Initial Comments:
Based on the findings of an onsite unannounced Medicare Re-Certification Survey completed April 14, 2022, BMA of Mount Pleasant was found to be in compliance with the following 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 Re-Certification Survey completed April 14, 2022, BMA of Mount Pleasant 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 observations, review of facility policy, and staff (EMP) interview, the facility failed to ensure employees performed hand hygiene in accordance with agency policy for three (3) of four (4) observations of Access of AV Fistula or Graft for Initiation of Dialysis (OBS 2-4) and one (1) of two (2) observations of Discontinuation of Dialysis or Post dialysis Access Care for AV Fistula or Graft (OBS 1).
Findings included:
Review of facility policy conducted on April 13, 2022 at approximately 1:00pm revealed:
"Hand Hygiene...Hands Will Be...Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water...Immediately after removing gloves..."
Access of AV Fistula or Graft OBS 2- 4/12/2022 at approximately 8:30am at station 10 EMP 4 located/palpated cannulation sites, removed gloves, and donned clean gloves without performing hand hygiene.
Access of AV Fistula or Graft OBS 3- 4/12/2022 at approximately 9:05am at station 5 EMP 3 located/palpated cannulation sites, removed gloves, and donned clean gloves without performing hand hygiene. After hooking patient up to dialysis maching EMP 3 removed and donned new gloves without performing hang hygiene, provided care at station 5, removed and donned new gloves and proceeded to station 13 without performing hand hygiene between glove changes.
Access of AV Fistula or Graft OBS 4- 4/12/2022 at approximately 10:20am at station 8 EMP 3 located/palpated cannulation sites, removed gloves, and donned clean gloves without performing hand hygiene.
Discontinuation of Dialysis or Post dialysis Access Care OBS 1- 4/12/2022 at approximately 9:20am at station 4 EMP 5 reinfused extracorporeal circuit, removed gloves, and donned clean gloves without performing hand hygiene.
An interview with the Center Manager and Director of Operations on April 14, 2022 at approximately 11:30 am confirmed the above findings.
Repeat deficeincy: previously cited 4/17/13
Plan of Correction:V 113
The clinic manager (CM) or designee re-educated all direct patient care (DPC) staff on the following policies:
- Hand Hygiene
Special emphasis was placed on ensuring that hand hygiene is performed at any time gloves are removed and prior to donning a new pair of gloves according to policy.
The in-servicing will be completed by April 25, 2022, with documentation of the training on file at the facility.
The CM or designee will perform daily audits for 2 weeks. At that time if one hundred percent 100% compliance is observed, the audits will then be completed two (2) times/week for 2 weeks to ensure that compliance is maintained. At that time, if compliance is sustained, the audits will then follow the monthly Quality Assessment Improvement (QAI) schedule. A plan of correction (POC) audit tool will be used for the audits.
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.
Completion Date: May 31, 2022
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 observations and review of facility policy the facility failed to ensure appropriate cleaning and disinfection of contaminated surfaces, medical devices, and equipment for one (1) of two (2) observations of "Cleaning and Disinfection of the Dialysis Station (OBS1)
Findings included:
Review of facility policy conducted on April 13, 2022 at approximately 1:00pm revealed: "Cleaning and Disinfection of the Dialysis Station Procedure...4. Clean all surfaces. Make the surfaces glisteningly wet and allow to air dry..."
OBS 1- conducted on 4/13/22 at approximately 10:00am surveyor observed EMP 4 empty prime waste container, disinfect dialysis machine and return prime waste container without wiping interior.
An interview with the Center Manager and Director of Operations on April 14, 2022 at approximately 11:30 am confirmed the above findings.
Repeat deficiency: previously cited 4/17/13
Plan of Correction:V 122
To ensure compliance the CM or designee will in-service all DPC staff on policy:
- Cleaning and Disinfection of the Dialysis Station
The meeting will focus on ensuring that the dialysis station and all surfaces and reusable items or supplies that are potentially contaminated, including the prime waste container and the interior of the container, are thoroughly cleaned, and disinfected after each patient use.
Inservicing will be completed by April 25, 2022. All training documentation is on file at the facility.
The CM or designee will perform daily audits for 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 QAI schedule. A 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 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.
Completion Date: May 31, 2022
494.60(b) STANDARD
PE-EQUIPMENT MAINTENANCE-MANUFACTURER'S DFU
Name - Component - 00
The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer's recommendations.
