Initial Comments:
Based on the findings of an unannounced onsite Medicare recertification survey completed September 11, 2024, BMA of Carbon County was identified to be in compliance with the following requirements of 42 CFR, Part 494.62, Subpart B, Conditions for Coverage for End-Stage Renal Disease (ESRD) Facilities-Emergency Preparedness.
Plan of Correction:
Initial Comments:
Based on the findings of an unannounced onsite Medicare recertification survey completed September 11, 2024, BMA of Carbon County 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 a review of facility policy/procedure, observations, and an interview with the facility Administrator, the facility failed to ensure staff followed infection control protocols, included but not limited to, hand hygiene/don clean gloves, for two (2) of two (2) 'Parenteral Medication Preparation and Administration' observations (Observation #1, Observation #2).
Findings include:
A review was conducted of facility policy/procedure on September 11, 2024, at approximately 11:30 a.m. 'Medication Preparation and Administration Procedure' (Setting: IC, HT) 'Medication Administration Procedure' Step (1) "Wash hands. Apply PPE. ....(3) Take the medication to the patients chair or bedside."
Observations conducted in the patient treatment area on September 9, 2024 between approximately 9:15 a.m. and 1:10 p.m. revealed the following:
Observation #1 of 2: During observation of 'Parenteral Medication Preparation and Administration' on 09/09/24 at approximately 12:55 p.m., of patient #2, Employee #7 at station #3 did not perform hand hygiene after preparing the patient medication and prior to administering the medication. Employee #7 only donned clean gloves.
Observation #2 of 2: During observation of 'Parenteral Medication Preparation and Administration' on 09/09/24 at approximately 1:10 p.m., of patient #1, Employee #2 at station #2 did not perform hand hygiene after preparing the patient medication and prior to administering the medication. Employee #2 only donned clean gloves.
An interview with the facility Administrator on September 11, 2024 at approximately 12:00 p.m. confirmed the above findings.
Plan of Correction:To ensure compliance the Clinic Manager (CM) or designee will in-service all direct patient care (DPC) staff on:
· Medication Preparation and Administration
The meeting will focus on ensuring that hand hygiene is always performed per Fresenius policy. This includes always completing hand hygiene after preparing a medication for administration and before donning gloves to administer the medication.
Inservicing will be completed by September 20, 2024. All training documentation is on file at the facility.
The CM or designee will perform daily audits for two (2) weeks. At that time if one hundred percent (100%) 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 Quality Assessment and Performance Improvement (QAPI) schedule. A Plan of Correction (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 QAPI Committee at the monthly meeting. Sustained compliance will be monitored by the QAPI committee.
Completion Date: October 18, 2024
494.30(a)(2) STANDARD
IC-STAFF EDUCATION-CATHETERS/CATHETER CARE
Name - Component - 00
Recommendations for Placement of Intravascular Catheters in Adults and Children
I. Health care worker education and training
A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections.
B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters.
II. Surveillance
A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site.
Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients.
VI. Catheter and catheter-site care
B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections].
Observations:
Based on a review of facility policy/procedure, observations, and an interview with the facility Administrator, the facility failed to ensure that clinical staff maintain aseptic technique for the care of vascular accesses, including intravascular catheters for two (2) of two (2) 'Central Venous Catheter (CVC) Exit Site Care' and 'Initiation of Dialysis with Central Venous Catheter' observations (Observation #1, Observation #2).
Findings:
A review was conducted of facility policy/procedure on September 11, 2024, at approximately 11:30 a.m.
Policy 'Changing the Catheter Dressing Procedure' (Setting: IC, HT) 'Applying the Dressing' (1) Using aseptic technique, apply the catheter dressing ...
Policy 'Initiation of Treatment using a Central Venous Catheter (CVC) and Optiflux Single Use Ebeam Dialyzer' (Setting: IC, IPS) 'Prior to Initiation: Assessment and Machine Parameters' step (9) states ".... doff (remove) gloves, perform hand hygiene then don new gloves." 'Preparing the Catheter: Disinfection of the Catheter Connections, Heparin Removal, Flushing the Catheter and Heaprin Administration' step (1) states "Check to make sure catheter clamps are closed. Step (2) states "Remove cap from clamped arterial limb." Step (3) states "Using a sterile alcohol pad ....."
Observations conducted in the patient treatment area on September 9, 2024 between approximately 9:15 a.m. and 1:10 p.m. revealed the following:
Observation #1: On 09/11/24 at approximately 10:35 a.m. while observing 'Central Venous Catheter Exit Site Care' observation #1, for patient #6, station #1, employee #4 did not remove gloves/perform hand hygiene/don clean gloves after applying the sterile dressing and before initiating dialysis. Employee #4 removed gloves/performed hand hygiene after cleansing the area around the CVC exit site and prior to applying the sterile dressing.
