team administrator, the facility did not provide a safe and functional environment regarding the labeling of supplies.

Findings include:

A review of facility policy "Expiration Dates Sterile Supplies" on December 10, 2020 at 1:45 PM states: "This policy provides guidance on checking expirations dates to assure that sterile supplies are taken out of circulation by the expiration date..."

Observation of the clinical area was conducted on December 8, 2020 from 8:40AM-12:30PM and December 9, 2020 from 10:00AM-10:30AM.

Three (3) Hach residual chlorine strip vials located at the clean sink near rear of treatment area, an open bottle of ExCept and a bottle of Mesa Lab Conductivity Standard Solution located at the clean sink with the Myron L meters were all open but date of opening and the initial of the person who opened them was not present.


An interview with the clinical manager and team administrator on December 10, at 2:15PM confirmed the above findings.






Plan of Correction:

By 12/18/2020 all supplies, medications, and solutions with expiration dates will be audited by the CM/designee to ensure no outdated supplies are in the facility.

By 12/18/2020, the Clinical Manager (CM) will hold huddles and a staff meeting, elicit input, and reinforce the expectations and responsibilities of the facility staff on the following Policies and Procedures.

- FMS-CS-IC-II-120-008A - Expiration Date of Sterile Supplies Policy

Emphasis was placed on:
- The requirement to date and initial all solutions and supplies designed for multiple uses immediately when opened.

Effective 12/18/2020, CM or designee will conduct weekly audits x 4 weeks to ensure no outdated supplies, solutions, or medications are in the facility, utilizing a POC specific tool. Once compliance is sustained, the Governing Body will resume regularly scheduled audits based on QAI calendar. Monitoring will be done through the QAI Audit tools.

The Medical Director will review the results of audits each month at the QAI Committee meeting monthly.

The Clinical Manager is responsible to review, analyze and trend all data and Monitor/Audit results as
related to this Plan of Correction prior to presenting to the QAI Committee monthly.

The Director of Operations is responsible to present the status of the Plan of Correction and all other actions taken toward the resolution of the deficiencies at each Governing Body meeting through to the sustained resolution of all identified issues. The QAI Committee is responsible to provide oversight, review findings, and take actions as appropriate.

The Governing Body is responsible to provide oversight to ensure the Plan of Correction, as written to address the issues identified by the Statement of Deficiency, is effective
and is providing resolution of the issues.

Documentation of education, monitoring, QAI, and Governing Body is available for review.

The Clinic Manager is responsible for overall compliance. Completion Date: 1/4/21