Initial Comments:
Based on the findings of an unannounced Medicare recertification survey conducted 7/11/2023-7/12/2023, BMA of Cumberland County, was found to be in compliance with the requirements of 42 CFR, Part 494.62, Subpart B, Conditions for Coverage for End-Stage Renal Disease (ESRD) Services- Emergency Preparedness.
Plan of Correction:
Initial Comments:
Based on the findings of an unannounced Medicare recertification survey conducted 7/11/2023 through 7/12/2023, BMA of Cumberland County, was found to have the following standard level deficiencies that were determined to be in substantial compliance with the 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 review of facility policies/procedures, observations of the patient care treatment area and an interview with the facility Director of Operations, it was determined the facility failed to ensure the staff followed infection control protocols, included but not limited to, hand hygiene/don clean gloves for one (1) of two (2) 'Central Venous Catheter (CVC) Exit Site Care' observations (Central Venous Catheter Exit Site Observation # 2); for one (1) of (2) 'Cleaning and Disinfection of the dialysis station' observations (Cleaning and Disinfection of the dialysis station Observation #2); and for one (1) of one (1) treatment area observations. (Treatment Area Observation # 1)
Findings:
Review of facility policy, 'Handy Hygiene' on 7/11/2023 at approximately 11:00 a.m. states, "Policy:...Hands will be...Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water...When...immediately after removing gloves, after contact with body fluids or excretion, mucous membranes, non-intact skin, and wounds dressings if hands are not visibly soiled, after contact with inanimate objects near the patient, when moving from a contaminated body site to a clean body site of the same patient, after contact with dialysis wall box, concentrate, drain or water lines, after contact with other objects within the patient space or treatment space..."
Observations of the patient care treatment area was conducted on 7/11/2023 between approximately 9:18 a.m. to 12:20 p.m. and on 7/12/2023 between approximately 8:46 a.m. and 10:00 a.m. revealed the following:
Central Venous Catheter Exit Site Observation # 2 on 7/11/2023 at approximately 12:12 p.m., employee # 2 failed to remove gloves and perform hand hygiene and don clean gloves after removing old dressing and prior to cleansing area around CVC exit site with antiseptic.
Cleaning and Disinfection of the dialysis station Observation #2 on 7/11/2023 at approximately 10:01 a.m., employee # 2 failed to remove gloves and perform hand hygiene and don clean gloves after emptying prime waste receptacle and prior to disinfecting dialysis machine.
Treatment Area Observation # 1 on 7/11/2023 at approximately 9:21 a.m., employee # 3 was opening clean supplies at station # 6 with patient # 23 sitting in dialysis chair, then employee # 3 walked to station # 9 with patient # 19 sitting in dialysis chair and touched the beeping dialysis machine. Employee # 3 failed to remove gloves, perform hand hygiene and don clean gloves after leaving station # 6 and prior to touching dialysis machine at station # 9.
Interview on 7/12/2023 at 2:30 p.m. with Director of Operations confirmed the above findings.
Plan of Correction:The Clinic Manager (CM) will in-service all direct patient care (DPC) staff on policy:
- Hand Hygiene
The in-service will focus on the staff ensuring that
Hand hygiene is always performed per policy. This includes after removal of the old catheter dressing and prior to cleansing the site when performing catheter care. The meeting will also review that hand hygiene is also required after emptying the contents of the prime waste receptacle and after touching any dialysis machine and before starting another task.
In-servicing will be completed by August 8, 2023, and the training documentation will be 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 times/week for 2 weeks. At that time, if compliance is maintained, the audits will then follow the monthly Quality Assessment and Performance Improvement (QAPI) schedule. A Plan of Correction (POC) specific auditing tool will be used for the audits.
Issues of non-compliance will be addressed by the CM with re-education and counseling.
The CM will review the audit results and report the findings at the monthly QAPI meetings for ongoing oversight and compliance.
Completion Date: September 8, 2023
494.80(a)(2) STANDARD
PA-APPROPRIATENESS OF DIALYSIS RX
Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:
(2) Evaluation of the appropriateness of the dialysis prescription,
Observations:
Based on review of facility policies/procedures, observations of the patient care treatment area and an interview with the facility Director of Operations, it was determined the facility failed to ensure that the patient prescription (PP) was being implemented as ordered by the physician for one (1) of four (4) PPs reviewed. (PP# 1)
Findings:
Review of facility policy, 'Pre-Treatment Safety Checks Procedure' on 7/11/2023 at approximately 10:45 a.m. states, "Policy:...Pre-Dialysis Safety Checks: Verify the following elements by two staff members prior to treatment initiation: Disinfectant (Bleach or other) is negative- if applicable, Prescribed dialyzer, Dialysate flow rate, Prescribed Dialysate composition..."