Observations:
Based on observations, review of facility policy, and staff (EMP) interview, the facility failed to ensure the the crash cart was monitored monthly for expired supplies per facility policy.
Findings included:
Review of facility policy conducted on April 13, 2022 at approximately 1:00pm revealed: Emergency Medication, Equipment and Supplies...Purpose The purpose of ths policy is to provide guidelines for staff when determining and maintaining emergency equipment and supplies....Emergency Cart...The emergency cart must be:...Checked monthly or after use for contents, expiration dates, cleanliness, and proper functioning of all equipment..."
Observation of 'Supply Management' conducted in patient treatment area on April 12, 2022 at approximately 8:00am by surveyor identified :
1-14 F Urethral Catheter expired 12/12/2021
4-Nitpro SafetouchII 16g safety Fistula Needles expired 2/28/2022
7-SafeDay IV Administration Set expired 3/31/2021
1 box- Alcohol Prep Pads 200 count expired 07/2021
1- Gel Rite Hand Sanitizer 4oz expired 07/2019
Interview with Center Manager on April 13, 2022 at approximately 8:00am revealed that the crash cart review checklist was not being utilized. "We discovered the log was not in our electronic system, so it did not prompt the task to be completed..."
An interview with the Center Manager and Director of Operations on April 14, 2022 at approximately 11:30 am confirmed the above findings.
Plan of Correction:V 403
For immediate compliance on April 13, 2022, all expired supplies found at the time of the survey were removed and discarded by the CM.
For ongoing compliance, the CM will in-service all direct patient care DPC staff on the following policy:
- Storage of Supplies
- Emergency Medication, Equipment and Supplies
Emphasis will be placed on ensuring that all supplies, including the emergency cart supplies, are all within the current date for use. The meeting also reviewed with the DPC staff that the emergency cart must be checked monthly or after use, with documentation on the emergency cart checklist. Staff were also re-educated that the cart must be rotated First In – First Out when restocking.
The inservice was completed by April 25, 2022, and the education records will be on file in the facility.
The CM or designee will conduct daily audits for 2 weeks. If 100% compliance is observed at that time, the audits will then continue 2 times/week for 2 weeks. If compliance has been sustained audits will continue monthly per the QAI program. A POC specific audit 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. Sustained compliance will be monitored by the QAI committee.
Completion Date: May 31, 2022
494.90(a)(5) STANDARD
POC-VASCULAR ACCESS-MONITOR/REFERRALS
Name - Component - 00
The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement.
Observations:
Based on observations, review of facility policy, and staff (EMP) interview, the facility failed to ensure that cannulation sites were not palpated by staff after disinfection for three (3) of four (4) observations of "Access of AV Fistula or Graft for Initiation of Dialysis" (OBS 2-4)
Findings included:
Review of facility policy conducted on April 13, 2022 at approximately 1:00pm revealed: "Access Assessment and Cannulation...Skin Disinfection...3...Do not touch cannulation sites after skin disinfection...
OBS 2- 4/12/22 at approximately 8:30am surveyor observed EMP 4 disinfect arm of patient at station 10 with alcohol. EMP 4 palpated cannulation site after antisepsis performed.
OBS 3- 4/12/22 at approximately 9:05am surveyor observed EMP 3 disinfect arm of patient at station 5 with alcohol. EMP 3 palpated cannulation site after antisepsis performed.
OBS 4- 4/12/22 at approximately 10:20am surveyor observed EMP 3 disinfect arm of patient at station 8 with alcohol. EMP 3 palpated cannulation site after antisepsis performed.
An interview with the Center Manager and Director of Operations on April 14, 2022 at approximately 11:30 am confirmed the above findings.
Plan of Correction:V 550
The CM or designee re-educated all the DPC staff on the following policy:
- Access Assessment and Cannulation
The meeting reinforced the importance of ensuring that the patient's access sites are not touched after skin disinfection.
The in-servicing of staff will be completed by April 25, 2022, with documentation of the training on file at the facility.
The CM or designee will perform daily audits for 2 weeks. At that time if 100% compliance is observed, the audits will then be completed 3 times/week for 2 weeks to ensure that compliance is maintained. At that time, if compliance is sustained, the audits will then follow the monthly QAI schedule. A POC audit tool will be used for the audits.
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 with oversight by the GB.
Completion Date: May 31, 2022
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