Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on May 1, 2023 through May 3, 2023, Dialysis Center At Oxford Court was identified to have the following deficiencies that were determined to be in substantial 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:
494.62(a)(1)-(2) STANDARD
Plan Based on All Hazards Risk Assessment
Name - Component - 00
§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*
(2) Include strategies for addressing emergency events identified by the risk assessment.
* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.
*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.
*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.
Observations:
Based on a review of the facility emergency preparedness plan, facility policy, and an interview with the administrator, group administrator and clinical services manager, the facility did not develop and maintain an emergency preparedness plan based on and include a documented, facility based and community based risk assessment using an all hazards approach.
Findings include:
A review of Policy 4-07-01 "The Facility Emergency Management Plan (ICHD Home)" on May 1, 2023 at 1:30 PM states: "5.b. The FA or designee is responsible for Maintaining a clear understanding and ongoing awareness of the hazards that may affect the patients, teammates, and the facility's operating ability. This includes, but not limited to local weather conditions, natural, and man-made hazards, as identified on the Facility Hazard Vulnerability Assessment."
A review of the facility's emergency preparedness binder was conducted on May 1, 2023 at 1:00 PM.
The binder did not contain a facility and community based all hazards approach since 2019. A "Hazard Vulnerability Assessment Form" dated 5/1/23 was obtained from the facility management.
An interview with the administrator, group administrator and clinical services manager conducted on May 3, 2023 at 1:00 PM confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 5/9/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 4-07-01 "Emergency Management Plan (EMP) (ICHD, Home) with emphasis on but not limited to: 1)The Facility Hazard Vulnerability Assessment (HVA) provides a systematic approach to recognizing hazards that may affect the community and facility's ability to provide dialysis services and meet the health and safety needs of the patient population The risks associated with each hazard are analyzed to prioritize planning, mitigation, response and recovery activities. This tool serves as a needs assessment for the Emergency Management Plan. Verification of attendance is evidenced by teammate's signature on the in-service sheet. The Hazard Vulnerability Assessment tool was updated on 5/1/23 to include Flood, tornado, winter storm/ice, infectious disease, bomb threat, fire, utility outages, civil disorder, biological agents, active shooter. "Probability", "Risk" and "Preparedness" sections were completed. Facility action plan was reviewed with the facility team starting on 5/9/23, with information on [Your specific hazards] found on the Incident Management Tool. Teammate training will take place with all new hires, annually and if changes are made to the Hazard Vulnerability tool. The updated Hazard Vulnerability Assessment tool will be reviewed with the Medical Director during monthly Quality Assessment Performance Improvement meeting known as Facility Health Meeting, with supporting documentation included in the meeting minutes. The Facility Administrator will review it in the next Governing Body meeting, scheduled for 5/17/23. It is maintained and reviewed annually with the Emergency Management Plan, and updated as warranted throughout the year. The Facility Administrator is responsible for compliance with this plan of correction.
494.62(d)(1) STANDARD
ESRD EP Training Program
Name - Component - 00
§494.62(d)(1): Condition for Coverage:
(d)(1) Training program. The dialysis facility must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
Staff training must:
(iii) Demonstrate staff knowledge of emergency procedures, including informing patients of-
(A) What to do;
(B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated;
(C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and
(D) How to disconnect themselves from the dialysis machine if an emergency occurs.
(iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and
(v) Properly train its nursing staff in the use of emergency equipment and emergency drugs.
(vi) Maintain documentation of the training.
(vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures.
Observations:
Based on a review of the facility Medical Records (MR), facility policy, and an interview with the administrator, group administrator and clinical services manager, the facility did not conduct fire safety drills according to facility policy for two (2) of six (6) MRs. MR# 1 and 6.
Findings include:
A review of Policy 4-07-01 "The Facility Emergency Management Plan (ICHD Home)" on May 1, 2023 at 1:30 PM states: "Fire Safety Drills: b. Required on a QUARTERLY basis. c. One drill to be conducted for each shift of patients..."
A review of Medical Records was conducted on May 2, 2023 at 9:30 AM-3:00 PM.
