Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on October 30, 2023 through November 2, 2023, Dialysis Clinic Inc. - Parks Bend 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 on November 2,2023, Dialysis Clinic, Inc. - Parks Bend 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-IF TO STATION=DISP/DEDICATE OR DISINFECT
Name - Component - 00
Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient.
-- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient.
-- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient's station should be used only for that patient and should not be returned to a common clean area or used on other patients.
Observations:
Based on policy and procedure review, observations (OBS), and an interview with the nurse manager and facility administrator, it was determined the ESRD failed to ensure the disinfection of non-disposable equipment after patient usage for 3 (three) of 3 (three) Nursing Assessment observations (OBS#1, OBS#2 and OBS#3).
Findings include:
10/31/23 at approximately 10:30 am a review of policy # 160 "General Facility Infection Control" ... 5. "Items taken into the dialysis station should either be disposed of, dedicated for single use only on a single patient, or cleaned and disinfected before being taken to a common clean are or used on another patient (CMS V116).
OBS#1: 11-1-2023 at approximately 10:15 a.m., surveyor observed one (1) stethoscope located around employee's neck on top of the personal protective gown while in the patient treatment area. The employee then immediately removed stethoscope from around neck and utilized the stethoscope to assess patient at station (ST) #1. Employee then removed alcohol swab/wipe from their pocket and proceeded to wipe/disinfect the bell portion of the stethoscope with the alcohol wipe. Employee did not wipe/disinfect the entire stethoscope. Surveyor asked employee what the procedure for disinfected equipment was for the facility. Employee responded "I keep the alcohol wipes in my pocket and just wipe the part of the equipment that touched the patient."
OBS #2 and #3: 11-1-2023 at approximately 10:30 am, surveyor observed nurse manager utilize one stethoscope to assess the patient at ST#13, immediately after assessment draped stethoscope around their neck without performing disinfection. Nurse manager then move to the patient at ST#16 to assess that patient with the same stethoscope. Surveyor asked nurse manager what the facility procedure is for equipment disinfection, nurse manager replied "I wipe it down in between patients and place it on the clean counter." Note: "clean counter" is designated area in the center of the treatment area with clean supplies.
An interview with the facility administrator and nurse manager on 11-1-2023 at approximately 3:45 PM confirmed the above findings.
Plan of Correction:All clinical staff will be re-trained by the Nurse Manager and/or Designee on the facility's "General Facility Infection Control" policy. Training will include instruction on disinfecting equipment once an item leaves a dialysis station, with emphasis on the requirement to disinfect the entire device (stethoscope). This training will be completed by November 13, 2023.
All clinical staff will sign acknowledgment of understanding of policies. A copy of acknowledgment will be placed in the respective employee files.
Nurse Manager and/or Designee will conduct an infection control employee skills checklist for all patient care staff by November 15, 2023.
Nurse Manager and/or Designee will observe facility staff daily for one (1) week to ensure that staff is following proper infection control standards and to ensure that staff adheres to infection control standards. If standards are met, the clinic staff will be observed weekly for four (4) weeks. If standards are met, the clinical staff will be observed monthly for three (3) months. If standards are met, the clinical staff will be observed quarterly. The respective audit results will be reviewed at monthly QAPI/GB meetings. Governing Body will determine frequency of future audits based upon compliance.
494.30(a)(1)(i) STANDARD
IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS
Name - Component - 00
If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies.
Do not carry medication vials, syringes, alcohol swabs or supplies in pockets.
Observations:
Based on review of facility policy, clinical treatment area observations (OBS), and an interview with the nurse manager, it was determined facility failed to ensure dialysis supplies are not stored in pockets for 1 (one) of 3 (three) observations. (OBS #1).
Findings include:
10/31/23 at approximately 10:30 am a review of policy #160 "General facility infection control"... "13. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets (CMS V119).
