Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted July 13, 2021 through July15, 2021, Fresenius Medical Care Sellersville 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 July 13, 2021 through July 15, 2021, Fresenius Medical Care Sellersville was identified to have the following standard level deficiency that was 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 of the clinical area, facility policy and an interview with the clinical manager, the patient care staff did not follow infection control procedures for four (4) of four (4) observations (Obs). Obs # 1, 2, 3, and 4.
Findings include:
A review of facility policy FMS-CS-IC-II-155-090 A "Hand Hygiene" on July 15, 2021 at 3:00 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..."
Policy Clinical Services "Access Assessment and Cannulation" states: "Step 1 Prior to treatment, ask you patient to wash access area with liquid soap for one minute, rinsing well..Wash access (per above) if patients unable to clean their access."
Observation of the clinical area was conducted on July 13, 2021 from 9:30 AM-12:30 PM and July 14, 2021 from 8:45 AM-10:00 AM.
Obs#1 station #17 patient care staff cannulated the patient's vascular access using antiseptic only. When questioned the patient stated the patient did not wash access arm with soap and water prior to cannulation and the staff was not observed to wash the access arm prior to cannulation.
Obs#2 station#15 patient care staff cannulated the patient's vascular access using antiseptic only. The patient was not observed to wash the patient's access arm with soap and water prior to cannulation and the staff was not observed to wash the access arm prior to cannulation.
Obs#3 and #4 station 18 during discontinuation of treatment, patient care staff reinfused extracorporeal circuit, disconnected bloodlines, removed gloves, donned new gloves without performing hand hygiene. Same staff member was then observed to remove gloves, don new gloves without performing hand hygiene after removing the second needle from the vascular access.
An interview with the clinical manager on July 15, 2021 at 12:00 PM confirmed the above findings.
Plan of Correction:The Clinic Manager 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 that the patient's access site is washed with soap and water, by either the patient or staff, prior to preparing the site for cannulation. Also addressed at the meeting was the importance of ensuring that when gloves are removed, hand hygiene performed before donning new gloves.
In-servicing is scheduled to be completed on July 31, 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 and 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, 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: August 14, 2021
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