Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on August 14, 2023, through August 16, 2023, and completed off-site August 18, 2023, Fresenius Medical Care Lansdale 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 August 14, 2023, through August 16, 2023, and completed off-site August 18, 2023, Fresenius Medical Care Lansdale Dialysis was identified to have the following standard level deficiency that was 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 observations, facility policy, and an interview with the facility staff, the facility failed to ensure that non-disposable items taken into the dialysis station were cleaned and disinfected before being used on another patient for two observations (Observation #1 and 2).
Findings include:
A review of policy #47806 on August 18, 2023, at approximately 12:00 P.M. states, "General Cleaning: ... After use, any non-disposable equipment and supplies brought into the dialysis station (ex. stethoscope) must be disinfected wit 1:100 bleach or EPA registered disinfectant before being removed from the dialysis station."
Observation #1: On August 15, 2023, at approximately 11:20 A.M., RN #1 was observed assessing the patient in Station # 6, using a non-disposable stethoscope. RN#1 placed the stethoscope around her neck and left Station #6 without cleaning and disinfecting the stethoscope after assessing the patient.
Observation #2: On August 16, 2023, during observations between 11:00 A.M. and 12:00 P.M., RN #1 was observed assessing the patients in Station #13 and Station #16 using a non-disposable stethoscope without cleaning and disinfecting the stethoscope between patient assessments. RN #2 was observed assessing patients in Station #11 and Station #12 using a non-disposable stethoscope without cleaning and disinfecting the stethoscope between patient assessments.
An interview with the Clinical Manager Lansdale, Clinical Manager Abramson, Director Operations, and the Medical Director on August 16, 2023, at approximately 3:00 PM confirmed the above findings.
Plan of Correction:V 116
The Clinic Manager (CM) or designee will re-educate all the direct patient care (DPC) staff on:
- Cleaning and Disinfection of the Dialysis Station
The in-service will emphasis that all non-disposable items, including stethoscopes, taken into the patient treatment station are cleaned and disinfected per policy after each use and/or between use at another patient station.
The inservicing will be completed by August 28, 2023, with documentation of the training on file at the facility.
The CM or designee will perform daily audits on the DPC staff for two (2) weeks. At that time if compliance is observed the audits will then be completed 2 times/week for 2 weeks to ensure that compliance is maintained. At that time the audits will then follow the monthly Quality Assessment and Performance Improvement (QAPI) schedule.
Staff found to be non-compliant will be re-educated and referred for counseling.
The CM will review the audit results and report the findings to the QAPI Committee at the monthly meeting. Sustained compliance will be monitored by the QAPI committee.
Completion Date: September 29, 2023
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