Clinical treatment area observations conducted on November 1, 2023 between approximately 9:15 am and 11:00 am revealed:
OBS#1: 11-1-2023 at approximately 10:15 a.m., surveyor observed one (1) stethoscope located around employee's neck on top of the personal protective gown while in the patient treatment area. The employee then immediately removed stethoscope from around neck and utilized the stethoscope to assess patient at station (ST) #1. Employee then removed alcohol swab/wipe from their pocket and proceeded to wipe/disinfect the bell portion of the stethoscope with the alcohol wipe. Employee did not wipe/disinfect the entire stethoscope. Surveyor asked employee what the procedure for disinfected equipment was for the facility. Employee responded "I keep the alcohol wipes in my pocket and just wipe the part of the equipment that touched the patient."
An interview with the nurse manager on November 1, 2023 at approximately 3:30 p.m. confirmed the above findings.
Plan of Correction:All clinical staff will be re-trained by the Nurse Manager and/or Designee on the facility's "General Facility Infection Control" policy. Training will include instruction on not transporting supplies in pockets. This training will be completed by November 13, 2023.
All clinical staff will sign acknowledgment of understanding of policies. A copy of acknowledgment will be placed in the respective employee files.
Nurse Manager and/or Designee will observe clinic staff for one (1) week to ensure that staff are following proper infection control standards regarding supplies taken into a dirty area. If standards are met, the clinic staff will be observed weekly for four (4) weeks. If standards are met, the clinical staff will be observed monthly for three (3) months. If standards are met, the clinical staff will be observed quarterly. The respective audit results will be reviewed at monthly QAPI/GB meetings. Governing Body will determine frequency of future audits based upon compliance.
494.30(a)(1)(i) STANDARD
IC-HBV-ISOLATION (EXISTING FACILITY)
Name - Component - 00
Isolation of HBV+ Patients
To isolate HBsAg positive patients, designate a separate room for their treatment.
For existing units in which a separate room is not possible, HBsAg positive patients should be separated from HBsAg susceptible patients in an area removed from the mainstream of activity.
Observations:
Based on a review of facility documents and staff (EMP) interviews, it was determined that the facility, which does not currently accept or treat hepatitis B positive patients, failed to request a waiver and failed to notify the state survey agency and CMS a copy of the transfer agreement documentation with a local chronic facility which has capacity for isolation stations.
Findings Included:
During an interview with facility administrator (EMP1) on 10-30-2023 at approximately 10:30 AM the facility administrator confirmed the facility had no "functioning" isolation room and does not have a hepatitis B positive patient. The surveyor asked question number thirteen (13) from the entrance conference questions " If opened or expanded on or after 10/14/2008, does the facility have a waiver from CMS for the requirement of an isolation room? " EMP1 could not confirm the date of when the facility was built, but provided a Pennsylvania Department of Health and Human Services with a " ...(X3) DATE SURVEY COMPLETED: 04/25/2007... " EMP1 replied "Our water system was replaced and the new system we have in place can only support water supply to the 16 stations we have up and running. The isolation room was not one of the stations that the new water lines were designated for." During an observation tour of the facility on 10-30-2023 at approximately 9:30 AM with facility nurse manager, no isolation was available.
The surveyor informed EMP1 on 11-1-2023 at approximately 12:00 PM of the requirements for a waiver and or transfer agreement for patients with hepatitis B positive status to another facility which has an isolation room. EMP1 replied "I can complete a waiver request and provide you with the list of facilities for a transfer agreement."
An interview was conducted on 11-1-2023 at approximately 12:40 PM with the facility administrator and nurse manager confirmed the above findings.
Plan of Correction:On Monday, October 30, 2023, Area Operations Director presented Pennsylvania DOH Surveyor with the clinic's patient transfer agreement, dated July 1, 2023, indicating local chronic facilities with isolation room(s). Additionally, on Wednesday, November 1, 2023, Area Operations Director prepared, and delivered, an isolation waiver request to Pennsylvania DOH Surveyor, listing chronic facilities within the geographical region that have isolation room(s).
On Wednesday, November 8, 2023, Area Operations Director submitted the clinic's patient transfer agreement and the isolation waiver request to CMS/ESRD Network Liaison.
All facility staff will be notified of established transfer agreement in the event that a hepatitis B+ patient is admitted to the facility or have a current patient seroconvert to hepatitis B+. All staff will review and sign acknowledgement of understanding of agreements. Acknowledgement will be placed in respective employee files.
Area Operations Director and/or Designee will review waiver/transfer agreements annually to assure adherence to plan of correction.
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