MR#1 admission date 1/26/19 did not have a fire safety drill conducted for the second quarter of 2022.
MR#6 admission date 3/25/22 did not have a fire safety drill conducted on admission and the third quarter of 2022.
An interview with the administrator, group administrator and clinical services manager conducted on May 3, 2023 at 1:00 PM confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 5/9/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 4-07-01 "Facility Emergency Management Plan" with emphasis on but not limited to: 1) Facility Administrator or designee, is responsible to... Conduct and review quarterly fire safety and evacuation training and drills for compliance. 2) Fire safety drills are required on a quarterly basis; one drill to be conducted for each shift of patients. 3) Include patient emergency takeoff procedure, policy. 4) Document training for both patients and teammates: i. Patients use Reggie form "Emergency Evacuation Acknowledgement Form"; ii. Teammates use policy: "Training/In-service Documentation Form"; iii. Identify patients requiring assistance in an evacuation. 4) Document in Governing Body meeting. 5) Maintain with facility Emergency Management Plan. Verification of attendance is evidenced by teammate signature on in-service sheet.
The Facility Administrator or designee will audit fire drill documentation for three (3) quarters to verify compliance for all shifts of patients. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audits. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit results with the Medical Director during the monthly Quality Assessment Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on May 1, 2023 through May 3, 2023, Dialysis Center At Oxford Court 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 on observation of the clinical area, facility policy and an interview with the facility administrator, group administrator and clinical services manager, the facility did not ensure infection control procedure regarding glove removal and handwashing for five (5) of twelve (12) observations (OBS). OBS#1, 2, 3, 4, and 5.
Findings include:
A review of policy 1-05-01 "Infection Control For Dialysis Facilities" on May 2, 2023 at 9:30 AM states: " 1. All teammates...will perform hand hygiene b. prior to gloving and immediately after removal of gloves. c. after contamination with blood or other infectious material. d. after patient and dialysis delivery system contact,,,7a Gloves should be changed when: ii. When going from a "dirty" area or task to a "clean" area or task. ii. When moving from i. contaminated body site to a clean body site of the same patient; and iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient's dialysis delivery system....11.a. ...alcohol swabs, gloves or other supplies will not be carried in pockets..."
Observation of the clinical area was conducted on 5/1/23 9:45 AM-12:30 PM and 5/2/23 9:15 AM-10:15 AM and 12:30 PM- 1:55 PM.
OBS#1 Machine 14 RN3 after touching dialysis machine did not discard gloves, perform hand hygiene and don new gloves prior to discontinuing dialysis for a patient with a central venous catheter. RN3 began the termination of treatment by removing the arterial line from the arterial catheter port and applying a saline syringe without performing the aforementioned procedure.
OBS#2 Machine 7 PCT 2 after wiping the Myron L meter then returned to machine 7 and touched the screen without discarding gloves, performing hand hygiene and donning new gloves prior to cannulation of the vascular access.
OBS#3 Machine 11 PCT 2 after touching the machine screen, did not discard gloves, perform hand hygiene and don new gloves prior to removing the fistula needle from the patient's vascular access.
OBS#4 Machine 7 PCT 2 after obtaining a clamp from the supply area, removed gloves, donned new gloves without performing hand hygiene.
OBS#5 RN 1 observed to place alcohol prep pads in pocket for future use taken from medication prep area.
An interview with the administrator, group administrator and clinical services manager conducted on May 3, 2023 at 1:00 PM confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 05/04/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" rev. April 2023 and Policy 1-04-02B "Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure" with the emphasis on but not limited to: A. Infection control: 1) All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene ...b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, d. after patient and dialysis delivery system contact ... g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. 2) Gloves should be changed when: i. When soiled with blood, dialysate or other body fluids ii. When going from a "dirty" area or task to a "clean" area or task iii. When moving from a contaminated body site to a clean body site of the same patient; and iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient's dialysis delivery system. 3) Unused supplies (syringes, alcohol swabs, tape, etc.) or medications (including multiple dose vials containing diluents) taken into the station should be used only for that patient and should not be returned to a common clean area or used on other patients. B. Upon completion of dialysis (CVC): 1) Step #26: Perform hand hygiene per procedure. Rationale: Hand hygiene protects patient and teammate from cross contamination. PPE is worn to protect teammate.
Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
The Facility Administrator will conduct hand hygiene audits to verify hand hygiene and glove changes are performed by teammates per policy: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly infection control audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review the audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assessment and Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
494.90(a)(1) STANDARD
POC-MANAGE VOLUME STATUS
Name - Component - 00
The plan of care must address, but not be limited to, the following:
(1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient's volume status;
Observations:
Based on a review of medical records (MR), facility policy, and an interview with the administrator, group administrator and clinical services manager, the facility did not follow its policy for blood pressure management for two (2) of six (6) MRs. MR#1 and 6.
Findings include:
A review of facility policy 1-03-08 "CWOW-Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment" conducted on May 2, 2023 at 2:00 PM states: "Intradialytic Data Collection/Assessment 11. Abnormal findings...will be reported to the licensed nurse immediately...Post Treatment Data Collection/Assessment 16. If an abnormal finding(s) or concern is identified post treatment, this nneds to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 17. The licensed nurse will use his/her clinical judgement...to determine if any clinical interventions or notification of the physician (or NPP as applicable) is necessary prior to discharge of the patient from the facility...Abnormal Findings: Blood Pressure-Intradialytic- Difference of 20 mm/Hg or decrease from patient's last Intradialytic BP reading..."
Findings include:
A review of Medical Records was conducted on May 2, 2023 at 9:30 AM-3:00 PM.
MR#1 admission date 1/26/19. A review of treatment sheet revealed the following:
4/17/23
Pre BP sitting 152/99
1 PM BP 183/108 comments state"Patient awake and alert; and states no complaints at this time."
1:30 PM BP 172/132 "Patient monitored: watching tv no complications"
1:34 PM BP 176/101 "Patient monitored: watching tv no complications"
2 PM BP 179/102 "Patient awake and alert; and states no complaints at this time."
2:30 PM BP 183/105 "Patient awake and alert; and states no complaints at this time."
2:59 PM BP 186/104 "tx (treatment) terminated; normal rinseback given"
Post BP 155/110
The PCT (patient care technician) did not report the above elevated blood pressures to the licensed nurse and therefore the licensed nurse did not assess the BP during the treatment nor complete a post treatment assessment.
MR#6 admission date 3/25/22 A review of treatment sheet for 4/17/23 revealed the following:
Pre BP 152/88
8:30 AM BP 83/46 and rechecked at 8:37 AM 83/44 goal lowered by PCT
9:00 AM BP 87/52 RN entry "BP low, pt (patient) denies any c/o (complaints) uf (ultrafiltration) d/c (discontinued).
There was no notification to the RN about the low BP's. The RN was aware at treatment termination but did not perform a post nursing assessment.
An interview with the administrator, group administrator and clinical services manager conducted on May 3, 2023 at 1:00 PM confirmed the above findings.
Plan of Correction:
The Facility Administrator or designee held mandatory services for all Clinical Teammates starting on 5/4/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-03-08 Pre-Intra-Post treatment Data Collection Patient identity, Monitoring and Nursing Assessment emphasizing but not limited to: 1) Intra dialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes vital signs and treatment monitoring at least every 30 minutes. 2) Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately. 3) If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 4) The licensed nurse will utilize their clinical judgement to determine if clinical interventions or physician notification is necessary prior to discharge from the facility... 5) Abnormal Findings: Blood Pressure-Intradialytic- Difference of 20 mm/Hg or decrease from patient's last Intradialytic BP reading. Verification of attendance is evidenced by teammate's signature on the in-service sheet.
The Facility Administrator or designee will conduct audit of treatment records to verify abnormal BP findings are documented appropriately, along with documentation of licensed nurse notification and response, including prn medications and/ or physician notification as applicable: on twenty five percent (25%) treatment records daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review the audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assessment and Performance Improvement meetings known as Facility Health Meetings, with supporting documents included in the meeting minutes. The Facility Administrator is responsible for compliance with the plan of correction.
|