Observation #2: On 09/11/24 at approximately 12:40 p.m. while observing 'Central Venous Catheter Exit Site Care' observation #2, for patient #7, station #4, employee #4 did not remove gloves/perform hand hygiene/don clean gloves after applying the sterile dressing and before initiating dialysis. Employee #4 removed gloves/performed hand hygiene after cleansing the area around the CVC exit site and prior to applying the sterile dressing.
An interview with the facility Administrator on September 11, 2024 at approximately 12:00 p.m. confirmed the above findings.
Plan of Correction:To ensure compliance the CM or designee will in-service all DPC staff on the following policies and procedure:
· Initiation of Treatment Using a Central Venous Catheter and Optiflux Single Use Ebeam Dialyzer
· Changing the Catheter Dressing Procedure
The meeting will emphasize that all staff must ensure that strict infection control practices per policy are adhered to when caring for a patient with a central venous catheter (CVC). The meeting will reinforce that after the dressing is applied to the catheter site, gloves must be removed and discarded, hand hygiene performed and new gloves donned before the initiation of treatment.
The in-service will be completed by September 20, 2024. Documentation of the meeting will be onsite 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 2/week for 2 weeks to ensure that compliance is maintained. At that time, the audits will then follow the monthly QAPI 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 QAPI Committee at the monthly meeting. Sustained compliance will be monitored by the QAPI committee.
Completion date: October 18, 2024
494.150(c)(2)(i) STANDARD
MD RESP-ENSURE ALL ADHERE TO P&P
Name - Component - 00
The medical director must-
(2) Ensure that-
(i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;
Observations:
Based on a review of facility policy/procedure, observations, and an interview with the facility Administrator, the facility failed to ensure clinical staffs personal belongings/food was stored out of/away from the patient treatment area, per policy/procedure for general cleanliness and infection control guidelines, for one (1) of one (1) treatment floor observations (Observation #1).
Findings:
A review was conducted of facility policy/procedure on September 11, 2024, at approximately 11:30 a.m.
Policy 'General Cleanliness and Infection Control Guidelines' (Setting: IC, HT) 'Purpose' "The purpose of this policy is to provide guidance for FKC staff on preventing the spread of infectious disease and maintain a clean, safe, and aesthetically pleasing environment for patients, staff, and visitors." 'Policy' "All areas must be kept clean and organized ...... ....Eating, drinking, .... are prohibited in work areas where there is reasonable likelihood of occupational exposure."
Observations conducted in the patient treatment area on September 9, 2024 between approximately 9:15 a.m. and 1:10 p.m. revealed the following:
Observation #1: On 09/09/24 at approximately 9:20 a.m. while conducting treatment area observations near the staff work station next to the 'Lab Prep' room, a black backpack was observed hanging on a chair at the station. The backpack had unwrapped/unopened syringes (containing saline) in the side pocket. A pair of white shoes were under the work station counter. An open small black carry purse/bag contents included but not limited to a clear bag of grapes. An open small red purse/bag contained pens, pencils, post-its, a Tylenol bottle, and a wrapped piece of candy.
The charge nurse (employee #7) was notified at approximately 9:25 a.m. and it was determined the above items belonged to employee #3, who was present and working at the time.
An interview with the facility Administrator on September 11, 2024 at approximately 12:00 p.m. confirmed the above findings.
Plan of Correction:By September 20, 2024, the Director of Operations (DO) and the CM will meet with the Medical Director to review the Medical Director Responsibilities as defined in the Conditions for Coverage. The meeting also reviewed the following policy:
· General Cleanliness and Infection Control Guidelines
The Medical Director will be informed at the meeting with the DO and CM that the staff will be re-educated on the above policy. The focus of the staff meeting will be on ensuring that all areas of the unit must be kept clean and organized at all times. No personal items are permitted in the treatment area or workstations. This includes backpacks and/or purses, saline syringes, shoes, food and/or candy of any kind, pens, pencils, post it notes, medications including Tylenol,
The in-service will be completed by September 20, 2024. Documentation of the meeting will be onsite 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 2/week for 2 weeks to ensure that compliance is maintained. At that time, the audits will then follow the monthly QAPI 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 Medical Director prior to the QAPI meetings. The audit results will also be reviewed at the QAPI Committee at the monthly meeting. Sustained compliance will be monitored by the QAPI committee.
Completion date: October 18, 2024
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