Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on March 17, 2023, Radnor Dialysis, 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 March 17, 2023, Radnor Dialysis, was identified to have the following standard level deficiencies, and 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)(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 upon observation, policy and procedure review, and an interview with the facility administrator, it was determined the ESRD failed to ensure the cleaning of visible blood on surfaces, was conducted per ESRD policy, for one (1) of one (1) observation of visible blood clean up (Observation #4).
Findings include:
Review of policy "Infection Control For Dialysis Facilities ", on 3/16/2023 at approximately 11:00 AM states "....45. For visible blood or gross blood spills, a 1:10 (one to ten) bleach solution must be utilized. After all visible blood is cleaned with the 1:10 (one to ten) bleach solution, teammates are to use a new disposable towel soaked with 1:10 (one to ten) bleach solution and clean area a second time."
Observation #4: On 3/15/2023, at approximately 10:30 AM at Station #9, PCT #1 was observed cleaning visible blood from the patient hemodialysis chair. PCT #1 did not return after initially cleaning with a new disposable towel soaked with 1:10 (one to ten) bleach solution and clean area a second time.
An interview with the ESRD administrator on 3/15/2023 at approximately 2:00 PM confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 03/22/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" with the emphasis on but not limited to: 1) Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials. For visible blood or gross blood spills, a 1:10 (one to ten) bleach solution must be utilized. After all visible blood is cleaned with the 1:10 (one to ten) bleach solution, teammates are to use a new disposable towel soaked with 1:10 (one to ten) bleach solution and clean area a second time.
Verification of attendance is evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee will conduct infection control audit to verify teammates are cleaning visible blood spills with 1:10 bleach solution twice, using a new cloth with 1:10 bleach solution to clean the area a second time: daily for two (2) weeks, and weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly infection control audit. Instances of non-compliance will be address immediately.
The Facility Administrator or designee will review the audit results with teammates during homeroom meetings, and with Medical Director during monthly Quality Assessment and Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
494.30(c)(2) STANDARD
IC-CATHETERS:GENERAL
Name - Component - 00
(2) The "Guidelines for the Prevention of Intravascular Catheter-Related Infections" entitled "Recommendations for Placement of Intravascular Catheters in Adults and Children" parts I - IV; and "Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients," Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html
Observations:
Based upon observation, policy and procedure review, and an interview with the facility administrator, it was determined the ESRD failed to ensure the Central Venous Catheter (CVC) dressing change, was conducted per ESRD policy, for two (2) of two (2) observations of initiation of dialysis with a CVC (Observation #2 and Observation #3).
Findings include:
Review of policy "Central venous Catheter (CVC) with clearguard HD Antimicrobial End Caps Procedure ", on 3/16/2023 at approximately 11:05 AM, .3. ...Place the second moisture proof barrier under catheter limbs....4. remove old dressing and discard...7. Remove gloves and discard. Perform hand hygiene per procedure and reglove 8. ...clean exit site with 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol swab for a minimum of 30 seconds..."
Observation #2: On 3/15/2023, at approximately 10:15 AM at Station #8 , PCT #1 was observed removing and discarding the used CVC dressing, then placing a moisture proof barrier under the catheter limbs, then cleaning the exit site, without removing gloves and performing hand hygiene until after completion of cleaning the exit site.
Observation #3: On 3/15/2023, at approximately 10:25 AM at Station #7 , PCT #1 was observed removing and discarding the used CVC dressing, then placing a moisture proof barrier under the catheter limbs, then cleaning the exit site, without removing gloves and performing hand hygiene until after completion of cleaning the exit site.
An interview with the ESRD administrator on 3/15/2023 at approximately 2:00 PM confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 03/22/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-04-02B "Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure" with emphasis on but not limited to: [CVC dressing change]: 1) Step #3: Verify patient's clothing is secured away from the exit site/work area. Place the second moisture proof barrier under catheter limbs. Instruct patient to turn head to opposite side of CVC exit site. 2) Step #4: Remove old dressing and discard. 3) Step #7: Remove gloves and discard. Perform hand hygiene per procedure and re-glove. 4) Step #8: Holding catheter with the nondominant hand and using aseptic technique, clean exit site with 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol swab for a minimum of 30 seconds...
Verification of attendance is evidenced by teammate's signature on the in-service sheet.
The Facility Administrator or designee will conduct infection control audits to verify teammates perform CVC exit site care using proper glove change with hand hygiene, per policy: daily for two (2) weeks, and weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly infection control audit. Instances of non-compliance will be address immediately.
The Facility Administrator or designee will review the audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assessment and Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
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 upon observation, policy and procedure review, and an interview with the facility administrator, it was determined the ESRD failed to ensure the Arterial Venous Fistula/Graft access sites to not be touched post skin antisepsis prior to cannulation for one (1) of two (2) observations for Access of AV fistula/graft for Initiation of Dialysis (Observation #1).
Findings include:
Review of policy "AV Fistula of Graft Cannulation With Nipro or Medisystems Safety Fistula Needles and Administration of Heparin Loading Dose" on 3/16/2023 at approximately 11:10 AM states "...13. Do not palpate insertion site once area has been prepped..Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation..."
Observation #1, conducted on the hemodialysis treatment floor on 3/15/2023 at approximately 10:40 AM revealed, PCT #1 at Station #17, to apply antiseptic to the patient's skin over the cannulation sites, then proceeded to touch the cannulation sites, while failing to then reapply antiseptic prior to cannulating.
An interview with the facility administator on 3/15/23 at approximately 2:00 PM confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 03/22/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-044-01E "AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose" with emphasis on but not limited to: 1) Step #8: Locate and palpate the needle cannulation sites prior to skin preparation. 2) Step #11: While maintaining aseptic technique, cleanse the site... 3) Step #13: Do not palpate insertion site once area has been prepped. Rationale: Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation.
Verification of attendance is evidenced by teammate's signature on the in-service sheet.
The Facility Administrator or designee will conduct audits to verify AV fistula/graft cannulation preparation follows aseptic technique per policy: daily for two (2) weeks, and weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly infection control audit. Instances of non-compliance will be address immediately.
The Facility Administrator or designee will review the audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assessment and Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
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