Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on December 20, 2024, Dci Renal Services of Pittsburgh, Llc 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 on December 20, 2024, Dci Renal Services of Pittsburgh, Llc was found 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 review of facility policy, observation, and staff (EMP) interview, the agency failed to ensure staff and patients wore gloves or sanitized hands after glove removal for three (3) of three (3) patients observed (OBS 1, 2, and 3) during discontinuation of dialysis with an arteriovenous fistula (AVF), and one (1) of one (1) staff observed washing their hands in the sink (EMP8).
Findings:
Review of facility policy on December 20, 2024, at 11:05 a.m. showed:
"PROCEDURE NO: 313 ... PURPOSE: To provide guidance for hand hygiene using hand sanitizers and hand washing to reduce to reduce the spread of germs ... Hand hygiene should be performed ... After glove removal ... 2. When cleaning your hands with soap and water: ... Use towel to turn off facet."
"SUBJECT: FRESENIUS 2008T TAKE OFF PROCEDURE: ... 14. For arm access, pull needles ... Patient to hold sites with gloved hand ... Patient to do hand hygiene once glove is removed."
Observation (OBS1) of discontinuation of dialysis with an AVF on December 17, 2024, at 11 a.m. at station 1 revealed patient holding their access with an ungloved right hand to stop bleeding after needles were removed. Once bleeding had stopped, the patient left the station without performing hand hygiene, proceeded to the scale to be weighed, and exited the facility. Interview with EMP8 at 11:30 a.m. confirmed findings.
Observation (OBS2) of discontinuation of dialysis with an AVF on December 17, 2024, at 11:15 a.m. at station 14 revealed patient holding their access with a gloved left hand to stop bleeding after needles were removed. Once bleeding had, stopped, the patient removed their glove, failed to perform hygiene, and exited the facility. Interview with EMP6 after the observation at 11:26 a.m. conformed findings.
Observation (OBS3) of discontinuation of dialysis with an AVF on December 18, 2024, at 10:55 a.m. at station 5 revealed patient holding their access with a gloved right hand to stop bleeding after needles were removed. Once bleeding had stopped, the patient removed their glove, failed to perform hygiene, and exited the facility. Interview with EMP18 after the observation at 11 a.m. conformed findings.
Observation on the treatment floor on December 17, 2024, at 11 a.m. revealed EMP8 remove their gloves after providing patient care. EMP8 then proceeded to wash their hands in the sink. When EMP8 was done washing their hands, they turned the faucet off without using a towel. Interview with EMP8 at 11:14 a.m. confirmed findings.
Plan of Correction:The Nurse Manager and/or designee will ensure all staff are in-serviced on policy & procedure 313 Hand Hygiene and Use of Alcohol based Sanitizers with emphasis of each glove change. Evidence of the policy review will be kept documented in each employee's file. This education will be completed by January 17, 2025.
In addition, the Nurse Manager and/or designee will review the steps in policy H-18 Fresenius Take off Procedure with employees and will also provide education to the patients with emphasis on the requirement of the patient to wear a glove while holding sites post treatment and once removed the requirement of the patient to complete hand hygiene. Evidence of the policy review will be documented in the employee files. Evidence of the patient education provided will be documented in the patients' charts. This education will be completed by January 17, 2025.
Beginning the week of January 20, 2025, the Nurse Manager, Nurse Educator, and/or designee will audit overall staff hand hygiene as well as audit patient compliance with wearing a glove while holding sites and hand washing or sanitizing their hands post treatment. Auditing and observations will be performed weekly on each shift for four weeks or until 100%, with re-education provided as needed when indicators are not met. Once 100% is obtained the auditing will continue once per month for six months, and then quarterly for the remainder of the calendar year. All audit findings will be shared with the Governing Body at monthly meetings for review, oversight and subsequent recommendations as needed. Documentation of audit results will be found in Governing Body Meeting minutes.
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 review of facility policy, observation (OBS), and staff (EMP) interview, the facility failed to ensure the patient vacated the station prior to disinfection of the station for one (1) of two (2) staff observed (EMP8) disinfecting the dialysis station (EMP8).
Findings:
Review of facility policy on December 20, 2024, at 11:58 a.m. showed, "Routine Disinfection in the Hemodialysis Unit ...14. Staff will not begin cleaning or disinfection of the station and set up for the next patient until the station has been completely vacated by the previous patient."
Observation of discontinuation of dialysis with an AVF on December 17, 2024, at 11 a.m. at station 1 revealed patient holding their access with an ungloved right hand to stop bleeding after needles were removed. At around this time, and while patient was still seated at the station holding their access, EMP8 began disinfecting the hemodialysis station by wiping the machine with a disinfecting wipe. Interview with EMP8 and EMP19 (nurse educator) at 11:20 a.m. confirmed findings. When EMP8 was asked about why they began disinfecting the station with the patient present they noted, "I'll finish [station] when [patient] leaves."
Plan of Correction:The Nurse Manager and/or designee will ensure policy and procedure 300 Routine Disinfection of the Hemodialysis unit is reviewed with all staff with emphasis on not being permitted to disinfect and/or set up the machine and/or disinfect the machine or station for the next patient, until the previous patient has vacated the station. Evidence of the policy review will be kept documented in each employee's file. This education will be done by January 17, 2025.
