Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on 8/1/23 & 8/2/23, Lock Haven Dialysis Clinic 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 unannounced Medicare recertification survey conducted on 8/1/23 & 8/2/23, Lock Haven Dialysis Clinic, was found to have the following standard level deficiencies that were determined to be in substantial compliance with the 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, review of policy and procedure, and an interview with the facility clinical manager, it was determined the facility failed to ensure staff #2 performed hand hygiene for (1) one of (6) six observations. (Observation #2)
Findings Include:
Review of policy "Hand Hygiene/Handwashing on 8/3/23 at 12:00 PM states, " Handwashing/Hand Hygeine is performed, 1. before touching a patient, 4. after touching a patient, 5. After touching blood, body fluids, mucus membranes, wound dressings, or dialysis fluids, 8. before and after touching medical equipment or other items at the dialysis station, 9. after touching patient belongings, 10. before touching computer, 11. after removing gloves, 12. moving out of dirty area, 13. prior to entering station to provide care. Hand hygiene may also be completed using hand sanitizer after an initial complete hand-washing with soap and water."
Policy section: Organization functions Environment of Care: Hand Hygiene Opportunity Category: 1. "Prior to touching a patient: prior to entering station to provide care to patient..."; 3. "After touching a patient: when leaving station after performing patient care, after removing gloves, when moving from a soiled body site to a clean body site.."; 4. "After touching patient surroundings: After touching dialysis machine, After touching other items within the dialysis station, when leaving station, after removing gloves..."
Observation #2 on 8/1/23 at approximately 10:30 AM revealed staff #2 at station #7, after changing soild bandages, removed gloves but did not perform hand hygiene, new gloves were applied, the hemodialysis machine was touched then the patient belongings were touched with no hand hygiene performed.
An interview with the Administrator on 8/2/23 at 4:00 PM confirmed the above findings.
Plan of Correction:Plan of Correction:
1. Corrective Action: Hand Hygiene education provided to all center staff followed by a written test to prove competence. The process will be audited for competency on a monthly basis and results tracked in our monthly quality meetings to monitor improvement.
2. Problem Identification: Patient Care Technician was observed not performing hand hygiene between glove changes violating policy EC04.
3. Process Changes: Policy EC04 adherence is audited 30 times per month in an effort to reduce blood stream infections and promote safe patient care. For the next 3 months or until 100% compliance is achieved, EC04 auditing surveillance will increase 45 time per month.
4. Monitoring of Changes: policy EC04 contains an audit tool within it. Audits activities will ramp up for 3 months and will end when 100% compliance is achieved.
5. POC Completion Date: 10.30.2023
494.30(a)(1)(i) STANDARD
IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK
Name - Component - 00
Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory.
Observations:
Based on review of facility policy, observations, and an interview with the Clinical Nurse Manager, the facility failed to ensure that the staff followed infection control protocols, included but not limited to, use of Personal Protective Equipment (PPE), for three (3) of three (3) observation. ( Observation # 1- # 3).
Findings include:
Review of agency policy on 8/2/2023 at 3:30 PM titled " Personal Protective Equipment (PPE)" stated " Policy: "PPE that is appropriate to the specific requirements of each task is provided by this facility to employees." (4) Employees will wear full PPE while on the treatment floor. 10) All PPE must be removed when leaving an isolation room or when exiting the specific treatment area."
Observation # 1 on 8/1/2023 between 11:10 AM-11:30 AM: EMP #2 was observed exiting the treatment room floor to outside lobby without removing her personal protective equipment (PPE) and returned with a wheelchair without changing her PPE.
Observation #2: 8/1/23 between 11:30 AM-11:35 AM: EMP #1 was observed exiting the treatment room floor to outside lobby without removing her PPE to assist a patient back to the treatment room floor.
Observation #3: 8/2/23 between 3:30 PM-3:35 PM: EMP #1 was observed exiting the treatment room floor to outside lobby without removing her PPE including gown, face mask, face shield, and gloves then returned to treatment floor without changing PPE.
An interview with the Clinical Nurse manager on 8/2/23 at approximately 4:00 PM confirmed the above findings.
Plan of Correction:Plan of Correction:
1. Corrective Action: Staff training and testing will be implemented through our PPE learning module. Audits of the process will be completed monthly and reviewed in our quality meeting.
2. Problem Identification: Clinicians were observed wearing PPE gowns off the treatment floor.
3. Process Changes: Policy EC06 states that gowns should be removed when exiting the treatment floor. We've added an audit of this process to our monthly NHSN observation process. We've introduced audit form EC119c to our process and will include these findings in the audit section of our monthly quality meetings. Staff will be retrained on this process through our PPE learning module and competency will be tested.
4. Monitoring of Changes: Audit activities will continue for 3 months and will end when 100% competency is achieved.
5. POC Completion Date: 10.30.2023
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 reviews of observations, facility policy, and an interview with the facility clinical manager, the facility failed to ensure proper inventory control for one (1) of three (3) supply observations (Observation #3).
