Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey and addition of Peritoneal Dialysis (home training and support) services survey conducted on May 24, 2021 through May 26, 2021, Jennersville Dialysis Center, 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 and addition of Peritoneal Dialysis (home training and support) services survey conducted on May 24, 2021 through May 26, 2021, Jennersville Dialysis Center, 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)(i) STANDARD
IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK
Name - Component - 00
Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory.
Observations:
Based upon observation, review of facility policy and procedure, and an interview with the facility administrator, it was determined the facility failed to ensure the Patient Care Technician (PCT), to correctly don a surgical mask, prior to performing Central Venous Catheter Exit Site Care and Central Venous Catheter treatment initiation (Observation #1).
Findings include:
Review of policy "Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure" on 5/25/21 at approximately 10:30 AM states "... Teammate and Patient will wear masks covering the nose and mouth during this procedure..."
Observation #1: On 5/24/21 at approximately 11:55 AM, PCT#1 was observed at Station #5, performing Central Venous Catheter Exit Site Care and Central Venous Catheter treatment initiation while wearing a surgical mask below the nose.
An interview with the agency administrator on 5/26/21 at approximately 12:30 PM confirmed the above findings.
Plan of Correction:The Facility Administrator (FA) will in-service all clinical teammates (TMs) on policy 1-04-02B Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure by 6/3/21 which outlines that TMs and patient will wear masks covering the nose and mouth during this procedure. Verification of attendance is evidenced by TM signature on in-service sheet. The FA or designee will perform observational audits daily for one (1) week on various shifts then twice weekly for four (4) weeks followed once monthly during internal infection control audits to verify compliance. Instances of non-compliance will be addressed immediately. The results of the audits will be reviewed with the TMs during homeroom meetings and with the Medical Director during monthly Facility Health Meetings (FHM-QAPI) with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.
494.30(a)(1)(i) STANDARD
IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS
Name - Component - 00
Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled.
When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station.
Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients.
Observations:
Based upon observation, policy and procedure review, and an interview with the facility administrator, it was determined the facility failed to ensure a designated clean sink to be separated from a patient hemodialysis station (Observation #2).
Findings include:
On 5/25/2021 at approximately at 10:30 AM, review of the facility policy titled "Infection Control for Dialysis Facilities" revealed the following: "Teammate/Patient Safety...45. Clean areas should be clearly designated for the preparation, handling, and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled."
Observation #2: On 5/24/2021 at approximately 10:45 AM, Station #16 was observed to contain a sink labeled "Clean Sink" directly behind the patient chair with no barrier of separation.
An interview with the agency administrator on 5/26/21 at approximately 12:30 PM confirmed the above findings.
Plan of Correction:The FA will in-service all clinical TMs on Policy 1-05-01 Infection Control for Dialysis Facilities by 6/11/21. Education will include but not be limited to: 1) Clean areas should be clearly designated for the preparation, handling, and storage of medications and unused supplies and equipment. 2) Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Verification of attendance will be evidenced by TM signature on in-service sheet. On 5/24/21, the clean sink was designated a dirty sink per surveyor recommendation.
The FA or designee will perform observational audits daily for one (1) week on various shifts then twice weekly for four (4) weeks followed once monthly during internal infection control audits to verify compliance. Instances of non-compliance will be addressed immediately. The results of the audits will be reviewed with the TMs during homeroom meetings and with the Medical Director during monthly Facility Health Meetings (FHM-QAPI) with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.
494.60(a) STANDARD
PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY
Name - Component - 00
The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public.
Observations:
Based upon observation, policy and procedure review, and an interview with the agency administrator, it was determined the agency failed to ensure proper maintenance of the following: floor trim on hemodialysis unit floor (Observation #3), wall below Clean sink #1 (Observation #4), Clean Sink #1 (Observation #5), frame on Reverse Osmosis unit (Observation #6), Drain #1 and Drain #2 in water room (Observation #7), and floor epoxy in water room (Observation #8).
Findings include:
Review of Policy "Physical Environment" on 5/25/2021 at approximately 11:00 AM states " 1. The dialysis facility will be designed, constructed, equipped, and maintained to provide dialysis patients, teammates, and the public a safe, functional, and comfortable treatment environment."
Observation #3: On 5/24/2021 at approximately 11:30 AM, on the in-center hemodialysis unit, the floor adjacent to Station #16 was observed to contain loose wall trim and not adhering to the wall floor trim.
Observation #4: On 5/24/2021 at approximately 11:35 AM, on the in-center hemodialysis unit, the wall below Clean Sink #1 was observed to be missing drywall.
Observation #5: On 5/24/2021 at approximately 11:40 AM, on the in-center hemodialysis unit, Clean Sink #1 to observed to have a steady water drip at the faucet.
Observation #6: On 5/24/2021 at approximately 12:00 PM, in the facility Water Room, the Reverse Osmosis frame was observed to contain rust patches over the paint.
Observation #7: On 5/24/2021 at approximately 12:05 PM, in the facility Water Room, the floor Epoxy was observed to be peeling from the floor on the right hand side of the room.
Observation #8: On 5/24/2021 at approximately 12:10 PM, in the facility Water Room, two (2) floor drains, Drain #1 and Drain #2, were observed to not contain drain covers.
An interview with the agency administrator on 5/26/21 at approximately 12:30 PM confirmed the above findings.
Plan of Correction:The FA will in-service all clinical TMs on Policy 8-04-01 Physical Environment by 6/12/21. Education will include but not be limited to: 1) the dialysis facility will be designed, constructed, equipped, and maintained to provide dialysis patients, teammates, and the public a safe, functional, and comfortable treatment environment. TMs were instructed to report all safety issues to the FA or designee timely. Verification of attendance will be evidenced by TM signature on in-service sheet.
The FA is responsible to ensure the building is maintained to ensure the safety of the patients, staff and public through routine maintenance and repairs.
The FA or designee along with the biomedical TM will conduct ongoing monthly audit to verify processes are in place to identify, repair, and follow up on building issues that arise. The Governing Body will review audits monthly for the next six (6) months and then as needed.
The loose wall trim by station #16 will be repaired by 5/24/21.
The dry wall below the clean sink, now a dirty sink will be repaired by 6/6/21.
The repair to the clean sink, now a dirty sink will be completed by 6/6/21.
The repairs to the RO frame in the water room will be completed by 6/8/21.
The water room flooring will be assessed by 6/5/21 and repairs will be completed by 6/8/21.
The repairs to the floor drains will be completed by 6/5/21.
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