Beginning the week of January 20, 2025, the Nurse Manager, Nurse Educator, and/or designee will audit staff compliance with not disinfecting the station and/or setting up the machine for the next patient ahead of the previous patient leaving the station. Auditing and observations will be performed weekly on each shift for four weeks or until 100%, with re-education provided as needed when indicators not met. Once 100% is obtained, auditing will continue once per month for six months, and then quarterly for the remainder of the calendar year. All audit findings will be shared with the Governing Body at monthly meetings for review, oversight and subsequent recommendations as needed. Documentation of audit results will be found in Governing Body Meeting minutes.
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 review of policy, National Kidney Foundation (NKF) Guidelines, observation (OBS), and staff (EMP) interview, the facility failed to ensure two (2) of two (2) patients with an arteriovenous fistula (AVF) washed their access prior to disinfection and initiation of dialysis.
Findings:
Review of facility policy posted by the sink where patients enter the treatment floor, on December 18, 2024, at 12:46 p.m. showed, "Patient Education: Washing your vascular access sites before dialysis ... At every treatment, your dialysis staff is asking you to stop at the sink and wash your hands and vascular access just before going to your dialysis chair. ... The reason the staff is asking you to wash your hands and access is simply to protect you from getting an infection in your vascular access, or even worse your bloodstream. ... Always wash your hands and vascular access just before going back to your treatment chair."
Review of facility policy on December 20, 2024, at 11:30 a.m. showed, "INSERTION OF ACCESS NEEDLES ... PROCEDURE: 1. Patients will wash access arm at sink, using bacteriostatic soap before canulation [inserting needles] of access. Encourage patients to make this part of their routine. If patient does not was their own arm, staff is to wash the access with soap and water. ... 6. Cleanse area with approved-microbial and allow to dry, if indicated. ... Betadine [antiseptic] is 30 second contact time with 2 minute dry time. Alcohol [antiseptic] is a 60 second contact time with each alcohol pad and no dry time, ... Chlorhexadine [antiseptic] is a 30 second contact time ... Ex-Sept [antiseptic] is a 60 second contact time with a 2 minute dry time."
Note: the below disinfection process using "BZK Antiseptic Towelette" followed by 70% is not an approved process since patients are to wash their arms with soap and water at the sink followed by an approved antiseptic. "BZK Antiseptic Towelette[s]" are not approved antiseptic or method per policy.
According to NKF Guidelines, "Tips for Everyday Care of Your AV Fistula or Graft Prevent Infection ... Wash your access site before every dialysis treatment. Your dialysis center has hand washing sinks and antimicrobial soap." Retrieved from https://www.kidney.org/sites/default/files/11-50-0216_va.pdf
Observation on treatment floor on December 18, 2024, at 11:41 a.m. revealed patient walk to station 26 without first washing his/her access in facility sink. EMP9 wiped the patient's AVF with a "BZK Antiseptic Towelette" followed by another type of disinfectant wipe (alcohol 70%), inserted both needles, and initiated dialysis. Interview with EMP9 (dialysis technician) and EMP14 (registered nurse) after the observation confirmed the patient did not wash their access in the sink.
Observation on treatment floor on December 18, 2024, at 11:50 a.m. revealed patient walk to the dialysis station without first washing his/her access in the facility's sink. EMP18 wiped the patient's AVF with a "BZK Antiseptic Towelette" followed by another type of disinfectant wipe, inserted both needles, and initiated dialysis. Interview with EMP14 after the observation confirmed the patient did not wash their access in the sink.
Review of "BZK Antiseptic Towelette" on December 18, 2024, at 12 p.m. showed, "Use First aid to help reduce the risk of infection in minor cuts, scrapes and burns." BZK wipes are not listed per policy as an approved disinfectant.
Plan of Correction:The Nurse Manager and/or designee will ensure all staff are in-serviced on policy & procedure H-61 Insertion of Access Needles with regards to the requirement of all patients with an arm access to wash their access arm prior to treatment and cannulation. Emphasis to the staff will be their role in teaching and encouraging the patients to comply. Emphasis will also be placed on reminding staff if patients are unable to wash at the sink, the staff will wash the patients arm with soap and water chairside as stated in the policy in place of the noted towelettes, which will be removed from use. Evidence of the policy review will be kept documented in each employee's file. This education will be done by January 17, 2025.
The Nurse Manager and/or designee will educate the patients regarding the necessity for them to wash their arm access upon entry to the dialysis unit prior to cannulation. A log will be kept ensuring all patients have been educated and shown return demonstration of appropriate washing technique. Once 100% of patients have demonstrated understanding, evidence of the patient education provided will be documented in the patients' charts. This education will be done by January 17, 2025.
Beginning the week of January 20, 2025, the Nurse Manager, Nurse Educator, and/or designee will audit the patients washing their arm accesses at the sink prior to cannulation. For any patients unable to wash their arm access at the sinks, staff will be audited on the use of soap and water to do so chairside. Auditing and observations will be performed daily each shift weekly for four weeks or until 100%, with re-education provided as needed when indicators are not met. At this point the auditing will continue once per month for six months, and then quarterly for the remainder of the calendar year. All audit findings will be shared with the Governing Body at monthly meetings for review, oversight and subsequent recommendations as needed. Documentation of audit results will be found in Governing Body Meeting minutes.
|