Findings include:
Review of policy Rotation of Stock on 8/3/23 at 10:30 AM states, "Policy Statement: In order to provide quality care, a facility must maintain adequate stock to sustain them through daily operations and in emergent events such as inclement weather where routine deliveries cannot be made. It is important to verify that stock is being rotated as it is delivered so that expiration dates if applicable are not being reached and that stock on the shelves is used prior to that which just arrived...Expiration dates will be checked on all stock, both incoming and existing."
Observations conducted in the center on 8/1/23 between approximately 9:30 AM-12:00 PM revealed the following:
Observation #3: Review of lab room on 8/1/23 at approximately 11:00 AM revealed six (6) vacutainer lab vials #2013576 in a biohazard bag with an expiration date of 6/30/23
Interview with the clinical manager on 8/2/23 at 4:00 PM confimed the above findings.
Plan of Correction:Plan of Correction:
1. Corrective Action: Center administrative assistant will utilize checklist EC119c to track lab supply expiration dates and rotate stock accordingly.
2. Problem Identification: Expired hospital lab blood tubes were identified during an audit of the supplies in the center's lab.
3. Process Changes: Policy EC119 directs staff on the practice of stock rotation and expiration tracking. The policy was adjusted to include an expiration check for lab supplies. Each month, the center administrative assistant will stock new lab supplies, rotate stock and check for expiration dates. Findings will be shared with the center biomed.
4. Monitoring of Changes: Center Manager will audit activities for 3 months and will end when 100% competency is achieved.
5. POC Completion Date: 10.30.2023
494.60(a) STANDARD
PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY
Name - Component - 00
The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public.
Observations:
Based on observations, review of facility's checklists, policies/procedures, and an interview with the facility unit manager and the facility administrator; the facility failed to maintain the integrity of the walls and the floors within the dialysis treatment area for eleven (11) of fifteen (15) observations. OBS #1-# 11.
Findings include:
OBS # 1-3 completed 8/1/23 between 9:35 AM and 9:40 AM, Rust colored water stains on water connection access panels, paint chipping of walls and backboards behind the dialysis machines at the base by the water connection access drains for dialysis station #3, # 4 and # 5.
OBS # 4 completed 8/1/23 at 9:40 AM, Cracked corner piece of wood on nurse ' s station located on left side of desk when standing in front of nurse ' s station.
OBS # 5 completed 8/1/23 at 9:45 AM, wallpaper in corner of station # 10 revealed paint chipping and water damage.
OBS # 6-8 completed 8/1/23 between 9:45 AM and 9:50 AM, Rust colored water stains on water connection access panels, paint chipping of walls and backboards behind the dialysis machines at the base by the water connection access drains for dialysis station #7, # 8 and # 9.
OBS # 9 completed 8/1/23 between 9:50 AM-10:00 AM, wall molding loose behind station # 7.
OBS # 10 completed 8/1/23 at 11:08 AM, hole approximately a half inch by half inch in dirty sink floor by station # 10.
OBS # 11 completed 8/1/23 at 11:10 AM, torn piece of wallpaper by station # 12.
Review of Facility's Checklist for July 13, 2023 on 8/3/23 at 5:55 PM revealed: facility has been aware of the condition of the treatment room floor.
Disinfection of Dialysis Control Unit and Dialysis Station: Policy Statement reviewed on August 2, 2023 at 2:00 PM revealed: "The dialysis control unit and station are disinfected between patients and at the end of the workday. Throughout the treatment day, they will be maintained in a clean and organized state..."; Procedure: 4. After each treatment the dialysis station is wiped down with a one percent (1%) bleach solution. This includes: d. blood spills or splashes on the flooring, walls, wall boxes, computer (including touchscreen, keyboard, and mouse) or anywhere in the immediate vicinity of the control unit.; 5. The treatment station and surroundings will be inspected and detailed to assure: d. "Ledges between stations and half walls are clean and disinfected..." " Wall boxes will be disinfected daily " ; 6. "During the workday, the dialysis station and its immediate surroundings will be monitored to be certain that the area is maintained to assure adherence to this policy...."
Interview with Clinic Administrator, who was present at clinic during this time, on 8/1/23 at approximately 9:13 AM revealed: "Yes we know about treatment room floors, we are planning a remodel and a new water system here just like at Williamsport. I think the remodel is starting here in September or October. Yes please, you can show me the areas on the floor. The hole in the sink floor was from a bleach spill. We will definitely keep you posted with the remodel. "
An interview conducted with the Clinic Administrator on August 1, 2023 at approximately 9:30 AM confirmed the above the findings.
Plan of Correction:Plan of Correction:
1. Corrective Action: On 8.9.2023 all issues were reviewed with a contractor. Repairs will be completed by 8.31.2023. A more extensive remodel will be completed in concert with the water system replacement in Q4 2023.
2. Problem Identification: Survey identified 11 areas of concern that include; chips in cabinetry, chipped paint, torn wallpaper and under sink bleach damage.
3. Process Changes: An internal survey is conducted quarterly and identified all of these concerns. Checklist EC22b was completed on 7.13.2023. Quarterly checks will continue and findings will be discussed at our quarterly governing body meetings.
4. Monitoring of Changes: Checklist EC22b will be completed during the week of 9.11.2023 to ensure all repairs are satisfactory.
5. POC Completion Date:8.31.2023
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