QA Investigation Results

Pennsylvania Department of Health
BMA CUMBERLAND COUNTY
Health Inspection Results
BMA CUMBERLAND COUNTY
Health Inspection Results For:


There are  12 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:

Based on the findings of an unannounced Medicare recertification survey conducted 7/21/2020- 7/24/2020, BMA of Cumberland County, was found to be in substantial 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 onsite unannounced Medicare recertification survey conducted July 21, through July 24, 2020, BMA of Cumberland 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)(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 on review of facility policy, observations, and an interview with the Clinical Nurse Manager ( EMP # 1), the facility failed to ensure that the staff followed infection control protocols, included but not limited to, use of Personal Protective Equipment (PPE), for three (3) of three (3) observations (Observation #1-6).

Findings include:

Review of facility policy on 7/24/2020 between approximately 2:00 PM-3:00 PM titled " Personal Protective Equipment policy # FMC-CS-IC-II-155-080A"' states:
"Personal protective equipment such as a full face shield or mask......fluid resistant gowns and gloves will be worn to protect and prevent employees from blood or other infectious material to pass though to or reach the employees skin when performing procedures during which spurting or spattering of blood might occur.".
" all personal protective equipment shall be removed prior to leaving the treatment area" "disposable gloves must be used: " when touching blood, body fluids, secretions, excretions, or items or surfaces potentially contaminated with these substances. When touching any part of the dialysis machine or equipment at the dialysis station."



Observation # 3, 7/22/2020 at 8:55 AM observed physician, (EMP # 3), touching patient screen at machine # 19, without wearing gloves, on approximately five (5) different times.


Observation # 5, 7/23/2020 between approximately 9:30AM-11:00 AM patient # 11, machine # 17, had his face mask below his nose and only covering his mouth. PF # 7 working with patient and failed to instruct patient to pull up his face mask.

Observation # 6, 7/23/2020 between approximately 9:30AM-11:00 AM patient # 6, machine # 10, had his face mask below his nose and only covering his mouth. PF # 6 working with patient and failed to instruct patient to pull up his face mask.


An interview with the EMP # 1 on 7/24/2020 at approximately 3:00 PM confirmed the above findings.






Plan of Correction:

The Clinic Manager (CM) will in-service all direct patient care (DPC) staff on 8/24/20, on the following:

- FMS-CS-IC-II-155-080A Personal Protective Equipment Policy

The in-service will focus on the staff ensuring that the patient's face mask covers his/her nose at all times. Staff will be reminded at the meeting that they must reinforce with the patients the importance of proper wearing of the face mask with their nose covered.

The Director of Operations met with the clinic physicians on 8/19/20, and reviewed the above policy. The physicians were reminded that machines may not be touched without wearing gloves. Hand hygiene before and after donning gloves was also reinforced with the physicians.

In-servicing will be completed by 8/24/20, 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 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 Improvement (QAI) 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 QAI


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 on observation and interview with ( EMP # 1) the Clinical Nurse Manager, the facility failed to discard outdated supplies for one (1) of one (1) observation. ( Observation # 1).

Findings include:

Observation on 7/22/2020 at approximately 11 AM-12 PM during tour of facility and inspection of supplies noted two (2) suture removal kits with expiration date of 11/30/2019 still on the stock shelf.


An interview with the EMP # 1 on 7/24/2020 at approximately 3:00 PM confirmed the above findings.






Plan of Correction:

For immediate compliance on 7/24/20, the CM disposed of the outdated supplies identified during the survey. On the same date, all other items were inspected for expiration dates.

To ensure compliance, the CM will hold a staff meeting with the direct patient care (DPC) staff on 8/24/20, and review the following:

FMS-CS-IC-II-120-005A Storage of Supplies Policy

The emphasis of the meeting will be on ensuring that all supplies are rotated according to expiration dates when being placed into storage. The importance of validating the expiration date of a supply before it is opened for use will also be reviewed.

The inservice will be completed on 8/24/20. Documentation of the in-service will be on file at the facility.

For ongoing compliance, monthly auditing of the supply stock for expiration dates will be completed by the CM or designee. The audits will be reviewed in the QAI program for ongoing oversight. Issues of non-compliance will be addressed with re-education and counseling.



494.80(a)(3) STANDARD
PA-IMMUNIZATION/MEDICATION HISTORY

Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:

Immunization history, and medication history.




