Initial Comments:
Based on the findings of an onsite unannounced recertification survey completed on September 8, 2021, through September 11, 2021, Fresenius Kidney Care-Northwest 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 September 8, 2021, through September 11, 2021, Fresenius Kidney Care-Northwest 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(b)(1) STANDARD
IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P
Name - Component - 00
The facility must-
(1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit;
Observations:
Based on reviews of observations, and an interview with the facility administrator, the facility failed to Monitor infection control activities within the dialysis unit for one (1) of two (2) observations conducted on a employee who had not completed training. (Observation #1 with PF #6).
Findings include:
On September 10, 2021 at approximately 1:00 p.m., a review of PF #6 revealed a date of hire on May 3, 2021, as a transferred from a sister Dialysis unit. Review of a Document titled, "ESRD Core Survey Facility Worksheet," revealed that to date, PF #6 remained in training for Competencies, Water, Dialysate, and/or Machine training.
On September 9, 2021 between 11:40 a.m., and 11:55 a.m., while conducting an, "Access of AV Fistula or Graft for Initiation of Dialysis," (page 22), observation, PF #6 was observed at Station #10. PF #6 proceeded to initiate Dialysis in the following order:
1. Palpated cannulation sites.
2. (Without changing gloves or hand Hygeine), inserted the cannulation needles, and tape in place.
3. Turned to touch the keys on the Dialysis machine.
4. (Without changing gloves or hand Hygeine), Turned back to the Patient's cannulas, and appeared to loosened the tape.
5. Appeared to flushed one cannula line with a syringe.
6. Turn to reset the Dialysis machine keys again. Machine began to run.
7. (Without changing gloves or hand Hygeine), PF #6 returned to re-secure the loosened cannula tapes.
8. Removed gloves and completed hand Hygiene.
In an interview with the facility administrator on September 9, 2021 at approximately 2:45 p.m. it was confirmed that the facility failed to monitor and supervise infection control activities within the dialysis unit for employees that had not completed training.
Plan of Correction:The Clinic Manager (CM) or designee will re-educate all the direct patient care (DPC) staff on:
- Hand Hygiene Policy
- Access Assessment and Cannulation
Emphasis will be placed on ensuring the importance of ensuring that hand hygiene is performed per policy. This includes after completing an access evaluation, after cannulation, and touching inanimate objects such as the computer. The staff were also reeducated on the fact that gloves must be removed, and hand hygiene performed before/after direct contact with the patient or performing any invasive procedure.
In-servicing is scheduled to be completed by September 27, 2021
Documentation of the training will be on file at the facility.
The CM or designee will perform daily audits for two (2) weeks on the DPC for proper access preparation, hand washing and glove use. At that time, if improved compliance is observed the audits will then be completed 2 times/week for 2 weeks. If compliance is maintained after the 2 weeks, the audits will be completed monthly following the Quality Assessment Improvement (QAI) program. A Plan of Correction (POC) specific auditing tool will be used for the audits.
Staff found to be non-compliant will be re-educated and counseled.
The CM will review the audit results and report the findings to the QAI Committee at the monthly meeting for ongoing guidance and sustained compliance.
Completion date: October 15, 2021
494.30(b)(2) STANDARD
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
Observations:
Based on reviews of observations, facility policy, and an interview with the facility administrator, the facility failed to ensure compliance with current aseptic techniques to disinfect IV ports for one (1) of two (2) observations. (Observation #2).
Findings include:
On September 9, 2021 at approximatley 3:00 p.m., a review of Facility Policy, titled, "Medicaiton Preparation and Administration," Setting: IC, HT 04/0/2021, revealed that, " The following steps must be taken to ensure infection control: Step #5 Disinfect IV ports prior to assessing, using friction and 70% alcohol, iodophor or chlorhexidine/alcohol agent. Cleanse the diaphragm with a new alcohol wipe each time an IV port is accessed. Allow to dry prior to accessing.
On September 9, 2021 at approximately 12:00 p.m.
Observation #2: On September 9, 2021 at approximatley 12:00 p.m., PF #17 was observed to approach Station #12, and proceed to administer an Intravenous, (IV), medication via the IV port before cleansing the diaphragm on the port.
In an interview with the facility administrator on September 9, 2021 at approximately 2:45 p.m. it was confirmed that PF # 17 failed to cleanse the injection port at Station #12, before administering the medication.
Plan of Correction:To ensure compliance the CM or designee will in-service all DPC staff on policy:
- Medication Preparation and Administration
Emphasis on ensuring that the diaphragm of all Intravenous (IV) medication ports will be wiped with a new alcohol pad each time an IV port is accessed.
In-servicing is scheduled to be completed by September 27, 2021
Documentation of the training will be on file at the facility.
The CM or designee will perform daily audits for 2 weeks on the DPC for proper access preparation, hand washing and glove use. At that time, if improved compliance is observed the audits will then be completed 2 times/week for 2 weeks. If compliance is maintained after the 2 weeks, the audits will be completed monthly following the QAI program. A POC specific auditing tool will be used for the audits.
Staff found to be non-compliant will be re-educated and counseled.
The CM will review the audit results and report the findings to the QAI Committee at the monthly meeting for ongoing guidance and sustained compliance.
Completion date: October 15, 2021
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