Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on September 13, 2021 through September 15, 2021, BMA of Carbon County 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 13, 2021 through September 15, 2021, BMA of Carbon County 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 treatment area, facility policy and procedures, and an interview with the facility administrator, the facility did not follow its policy with regard to changing gloves and performing hand hygiene for seven (7) of nineteen (19) observations (OBS #1, OBS #2, OBS #3, OBS #4, OBS #5, OBS #9, and OBS #11).
Findings include:
A review of policy and procedure, "Hand Hygiene" on September 15, 2021 at approximately 11:30 AM revealed the following: "Hand hygiene includes either washing hands with soap and water or using a waterless alcohol-based antiseptic hand rub with 60-90% alcohol content...Hands will be...decontaminated using alcohol-based rub or by washing hands with antimicrobial soap and water when... Before or after direct contact with patients...Before performing any invasive procedure such as vascular access cannulation...After removing gloves...".
Observations of the treatment area conducted on September 13, 2021 between approximately 10:00 AM and 12:30 PM and on September 14, 2021 between approximately 11:55 AM and 12:20 PM revealed the following:
OBS #1, 9/13/2021 at 12:00 PM: RN 1 discarded old dressing on central venous catheter exit site, removed gloves, donned new gloves without hand hygiene in between.
OBS #2, 9/14/2021 at 12:05 PM: RN 2 approached new patient that had arrived for treatment. Donned new gloves without hand hygiene. Began removing old dressing of central venous catheter exit site.
OBS #3, 9/13/2021 at 12:05 PM: RN 1 cleaned exit site with Chlroraprep, placed sterile dressing over exit site. Began scrubbing venous limb of central venous catheter with alcohol pad without first removing gloves, performing hand hygiene, and donning clean gloves.
OBS #4, 9/14/2021 at 12:10 PM: RN 2 cleaned exit site with Chloraprep, placed sterile dressing over exit site. Began scrubbing venous limb of central venous catheter with alcohol pad without first removing gloves, performing hand hygiene, and donning clean gloves.
OBS #5, 9/13/2021 at 10:40 AM: PCT 1 found to be typing in treatment data for end of dialysis treatment during reinfusion of extracorporeal circuit. Began disinfection of central venous catheter limbs after reinfusion without first removing gloves, performing hand hygiene, and donning clean gloves.
OBS #9, 9/13/2021 at 11:05 AM: RN 1 found to be typing in pre-dialysis treatment data for beginning of dialysis treatment. Began disinfection and cannulation of arteriovenous fistula (AVF) without first removing gloves, performing hand hygiene, and donning clean gloves.
OBS #11, 9/13/2021 at 10:43 AM: RN 1 found to be typing in treatment data for end of dialysis treatment during reinfusion of extracorporeal circuit. Began removing needles in AVF without first removing gloves, performing hand hygiene, and donning clean gloves.
An interview with the facility administrator on September 15, 2021 at approximately 1:00 PM confirmed the above findings.
Plan of Correction:The Clinic Manager (CM) or designee will re-educate all the direct patient care (DPC) staff on:
- Hand Hygiene Policy
Emphasis will be placed on ensuring the importance of ensuring that hand hygiene is performed every time before donning gloves. The meeting reviewed that when gloves are removed, hand hygiene performed before donning new gloves. 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 24, 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, 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.
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