Observations:


Based on facility policy, medical records (MR), and interview with ( EMP # 1) the Clinical Nurse Manager, the facility recorded an incomplete initial comprehensive assessment for one (1) of one (1) MR reviewed. ( MR # 1).

Findings include:

Policy review on 7/24/2020 at approximately 2 :00 PM- 3:00 PM titled "Comprehensive Interdisciplinary Assessment and Plan of Care" stated " An initial comprehensive interdisciplinary assessment (CIA) and plan of care (POC) must be conducted on all patient new to dialysis.."

Review of MR on 7/22/2020 between approximately 12:30 PM-2:00 PM and 7/23/2020 between approximately 11 AM-12:00 PM and 12:30 PM-3:30 PM revealed:

MR # 1, Start of Care (SOC) 6/2/2020; initial comprehensive assessment started on 6/2/2020 and documentation was incomplete. Missing in-center and home medications, allergies, vaccination/immunization status, hospitalizations, modality education, general health status, assessment.

An interview with EMP # 1 on 7/22/2020 to confirm assessment was incomplete, stated " I am not sure why it was not finished"

An interview with the EMP # 1 on 7/24/2020 at approximately 3:00 PM confirmed the above findings.



















Plan of Correction:

For compliance, the CM will hold an in-service with the Interdisciplinary Team (IDT) on 8/24/20 to review:

- FMS-CS-IC-1-110-125A
Comprehensive Interdisciplinary Assessment and Plan of Care

Emphasis of the meeting will be placed on ensuring all patients newly admitted to the facility have an initial Comprehensive Interdisciplinary Assessment (CIA) completed within thirty (30) days or thirteen (13) treatments of admission. The IDT members will be re-educated that while there is currently a Centers for Medicare and Medicare Services (CMS) waiver regarding the on-time requirement for the initial and follow-up assessment, all efforts should be made by the IDT to complete the assessment in a timely manner.

All training documentation will be on file at the facility. In-servicing will be completed by 8/24/20.

The CM/designee will perform audits on all new patients for the next three (3) months to ensure that the assessments are complete. Ongoing monitoring will follow the QAI schedule. A POC auditing tool will be sued 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 QAI Committee meeting. The QAI committee will monitor for sustained compliance.



494.80(d)(1) STANDARD
PA-FREQUENCY REASSESSMENT-STABLE 1X/YR

Name - Component - 00
In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted-
(1) At least annually for stable patients;





Observations:


Based on facility policy, medical records (MR), and interview with ( EMP # 1) the Clinical Nurse Manager, the facility failed to complete an annual comprehensive reassessment for one (1) of four (4) MR reviewed. ( MR # 2, ID # 6).

Findings include:

Policy review on 7/24/2020 at approximately 2 :00 PM- 3:00 PM titled "Comprehensive Interdisciplinary Assessment and Plan of Care" stated " An initial comprehensive interdisciplinary assessment (CIA) and plan of care (POC) must be conducted on all patient new to dialysis.. and reassessed annually thereafter.. 12 months after the completion of the 3 month assessment"

Review of MR on 7/22/2020 between approximately 12:30 PM-2:00 PM and 7/23/2020 between approximately 11 AM-12:00 PM and 12:30 PM-3:30 PM revealed:

MR # 2, ID # 6, Start of Care (SOC) 3/13/2019; 90 day assessment completed on 6/24/2019 and no documentation present that annual reassessment was conducted.


An interview with the EMP # 1 on 7/24/2020 at approximately 3:00 PM confirmed the above findings.







Plan of Correction:

The CM or designee will in-service the IDT members on 8/24/20 on the following
:

- FMS-CS-IC-I-110-125A Comprehensive Interdisciplinary Assessment and Plan of Care Policy.

Emphasis will be placed on ensuring that the CIA on all stable patients must occur within twelve (12) months of the completion of the 90 Day Assessment. The IDT members were re-educated that while there is currently a CMS waiver regarding the on-time requirement for the initial and follow-up assessment, all efforts should be made by the IDT to complete the assessment in a timely manner.
The in-service will be completed by 8/24/20. Documentation of the education will be on file at the facility.

To ensure compliance the CM or designee will monitor all annual assessments monthly for the next 3 months for timely completion. Ongoing monitoring will follow the QAI schedule. A POC auditing tool will be used for the audits.

Issues of non-compliance by IDT team will result in reeducation and counseling.

Results of the audit will be summarized by the CM and will report the findings at monthly QAI meetings. The QAI committee will provide oversight for sustained compliance