QA Investigation Results

Pennsylvania Department of Health
DIALYSIS CENTER OF MONTGOMERY EAST
Health Inspection Results
DIALYSIS CENTER OF MONTGOMERY EAST
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite unannounced Medicare recertification survey completed September 25, 2020, Dialysis Center of Montgomery East 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 September 25, 2020, Dialysis Center of Montgomery East 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-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 on review of policy/procedure, observations and an interview with the Facility administrator the facility failed to ensure that multi-use vials of medications were stored in a clean area for one (1) of one (1) observations made OBS #1.

Findings include:

Review of policy completed on September 25, 2020 at approximately 12:30 PM revealed:
FMS-CS-IS-II-120-040A; "Medication Preparation and Administration", Pre-drawing Medications; bullet one: Medications may be pre-drawn...These pre-drawn medications shall be labeled and must be kept under the preparer's control or in a locked designated medication storage area or refrigerated if necessary, until delivery to the appropriate patient for administration ".

OBS #1 completed on September 24, 2020 at approximately 10:00AM revealed a used multi-dose vial of Heparin sodium in the top drawer of a storage cart located away from the medication preparation area. Drawer of cart was not locked, nor labeled as a designated area for medication storage.

An interview with the Facility Administrator completed on September 25, 2020 at approximately 2:30 PM confirmed the above findings.





Plan of Correction:

The Education Coordinator (EC) or designee will in-service all direct patient care (DPC) staff on the following policy:
- FMS-CS-IC-II-120-040A Medication Preparation and Administration Policy.

Emphasis will be placed on ensuring that all medications, including pre-drawn medications, are labeled per policy, and locked in a designated area until the time of administration to the patient.

The inservice will be completed by 10/16/2020.

The CM and/or designee will conduct daily audits for two (2) weeks. If one hundred percent (100%) compliance is observed, then audits will continue weekly x 2 weeks. If compliance has been sustained audits will continue monthly per Quality Assessment Improvement (QAI) clinical audit checks. A Plan of Correction (POC) specific audit tool will be used for the audits.

Staff found to be non-compliant will be re-educated and counseled.

The CM will review the audit results and report the findings to the QAI Committee at the monthly meeting. Sustained compliance will be monitored by the QAI committee.



494.150(c)(2)(i) STANDARD
MD RESP-ENSURE ALL ADHERE TO P&P

Name - Component - 00
The medical director must-
(2) Ensure that-
(i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;



Observations:

Based on review of policy, medical records (MR) and an interview with the Facility Administrator the facility failed to ensure documentation patients completed a fire drill quarterly for five (5) of nine (9) MR reviewed. MR #2, #3, #5, #6 and #9.

Findings include:

Review of policy: FMS-CS-IC-II-130-013A, "Fire Drill", completed on September 25, 2020 at approximately 1:30PM revealed, "section: "Fire Drills; bullet one: Quarterly, all FKC facilities shall perform a fire drill for each shift of patients and staff...".


Review of medical records completed on September 24, 2020 between approximately 2:00PM and 3:00PM and September 25, between approximately 9:00AM and 11:00AM revealed:

MR #2, admission date: 1/16/2015, contained no documentation of a fire drill being conducted during the first quarter (Jan-March) of 2019.

MR#3, admission date: 2/18/2002, contained no documenation of a fire drill being conducted second quarter (Apr-June) 2018 nor fourth quarter (Oct-Dec) 2018.

MR#5, admission date: 9/20/2018, contained no documenation of a fire drill being conducted first quarter (Jan-March) of 2019

.MR#6, admission date: 12/11/2017, contained no documenation of a fire drill being conducted first quarter (Jan-March) of 2019.

MR#9, admission date: 1/11/2016 contained no documentation of a fire drill being conducted second quarter (Apr-June) 2019.


An interview with the Facility Administrator completed on September 25, 2020 at approximately 2:30 PM confirmed the above findings.








Plan of Correction:

On 10/15/2020 the Director of Operations (DO) and the FA met with the Medical Director to review the Medical Director Responsibilities as defined in the Conditions for Coverage. The meeting also reviewed the Medical Staff Bylaws and policy:
- FMS-CS-IC-II-130-013A Fire Drill Policy

The meeting focused on the importance of the completion of quarterly fire drills with review of completion of fire drills at QAI.

The Medical Director was informed at the meeting that the CM and the staff will receive education on:
- FMS-CS-IC-II-130-013A Fire Drill Policy
- FMS-CS-IC-II-130-013D2 Patient Participation in Fire Drills

Emphasis will be placed on ensuring that fire drills are completed for all patients quarterly. The meeting also focused on ensuring that all newly admitted patients will have a fire drill completed upon admission to the unit. The meeting will also reinforce the importance of completing the Patient Participation in Fire Drill form for all patients and placing the form in the patient's medical record.

Audit of current Fire Drills revealed that all Fire Drills are up to date for this quarter.

To ensure ongoing compliance with quarterly fire drills, the CM or designee will develop a Fire Drill tracking calendar for 2020 and 2021 with the weeks that the fire drills are to be held clearly identified. This calendar will be posted at the nurse's station. The CM will also have the weeks of the fire drills for 2020 and 2021 marked in the computer's electronic calendar. The Fire Drill Tracking calendar will be reviewed in QAI.

The QAI committee will be informed of the weeks that the drills are scheduled for 2020 and 2021. The results of the fire drills, when conducted, will be reviewed by the CM at the monthly QAI meeting for ongoing oversight.

Issues of non-compliance will include re-education and counseling by the DO.