Initial Comments:
Based on the findings of an onsite unannounced Medicare complaint survey conducted onsite August 5, 2024 and off site August 7, 2024 and August 13, 2024. BMA of Cambria 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:
494.60 STANDARD
PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT
Name - Component - 00
The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment.
Observations:
Based on a review of facility policy/procedure, observations, and an interview with the Facility Administrator, the facility failed to ensure the facility was secured against unauthorized individuals for one (1) of one (1) observations (Observation #1).
Findings:
Observations conducted in the facility on August 5, 2024 at approximately 8:51 a.m. revealed the following:
Observation of the main front entrance, security gate down with a worn out sign " Attention all patients please use backside gate for entrance. See security guard for assistance". Entered backside gate next to parking lot. Observed 2 exterior doors, second exterior side door (unlocked) which belonged to the dialysis center. Surveyors walked into the Water Treatment/ Biomed storage area. Passed the storage area, another door was propped open into the corridor, directly into the patient treatment area.The second exterior side door that was unlocked does not provide a secure and safe enviroment against unauthorized individuals.
A review was conducted of facility policy/procedure on August 5, 2024 at, at approximately 12:24 p.m. Fresenius Kidney Care Physical Security and Facility Access Policy:
To ensure a secure and safe environment for all staff, visitors, and patients while on FKC properties. Physical security: Doors from the waiting area to the treatment area should remain closed and locked at all times while still allowing emergency access/exits. No persons other than the patient scheduled for treatment and authorized staff are to be admitted into the treatment area while dialysis is taking place ... ... ... All secondary external entrances(employee entrance doors, delivery doors) to the facility are to be kept closed and locked when not in use while still allowing emergency egress. No persons other than authorized personnel are to be admitted to the facility through secondary entrances.
An interview with the Facility Administrator on August 5, 2024 at approximately 1:18 p.m. confirmed the above findings.
Plan of Correction:V 401
To ensure compliance, the Facility Administrator (FA) and the biomedical technician (BMT) met on August 5, 2024, to review the status of the repair of the broken gate. The BMT reached out to the vendor for an update on the repair of the gate.
For ongoing compliance, the FA, BMT or designee will re-educate all staff on the following policy:
- Physical Security and Facility Access
Emphasis will be placed on ensuring that all staff is aware that all secondary, exterior doors must be always closed and locked. Only authorized people are permitted access. This is to ensure a safe and secure environment for all staff, visitors and patients. The meeting will also reinforce that the door from the patient waiting area into the treatment floor must also be locked at all times and no one other than patients or authorized staff are permitted into the treatment area. The doors in the storage area exiting onto the treatment floor must be closed and not propped open. Staff will be informed at the meeting to inform the FA and the BMT if there is any issue noted with the ability to lock any doors.
Inservicing will be completed by September 10, 2024. All training documentation will be on file at the facility.
To ensure ongoing compliance, the FA or designee will perform daily audits for two (2) weeks. At that time if compliance is noted, the audits will then be completed 2 times/week for 2 weeks to ensure that compliance is maintained. At that time, if one hundred percent (100%) compliance is sustained, the audits will then follow the monthly Quality Improvement and Performance Improvement (QAPI) 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 FA 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: September 30, 2024
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