Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on March 15, 2022, through March 18, 2022, Wyncote 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 conducted on March 15, 2022, through March 18, 2022, Wyncote Dialysis, 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) 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 upon observation, policy and procedure review, and an interview with the facility staff, it was determined the facility failed to ensure hand hygiene and donning of new gloves during access of the AV (arterial venous) fistula or graft for initiation of dialysis for two (2) of two (2) observations (Observations #7 and #8) and while performing Central Venous Catheter (CVC) exit site care for one (1) of two (2) observations (Observation #3) and while performing initiation of dialysis with a CVC for one (1) of two (2) observations (Observation #1).
Findings include:
Review of facility policy: 1-04-02A " Central Venous Catheter (CVC) Procedure" on March 18, 2022, at approximately 11:00 A.M. states: "2. Perform hand hygiene per procedure..."
Observation of the clinical area was conducted on March 15, 2022, from approximately 9:15 A.M. to 12:45 P.M., 2:15 P.M. to 3:00 P.M., and March 16, 2022, from 9:15 A.M. to 11:30 A.M..
Observation #1 on March 15, 2022, at approximately 2:35 P.M. at Station #11. During the initiation of dialysis with a CVC, the patient care technician (PCT #1) was observed arriving at the dialysis station for initiation of dialysis and donning gloves without first washing hands.
Observation #3 on March 15, 2022, at approximately 2:30 P.M. at Station #11. During CVC exit site care, PCT #1 was observed removing and discarding the soiled dressing and removing gloves. PCT #1 did not perform hand hygiene prior to donning clean gloves to begin cleansing the catheter exit site. After applying the sterile dressing, PCT #1 removed gloves and did not perform hand hygiene.
Review of facility policy #1-04-01E titled "AV Fistula or Graft Cannulation With Nipro or Medisystems Safety Fistula Needles (SNF) and Administration of Heparin" on March 18, 2022, at approximately 11:00 A.M. states: "Procedure: 8. Locate and palpate the needle cannulation sites prior to skin preparation... 11. While maintaining aseptic technique, cleanse the site by applying skin antiseptic... 13. Do not palpate insertion site once area has been prepped... 16. Remove gloves, perform hand hygiene and put on clean gloves prior to cannulation..."
Observation #7 on March 15, 2022, at approximately 9:47 A.M. at Station #6. After insertion of the cannulation needles for initiation of dialysis, PCT #1 removed gloves and did not perform hand hygiene.
Observation #8 on March 15, 2022, at approximately 11:10 A.M.at Station #3. PCT #5 pushed the patients sleeve above the access site on the left upper arm and placed the tourniquet. After inserting the first cannula, the patient's sleeve slipped down over the area that had been cleansed. PCT #5 pushed the sleeve back up the patient's arm and inserted the second cannula without re-cleaning the area and performing hand hygiene and donning clean gloves. At the end of the procedure PCT #5 touched the dialysis machine screen without changing gloves and hand sanitizing.
Interview with the facility administrator and clinical coordinator on March 18, 2022, at approximately 12:00 P.M. confirmed the above findings.
Plan of Correction:"V113
The Clinical Coordinator held a home room on 03/18/2022 and 03/21/2022 to discuss policy 1-05-01 and provided a copy to all tms to review and have in possession to reiterate the appropriate steps.
The Facility Administrator or designee held mandatory in-service(s) for all Clinical Teammates starting on 3/21/22. Surveyor observations were reviewed. Education included but was not limited to: 1) a review of Policy # 1-05-01 Infection Control for Dialysis Facilities with the emphasizing hand hygiene is to be performed prior to gloving and after removal of gloves. 2) A review of Policy # 1-04-02A Cental Venous Catheter (CVC) Procedure emphasizing teammates are to perform hand hygiene prior to donning gloves for procedure, after removal of gloves when going from dirty to clean task, and before donning clean gloves. 3) A review of Policy # 1-04-01E AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles and Administration of Heparin emphasizing teammates willperform hand hygiene after removing gloves and prior to donning clean gloves. Teammates must re-cleanse the access site if the site becomes contaminated. Teammates will remove gloves and perform hand hygiene between each patient and/or station and between clean and dirty tasks. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Facility Administrator or designee will conduct infection control audits daily for two (2) weeks then weekly for two (2) weeks then monthly during internal infection control audits to verify compliance. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review the results of the audits with teammates during homeroom meetings and with Medical Director during monthly Qaulity Assurance and Performance Improvement meetings know as Facility Health Meetings with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction."
494.60 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, observation and an interview with the administrator and clinical services specialist, the facility did not maintain a safe and functional environment by failing to remove expired supplies from the treatment area.
Findings include:
A review of policy 7-03-07 titled "Disposable Supplies" on March 18, 2022, at approximately 11:00 A.M. states: "1. The expiration date must be checked on all disposable supplies before the package is opened and the contents are used. 2. The contents of packages will not be used beyond the expiration date on the package."
During the observational tour of the supply storage room on March 15, 2022, at approximately 9:20 A.M., a box of Nipro Safe Touch Tulip Safety Fistula Needles 14 Gauge were found to have expired on June 30, 2021.
An interview with the administrator and clinical coordinator on March 18, 2022, at approximately 12:00 P.M. confirmed the above findings.
Plan of Correction:"V401
FA performed an audit on 03/15/2022 of all supplies and all expired items were immediately discarded.
The Facility Administrator or designee held mandatory in-service(s) for all clinical teammates starting on 03/21/2022. Surveyor observations were reviewed. Education included but was not limited to a review of Policy # 1-05-01 Infection Control for Dialysis Facilities. Emphasis was place on: 1) The expiration date must be checked on all disposable supplies before the package is opened and the contents are used. 2) The contents of packages will not be used beyond the expiration date on the package. All supplies are checked monthly for expiration dates. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Facility Administrator or designee will conduct audits for two (2) weeks then weekly for two(2) weeks then monthly during during the inventory process to verify compliance. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review the results of the audits with teammates during homeroom meetings and with the Medical Director during monthly 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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