Observations of the patient care treatment area was conducted on 7/11/2023 between approximately 9:18 a.m. to 12:20 p.m. and on 7/12/2023 between approximately 8:46 a.m. and 10:00 a.m. revealed the following:
Patient Prescription #1: Prescription verification conducted on patient #13, station #10 on 7/11/2023 at approximately 11:00 a.m. revealed Hemodialysis treatment prescription flowsheet dated 7/11/2023 show Dialysate order for "3K (Potassium), 2.5 Ca (Calcium)". The dialysis machine was connected to "2K, 2.5 Ca".
Interview on 7/12/2023 at 2:30 p.m. with Director of Operations confirmed the above findings.
Plan of Correction:For compliance, the CM or designee held an in-service with the DPC staff to review procedure:
- Pre-Treatment Safety Checks Procedure
Emphasis of the meeting was placed on ensuring the patient's machine settings are programmed following the physician orders and verified by 2 staff members. This includes that the prescribed dialysate bath is in use.
All training documentation is on file at the facility. In-servicing will be completed by August 8,2023.
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 times/week for 2 weeks. At that time, if compliance is maintained, the audits will then follow the monthly QAPI schedule. A POC specific auditing tool will be used for the audits.
Staff found to be noncompliant will be re-educated and counseled.
The CM will review the audits and report the findings monthly at the QAPI Committee meeting. The QAPI committee will monitor for sustained compliance.
Completion date: September 8, 2023
494.90(a)(1) STANDARD
POC-ACHIEVE ADEQUATE CLEARANCE
Name - Component - 00
Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis.
Observations:
Based on review of facility policy, medical records (MR) and an interview with facility Director of Operations, it was determined that the facility failed to ensure treatments were delivered in accordance with the dialysis prescriptions ordered by the physician for two (2) of two (2) home therapy prescription verifications reviewed. (MR# 4 and MR# 5)
Findings include:
Review of facility policy, 'Review and Documentation of Home therapies Patient Health Data' on 7/12/2023 at approximately 1:00 p.m. states, "Policy: The patient will create a treatment record for every dialysis treatment according to policy and regulatory requirement. Treatment data will be reviewed by the home therapies nurse in order to identify trends, determine if patients are following their treatment plans or having problems with their dialysis at home..."
Review of medical records (MRs) on 7/12/2023 between approximately 10:45 a.m. to 2:00 p.m. revealed the following:
MR# 4, admission date: 6/4/2022. Patient began peritoneal dialysis on 12/7/2020. Treatment sheets reviewed dated between 3/31/2023-5/29/2023. Physician orders dated 3/31/2023- Peritoneal Dialysate order: Dextrose 1.5; 2.5; 4.25% (percent).
- Dialysate section left blank on flowsheets to indicate which strength of Dextrose was used.
- No documentation provided of therapy nurse identifying this trend while reviewing treatment sheets.
MR# 5, admission date: 8/10/2022. Patient began home hemodialysis on 2/27/2023. Treatment sheets reviewed dated between 6/16/2023-7/10/2023. Physician orders dated 5/3/2023- Heparin order: Heparin Pork 1,000 Units/mL (milliliters) systemic self administer home Bolus 2,000 units IVP (intravenous push) every treatment
- Medication section left blank on flowsheets for treatment sheets reviewed 6/16/2023-7/10/2023.
- No documentation provided of therapy nurse identifying this trend while reviewing treatment sheets.
Interview on 7/12/2023 at 2:30 p.m. with Director of Operations confirmed the above findings.
Plan of Correction:To ensure compliance the CM, Home Therapy Program Manager (HTPM) or designee will in-service the Home Therapy (HT) RNs on the following policy:
- Review and Documentation of Home Therapies Patient Health Data
The in-service will provide re-education on ensuring that the home therapy (HT) patients' flowsheets are reviewed on a routine and ongoing basis for issues with trends identified. This review is to occur between clinic visits with documentation of the review in the medical records. The review includes verification of the proper administration and documentation of both the prescribed dextrose solution and heparin dose. The documentation will also include re-education if the flowsheet review indicates a lack of treatment compliance with heparin dosing.
The training will be completed by August 8, 2023, with documentation on file at the facility.
The CM or designee will perform audits for the next three (3) months to ensure compliance. At that time, if compliance is sustained, the audits will then follow the monthly QAPI schedule. A POC 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 and oversight will be monitored by the QAPI committee.
Completion Date: September 8, 2023
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